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JULY-SEPTEMBER 2019 Journal of the International Society of Air Safety Investigators

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JULY-SEPTEMBER 2019 Journal of the International Society of Air Safety Investigators Air Safety Through Investigation JULY-SEPTEMBER 2019 Journal of the International Society of Air Safety Investigators Developing a Photogrammetric Model for Wind Simulation page 4 Investigating a Unique UAV Gear Collapse page 12 Application of Innovative Investigation Technologies page 15 5 Millimeter Crack Leading to an Engine Fire page 18 ISASI Kapustin Scholarship Essay—Skydiving Operations and Safety Investigation page 26 CONTENTS Air Safety Through Investigation Journal of the International Society of Air Safety Investigators FEATURES Volume 52, Number 3 Publisher Frank Del Gandio Richard B. Stone 4 Developing a Photogrammetric Model for Wind Simulation Editorial Advisor Editor J. Gary DiNunno By Michael Bauer, William English, and Michael Richards, U.S. National Transportation Design Editor Jesica Ferry Safety Board, and Matthew Grzych, the Boeing Company—The authors noted that the Susan Fager activities conducted serve as a proof of concept for an innovative investigative technique, Associate Editor demonstrating the breadth of potential use cases for sUAS to support accident investigation. ISASI Forum (ISSN 1088-8128) is published quar- terly by the International Society of Air Safety Investigators. Opinions expressed by authors do 12 Investigating a Unique UAV Gear Collapse not necessarily represent official ISASI position By James Buse, Senior Technical Lead System Safety, and Jeff Kraus, UAS Flight Test or policy. Safety Lead, the Boeing Company—The authors describe their investigation of a landing Editorial Offices: Park Center, 107 East Holly Ave- incident during the first flight of a high-tech drone in June 2012 and the measures Boeing nue, Suite 11, Sterling, VA 20164-5405. Telephone took to correct the problem. 703-430-9668. Fax 703-430-4970. E-mail address, [email protected]; for editor, jgdassociates@ starpower.net. Internet website: www.isasi.org. 15 Application of Innovative Investigation Techniques ISASI Forum is not responsible for unsolicited By Sundeep Gupta, Accident Investigator, Product Safety, Airbus—TThe author describes manuscripts, photographs, or other materials. innovative investigation technology, including satellite imagery, ballistic analysis, radar Unsolicited materials will be returned only if scanning, and 3-D laser scanning used to locate engine components scattered from an submitted with a self-addressed, stamped enve- lope. ISASI Forum reserves the right to reject, uncontained engine failure on an A380 cruising at 37,000 feet over Greenland. delete, summarize, or edit for space con- siderations any submitted article. To facilitate editorial production processes, American Eng- 18 5 Millimeter Crack Leading to an Engine Fire lish spelling of words is used. By David Lim, Principal Investigator, Transport Safety Investigation Bureau, Singapore— The author presents lessons learned from investigation of an engine fire on a B-777-300ER that Copyright © 2019—International Society of Air departed from Singapore to Milan in June 2016. Safety Investigators, all rights reserved. Publica- tion in any form is prohibited without permis- sion. ISASI Forum registered U.S. Patent and 26 ISASI Kapustin Scholarship Essay—How an Extreme Sport T.M. Office. Opinions expressed by authors do not necessarily represent official ISASI position Highlights Broader Issues for Air Safety Investigators: Sky Diving or policy. Permission to reprint is available upon Operations and Safety Investigations application to the editorial offices. By Avery Katz, Embry-Riddle Aeronautic University, 2018 ISASI Rudolf Kapustin Memorial Publisher’s Editorial Profile: ISASI Forum is print- Scholarship Recipient—The author discusses how an extreme sport presents unusual and ed in the United States and published for profes- broader issues that accident investigators must address. sional air safety investigators who are members of the International Society of Air Safety Inves- tigators. Editorial content emphasizes accident investigation findings, investigative techniques and experiences, regulatory issues, industry ac- DEPARTMENTS cident prevention developments, and ISASI and member involvement and information. 2 Contents 3 President’s View Subscriptions: A subscription to members is pro- 28 News Roundup vided as a portion of dues. Rate for nonmem- 30 ISASI Information bers (domestic and Canada) is US$28; Rate for 32 ANZSASI Holds Annual Regional Seminar nonmember international is US$30. Rate for all libraries and schools is US$24. For subscription information, call 703-430-9668. Additional or replacement ISASI Forum issues: Domestic and Canada US$4; international member US$4; do- ABOUT THE COVER mestic and Canada nonmember US$6; interna- tional nonmember US$8. A Boeing Phantom Eye UAV liquid-hydrogen-fueled prototype lifts off from a lakebed at Edwards Air Force Base in California, USA, in June 2012 for its first flight. The high-altitude, long-endurance aircraft is designed to remain airborne for up to four days while reaching altitudes of up to 65,000 feet. Upon landing, the nosewheel separated as it contacted the runway, leading to a unique inves- tigation that required unusual procedures (see page 12). INCORPORATED AUGUST 31, 1964 2 • July-September 2019 ISASI Forum PRESIDENT’S VIEW CONTINUING TO IMPROVE FLIGHT SAFETY IN THE YEARS TO COME WE’RE PROUD OF OUR HISTORY, OUR PRESENT EFFORTS, AND OUR WILLINGNESS TO PROJECT OUR EXPERIENCE AND EXPERTISE INTO AIR SAFETY’S FUTURE. s I write my opening to offer aviation students a of interesting air safety distributed to ISASI 2019 statement for ISASI scholarship that allows them professionals who are just participants and then will 2019 in early Sep- to attend our seminar and starting their careers. This be posted on our website. A tember, I think about other aviation safety training magazine format is sent It’s safe to say that ISASI, many of the programs our programs. We’re a sponsor of electronically to members through our members, has Society has to offer to ISASI the Harry Robinson Fellow- and subscribers who prefer some presence everywhere members and to air safety ship program that provides to receive their information in the world where air safety throughout the world and the a stipend to an advanced through computers or other is an issue. We’re proud of efforts ISASI makes in prepa- college degree student who’s electronic devices, rather our history, our present ration for the future. Yes, our conducting research in an than a printed and mailed efforts, and our willingness premier event is the annual air safety subject. copy. Receiving either to project our experience seminar that gives air safety We’re an active participant format has two require- and expertise into air professionals an opportu- as an official observer organ- ments: You must be an ISASI safety’s future. That future nity to share their expertise ization in International Civil member in good standing may take us farther than through tutorials, technical Aviation Authority (ICAO) and your mailing or e-mail this world. The future of air presentations, and informal proceedings and rulemaking. address must be accurate. safety investigation depends networking discussions. But ICAO is the global aviation If you need to “fix” either of upon those of us who have there is a great deal more oc- authority within the United these requirements or wish experience to pass the torch curring throughout the year. Nations. For the last five to switch your magazine de- to next-generation air safety We recently participat- years, our Society represent- livery option, please contact professionals who can ed in the 54th Reachout atives have been a part of ISASI’s editorial offices (see assimilate what we learned program that provided air the ICAO Accident Investi- page 2 of this issue). and practiced while adding safety instruction not only gation Panel that meets an- During the spring new expertise and experi- to ISASI members in Paki- nually in Montreal, Quebec, ISASI International Council ence to continue improving stan, but also to government Canada. The work of the meeting, a committee was air and space flight safety in officials and personnel, group leads to updates and established to review the the years to come. members of the military, additions to ICAO standards Society’s official Positions and other safety profession- and procedures for accident on Air Safety Issues, which is als. There have been 3,272 investigations throughout posted on our website under participants in Reachouts the world. the Guidelines tab. This since this program’s incep- Our recent inauguration periodic review is designed tion in 2001. of a digital ISASI Forum is to ensure that our policies We encourage aviation an attempt to better reach and positions are current. students to learn about air members and subscribers The committee determined safety careers through our who are often away from that no changes are required student outreach programs their homes or worksites at this time. that include student ISASI and may want to read our A pamphlet about the chapters at accredited avi- magazine in a more timely Society’s history and Frank Del Gandio ation colleges and continue manner and also as a means accomplishments will be ISASI President July-September 2019 ISASI Forum • 3 DEVELOPING A PHOTOGRAMMETRIC MODEL FOR WIND SIMULATION By Michael Bauer, William English, and Michael Richards, U.S. National Transportation Safety Board, and Matthew Grzych, the Boeing Company uring the on-scene investigation of an Incomplete meteorological data accident in which
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