Air Accident Investigation Authority—The Application to the Editorial Offices

Air Safety Through Investigation OCTOBER-DECEMBER 2018 Journal of the International Society of Air Safety Investigators

2018 Kapustin Helicopter Scholarship Essay: Accident Electric Air Taxis Passenger Brace The Impact of Trends in and the Adaptation Position in Using Data to Assess Hollywood on Eight ISASI of Air Safety Aircraft Accident Performance of Safety Accident A Trip to the Countries Investigators Investigations Management Investigation Land of Merlion page 4 page 13 page 16 page 20 page 24 page 27 CONTENTS Air Safety Through Investigation Journal of the International Society of Air Safety Investigators FEATURES Volume 51, Number 4 4 Helicopter Accident Trends in Eight ISASI Countries Publisher Frank Del Gandio By Robert Matthews, Former U.S. Federal Aviation Administration Senior Safety Analyst, Editorial Advisor Richard B. Stone Office of Accident Investigation; Rex Alexander, Safety Consultant; and Richard “Dick” Editor J. Gary DiNunno Stone, ISASI Executive Advisor—The authors review helicopter accident data to highlight Design Editor Jesica Ferry safety improvements, suggest ongoing problem areas, and make recommendations to con- Associate Editor Susan Fager tinue improving helicopter flight safety. ISASI Forum (ISSN 1088-8128) is published quar- 13 2018 Kapustin Scholarship Essay: Electric Air Taxis and the Adapta- terly by the International Society of Air Safety tion of Air Safety Investigators Investigators. Opinions expressed by authors do not necessarily represent official ISASI position By Nicolette R. Meyer, Embry–Riddle Aeronautical University—The author offers a or policy. preview of air traffic and air safety issues in the near future that accident investigators may face. This is the first of four 2018 Kapustin scholarship essays that will appear inISASI Editorial Offices: Park Center, 107 East Holly Ave- Forum. nue, Suite 11, Sterling, VA 20164-5405. Telephone 703-430-9668. Fax 703-430-4970. E-mail address, 16 Passenger Brace Position in Aircraft Accident Investigations [email protected]; for editor, jgdassociates@ By Jan M Davies, Professor, University of Calgary; Martin Maurino, Technical Officer, starpower.net. Internet website: www.isasi.org. Safety, Efficiency, and Operations, International Civil Aviation Organization; and Jenny ISASI Forum is not responsible for unsolicited manuscripts, photographs, or other materials. Yoo, Advisor to the Korea Aviation and Railway Accident Investigation Board and Cabin Unsolicited materials will be returned only if Safety Analysis Group Chair, Korea Transportation Safety Authority, on behalf of the submitted with a self-addressed, stamped enve- members of IBRACE—The authors studied 34 U.S. National Transportation Safety Board lope. ISASI Forum reserves the right to reject, accident reports from 1983 through 2015 and found that only five mentioned the brace delete, summarize, or edit for space con- position and only one included brace position recommendations. siderations any submitted article. To facilitate editorial production processes, American Eng- 20 Using Data to Assess Performance of Safety Management lish spelling of words is used. By Nektarios Karanikas, Associate Professor of Safety and Human Factors, Aviation Copyright © 2018—International Society of Air Academy, Faculty of Technology, Amsterdam University of Applied Sciences, Amsterdam, Safety Investigators, all rights reserved. Publica- the Netherlands—The author identifies positive and negative areas of safety management tion in any form is prohibited without permis- systems through analysis of data and discussions with organization staff. sion. ISASI Forum registered U.S. Patent and T.M. Office. Opinions expressed by authors do 24 The Impact of Hollywood on Accident Investigation not necessarily represent official ISASI position By Dr. Katherine A. Wilson, U.S. National Transportation Safety Board, and Darren Straker, or policy. Permission to reprint is available upon Chief Inspector of Air Accidents, Hong Kong Air Accident Investigation Authority—The application to the editorial offices. authors examine how movies and other media that portray air accident investigations can Publisher’s Editorial Profile: ISASI Forum is print- delve into fiction for the sake of drama. ed in the United States and published for professional air safety investigators who are members 27 A Trip to the Land of Merlion of the International Society of Air Safety Inves- By Fasial Bashir Bhura, Squadron Leader, Pakistan Air Force, and Directing Staff at the tigators. Editorial content emphasizes accident College of Aviation Safety Management, PAF Base, Masoor—The author provides a personal investigation findings, investigative techniques account about attending a fellowship training program held at the Singapore Aviation and experiences, regulatory issues, industry ac- Academy. cident prevention developments, and ISASI and member involvement and information.

Subscriptions: A subscription to members is provided as a portion of dues. Rate for nonmem- DEPARTMENTS bers (domestic and Canada) is US$28; Rate for nonmember international is US$30. Rate for all 2 Contents libraries and schools is US$24. For subscription 3 President’s View information, call 703-430-9668. Additional or 28 News Roundup replacement ISASI Forum issues: Domestic and 30 ISASI Information Canada US$4; international member US$4; do- 32 Hong Kong Accident Investigation Authority Begins Operations mestic and Canada nonmember US$6; international nonmember US$8. ABOUT THE COVER

The Hong Kong Air Accident Investigation Authority. INCORPORATED AUGUST 31, 1964

2 • October-December 2018 ISASI Forum PRESIDENT’S VIEW

WITH JUST EIGHT MAJOR FATAL PASSENGER ACCIDENTS OCCURRING IN NEARLY THREE YEARS,…WE MIGHT FEEL AS THOUGH WE’VE ESSENTIALLY ACHIEVED OUR ULTIMATE AIR SAFETY GOALS—THAT NOT MUCH MORE CAN BE ACHIEVED. THE THEME OF THIS YEAR’S SEMINAR CHALLENGED SUCH COMPLACENT THINKING. FACING FUTURE INVESTIGATION CHALLENGES

recently had the opportunity biggest international airlines in MENASASI planned a strong achieved our ultimate air safety to welcome ISASI members; the world, plus Etihad Airways, seminar. The theme of this goals—that not much more government, industry, and which is based in Abu Dhabi. year’s seminar was “The Future can be achieved. The theme of Icorporate air safety repre- Two large low-cost carriers also of Aircraft Accident Investi- this year’s seminar challenged sentatives; and students to our are based in the UAE: Air Ara- gation.” The theme was timely such complacent thinking. 49th annual ISASI seminar. Our bia, which is based in Sharjah, because aviation is undergoing I concluded with my usual annual international accident and Flydubai. In 1971, all of this fundamental changes—as will challenge to seminar partici- investigation and prevention was simply unimaginable. the nature and investigation pants: to be engaged, to conference has been hosted Our seminar host society of aviation accidents. Aviation recognize that everyone can multiple times in Asia, Austral- was the Middle East North has always been rapidly chang- still learn something, and to ia, Europe, and North America. Africa Society of Air Safety ing. Though lots of industries share knowledge freely with This year, ISASI added the Investigators (MENASASI). The have undergone rapid tech- our colleagues, especially with annual seminar’s footprint to rapid growth of MENASASI nological change, few have the younger professionals in yet another region of the world mimics the growth of the UAE. experienced the constant, attendance. I encouraged all with our first seminar in the The chapter was chartered major change for 115 years students and newer members Middle East. I was pleased to just more than five years ago that aviation has. The pace of of this community to take welcome seminar participants in August 2013. Yet in that change for aviation shows no advantage of the experience to Dubai and to the United short time, MENASASI has signs of slowing. and expertise present at the Arab Emirates (UAE). sponsored several regional The temptation might be to seminar. These same challeng- The changes that have seminars and has more than 40 rest on the successes that have es hold true for all of us even if occurred since the UAE was members. This level of activity made aviation incredibly safer we weren’t able to attend founded in 1971 have been and growth indicates the effort in recent years. I can tell you ISASI’s annual seminar. breathtaking. In 1971, the and leadership of people like from personal experience that entire UAE was home to just Ismaeil Al Hosani, the current not so long ago investigators 300,000 people. Today, the UAE president of MENASASI, and from countries with large, well has a population of about 9.5 Mohamed Aziz, the fromer established air safety investi- million, with two-thirds of the president of MENASASI. Al Ho- gation systems were seldom people living in Dubai and Abu sani is the founder and the man home because major air safety Dhabi. ISASI is here at least with the insight to organize the events occurred with a fre- partly because the UAE is now region. He was well supported quency that isn’t experienced among the most important by the other officers and board in the industry today. international aviation hubs, members of MENASASI. I sin- With just eight major fatal with major airports such as cerely express my thanks and passenger accidents occur- Al Maktoum International my respect to these gentlemen ring in nearly three years, Airport here in Dubai and and to the members who’ve compared to the numerous the Abu Dhabi International worked hard to make this accidents experienced in the Airport. The UAE also is home regional society an outstanding not-so-distant past, we might Frank Del Gandio to Emirates airlines, one of the success in such a short time. feel as though we’ve essentially ISASI President October-December 2018 ISASI Forum • 3 he helicopter safety community has sues include poor or no preflight planning HELICOPTER had a good story to tell in recent or preflight inspection, conscious risk years. Fatal accidents have de- taking, piloting skills, maintenance issues Tcreased steadily while flight hours (most often a failure to obtain mainte- ACCIDENT have increased by more than half from nance), taking off with known deficien- 2001 through 2015. The result has been a cies, or failing to ensure adequate fuel. significant reduction in the fatal accident These basic factors commonly express TRENDS rate for helicopters, especially in the past themselves in accidents involving visual 10 years. Part of the credit for this happy flight at night, visual flight into weath- state of affairs can be attributed to sever- er, low-altitude flight, fuel exhaustion, IN EIGHT al important efforts to reduce accidents. etc. The same factors also influence the These efforts include the International most common and most lethal accident Helicopter Safety Team, the European Heli- scenarios, i.e., loss of control (LOC) and ISASI copter Safety Team, and the U.S. Helicopter controlled flight into terrain (CFIT). We Safety Team, plus major efforts by regula- also focus on differences in fatal accident tory authorities and industry groups, such rates among the three primary categories COUNTRIES as the Helicopter Association International of helicopters (piston, single-engine tur- and the National EMS Pilots Association. bines, and twin turbines), which may be The most promising efforts involve the somewhat overlooked in some cases. International Helicopter Safety Team Our suggested interventions also em- and several national or regional efforts, phasize the basics. They include the de- such as the U.S. Helicopter Safety Team velopment of and adherence to adequate By Robert Matthews, Former U.S. and a European effort. These efforts have procedures and the use of contemporary Federal Aviation Administration accomplished a lot already, but they are data monitoring, training, and the need Senior Safety Analyst, Office still in relatively early stages. Consequently, to continue emphasizing attention to pro- of Accident Investigation; Rex a small ISASI team decided to conduct its cedure. However, multiple technological interventions are also recommended as Alexander, Safety Consultant; own review of fatal helicopter accidents in several countries with large helicopter valuable enhancements where feasible. and Richard “Dick” Stone, ISASI fleets and large numbers of ISASI mem- The report is organized as follows. Part Executive Advisor bers. The team’s aim was to develop an One briefly outlines our process and the independent understanding and, perhaps, nature of the data, with a broad overview of basic trends. Part Two reviews the (Adapted with permission from the authors’ to identify selected characteristics of fatal technical paper titled Helicopter Accident accidents that might be useful targets for fundamental issues noted above, starting Trends in Eight ISASI Countries and How the various working groups to consider as with fleet characteristics and differences We Might Improve the Fatal Accident Rate they work to reduce the number and rate in accident rates among categories of hel- Even Further presented during ISASI 2017, of accidents even further. icopters, followed by a review of several Aug. 22–24, 2017, in San Diego, California, Our findings are consistent with early accident categories. The report concludes USA. The theme for ISASI 2017 was “Do findings from the groups cited above, but with recommendations and a summary. Safety Investigations Make a Difference?” our findings vary somewhat in their em- The full presentation can be found on the ISASI website at www.isasi.org in the Library phasis. For example, our study found that Process, data, and broad trend tab under Technical Presentations.—Editor) basic issues continue to be common in The team limited itself to fatal accidents fatal helicopter accidents. Those basic is- from 2001 through 2015 in the belief that,

Robert C. Rex Richard B. Matthews Alexander Stone was the senior safety analyst in U.S. Federal is a former U.S. Army aeroscout helicopter pilot, was a former president of ISASI and is now Aviation Administration’s Office of Accident instructor pilot, and standardization instruc- executive advisor of ISASI. He is a retired Delta Investigation for 15 years and as an ISASI mem- tor. After leaving the military, he spent some 20 pilot and a former U.S. Air Force pilot with ber has presented many papers to ISASI semi- years as a helicopter air ambulance pilot, safety some 26,000 flight hours. Stone also was a manager, base manager, and regional manager nars. He has a Ph.D. in political economy from for Omniflight Helicopters. Alexander has a B.S. former accident investigator for Delta and the Virginia Tech’s Center for Public Administration from Parks College of Aviation and Aerospace Air Line Pilots Association. He has a B.S. from and Policy Analysis and was an assistant profes- Technology. He is a safety consultant and lectur- the University of Illinois and an M.S. from the sor (adjunct) at the University of Maryland. er for helicopter operations and infrastructure. University of New Hampshire. 4 • October-December 2018 ISASI Forum sheet also included a text field to sum- rates by class of aircraft. However, some marize the narrative for each accident, countries provide only limited public plus multiple fields that identified various access to data on fleets and flight hours problems and potential interventions. in deference to privacy. In addition, where The team of three then reviewed each data is available, countries often summa- accident. The accidents also were divided rize their respective datasets in ways that equally among an additional team of six are not directly comparable. Consequent- volunteers, including five professional ly, summary data in this paper sometimes helicopter pilots and one professional will be presented with variations in the safety analyst, for an independent review number of years addressed, and some and a reality check. In short, each acci- comparisons will include only selected dent was assessed by at least three peo- countries. ple, while most accidents in the dataset Given the size of its system, the U.S. Figure 1. Fatal helicopter accidents in dataset, by country of operator, 2001–2015. were assessed by four people and some by dominates the accident data and other Total 672. five people. data among the eight countries. Figure The data captured 672 fatal accidents 1 shows the distribution of the accident on balance, fatal accidents simply merit from 2001 through 2015 that involved 678 dataset by country. The U.S. accounts for more attention, though we recognize helicopters and 1,308 fatalities. The eight 380 of 672 fatal accidents in the dataset, that we can learn important lessons from countries may not define the experience or 56.5 percent. Nevertheless, the remain- nonfatal accidents as well. Since the of all ISASI member countries, but they ing 292 fatal accidents (43.5 percent) team lacked the resources to search and constitute a dominant share of influence findings and illustrate some analyze fatal accidents in every country, ISASI-wide helicopter fleets and flight differences in national characteristics. we focused on countries with large civil hours and a large share of worldwide op- helicopter systems and those countries erations. Data from FlightGlobal suggests where all or at least most accident reports the eight countries include the world’s Overall trends are easily available online. For practical two largest national helicopter systems Perhaps the most basic measures of reasons, we also limited ourselves to as of 2015 (the U.S. and Canada) plus the helicopter safety are the number of fatal countries where we could read reports fourth, sixth, and seventh largest (Aus- accidents and fatal accident rates. Those in the local language, namely French and tralia, the UK, and France). Combined, numbers show persistent improvement English. The resulting dataset initially FlightGlobal indicates the eight countries over the past decade. Figure 2 shows that included fatal accidents from seven coun- account for 63 percent of the world’s the number of fatal helicopter accidents tries: Australia, Canada, France, New Zea- piston helicopters and 47 percent of its for the eight countries continues to land, South Africa, the UK, and the U.S. turbine fleet, or just more than half of the decrease despite steady growth in fleets Ireland, which added just four fatal hel- total fleet. and flight hours, which Figure 3 (see page icopter accidents over the 15-year study The paper used available data on flight 6) shows for the four countries for which period, was included after searching Irish hours and fleet composition from several adequate data was available (Australia, reports for G-registered helicopters. The countries to place a sense of scale on fatal Canada, New Zealand, and the U.S.). study excluded amateur-built helicopters, accident rates, including fatal accident Given the combined size of these national gyrocopters, and military operations. The team consisted primarily of three members who relied mostly on official accident reports from the eight countries. However, to ensure that the search was as complete as possible, the team also reviewed the World Aircraft Accident Summary and several popular websites, particularly the Aviation Safety Network, to add information on any fatal accidents that did not appear on official sites or for accidents for which only cryptic sum- maries were available. Press reports also were searched in some of the more recent accidents to augment basic information on accidents for which only preliminary reports were available. Information on each accident then was summarized in an Excel file that identified typical data fields, such as date, location, make-model, fatalities, serious Figure 2. Fatal helicopter accidents 2001–2015, eight states in study and subset of 4 injuries, basic weather, etc. The spread- states with adequate data on fleet or hours.

October-December 2018 ISASI Forum • 5 Eight South New Country Class Ireland France Africa UK Canada Zealand Australia U.S. Total Piston 40.6 36.5 58.4 38.4 24.8 45.1 58.2 31.3 36.1

1-E Turbine 19.8 39.0 34.4 25.7 60.2 46.4 27.7 51.3 47.7

2-E Turbine 39.6 24.5 7.2 35.9 15.0 8.5 14.1 17.4 16.2

Turbine Sub-Tot 59.4 63.5 41.6 61.6 75.2 54.9 41.8 68.7 63.9

Total Fleet Size 32 853 969 1,076 2,303 844 1,862 9,851 17,990

Table 1 Distribution in Percent of Active National Fleets, by Helicopter Class, 2015 systems, they are assumed to indicate between classes of helicopters and the Disparities in accident rates among trends among all eight countries. From persistence of several age-old and funda- classes of helicopters are affected by 2001 to 2015, the helicopter fleet in the mental factors among the fatal accidents multiple factors, such as differences in four countries increased by two-thirds that we continue to see. For example, the percentage of hours flown in day- while flight hours increased by 54 per- piston-powered helicopters account light or at night, differences in the mix cent. for 40 percent of the fatal accidents in of missions, broad variations in pilots’ With a steady increase in flight hours our eight-country dataset though they skills and experience, plus differences in and a steady decrease in fatal accidents, account for less than 25 percent of flight helicopters’ instrumentation and gener- the result is straightforward: the fatal hours. Data for 2006 through 2015 (10 al capabilities. However, since fleet mix accident rate for those four countries, years) from the U.S. suggests that pis- can vary significantly between countries, and by extension all eight countries, has ton-powered helicopters continue to have disparities in accident rates by class can improved dramatically over the past 15 a fatal accident rate that is twice the rate inflate or deflate a country’s overall fatal years, as shown in Figure 4. For decades for turbine helicopters (1.16 vs. 0.59 fatal accident rate. Table 1 shows the distribu- the fatal accident rate for helicopters had accidents per 100,000 hours). Similarly, tion of national fleets by class of helicop- been considerably higher than the rate the fatal accident rate for single-engine ter in 2015 while Figure 5 (see page 8) for fixed-wing aircraft in general aviation, turbines is nearly twice the rate for shows the distribution of fatal accidents at least as measured by flight hours. This twin turbines (0.66 vs. 0.35). Data from by class of helicopter in seven coun- is no longer true as fatal accident rates Australia and New Zealand appears to be tries (Ireland is excluded due to its very in helicopters, measured by flight hours, consistent with U.S. data, though a direct small fleet). In four countries (Australia, now are well below fixed-wing rates. comparison by type of powerplant is pre- Ireland, New Zealand, and South Africa), Again, this is a good story to tell, but cluded by slight differences in the manner piston helicopters account for half of the good overall trends obscure impor- in which the three countries organize the combined fleet, but they account for tant differences in fatal accident rates their published data on flight hours. two-thirds of all fatal accidents. Among the other four countries, piston-powered helicopters account for just 26 percent of the combined fleet and one-third of fatal accidents. Estimates for piston fleets and the sum of turbine fleets are based on data from FlightGlobal. The sum of turbine fleets from FlightGlobal then was split between single-engine turbines and twin turbines based on national data from Rotorspot. Due to limitations on data for flight hours, we were able to estimate long- term fatal accident rates for just four of the eight countries (Australia, New Zealand, Canada, and the U.S.). Those four countries indicate that a country’s fatal accident rate increases as the share of piston helicopters in the fleet increas- Figure 3. Trends in helicopter fleet and flight hours, Austria, Canada, New Zealand, and the es. In Australia and New Zealand, where United States (hours in million, fleet in thousand). piston-powered helicopters account for 6 • October-December 2018 ISASI Forum half of the fleet, the combined 15-year fatal accident rate was about 1.15 fatal accidents per 100,000 flight hours compared to a rate of about 0.84 in Canada and the U.S., where piston-powered helicopters account for just a quarter of the fleet. Consequently, to gain an accurate sense of how any single country’s fatal accident rate compares to other countries, rates need to be weighted by fleet composition.

Night VFR Despite the substantial improvement in fatal accident rates and absolute numbers, we found many of the fatal accidents that continue to occur involve truly basic factors. For example, flying under visual flight rules (VFR) at night or flying VFR Figure 4. Fatal accident rate trend line: Austraila, Canada, New Zealand, and the United in instrument meteorological conditions States, 2001–2015. (IMC, weather) obviously increases risk and mostly for the same reason: visual to piston-powered helicopters, a greater at accident sites is prohibited at night. flight assumes we can rely on vision to fly share of helicopters that are VFR-capable, A second significant difference in the safely, but we simply cannot see properly more pilots who are IFR-capable, differ- number of night VFR accidents in the U.S. when flying in darkness or in weather. ences in average pilot experience or train- is the prevalence of emergency medical IMC, of course, can introduce multiple ing, the presence of standard operating services (EMS)-related helicopters among issues, and the capacity to see properly is procedures (SOPs), etc. those accidents. Of 134 night VFR acci- certainly one of them. Overall, 20 percent of fatal accidents dents among the eight countries, 45 (33.5 We recognize that pilots can fly VFR in our dataset involved VFR at night, but percent) are related to EMS. This includes safely at night, and many pilots do so with some differences among countries. flying to and from accident sites and regularly throughout the world. Never- The highest percentage was in the U.S., hospitals, plus one training flight and one theless, risk increases at night, and it where 24.7 percent of fatal accidents test flight. Of those 45 accidents involving increases a lot. Overall, U.S. data suggests occurred under night VFR. Night flying in VFR at night, the U.S. accounted for 41. that the fatal accident rate for helicopters Australia and the U.K. accounted for 19 All 41 were single-pilot flights while most is 72 percent higher than when flying in and 18 percent, respectively, and 14 per- countries require two pilots at night or day VFR. However, even at 72 percent cent in Canada. Night flying accounted at all times. They also typically operate higher, this aggregated rate understates for a more modest share of fatal accidents twin-engine helicopters and may impose the added risk of flying at night because in South Africa and France, with 12.5 and other restrictions on night operations, as daytime and nighttime flying involves 11.4 percent, respectively. In contrast, of in South Africa where the Health Ministry very different mixes of fleets, missions, New Zealand’s 36 fatal accidents in our prohibits night landings by EMS helicop- etc. When we compare like aircraft to dataset, just two (5.6 percent) involved ters at accident sites. like aircraft, the increased risk associated VFR at night compared to 94 of 380 fatal Several types of interventions might with night VFR becomes clearer. accidents in the U.S. If prorated by total reduce the overall number of night VFR For piston-powered helicopters, the fleet size, per FlightGlobal data, no other accidents in all flight missions. Outreach fatal accident rate is three times greater country in our dataset challenges U.S. may be the easiest and also the most for night VFR compared to day VFR (2.9 accident numbers involving night VFR. difficult of these interventions. It could be vs. 1.0 per 100,000 hours). Piston-powered The difference starts with national easy because the message is simple: avoid helicopters account for just more than regulatory philosophy. For example, as in or at least minimize exposure to VFR at 29 percent of night VFR fatal accidents many countries, pilots in New Zealand night unless you have proper training and in the U.S. for the 15-year study period, must be authorized to fly VFR at night experience. However, if this were simple, though they account for just 11.7 percent and must operate IFR-capable aircraft the issue would have been resolved in of all night hours compared to 27 percent when doing so. Neither is required in aviation decades ago. The difficulties of daytime hours. For turbine helicopters, the U.S., where the numbers are highest, include at least two basic challenges. which account for more than 88 percent though the U.S. requires a small number First, reaching private pilots and small of all night hours, night rates are “only” of flight hours at night to earn a private operators in a meaningful way is difficult. 66 percent higher—but this, too, is a sub- license. In addition, many flight missions Journal articles and outreach efforts help, stantial increase. This somewhat lower in New Zealand and elsewhere, such as as do efforts by manufacturers, but the disparity for turbine helicopters likely emergency medical services, require two message must be communicated widely reflects a greater share of professional pi- pilots and operate in twin-engine turbine and repeatedly to be effective. Second, lots operating turbines at night compared helicopters, or as in South Africa, landing the message that VFR at night involves a October-December 2018 ISASI Forum • 7 threefold increase in risk must be stated clearly but somehow without sounding like a parental message reminding our children to be careful. Again, this is far more difficult than it sounds. Otherwise the problem would have been solved decades ago. Establishing good SOPs, adhering to them, and training to them would be more promising, along with good risk-management programs. And data-monitoring or nonpunitive safety reporting program both could go a long way. However, as a practical matter, these approaches may be more feasible for operators that enjoy some degree of critical mass and who in fact have people who know how to interpret the data. Reach- Figure 5. Percent distribution of fatal helicopter accidents, by country and class of ing private pilots and small commercial helicopter, 2001–2015. operators is more difficult. They can be reached, but perhaps not as easily. since nearly 8 percent of cases involve private or personal flying. However, at A third option involves a dreaded word both factors. Yet a meaningful compar- the extreme, flying VFR into IMC can be in some circles: regulation. Depending ison of fatal helicopter accident rates the product of a simple failure to obtain on national experiences with night VFR while flying in IMC vs. VMC is impossible. weather. accident rates and depending on their Though 14 percent of fatal helicopter Perhaps a more common issue is current regulatory requirements, regula- accidents in the U.S. and 16.2 percent of inadvertent VFR into IMC despite proper tors could consider at least the following: the fatal helicopter accidents in the eight preflight planning, obtaining weather require a night VFR rating, limit night countries occurred while flying VFR in reports, etc. This reflects the absence of VFR to IFR-capable helicopters and/or to IMC, pilots report zero VFR hours in IMC, an enroute weather system. Only ground IFR-qualified pilots, and perhaps require even in anonymous surveys. The result level sites report weather, but the weather two-pilot crews for certain commercial is that 14 to 16 percent of fatal accidents at 500 or 1,000 feet is not reported. An activities at night. All these options likely apparently occur when nobody is flying. “enhancement” that reports clouds or low would be opposed by many operators How does that work? visibility directly in front of the helicopter who would be newly affected, but they Figure 6 shows the share of fatal could help to avoid these events. need to be considered where they do not accidents, by country, that involve VFR The risk of inadvertent VFR into IMC already exist. in IMC and VFR at night. The figure is especially difficult at night, when the indicates that VFR into IMC is a more helicopter pilot must watch for clouds VFR into IMC significant issue in some countries than while flying in inherently low-visibility At nearly 20 percent of our accident set, in others, with the UK at the top of the conditions, i.e., darkness. If the single the high proportion of accidents that list (31 percent) followed by France (25 pilot in this scenario also lacks recent or occurs at night may be the most startling percent) and Canada (20 percent), with any instrument experience, and is operat- fact in our review of the accident data. the U.S. near the norm. However, the ing with minimum instrument panel, that Even when driving an automobile, we rec- mix of accident categories involving VFR pilot can quickly get into trouble. Other ognize that the entire visual scene outside into IMC is consistent among the eight common manifestations involve inade- the vehicle is suppressed, while the inside countries. Predictably, LOC and CFIT or quate fuel planning, flying with known is muted, all of which slows our detection into obstacles account for more than 90 maintenance issues, weight and balance, of and response to our surroundings. If percent of cases. inadequate fuel supply, and conscious we were to add weather to this equation, VFR into IMC involves both a lack of risk taking—including inappropriate “no- drivers immediately recognize the added preflight planning and risk. A lack of pre- go” decisions in weather or with known difficulty of driving at night in fog, rain, flight planning or proper risk assessment mechanical problems. Complicating all or heavy storms. Now add the dimension in turn can reflect self-imposed pressure these issues is the near absence of nav- of altitude and the inability to simply pull to perform a mission, or continuing to igational aids at lower altitudes, where off the road, and even the nonaviation press ahead even as a pilot recognizes helicopters earn their keep. world can begin to sense the increased that weather is deteriorating. This per- Technology obviously can contribute. challenges. haps is most common with EMS missions, We might start with the development VFR into IMC continues to influence but it also is present in other flight activ- of an onboard device that detects low just more than 16 percent of fatal acci- ities, such as some air taxi operations or visibility or clouds. Similarly, the devel- dents. The data on VFR at night and VFR other commercial activities, and it helps opment of a low-level IFR system could into IMC includes some double counting, to explain more than a few accidents in prove to be a major enhancement. To 8 • October-December 2018 ISASI Forum these we can add greater access to cur- These numbers include 26 accidents the prevalence of system and component rent weather information and ensuring that checked both boxes: VFR at night failures, particularly maintenance that that helicopters have enough instrumen- into IMC. Four other fatal LOC accidents was not performed plus several in-flight tation to enable a 180-turn when VFR involved IFR flight in IMC, three of which breakups due to structural fatigue. The pilots find themselves inadvertently in were at night. nature of the operations also can invite IMC. The 31 percent of LOC accidents that extra risk from foregoing prudent cabin Training on how to escape IMC also involved VFR at night or VFR in IMC, or safety practices. For example, doors often has a place here, though with the caveat both, suggests weaknesses in preflight are removed on the pilot’s side to ensure that one-off training (a singular or limited planning, go/no-go decisions, and per- the ability to monitor long lines and the training) efforts have little to no effect. haps a failure to recognize just how dra- like, and shoulder harnesses often are not To be effective, such training must be matically risk increases when flying VFR used to give pilots upper-body flexibility repeated and, where appropriate, reflect in those conditions. Those failures also to perform the same monitoring. The an operator’s SOPs and risk-assessment involve more than pilots; they also involve result is that pilots can be exposed to criteria. Pilots acknowledge that de- management and dispatch practices in needlessly severe injuries. pendable IFR skills are perishable, which various types of organizations. Other accidents involving system-com- makes currency of experience important. Yet two-thirds of all fatal LOC accidents ponent failures include the full range of Finally, regulators also could help via involve neither IMC nor VFR at night. maintenance issues, from issues relat- more surveillance of operators’ SOPs or LOC is more complex than these two ed to production or premature failure assistance in the development of SOPs factors because it captures such a variety and various maintenance errors. Again, and risk-assessment programs. of factors and flight missions. The variety though, the more frequent issue is a sim- Reducing these accidents must rely of missions is significant here. Many ple failure to obtain proper maintenance. on establishing, adhering to, and train- missions invite LOC accidents due to In short, maintenance organizations and ing to good SOPs and risk-assessment frequent and abrupt maneuvers from low managers also can benefit from adopting programs, with particular emphasis on altitude and perhaps from relatively slow internal reporting programs and by devel- currency of experience, preflight planning speeds, as in surveillance flights, herding, oping and enforcing good SOPs. and go/no-go decision-making. More law enforcement, aerial application, and The fleet mix in LOC accidents also broadly based SMS programs and nonpu- more. Of the 316 LOC accidents, EMS may be telling. Of the 316 helicopters nitive or confidential reporting programs accounted for 31 while instruction/train- involved, 138 (44 percent) were light pis- also need to be part of the effort. Again, ing accounted for 40 (of 62 instructional ton-powered helicopters. This compares though, this approach faces challenges flights in our dataset). to just 25 percent of flight hours attribut- trying to reach private pilots and small LOC also captures a high concentra- able to reciprocating helicopters. Part of operators. Even small operators, of tion of fatal accidents involving heavy lift this disproportionate share of accidents course, can benefit from such programs, and other work (44 of a total 70). Many reflects the common use of these helicop- but they may lack the necessary manage- of these events involved the inherent ters for instruction—33 of the 138 recip- ment capacity. challenges to any pilot during these op- rocating helicopters involved in LOC were erations, including long-line operations, on instructional flights. In contrast, just 7 LOC and CFIT with ground support playing a role. In of 178 turbine helicopters involved were By far, the most common and the most addition to LOC, the remaining common operating instructional or training flights. lethal fatal accidents are LOC and CFIT, factor in heavy-lift and work accidents is Nevertheless, low-rotor RPM continues to which may or may not include wire strikes, depending on definition (not included here). LOC and CFIT are strongly influenced by several common factors, such as VFR at night and VFR into IMC, and they both should be affected by several common interventions. Consequently, possible interventions will be discussed jointly.

LOC accidents Regardless of how one defines LOC accidents, they easily constitute the largest single category of fatal accidents, as noted by all the industry-government working groups. By our count, LOC accounted for 316 fatal accidents in our dataset (47 percent). Of the 316 accidents, 72 involved night VFR (23 percent) and Figure 6. Percent of fatal helicopter accidents VFR in ICM and VFR night, by country of 52 (16.6 percent) involved VFR into IMC. operator. October-December 2018 ISASI Forum • 9 be an issue among these accidents, as are tions during low-level flight operations tion. At 3 percent of our accidents, this is mast bumping and carburetor icing. in confined spaces and various work a small but not a trivial share, and several The U.S. National Transportation Safety operations. more cases likely occurred but were not Board (NTSB) has noted multiple times or could not be documented. in accident reports that low-rotor RPM Wire strikes In several of the 20 cases, employers often is the result of a simple failure to Independent of CFIT accidents, we also could have or should have detected prob- maintain power. Similarly, the Australian identified 81 fatal wire strikes, or 12 per- lems. The two most obvious examples in- Transportation Safety Bureau and the UK cent of the fatal accidents in the dataset. volved alcohol. In one case, a pilot’s blood Air Accidents Investigation Branch both These accidents are concentrated in three alcohol content (BAC) was reported at have noted in several accident reports countries. In South Africa, 20 percent 0.153 percent. Performance, of course, that the issue remains too common, espe- of all fatal helicopter accidents involve deteriorates with just a single drink, but cially in light-piston helicopters. wires strikes, with Australia close behind we begin to meet common definitions of Piloting skill and knowledge, or at least at 19 percent, followed by the U.S. at 14 “drunk” by 0.08 percent. At 0.153 percent, pilot performance on accident flights, are percent. In contrast, wire strikes account this pilot would have been visibly drunk. perhaps the most obvious issues in all for just 5 percent of fatal accidents in A second example involved a pilot who LOC accidents, including a failure to re- New Zealand and Canada, while the UK crashed after losing control at 0900 in the spond properly to manageable problems had no fatal wire strikes in the 15-year morning and was found to have a BAC or failure to execute a proper autoro- dataset. of 0.08 percent—at 0900. He had report- tation when a successful autorotation Just more than half of these accidents ed for duty earlier that morning after was possible. In some cases, it is poorly involved missions that inherently require drinking wine “late into the night...with designed infrastructure, e.g., the heliport low-level flight, including agricultural colleagues” on the operator’s premises appears to have been a factor leading to a operations, mustering/herding, observa- then was paired with a copilot who was pilot’s loss of control. By our count, up to tion/surveillance, search and rescue, and not qualified on the aircraft. 47 of the 316 fatal accidents (7 percent), some lift operations. Private or personal In either case, a random alcohol test- not all of which were scored as LOC, may flights accounted for 22 of the 81 (27 per- ing regime likely could have identified have been averted by earlier entry into cent), followed by training/instruction as problems with both pilots well before the autorotation or if the autorotation were a distant third-most-common mission. accidents or a comment from a cowork- executed properly. This excludes cases in Night VFR was less of an issue in wire er could have prevented the accidents. which successful autorotations were not strikes than in many accident categories. However, preventive action is more dif- feasible due to the absence of safe landing Night VFR accounted for just seven of the ficult with private pilots flying their own areas or due to insufficient altitude when 81 accidents, or 8.6 percent compared to aircraft. the need to autorotate developed. 21.5 percent of all other accident cate- We also identified 28 other fatal gories. Significantly, though, of the seven accidents in which behavior often was CFIT accidents night VFR wire strikes, just one involved a egregiously irresponsible or at least invited a reaction of “what was he thinking?” We identified 118 fatal CFIT accidents in mission that inherently requires low-level Several of them involved buzzing and the 15-year dataset, or 17.5 percent of our flying (police action). ostentatious display, including the classic dataset. This includes high or flat terrain, Preflight preparation was a common “watch this.” A few more such cases may water, and obstacles but excludes wire issue in wire strikes, as was a failure to have occurred but with no survivors to strikes. Of those 118 fatal accidents, a follow planned routes. In-flight deci- describe the events. Some of the pilots large majority occurred while flying VFR sion-making also was a significant factor involved in these examples, like the two in IMC or VFR at night, or both. Just two in wire strikes during private flying and alcohol examples noted above, very likely of the 118 involved IFR operations (both training. Some of these accidents includ- would have been flagged by their com- in IMC, one day and one night), and one ed rather brazen behavior that involved mercial operators if those operators had involved a GPS flight in day IMC. Of the flying at very low altitudes. data monitoring or other internal report- 118 accidents, 53 involved VFR in IMC (45 Technology could help to reduce these ing programs. percent), while 45 (38 percent) involved accidents. Wire strike prevention systems Other examples include various catego- VFR at night. However, rather than add- (e.g., wire cutters) might be the most ob- ries of commercial operators knowingly ing up to 98, they in fact add up to “only” vious tool, but other tools would include more use of radio altimeters, alerts based using helicopters that were not airwor- 74, as 24 of the accidents involved both thy, knowingly using a pilot who was VFR at night in IMC. At least 39 of the 74 on preset altitudes, GPS mapping, or other detailed mapping of obstructions. not properly licensed, etc. Finally, the 28 pilots were IFR-rated in helicopters. include several extreme cases of pressing These high percentages illustrate the to get home or to complete a mission. In increased risk when flying VFR at night Behavioral issues short, up to 8 percent of fatal accidents or VFR in weather. When a flight com- In addition to all the above issues, some involved impairment from alcohol or bines the two factors, the increase in risk accidents involve serious behavioral drugs or irresponsible behavior. This may is essentially infinite. The remaining 43 issues. For example, of the 672 accidents be a modest share, but it is not trivial. CFIT accidents that occurred in day VFR in our dataset, 20 reports identified pilots and day VMC were affected by a variety who were impaired by alcohol, medica- Do investigations make a difference? of factors, including impact with obstructions, or illicit drugs, or some combina- The theme of this year’s ISASI seminar

10 • October-December 2018 ISASI Forum asks whether investigations really make Training recommendations to these issues would be especially useful a difference. The short answer is yes. Every safety study seems to include in light-piston helicopters, but the issues Accident and incident investigations doc- suggestions for training. This one is no ex- can apply to turbine helicopters as well. ument facts and allow us to analyze what ception. We recognize the increased costs happened and how and why. The process and time that more training requires, and Line Orientation Flight Training (LOFT), has informed the aviation community for we recognize the limitations of training, the effectiveness of which is well estab- nearly 100 years about interventions that particularly one-off efforts. Nevertheless, lished in the commercial airplane world, could improve safety. In today’s data-rich the accident data suggests that more should be instituted in commercial world, investigations have been the pri- training can help. Below is a list of recom- helicopter operations, including but not mary source for identifying what factors mended targets, starting with some of the limited to EMS and passenger air taxis. we track and analyze from operational more basic targets. It should also be considered by private data. Investigations also continue to be entities that regularly transport their the primary source of documentation for Preflight planning, with particular own employees or contract employees. current efforts to improve helicopter safe- attention to weather, fuel, and known Training scenarios would be based on ty, such as the effort by the U.S. Helicopter mechanical issues, requires more atten- well-documented accidents and should Safety Team. However, two investigative tion in instructional programs, recurrent involve inadvertent entry into IMC, spa- tools could help the investigative process training or review programs, and training tial disorientation, LOC, and CFIT. to improve our understanding and analy- programs operated by larger operators. sis of helicopter accidents. Preflight should be regularly assessed as Require mandatory quarterly instrument First, as the investigation community part of any routine training or as part of training for pilots in certain commercial has recommended for years, digital flight any internal reporting or data-monitoring operations, such as EMS and passen- programs. ger-carrying air taxis, to acquire 1.5 to data recorders (FDRs) need to become 3 hours in high-fidelity simulators or commonplace in helicopters, at least Risk assessment is a close relative to better in actual helicopter flight with a safety in commercial operations. FDRs would preflight planning, with emphasis on pilot. This training should include basic produce data with which to document weather, the substantial increase in risk IFR skills, such as climbs, turns, descent, exactly what happened in most cases. when flying VFR at night, the quality of unusual attitude recovery, and ILS and Voice recorders also would help, even the planned landing zone, pilot pairing GPS approaches. Where special ratings or in single-pilot operations, by capturing in two-pilot crews, etc. Like preflight authorization is required for pilots to fly onboard sounds, but flight recorders are training, risk assessment needs to be a VFR at night, the training could apply to more urgent. This is always a controver- basic element in any routine training as all authorized pilots, albeit with less-de- sial suggestion, primarily due to cost, but well as any data-monitoring and internal manding requirements for private and they would substantially reduce findings reporting program. The ultimate target some small commercial operators. This such as “lost power for unknown reasons” would be to influence go/no-go decisions type of systematic training, rather than a or “lost rotor RPM for unknown reasons.” and in-flight decision-making. one-off effort, could help to reduce both The second and easier tool to imple- LOC and CFIT accidents, but particularly ment would be the development of an How to exit IMC and how to recognize LOC accidents. investigator’s checklist designed explicitly signs of deteriorating weather could help for helicopter accidents. Investigations to address the high share of fatal acci- Upset training should be added to training often are undertaken with an airplane dents that involve IMC in all categories of programs that use high-fidelity simula- frame of reference, and more than a few helicopter operations. tors. Again, as a systematic effort, such issues that are unique to helicopters can training could help to reduce LOC acci- be overlooked. A checklist specifically Proper autorotations, including the early dents, many of which appear to involve designed to address the idiosyncrasies recognition of when an autorotation is spatial disorientation. of helicopter operations could help to prudent or required, could reduce LOC provide complete information that may accidents, and also a significant number Process recommendations otherwise not be captured in the course of accidents that occur on landing or The aviation safety community has long of an investigation. while responding to manageable in-flight advocated the adoption of several key problems. We recognize that successful processes to reduce accidents through- autorotations sometimes are not feasible out the system. These include at least the Recommended interventions due to an absence of safe landing areas following: We have outlined some opportunities for or due to insufficient altitude when a training and outreach, management pro- problem develops, but about 7 percent Establish and enforce good SOPs and to cesses, and technology. Below is a more of all fatal accidents included a failure train to those SOPs. This clearly is more explicit listing of interventions that we to enter timely autorotations or a failure feasible for larger operations and larger recommend at least for consideration. We to execute them properly. When related maintenance facilities. However, pro- recognize that some face practical barri- factors are included, such as low-rotor grams operated by manufacturers, safety ers, primarily the difficulty of influencing RPM, mast bumping, and low-G maneu- alerts from safety organizations, and actual behavior, while others may face vers, the modest number of 7 percent efforts by various user groups can and pricing barriers and/or political barriers. increases substantially. Note that training do provide assistance to private pilots or

October-December 2018 ISASI Forum • 11 small operators. The central objective of paragraphs target the factors that are initial purchase, the cost of maintenance, all these efforts is straightforward: to the dominant in our dataset, particularly and the need for initial and recurrent degree possible, do it the same way every night flight, weather, LOC, and CFIT. training. Nevertheless they can substan- time. tially increase situational awareness at Helicopter terrain avoidance systems night and could reduce LOC, CFIT, and (HTAWS) Establish nonpunitive reporting systems to have been greatly improved landing accidents. help identify unanticipated or unrecog- since they became available around 2001 nized issues. Again, this may appear more and now are required in EMS operations Onboard color-coded weather displays feasible for larger operators, but, in fact, it in the U.S., where they had already pene- similar to the current computer-gen- is equally pertinent to small operators. trated about 20 percent of the EMS fleet erated online helicopter emergency by 2014. However, HTAWS could prove medical services weather tool provided Establish data-monitoring programs to equally effective in any other helicopter by the Aviation Weather Center could monitor aircraft health and operational operations involved in the movement display color-coded ceiling and visibility consistency. Doing this right requires a of passengers, especially at night, where in the cockpit. This would help to reduce staff that can interpret this data. Again, it could assist pilots who lack external inadvertently flying into IMC, and it this may be more feasible for larger visual clues in low-visibility conditions. would provide intuitive information more organizations, but various programs Cost remains a barrier. Retrofits would rapidly to pilots who may be dealing with operated by manufacturers and some cost about $35,000 per unit. any kind of onboard problem. It would industry groups can enable private pilots negate the need to page through multi- Three-axis autopilots and small operators to benefit from such would enable pilots ple weather reports or listen to multiple programs. to maintain a stable flight path and would AWOS stations, both of which could lead thereby reduce a pilot’s workload and sus- to head-down situations and increased Improve heliport oversight and enforce- ceptibility to spatial disorientation during susceptibility to spatial disorientation. ment to correct and avoid improperly low-visibility operations and during It also would be a valuable tool for pilots designed helicopter infrastructure or recovery maneuvers after inadvertently who must make quick go/no-go decisions improper implementation of aviation entering IMC. This would reduce LOC to or from remote sites. standards, which can create needless risk. at night and during other low-visibility Examples include nonexistent approach conditions. EMS is an obvious candidate, Integrate available weather reporting or departure paths, confined areas that but the equipment would benefit other stations into weather information that require maximum performance capabil- passenger operations as well. Again, cost currently is distributed by civil aviation ities, architecturally induced turbulence, is the primary barrier, with retrofits cost- systems. These systems typically report nearby and on-site obstructions, etc. ing up to $25,000 per unit. weather within a 30-mile radius of an Operators may range from large hospitals aviation weather reporting station, An onboard forward-looking device and off-shore energy platforms to resort should which leaves large areas, especially at low hotels or restaurants, and everything in be developed to identify low-visibility altitude, with no reported weather. Yet between. This could be accomplished by conditions ahead or to display narrow countless other weather stations exist more comprehensive regulatory authority spreads between air temperature and that can offer pertinent information if or by a third-party program for heliport dew point at various altitudes. The they were integrated into the standard accreditation administered by insurers device would include a warning to the system of weather dissemination. The in- or industry organizations. Effectiveness pilot when visibility ahead is likely to formation often would not be as compre- obviously would be limited to operations deteriorate with an estimate of distance hensive as official weather systems, but to or from something that qualifies as a in order to inform the pilot’s in-flight some information is far better than no heliport. The objective would be to ensure decision-making. information. This is especially important that proper safety standards are incor- for EMS helicopter operators and some Night-vision goggles (NVGs) porated and then maintained in heliport obviously air taxis that operate in sparsely popu- design and operations. target only accidents that occur in dark- lated areas since they do not normally ness. But by capturing minimal ambient operate from airports where there are light or even limited star light to provide Recommended technology no aviation weather reporting systems an external image, broader use of NVGs available. Instead, they often are required More extensive use of technology could could substantially reduce the 20 percent to operate from rural and remote sites help to continue lowering helicopter acci- of fatal helicopter accidents that occur or hospitals where no aviation weather dent and fatal accident rates, particularly at night. NVGs, of course, have limits, reporting stations within 30 to 60 miles. in larger commercial fleets. Substantial such as minimal effectiveness in absolute gains already have been achieved with darkness or in brightly lit areas, and the tools like FADECs, engine control units, visual field is monocolored, which invites Summary the application of three-axis autopilots, a loss of depth perception. They also can The helicopter community has a good etc. Nevertheless, a broader application feel cumbersome and, depending on the safety story to tell. The fatal accident of technology could substantially reduce version being used, may have a limited rate has improved by 60 percent since the fatal accident rate. Most of the tech- field of view of 40 to 60 degrees. The big- 2003, and the rate continues to improve. nologies recommended in the following gest barriers to greater use are the cost of (Continued on page 30)

12 • October-December 2018 ISASI Forum 2018 Kapustin Scholarship Essay The following article is the first of four essays from the 2018 Kapustin Scholarship winners. The number of scholars selected each year depends upon the amount of money ISASI members ELECTRIC AIR TAXIS AND donate annually to the scholarship fund. Scholarship applica- THE ADAPTATION OF AIR tion forms and additional information can be found on the ISASI SAFETY INVESTIGATORS website at www.isasi.org. Appli- cation and essay deadlines are mid-April of each year.—Editor By Nicolette R. Meyer, Embry–Riddle Aeronautical University

ith extraordinary design a must regarding all aspects of the trade comes extraordinary for air safety investigators, including risk—even with the most the need to accommodate for any new Wproclaimed foolproof and genre of aircraft that may be introduced advanced technology. When the results to the industry. of these risks turn into incidents and In an ever-changing business, follow- accidents, the air safety investigator ing the progression of up-and-coming must be prepared for them. What was companies’ as well as well-established once merely just a concept is slowly companies’ products can set one ahead becoming a reality and making its way of others. Volocopter, a small, privately into our airspace one successful test owned German company established flight at a time: electric vertical takeoff in 2012 with the goal of integrating air Nicolette R. Meyer and landing (VTOL) commuter aircraft, taxi services into the airspace, has been also known as air taxis or urban air contributing to recent innovations. In is a student in the aerospace and transport. Large and small companies 2016, Volocopter received an ultralight occupational safety bachelor of science around the world have taken their fair aircraft flying permit from the German degree program at Embry–Riddle Aer- shot at participating in drone, helicop- office of the European Aviation Safety onautical University in Daytona Beach, ter, and airplane hybrid commerciali- Agency for its Volocopter 2X aircraft, Florida, USA, and currently resides in zation, including Airbus and Volocop- and within the past few years has been Oviedo, Florida. She holds an associ- ter. While some of these companies performing more than 100 test flights— ate of arts degree from the University presume that integrating their hybrid including tests within the United States of Central Florida where she studied aircraft into the national airspace will (Mohr, 2016). Powered by nine “high-ca- aerospace engineering for two years. take years, their progression is unyield- pacity” batteries, 18 drives or rotors are Nicolette previously pursued internships ing. For air safety investigators, there is controlled by a simple joystick aimed with Delta Air Lines as a flight safety no time to fall behind the curve when to reduce the possibility of human error investigations intern and with Lock- heed Martin Space Systems as a safety it comes to understanding how tech- and maximize redundancy of aircraft engineering intern, where she has begun nological advancement can shape their systems (“Our High Flier: The Volocop- obtaining necessary knowledge through role. ter 2X”). experience toward her goal of becoming A study completed by the Interna- Airbus’s A³, which is similar to a safety professional in the aerospace tional Air Transport Association in 2017 Volocopter but on a much larger scale, industry. In her spare time, she enjoys titled “Future of the Airline Industry is in the midst of certifying its electric, playing music on the guitar, clarinet, 2035” states that change can be sudden self-piloted VTOL passenger aircraft, and saxophone; finding various activi- and overwhelming or gradual and Vahana. Much like the Volocopter 2X, ties to do outside; and traveling to places unnoticed; in either case, the result can Vahana is fully powered by electricity, she has never been. Nicolette is currently be hard to manage—and sometimes but with more of an emphasis on being working toward finishing her last year fatal—for organizations not actively fully autonomous and being equipped of coursework to achieve a bachelor of science degree in aerospace and occupa- preparing for it. The qualities of being with sense-and-avoid technology to fur- tional safety. flexible and able to adapt to change are ther prove its worthiness of being safe October-December 2018 ISASI Forum • 13 2018 Kapustin Scholarship Essay

enough to double as urban transportation terns at any airport, heliport, or seaplane es while the demand for safety profession- (“A³ by Airbus Group”). With new technol- base” (Code of Federal Regulations–Title als increases. ogy comes new practices and processes 14 Part 107.43). On face value, this regula- In a future that companies such as Vo- of manufacture, operation, regulation, tion appears to be of good intent, but it’s locopter and Airbus’s A^3 are envisioning, and maintenance, and this is bound to only effective when followed by the target these electric autonomous VTOL aircraft have an impact on the aviation industry, audience. are entirely replacing the on-land com- not to mention the role of the air safety On July 2, 2017, a pilot in a Bombardier mute to get to increasingly popular desti- investigator. CRJ900 on final approach into John F. nations. In translation, these autonomous For air safety investigators, the birth Kennedy International Airport (JFK) in aircraft could very well be flying over of these aircraft means understanding Queens, New York, USA, reported observ- thousands of people in vehicles on high- machines with an entirely new method ing a three-foot-wide UAS directly off to ways hundreds of feet below. Although the of flying. Incorporating systems un- the left side of the aircraft at the same intent is always to create the most failsafe common to manned aircraft, such as altitude of 1,200 feet (“Reported UAS technology and operations, every new automated sense-and-avoid technology Sightings [July 2017–September 2017],” idea has kinks that need to be worked out. currently found in ground vehicles and 2017). The pilot reported the UAS sighting And they aren’t always worked out during small unmanned aircraft systems (UAS), and proceeded to land uneventfully at the testing phase, further emphasizing requires investigators to have an even JFK. The implementation of regulations the need for air safety investigators. better understanding of how they operate. that prohibit operating UAS in the vicinity The increase in automation in these Although air safety investigators will still of airports didn’t prevent this incident electric aircraft with a goal to eventually reach out to subject-matter experts (SME) from happening, and a matter of feet become fully automated to reduce the and SMEs will still maintain their role and could have made the outcome of this chance of human error may not com- importance in an investigation, the areas occurrence much, much worse. pletely be the asset it’s advertised to be. of expertise among SMEs could expand— The coexistence of piloted and pilotless Flight controls in the form of a joystick, or possibly contract—in the future. For aircraft has already created a risk with- or 18 propellers, or eight backup batteries instance, with the rise of electric-powered in itself. Even with heavy regulations to can sound appealing and quite convinc- aircraft, SMEs with a focus in high-capaci- further operate larger UAS/drone-like ing to an audience, but consider the sce- ty batteries and software-driven technolo- aircraft in the airspace, the regulations nario where all eight innovative and new gies could become much more prominent may be broken whether intentional or batteries of the same make and model are in investigations than SMEs well versed in not. This is the type of change that in recalled due to fire hazard unbeknownst the “ins” and “outs” of weekender Cess- the worst-case scenarios could be fatal. to the operator. The occupant behind na 172 Lycoming O-360 engines or any With ever-increasing numbers of manned the joystick in the automated air taxi has leisure aircraft engine. drone-like vehicles entering the airspace never had a day of flight training in his or More so in the near future rises an with commercial jets, the need for air her life and is now put into a position over advancement of a similar caliber: in- safety investigators will be crucial. a traffic jam on a four-lane highway. tegration of UAS into airspace more The responsibility of an air safety inves- Comparable to many new discoveries populated than ever before. Given that tigator is to prevent similar incidents and that occur with any technology, until we’re years from incorporating manned, accidents from happening again in the something malfunctions, it can some- car-sized aircraft into the airspace for future by producing recommendations times be close to impossible to predict urban transportation use, integrating on how to improve current conditions. with the given resources. To illustrate, in small UAS through strict regulations is But when innovation constantly drives 1944 the British government requested the first step toward making the former change in this new age, it’s vital to adapt airplane manufacturers to begin drafting a reality. The Code of Federal Regulations to make valuable recommendations. Air designs for passenger jet airliners. Five Title 14, Federal Aviation Regulations Part safety investigators could potentially be years later, the de Havilland Comet was 107.43, states, “No person may operate a in high demand as the market for electric constructed and test flights compris- small unmanned aircraft in a manner that autonomous VTOL aircraft expands. Im- ing long-distance trips ensued from the interferes with operations and traffic pat- agine an era where pilot demand decreas- United Kingdom to Italy, South Africa, 14 • October-December 2018 ISASI Forum References

1. A³ by Airbus Group. (n.d.). Retrieved from https://www.airbus-sv.com/projects/1.

2. Code of Federal Regulations- Title 14 Part 107.43. (n.d.). Retrieved from https://www.ecfr.gov/cgi-bin/text idx- Singapore, and Egypt; all succeeded with ?SID=773424e9ce2406b6df4e627c78ecf- flying colors (“de Havilland Comet,” 2009). 1ca&mc=true&node=pt14.2.107&rgn=- In the following years, three Comets div5#se14.2.107_143. crashed, and all Comets were grounded as an investigation ensued. As the cause 3. De Havilland Comet. (2009). In Flight and of each accident remained unknown, Motion: The History and Science of Flying modifications were made to address any possible cause of failure, including flutter (Vol. 2, pp. 202–205). Armonk, NY: M.E. of control surfaces, primary structural Sharpe. Retrieved from http://go.galegroup. failure due to gusts, flying controls, explo- com.ezproxy.libproxy.db.erau.edu/ps/i. sive decompression, engine fire, failure of do?p=GVRL&u=embry&id=GALE|CX- a turbine blade, and fatigue of the wing 1969400061&v=2.1&it=r&sid=summon. (Federal Aviation Administration). When yet another Comet crashed after these 4. Federal Aviation Administration. (n.d.). De modifications, investigators resorted to Havilland Comet DH-106 Comet 1. Retrieved performing more than 1,000 full-scale from http://lessonslearned.faa.gov/ll_main. pressure tests on Comet fuselages by cfm?TabID=1&LLID=28&LLTypeID=2. submerging them in water tanks until the pressure inside was equivalent to that in 5. Future of the Airline Industry 2035 flight. The culprit was revealed to be the fuse- [Scholarly project]. (2017). In International lage failing at a corner of a square-shaped Air Transport Association. Retrieved from escape hatch window, and the concept of https://www.iata.org/policy/Documents/ia- structural fatigue was exposed. Although ta-future-airline-industry.pdf. the point could be made that this accident occurred nearly 80 years ago and 6. Mohr, K. (2016, April). Volocopter is flying aircraft manufacturing and testing have manned! Retrieved from https://press. come a long way, the main idea that not volocopter.com/index.php/volocopter-is-fly- all imperfect components can be caught ing-manned. in the testing phase of a new design remains. 7. Our High Flier: The Volocopter 2X. (n.d.). With time, money, and new technology, Retrieved from https://www.volocopter.com/ kinks will be worked out. Air safety investigators will be alongside the brains en/product. that created these innovative machineries to provide a safe atmosphere for an 8. Reported UAS Sightings (July 2017-Sep- ever-changing industry; but until then, tember 2017) [XLSX]. (2017, December preparing for the expected is key. The 11). Federal Aviation Administration. electric VTOL commuter aircraft companies around the world, both large and small, have demonstrated that they’re taking no yield to sprint toward innovations of the future, and air safety investigators must be proactive and educate themselves with the vision of safe advancement alike. October-December 2018 ISASI Forum • 15 Passenger Brace Position in Aircraft Accident Investigations

By Jan M Davies, Professor, University of Calgary; Martin Maurino, Technical Officer, Safety, Efficiency, and Operations, International Civil Aviation Organization; and Jenny Yoo, Advisor to the Korea Aviation and Railway Accident Investigation Board and Cabin Safety Analysis Group Chair, Korea Transportation Safety Authority, on behalf of the members of IBRACE.

(Adapted with permission from the authors’ tion on brace positions. Therefore, ICAO were also developed and are discussed technical paper titled The Passenger Brace formed the Ad Hoc Group on Brace later in this paper. Position in Aircraft Accident Investigation Position, inviting the subject-matter ex- IBRACE members also developed presented during ISASI 2017, Aug. 22–24, perts and other stakeholders to carry out 2017, in San Diego, California, USA. The and had posted the IBRACE Wikipage theme for ISASI 2017 was “Do Safety further work about recommended brace (https://en.wikipedia.org/wiki/Interna- Investigations Make a Difference?” The full positions as a sub-group of the ICSG. In tional_Board_for_Research_into_Air- presentation can be found on the ISASI web- November 2016, 13 experts met at the craft_Crash_Events). In addition, site at www.isasi.org in the Library tab under Royal College of Physicians in London, searches have been initiated for funding Technical Presentations.—Editor) England, to advance the work of the and for research student(s). IBRACE group. is a not-for-profit board and has been he International Civil Aviation During discussions, members noted self-funding to date. It’s vital that fund- Organization (ICAO) called the need to raise funds to support further ing be found to support ongoing board upon subject-matter experts in research into the brace position, particu- activities and for research endeavors. Tthe field of “brace-for-impact” larly for sled-impact tests. To fulfil this positions to provide their advice to the expanded mandate, members agreed to Question posed and aim of study ninth meeting of the ICAO Cabin Safety establish an independent group. Thus, The theme of the 48th ISASI seminar Group (ICSG/9) held in April 2016. The the International Board for Research was “Do Safety Investigations Make a ICSG/9 had the task of developing a into Aircraft Crash Events (IBRACE) was Difference?” Overall there is no doubt new ICAO manual on safety-related founded. The purpose of IBRACE is to that aviation safety has improved in the information and instructions that produce an internationally agreed-upon, 109 years since the first aviation acci- should be transmitted to passengers. evidence-based set of impact bracing dent investigation. But what about pas- This manual includes a chapter on the positions for passengers and (eventually) senger safety related to the passenger brace-for-impact position, common- cabin crewmembers in a variety of seating brace position? What can be learned ly referred to as the brace position. configurations to be submitted to ICAO from accident investigation reports The ICSG required specific expertise through the ICSG. about survival factors, particularly the and conclusions from internationally The 13 founding members brought with passenger brace position? recognized studies in order to develop them a variety of backgrounds and exper- This paper reviews U.S. Federal recommendations. tise, including Aviation Regulations (FAR) Part Representatives from the U.S. Fed- • aviation (cabin safety and accident/ 121 (scheduled air carrier) accident eral Aviation Administration (FAA) incident investigation), reports for 1983 to 2015 to look for Civil Aerospace Medical Institute; the • engineering (sled-impact testing, passenger and cabin crew survival Nottingham, Leicester, Derby, Bel- aerospace materials, lightweight ad- factors related to the emergency brace fast Study Group (which developed vanced-composite structures, and air position. recommendations following the British transport safety and investigation), Midland Airways Flight 92 accident); • clinical medicine (orthopedic trauma and TÜV Rheinland (which developed surgery and anesthesiology), and Methods studies commissioned by the German This study had two parts. Part 1 government) were among the pre- • human factors. involved a review of accident reports senters. Due to the different results To date, the members of IBRACE have for 1983 to 1999, and Part 2 involved a presented by the experts, the ICSG completed many tasks. Most importantly, review of accident reports for 2000 to noted that the studies did not lead to members contributed content and illus- 2015. a single, universal recommendation trations to Chapter 6, “Instructions for A decision was made to use the U.S. about brace positions. Brace Positions,” of the new ICAO Manual National Transportation Safety Board The group concluded further work on Information and Instructions for Pas- (NTSB) report “Survivability of Acci- was needed so that ICAO might senger Safety, First Edition, 2017 (Doc. dents Involving Part 121 U.S. Air Carrier provide a harmonized recommenda- 10086). Two Investigation questionnaires Operations, 1983 through 2000 Safety

16 • October-December 2018 ISASI Forum Report,” NTSB/SR-01/01, as the basis for the initial analysis. The purpose of this NTSB report was to examine occupant survivability, with the twin goals of helping dispel the public’s perception that most accidents are not survivable and identifying factors to improve survivability. Two concepts were defined in the NTSB report: “survivabil- Jan M. Davies ity” and “serious accident.” When talking about cabin safety, has undertaken research in system safety in health care and aviation probably the most basic concept is that of survivability. A since 1983. Starting in the late 1980s, she spent more than a decade useful definition is one published by the NTSB in 2001. The visiting the (former) Bureau of Air Safety Investigation, where she condition of survivability exists when the “forces transmitted and Dr. Rob Lee, the director, codeveloped a systematic method to to occupants through their seat and restraint system cannot investigate anesthetic-related deaths. Together with Jim Reason, she exceed the limits of human tolerance to abrupt accelerations.” and an anesthetic colleague were the first to apply the Reason model In addition, the “structure in the occupant’s immediate envi- to a health-care investigation. In 1996, she finalized development of ronment must remain substantially intact,” so as to provide a the model that underpins an evolution of her systematic, human-factors-based method for system-level investigations, Systematic Systems “livable volume throughout the crash sequence.” Analysis, now a University of Calgary certificate course. Another definition relevant to this paper is that of serious accident. The same NTSB report stated that a serious accident was one in which there was a fire, either precrash or postcrash, at least one serious injury or fatality, and substantial aircraft damage or complete destruction of the craft. Rather than using the ICAO definitions of accidents, serious incident, and survivable crash environment, this definition was used because of the review of NTSB crash reports.

Part 1 (1983–1999) Table 4 in the report provided a list of “fatality and survivor Martin Maurino data, by individual accident, from NTSB investigation records for all Part 121 U.S. passenger flight accidents involving fire, began his aviation career as cabin crewmember with Air Canada. In serious injury, and either substantial airplane damage or 2003, he joined the International Air Transport Association (IATA) as a safety analyst and in 2006 was appointed manager, safety analysis, complete destruction,” for 1983 through 1999. The list of acci- responsible for accident analysis and publication of the annual IATA dents was used to find the corresponding NTSB investigation Safety Report. Maurino went on to join Transport Canada as the civil reports. These reports, where available, were searched manual- aviation program manager, working on implementation of safety man- ly and/or electronically, looking for two terms: “brace position” agement systems, fatigue risk management systems, and human fac- and “recommendations about the brace position.” tors. In 2010, he joined the International Civil Aviation Organization (ICAO), and is the technical officer, safety, efficiency, and operations. Part 2 (2000–2015) He is responsible for all of ICAO’s cabin safety activities and acts as A search was conducted of the NTSB investigation reports secretary to the ICAO Cabin Safety Group. (where available) for Title 14 Code of Federal Regulations Part 121 U.S. passenger flight accidents for 2000 through 2015. As in Part 1, accidents in which suicide or sabotage was (thought to be) involved were excluded from the study. A manual and electronic search was conducted for the same terms as in Part 1. In addition, for all years, 1983–2015, a search was conducted for other accidents, that is, nonserious accidents, using the NTSB definition of serious accident. Again, the same search terms were used: the brace position and/or recommendations about the brace position. Jenny Yoo

Results started as a cabin crewmember for a major international airline, holding various positions, including cabin crew team executive. In With respect to serious accidents, there were 26 between 1983 2001, she earned a certificate in aircraft accident investigation and and 1999, with seven of these classified as nonsurvivable (one prevention from the Southern California Safety Institute. Subsequently or fewer survivors). Between 2000 and 2015, seven accidents Yoo joined the Air China 129 accident investigation (2002) and was were identified, five of which were considered nonsurvivable, the chair of the Survival Factors Group as well as the investigation using the same criteria as above. Of the serious accidents report editor. She is an appointed advisor to the Korea Aviation and between 1983 and 1999, only three of the 26 mentioned the Railway Accident Investigation Board and an appointed Cabin Safety brace position, and there were none in which recommenda- Analysis Group chair of the Korea Transportation Safety Authority. tions about the brace position were made. These three Yoo organized the Korean Society of Air Safety Investigators.

October-December 2018 ISASI Forum • 17 accidents were individually prior to the landing to senger brace position in airplanes with • United Airlines Flight 232 (Sioux ensure that each one knew the emer- nonbreakover seats installed. If the City, Iowa, USA, 1989): Numerous gency procedures that would take research deems it necessary, issue new mentions of the term brace were place and how to properly brace.” guidance material on passenger brace made. The captain “said that there (Section 1.15, Survival Aspects.) positions.” would be the signal ‘brace, brace, • US Airways Flight 1549 (New York brace’ made over the public ad- City, New York, USA, 2009): There are dress system to alert the cabin oc- Discussion “numerous mentions of the brace Definitions cupants to prepare for the landing.” position. slide/raft stowage; passen- Use of the term serious accident was (Page 22, Section 1.11.1, Cockpit ger immersion protection; life line based on the review of accidents listed Voice Recorder.) “All of the flight at- usage; life vest stowage, retrieval, and tendants and passengers were in a donning; preflight safety briefings; in the NTSB report. In that report, the brace-for-impact position when the and passenger education.” safety board reviewers determined that airplane landed.” (Page 40, Section passenger and crew survival was “never 1.15.1, Cabin Preparation.) One of the references to the brace threatened” in the majority of Part 121 position was with respect to the brace • USAir Flight 405 (LaGuardia, New accidents up to the end of 1999. The York, USA, 1992): “Prior to impact, position shown on the safety card. “The safety board therefore focused on the passengers did not assume the airplane had safety information cards “survivability in serious accidents” and brace position.” (Page 33, Section in the passenger seatback pockets that determined that, as with all Part 121 1.15.1.2, The Passengers and Seats.) provided instructions on the operation of accidents, most occupants survived the the emergency exits. A section of the card • American Airlines Flight 1420 “serious survivable accidents” also shows the passenger brace positions. (Little Rock, Arkansas, USA, 1999): There is a difference between this “Passengers also reported that the The brace positions shown on the US Air- NTSB term and definition and the ICAO flight attendants yelled ‘brace’ to ways safety information card were similar terms and definitions. ICAO’s Annex 13 prepare for the impending impact.” to the current FAA guidance on brace po- defines an accident as an “occurrence (Page 54, Section 1.15.4, Passenger sitions, which is contained in AC 121-24C, associated with the operation of an Statements.) Appendix 4, which states, ‘in aircraft with aircraft that, in the case of a manned high-density seating or in cases where Between 2000 and 2015, there were aircraft, takes place between the time passengers are physically limited and no investigation reports of serious acci- any person boards the aircraft with the are unable to place their heads in their dents in which the brace position was intention of flight until such time as all laps, they should position their heads mentioned or recommendations made. such persons have disembarked, or in and arms against the seat (or bulkhead) However, one additional report was the case of an unmanned aircraft, takes in front of them.’ Two female passengers found of an accident (that occurred place between the time the aircraft is who sustained very similar shoulder frac- ready to move with the purpose of flight between 1983 and 1999) not included tures both described assuming similar until such time as it comes to rest at in the NTSB report and in which there brace positions—putting their arms on the end of the flight and the primary was a mention of the passenger brace the seat in front of them and leaning over. propulsion system is shut down,” in position. This was They felt that their injuries were caused • USAir Flight 5050 (LaGuardia, which a person is fatally or seriously during the impact when their arms were New York, USA, 1989): “The flight injured…, the aircraft sustains damage driven back into their shoulders as they attendants immediately reacted or structural failure…, or the aircraft is when they realized that the takeoff were thrown forward into the seats in missing or is completely inaccessible. was deteriorating. As the airplane front of them.” A “serious incident” is defined as an departed the runway’s deck, they The NTSB concluded that “the FAA’s “incident involving circumstances indi- told the passengers to brace.” (Page current recommended brace positions cating that there was a high probability 53, Section 2.12, Survival Factors.) do not take into account newly designed of an accident.” ICAO does not define a There were no recommendations seats that do not have a breakover feature serious accident. about the brace position. and that, in this accident, the FAA-recom- The decision was made to use the For the period between 2000 and mended brace position might have con- NTSB term and definition because of 2015, two accident reports were iden- tributed to the shoulder fractures of two the review of accidents for 1983 to 1999 tified in which there were mentions of passengers. Therefore, the NTSB recom- listed in the NTSB 2001 report. The the brace position. These were mends that the FAA conduct research to same definition was therefore used for • JetBlue Flight 292 (Los Angeles, determine the most beneficial passenger the review of accidents for 2000 to 2015. California, USA, 2005): “Prior to brace position in airplanes with non- touchdown, the captain announced breakover seats installed. If the research Results ‘brace,’ and the flight attendants deems it necessary, issue new guidance Accident investigation findings and also transmitted ‘brace’ over the material on passenger brace positions.” recommendations have helped improve public address system.” (Section A recommendation about the brace aviation safety. In the course of the 1.1, History of Flight.) “The flight position was made. “Conduct research study, it was noted that most investi- attendants spoke to the passengers to determine the most beneficial pas- gation reports make no mention of,

18 • October-December 2018 ISASI Forum IBRACE also aims to contribute to the better understanding of survival factors and thus to develop and implement recommendations about them.

or recommendations about, the brace survival information. imprints on the skin overlying the lower position. However, the authors of the abdomen, iliac crests, greater trochant- NTSB report determined that in serious Additional tools ers, or upper thighs? (yes or no).” accidents for the period 1983–1999, Recently, ICAO released the new Man- These questionnaires have three fatalities related to the impact of the ual on the Investigation of Cabin Safety goals: to assist investigators in their crash were about five times more Aspects in Accidents and Incidents (Doc. findings and recommendations about frequent than fire-related fatalities. 10062). This document includes recom- survival factors, to gather information One implication of this finding is that mendations to ask survivors about such about brace positions, and to assist in more passengers might have survived details as seat belt use and brace position developing evidence-based recommen- had they assumed and maintained an adopted. However, accident investiga- dations for brace positions for passen- appropriate brace position. In addition, tors might find it helpful to have more gers and cabin crewmembers. more can be learned from accident detailed questions. IBRACE therefore investigations that focus on survival developed two new questionnaires: the factors. For example, changes to pas- illustrated Survivors’ Questionnaire and Conclusions senger seating and cabin configurations the Deceased Questionnaire. The review of NTSB reports of 34 influence how passengers brace for The Survivors’ Questionnaire is for accidents, between 1983 and 2015, impact. During the discussion at the completion by survivors, either with or included mention of the brace position latest IBRACE meeting, members noted without assistance from investigators, in five reports and recommendations that it would be impossible to conduct and has 18 questions—most with dia- about the brace position in only one any sled-impact testing in seats with a grams. Two typical questions are “In what report. One of the goals of IBRACE is to 28-inch pitch and using the standard direction did your seat face? (forward or encourage investigators to gather, Hybrid III dummy because it would not backward)” (see Figure 1) and “Did you analyze, and incorporate information fit. assist another person/child? (yes or no)” regarding the brace position in accident Therefore, it is important for inves- (see Figure 2). reports, using standardized question- tigators to look for survival factors, for The Deceased Questionnaire pertains naires. IBRACE also aims to contribute example, an appropriate brace position. to deceased victims, for completion by ac- to the better understanding of survival Currently, sources of information for accident investigators and medical/forensic factors and thus to develop and cident investigators include survivors’ personnel, and has 10 questions but no implement recommendations about testimonies, medical or pathological diagrams. Typical questions include “Was them. This, in turn, should contribute information, and evaluation of various the deceased seated at the time of the to a reduction of passenger and cabin brace positions’ usefulness in surviving accident (yes or no).” “If yes, was the seat crew fatalities and injuries, thus leading an accident. However, accident investi- belt buckled at the time of the accident? to further improvements in aviation gators need additional tools to obtain (yes or no).” “Were there any clothing safety.

Figure 1. In what direction did your seat face? Figure 2. Did you assist another (forward or backward) person/child?

October-December 2018 ISASI Forum • 19 USING DATA TO ASSESS PERFORMANCE OF SAFETY By Nektarios Karanikas, Associate Professor of Safety and Human Factors, MANAGEMENT Aviation Academy, Faculty of Technology, Amsterdam University of Applied Sciences, Amsterdam, the Netherlands

(Adapted with permission from the author’s safety investigations can be used to assess with operational decisions and remedial technical paper titled How Data from Internal safety management’s role, the speed of actions; the principal duty of department Safety Investigations and Processes Can safety communication, the timeliness of managers is to implement solutions for Be Used to Assess Performance of Safety safety investigation processes and real- safety deficiencies. Individuals responsi- Management presented during ISASI 2017, ization of safety recommendations, and Aug. 22–24, 2017, in San Diego, California, ble for affected functional areas must be USA. The theme for ISASI 2017 was “Do Safety the extent of convergence between safety directly involved in the decision-making Investigations Make a Difference?” The full management and investigation teams. process and assigned with the responsibil- presentation can be found on the ISASI website The results of the study suggested an in- ity and accountability for implementing at www.isasi.org in the Library tab under terfering role of the safety department into appropriate corrective actions. As such, Technical Presentations.—Editor) operations, severe delays of internal safety functional directors are actively involved investigations, timely implementation of in safety management and operationalize recommendations, quick dissemination their safety responsibilities in their area. he investigation of serious inci- of investigation reports to employees, and Safety investigations make up a funda- dents and accidents has been a a low ratio of investigation team recom- mental safety management practice, and mandatory safety assurance meth- mendations included in the final safety their contribution to safety assurance are od. The value of such investigations T investigation reports. The findings were highly valuable. The distinct role of safety in learning from the past and improving discussed with safety staff of the organiza- investigations in safety management stems the safety features of our systems is unde- tion who attributed them to nonscalable from the potential to uncover causal and batable. Serious incidents and accidents safety investigation procedures, ineffective contributing factors and present the af- are investigated by independent agencies/ resource management, lack of consistent termaths derived from analyses of factual authorities, and they are typically support- and bidirectional communication, lack of data. High-quality investigations, in terms ed by all stakeholders involved or affected investigators’ awareness about the overall of depth, clarity, punctuality, and objec- who devote resources such as time, staff, organizational context, and a weak com- tivity, along with management support in equipment, facilities, and expertise. mitment of operating departments to the realizing remedial actions, decisively affect However, when it comes to incidents realization of safety recommendations. an organization’s safety culture. that organizations investigate internally, Overall, the specific research demon- Resources allocated to investigations the principle of independence and the strated an alternative way of exploiting determine their extent and depth; as expectation for adequate resources might available data from safety investigation recognized, available resources will curtail not be guaranteed. This might occur par- processes and reports in the context of an some safety investigations. Nonetheless, tially because internal safety investigators internal performance-based evaluation of the formulation of safety recommenda- report to managers of various organiza- safety management. tions is the ultimate goal of safety inves- tional levels, and they are not always posi- tigations. Specific requirements must be tioned in the safety department/office that Expectations from safety management set for safety recommendations: they must reports directly to senior management. Senior management is responsible for be addressed to the most proper opera- That an internal investigation team is defining safety policies and procedures, tional or management level that holds the composed of employees and experts serv- allocating the resources required to authority to make the necessary changes; ing in positions other than safety-related accomplish safety activities, adapting the suggestions must address objectives ones is not unusual. Hence, internal safety best industry practices, and incorporat- instead of specific actions to meet objec- investigators might face challenges in ob- ing regulations of state and international tives; and the recommendations must be serving internal or external investigation authorities and bodies. In a clearly scoped developed following a dialogue among the standards and guidelines and ensuring and mature safety management system, involved parties to avoid unexpected and that the outcomes of their investigations safety personnel should not interfere undesirable denial and resistance to their are of high quality and effective. Further- more, the support of internal investigations, utilization of respective reports, and response to those might indicate the has been an associate professor of safety and human factors at importance that management assigns to the Aviation Academy of the Amsterdam University of Applied internal investigations and reflect the level Sciences since 2014. He holds an MSc in human factors and safety assessment in aeronautics (Cranfield University) and a doctorate in of safety management’s maturity within safety and quality management (Middlesex University). Nektarios the organization. graduated from the Hellenic Air Force Academy as an aeronautical This article presents the main parts of a engineer and served for 18 years in the Hellenic Air Force in various study conducted at a large aviation organi- positions related to maintenance and quality management and zation and demonstrates how quantitative Dr. Nektarios safety investigations. He was also a lecturer and an instructor for and qualitative data related to internal Karanikas safety and human factors courses. 20 • October-December 2018 ISASI Forum implementation. Deviation Also, safety communication is an Maximum Actual Between inextricable part of a well-operated safety Duration Average Investigation Phase Actual and management scheme. Transport Canada Foreseen Duration Maximum combined good communication and effec- (days) tive training with increased probability of a (days) Duration successful safety management. Under this requirement, all organizational levels and Operating Unit (completion of functions must be aware of the strengths investigation team tasks and first 50 119 +138% and weaknesses that affect operational ac- commentary) tivities. Information must not be restricted to safety topics; in a mature organizational Middle-Management Sector culture, employees need to be knowledge- 20 50 +150% able about total organizational perfor- (second commentary) mance and benchmarking results. Inclusive electronic databases should Senior Management allow employees to retrieve information Directorates 20 15 -25% about industry and international stand- (third commentary) ards, organizational plans and their incar- nation progress, operational procedures, Safety Department quality-assurance findings, and remedial (publication of final safety inves- 60 60 0% actions. Specifically, in the context of tigation report) safety investigations, the goal is to keep organizational memories alive, circulate Total Process Time 170 432 +154% aftermaths, and increase risk awareness so that similar negative events can be Table I Duration of Safety Investigation Phases avoided. the results were communicated to seven The combination of the report and Research methodology safety professionals within the AO, and comments constitutes the draft inves- The study was conducted at an aviation or- individual interviews were scheduled to tigation folder. ganization (AO) and explored how it could discuss and explain the findings. The aim • Afterwards, the sector that the opera- use data from safety investigation process- was to combine perspectives from safety tional unit reports to should comment es and reports to develop relevant safety professionals with various roles in the AO. on the investigation folder in 20 days. management performance metrics in All interviewees were experienced safety This additional commentary should addition to measuring incident rates and investigators, and four of them had safety become part of the draft investigation frequencies of contributing/causal factors. management-related positions at the time folder. The AO’s hierarchical structure includes of the interviews. The metrics employed • Next, within 20 days senior direc- senior management, where the safety to evaluate aspects of safety management torates addressed during the safety department resides; three middle-manage- and the results of the quantitative and investigation should add comments to ment sectors, each supported by a safety qualitative analysis are jointly described in the investigation folder. Directorates’ department; and air operations, mainte- the following sections; the reader can refer comments should also supplement nance, logistics, and ground support units, to the full article for further details. the investigation folder. each reporting to a section and running a • After all commentary is collected, the safety office. Metric 1: Duration of safety investiga- safety department should publish the The data used includes the AO’s safety tion phases final investigation report in 60 days. investigation progress records, investiga- Description • Taking into account the timeline re- tion team reports submitted to the AO’s This metric regarded the time elapsed ferred above, along with an allowance safety department, final investigation of 20 days for secretarial procedures, among the several phases of safety inves- reports released after processing investi- the safety department should issue the tigations. A considerable deviation from gation team reports, and recommendation official report no later than 170 days the foreseen deadlines could be attributed logs. The data already existed within the after the date that the safety event to mismanagement or lack of resources occurred. organization but had not been previously in the investigation process or unrealistic used to assess aspects of its safety man- expectations. According to the AO’s safety agement. The sample was provided by the investigation procedures: Results AO’s safety department and covered re- • The investigation team should submit As Table I shows, the organization under ports and records of 810 safety events that its report no later than 50 days after occurred between 2004 and 2014 during the event’s occurrence, accompanied study experienced severe delays in its flights or on the ground. by comments from the operating unit investigation phases at the operating unit Following the analysis of the datasets, involved and/or affected by the event. and middle-management sectors. All October-December 2018 ISASI Forum • 21 interviewees attributed those findings to recommendations stated in the investiga- turn, was ascribed to the lack of a central ineffective resource management at the tion team reports and the ones included data storage system where such infor- aforementioned organizational levels. in the final reports; second, the number mation could be stored and retrieved. Although investigation team members of common recommendations between Additionally, the safety department had should be released from their normal investigation teams and the safety depart- not communicated to the investigators the reasons for the differences between what duties during each safety investigation, ment. According to the AO’s procedures, the recommendations generated by the the investigation teams had suggested and this was not practiced by the managers of investigation teams were not binding and what management adopted, because the the operating units. At the middle-man- were subject to changes, additions, etc., AO lacks relevant procedures. agement sector, the delays were linked based on the comments received by the to understaffing and the requirement sectors and senior directorates and a final Metric 4: Type of recommendations to accomplish a variety of activities in evaluation by the safety department. The Description addition to coordinating the commentary AO provided safety investigation training Taking into consideration that standards of safety investigation folders. Safety staff to staff members who had been already propose a supportive role of safety man- of the operating unit and safety investiga- trained as safety officers and implemented agers and officers in developing remedial tors claimed that the safety investigation the risk-assessment process of the organi- measures, each safety recommendation procedures applied across the whole AO zation as part of their duties. was classified as “assignment,” “action,” were not scalable and flexible enough to According to the AO’s safety investiga- or “reminder,” as explained below. The account for the variety of special condition procedures, investigation teams were frequency of each recommendation type tions in each section and operating unit. expected to formulate recommendations would indicate to what extent the AO’s after evaluating various options, their safety department had been supportive or Metric 2: Timeliness of communication possible effects on operability, side effects interfering in operational managers’ duties of final investigation reports to other organizational functions, asso- concerning generating and implementing ciated costs, etc. This particular metric Description corrective actions. indicated the distance between the inves- The specific metric regarded the time -re tigation teams and the AO’s safety depart- quired for communicating the final inves- Assignment ment in terms of number and resem- tigation report to end users at operating The recommendation stated the objective blance of recommendations. A significant units and departments. The AO distrib- to be achieved, meaning “what” should distance could be attributed to flaws in uted the reports in hard copy format and be fixed. This type of recommendations information sharing among investigation imposed documentation controls to avoid indicated a supportive role of the safety teams and the safety department. This publicizing the investigation reports and department because the latter did not could imply ineffective communication the negative implications on individuals restrict managers in the way they would across the organization. and the organization as a whole. Although tackle the problems revealed during safety the AO had not set a specific timeframe investigations. for the communication of final investiga- Results tion reports, such a metric was consid- The final investigation reports included Action ered as indicative of safety management 48% more recommendations than those The recommendation stated specific performance. formulated by the investigation teams. methods to address a deficiency, thus Also, only 61% of the recommendations minimizing the degree freedom managers Results proposed by the investigation teams were had to devise solutions. This indicated an In average, each report was communicat- stated in the final reports. During discus- interfering role of the safety department. ed to the end users of operating units in sions on this topic, the AO’s safety staff pointed out that safety investigators had 11 days; taking into account secretarial Reminder procedures, communication of final safe- put much effort in their tasks and were highly concerned about the quality and The recommendation referred to an exist- ty investigation reports to the end users ing rule/procedure that was not followed did not show important delays. The AO’s completeness of their reports. However, investigators were not cognizant of the by the employees, and its reinforcement safety personnel stated that the organiza- was suggested. In this case, the role of tion recognized the merit of effective and “big” picture of the organization in terms of complexity and resource constraints. the safety department was perceived as timely communication of investigation supportive since it did not introduce an reports across all organizational levels Moreover, investigators were not able to estimate costs when they were design- action (e.g., how the reinforcement will be to prevent unwanted events through the achieved). aftermaths formulated in such reports. ing recommendations, and they were not aware of any other planned corrective actions that possibly were overlapping with Results Metric 3: Number and resemblance of the remedies proposed by the teams. The The safety department published about recommendations interviewees further noted the findings in 39% action, 22% assignment, and 39% Description the incomplete information investigators reminder recommendations. Safety staff This metric regarded two measurements: had obtained regarding the organization’s of the safety department claimed that first, the difference between the number of plans, initiatives, constraints, etc. This, in although the AO’s procedures described 22 • October-December 2018 ISASI Forum the distinct roles of several functions was calculated for the time allotted by the department and investigators. Although in the safety investigation process and safety department for the realization of the AO was expecting investigators to be generated recommendations, results from each recommendation type. aware of the wider organizational context monitoring the corrective actions showed The AO’s safety staff anticipated the when they were formulating recommen- that those roles had not been practiced. aforementioned results, which suggested dations, the quantitative and qualitative Operating units and/or middle-man- that safety department requested almost differences in generating safety recom- agement sectors had delayed, or even immediate implementation of recommendations were attributed to the lack of unilaterally rejected, corrective actions mendations. The interviewees argued that consistent information sharing between without providing relevant feedback to most of the action-type recommendations senior/middle management and investi- the safety department. Consequently, the regarded easy-to-implement changes (e.g., gators. safety department was concerned that subtle amendment of procedures) and Moreover, the lack of a central informa- the deficiencies revealed through investi- that reminder-type measures required tion system did not support investigators’ gations would not be timely or addressed by default a short implementation time. awareness of the overall organizational at all, and subsequently in many cases the Since action and reminder recommenda- context and led to proposing remedies specific department had undertaken the tions made up 78% of the total number of that were not completely aligned with the role of managers. recommendations published by the AO, plans, constraints and other conditions The rest of the interviewees acknowl- the short average implementation time of the AO. In addition, it seems that, even edged that safety recommendations were revealed by the particular metric was under the lack of such a central system, a frequently strict and did not give flexibility expected. bidirectional communication between the to operating units and middle-manage- On the other hand, assignment recom- safety department and investigators could ment levels to implement the remedies. mendations usually referred to the intro- have alleviated over time the discrepancy These interviewees added that sometimes duction of new technology or technical regarding the quantity and quality of safety the action recommendations did not modifications, extensive changes to proce- recommendations. Thus, the organization match the special conditions, resources, dures, and further research for deficiencies missed the opportunity to minimize the and other factors of the various operating identified during safety investigations. aforementioned gap over time. units, thus occasionally increasing the im- Such recommendations required detailed On the positive side, the quick dissemination of safety investigation reports to the plementation time and possibly the quality planning and research and consequently end-user level and the timely implemen- of the corrective actions. The frequency of increased time for their delivery. However, tation of safety recommendations were reminder recommendation types in final they made up about one-fifth of all recom- attributed to the appreciation of commu- investigation reports was perceived by mendations, and they did not significantly nication of such information across the the AO’s safety personnel as positive. They affect the results of the specific metric. claimed that it was not necessary to over- organization and the importance given to the efforts for preventing future accidents whelm other organizational functions by The overall picture publishing additional directives regarding and incidents. It seems that the AO suc- The analysis of data in combination cessfully estimated the time planned and reinforcement of established procedures the resources allocated to the implemen- and rules. with the discussions held with the organization’s staff revealed both positive tation of remedies. However, the metric of and negative performance of the safety timely implementation of safety recom- Metric 5: Timeliness of implementing management aspects considered in the mendations does not account for the recommendations study. The significant delays in safety inves- quality and effectiveness of the remedial Description tigations were attributed by the AO staff actions, which were not possible to eval- This metric regarded the time gap between to ineffective resource management and uate through the analysis of investigation delivery deadlines of recommendations investigation procedures, which led to a reports and records. and dates of their actual implementation gap between AO expectations and actual The relatively high percentage of in total and per-recommendation type. deliverables. Although a timely and ade- action-type recommendations indicates This metric would indicate potential quate allocation of resources will benefit that the AO’s safety department played an delays in implementing corrective actions organizations in terms of depth and speed interfering role in the responsibilities of and trigger an exploration of underlying of investigations, it seems that the specific other departments. This was the result of reasons. organization did not realized the extent managers’ inadequate commitment to the to which such resources were not always realization of assignment-type recommen- Results available or committed to investigations. dations in the past. This, in turn, resulted Managers implemented recommendations Hence, it was not always feasible for the in important delays in the implementation one month after the publication of the AO to derive lessons from safety investiga- of remedies and increasingly forced the final safety investigation reports. The rec- tions in a timely manner. safety department to formulate safety ommendations’ delivery deadline defined The fact that 48% more recommenda- recommendations based on what should in those reports had a median value of tions were stated in the final reports com- be performed instead of what should be zero. Statistical tests showed that assign- pared to the number of remedies stated in achieved. Such an approach literally vio- ment-type recommendations needed more the investigation team reports—and that lated the scope of the recommendations time for implementation, followed by the only 61% of the latter were adopted—in- referred to in the standards; the AO’s staff action and reminder types. The same order dicated a dissociation among the safety (Continued on page 30) October-December 2018 ISASI Forum • 23 FICTION -VS- THE IMPACT OF HOLLYWOOD REALITY ON ACCIDENT INVESTIGATION

viation accidents are generally a story that keeps the audience engaged. While the captain’s difficulty maintaining high-profile events. News outlet But what if a story is so well told, so his intended airspeed on final approach reports lead to wide speculation believable that audiences can’t separate was cited as contributing to the fuselage A before the accident team even fact from fiction? And what if that story damage, the flight crew’s decision-making arrives on scene, often using misinforma- jeopardizes an organization’s reputation and crew resource management was cited tion to be the first to get a story out. And and its ability to do its job? This is no as contributing to the survivability of the social media allows for the mass propa- surprise, and the website HistoryvsHol- accident, something rarely seen in acci- gation of false stories and half-truths that lywood.com attempts to parse out fact dent reports. There were other fortuitous many readers take as hard facts. What from fiction in Hollywood stories. Movies circumstances on that day—the airplane used to take days for a story to spread, featuring aviation disasters are generally being equipped for overwater operations, now takes mere minutes. While many human-centric, concentrating on the hu- performance of the cabin crew, and the investigations take at least a year to com- man element of the story rather than the proximity of emergency responders—that plete, aviation experts have weighed in on technical aspects of the event itself. The were also cited for contributing to surviv- the cause of the accident within months, movie Flight, starring Denzel Washington, ability. sometimes even days. Take the loss of told the story of a drug-addicted airline Fast-forward seven and a half years Malaysia Airlines Flight 370 more than pilot who miraculously crash lands an air- when the Clint Eastwood-directed movie three years ago—the total amount of air plane, saving most occupants on board. Sully is released in theaters nationwide. time dedicated to postulating speculative In contrast, Nat Geo’s Air Crash Inves- The story is based on Capt. “Sully” Sullen- theories was astonishing. tigation TV series is a technically-driv- berger’s autobiography Highest Duty: My At the 2012 ISASI meeting in Baltimore, en linear chronology of an accident. Search for What Really Matters and tells Maryland, USA, a U.S. National Transpor- The Smithsonian Channel attempted the tale of the accident and its subse- tation Safety Board (NTSB)-sponsored to bridge the gap between human and quent investigation from Sullenberger’s topic on accident communications technical elements with its show Alas- perspective. To what extent the basis for discussed how the news media is a quick ka Aircrash Investigations. This paper the film accurately follows the content reacting, sensationalist-driven process contemplates the potential impact that of the book is questionable. The film’s feeding a ratings and revenue-driven Hollywood films have to compromise underlying pretense is that the NTSB was news cycle. This can lead to distrust of the investigators’ ability to effectively do their second-guessing Sullenberger’s judgment investigative agency. For example, during job and whether Hollywood “investiga- to ditch the airplane on the Hudson River the investigation of Air France Flight tions” really matter. and threatening the career of a “national 447, due in part to leaks, online rumors, hero.” At least this is the public percep- and news media speculation, France’s “The Miracle on the Hudson” tion. USA Today wrote an article stating, Bureau of Enquiry and Analysis for Civil “Both pilots are hauled in front of the Hollywood dramatized the accident Aviation Safety (BEA) was accused of a National Transportation Safety Board, the involving US Airways Flight 1549, which lack of transparency that led some family closest the movie comes to having actual on Jan. 15, 2009, experienced an almost members to become disenfranchised with antagonists. They’re seemingly bound total loss of thrust in both engines after the agency. and determined to prove that Sully was in encountering a flock of birds soon after Likewise, Hollywood, through cinema, error and could have made it to a nearby television, and countless pulp fiction, departing LaGuardia Airport in New York airport. (The unsubtle message is that the loves a good story, one with a hero and City, New York, USA. The Airbus A320 powers-that-be would have rather saved an antagonist. But these stories are was subsequently ditched on the Hudson a plane.)” scripted with a plot pitting good versus River 208 seconds after takeoff. All 155 evil, a feel-good factor engendered in the passengers and crew survived. The news narrative to provide a hero to a story. That media quickly dubbed the accident “The Do Hollywood “investigations” is entertainment. Rarely do these stories Miracle on the Hudson.” matter? accurately portray real-life events, as The NTSB launched a full go-team to The storyline inSully is not a huge sur- real-life events are usually not so engag- New York City to investigate and com- prise. Accident reports are factually based ing. Tag lines purporting to be “based on pleted its investigation about 15 months consensus documents. Numerous or- true events” should be taken with a grain later. The agency determined that the ganizations with competing agendas are of salt. Hollywood is a master at ensuring probable cause of the accident was “the collectively drawn into an International facts do not spoil a good story. ingestion of large birds into each engine, Civil Aviation Organization (ICAO) Annex The consequences of Hollywood which resulted in an almost total loss 13-based framework, and each participate embellishments of a true tale are often of thrust in both engines and the sub- is obliged to forward its agenda, but the trivial. There is no harm, no foul in telling sequent ditching on the Hudson River.” result is a thorough, professional report, 24 • October-December 2018 ISASI Forum By Dr. Katherine A. Wilson, U.S. National Transportation Safety Board, and Darren Straker, Chief Inspector of Air Acci- dents, Hong Kong Air Accident Investigation Authority written by investigators whose primary goal is to save lives. Some reports are “There Is No Truth. There Is Only Perception.” contentious, but most are sober reading —Gustave Flaubert with little or no latitude for speculation and conjecture. This is what the traveling public wants—a serious professional attitude (Adapted with permission from the authors’ technical paper titled Fiction Versus Reality: The to an event report. As a vehicle for a Impact of Hollywood on Accident Investigation presented during ISASI 2017, Aug. 22–24, plot-driven, emotive narrative, this will 2017, in San Diego, California, USA. The theme for ISASI 2017 was “Do Safety Investigations Make a Difference?” The full presentation can be found on the ISASI website at www.isasi. hardly fill the seats in a local cinema. But org in the Library tab under Technical Presentations. The views expressed in this article do these entertainment genre stories open not necessarily represent the views of the National Transportation Safety Board or the United up the debate to the age-old question: States.—Editor) who watches the watchmen? Despite how the NTSB is portrayed in Sully, quite the opposite is true. From the perspective of investigators who participated in the investigation (the lead author of this paper included), the film accurately portrays the accident sequence as it occurred, but that’s where history and Hollywood diverge. The NTSB has the factual basis to back up its claims. All of the factual information collected is publicly available. It seems Eastwood didn’t take the time to read the facts, and he, like many others, has gotten the story wrong. He’s quoted as saying, “Until I read Dr. Katherine A. Wilson Darren Straker the script, I didn’t know the investigative board [NTSB] was trying to paint the is a senior human performance investigator is the chief inspector of air accidents with picture that he had done the wrong thing. with the Office of Aviation Safety at the the Hong Kong Air Accident Investigation They were kind of railroading him.” U.S. National Transportation Safety Board Authority. He was the director of Straker This isn't the first time one of East- (NTSB). She’s been with the NTSB since System Safety, an investigation consultancy wood’s films has been criticized for in- 2008. She recently served as the human working with the MIT Partnership for accuracies. American Sniper was fraught performance investigator for the Virgin Systems Approaches to Safety and Security with half-truths and exaggerations as Galactic SpaceShipTwo accident in using the Systems-Theoretic Accident Model well. If Eastwood, and others, had taken Mojave, California, USA, and Air Methods and Processes (STAMP) while applying helicopter accident in Frisco, Colo., USA. causal analysis based on STAMP for air the time to read the NTSB’s final report, She’s also supported the investigation of accident analysis for new and emerging this statement couldn’t be further from both domestic and international accidents aviation technologies. Prior to working the truth. The NTSB, and all investigative and incidents, including US Airways Flight in the private sector, Straker was a chief boards, have an obligation to thoroughly 1549 landing in the Hudson River, New air accident investigator with the General investigate all accidents, not just those York, New York, USA; Global Exec Aviation Civil Aviation Authority in the United Arab that result in tragedy. Learjet 60 in Columbia, South Carolina, Emirates for seven years, where he was the Sully and other docudramas run the USA; UPS Flight 61 in Incheon, South investigator-in-charge of the UPS B-747 risk of distorting the perceptions of the Korea; Southwest Airlines Flight 345 at freighter accident that occurred in 2010. investigative process, both in the eyes of LaGuardia Airport, Flushing, New York, Working for Airbus in France, Straker was pilots involved in future investigations USA; and the midair collision between a part of the Airbus accident go-team for and in the eyes of the public. While those Cessna and F-16 near Moncks Corner, South several years while also working on the Carolina, USA. Wilson holds a Ph.D. in A380 design, research, and development, familiar with the accident investigation applied experimental and human factors and flight test safety and entry into service process understand that the events por- psychology from the University of Central requirements. He is an experienced pilot trayed incorporate much artistic license Florida, a M.S. in modeling and simulation of both fixed- and rotary-wing aircraft to tell a compelling story, much of the from the University of Central Florida, and with a specific background in acceptance, public sees these Hollywood reenact- a B.S. in aerospace studies from Embry– developmental test, and evaluation and has ments as something far less fictional. It Riddle Aeronautical University. an airline transport pilot license. October-December 2018 ISASI Forum • 25 shouldn’t surprise anyone that accident the cooperation of investigative parties— @NTSB trying to nail the pilot.” investigations make a difference. Yet it’s a airlines, other federal agencies, unions, @JoeBurlas 12/28/16 slippery slope as Hollywood takes a rela- and manufacturers. Even more critical • “Eastwood’s Sully takes liberty with tively benign 208-second flight and turns it is the willingness of those involved in an ‘Miracle on the Hudson’ facts to into a major motion picture. accident—the pilots, flight attendants, tarnish hard-working NTSB investiga- The NTSB’s “highest duty” is to provide and mechanics—to share their firsthand tors.” @stevepearl 11/26/16 an objective factual analysis of the event perspective about what happened leading and make recommendations as necessary to and during an accident sequence. • “Watching Captain Sully doesn’t give to prevent such an accident from occur- Tom Hauter, the former director of the me faith in the NTSB and aviation ring again. And the agency’s track record NTSB’s Office of Aviation Safety, is quoted industry.” @YoungHils 12/26/16 over the last 50 years is pretty remarkable. as saying, “I understand the need to make • “Just streamed Sully on TV and really The NTSB’s role is not to play favorites or money. But I have gotten a lot of calls from enjoyed that flick; amazing though neglect to conduct a thorough investiga- pilots blasting the NTSB [because they that the NTSB would even investigate tion because the flight had a successful believe] the false story shown in the film is anything when all survived.” @Tyson- outcome. Every good drama needs a absolutely real. This is going to be detri- WSchmidt 12/10/16 villain, and the NTSB fits the bill perfectly. mental to future accident investigations But while Sully was concerned about his because people who see the film think they • “After watching Sully, the NTSB was a reputation throughout the investigation, can’t trust the NTSB.” Aviation websites bit nasty to a real hero. I get trying to Sully the movie puts at risk the reputation such as PPRuNe and Aviation Stack Ex- do your job, but dang…155/155 people of the NTSB (and other investigative agen- change have people asking, “Is the NTSB survived a forced landing.” @lostpilot- cies) by portraying spurious and exagger- hostile to pilots, as depicted in the movie er 10/26/16 ated facts. Sully?” But is this much ado about noth- • “If you think the #NTSB [was] trying Much of the news media showed sup- ing? Or do agencies, such as the NTSB, to mask #Sully out as wrong, read the port for the film, acknowledging the mas- deserve more respect? Will these inaccu- report. It’s pretty complimentary.” terful screenplay and acting. The authors racies tarnish the reputation of an agency @billpennock 9/23/16 do not disagree. However, former and that was simply doing its job? current NTSB management and staff have The US Airways Flight 1549 docket of • “Clint Eastwood vs. NTSB—The $65 publicly commented on the inaccuracies more than 4,000 pages of factual informa- Million Misunderstanding—Roger in the film and concerns about its implication collected throughout 20,000 hours is Rapoport, Flight Safety Information.” tions. For example, the movie suggests that available to the public. While few will read 9/20/16 it was Sullenberger himself who suggested the docket in its entirety and only some • “Apparently, entire point of Sully movie to investigators during the investigative have read the NTSB’s final report (much is to demonize NTSB, which deserves hearing that they consider the “human more reader friendly at about 200 pages), respect instead.” @OneEricJohnson factors” involved in his decision-making. millions have watched Sully and formed 9/19/16 How clueless could investigators be? In opinions, many inaccurate, about the fact, these simulations had been complet- NTSB’s investigation. Should an inves- • “Sullied: with Sully, Clint Eastwood is ed almost two months before without any tigative body have to justify its motives weaponizing a hero—Stephen Cass, involvement from the flight crew. because of a Hollywood film? We know The Guardian.” 9/12/16 The film also portrayed the cockpit that when the movie touts to portray “the • “Review: Sully landed the plane. Then voice recorder (CVR) being played during untold story” of a national hero, the public he had to endure the spotlight— the hearing—a public setting with dozens listens. Manohla Dargis, The New York Times.” watching—when the reality is that the The news media frenzy and barrage of 9/8/16 crew was afforded the opportunity to listen tweets said a lot about the public’s percep- to the CVR in a private setting (the NTSB’s tion. For many who watched the film, they What happens next? recorders lab) with just a few investigators can appreciate the artistic license given to Aviation accident investigations are present. The NTSB was also seen as favor- a screenwriter and director to add drama complex, and it’s important that investiga- ing the position of the insurance compa- for the sake of the audience. But as the say- tors get it right. To do this requires the ny, which wanted to place blame on the ing goes, “seeing is believing.” While some cooperation of numerous agencies and pilots, when in fact the investigative team’s could see the movie for what it was worth, people, both directly and indirectly interactions with an insurance company many others were angry and showed dis- involved. Aviation is about professionalism are minimal, and the insurance company dain toward the NTSB: and professional reputations. Without trust, has no say (or sway) in an investigation’s • “‘He saved all those people, why do an investigation will not be as successful. conclusions. they even care?’ My mom on the NTSB It’s yet unclear how the negative portrayal In most cases, there is no harm, no foul portrayed in Sully.” @silentdawnlb of the NTSB will influence the professional in the sensationalism of real-life events 12/30/16 pilot community, future investigations, and in Hollywood. But the NTSB and other • “So far, so good. Sully is right on ultimately aviation safety if the NTSB (or investigative agencies have a job to do. And weighing the investigation with public other investigative agency) is no longer a to do their job effectively, they must rely on perception. Painful to watch the trusted, reputable organization. 26 • October-December 2018 ISASI Forum A Trip to the Land of Merlion By Faisal Bashir Bhura, Squadron Leader, Pakistan Air Force Squadron Leader Faisal Bashir Bhura is a serving officer in the Pakistan Air Force. He is an aeronautical engineer and has participated in various field-level assignments pertaining to aviation maintenance and aviation safety during his professional career of 19 years. He earned a bachelor’s degree in engineering (aerospace) from the National University of Science and Technology and is currently completing an MBA in aviation management from PAF Karachi Institute of Economic and Technology. Bhura is also a qualified aircraft accident investigator with more than 2,500 investigations of premature failure of aircraft components and one major accident investigation into an F-16A. He is directing staff (technical training and development) at the College of Aviation Safety Management, Pakistan Air Force Base Masroor.

rofessional training seminars in foreign countries can Information and International Affairs Department of France’s be a key learning point in an individual’s life. They not Bureau of Enquiry and Analysis for Civil Aviation Safety for more only groom a person professionally, but they also create than 12 years. P opportunities to meet people of varying cultures and Among the guest speakers was Chan Wing Keong, the found- backgrounds across the globe. They can establish friendships ing member of the Air Accident Investigation Board of Singapore that go a long way in one’s life. who is currently as an advisor to the Transport Safety Investi- I was fortunate to have such an opportunity—to learn from gation Bureau of Singapore. He is extremely thorough and has aviation safety professionals and network with them. Naseem very strong professional credentials as an engineer and aircraft Syed Ahmed, president of the Pakistan Society of Air Safety accident investigator. He received the 2017 ISASI Jerome F. Investigators (SASI) and a retired wing commander, encouraged Lederer Award for his outstanding efforts for aviation safety in me to apply for a Singapore Cooperation Program fellowship in Singapore. October 2017. After reviewing applications from almost every The course covered the areas pertinent to managing the crash country in the world, in January 2018 I made the shortlist. site, forming investigation teams and related administrative As a full member of ISASI, I’ve also had the support of being matters, handling wreckage, managing the news media and affiliated with an international society for such training courses. bereaved families, studying FDR-CVR transcripts and soft- It was an honor to be the only Pakistani national selected for ware-based recordings of accidents, and reviewing multiple this fellowship program since there is only one seat allocated to studies on human factor cases at individual and organization- Pakistan for this particular program. al levels. This was followed by mutual group discussions. The I took part in the Aircraft Accident Investigation Management learning was extremely worthwhile, and the Singapore Aviation Course held at the Singapore Aviation Academy. More than Academy was very hospitable. 40 participants attended from all the continents. The course During the course, the Singapore Aviation Academy also took was managed by well-known senior aircraft investigators from us on a tour of China Town with its temples, which is reminis- Finland, Canada, France, and Singapore. Among them was cent of the traditional civilization of Singapore. The tour also ISASI International Councilor Caj Frostell, a highly experienced included a visit to Merlion Park where the Grand Merlion is and seasoned aircraft accident investigator affiliated with the standing and guarding the boundaries of this beautiful country. Society for a very long time. He is also a past winner of ISASI’s Je- In addition, I traveled almost the entire length and breadth of rome F. Lederer Award for his outstanding efforts in the field of Singapore on foot as well as taking subways and buses since the aircraft accident investigation. Frostell was supported by David transportation system is very safe, systematic, immaculate, and McNair, a former senior investigator at the Transportation Safe- effective. ty Board of Canada, and Allain Guilldou, a former head of the My affiliation with Pakistan SASI has been a great support to me. As an active member of the society, in 2018 I’ve submitted multiple papers on aviation safety to ANZSASI (Melbourne, Australia), the SERC meeting in July (Georgia, USA—the paper was selected), and the ISASI seminar (Dubai, United Arab Emirates—Rudolph Kapustin Scholarship essay). I believe that this professional organization will be a strong support to me in the future regarding important aviation events happening around the globe.

From left, Koan Sovantha, Cambodia; Caj, Frostell, ISASI international councilor; Allain Guilldou, former head of the Information and International Affairs Department of France’s Bureau of Enquiry and Analysis for Civil Aviation Safety; and Faisal Bashir Bhura, Paki- stan, gather during the Aircraft Accident Investigation Management Course held at the Singapore Aviation Academy.

October-December 2018 ISASI Forum • 27 NEWS ROUNDUP

Lederer Award Committee Seeks 2019 Nominations Correction to Table Published in April-June 2018 ISASI Forum Gale Braden, the Jerome F. Lederer Awards Committee chair, seeks new 2019 nominations. No new nominations for the award were received in 2018. “Usually we get one to three per year. Olivier Ferrante, European Society of Air Safety Investigators Surely there are some deserving investigators among us,” Braden president and senior advisor strategy for the French safety said. He urged ISASI members to “nominate a person, or per- investigation authority (BEA), notes on behalf of the BEA that AF447 and Germanwings Investigations: What sons, you believe deserves consideration for this award.” the paper titled Difference Do or Did They Make? The award, ISASI’s highest recognition for individual or that appeared in the April- ISASI Forum group efforts to promote or improve air safety through inves- June 2018 issue of requires a correction. The paper tigations, was established in honor of Jerome F. Lederer for by Arnaud Desjardin and Plantin de Hugues was presented his many significant contributions to aviation safety during during the ISASI 2017 seminar. his lifetime. Each year, at the Society’s annual seminar, ISASI Text in the table on page 20 referring to “BEA safety recom- presents the Jerome F. Lederer Award to the winner. The award mendation FRAN–2016–016” and to “Response sent by EASA,” recognizes positive advancement in the art and science of air states “none” but should say “Response received–Assessment safety investigations. pending” (response status as of August 2017). This mistake in To be considered for the 2019 Jerome F. Lederer Award, nom- the paper submission was corrected in the slides presented at inations must be received by the committee chair on or before ISASI’s seminar in San Diego, California, USA, in August 2017, ISASI May 31, 2019. but it remained in the paper that was published in Forum. “The criterion for the award is quite simple,” Braden said. The Lederer Award recognizes outstanding contributions to technical excellence in accident investigation. Any member AIB Nigeria Reviews Processes for Effective Accident of the Society in good standing may submit nominations. The Investigation award can be given to a group of people, an organization, or an individual, and the nominee does not have to be an ISASI Caj Frostell, ISASI international councilor, and Ismo Aalto- member. nen, chief air safety investigator with the Safety Investiga- The award may recognize a single event, a series of events, or tion Authority of Finland, visited the Accident Investigation a lifetime of achievement. The ISASI Awards Committee con- Bureau (AIB) of Nigeria in August 2018. At the invitation of siders such traits as duration and persistence, standing among Akin Olateru, the commissioner and chief executive officer of peers, manner and techniques of operating, and, of course, achievements. The nomination letter for the Lederer Award the AIB of Nigeria, they conducted a peer review of the AIB’s should be limited to a single page—if not, it will be edited to accident investigation functions. The review included organ- one page. The nominees are considered for three years. If not ization, technical personnel, training, equipment, processes selected, after a year they can be renominated. and procedures, and law and regulations. This is a prestigious award that usually results in positive Under the leadership of Olateru, the AIB of Nigeria has publicity for the recipient and may be beneficial in advancing a evolved as the leading accident investigation agency in Afri- recipient’s career or standing in the community. ca. The AIB facilities include a flight safety laboratory with Nominations should be mailed or e-mailed to the ISASI a state-of-the-art flight recorder readout capability. And the office or preferably directly to the Awards Committee chair: peer review was a link in the chain of activities aimed at fur- Gale E. Braden, 13805 Edmond Gardens Rd, Edmond, OK ther fine-tuning the AIB activities, policies, and procedures. 73013 USA or e-mail: [email protected]. More informa- At a press conference at the end of the peer review, tion can be found on the ISASI website under the Awards tab. Olateru reported that in the last 10 years the AIB has issued 147 safety recommendations, 70 percent of which have been DFW Regional Chapter Holds Annual Dinner fully implemented and 15 percent have been partially implemented. Olateru added that the AIB and the Nigerian Civil Erin Carroll, Dallas–Ft. Worth Regional Chapter president, Aviation Authority have established a committee to work reported that the chapter held its annual dinner on September out the modalities for further implementation of the safety 6. She noted that Tim Logan, spaceline safety director at Virgin recommendations issued by the AIB. Galactic, was the guest speaker. Tim “provided an interesting Earlier this year, the AIB of Nigeria reactivated its ISASI presentation on commercial space investigations,” Carroll said. corporate membership. The peer review provided an oppor- The dinner was well attended, and the chapter was able to tunity for Frostell to discuss the AIB’s participation in recruit a few new members. “We would like to thank Dennis ISASI’s annual seminar in Dubai in late October 2018 with Post [Southwest Airlines], John Lapointe [NASA], and Sean the AIB management team. The interest in Nigeria for a Mulholland [SevenBar Aviation] for generously donating door country or regional ISASI society or chapter was also ex- prizes,” Carroll concluded. plored.

28 • October-December 2018 ISASI Forum NEWS ROUNDUP

seminar in Lahore in December 2018 or January 2019. Speakers from across the globe will be invited to share their views on safety with Pakistani delegates from civil society, aviation, rail, road, and industrial safety organizations.

Shown during a news conference, from left: Caj Frostell, ISASI international councillor; Akin Olateru, commissioner and chief executive officer of the Accident Investigation Bureau of Nigeria; and Ismo Aaltonen, chief air safety investigator of the Safety Investigation Authority of Finland.

Bramble Appointed ISASI Human Factors Chair

ISASI President Frank Del Gandio recently appointed Dr. William Shown are Wing Commander Syed Naseem Ahmed, center right, with Assistant Chief of Air Staff Air Commodore Safety Shahid Jahangiri, center J. Bramble, the U.S. National Transportation Safety Board senior left, and Squadron Leader Faisal Bashir Bhura and Wing Commander human performance investigator, as chair of the Society’s Human Sohail, both instructors at the College of Aviation Safety Management. Factors Working Group (see “Analysis Techniques for Investigat- ing Human Performance,” ISASI Forum, July-September, pages 4–11.) Del Gandio tasked the new chair with establishing the 61st Fighter Interceptor Squadron Memorial working group agenda, meeting dates, procedures, and terms of reference. Working group reports and publications will be Tom McCarthy, ISASI Life Member and former ISASI Membership archived and distributed through the ISASI international office. Committee chair, recently served as master of ceremonies for a memorial dedication at the National Museum of the United States Air Force at Wright–Patterson Air Force Base, Ohio, USA, in honor ISASI Recognizes New Life Member of the 61st Fighter Interceptor Squadron. McCarthy is a former 61st pilot. ISASI member Larry Fogg was recently granted Life Member Providing a short history of the squadron, McCarthy noted status. Society President Frank Del Gandio wrote to acknowledge that the surviving members of the squadron decided to use the that Fogg has met the criteria for such designation—reaching age group’s remaining funds to purchase a full-size, black marble 70 and having paid annual dues for the past five years. Del Gandio memorial bench with laser etching representing the squadron congratulated Fogg for becoming a member in good standing for emblem, a F-89 Scorpion aircraft, and other data in the muse- life. A Life Member is no longer required to pay annual dues— um’s Memorial Park as a tribute to the accomplishments of although he or she continues to receive annual dues notices, those who served in the 61st Fighter squadrons. payment in whole or part is voluntary. Del Gandio thanked Fogg for his interest in and support of ISASI and hoped the new Life Member will continue to enjoy and participate in the Society’s activities.

SASI Pakistan Discusses Seminars with College of Aviation Annual Dues Deadline for All Members Safety Management ISASI membership dues must be paid before SASI Pakistan held a meeting with Assistant Chief of Air Staff Feb. 1, 2019, to avoid late fees and to stay (ACAS) Air Commodore Shahid Jahangiri at the College of current for ISASI benefits and services. If you Aviation Safety Management. Sayed Naseem Ahmed, SASI have questions or need more information, Pakistan president, briefed the new ACAS safety regarding ISASI and its major activities and invited him to attend the ISASI contact Ann Schull at [email protected] or call seminars in Dubai and the Hague. ACAS safety expressed 1-703-430-9668. appreciation for SASI Pakistan’s contribution to aviation safety in Pakistan. SASI Pakistan and ACAS agreed to look into possibilities of holding seminars and courses for Pakistan Air Force/SASI Pakistan. SASI Pakistan will be holding its annual

October-December 2018 ISASI Forum • 29 USING DATA TO ASSESS PERFORMANCE OF SAFETY MANAGEMENT (Continued from page 23) ISASI INFORMATION attributed the aforesaid evolving practice of the safety department to the lack of a productive dialogue across the various organizational levels. OFFICERS President, Frank Del Gandio ([email protected]) Conclusion Executive Advisor, Richard Stone The study described in this paper demonstrated the potential for using data from ([email protected]) Vice President, Ron Schleede safety investigation records and reports to assess the performance of various ([email protected]) safety management aspects and to monitor event rates and frequencies of con- Secretary, Chad Balentine tributing and causal factors. The findings from the analysis of such data triggered ([email protected]) Treasurer, Robert MacIntosh, Jr. respective discussions, through which positive and negative areas of safety man- ([email protected]) agement performance were identified. Each organization might record different data in regard to safety investiga- COUNCILORS tions, so the implementation of the whole set of metrics presented in this study Australian, Richard Sellers may not be always feasible. However, organizations can follow the method of this ([email protected]) Canadian, Barbara Dunn ([email protected]) study to develop metrics depending on the data they maintain in relation to European, Rob Carter safety investigation reports and processes and use those to improve their safety ([email protected]) management. The quality of safety recommendations and the depth of investiga- International, Caj Frostell ([email protected]) tions are examples of aspects that can also be evaluated depending on the New Zealand, Alister Buckingham resources and type of data available. Nonetheless, it is of paramount importance ([email protected]) that the results of such metrics be followed up with interviews and/or question- Pakistan, Wg. Cdr. (Ret.) Naseem Syed Ahmed ([email protected]) naires to interpret figures and inform decisions. United States, Toby Carroll ([email protected]) NATIONAL AND REGIONAL SOCIETY PRESIDENTS HELICOPTER ACCIDENT TRENDS IN EIGHT ISASI COUNTRIES AsiaSASI, Chan Wing Keong (Continued from page 12) ([email protected]) Australian, Richard Sellers ([email protected]) Nevertheless, the fatal accidents that continue to occur often involve age-old Canadian, Barbara Dunn ([email protected]) issues, such as a high rate of VFR flying at night, flying VFR into weather, and European, Olivier Ferrante ([email protected]) inadequate preflight planning, including go/no-go decisions. LOC and CFIT Korean, Dr. Tachwan Cho (contact: Dr. Jenny accidents continue to account for a substantial majority of accidents, and each Yoo—[email protected]) is strongly influenced by night flying and by weather. Other common issues -in Latin American, Guillermo J. Palacia (Mexico) Middle East North Africa, Khalid Al Raisi clude pilot performance (at least in accident flights), dispatch, and other issues ([email protected]) in larger organizations, including a failure to establish, follow, and monitor New Zealand, Graham Streatfield good SOPs. ([email protected]) Pakistan, Wg. Cdr. (Ret.) Naseem Syed However, accident rates differ significantly by category of helicopter. These Ahmed ([email protected]) rates are influenced by differences in basic capabilities, but perhaps more by Russian, Vsvolod E. Overharov differences in who is flying the equipment, the mixture of missions in each cat- ([email protected]) egory, differences in instrumentations, etc. Each country likely needs to adapt United States, Toby Carroll ([email protected]) any concerted safety effort to reflect its own fleet mix; one size may not fit all. Recommendations focused on the need for more thorough preflight plan- UNITED STATES REGIONAL ning and training as a starting point for reducing accidents in night VFR and in CHAPTER PRESIDENTS IMC. Training and better preflight are standard recommendations in any safety Alaska, Craig Bledsoe study, but they are difficult to do effectively. It must be repeated and sustained, ([email protected]) and this can be costly and time consuming. Arizona, Bill Waldock ([email protected]) We also have recommended that more organizations adopt nonpunitive Dallas-Ft. Worth, Erin Carroll ([email protected]) reporting programs and more use of meaningful data monitoring. These Great Lakes, Matthew Kenner approaches may be more difficult options when addressing private pilots and ([email protected]) small organizations, and even in larger organizations they require staff that can Mid-Atlantic, Ron Schleede ([email protected]) understand and analyze the information. Again, this is not free. Northeast, Steve Demko However, we also have recommended multiple technological interventions ([email protected]) that can further improve helicopter safety, particularly by reducing LOC and Northern California, Kevin Darcy ([email protected]) CFIT accidents. They include but are not limited to greater use of TAWS and Pacific Northwest, (Acting) John Purvis night-vision goggles, more use of onboard weather detection systems, three-ax- ([email protected]) is autopilots, greater attention to helipad design, and more. Cost is the most Rocky Mountain, David Harper ([email protected]) common barrier to broader application of these technologies. 30 • October-December 2018 ISASI Forum ISASI INFORMATION

Southeastern, Robert Rendzio Air Astana JSC Gulfstream Aerospace Corporation ([email protected]) Air Canada Hall & Associates LLC Southern California, Thomas Anthony Air Canada Pilots Association Hawaiian Airlines ([email protected]) Air Line Pilots Association HNZ New Zealand Limited Airbus Hogreen Air Airclaims Limited Honeywell Aerospace COMMITTEE CHAIRMEN Air New Zealand Hong Kong Airline Pilots Association Audit, Dr. Michael K. Hynes Airways New Zealand Human Factors Training Solutions Pty. Ltd All Nippon Airways Co., Ltd. (ANA) Independent Pilots Association ([email protected]) Allianz Insitu, Inc. Award, Gale E. Braden ([email protected]) Allied Pilots Association Interstate Aviation Committee Ballot Certification, Tom McCarthy Aloft Aviation Consulting Irish Air Corps ([email protected]) Aramco Associated Company Irish Aviation Authority Board of Fellows, Curt Lewis ([email protected]) Asiana Airlines Japan Transport Safety Board Bylaws, Darren T. Gaines ASPA de Mexico Jones Day ([email protected]) ASSET Aviation International Pty. Ltd. KLM Royal Dutch Airlines Code of Ethics, Jeff Edwards ([email protected]) Association of Professional Flight Attendants Korean Air Australian and International Pilots’ Association Korea Aviation & Railway Accident Membership, Tom McCarthy ([email protected]) (AIPA) Investigation Board Mentoring Program, Anthony Brickhouse Australian Transport Safety Bureau L-3 Aviation Recorders ([email protected]) Aviation Investigation Bureau, Jeddah, Learjet/Bombardier Aerospace Nominating, Troy Jackson Kingdom of Saudi Arabia Lion Mentari Airlines, PT ([email protected]) Aviation Safety Council Lockheed Martin Aeronautics Company Reachout, Glenn Jones ([email protected]) Avisure Middle East Airlines Scholarship Committee, Chad Balentine Azure Aero Ltd Midwest University ([email protected]) Becker Helicopters Pty. Ltd. Military Air Accident Investigation Branch Seminar, Barbara Dunn ([email protected]) Bundesstelle fur Flugunfalluntersuchung (BFU) Military Aircraft Accident & Incident Bureau d’Enquêtes et d’Analyses (BEA) Investigation Board CAE Flightscape Ministry of Transport, Transport Safety WORKING GROUP CHAIRMEN Cathay Pacific Airways Limited Investigation Bureau, Singapore Air Traffic Services, Scott Dunham (Chair) Centurion Aerospace Ltd. National Aerospace Laboratory, NLR ([email protected]) Charles Taylor Aviation National Institute of Aviation Safety and China Airlines Services Ladislav Mika (Co-Chair) ([email protected]) Civil Aviation Authority, Macao, China National Transportation Safety Board Airports, David Gleave ([email protected]) Civil Aviation Department Headquarters National Transportation Safety Committee- Cabin Safety, Joann E. Matley Civil Aviation Safety Authority Australia Indonesia (KNKT) ([email protected]) Civil Aviation Safety Investigation and Analysis NAV CANADA Corporate Affairs, Erin Carroll Center Pakistan Air Force-Institute of Air Safety ([email protected]) Colegio Oficial de Pilotos de la Aviación Pakistan Airline Pilots’ Association (PALPA) Critical Incident Stress Management (CISM), Comercial (COPAC) Pakistan International Airlines Corporation (PIA) David Rye--([email protected]) Cranfield Safety & Accident Investigation Papua New Guinea Accident Investigation Flight Recorder, Michael R. Poole Centre Commission (PNG AIC) Curt Lewis & Associates, LLC Parker Aerospace ([email protected]) Dassault Aviation Petroleum Air Services General Aviation, Steve Sparks DDAAFS Phoenix International Inc. ([email protected]) Defence Science and Technology Organisation Plane Sciences, Inc., Ottawa, Canada Co-Chair, Doug Cavannah (DSTO) Pratt & Whitney ([email protected]) Defense Conseil International (DCI/IFSA) PT Merpati Nusantara Airlines Government Air Safety Facilitator, Delft University of Technology Qatar Airways Marcus Costa ([email protected]) Delta Air Lines, Inc. Republic of Singapore Air Force (RSAF) Human Factors, Edma Naddof Directorate of Flight Safety (Canadian Forces) Rolls-Royce PLC Discovery Aur Defence Royal Danish Air Force, Tactical Air Command ([email protected]) Dombroff Gilmore Jaques & French P.C. Royal Netherlands Air Force Investigators Training & Education, DRS C3 & Aviation Company, Avionics Line of Royal New Zealand Air Force Graham R. Braithwaite Business RTI Group, LLC ([email protected]) Dubai Air Wing Saudia Airlines-Safety Military Air Safety Investigator, James W. Roberts Dutch Airline Pilots Association Scandinavian Airlines System ([email protected]) Dutch Safety Board Sikorsky Aircraft Corporation Unmanned Aerial Systems, Tom Farrier Eclipse Group, Inc. Singapore Airlines Limited ([email protected]) Education and Training Center for Aviation SkyTrac Systems Ltd Safety Southwest Airlines Company EL AL Israel Airlines Southwest Airlines Pilots’ Association CORPORATE MEMBERS Embraer-Empresa Brasileira de Aeronautica Spanish Airline Pilots’ Association (SEPLA) AAIU, Ministry of Transport S.A. State of Israel Abakan Air Embry-Riddle Aeronautical University Statens haverikommission Accident Investigation Board (AIB) Army Aviation Etihad Airways Swiss Accident Investigation Board (SAIB) Accident Investigation Board Norway European Aviation Safety Agency (EASA) The Air Group Accident Investigation Bureau Nigeria EVA Airways Corporation The Boeing Company Administration des Enquêtes Techniques Executive Development & Management Advisor The Japanese Aviation Insurance Pool (JAIP) Adnan Zuhairy Engineering Consultancy Finnair Plc Transportation Safety Board of Canada Aegean Airlines Finnish Military Aviation Authority Turbomeca Aer Lingus Flight Data Services Ltd. Ukrainian National Bureau of Air Accidents and Aero Republica Flight Data Systems Pty. Ltd. Incidents of Civil Aircraft Aerovias De Mexico, S.A. De C.V. Flight Safety Foundation UND Aerospace Agenzia Nazionale Per La Sicurezza Del Volo Fugro Survey Middle East Ltd. United Airlines Air Accident Investigation Bureau of Mongolia Gangseo-gu, Republic of Korea United States Aircraft Insurance Group Air Accident Investigation Bureau of Singapore GE Aviation University of Balamand/Balamand Institute of Accident Investigation Committee of Thailand General Aviation Manufacturers Association Aeronautics Air Accident Investigation Unit-Ireland German Military Aviation Authority, Directorate of University of Southern California Air Accident Investigation Sector, GCAA, UAE Aviation Safety Federal Armed Forces Virgin America Air Accidents Investigation Branch-UK Global Aerospace, Inc. Virgin Galactic Air Asia Group Grup Air Med S.A. WestJet

October-December 2018 ISASI Forum • 31 ISASI 107 E. Holly Ave., Suite 11 Sterling, VA 20164-5405 USA

INCORPORATED AUGUST 31, 1964 CHANGE SERVICE REQUESTED

Hong Kong Air Accident Investigation Authority Begins Operations

he Hong Kong Air Accident tigation facility consists of a command grated video and audible playback facility Investigation Authority (AAIA) is an center, a flight data recorder download and with upgrades planned to modernize the independent authority established playback center, a secure evidence hangar, capability. Tunder the Transport and Housing and adjoining interview rooms. The Given Hong Kong’s geographic location Bureau of the Hong Kong Special Admin- 200-square-meter command center has and diverse island groups, a maritime istrative Region (HKSAR). versatile audio-video systems with multiple search capability is integrated into the The AAIA is based at Hong Kong Inter- input and display units. The projectors and accident plan. The lab is equipped with a national Airport, Lantau, Hong Kong, and the LCD panel video wall system enable range of underwater locator beacon detec- is led by Darren Straker, chief inspectors of integrated or multiple display of real-time tors and a maritime response activation accidents, a seasoned investigator who was video conferencing, live ATC radar, runway plan for ditching or runway overrun in appointed to the position in September and helipad CCTVs, news, and social me- conjunction with a workshop for selective 2018 and reports directly to the Transport dia with access to emergency services relay. maintenance of the equipment. and Housing Bureau secretary. Three senior The command center can house 25 inves- The Hong Kong Air Accident Investiga- investigators and three investigators and tigators at desk stations with conferencing tion Authority is actively engaged in safety clerical staff support the chief inspectors of media. The flight recorder center is capable management, fulfilling ICAO obligations accidents. The team is made up of expe- of downloading and analyzing undamaged for independence investigation while rienced investigators with backgrounds flight data recorders and cockpit voice making valuable contributions to the in flight operations, airworthiness, design recorder line replaceable units. dynamic and busy Hong Aviation sector. and certification, flight test, flight safety, Operating the Plane Sciences light data Go to www.thb.gov.hk/aaia/eng/index.htm flight data analysis, airport operations, and analysis tools for animation and data for more information about this new air operational security. analysis, the flight data lab has an inte- accident investigation authority. Effective Sept. 10, 2018, the authority assumed the HKSAR’s obligations for air accident investigation from the Civil Aviation Department (CAD). Investigations previously initiated by the CAD will be taken over by the AAIA in accordance with the International Civil Aviation Organization’s (ICAO) Annex 13 to the Convention on International Civil Aviation and Hong Kong civil aviation (investigation of accidents) regulations (laws of Hong Kong Chapter 448B). Apart from the office accommodation being on a separate level and response equipment storage, the accident inves-

32 • October-December 2018 ISASI Forum