JULY–SEPTEMBER 2010

Using HET Taxonomy to Help Stop Human Error (Page 5) Three ‘Kapustin’ Scholars Selected (Page 11) Helicopter EMS Operations—At What Cost? (Page 16 ) Smoothing CDR Radar Data (Page 20) Accident Prevention: Pushing the Limits (Page 24) CONTENTS

Volume 43, Number 3 Publisher Frank Del Gandio Editorial Advisor Richard B. Stone FEATURES Editor Esperison Martinez Design Editor William A. Ford 5 Using HET Taxonomy to Help Stop Human Error Associate Editor Susan Fager By Wen-Chin Li, Don Harris, Neville A. Stanton, Yueh-Ling Hsu, Danny Chang, Annual Report Editor Ron Schleede Thomas Wang, and Hong-Tsu Young—Research results show that using Human ISASI Forum (ISSN 1088-8128) is published Error Template taxonomy will help improve safety when performing a go-around. quarterly by International Society of Air Safety Investigators. Opinions expressed by authors do not necessarily represent official 11 Three ‘Kapustin’ Scholars Selected ISASI position or policy. By Esperison Martinez, Editor—Students from Embry-Riddle Aeronautical Editorial Offices: Park Center, 107 East University, Florida, U.S.A.; Institut Superieur de l’Aeronautique et de l’Espace, Holly Avenue, Suite 11, Sterling, VA Toulouse, France; and Cranfield Safety and Accident Investigation Centre, 20164-5405. Telephone (703) 430-9668. Fax (703) 430-4970. E-mail address isasi@ Cranfield University, UK, have been selected as the 2010 recipients of ISASI erols.com; for editor, espmart@comcast. Rudolph Kapustin Memorial Scholarship. net. Internet website: www.isasi.org. ISASI Forum is not responsible for unso- licited manuscripts, photographs, or other 16 Helicopter EMS Operations—At What Cost? materials. Unsolicited materials will be By Christine Negroni (FO5208) and Dr. Patrick Veillette—The authors explain returned only if submitted with a self-ad- the special challenges in air medicine through a comprehensive and statistical dressed, stamped envelope. ISASI Forum reserves the right to reject, delete, sum- analysis of EMS helicopter accidents in the United States from 1985 to 2007. marize, or edit for space considerations any submitted article. To facilitate editorial production processes, American-English 20 Smoothing CDR Radar Data spelling of words will be used. By Ryan M. Graue, W. Jeffrey Edwards, Jean H. Slane, Dr. Robert C. Winn, and Copyright © 2010—International Society of Krista B. Kumley—The authors perform a comparison study of GPS data and Air Safety Investigators, all rights reserved. CDR radar data using a fully instrumented flight test to try to eliminate some Publication in any form prohibited without permission. ISASI Forum registered U.S. of the discrepancies that result from differing interpretations of radar data. Patent and T.M. Office. Opinions expressed by authors do not necessarily represent of- ficial ISASI position or policy. Permission to 24 Accident Prevention: Pushing the Limits reprint is available upon application to the By Bernard Bourdon, Accident Investigation Manager, European Aviation editorial offices. Safety Agency, the European Union—Within the framework of existing European Publisher’s Editorial Profile: ISASI Union treaties and institutions, the European Aviation Safety Agency was Forum is printed in the United States and published for professional air safety established and tasked to set and maintain a high uniform level of civil aviation investigators who are members of the In- safety in Europe. ternational Society of Air Safety Investiga- tors. Editorial content emphasizes accident investigation findings, investigative tech- niques and experiences, regulatory issues, DEPARTMENTS industry accident prevention developments, 2 Contents and ISASI and member involvement and information. 3 President’s View Subscriptions: Subscription to members 26 ISASI RoundUp is provided as a portion of dues. Rate for 30 ISASI Information nonmembers (Domestic and Canada )is 32 Who’s Who—A brief corporate member profile of the Republic of US$28.00; Rate for nonmember interna- tional is $US30.00. Rate for all libraries Indonesia’s National Transportation Safety Committee and schools is $US24. 00. For subscription information, call (703) 430-9668. Additional or replacement ISASI Forum issues: Do- mestic and Canada US$4.00; international About the Cover member $US4.00; domestic and Canada On Sept. 27, 2008, at 2358, EDT, an Aerospatiale (Eurocopter) AS365N1 helicopter, nonmember $US 6.00; and international nonmember $US8.00. operated by the Maryland State Police as a public-use medical evacuation flight, collided with trees and terrain in District Heights, Md. The flight had been cleared by ATC for an ILS approach to Andrews AFB, Camp Springs, Md. Instrument me- teorological conditions prevailed at the time of the accident. Four persons died; one survived the crash. The flight originated from Waldorf, Md. destined for the Prince George’s County Hospital (PG), Cheverly, Md. (Photo: NTSB Public Docket)

2 • ISASI Forum July–September 2010 PRESIDENT’S VIEW ISASI Bolsters Domestic and International Exposure By Frank Del Gandio, ISASI President For perhaps the first time, the European, icing, and the full range of activities encountered in winter Australia, New Zealand, and the U.S. Societies operations. Barbara Dunn, president of the Canadian Society, have conducted seminars in the same calendar noted that the event permitted ISASI to gain a bit more expo- year. The Canadian Society teamed up with sure than otherwise would have occurred and gave the many the Air Canada Pilots Association and held one attending Canadian Society members a chance to interact with last October, The Asian Society was formed, international peers, which she labeled as a big plus. and, of course, ISASI 2010 in Sapporo, Japan, The U.S. Society, directed by Toby Carroll, conducted its first will happen in September. This means that in the course of just seminar in June with more than 100 persons attending. The more than 12 months, ISASI-related groups have conducted 2-day event included three breakout sessions: general aviation, or co-sponsored safety seminars in Europe, Canada, the U.S., commercial aviation, and helicopter operations. Carroll de- Asia, Australia, and New Zealand. And when you add the ef- fects of the Reachout Workshop program, it measures as quite an accomplishment. or perhaps the first time, the European, For a considerable period of time, only the Australian and FAustralia, New Zealand, and the U.S. Societies New Zealand Societies combined their efforts in an annual have conducted seminars in the same calendar seminar. This, coupled with the annual ISASI international year.… This means that in the course of just seminar, constituted ISASI’s exposure through large group events. more than 12 months, ISASI-related groups have Australian Society President Lindsay Naylor noted that of conducted or co-sponsored safety seminars in late the new members drawn to the joint seminar come from Europe, Canada, the U.S., Asia, Australia, and “the younger generation.” So as older member leave the scene, New Zealand. And when you add the effects the membership base becomes a bit more youthful. He adds of the Reachout Workshop program, it measures that the “Y” generation brings with it a questioning attitude as quite an accomplishment. about traditional issues and responses. “It’s all to the good,” says Lindsay, “keeps the activities fresh.” Then in 2008 the European Society reactivated its program scribed the event’s impact this way: “The organizing committee and conducted a European seminar that drew more than 100 was pleased to provide an additional and complimentary venue persons to a 2-day event. In June, that Society completed its to chapter meetings and annual international seminars for third consecutive seminar. In all, the Society has drawn close U.S. Society members. We had more than 30 attendees submit to 300 safety advocates to its seminars. Dave King, European membership applications and were able to reach a significant Society president, said of his seminars: “The goal in 2008 was number of individuals who are not able to come to international to present a compact, high-quality technical program with low seminars. It was also encouraging to have a good turnout of the associated cost overheads to make the seminar affordable to next generation of air safety investigators.” delegates in a time of increasing financial constraint. This has The Society’s annual international seminar has continually been achieved with the help of generous corporate support in attracted high numbers of attendees from a considerable num- the donation of presentation venues and other logistical support. ber of countries. For example, ISASI 2009 drew 215 delegates The outcome has been an attendance representing a broad spec­ from 33 nations, and 2008 drew 284 from 34 countries. This trum of practitioners and managers, many of whom could not year’s event in Sapporo, Japan, is expected to again be a mag- get sponsorship to attend the ISASI seminar, stimulating de- net for those in the accident investigation profession as well as bate around topics of direct challenge to the current-day investi- other aviation specialties. gator and industry from a European perspective. We have other A measure of ISASI’s extended presence can be seen in the States registering an interest in hosting future events and an development of AsiaSASI, whose formation gained ISASI’s in- enthusiastic delegate base so we look to build on the program.” ternational council approval last September. The new Society’s In October of last year, the Canadian Society co-hosted an birthright reaches back to ISASI 2007, held in Singapore. It International Winter Operations Conference held in Ontario, was there that many ISASI Asian members who regularly at- Canada. It drew more than 200 attendees, from 13 countries, tend the annual event surfaced the idea of forming AsiaSASI. who listened to airport operators, weather forecasters, fire and Two years in the making and with many consultations with rescue experts, airline and aircraft manufacturers, and safety Caj Frostell, ISASI international councillor, the Asian society regulators discuss contaminated runways, airframe, and engine became a reality. All ISASI members in Asia automatically

July–September 2010 ISASI Forum • 3 PRESIDENT’S VIEW Continued . . .

ISASI 2010 SAPPORO, JAPAN

he International Society of Air Safety Investigators Please make your seminar registration and hotel reser- (ISASI) will hold its 41st annual international seminar vation arrangements through the seminar website at T(ISASI 2010) in Sapporo, Japan, from Sept. 6-9, 2010. http://www2.convention.co.jp/isasi2010/index.html or use The Japan Transport Safety Board (JTSB) will host ISASI the link from the ISASI website at www.isasi.org. 2010, and we expect attendance of more than 300 represen- Sponsorship and exhibitor opportunities are available tatives from government and industry from during the course of the seminar. around the world. The seminar theme is If you have any questions, please feel free “Investigating ASIA in Mind—Accurate, to contact any of the following: Speedy, Independent, and Authentic,” Ron Schleede, Sponsorship Chairman— with a sub-theme of “Over Cultural Differ- [email protected] ences and Language Barriers.” Bob Kosugi, 2010 Committee— The main seminar program will be held [email protected] September 7-9 with two tutorials being conducted on Sep- Koichi Saito, 2010 Committee—[email protected] tember 6. Tutorial No. 1 is entitled “Investigating Human Ann Schull, ISASI office manager—[email protected] Factors: The Human/Machine Interface” and Tuto- Barbara Dunn, ISASI Seminar Chair—[email protected] rial No. 2 is entitled “Aircraft Numbers Are Increasing Worldwide. How Do We Prevent Accidents?” We look forward to seeing all of you in Sapporo.

became members of AsiaSASI. It has 18 corporate members of expert ISASI volunteers…geographically dispersed around and its officers are organizations rather than individuals (see the world.” He added, “[We] continue to explore additional ISASI Forum, October–December 2009, page 26). AsiaSASI means of supporting organizations….” spokesman Chan Wing Keong noted: “This Asian regional Unquestionably, ISASI’s “internationalization” is not society of ISASI was established to promote aviation safety the result of any single event; it is all our activities combined and strengthen the cooperation between aircraft accident that works in this direction. Caj Frostell expressed this best investigation bodies within the region…. [We] believe that the with his recollection that “We held a number of Reachouts in AsiaSASI will serve as a regional cooperation forum linking Asia, which set the stage for ISASI 2007 held in Singapore, aircraft accident investigators in Asia and making contribu- leading to the formation of AsiaSASI.” Caj was also heavily tions to the international community.” involved in the Reachouts held in the Middle East, which he But by far, ISASI’S most grassroots-directed activity is said has created “ISASI faces” in that part of the world. But its Reachout Workshop program, which provides accident his most telling observation regarding ISASI’s increased investigation and safety management tools and procedures exposure is that “ISASI’s contribution to international avia- to any group that feels it can enhance its investigation pro- tion safety is well regarded within ICAO. This is evidenced by cesses through the program. Initiated in 1999, it has taken ISASI being invited as a recognized observer organization to its teaching tools to 36 workshops and has taught more than participate in the ICAO Divisional Meetings in 1992, 1999, and 1,900 persons in 21 countries in the following areas: Africa (1), 2008. At the 2008 meeting, we made a significant contribution Asia (11), Middle East (10), Europe (5), Australia (4), Americas to the AIG/2008 meeting (see ISASI Forum, January–March (5—South, Central, the U.S.). ISASI receives no income from 2009, page 4). this program. Except for seed funding, its operation and suc- There can be no doubt that the combined activities of our cess is owed to groups that recognize the impact the program societies and groups have greatly extended ISASI presence in may have on the organization and that sponsor the training. both the domain of each society and in the international realm John Guselli, chairman of the Reachout program, noted that of air accident investigation. ISASI members have much to be the program “continues to maintain substantial resources in a proud of, and a great deal of it is owed to themselves and the multitude of air safety related domains serviced by a register support they give to their Society’s activities and efforts. ◆

4 • ISASI Forum July–September 2010 Using HET Taxonomy Humanto Help EStoprror Research results will help to improve safety when performing a go-around by identifying potential errors on a step-by-step basis and allowing early remedial actions in procedures and crew coordination to be made. By Wen-Chin Li, Don Harris, Neville A. Stanton, Yueh-Ling Hsu, Danny Chang, Thomas Wang, and Hong-Tsu Young

(This article is adapted with permission around in a large commercial transport are exemplified in crashes such as the from the authors’ paper entitled Human aircraft. Nagoya Airbus A300-600 (in which the Error Prevention: Using the Human Er- HET was originally developed in pilots could not disengage the go-around ror Template to Analyze Errors in a Large response to a requirement for formal mode after its inadvertent activation; this Transport Aircraft for Human Factors methods to assess compliance with the was as a result of a combination of lack Considerations presented at the ISASI new human factors certification rule for of understanding of the automation and 2009 seminar held in Orlando, Fla., Sept. large civil aircraft introduced to reduce poor design of the operating logic in the 14-18, 2009, which carried the theme “Ac- the incidence of design-induced error on autoland system), the Cali Boeing 757 cident Prevention Beyond Investigation.” the flight deck (EASA Certification Speci- accident (in which the poor interface on The full presentation, including cited ref- fication 25.1302). The HET taxonomy was the flight management computer and a erences to support the points made, can be applied to each bottom-level task step in an lack of logic checking resulted in a CFIT found on the ISASI website at www.isasi. HTA of the flight task in question. A total accident), and the Strasbourg A320 ac- org.—Editor) of 67 pilots participated in this research, cident (in which the crew inadvertently including 12 instructor pilots, 18 ground set an excessive rate of descent instead light crews make positive contri- training instructor, and 37 pilots. Initial of manipulating the flight path angle as a butions to the safety of aviation results found that participants identified result of both functions utilizing a common operations. Pilots have to assess 17 operational steps with between 2 and 8 control interface and an associated poor continuously changing situations, different operational errors being identi- display). Human error is now the principal Fevaluate potential risks, and make quick fied in each step by answering questions threat to flight safety. A 1998 Civil Avia- decisions. However, even well-trained and based either on his/her own experience tion Authority worldwide survey of causal experienced pilots make errors. Accident or their knowledge of the same mistakes factors in commercial aviation accidents investigations have identified that pilots’ made previously by others. Sixty-five dif- determined that in 88% of cases the crew performance is influenced significantly ferent errors were identified. was identified as a causal factor; in 76% of by the design of the flightdeck interface. While high levels of automation in instances, the crew was implicated as the This research applies hierarchical task third-generation airliners have undoubt- primary causal factor. analysis (HTA) and utilizes the Human edly contributed considerable advances in The pilot of a modern commercial air- Error Template (HET) taxonomy to safety over earlier jet transport aircraft, craft is now a manager of the flight crew collect error data from pilots during new types of error have emerged on these and of complex, highly automated aircraft flight operations when performing a go- flight decks. These types of accidents systems. The correct application of com- plex procedures to manage activities on Wen-Chin Li was the topic presenter of this paper at ISASI 2009. He the flight deck is now an essential part of is head of the Graduate School of Psychology, National Defense Uni- ensuring flight safety. While pilot error versity, Taiwan. Don Harris is managing director of HFI Solutions is now the major contributory factor in Ltd., United Kingdom, and visiting professor in the School of Aero- aircraft accidents, a diagnosis of “error” nautics and Astronautics at Shanghai Jiao Tong University, People’s in itself says very little. It is not an expla- Republic of China. Neville A. Stanton is chair in the Human Factors nation; it is merely the beginning of an of Transport, School of Civil Engineering and the Environment, Uni- explanation. As S.W.A. Dekker proposed Wen-Chin Li versity of Southampton, United Kingdom. Yueh-Ling Hsu is a profes- in his 2001 article, ‘The Re-Invention of sor in the Department of Air Transportation, Kainan University, Taiwan. Danny Human Error,” errors are systematically Chang is head of the Training Division, China Airlines, Taiwan. Thomas Wang is connected to many features of a pilot’s director of the Flight Safety Division, Aviation Safety Council, Taiwan. Hong-Tsu tools and tasks and that the notion of er- Young is managing director of the Executive Yuan, Aviation Safety Council, Taiwan. ror itself has its roots in the surrounding

July–September 2010 ISASI Forum • 5 HET has been demonstrated to be a reliable and valid methodology. It has been socio-technical system associated with benchmarked against functionally related) are more likely to be aircraft operations. The question of hu- three existing techniques: omitted; a step is more likely to be omit- man error or system failure alone is an ted if instructions are given verbally (for oversimplification. The causes of error SHERPA—Systematic example, in the “challenge and response” are many and varied and almost always Human Error Reduction format used on the flight deck); and inter- involve a complex interaction among the and Prediction Approach; ruptions during a task that contains many pilot’s actions, the aircraft flight deck, Human Error HAZOP— steps are most likely to cause errors. W-C the procedures to be employed, and the Li and D. Harris in 2006 observed that operating environment. Hazard and Operability 30% of accidents relevant to “violations” During the last decade, “design-in- study; and HEIST—Human in military aviation included intentionally duced” error has become of particular Error In Systems Tool, and ignoring SOPs, neglecting SOPs, applying concern to the airworthiness authorities, outperformed all of them improper SOPs, and diverting from SOPs. particularly in the highly automated The figure was higher in commercial third- and fourth-generation airliners. in a validation study aviation, with almost 70% of accidents A 1996 FAA-commissioned study of the including some aspect of a deviation (or pilot-aircraft interface on modern flight However, such rules relating to design can non-adherence) to SOPs. decks identified several major design de- only address the fabric of the airframe Formal error identification techniques ficiencies and shortcomings in the design and its systems; the new regulations can implicitly consider simultaneously both process. There were criticisms of the only minimize the likelihood of error as a the design of the flightdeck interfaces and flightdeck interfaces, identifying problems result of poor interface design. The new the procedures required to operate them. such as pilots’ autoflight mode awareness/ regulations cannot consider errors result- They can be applied at early design stages indication; energy awareness; position/ ing from such factors as the inappropriate to help avoid design-induced error during terrain awareness; confusing and unclear implementation of procedures, etc. the flightdeck design process, but they can display symbology and nomenclature; From a human factors viewpoint, which also be used subsequently during flight a lack of consistency in FMS interfaces assumes that the root causes of human operations to diagnose problems with and conventions, and poor compatibility error are often many and interrelated, SOPs and provide a basis for well-founded between flightdeck systems. The Depart- the new regulations have only addressed revisions. However, it should be noted that ment of Transportation (DOT) subse- one component of the wider problem. The formal error prediction methodologies quently assigned a task to the Aviation design of the flightdeck interfaces cannot only really address Reason’s skill-based Rulemaking Advisory Committee (ARAC) be separated from the aircraft’s operating (and some rule-based) errors within a to provide advice and recommendations procedures. Complex flightdeck inter- fairly well-defined, proceduralized con- to the FAA administrator to “review the faces, while potentially more flexible, are text. Hence they can only help in protect- existing material in FAR/JAR 25 and make also potentially more error prone (there ing against errors that relate either to the recommendations about what regulatory are far more opportunities for error). flightdeck interfaces or their associated standards and/or advisory material should Analysis of aircraft accident investigation operating procedures. be updated or developed to consistently reports has suggested that inappropri- HET, developed by A. Marshall, N. address design-related flight crew per- ate system design, incompatible cockpit Stanton, M. Young, P. Salmon, D. Harris, formance vulnerabilities and prevention display layout, and unsuitable standard J. Demagalski, T. Waldmann, and S. Dekker (detection, tolerance, and recovery) of operating procedures (SOPs) are major is a human error identification (HEI) flight crew error.” (DOT, 1999) Since Sep- factors causing accidents. tech­nique designed specifically for ap- tember 2007, rules and advisory material plication on the aircraft flight deck. Ad- developed from ARAC tasking have been Checklists and procedures visory Circular AC25.1309-1A suggested adopted by EASA (European Aviation With regard to checklists and procedures, that the reliable quantitative estimation Safety Agency) as Certification Specifi- various axioms have been developed over of the probability of crew error was not cation (CS) 25.1302 and with supporting the years. For example, J.T. Reason in possible. As a result, HET was developed advisory material in AMC (Acceptable 1988 observed that the larger the num- specifically for the identification of po- Means of Compliance) 25.1302. ber of steps in a procedure, the greater tential errors using formal methods, not Perhaps the true significance of the the probability that one of them will be their quantification. It was developed as establishment of this regulation is that for omitted or repeated; the greater the in- a diagnostic tool intended as an aid for the first time there is a specific regulatory formation loading in a particular step, the the early identification of design-induced requirement for “good” human factors on more likely that it will not be completed errors, and as a formal method to dem- the flight deck. It is an attempt to eradicate to the standard required; steps that do onstrate the inclusion of human factors many aspects of pilot error at the source. not follow on from each other (i.e., are not issues in the design and certification

6 • ISASI Forum July–September 2010 Error Modes

Sub-task for performing Task execution incomplete Task Wrong task executed Wrong executed too early Task executed too much Task Misread information Go-around by HTA Fail to execute executed in wrong Task direction repeated Task executed on wrong Task interface element executed too late Task executed too little Task Other

1.1.1 Press TO/GA Switches 33.93 16.07 7.34 26.79 16.07 7.34 16.07 25.00 1.79 0.00 1.79 3.57

1.1.2 Thrust has advanced 26.79 48.21 0.00 0.00 0.00 0.00 5.36 5.36 10.71 0.00 5.36 8.93

1.2.1 PF command flap 20 42.86 12.50 0.00 5.36 0.00 0.00 3.57 42.86 1.79 1.79 0.00 0.00

1.2.2 PM place flap lever to 20 19.64 14.29 10.71 5.36 0.00 3.57 5.36 19.64 3.57 0.00 0.00 7.14

1.3.1 Verify TO/GA mode annunciation 48.21 26.79 1.79 1.79 0.00 5.36 0.00 8.93 0.00 1.79 12.50 7.14

1.3.2 Rotate to proper pitch attitude 5.36 39.29 3.57 1.79 1.79 0.00 5.36 25.00 35.71 8.93 3.57 1.79

Verify adequate thrust 1.4.1 53.57 39.29 7.14 5.36 0.00 0.00 3.57 8.93 1.79 3.57 10.71 3.57 for go-around

1.4.2 Announce go-around thrust set 62.50 26.79 0.00 1.79 0.00 0.00 1.79 12.50 0.00 3.57 0.00 0.00

1.5.1 Verify positive rate of climb 32.14 19.64 7.14 0.00 0.00 0.00 1.79 23.21 0.00 0.00 0.00 12.50

1.5.2 Place gear lever to up 39.29 7.14 5.36 3.57 0.00 1.79 19.64 42.86 0.00 0.00 0.00 8.93

1.6.1 Select Roll mode 26.79 14.29 14.29 10.71 0.00 8.93 5.36 51.79 0.00 0.00 3.57 3.57

1.6.2 Verify Roll mode annunciation 35.71 23.21 1.79 3.57 0.00 0.00 0.00 17.86 0.00 3.57 3.57 8.93

1.6.3 Turn into correct track 5.36 28.57 10.71 5.36 0.00 1.79 5.36 41.07 3.57 0.00 0.00 3.57

1.7.1 Select Pitch mode 23.21 26.79 23.21 5.36 0.00 3.57 8.93 50.00 1.79 1.79 3.57 3.57

1.7.2 Verify Pitch mode annunciation 26.79 26.79 3.57 3.57 0.00 0.00 1.79 21.43 0.00 3.57 0.00 10.71

1.7.3 Maintain proper pitch attitude 12.50 46.43 12.50 1.79 0.00 1.79 1.79 21.43 7.14 8.93 3.57 1.79

1.8 Follow M/A Procedure 10.71 50.00 25.00 17.86 0.00 7.14 8.93 30.36 0.00 0.00 12.50 3.57

Table 1: The Results for the Human Error Modes in Aircraft X When Performing a Go-Around Numbers in the Cells Show Percentage (%) of Respondents Reporting That Error Mode in Each Task Step process of aircraft flight decks. Operability study; and HEIST—Human to be simple to learn and use, requiring HET has been demonstrated to be a Error In Systems Tool, and outperformed very little training, and is so designed reliable and valid methodology. It has all of them in a validation study comparing to be a convenient method to apply in a been benchmarked against three existing predicted errors to actual errors reported field study. The error taxonomy used is techniques: SHERPA—Systematic Human during an approach and landing task in comprehensive as it is based largely on Error Reduction and Prediction Approach; a modern, highly automated commercial existing error taxonomies from a number Human Error HAZOP—Hazard and aircraft. The HET method has been proven of HEI methods, but it has been adapted

July–September 2010 ISASI Forum • 7 Description of Errors Occurred Occurrence rate Modes of Error during Go-Around ME OTHERS AVERAGE Fail to execute Q5. Failed to check thrust level 38.81% 56.72% 47.76% Q8.Thrust lever were not advanced manually when the auto-throttles Task execute incomplete 29.85% 53.73% 41.79% became inoperative Fail to execute Q9. Failed to command ‘flap 20’ due to pilot’s negligence 25.37% 67.16% 46.26%

Fail to execute Q15. Failed to check whether TO/GA mode was being activated 44.78% 46.27% 45.53%

Task execute too late Q17. Late rotation, over / under rotation. 46.27% 50.75% 48.51% Task execute incomplete Q18. No check for primary flight display 26.87% 56.72% 41.79% Fail to execute Q23. Failed to check go-around thrust setting 53.73% 52.24% 52.99% Task execute too late Q25. Did not identify and correct speed deviations on time 46.27% 47.76% 47.015% Fail to execute Q26. Forgot to call ‘go-around thrust set’ 68.66% 70.15% 69.41% (1)

Task execute too late Q27. Did not identify and correct go-around thrust deviations on time 35.82% 58.21% 47.02%

Fail to execute Q30. Forgot to put the landing gear up until being reminded 40.30% 59.70% 50%

Task execute too late Q33. Did not engage LNAV mode on time failed to capture 49.25% 58.21% 53.73% (3)

Fail to execute Q37 Failed to check whether LNAV/ HDG was being activated 31.34% 64.18% 47.76%

Task execute on wrong Q39. Mixed up the IAS/HDG bugs on the MCP 34.33% 49.25% 41.79% interface

Fail to execute Q42. Did not engage VNAV mode on time failed to capture 44.78% 62.96% 53.37%

Task execute incomplete Q46. No check whether VNAV or FLCH was being activated 38.81% 56.72% 47.76%

Task execute incomplete Q48. Did not monitor the altitude at appropriate time 38.81% 55.22% 47.02% Task execute too little Q62 Poor instrument scan 43.28% 55.22% 49.25% Q65. Not using auto-flight system when available and Task execute incomplete 55.22% 65.67% 60.45% (2) appropriate. Table 2: The Occurred Rates of Error Break Down by Detail Operational Behaviors for Aircraft X Performing Go-around (Shown the Average Error More Than 40% for Both ME and OTHERS) and extended specifically for the aerospace go-around procedures in a large commer- process of reviewing the integration of environment. cial aircraft to identify potential areas for hardware design, standard operating The International Air Transport As- improvement in the design of the SOPs procedures, and pilots’ actions during a sociation (IATA) analyzed data from 240 involved. go-around. The task analysis undertaken member airlines and found that about 50% was for the go-around on a large, four- of accidents in 2007 occurred during the Study method engined, intercontinental jet transport phrases of final approach and landing, a Participants: Sixty-seven pilots partici- aircraft (aircraft X). period that comprises (on average) only pated in this research, including 25 captains Task Decomposition: Go-around opera- 4% of the total flight time. Most pilots are and 42 first officers. Twenty-one pilots had tions can be considered as the required trained that executing a go-around is the in excess of 10,000 flight hours; 18 pilots had actions to be made by a pilot to achieve prudent course of action when a landing between 5,000 and 9,999 hours; 17 pilots the associated goal and based on the SOPs. is not progressing normally and a safe had between 2,000 and 4,999 hours, and 11 Once the overall task goal (safely perform- outcome is not ensured. This is the best pilots had below 1,999 flying hours. There ing a go-around) had been specified, the practice, but it isn’t always a straightfor- were 12 instructor pilots, 18 ground train- next step was to break this overall goal ward decision. Knowing how to execute the ing instructors, and 37 pilots with teaching down into meaningful sub-goals, which go-around maneuver and being proficient experience. The age range of participants together formed the tasks required to in its execution are extremely important, was between 28 and 60. All participants achieve the overall goal. but still more is required. Pilots must held a type-rating for the large jet trans- In the task “safely performing a go- possess the skill and knowledge to de- port aircraft under consideration. around,” this overall goal was broken cide when to execute a go-around. Many Description of the Task: The first step down into sub-goals, for example: 1.1 accidents have happened as a result of was conducting a hierarchical task analy- Press TO/GA Switches, 1.2 Set Flaps hesitating too much before deciding to sis (HTA) to define clearly the task under Lever to 20, 1.3 Rotate to Go-around At- abort the landing. This research applies analysis. The purpose of the task analysis titude, 1.4 Verify Thrust Increase, 1.5 Gear the HET to the retrospective analysis of in this study was an initial step in the up, 1.6 Select Roll Mode, 1.7 Select Pitch

8 • ISASI Forum July–September 2010 Participants responded to items based upon the 17 sub- tasks in which each step could Mode, and 1.8 Follow Missed Approach include any one (or more) of of the form that the error would take was Procedures. The analysis of each task goal 12 different types of human required and the outcome or consequence was broken down into further sub-goals, associated with the error was determined. and this process continued until an ap- errors (see Table 1). Each sub- The likelihood of the error was estimated propriate operation was reached. The bot- task consisted of operational using a very simple scale (low, medium, tom level of any branch in a HTA should behaviors for participants or high) as was the criticality of the error always be an operation. For example, the to evaluate based on his/her (low, medium, or high). If an error was sub-goal 1.7 Select Pitch Mode was broken given a high rating for both likelihood and down into the following operations: 1.7.1 own experience (ME) or if criticality, the task step was then rated Select Pitch Mode, 1.7.2 Verify Pitch Mode he/she knew of someone who as a “fail,” meaning that the procedure Annunciation, and 1.7.3 Maintain Proper had committed the errors involved should be examined further and Pitch Attitude. Seventeen bottom-level (OTHERS). it should be considered for revision. tasks were identified in this analysis. Many of the errors observed during the Classifying Error Modes: HET is a go-around show an interaction between checklist-style approach to error predic- category). It was hoped that this format procedures and the design of the flight tion utilizing an error taxonomy comprised would increase the participant’s confidence deck. They are not simply the product of of 12 basic error modes. The taxonomy in being able to report errors. For example, either poor design or inadequate SOPs was developed from reported instances of if they had made the error themselves but alone. For example, the responses to actual pilots and extant error modes used had no desire to admit to making the error, Question 8 (see Table 2) suggested that in contemporary HEI methods. The HET they could check the “OTHERS” box. on many occasions the thrust levers were taxonomy is applied to each bottom-level not advanced manually when the auto- task step in an HTA of the flight task in Results and discussion throttles became inoperative. There could question. The technique requires the ana- Participants responded to items based be several reasons for this. For instance, lyst to indicate which of the HET error upon the 17 sub-tasks in which each step when a pilot decides to go around, the modes are credible (if any) for each task could include any one (or more) of 12 dif- first step is to press the TO/GA switches, step, based upon their judgment. There ferent types of human errors (see Table 1). which will activate the correct mode of the are 12 basic HET error modes: “Failure Each sub-task consisted of operational be- autothrust system. However, to control to execute,” “Task execution incomplete,” haviors for participants to evaluate based thrust manually, pilots need to press the “Task executed in the wrong direction,” on his/her own experience (ME) or if he/ autothrust disengage switches. Since the “Wrong task executed,” “Task repeated,” she knew of someone who had committed TO/GA switches and autothrust disengage “Task executed on the wrong interface the errors (OTHERS). switches are next to one another, pilots element,” “Task executed too early,” There were 19 task steps with a very may accidentally press the wrong switch, “Task executed too late,” “Task executed high percentage of errors during go- which would cause the thrust levers not to too much,” “Task executed too little,” around—defined as being when the aver- advance during the go around. “Misread information,” and “Others.” A age number of errors for both ME and The following are some incidents related full description of the methodology and all OTHERS was more than 40% (see Table to the sub-task of “Press TO/GA Switches,” materials can be found in Development of 2). The most common error mode for pilots (1) Pilot retried to push the TO/GA switch the Human Error Template–A New Meth- performing the go-around was “Failure to immediately, aircraft continued the go- odology for Assessing Design Induced execute,” the second highest was “Task around operation; (2) Pilot failed to press Errors on Aircraft Flight Decks (2003) execution incomplete,” the third highest TO/GA switch, aircraft touched down on by A. Marshall, N. Stanton, M. Young, was “Task executed too late” (see Table 2). the runway due to no go-around thrust be- P. Salmon, D. Harris, J. Demagalski, T. The most commonly occurring operational ing delivered and caused a hard landing in- Waldmann, and S. Dekker. error when performing the go-around cident; (3) Aircraft became unstable during The Design of the Evaluation: These 17 was “Forgot to call go-around thrust set” approach due to unsuccessful go-around. bottom-level tasks were broken down into (average 69.41%); the second highest was Aircraft went into incorrect pitch attitude, 65 operational items to be evaluated by all “Not using autoflight system when avail- either below normal flight path or pitched participants using a structured question- able and appropriate” (average 60.45%); up to high pitch attitude; (4) Flight director naire. The questionnaire format asked the third most common error reported (F/D) did not display go-around pitch be- participants if they had ever made the was “Did not engage LNAV mode on time cause of autoflight display system (AFDS) reported error themselves (by checking failed to capture” (average 53.73%). was not triggered; it wouldn’t provide cor- the “ME” category) and/or if they had These 17 bottom-level sub-tasks were rect pitch guidance because pitch mode observed anyone else who had made the further evaluated by all participants. For annunciation did not change to go-around same error (by checking the “OTHER” each credible error identified, a description mode. However, the error data also show a

July–September 2010 ISASI Forum • 9 It is hoped that the implementation of new human factors certification failure to follow the required procedures— standards and the analysis dict design-induced error on the flight deck. in this instance Question 23 (“failed to check of associated procedures This study also demonstrates that it can be go-around thrust setting”), which should used in the opposite manner to structure pick up the failure of the thrust levers to using a validated formal error data collection and provide an analytical advance to the appropriate setting. prediction methodology will taxonomy for the retrospective collection of Such confusion of system interface com- help to ensure that many of error data. Looking ahead, the HET meth- ponents is not new. Alphose Chapanis in these potential errors will be odology can also be applied to prospectively his book The Chapanis Chronicles recalls test any revised SOPs to assess their error his work in the early 1940s in which he eliminated in the future. potential prior to instigating them, thereby investigated the problem of pilots and co- avoiding the requirement for an error his- pilots retracting the landing gear instead However, many of the procedural er- tory to develop before the reevaluation of of the landing flaps after landing in the rors observed are not direct products of the revised procedures is possible. Boeing B-17. His investigations revealed the flightdeck interface. They are mostly that the toggle switches for the gear and errors of omission (a failure to do some- Conclusion the flaps were both identical and next to thing); for example, see Table 2, questions By the use of a scientific HTA-based ap- each other. He proposed coding solutions 5, 9, 15, 23, 30, etc. Some of these errors proach to evaluate current SOP’s design to the problem: separate the switches in the execution of the SOPs could be together with a formal error analysis, (spatial coding) and/or shape the switches mitigated by changes to the aircraft’s in- and consideration of the interface layout to represent the part they control (shape terfaces and warning systems (and indeed and operating procedures, flight safety coding) enabling the pilot to tell either some are, for example, a speed warning will be enhanced and a user-friendly by looking at it or by touching the switch on the landing gear position—question task environment can be achieved. This what function it controlled. This was par- 30, better interface design—question 39, research used the HET error identifica- ticularly important especially in a stressful better mode indication—question 46). tion methodology (originally developed situation (for example, after the stresses These all address the first bullet point to assess design induced error as part of a combat mission or in this case, when in the previous list, enabling the crew to of the compliance methodologies under performing a go-around). detect or recover from error. However, AMC25.1302) in a retrospective manner Even experienced, well-trained, and many of the errors listed in Table 2 would to assess error potential in existing SOPs rested pilots using a well-designed flight- not be mitigated by better design (for ex- when performing a go-around in a large deck interface will make errors in certain ample, questions 48 and 62). Simplifying commercial jet transport aircraft. It was situations. As a result, CS 25.1302 requires or redistributing the go-around proce- found that pilots committed three basic that “to the extent practicable, the installed dures between the flightcrew members types of error with a high likelihood of equipment must enable the flight crew to may, however, have a beneficial effect as occurrence during this maneuver: “Fail manage errors resulting from flight crew a result of either redistributing workload to execute,” “Task execution incomplete,” interaction with the equipment that can (allowing more time for other tasks, such and “Task executed too late.” Many of be reasonably expected in service, assum- as monitoring the flight instruments) or these errors had roots resident in the ing flight crews acting in good faith.” To reducing the number of procedural steps design of the procedures or resulted from comply with the requirement for error each pilot is required to execute. an interaction between the procedures and management (which is actually closely Both Reason and Dekker have proposed some aspects of the flightdeck design. It associated with procedural design), the that human behavior is governed by the is hoped that the implementation of new flightdeck interfaces are required to meet interplay between psychological and situ- human factors certification standards the following criteria. They should ational factors. The opportunities for error and the analysis of associated procedures • enable the flight crew to detect and/or are created through a complex interaction using a validated formal error prediction recover from error or among the aircraft flightdeck interfaces, methodology will help to ensure that many • ensure that effects of flight crew errors system design, the task, the procedures to of these potential errors will be eliminated on the airplane functions or capabilities be employed, and the operating environ- in the future. ◆ are evident to the flight crew and contin- ment. It is naive to assume that simply ued safe flight and landing is possible or improving one component (such as the (Acknowledgement—This project is sup- • discourage flight crew errors by using flightdeck interfaces) will have a major ported by the grant from the National switch guards, interlocks, confirmation effect in reducing error by considering it Science Council of Taiwan [NSC-98- actions, or similar means, or preclude the in isolation. 3114-Y-707-001]. The authors would like to effects of errors through system logic and/ With regard to the HET methodology express their appreciation to the Aviation or redundant, robust, or fault-tolerant employed, prior to this study it has always Safety Council for providing a financial system design. been used in a prospective manner to pre- endowment to carry out this research.)

10 • ISASI Forum July–September 2010 aggie Wai Yee Wong, program. It is totally depen- Additionally, I can even have a model the effects of runway Embry-Riddle (ERAC); dent upon voluntarily (tax closer look into aircraft. Upon contamination on aircraft take- MLogan Jones, Institut free in the U.S.) contributions. my graduation, I will continue off and landing performance. Superieur de l’Aeronautique Since the program’s inception, to pursue a career in aviation By better understanding the et de l’Espace (ISAE); and more than $35,166 have been safety and a masters degree in effects, we can build better Leigh Dunn, Cranfield Safety donated. Much of the fund- a related field.” models to calculate the air- and Accident Investigation ing has come from donations Her professional aspira- craft takeoff and landing dis- Centre, Cranfield University, made by ISASI chapters and tions? “Making a difference.” tances. The subject intrigued have been selected by ISASI societies. Logan Jones is pursuing a me due to the enormity of the scholarship fund adminis- Maggie Wong is seeking Ph.D. in aeronautical science— current problem; 30% of all trators as 2010 recipients of accidents are runway excur- the ISASI Rudy Kapustin sions, of which the majority Memorial Scholarship. The had runway contamination/ Scholarship was established in poor braking as a contributing memory of all ISASI members Three ‘Kapustin’ factor. Therefore, if we can get who have died and was named the pilots better information in honor of the former ISASI Scholars Selected in the cockpit regarding the Mid-Atlantic Regional Chap- runway state and its effect on ter president. Students from Embry-Riddle Aeronautical the aircraft performance, we The Scholarship is intended University, Florida, U.S.A.; Institut Superieur de can vastly improve safety. As to encourage and assist col- l’Aeronautique et de l’Espace, Toulouse, France; part of the thesis work, I have lege-level students interested and Cranfield Safety and Accident Investigation studied several runway over- in the field of aviation safety run accidents and performed and aircraft occurrence inves- Centre, Cranfield University, UK, have been numerous aircraft flight per- tigation, according to Richard selected as the 2010 recipients of ISASI’s Rudolph formance reconstructions to Stone, ISASI executive advi- Kapustin Memorial Scholarship. determine the effects of the sor and one of the two fund By Esperison Martinez, Editor runway state. It was this work administrators. Contributions and my interest in aircraft ac- such as those made at the re- cidents and safety that led me cent MARC meeting (see page an undergraduate degree in modeling aircraft takeoff and to ISASI.” 26) have and will continue to safety science (aviation). She landing performance on con- His professional aspirations? provide an annual allocation of will graduate in May 2011 taminated runways—from “To continue to contribute to funds for the Scholarship. from ERAU, Daytona Beach, ISAE; he is expected to com- aeronautical safety. Whether The ISASI executive advisor Fla. She was born in Hong plete his degree in February that be on the manufacturer and ISASI vice-president, of- Kong, calls Fayetteville, Ga., 2012. His birth place and home side to continue to innovate fices presently filled by Stone her hometown, and presently is Alberta, Canada; but he aircraft systems to reduce and Ron Schleede, serve as lives in Daytona Beach. Her resides in Toulouse, France. accidents or on the investiga- executors and administrators interests are varied: art, music, Jones holds a BSc in mechani- tive side to explain the cause of the fund. They review all ap- cooking, language, shopping, cal engineering from the Uni- of accidents and implement plications, which include a 1,000 traveling, and flying. versity of Alberta, Canada, and measures to reduce the risk of (+/- 10%) word essay in English She says about herself: “I an MSc in aeronautical engi- reoccurrence.” addressing the challenges for am a college senior who was neering from ISAE in France. Leigh Dunn is pursuing his air safety investigators. The also the student president for He is licensed as a private Ph.D. from the Cranfield Safety Scholarship consists of an an- the ISASI student chapter for pilot and enjoys scuba diving, and Accident Investigation nual $2,000 award, a one-year the academic year 2009 to 2010. traveling, and soccer. Centre at Cranfield University, ISASI membership, and a fee- Since I was little, I have always His intense interest in aero- UK. He is researching com- free attendance at an accident enjoyed looking at planes and nautics is evident from his posite material failure analysis investigation course at both the eventually decided to become undergraduate and graduate from the field investigator’s FAA’s Transportation Safety a pilot. However, after obtain- studies and accomplishments, perspective. Born in the UK, Institute and the Southern ing my private pilot license in which he described in response his home is in Hockliffe, UK. He California Safety Institute. high school, I realized that I to a query from the Forum. holds a BEng in aerospace engi- The award’s intent is to would like flying more if I were “After receiving my MSc, neering from the University of grant a student membership to do it for recreation. After I accepted to do a thesis in Hertfordshire. He is licensed as in ISASI and to assist the consulting some professors in collaboration with ISAE, the a private pilot and flies gliders. recipient(s) to attend the re- the safety field, I decided to French aeronautic research lab Married, he spends his extra spective year’s ISASI annual begin an education in aviation Onera, and Airbus. It was the time with his 16-month-old international seminar on air safety. Not only can I save subject of the thesis work and daughter and rides a motorbike accident investigation. No dues lives by making changes, but its applications that intrigued for recreation. funds are used to support this I can also make a difference. me. The subject is to study and Here is his response to the

July–September 2010 ISASI Forum • 11 Forum’s request for a short aerospace industry. In 2009 with a fantastic opportunity who donated to the ISASI, biography: “I’m 29 and started I became a full-time Ph.D. to assist in my aspirations to Rudolf Kapustin Memorial flying gliders at the age of 13. candidate and expect to gradu- work within the investiga- Scholarship program, ISASI, At the age of 19, I entered ate in 2012. It is a personal tion community, whether it is and the training institutes the University of Hertford- imperative that the product of through the training opportu- who offered free attendance to shire. While there, I flew in the my Ph.D. is of benefit to the nities it provides or through courses. To these I am excep- RAF University of London Air accident investigation commu- the exposure to the accident tionally grateful.” ◆ Squadron. After graduation in nity as well as to the academic investigation community. This 2002, I joined a global company community. The Kapustin would not be possible if it were The Scholarship essays of the that supplied metallics to the Scholarship has provided me not for the generosity of those awardees follow.

vital evidence become bleak. that humans are only able to Furthermore, the Atlantic recover about 30% of what The Untraceable Aircraft Accidents Ocean and Indian Ocean are they see (Wood and Sweginnis, By Maggie Wong more than 13,000 feet deep. 2006). Sometimes witnesses The ocean currents may even may have poor memory and A m o n g t h e was an over-the-sea aircraft move the debris and black distance estimations. Differ- many prob- accident that has a compli- boxes to remote areas. Thus, ent age groups may provide lems such as cated investigation. The Airbus information or evidence that different statements based stress, fatigue, crashed into the Atlantic Ocean is available to investigators on their experience and level time restraints, on June 1, 2009. It was the becomes scarce. It elevates the of education. They can also and legal issues first accident in many years difficulty level in conducting an be biased about what they that air safety that left almost no trace for investigation. see according to their back- investigators the investigators to examine An aircraft accident in- grounds. Furthermore, their confront, the biggest challenge (Michaels and Pasztor, 2010). vestigation is like composing aeronautical vocabulary may is determining the causes of an The flight departed from Brazil a gigantic puzzle. Without a be limited to describe certain accident when little evidence and intended to land in Paris. sample image of it, it is hard to aircraft parts, and they may is available. When an aircraft Before the crewmembers lost put it back together. An inves- give inaccurate descriptions. accident occurs, air safety in- communication with air traffic tigation becomes challenging Therefore, investigators can- vestigators are interested in control, they sent out numer- if the sample image, or the not solely rely on witness knowing what happened, why ous aircraft communications it happened, and how they addressing and reporting sys- can prevent it from happening tem (ACARS) messages be- n aircraft accident investigation is like again. However, the challenge fore crashing into the Atlantic Acomposing a gigantic puzzle. Without a becomes greater when the Ocean. All 228 people on board sample image of it, it is hard to put it back black boxes (cockpit voice re- were assumed deceased after together. An investigation becomes challenging corder and flight data recorder) long searches. Currently, 10 if the sample image, or the black boxes, is not and other critical information months after the crash, search cannot be recovered. With the ships have been launched again accessible. Since the mid-1970s, missing or lack of information, investiga- for their third attempt to locate damaged black boxes have blocked investigations tors have to gather and link all the black boxes. in a small number of major airline crashes. the tiny bits of evidence to de- Similar to Air France Flight termine the causes. Sometimes, 447, Yemenia Airways Flight witness statements, air traffic 626 also had difficulty in re- black boxes, is not accessible. statements. Similarly, if only control data, maintenance re- covering the black boxes. The Since the mid-1970s, missing air traffic control radar data, cords, and small amounts of flight originally departed from or damaged black boxes have maintenance records, and debris may be the only evidence Paris and intended to land in blocked investigations in a some insignificant debris are that is available. The auto- Sana’a, Yemen’s capital, on small number of major airline obtainable, the investigators mated dependent surveillance- June 30, 2009. When it took off crashes (Michaels and Pasztor, will probably have no other broadcast (ADS-B) is a new again to Comoros, the aircraft 2010). Just like Air France ways to seek information. technology that can enhance crashed into the Indian Ocean Flight 447, investigators are If an accident aircraft is aircraft accident investigations with only one survivor. Search still unable to determine the equipped with the ADS-B, in- by providing additional, precise teams struggled to locate the causes of the accident because vestigators will have an extra flight data. black boxes but eventually re- of the inability to locate the source for accurate flight infor- Aircraft accidents do not covered them. With over-the- black boxes and other signifi- mation. ADS-B’s main purpose always happen in a convenient sea accidents like Air France cant information. Although an is to provide real-time flight place where all vital evidence Flight 447 and Yemenia Flight accident may have eyewit- information to pilots and air can be easily recovered. For 626, the chances of recover- nesses available to investiga- traffic controllers in order to instance, Air France Flight 447 ing the black boxes and other tors, psychologists estimate improve aviation safety. How-

12 • ISASI Forum July–September 2010 ever, ADS-B can supply the a valuable investigative tool tool, but it can also improve sibly prevent the accident from investigators with additional that can give a much better overall aviation safety by pro- happening again. ◆ information of the flight when picture of the events leading viding real-time and accurate References black box or full wreckage to an accident and reduce information to pilots and air ADS-B ARC Report with recovery is impractical. hind­sight bias (Zwegers, 2009). traffic controllers. FAA. (2008, October). Air Safety According to ADS-B Tech- With ADS-B, investigators In 2007, the FAA issued a Week, 22(38). Retrieved April 1, 2010, from Career and Technical Education. nologies, LLC, although the in- will at least be able to have a notice of proposed rulemak- (Document ID: 1568395571.) formation that ADS-B contains basic understanding of what ing (NPRM) that planned to ADS-B Technologies, LLC. (2009). What may not be as thorough as the an ADS-B-equipped aircraft require all aircraft operating is ADD-B? Retrieved April 2, 2010, from http://www.ads-b.com/home.htm. black boxes, it is able to pro- was doing before a crash when in the United States to install Comair Flight 5191: The Captivating vide precise and real-time in- other data are limited. ADS-B by 2020. Besides the Rhythm of Induced Error. (2006, Sep- formation such as speed, head- An aircraft accident investi- FAA, according to Air Safety tember). Air Safety Week, 20(35), 1. Retrieved April 1, 2010, from Career ing, altitude, flight number, gation with limited information Week, the Air Transport Asso- and Technical Education. (Document weather, and terrain informa- is often a challenge to investi- ciation (ATA) and its member ID: 1125682461.) Daniel Michaels, & Andy Pasz- tion without degradation due gators. Fortunately, ADS-B is airlines are also strong advo- tor. (2010, March 29). Corporate to atmospheric conditions and a new technology that can aid cates of this new technology. News: EU Makes Push for Real-Time range. It is a satellite-based aircraft accident investiga- The European Union and other Flight Data--In Wake of Crashes Where “Black-Boxes” Were Lost or global positioning system that tions by providing additional European aviation organiza- Hard to Locate, Regulators Hope Sat- broadcasts the aircraft position flight information, despite the tions also support installing ellites Can Stream Information. The and other data to other aircraft wreckage location. As long as ADS-B, especially after the Wall Street Journal (Eastern Edi- tion), p. B.3. Retrieved April 1, 2010, and ground stations that are an aircraft is equipped with tragedy of Air France Flight from ABI/INFORM Global. (Docu- equipped with ADS-B. Along ADS-B, investigators will be 447. If Air France Flight 447 ment ID: 1996002901.) with the ADS-B software, able to know its flight informa- was equipped with ADS-B, Wood, Richard & Sweginnis, Robert . (2006). Aircraft Accident Investiga- flight data can be collected tion such as speed, altitude, investigators would have a tion. Casper: Endeavor Books. on the ground and is always and direction at a minimum fundamental understanding Zwegers, David. “Using ADS-B for Ac- accessible. Along with the air when other critical evidence of the accident, be able to give cident Investigation and Prevention, an Embry-Riddle Aeronautical Uni- traffic control audio recording, cannot be retrieved. ADS-B is answers to the families and versity Perspective.” Accident Preven- the ADS-B flight data can be not only a great investigative friends of the victims, and pos- tion Beyond Investigations (2009).

monitoring, and others, have preliminary investigations will authorities currently deliber- aid in categorizing future UAS Shaping the Future of Unmanned ating regulations. operations based on the notion Operations: The Challenge for Unmanned operations rep- of acceptable risk. resent a fundamental change UASs can take a vast range Aircraft Safety Investigators to the manner in which vehicles of size, shape, and form: from By Logan Jones travel through our airspace. micro-drones weighing less This fundamental change than 1 lb to large aircraft weigh- As we reflect the cockpit and place them means that new regulations ing more than 40,000 lbs. Regu- back on the last in front of a control station, may be necessary to encom- lations must be put in place to 100 years of where they can either monitor pass UASs. As with any new ensure that during UAS opera- manned flight, autonomous operations of the type of technology, incidents tions, safety is maintained for we recognize vehicle or take control and pilot and accidents are inevitable; pilots in the air and the public the crucial role the vehicle themselves. UAS aircraft safety investigators on the ground. At the same that aircraft use can be broken down into will play a critical role, par- time, new regulations should safety investi- three sectors: military, civil, ticularly in the early years of take care not to unnecessarily gators (ASIs) have played in and commercial. Military use UAS operations, in shaping burden this new industry. The ensuring aviation safety. Their of UASs is wide spread, but the regulatory landscape and operational risk posed by a investigations and resulting they are generally operated making recommendations to 10,000-lb Predator B UAS and safety recommendations from outside of the national airspace ensure safety in the skies. the 430 g Wasp UAS are clearly accidents and incidents have (NAS). Civil use is limited and Several challenges exist for different. However, the risk is led to air travel continually is granted on a case-by-case ASIs in analyzing UASs due defined not only by size, but reducing its accident rate to base, while commercial use is to their considerable range of also by area of operation. The the record low levels of today. currently prohibited due to the size, mass, and velocity. Due same 430 g Wasp UAS operat- As we enter the second century lack of regulations. Neverthe- to the fact that there are cur- ing in an urban setting poses a of flight, a new type of aircraft less, the potential benefits rently no specific regulations different risk than a Predator operation is on the verge of en- of UASs in the commercial classifying different unmanned B operating over the Pacific tering into commercial use: un- and civil sectors, for opera- platforms, each investigation Ocean. It is apparent that defin- manned aerial systems (UASs). tions such as crop monitoring, is treated on a case-by-case ing acceptable risk will not be UASs pull the pilots out of search and rescue, weather basis. The results from these straightforward. Therefore, the

July–September 2010 ISASI Forum • 13 categorization of UASs will de- of Homeland Security, had its the initial failure, the lockup design. The challenge to air- pend on several factors such as fuel flow valve accidentally in the ground control unit, craft safety investigators will size, velocity, area of use, pilot shut off during a changeover occurred nine times in the be to take into account all of experience, platform reliability, in control units. This cascaded previous 3 months and yet the the factors involved in the op- system redundancy, and more. into a loss of data-link with the root cause of these lockups was eration of UASs and determine Regulations clearly cannot be pilot and subsequent crash into never discovered. Oversights the risk posed. Reliability, size “one size fits all.” A balance terrain. The ensuing NTSB such as this are not toler- and weight, area of use, pilot must be found to satisfy both investigation yielded deficien- ated in commercial manned experience, and system redun- safety concerns and industry. cies in all aspects of the UAS flight operations, and clearly dancy all will contribute to the The investigations into UAS operation: pilot experience, should not be for unmanned risk. The reports and safety incidents and accidents will incident reporting, ATC com- operations either. The NSTB recommendations from ASIs play a large role in determin- munication, A/C airworthiness, concluded that “now is the will shape the categorization ing where to draw the line emergency procedures, and the time…to build critical safety of UASs and ensure that the between different types of UAS lack of a safety plan to identify knowledge on how to operate benefits of civil and commer- UASs.” (NTSB, 2007) cial applications of UASs can The hurdle to widespread be achieved while maintaining he hurdle to widespread unmanned aerial UAS use is the regulations safety in our skies. ◆ Tsystems (UAS) use is the regulations governing governing safe operation in the safe operation in the national airspace. The national airspace. These regula- References tions will be based on providing La Franchi, Peter. “ICAO asks Air Navi- reports and safety recommenda­tions from ASIs gation Commission to recommend on an acceptable level of risk in the will shape the categorization of UASs and UAV Accident Investigation Require- air and on the ground. An effec- ments” Flight Global, 03 Oct. 2007. ensure that the benefits of civil and commercial tive process for the reporting Web. Mar. 18, 2010. applications of UASs can be achieved while National Transportation and Safety and analysis of incidents and Board. “CHI06MA121” NSTB, 09 maintaining safety in our skies. malfunctions will provide essen- May 2006. Web. Mar. 18 2010. tial knowledge for UAS design National Transportation and Safety Board “Safety Recommendations and will mitigate the risk of a A-07-65 through -69” NTSB, Oct. 24, operations. By analyzing inci- hazards (NTSB 2006). In total, catastrophic accident. These 2007. dents and most importantly by the NTSB issued 22 safety early investigations by ASIs Security Innovator, “NTSB Cites Wide Range of UAV Safety Issues” Security asking the “what if ” questions, recommendations. Regarding will provide the framework for Innovator, 17 Oct 2007. Web. Mar. 20, investigators will provide in- the accident, NTSB chairman future UAS regulations and 2010. valuable knowledge regarding Mark V. Rosenker said, “The the acceptable risk posed by fact that we approved 22 safety the great variety of UASs. One recommendations based on of the most important factors our investigation of a single The Challenges for Air Safety in determining acceptable risk accident is an indication of the Investigators: From Kicking Tin to is reliability. scope of the safety issues these In September 2008 at the unmanned aircraft are bring- Kicking Composites ICAO General Assembly, a ing into the national airspace By Leigh Dunn proposal was made to include system.” (SecurityInnovator, the routine collection of UAS 2007) Composite ma- approximately 50% composite accident and incident data (La One of the key recommenda- terials are not material by structural weight Franchi, 2007). The analysis of tions from this accident inves- new to either with the aluminum content this data is necessary to deter- tigation was incident reporting. the aerospace being 20%. In contrast, the mine the reliability that UAS Quoting from the NTSB safety industry or to Boeing 777, which first flew platforms can provide. With a recommendations: “Require accident in- in June 1994, contains 12% database of UAS incidents and that all unmanned aircraft vestigators. It composite materials and 50% accidents, ASIs and regulators operators report to the FAA all was as early as aluminum. can determine operational weak incidents and malfunctions 1957 when the FS-24 Phoenix, A significant challenge for points and establish where sys- that affect safety; require that a sailplane constructed almost air safety investigators is keep- tem redundancy is needed. operators are analyzing these entirely from a glass fiber ing up with developments in The importance of this issue data in an effort to improve reinforced polyester resin and aircraft technologies. One was brought forth during the safety; and evaluate these data balsa sandwich, first flew. It is current and significant devel- first-ever civil UAS accident to determine whether programs only in recent years, however, opment is presented by com- investigated by the NSTB. and procedures remain effec- that composite materials have posite materials. As Rakow & A brief background into the tive in mitigating safety risks.” taken prominence in new com- Pettinger (2006) suggested at accident: On April 25, 2006, (NTSB, 2007) mercial aircraft designs. The ISASI’s 37th annual interna- a 10,000-lb Predator B UAS, In fact, during the accident Boeing 787, which first flew tional seminar, “Aircraft struc- operated by the Department investigation, it was found that in December 2009, contains tures of the current decade are

14 • ISASI Forum July–September 2010 progressing through a major fatigue resistant. Significant of metallics, a suspect fatigue- material technology. In addi- transition from metallic struc- fatigue crack growth may not initiated failure may be visibly tion, other challenges include tures to composite structures, develop until 60% of static fail- identified by beach marks and accident site hazards and crash- similar to the transition from ure stress so will we see fewer the presence of two distinctly worthiness investigations. So wood to metal in the 1920s.” traditional fatigue failures? different fracture zones. These how does the investigation com- This apparent shift in air- Delamination is a failure visual clues can also provide the munity meet these challenges? frame technology presents mechanism that is considered investigator with an indication Steps could include the sharing various challenges for air safety a significant issue for laminate as to the initiation site. In the of accident experiences, the cre- investigators. In the event of composite materials but one case of composites, visual ex- ation of literature, such as those a major accident involving a that does not affect traditional amination of most failure modes produced by Exponent and the composite airliner such as the aluminum materials. Delami- can be complicated through ATSB, conducting academic Boeing 787 or Airbus A350, nation involves the subsurface a substantial increase in the research, or by learning from the initial reaction of the news separation of plies of a laminate number of fracture surfaces, the experience of other sectors. media is likely to question the and may be initiated by rela- a general difficulty in visual The most important step, which safety of composite materials. tively low energy impacts. The identification, a high suscepti- is relevant to all of the above, This pressure will be intensified full extent of such damage may bility to post-fracture damage, is through the sharing of in- by the general public whose remain barely visible under and the lack of any significant formation within the investiga- primary source of information visual examination. Thus early permanent deformation. In tion community. This is where is through the news media. detection is reliant on nonde- the case of the latter, the per- ISASI, as a society established The world may well be sud- structive evaluation (NDE). denly looking to investigators Ransom et al (2008), however, to answer the question, “Are has recently questioned the ef- he understanding of metallic failure modes and composite aircraft safe?” fectiveness of NDE inspections Thow to make a preliminary visual identification Composite materials, unlike claiming that “nondestructive has benefited from decades of failures and aluminum, are relatively young evaluation (NDE) techniques of subsequent investigations.… Unfortunately, this in the development cycle and complex structures are gener- accrued knowledge and understanding of metallic are undergoing significant ally inadequate to detect dam- advancement and variations age during typical in-service failures cannot necessarily be transferred to the in designs. For example, the inspections.” understanding of composite material failures fuselage of the A380 contains The understanding of metal- due to key differences between metallics and GLARE, the Boeing 787 fuse- lic failure modes and how to composite materials. lage is filament wound carbon make a preliminary visual iden- fiber, and the A350 fuselage tification has benefited from is constructed of carbon fiber decades of failures and sub- manent deformation of metallic to promote air safety by the panels. These differences in sequent investigations. In the structures can provide valuable exchange of ideas, experiences, design are likely to complicate case of metal fatigue, Wanhill clues as to what was occurring and information, offers the ideal the investigation of composite (2002) discusses advances in the to the aircraft prior to or at the platform to ensure the chal- material accidents. knowledge of fatigue linked to time of impact. lenges presented are met by the What failure mechanisms notable aircraft accidents such For example, Frank Taylor community and not left to the are investigators likely to as the Comet disasters of 1954, (1998), in his paper discussing individual investigator. ◆ face? In 2002 Qinetiq, which which gave a general awareness the wreckage analysis of a provides forensic analysis of of finite aircraft fatigue life, DC-9 operated by Itavia that References Findlay & Harrison (2002). Why structural failures to the UK the F-111 wing failure in 1969, crashed off Ustica, discusses Aircraft Fail. Materials today, 5:11, AAIB, observed that the top which highlighted that aircraft how the permanent deforma- p18–25. three metallic failure mecha- should be damage tolerant; the tion of the aircraft structure Taylor (1998). The Study of Aircraft Wreckage: The Key to Aircraft Ac- nisms were fatigue (55%), Dan Air 707 accident in 1977, can be used to determine the cident Investigation. Technology, Law corrosion (16%), and overload which presented the fatigue of break-up sequence and to and Insurance, 3: 2, p129–147. (14%) (Findlay & Harrison, geriatric aircraft; and the Aloha locate the most probable posi- Wanhill (2002). Milestone Case Histories in Aircraft Structural integrity. Am- 2002). This result is perhaps Airlines 737 accident in 1988, tion of an explosive device. An sterdam: National Aerospace Labora- not surprising as typically the which highlighted multiple site absence of this “recording” tory NLR. fatigue limit of light alloys fatigue damage. of evidence may have ma- Rakow & Pettinger (2006). Failure anal- ysis of composite structures in aircraft can be as little as 10% of the Unfortunately, this accrued jor implications on accidents accidents. ISASI 37th Annual Inter- ultimate static strength. This knowledge and understand- where evidence from alterna- national Seminar, September 11–14, experience has provided an ing of metallic failures cannot tive sources is limited. 2006, Cancun, Mexico, p38–45. Ransom et al (2008). Lessons Learned understanding to the accident necessarily be transferred to The above has briefly high- from Recent Failure and Incident In- investigation community as the understanding of composite lighted the challenges of com- vestigations of Composite Structures. to how metallic aircraft pre- material failures due to key dif- posite failure analysis, the 49th AIAA/ASME/ASCE/AHS/ASC Structures, Structural Dynamics, maturely fail. Composites, on ferences between metallics and diversity of materials, and the and Materials Conference. April 7-10, the other hand, are relatively composite materials. In the case projected growth in composite 2008, Schaumburg, Illinois, p1–10.

July–September 2010 ISASI Forum • 15 Helicopter EMS Operations—At What Cost? The authors explain the special challenges in air medicine through a comprehensive and statistical analysis of EMS helicopter accidents in the United States from 1985 to 2007. By Christine Negroni (FO5208) and Dr. Patrick Veillette (This article is adapted with permission the high workload environment, and the States, Schaefer Air Service in Califor- from the authors’ paper entitled At What often-unplanned nature of the inflight nia started moving patients in specially Cost? A Comprehensive and Statistical route and landing zone all contribute to the equipped airplanes shortly after the end Analysis of EMS Helicopter Accidents unique nature of helicopter ambulances. It of the Second World War in the United States from 1985 to 2007 is a vastly different world and a markedly It was the wartime practice of moving presented at the ISASI 2009 seminar held more hazardous one than fixed-wing medi- American casualties during conflicts in in Orlando, Fla., Sept. 14-18, 2009, which cal flights. For these reasons, helicopter Korea and then Vietnam that inspired carried the theme “Accident Prevention EMS (HEMS) operations are the focus the idea of using helicopters to move the Beyond Investigation.” The full presenta- of this report. sick and injured in the civilian world. In tion, including cited references to support Contemporary air safety philosophy 1972 St. Anthony’s Hospital in Denver, the points made, can be found on the ISASI values the analysis of incidents and events Colo., became the first to offer helicopter website at www.isasi.org.—Editor) including self-reporting as a more proac- ambulance services in the U.S. tive method of reducing risk. Toward that From one in 1972, hospital helicopter viation in the United States is a end, this article analyzes FAA incidents, highly regulated environment, industry reported events, and 369 ASRS Christine Negroni is but air medical transport is an narratives filed anonymously by pilots who an aviation writer and odd exception. Operating under experienced a safety issue in flight as well safety specialist in differentA rules depending on the phase as accidents investigated by the NTSB. New York. She reports of flight, each air service sets its own In reviewing incidents and events, on aviation for The standards for pilot qualifications, aircraft such as aircraft malfunctions and adverse New York Times and equipment, and use of safety apparatus. weather conditions, the threat and error other publications. From In 2008, between helicopters and air- management assessment model was used 2000-2005, Negroni served on the FAA’s planes there were 16 crashes, 8 of them to see how these episodes were handled Aging Transport Systems Rulemaking fatal, killing 28 people—5 of them patients. and if the threat progressed to an “unde- Advisory Committee (ATSRAC). She This was the deadliest year on record for sired aircraft state.” is the author of the New York Times air medicine, and it renewed attention on The review shows that a large percent- notable book, Deadly Departure: Why the safety issues in this industry. While age of threats degrade to undesired air- the Experts Failed to Prevent the TWA we focus attention on EMS aviation in craft states. The narratives of participants Flight 800 Disaster and How it Could the United States, use of aircraft to trans- help to illuminate more thoroughly what Happen Again (HarperCollins 2000) port patients is growing throughout the happened, and some of those narratives and the forthcoming The Crash Detec- world. The issues raised here are widely are included in this report. tives: The Forensics of Fatal Transpor- applicable. Threats to safety will emerge in every tation Accidents. (Photo by Antonio It is important to discuss the history flight. Removing the known threats is an Schembari) and evolving business model of EMS avia- important first step. The NTSB has issued tion in the United States to understand multiple sets of safety recommendations Dr. Patrick Veillette is the pressures that have resulted from the going back to 1988. The FAA has chosen a professional corporate growth of the industry and subsequent to suggest rather than mandate many of Photo Not pilot, air safety special- Available safety issues. these recommendations. The analysis of ist, and aviation writer. We have created the Comprehensive the CMAS database and ASRS reports His articles have ap- Medical Aviation Services database also leads us to make several safety rec- peared in Aviation Safety (CMAS), which is comprised of accidents, ommendations. Journal and the Flight incidents, events, and a review of reports Safety Digest. He was named Aerospace from NASA’s Aviation Safety Reporting History Journalist of the Year (safety category) System (ASRS) from 1985 to 2008. This is The Royal Flying Doctor Service is prob- by the Royal Aeronautical Society in the information on which we rely to explain ably the oldest air ambulance in the world, 2007. In 25 years of piloting experience, the special challenges in air medicine. Of starting in 1928. A mission of the Presby- he has accumulated more than 15,000 the 1,132 air ambulances in the United terian Church, the service flew doctors to hours. Dr. Veillette is 1983 graduate of States, nearly two-thirds are rotorcraft. patients rather than the present model of the U.S. Air Force Academy and the The inherent instability of helicopters, flying patients to hospitals. In the United author of Loss of Control.

16 • ISASI Forum July–September 2010 Helicopter EMS Operations—At What Cost? The authors explain the special challenges in air medicine through a comprehensive and statistical analysis of EMS helicopter accidents in the United States from 1985 to 2007. By Christine Negroni (FO5208) and Dr. Patrick Veillette ambulance programs grew quickly. There The reimbursement criteria means dations, the following threat and error were 32 by 1980 and 174 by 1990, a five- there is no business incentive for flying management review of the EMS accident fold increase. Entering the 21st century, larger aircraft, twin-engine helicopters, or and incident data leads us to suggest the number of operators slowed but the installing anything beyond the minimum- several others. number of aircraft flying continued to required safety equipment. The decision grow, from 231 helicopters in 2000 to 840 of what safety equipment or whether to Threat and error management in 2008. install safety equipment is left up to the A “threat” is an external event or an error The increase was attributed to a 2002 operator. outside of the flight crew’s influence but re- change in federal Medicare policy that As a result, in 2009, less than half— quiring the active management of the crew revised the fees operators would be 40%—of HEMS operators had terrain to prevent it from impacting safety. An paid, doubling and in some cases tripling awareness and warning systems (TAWS); “error” is a deviation from organizational reimbursement for flying patients. The slightly more than half—57%—used twin- or crew expectations, and an “undesired Medicare fee schedule guaranteed a flat engine aircraft and were therefore capable aircraft state” is a compromised situation payment from the government. It also af- of autopilot or IFR; 30 % used night vision placing the flight at increased risk. fected what private insurance companies goggles; and less than 1% of HEMS opera- Pressure is the most common threat, would pay because often the insurance tors fly two-pilot crews. present in 93% of all the pilot reports. This rate is pegged to Medicare’s rate. Seem- Rather than elevating industry stan- can be from insufficient time to prepare for ingly overnight private companies found dards, the geography/distance payment a flight, patient conditions, management it profitable to get into the business of method depresses safety by pressuring pressures, deteriorating weather, etc. An medical transport. conscientious companies to reduce their excellent example is contained in the fol- costs to match the lowest competitor as lowing pilot narrative. What is medical transport? explained by Gary Sizemore, an EMS “The flight was flying from a hospital The typical HEMS flight is defined by its helicopter pilot and past president of the with a patient on board. The rain had atypicality. It can be any time of the day or National EMS Pilots Association. “One picked up, and the visibility was less than night, departing and landing at helipads or company is flying substandard; it’s using reported….I was able to maintain a couple on highway shoulders, carrying accident the cheapest aircraft available, saturating of lights to the side but forward lights all victims, premature babies, or organs for the area, flying with no safety equipment,” disappeared…. The problem is having a transplant. The constants are that the he said. “It is going to cause the large ven- patient on board and feeling the pressure EMS helicopter pilot will operate under dor to reduce overhead to compete.” to try to continue the flight in less than time pressure in a high-workload environ- Since its first hearing on EMS safety in reported conditions. They had discon- ment, often with a lack of enroute and/ 1988, the NTSB has held two more hear- nected the autopilot so it was inoperative. or destination information and weather ings urging the FAA to mandate certain I am ATP rated but not current IFR. We reporting and will be expected to oper- equipment and operational practices. In do have an IFR ship that should have been ate through obstacles and obstructions 2009 the NTSB recommended requiring sent on the flight but we are closer by 18 and into or out of non-standard landing all EMS operators to mi (sic) and our ship is much cheaper to zones including rooftops, highways, and • operate under Federal Aviation Regula- fly…. It is too bad that we sometimes have parking lots. tions Part 135 on all flights with medical to have less than favorable flight to get The industry works under several im- personnel on board (A-06-12), non-aviation people to realize closer and portant parameters. Federal and insurance • use risk evaluation programs and cheaper are not always the right thing to payments have encouraged the growth of train in the evaluation of flight risks (A- do.” (ASRS No. 635667) air medicine, and air medicine is considered 06-13), requiring EMS operators to use Time pressure is commonly cited in vital and important in American society. formalized dispatch and flight-following ASRS and greatly increases the prob- Helicopter ambulance companies operate procedures including up-to-date weather ability of human error. Dr. James Reason, in an environment in which moving patients information flight risk assessment deci- professor emeritus at the University of is the only method of generating a return sions (A-06-14), Manchester and an expert on human error, on a capital-intensive investment. Payment • install terrain awareness and warning found that the perception of a shortage of for flights is based on geography—where systems on aircraft and train flight crews time increases the probability of human the helicopter is flying—and distance—how on the use of this equipment (A-06-15). error by 11 times. The following ASRS

far the patient is flown. While we agree with these recommen- narrative illustrates this point. PHOTO: NTSB

July–September 2010 ISASI Forum • 17 “I arrived at work for a shift change. B airport before I recognized the error conditions, cited in 18% of the sampled After parking the car, I heard one of our and reversed course. I was coordinating ASRS reports; 78% occurred at night. The hospital helicopters turning on the hos- with dispatcher, medic command (flight- NTSB’s 1988 study determined that the pital helipad. I ran to the pad so I could following/status reports,) and emergency single most common factor in fatal EMS relieve the night pilot and take the flight…. vehicle on scene and broadcasting position helicopter accidents was unplanned entry We were responding to a multiple car ac- reports and intentions on Unicom….The into instrument meteorological conditions. cident with serious injuries…. I remember approach supervisor advised me that I “Inadvertent IMC” should receive focused glancing at my instrument gauges before entered his airspace and did not properly attention as it often results in a serious liftoff. Everything looked good. I made coordinate with his controller….I was degradation of aircraft control (14% of the the appropriate calls and began the take- working four frequencies and receiving sampled reports) or a serious loss of sepa- off process…. As we moved forward, my warning lights and horns for low rotor rpm came on. My rotor rpm’s began to drop, Behind the phenomenal growth of helicopter EMS from one and the aircraft slowly began to settle…. hospital in 1972 to the multimillion-dollar business it is I turned and was able to settle back on the today is a disturbing business model; fly the helicopters as pad and appeared to land without incident. I looked at the gauges and around the inexpensively as possible—with one pilot and a minimum cockpit. Everything was normal again, of safety equipment. This has created an inherently unsafe except I noticed that my engine throttles were not full forward. I assumed that system. As one EMS pilot said, “If they knew what I knew, was the problem. I pushed the throttles even the nurse and paramedic wouldn’t get on board.” forward completely, lifted off again, and flew the flight to the accident scene as if conflicting coordinates from the ground ration with terrain (8% of the sampled re- everything was normal. Upon landing and while searching for the landing zone. I was ports.) Inadvertent IMC continues to be a shutting down at the scene, I discovered aware of my close proximity to the airport large contributor to fatal EMS accidents. that approximately 2-3 inches of each tail traffic area. I was preoccupied with the Of the 210 accidents in the CMAS da- rotor blade (2) were chopped off. I gave the traffic avoidance while coordinating with tabase over the past 20 years, 69—or 1 in remaining rotors a detailed inspection and the ground vehicles during the search for 3—involved the aircraft hitting something. checked the drive train from the engines to and subsequent approach and landing at Confined-area operations were present in the rotors and found everything in place. the landing zone.” (NASA ASRS Acces- 29% of the ASRS reports. HEMS pilots The patient was brought to the aircraft, sion Number 181754) frequently deal with limited maneuvering dying, and placed inside. I made the deci- With the exception of half-a-dozen room, proximity of obstacles, lack of infor- sion that I could make the 5-minute flight hospital operators, HEMS operations are mation about obstacles, inadequate lighting back to the hospital safely.” The flight went conducted with single-pilot crews. Single to detect obstacles, adverse wind conditions back without incident. pilots lose the benefit of error management during departure from a confined area, and “Problem areas: The quick EMS heli- by cross-check and pilot monitoring. a lack of guidance from the ground to avoid copter responses, the numerous interrup- HEMS’ great asset is the helicopter’s obstacles. Approximately 14% of the ASRS tions of the EMS pilot during start-up, ability to operate off-airport, at disaster reports indicated this threat had not been and the pilot allowing this to happen. scenes, highway accidents, and other adequately managed. Plus, the added pressure of a dying person inaccessible areas. However, “on scene” Pilot factors included fatigue and lack causing the pilot to make emotional deci- operations often present problems with of IFR currency/proficiency. In its 1988 sions instead of safe ones.” (Italic added inadequate information about weather study, the NTSB suggested that pilot fa- for emphasis) (NASA ASRS Accession and obstacles; 53% of the ASRS reports tigue could be a primary contributor to the Number 118240) indicated this threat. Approximately 42% industry’s poor safety performance. The The EMS pilot works in a “very high of these threats were not adequately topic of fatigue in EMS operations was threat” mission environment. The exces- managed. revisited during the 2009 NTSB hearings sive workload faced by helicopter am- Adverse weather conditions were pres- on HEMS. This threat was present in 17% bulance pilots is most clearly present in ent in 45% of the ASRS reports. This cat- of the reports and inadequately managed 84% of the ASRS reports. These included egory included not only limited visibility in 9% of the time. The Safety Board be- workload induced by single-pilot opera- and cloud ceilings that create higher risks lieves “that EMS helicopter pilots work in tions in helicopters and the lack of a pilot for helicopter operations, but also weather an environment and operate on a schedule monitoring for cross-checking. This is forecasts with “chance of marginal con- conducive to acute and chronic fatigue that aptly stated by an EMS pilot in the fol- ditions,” or a lack of definitive weather can influence the pilot’s ability to operate lowing ASRS report. reports along the route or destination, the aircraft safely.” “I was flying an EMS helicopter dis- deteriorating weather, and unexpected Helicopter factors included the air- patched from XYZ hospital, in City A, to weather. About 34% indicated this threat craft not being IFR capable, operating recover a patient at the mall, City B. The category was not adequately managed. with inoperative components, and/or a coordinates provided were incorrect and This, of course, can lead to the threat mechanical failure. About 16% of the took me 5 nautical miles south of the City of inadvertent penetration of instrument reports indicated the presence of this

18 • ISASI Forum July–September 2010 threat; and it was not properly handled Weather reports are often a significant A number of aviation organizations, 15% of the time. distance from the destination, making it from the International Civil Aviation These are the leading threats, and they difficult for EMS pilots to make an edu- Organization to the Professional Helicop- have changed little since the Flight Safety cated decision. Examining NTSB accident ter Pilots Association, claim two-engine Foundation’s study of EMS safety in 2001 reports, the nearest weather reporting helicopters are necessary for safety. The conducted by the author Veillette, or for stations in 10 accidents were 15 to 25 PHPA position is that the standard “should that matter, since the NTSB’s first report miles away, and in 8 accidents the weather be a multi-engine, fully IFR-certified heli- on HEMS safety 21 years ago. reporting was even more remote. One was copter.” Medical helicopters in Canada and Given the frequency and severity of 47 miles away. air rescues conducted by the U.S. Coast the IMC-related accidents, the NTSB has Under Part 135 flight rules, pilots are Guard require two-pilots. repeatedly warned about the weather mini- still allowed to make their own weather The ASRS reports feature stress as a mums authorized for HEMS flights and has observation. “For operations under recurrent theme. EMS piloting with high recommended the development of visual VFR, the pilot-in-command may…use workloads and unpredictable operating flight weather minimums for individual weather information based on the pilot’s environment has become its own “error helicopter programs based on local terrain own observations or on those of other trap.” This makes the need for two pilots and weather. These weather minimums persons competent to supply appropriate obvious. should be communicated to the pilots in observations.” In a study of turbine-engine airplane writing, and deviation below the program In actual operation, EMS pilots often fail accidents, aviation research company minimums should be prohibited. to keep their weather assessment objective. Robert E. Breiling Associates of Florida The FAA has recently implemented A review of ASRS reports for the Flight concluded that single-pilot flights are an amendment to weather minimums Safety Foundation’s 2001 study found that riskier than those with two pilots. The authorized for HEMS operators. Oper- an astounding 67% of the EMS pilot reports statistics show the risk of a fatal accident ating Specifications A021, “Helicopter documented that knowledge of the patient’s is 3.7 times greater with a single pilot. In Emergency Medical Services Operations,” condition influenced their decision-making. publishing these findings, AOPA Pilot requires a minimum of 800-2 (800 foot A survey of flight paramedics conducted wrote, “Single-pilot operations create ceiling, 2 nm visibility) for a “local” flight by the International Association of Flight higher workloads and greater demands in day conditions, and 800-3 for a cross- Paramedics and presented at the NTSB’s on pilot skill when the chips are down and country flight in day conditions. At night, special hearing on EMS safety revealed stress levels run high.” an operator without a night vision imag- 30% of the respondents reported that the Behind the phenomenal growth of ing system or terrain awareness warning pilot is aware of the urgency of the flight HEMS from one hospital in 1972 to the system will require 1,000-3 for local flights request, despite attempts to shield that multimillion-dollar business it is today and 1,000-5 for cross-country flights. information to avoid pressuring the pilot is a disturbing business model; fly the This study compared the weather in 55 to conduct the flight. In light of this real- helicopters as inexpensively as possible— IMC-caused accidents occurring between ity, giving the pilot the authority to take with one pilot and a minimum of safety April 1, 1988, and Sept. 27, 2009, against off even in weather others would judge equipment. This has created an inherently the recently amended weather minimums. questionable should be addressed. unsafe system. As one EMS pilot said, “If In more than half of the 55 accidents, Since weather and reduced visibility they knew what I knew, even the nurse and the actual weather was better than the (including night flight) creates layers of paramedic wouldn’t get on board.” recently amended HEMS weather mini- risk, management is required on several This report lists some of the recom- mums. This shows that even without the fronts. Between 1987 and 2008, there have mendations made by the NTSB. Based existence of significant loopholes in the been 305 EMS helicopter accidents or on the threat and error management Part 135 weather minimums, this recent significant safety incidents in the United analysis of the ASRS data, further rec- change to weather minimums may not States, according to the CMAS database, ommendations would improve safety have a wide-reaching effect. and nearly half of them occurred either for the industry as a whole and serve as Loopholes within the Part 135 weather at night or in weather that obstructed the guidance to other countries where the minimums would still allow a pilot to pilot’s vision. HEMS industry is not as well developed launch into weather hazardous to the In addition to changing weather mini- or as influenced by private for-profit op- flight. One of these “loopholes” is weather ma, providing EMS pilots and dispatchers erations. These include forecasts that contain “probability of ‘x’ with more accurate weather information, • two pilot (IFR proficient and current), conditions” or “temporary” weather con- and removing subjective decision-making two-engine, IFR-qualified helicopter. ditions. For example, a weather forecast in questionable weather with a formalized • advanced avionics (autopilot, satellite may state, “Ceilings better than 3,000 feet flight risk assessment program, EMS weather capability). and visibilities better than 5 miles….with a aircraft should be equipped to fly in these • night vision technologies. 40% chance of rain showers and occasional conditions. This is problematic since • automatic dependent surveillance-B. visibilities below 1 mile and ceilings below engine helicopters are unable to accom- • scenario-based simulator training. 800 overcast.” Such a forecast would still modate autopilots and IFR equipment • a safety management system. allow a pilot to launch. and the recent trend is toward replacing • further refinement and eventual ap- The lack of on-site weather reports also twin-engine aircraft with single-engine for proval of the HEMS weather tool.

impacts the preflight go/no-go decision. the fuel savings. • fatigue management. ◆ PHOTO: NTSB

July–September 2010 ISASI Forum • 19 Smoothing CDR Radar Data The authors perform a comparison study of GPS data and CDR radar data using a fully instrumented flight test to try to eliminate some of the discrepancies that result from differing interpretations of radar data. By Ryan M. Graue, W. Jeffrey Edwards, Jean H. Slane, Dr. Robert C. Winn, and Krista B. Kumley (This article is adapted with permission from the authors’ paper ing radar data, we devised an experiment to compare different entitled A Comparison Study of GPS Data and CDR Radar Data smoothing techniques against a “true” indication of all flight data. Using a Fully Instrumented Flight Test presented at the ISASI To accomplish this goal, a fully instrumented flight test was flown 2009 seminar held in Orlando, Fla., Sept. 14-18, 2009, which with multiple flight data recorders on board. A file containing carried the theme “Accident Prevention Beyond Investigation.” FAA continuous data recording (CDR) radar return information The full presentation, including cited references to support the was obtained for the same flight. Flight data recorder information points made, can be found on the ISASI website at www.isasi. served as the experimental control, while different smoothing org.—Editor) levels and calculation methods were applied to the radar data for comparison with the flight data recorder information. ircraft accident investigators often use radar data pro- To model various segments of accident flight scenarios, the vided by the FAA to aid in analyzing and reconstructing following maneuvers were flown: straight and level, climb, de- Aaccident scenarios. However, simply analyzing the raw scent, S-turns, steep turns, chandelles, instrument approach, radar returns usually yields unsatisfactory results due to noise and resolution limits in the recorded data. In order to obtain Ryan Graue made the presentation to the results that accurately reflect the flight path and give an ac- ISASI audience. He is an aeronautical curate time history of the flight parameters of the accident engineer at AvSafe, LLC. His work involves flight, accident investigators must smooth the data to reduce the determining aircraft flight paths and flight noise. In recent years, experts in flight path reconstruction have parameters using recorded radar data, creat- developed several different smoothing and analysis techniques ing simulations of aircraft accident scenari- to accomplish this goal. os, planning flight tests, and analyzing Unfortunately, most general aviation aircraft are not equipped flight test data. with flight data recorders. As a result, when an accident involv- ing a general aviation aircraft occurs, recorded radar data are William Jeffrey Edwards also presented at often the only evidence investigators can use to determine the the ISASI seminar. In 1997 he founded AvSafe, accident flight path and gain an understanding of the manner in LLC, an aviation safety consulting company which other parameters such as airspeed, altitude, bank angle, that provides consulting services to the in- and heading changed throughout the flight. Experts analyzing surance and legal industries. Edwards has data from the same accident flight may arrive at different conclu- consulted on more than 350 aircraft accident sions regarding the nature of the flight due to differences in the cases throughout his career, which includes U.S. smoothing and analysis techniques they choose. Since no other Navy service as a pilot flying A-6 Intruders and as an accident evidence may be available, these differing conclusions may lead investigator. the experts to differing opinions regarding flight paths and flight dynamics. The goal of the research described below is to try to Jean Slane is an aeronautical engineer specializing in eliminate some of the discrepancies that result from differing modeling and simulation software for Engineering Sys- interpretations of radar data. tems Inc. (ESI). Her consulting work has included the de- Radar data analysis involves two major aspects in the context sign and development of mathematical models for a variety of aircraft accident investigation: flight path reconstruction and of commercial, general aviation, and military aircraft flight parameter reconstruction. Flight path reconstruction is simulators. important because it tells the investigator where the aircraft was located at specific times throughout the flight. Flight parameter Dr. Robert Winn is a principal and the director of Colorado reconstruction is also critical because it gives the investigator an operations for Engineering Systems Inc. (ESI) in Colorado understanding of how the aircraft performed in order to generate Springs, Colo. He served as a pilot and engineer in the U.S. the radar recorded accident flight. As both of these aspects are Air Force for more than 22 years. He is a Fellow of the Ameri- key components of aircraft accident investigation, the flight test can Institute of Aeronautics and Astronautics. data analysis will include comparisons of the flight paths and the flight parameters. Krista Kumley joined Engineering Systems Inc. (ESI) in 2007. She has a master of science in forensic science and is Experimental setup currently working on a master of science in mechanical engi- In order to minimize the discrepancies in analyzing and interpret- neering with a specialization in dynamics and controls.

20 • ISASI Forum July–September 2010 and autopilot turn. The recorded radar data from each maneuver were processed using four levels of smooth- ing and two calculation methods. The flight parameters were calculated for each combination of smoothing level and calculation method. The flight pa- rameters compared in this study were ground speed, true airspeed, bank angle, load factor, magnetic Table 1. Average Position Error for All Maneuvers heading, and turn rate. and Smoothing Levels Aircraft and data recording equipment—The aircraft used for this testing was a Lancair IV-P. This particular aircraft was raw radar data points were converted to a position matrix in a chosen for its ability to perform all the necessary flight maneu- Cartesian coordinate system, using nautical miles east of the vers and fly at a wide range of airspeeds. Onboard equipment radar antenna for the “x” coordinates and nautical miles north included an Appareo Systems GAU 1000A flight data recorder of the radar antenna for the “y” coordinates. The altitude was with WAAS-enabled GPS, a Chelton Flight Systems Sport, and used as the “z” coordinate as recorded. In this smoothing tech- a WAAS-enabled Garmin GPSMAP 396. nique, a least squares quadratic function was fit using a specified Radar facility and description of radar data—Radar data number of points for each set of coordinates independently with were gathered from the St. Louis/Lambert (KSTL) Terminal time as the independent variable. As the number of points used Radar Approach Control (TRACON) ASR-9 antenna. Informa- to determine the quadratic function was increased, the amount tion obtained from the radar data file included the times of the of smoothing applied to the radar data increased. radar returns, range, and azimuth angle relative to the antenna It should be noted that many additional data smoothing and Mode C (pressure) altitude. techniques can be found in the literature (digital filter, weighted Flight path—The flight lasted approximately 2 hours and was moving average, spline, etc.). For this study, only the least squares flown in the area west of St. Louis in east central Missouri. More moving quadratic technique was used. than 1,300 radar returns were obtained from the flight. Flight path comparison—The flight paths that were recorded by the onboard data acquisition equipment did not always exactly Analysis match the radar returns that were recorded by the FAA radar Winds and temperature at altitude—To perform a flight pa- facility. In order to quantify the differences in the flight paths, rameter analysis, regardless of the smoothing level or calculation the straight line distance was calculated between each smoothed method, the winds and temperature at altitude are needed. The radar return location and the position information from the flight data acquisition systems on board the test aircraft were capable data recorder at the same moment in time. The distances between of calculating and displaying the winds being encountered; how- these points were calculated, yielding a set of position errors. ever, they could not be automatically recorded. In addition, it is The average position error was calculated for each of the eight very rare that an accident reconstructionist will know the true flight maneuvers using both smoothed and unsmoothed data. An wind and temperature profile throughout a flight. Without the assessment of the error between the onboard recorded data and assistance of an experienced meteorologist, the best approach the smoothed flight path points is shown in Table 1. The smooth- is to use weather data recorded by the National Oceanic and ing levels that gave the closest agreement are shaded. Atmospheric Administration. This agency records wind speed The results shown in Table 1 lead to the following conclu- and direction, temperature, and several other parameters at sions: locations across the country at 0 UTC and 1200 UTC every day. • For straight flight (straight and level, climb, descent, and The stations are typically located approximately 200 nautical instrument approach), high levels of smoothing generally re- miles apart. Because of the geographic and temporal separation sulted in the best agreement with the onboard recorded position of the recorded weather data, it is likely that the data will only data. give an approximation of the actual weather at altitude on the day • For maneuvering flight (S-turns, steep turns, chandelles, and of an accident. However, this is the best approximation available autopilot turns), little or no smoothing generally gave the closest in most accident reconstructions. agreement. The flight test occurred in an area nearly equidistant from the Flight parameter comparison—To compare the flight param- Lincoln, Ill., and Springfield, Mo., stations approximately 2 hours eters, each parameter was calculated using the smoothed and before the 0 UTC weather recording. For the flight parameter unsmoothed position matrices and compared to the logged flight analysis, the average winds and temperatures between these data. Values of ground speed, bank angle, load factor, and turn two stations were used. rate were compared to data from the Appareo unit, while true Smoothing data—A key step in analyzing the flight test data was airspeed and magnetic heading values were compared to data to smooth the radar data and generate sets of position matrices from the Chelton unit. for several different levels of smoothing. The following levels of The process of calculating the flight parameters is based on the smoothing were used: no smoothing, 5 point least squares moving seminal work done for NASA by R.E. Bach and R.C. Wingrove. quadratic, 9 point least squares moving quadratic, and 13 point In their 1980 work, “Equations for Determining Aircraft Mo- least squares moving quadratic. tions from Accident Data,” the path between smoothed points is To apply the least squares moving quadratic technique, the described by a straight line—a rectilinear approach. Recognizing

July–September 2010 ISASI Forum • 21 that an airplane cannot abruptly change direction at a point, a curvilinear approach was developed by J.H. Slane and R.C. Winn in “A Curvilinear Approach to Flight Path Reconstruction from Recorded Ra- dar Data.” In the curvilinear approach, a circular flight path is defined by three consecutive smoothed points. In both methods, the path between the points does not have to be in the horizontal plane. To determine which smoothing level and calculation method yielded the most accurate flight parameter reconstruction, the flight parameters that were logged on the flight data recorders were interpolated to the same times as the radar returns. Next, the errors between these logged flight parameter values and the calculated flight parameter values were determined for each maneuver, yielding a set of error values. The error sets were compared by taking the mean of the absolute values of the errors. The results shown in Table 2 give the mean absolute error for all flight parameters for each maneuver. The er- rors for each maneuver are shown in the columns of the table. The rows show the method (rectilinear or curvilinear) and smoothing level used to calculate the flight parameters. The shaded values show the calculation method and smoothing levels that had relatively low errors for that parameter and maneuver. These results lead to several observa- tions. As a general rule, nearly straight flight is best analyzed using high levels of smoothing, while maneuvering flight is best analyzed using low levels of smooth- ing. This is consistent with the earlier finding regarding the smoothing levels that resulted in the best flight paths. Here are some additional findings: • In almost every case, the calculation of true airspeed resulted in significantly larger error than the calculation of ground speed. To calculate true airspeed from ground speed, the winds at altitude were needed. Errors in the calculation of true airspeed were likely higher because of er- rors in the wind profile at altitude. • For straight and level, climb, and descent, the best results were obtained with 9 and 13 point smoothing for both rectilinear and curvilinear analyses. For the instrument approach, the calculation of ground speed using rectilinear analysis with 13 point smoothing was slightly more in error. Table 2. Flight Parameter Mean Absolute Error Results • For S-turns, steep turns, chandelles,

22 • ISASI Forum July–September 2010 by looking at the radar returns that were missed by the radar facility. In Figure 1, the radar data and the ground track of the airplane are shown. Notice that in the second (more northerly) of the two steep turns, several radar returns are missing. These missing returns are due to the airplane’s transponder antenna being shielded from the radar station. With several key radar returns missing, the distance between points is far less than the distance actually flown by the test airplane. For an unknown rea- son, the more southerly of the two steep turns was only missing one return. In Figure 2, the calculated bank angle history for this maneuver is shown. Notice that the first turn is reconstructed very accurately compared to the second steep turn; however, the results presented in Table 2 include the errors from both turns. This example shows the importance of critically studying the radar data before accepting the results. Many accident flight paths are composed of some essentially Figure 1. Ground track during steep turns. straight segments and other segments in which the airplane is maneuvering. This study showed that the best smoothing levels are different for straight and maneuvering flight. Therefore, it is possible that using one level of smoothing for an entire accident flight can cause some portion(s) of the analysis to have significant errors. As a result, it would be prudent for the reconstructionist to break the flight into segments of similar characteristics and apply different smoothing levels and calculation techniques to each segment. It should be noted that the above results were obtained using radar data that were recorded by an airport surveillance radar (ASR) system, which produces a return approximately every 4.6 seconds. Enroute radar, which is recorded by an Air Route Traffic Control Center (ARTCC), has lower resolution and frequency, producing a return approximately every 12 seconds. Results may vary when reconstructing flight paths and flight parameters from ARTCC radar returns.

Figure 2. Calculated and measured bank angle Conclusions during steep turns. The data recorded on board the test airplane proved to be a valuable tool to help determine the optimal level of smoothing and autopilot turns, low levels of smoothing are preferred; and best calculation method for each maneuver. Assuming that however, in most cases, 5 point smoothing yielded better results those data were “true” representations of the flight path and than no smoothing. Using high levels of smoothing generally flight parameters of the test flight, the calculation techniques results in the smoothed points being placed toward the inside and smoothing levels were quantitatively evaluated. The largest of each turn. This causes the calculated distance travelled to be source of error in the calculation of true airspeed and heading less than actual; therefore, the calculated ground speed is lower was in the accuracy of the wind profile that was used. than actual. The results showed that, in general, it is best to use a high • For S-turns, steep turns, chandelles, and autopilot turns, the level of smoothing for nearly straight flight and minimal smooth- errors in heading are quite large; however, this is expected when ing (but not zero smoothing) for maneuvering flight. It was also considering that the heading changed very rapidly during these found that, in general, the curvilinear approach provided slightly maneuvers. In nearly straight flight in which heading could be an better results than the rectilinear approach for maneuvering important issue, the calculated headings are quite accurate. flight. Unfortunately, many accident flight paths are composed • In general, for S-turns, steep turns, chandelles, and autopilot of segments that are essentially straight and other segments in turns, curvilinear analysis is superior to rectilinear. This is due which the airplane is maneuvering, so it may be appropriate to to the fact that the curvilinear analysis considers the airplane break the flight into segments and use different smoothing levels flying in a curved path between points, creating a much more in each segment. realistic reconstruction than the airplane flying a straight path It is likely that some returns will be missing from a set of radar and turning abruptly at each point. data, and those missing returns may result in calculations that To determine bank angle for steep turns, the best approach was have significant errors. The solution to this problem will likely determined to be 5 point smoothing with either the rectilinear or vary with the unique aspects of each analysis; however, it is ab- curvilinear approach; but even so, the calculated bank angle was solutely essential to use valid engineering judgment in assessing still rather high. The explanation for this finding can be found the significance of any missing returns. ◆

July–September 2010 ISASI Forum • 23 for products manufactured by international Accident Prevention: consortia (e.g., Airbus). Since 1987 its work has been extended to operations, mainte- nance, licensing, and certification/design Pushing the Limits standards for all classes of aircraft. Within the framework of existing European Union (EU) treaties and The new regulatory framework: the total system approach institutions, the adoption of Regulation (EC) No. 1592/2002 of the Within the framework of existing EU European Parliament and of the Council of July 15, 2002, established treaties and institutions, the adoption a European Aviation Safety Agency (EASA) tasked to establish and of Regulation (EC) No. 1592/2002 of the maintain a high uniform level of civil aviation safety in Europe. European Parliament and of the Council By Bernard Bourdon, Accident Investigation Manager, of July 15, 2002, established a European European Aviation Safety Agency, the European Union Aviation Safety Agency (EASA), and the full performance of its functions created a (This article is adapted with permission from the author’s pa- community competence for aviation safety. The EASA has been per entitled Accident Prevention: Pushing the Limits presented appointed the executive body tasked with the objective of establish- at the ISASI 2009 seminar held in Orlando, Fla., Sept. 14-18, ing and maintaining a high uniform level of civil aviation safety in 2009, which carried the theme “Accident Prevention Beyond Europe. It has to act upon the results of air accident investigations Investigation.” The full presentation, including cited references as a matter of urgency in order to ensure consumer confidence in to support the points made, can be found on the ISASI website air transport without prejudice to community law. at www.isasi.org.—Editor) Aviation behaves as a single network involving products (airplanes, parts, and appliances), users (crews, operators), and urope is an old continent with centuries of anchored tradi- supports (aerodromes, air navigation service providers). The tions and culture. On May 9, 1950, French Foreign Minister regulatory framework must eradicate safety gaps, conflicting ERobert Schuman proposed the creation of a single authority requirements, and confused responsibilities and enhance the to control the production of steel and coal in France and west integration of airborne and ground systems. This enhanced in- Germany, to be opened for membership to other European coun- tegration of all aviation domains in a single European regulatory tries. The proposal was realized in the European coal and steel framework initiated the “total system approach.” Uniformity is community, and the plan laid the foundations for the 1957 treaties achieved through implementing common rules adopted by the establishing the European Economic Community (EEC). Europe commission. Regulations are interpreted and applied in a single was born, and in 1965 the merger treaty established the Euro- way, and best practices are encouraged. Uniformity equally pean Community (EC), which set up a single council and a single means protecting citizens and providing a level playing field for commission of the European Communities, gradually eliminating the internal market and in the perspective of interoperability. The the control at the internal borders of the Schengen stakeholders total system approach also streamlines the certification processes and establishing a common market and then a common currency. and reduces the burden on regulated persons. Europe has been building up synergies ever since. The EASA system is in line with “better regulation.” Its possibil- In the domain of air transport, the European Civil Aviation Con- ity to combine “hard” and “soft” law provides a good answer to the ference (ECAC) has enabled civil aviation authorities of a number needs for subsidiarity and proportionality. The Agency’s approach of European States to cooperate in developing and implementing of performance-based rulemaking implements these principles by common safety regulatory standards and procedures. The Joint placing essential safety elements in the rule, leaving non-essential Aviation Authorities (JAA), launched in 1970, is an associated body implementation aspects to certification specifications or applicable of this cooperation whose intent is to provide high and consistent means of compliance, which, albeit of a non-binding nature, have standards of safety. Originally, its objectives were only to produce an important role to play in providing uniform implementation of common certification codes for large airplanes and for engines in common requirements with sufficient flexibility. order to meet the needs of European industry and particularly The gathering of executive functions is made in 3 steps:

EASA safety Bernard Bourdon is an engineer from France regulator for: and holds a masters degree in aeronautics Initial Basic Reg. 1592/2002 of Airworthiness The product from the French National Civil Aviation Regulation July 15, 2002 School (ENAC). He started his career in 1995 1st extension Reg. 216/2008 of OPS+FCL+TCO5 Those who use as a project manager in the French Civil February 20, 2008 the product Aviation Authority and joined the French 6 Approach

2nd extension Reg. xxx/xxxx ATM + Aerodrome Those who help System Total Investigation Office (BEA) in 1999 as a safety using the product investigator. After 7 years of managing safety investigations, he joined the European Aviation Safety Agency (EASA) in Therefore, the EU aviation system is now based on shared August 2006. He is currently the accident investigation man- responsibilities among members States, the European Commis- ager with EASA in charge of the interface with safety investi- sion, EASA, and the industry. Member States are essential pillars gation and the follow-up of safety recommendations. for implementing rules in their territory while EASA promotes

24 • ISASI Forum July–September 2010 community views regarding civil aviation safety standards and of reporting, personnel, and record keeping, while taking into rules and, therefore, has taken executive powers in account the specificity of each field. As a consequence, an air • production of all EU legislation and implementation materials operator already approved for air transport operation would related to the regulation of civil aviation safety and environmen- extend its activity to maintenance using its already approved tal compatibility, including products certification, licensing, and general organization requirements and focusing only on the operations; specific technical requirements for the new business. It will also • cooperation in setting international standards; avoid duplicating tasks during the oversight process (see chart • type certification and continued airworthiness of products, below left). parts, and appliances; • environmental approval of products; The active role of safety investigators in • approvals of organizations; a proactive approach to safety risks • standardization of States and the oversight of compliance with The risk assessment is commonly based on a probability common rules; and combined to a severity. It helps determine the likelihood of oc- • oversight of non-EU operators flying to Europe. currences and their consequences. Risk management aims at mitigating the consequences or reducing their likelihood. Last, The new regulatory framework: risk communication enhances the knowledge of risks through a proactive approach to safety risks better sharing of information. The historical perspective of the safety regulation shows that a reactive approach focusing on compliance with rules prevailed. The initial focus set on technical factors in the 1950s was extended to human factors in the 1970s and, today, is expanding to orga- nizational factors. Reactive approach to safety risk is in place for organizations. There are already requirements for quality systems, monitoring, and personnel qualification that provide compliance with rules and procedures. However, non-compliance still exists and is causing aviation accidents. It is obvious that eliminating the risk, even for an ultra-safe system, is not achiev- able. Therefore, accident prevention requires a significant step forward in managing the safety risk with a proactive approach. The proactive approach aims at identifying hazards, managing the risk, and disseminating information in a systematic way. It backs up compliance to the rules and is based on International Civil Aviation Organization (ICAO) safety management systems for organizations and state safety programs. As a matter of fact, EASA is implementing rules proposed in Therefore, it’s paramount that accident investigation authori- the latest Notice of Proposed Amendments 2008-22 aimed at ful- ties report and issue safety recommendations that close the safety filling this objective. It supports collective oversight, promoting loop to the EU safety system. This helps the following aspects standardization, stakeholders’ management of authorities and of the risk assessment: organizations, streamlining the approval processes, and creating • Qualitative risk assessment based on investigation reports a high and increasing safety level though common actions. with a detailed description of the risks encountered. It provides The new regulatory scheme defines the authority and organiza- an implicit and subjective approach. tion requirements applicable to States. The regulatory scheme • Quantitative risk assessment based on the reporting of acci- aims at improving the harmonization of requirements in terms dents and notifications. Meaningful statistics can be drawn if the reporting is good and a significant amount of data is available. It provides an explicit and transparent approach. Investigators provide essential input for fixing safety deficien- cies. Reporting and disseminating reports are of great benefit to authorities in their decision-making process. Reporting all investigated events in a central database is as important as writing a report. The aim is to make sure that whenever a simi- lar event is recorded, the risk assessment can be re-evaluated. Therefore, moving from a quantitative to a qualitative evaluation, the investigation work already done in the past can be reviewed in the light of the new developments. AeMC: Aeromedical Center 66: Maintenance Certifying staff ADREP, ICAO’s accident indent data reporting system, is based MED: Medical CC: Cabin Crew on a core common taxonomy for recording, exchanging, and classi- ATO: Air Transport Operator OPS: Operations fying occurrences. Therefore, cross-checking similar factors using 147: Training Organization TCO: Third Country Operators a central database is made possible with tools like Eccairs, which FCL: Flight Crew Licensing 145: Maintenance Organization promotes the proactive approach to safety deficiencies. ◆

July–September 2010 ISASI Forum • 25 ISASI ROUNDUP NTSB Chair Hersman Addresses MARC Spring Meeting

National Transportation Safety Board of $503. Other contributors were Chris 2011. She also announced that ISASI Chairman Deborah A.P. Hersman was Baum, Denise Daniels, Frank Del Gandio, 2012 is scheduled to be held in New the guest speaker at the ISASI Mid- Lucky and Virlene Finch, David J. Haase, Zealand and is to be hosted by the New Atlantic Council (MARC) annual spring Robert (Bob) Hendrickson, Tom and Gin- Zealand Society. dinner meeting held in Herndon, Va., ger McCarthy, Richard Newman, Alissa Speaker Toby Carroll outlined the April 29. The event was held in conjunc- Rojas, John Purvis and Nancy Wright, program “Learning from Investiga- tion with the spring ISASI International Kelly Skyles, Ron Schleede, and Richard tions” to be presented by the U.S. Council meeting. ISASI President Frank and Ruth Stone for a grand contributed Society in June 2010. The program, he Del Gandio also addressed the group. total of $3,775. said, will include three tracks during the During a refreshment hour, the 61 Just prior to calling Dick Stone, the 2 full days of training: general aviation, attendees caught up on “hellos” to those co-chair of the Scholarship program, commercial, and helicopter. To some friends who hadn’t been seen in a while. Ron reminded all that donations could USSASI investigators’ recollections, this MARC President Ron Schleede called be made at anytime. He noted that full seminar is a “first” for the Society. the meeting to order and outlined the information is on the ISASI website, ISASI President Del Gandio wel- evening’s program, thanked corporate www.isasi.org. Stone spoke of the 2010 comed all and followed Stone’s lead members for the donation of the many selection process. He noted that more about the worthiness of the Scholar- door prizes that lined the gift table, and than a half-dozen entries had been ship program. He said that the “poise announced that among the prizes were received, of which three were selected and demeanor shown by one of last three sets of roundtrip airline tickets to receive the scholarship: Leigh Dunn, year’s [2009] selectees would make one for travel to any destination within the a Ph.D. candidate with a special study think the 22-year-old was a veteran of U.S. Tickets were donated by Southwest area of composite materials; Logan the business. He is definitely a young Airlines, AirTran Airways, and jetBlue Jones, a Ph.D. candidate with a study man who is going to be filling a high- Airways. Other door prize contributors area of modeling aircraft takeoff and level position sometime in the future included the Air Line Pilots Association; landing on contaminated runways; and in this business.” Moving his attention Airbus; RTI Group, LLC; Continental Maggie Wong, a third-year student to ISASI’s highly successful Reachout Airlines; Julie Fischer Photography; the with a study area of crash survivability program, which was started 8 years ago, University of Southern California; and analysis and design and safety program he noted that in that time it has reached Crowne Plaza Hotel. management. Stone said, with a measure almost 2,000 persons in 21 countries. “I In his opening talk, Ron described of pride in his voice, “This is the caliber can’t say that we prevented a lot of ac- the funding methods used for the ISASI of students that your money is helping to cidents,” he said, “but I truly believe we Kapustin Scholarship fund, noting that bring to ISASI seminars.” have. We just can’t count them.” contributions made in the U.S. to the Barbara Dunn, chair of the national Following a re-presentation of the fund were tax-deductible and that all seminar program, also addressed the Jerome F. Lederer Award plaque to funding comes from contributions. He group. She said “We are going to have Richard Stone, because the original emphasized that no member dues mon- an exciting 3 years.” First, she gave plaque was “misplaced” at ISASI 2009, ies were used to fund the Scholarship. the most current update on the upcom- he introduced NTSB Chairman Deborah Because at the time of his passing ing ISASI seminar in Sapporo, Japan, A.P. Hersman. She addressed ISASI Rudy Kapustin was the president of September 6-9, saying that more infor- 2009 as the keynote speaker, just 7 MARC, a special fundraising tradition ex- mation is available via a link through weeks after being confirmed as the 12th ists at this meeting. This year the MARC the ISASI website, www.isasi.org. She NTSB chairman. Then, her talk ad- Chapter kicked it off by contributing $500 described a new registration method dressed the seminar’s theme “Accident and challenging higher contributions. utilizing a private “online” company and Prevention Beyond Investigation” by The Pacific Northwest Regional Chapter, added that the seminar site is “very asking the question “What is Next?” to Kevin Darcy, president, met the $500; user-friendly.” She added, in a caution- a room full of people who spend their Canadian Society of Air Safety Investiga- ary tone, that hotel registration must time solving puzzles, putting things back tors, Barbara Dunn, president, raised be made through the link on the ISASI together to figure out what failed and it to $502, and the Dallas-Ft. Worth website. In addition, she said planning how a design can be improved. Chapter, Tim Logan, president, capped was in full swing for the seminar to be On this occasion, Chairman Hers- the challenge with a contributing bid held in Salt Lake City, Utah, Sept. 12-15, man in opening her talk said, “I am so

26 • ISASI Forum July–September 2010 FAR LEFT: Chairman Hersman addresses the MARC audience. LEFT: Tom McCarthy helps a door prize winner make a selection.

easier and faster for members to vote and to significantly reduce postage, labor, and materials costs. The process is easy, and there are readily understandable prompts to take you to the ballot so those eligible members may cast their vote. All incumbents are standing for reelection. In addition, Paul Mayes has PHOTOS: E. MARTINEZ been nominated for the office of ISASI grateful for the opportunity to visit with works well for companies that are al- vice-president. He will run against the the men and women of ISASI who really ready “getting it right,” but may provide present incumbent, Ron Schleede. Other share a passion for aviation safety and little more than false confidence for com- present incumbents are President, making aviation as safe as it can be.” panies with less-than-robust safety cul- Frank Del Gandio; Secretary, Chris She then went on to discuss data- tures. Also, there are accidents caused Baum; Treasurer, Tom McCarthy. The driven systems to improve aviation by a combination of factors that SMS offices of international councillor and the safety. She told the audience that the use cannot possibly detect. As an example, U.S. councillor are also open for election. of data to manage and improve safety in Hersman mentioned the British Airways Present incumbents, Caj Frostell and the aviation industry has had a positive Boeing 777 crash at Heathrow Airport 2 Toby Carroll, are both standing for re- effect on the world’s improving aviation years ago involving a dual-engine failure election. No other nominations for those safety record. But she cautioned against on approach. It was not data analysis offices have been received. overreliance on these systems to the that solved the mystery, but detailed fo- Members can log on to the ISASI neglect of forensic investigation. She rensic analysis—the circumstances were website, www.isasi.org, and a link to noted, “We have reached an era in which so unusual that a data analysis system VoteNet will appear on the home page. aviation accidents are extremely rare....” would not pick them up. Click on the link and follow the easy-to- One reason is the use of data—particu- Hersman said she hoped that with all use instructions. There are three ballots larly, but not exclusively, safety man- the focus SMS will place on data collec- available: one for U.S. members, one for agement systems (SMS)—in accident tion and analysis, “let’s not lose focus on members of national societies, and one prevention and investigation. outcomes. The success of SMS won’t be for international members. When you in- She added, “The Board has been measured by how much data we collect, put your member number the correct bal- advocating the use of SMS for a decade, but by how many lives we save. lot will automatically show itself. There having issued 17 recommendations in fa- “I will enthusiastically support any is also a box you can check for a write-in vor of implementing SMS in the aviation approach that will make our nation candidate. Voting is strictly confidential, industry. When implemented correctly, safer,” she said. “But I think we need and only the results will be available to SMS holds real promise in a variety of a measured approach—one that ac- the Ballot Certification Committee. scenarios.” She noted several instances in knowledges the potential benefits and If any eligible member does not or which SMS helped eliminate potential un- limitations of SMS and, further, doesn’t cannot find access to the Internet to safe conditions, notably a corporate flight discount tried-and-true methods for vote, he or she may contact Ann Schull operation that used flight data to deter- identifying vulnerabilities, such as ac- or Tom McCarthy at the international mine that high bank angles occurred cident investigations.” ◆ office and a paper ballot will be made on repositioning flights, and a review of available. Contact may be made by call- commercial aircraft approach data that 2010 Int’l Council Election ing (703) 430-9668, faxing (703) 430-4970, indicated a high rate of TCAS [Traffic and e-mailing [email protected]. Alert and Collision Avoidance System] Voting Is Under Way The following members are not warnings at a particular airport. In these The 2010 ISASI International Council eligible to vote: Affiliate Members, Cor- instances, she said, “data management Election voting period will run June 15 to porate Members (status only), Honorary adeptly identified a clearly measurable Aug. 15, 2010. This year’s election will be Members, and Student Members. The set of information and allowed for a rela- conducted electronically via the Internet following ISASI members are eligible tively simple and effective solution.” using VoteNet. The goals for implement- to vote: Fellow Members, Full Members, However, Hersman noted that SMS ing the electronic ballot are to make it Associate Members, Life Fellow Mem-

July–September 2010 ISASI Forum • 27 ISASI ROUNDUP Continued . . .

bers, Life Full Members, Life Associate surer of the Australian Society, are both He is currently manager of safety Members, Life Charter Members, Char- candidates for the office of ISASI vice- investigations and analysis for the ter Members. U.S. members will vote for president during the ongoing Executive Cobham Group Operations in Australia the president, vice-president, secretary, officer position elections. Those elected and Papua, New Guinea. He is also a treasurer, and the U.S. councillor, and take office upon the completion of the Fellow of the Royal Aeronautical Society international members will vote for the annual seminar on September 10. and a chartered engineer, a flight in- president, vice-president, secretary, Schleede has served as ISASI vice- structor, and holds an ATPL. He served treasurer, and the international council- president since 2002 and for 21 years as air safety investigator lor. Society members will vote for the served as vice-president with the Bureau of Air Safety Investi- following: president, vice-president, of the ISASI Mid-Atlan- gation, Australia, including head of air secretary, and treasurer. ◆ tic Regional Chapter for safety investigations, head of safety 15 years before his elec- systems and analysis, and was with Schleede, Mayes Vie tion as its president. He Air New Zealand in Auckland, New is active in the Reachout Zealand, where he held senior safety For Int’l VP Office Ron Schleede Workshop program, management positions including aviation Ron Schleede, ISASI vice-president, and guides the corporate safety advisor for 8 years. ◆ Paul Mayes, the current secretary/trea- sponsorship program for the Society’s annual seminar, and was awarded the AAIB Singapore Scores 2002 ISASI Jerome F. Lederer Award. Schleede retired from the NTSB in High with First IAI Forum July 2000, after 28 years as an investiga- With strong support from the Inter- Moving? tor and senior manager. In an exchange national Civil Aviation Organization Please Let Us Know program, he served as director of air in- (ICAO), ISASI, the Flight Safety Foun- Member Number______vestigations at the Transportation Safety dation (FSF), and the European Civil Board of Canada from December 1999 to Aviation Conference (ECAC), the Air Fax this form to 1-703-430-4970 or mail to June 2000. He is currently an indepen- Accident Investigation Bureau of Sin- ISASI, Park Center 107 E. Holly Avenue, Suite 11 dent consultant in international aviation gapore (AAIB Singapore) organized a Sterling, VA USA 20164-5405 safety, a contract instructor and member very successful Inaugural International of the Advisory Board of the Southern Accident Investigation (IAI) Forum at Old Address (or attach label) California Safety Institute, and a member the Singapore Aviation Academy April Name______of the International Advisory Committee 21-23, 2010. Address______of the Flight Safety Foundation. The Forum was attended by some 160 City______Mayes has been a member of ISASI participants and speakers from about since 1978. He served as 30 ICAO Member States. The Forum State/Prov.______ISASI vice-president for theme, “Investigation in the New State Zip______three terms concluding Safety Program (SSP) Environment,” Country______in 2002. He has also brought topics such as SSP, recent New Address* served as chairman of amendments to ICAO’s standards for the ISASI Flight international investigation, interna- Name______Recorder Working tional cooperation, challenges in major Address______Group and Australian Paul Mayes accidents, and sharing and protection of City______councillor. He also is an safety information. State/Prov.______active member of Reachout and was an The panel discussions were spontane- instrumental member of the ISASI 1991 ous and participation was high. Many Zip______and 2004 annual seminar committees. He agreed that the IAI Forum was an Country______has been involved with organising the excellent platform for interaction and E-mail______programs of the biennial Australasian discussion of ICAO matters and for *Do not forget to change employment and Safety Seminars in Australia since their raising questions on various AIG issues. e-mail address. inception in 1992. Attendees also agreed that it provided

28 • ISASI Forum July–September 2010

NEW MEMBERS

Corporate Dudzinski, Michael, A., Oklahoma City, OK, SEPLA (Spanish Airline Pilots’ Association) USA Alberto Alvarez Moran, Chairman Duprie, Terry, L., Lake Charles, LA, USA Ariel Shocron, Technical Department Graham, Jr., Frank, R., Charlotte, NC, USA Member Ishihara, Yasuo, Kirkland, WA, USA Jones, Logan, P., Toulouse, France Individual Knox, Raymond, F., Memphis, TN, USA Alsrisari, Sami, M., Cranfield, Bedfordshire, Lam, Anthony, K., Ashburn, VA, USA United Kingdom Oosterbaan, Alexander, 9074MG Hallum, the Netherlands Armstrong, Gordon, W., Newstead, OLD, venue for this air safety investigators’ Australia Rohrbaugh, Nathan, K., Fairfax, VA, USA Atadja, Raynold, S., Daytona Beach, FL, USA Schmidt, Kevin, T., Daytona Beach, FL, USA opening reception event: Aviation Hall Bergnach, Stefano, Buttrio, Italy Shanney, Joseph, M., DuPont, WA, USA at the Australian War Memorial, with Strand, Fredrik, M., Jakobsli, Norway Bergstrand, Anders, Linkoping, Sweden appropriate videos playing on the walls Brabant, Steven, J., Winnipeg, MB, Canada Viola, James, A., Alexandria, VA, USA Cavannagh, Douglas, G., Singapore, Watt, James, C., Kennesaw, GA, USA and aircraft display all around. Republic of Singapore Western, Ron, J., Winnipeg, Canada ◆ ATSB Commissioner Martin Dolan gave the keynote address, followed by the annual Ron Chippindale Memorial opportunities for networking and build- succeeded Peter Wil- Lecture presented by Paul Mayes on ing rapport for future cooperation. liams, an air accident developments in safety investigation. Vincent Galotti, deputy director of investigator with the Other topics included cultural consider- ICAO’s Air Navigation Bureau, delivered Transport Accident In- ations, lessons from an RNZAF inves- the keynote speech, and Marcus Costa, vestigation Commission tigation, air services safety systems, chief of ICAO’s Accident Investigation (TAIC), who became bird hazard mitigation, adhesive failure and Prevention (AIG) Section, spoke vice-president. Russell assessment, and airline investigations. about the recent Annex 13 amendments. Kennedy, a flight safety The seminar concluded with excellent Although unable to attend the IAI Alan Moselen officer with RNZAF, was presentations on SMS, complex investi- Forum in person, Nancy Graham, direc- reelected to the secre- gations, predicting pilots risk behavior, tor of ICAO’s Air Navigation Bureau, tary/treasurer position. HFACS, fiber composite aircraft, private addressed the Forum through a prere- Moselen trained as an airframe fitter aircraft operations, the Blackhawk A25- corded video message. In her message, in the RNZAF, working on C130 Hercu- 221 fatal accident, and HF in minimiza- she affirmed ICAO’s support for the les and P3 Orion aircraft. He joined Air tion of error in maintenance. Presenta- Forum series and that ICAO will use New Zealand as a LAME and worked tions from the seminar are available at the IAI Forum as a platform to interact on DC-10s and DC-8s. In 1979 he began the ASASI website: www.asasi.org. with investigation officials from ICAO flight engineer training and went on to ASASI announced its thanks to Member States. crew DC-10s, DC-8s, B-727-200s, and B- seminar sponsors for their generous Paul-Louis Arslanian, ex-director of 747-200s for 20 years. In 1999 he became support. ◆ BEA, was honored for his dedication a safety investigator with Air New Zea- and contribution to the international land and has been an investigator with GASIG Working Group accident investigation scene with the the NZCAA since 2001 and an ISASI presentation of a plaque of appreciation member since 2000. He has a diploma Gains New Chair to his representative. Arslanian was un- in business studies and holds a current Marcus A. Costa has accepted President able to attend the Forum because of the commercial pilot license and has held Frank Del Gandio’s appointment as the flight disruption caused by volcanic ash a single-pilot multiengine instrument chairman of the Society’s Government clouds over Europe. rating. He is a member of Rotary Inter- Air Safety Investigators Group (GASIG) The AAIB notes that its event will be national and the Royal Aeronautical So- Working Group. Marcus is chief of the held once every 3-5 years in Singapore. ciety. Al is married with two daughters. Accident Investigation and Prevention The next IAI Forum is set for 2013. ◆ For relaxation, he enjoys golf, fishing, Section, ICAO headquarters. and the challenge of improving his BBQ He has been an air safety investigator New Zealand SASI chef performance. ◆ since 1981. From 1985 to 2004, he was a staff and faculty member with CENIPA/ Elects Officers ANZSASI 2010 Seminar Brazil and served as an accredited The New Zealand Society has held its representative of Brazil to accidents in election and seated existing officers to Well Attended the United States in 1995 and 1996. In new positions. The annual Australia and New Zealand 1999 he was the delegate of Brazil to the Former Vice-President Alan Moselen, Societies co-hosted seminar recorded ICAO AIG Divisional Meeting, served an air safety investigator with the Civil more than 100 participants, including as Chief of CENIPA in 2002 and 2003, Aviation Authority of New Zealand, representatives from Indonesia and Eu- and in 2008 he served as secretary of was elected to the president’s office. He rope. Seminar planners selected a fitting the AIG Divisional Meeting. A native

July–September 2010 ISASI Forum • 29 ISASI ROUNDUP ISASI Information Continued . . .

OFFICERS of Brazil, he served with Brazilian Air President, Frank Del Gandio ([email protected]) Force, retiring with the rank of Colonel. Executive Advisor, Richard Stone He completed the U.S. Air Force Flight ([email protected]) Vice-President, Ron Schleede Safety Officer’s Course in 1985 and ([email protected]) received a master’s degree in aviation Secretary, Chris Baum ([email protected]) safety from Central Missouri State Uni- Treasurer, Tom McCarthy versity in the United States in 1994. ([email protected]) As chairman, he will establish the COUNCILLORS agenda, meeting dates, and locations Australian, Lindsay Naylor and procedures of the Working Group. ([email protected]) Canadian, Barbara Dunn Responsibilities of the Working Group ([email protected]) include European, Anne Evans ([email protected]) • promoting the exchange of air safety International, Caj Frostell investigation information. ([email protected]) New Zealand, Peter Williams • promoting collaboration to avoid the ([email protected]) independent parallel efforts toward the European Society President Dave King United States, Toby Carroll ([email protected]) same end. welcomes attendees. • providing and encouraging the proac- NATIONAL AND REGIONAL tive approach to air safety investigation of the challenges ahead for his organiza- SOCIETY PRESIDENTS through the exchange of information tion. The BEA gave an interesting brief AsiaSASI, Chan Wing Keong ([email protected]) on research, research techniques, and on the AF447 loss and succinctly cap- Australian, Lindsay Naylor special studies. tured the complexities and challenges ([email protected]) Canadian, Barbara M. Dunn • promoting interaction between of the underwater search efforts by re- ([email protected]) safety professionals within the aviation minding us that the underwater locater European, David King ([email protected]) industry. beacons have an effective range of some Latin American, Guillermo J. Palacia • promoting the investigation by 2,000 m while the ocean floor was at a (Mexico) New Zealand, Alan Moselen government air safety organization of depth of some 3,300 m. In order to help ([email protected]) accidents and incidents for accident delegates appreciate the difficulties in Russian, Vsvolod E. Overharov ([email protected]) prevention purposes only. ◆ locating the wreckage they were shown SESA-France Chapter, Vincent Fave a map of the Swiss Alps with a circle of ([email protected]) United States, Toby Carroll European Society Conducts a 40-mile radius superimposed on it and ([email protected]) asked to imagine that it was a topo- Third Annual Seminar graphical map of the search area except UNITED STATES REGIONAL The European Society of Air Safety it was submersed at a depth of 3,000 m. CHAPTER PRESIDENTS Alaska, Craig Bledsoe Investigators held its third seminar in Investigators from the UK Air Accidents ([email protected]) Toulouse, France, April 29-30. The event, Investigation Branch (AAIB) gave two Arizona, Bill Waldock ([email protected]) hosted by Ecole National de l’Aviation fascinating presentations on the recent Dallas-Ft. Worth, Tim Logan Civle (ENAC) on the outskirts of Tou- North Sea helicopter accidents, while ([email protected]) Great Lakes, Matthew Kenner louse, was attended by more than 90 the UK military representative gave us ([email protected]) persons. As in previous years, the theme an insight into the unique challenges Los Angeles, Inactive Mid-Atlantic, Ron Schleede of the seminar was focused on the tech- the military faces while conducting ‘in ([email protected]) nical challenges and current European theater’ accident investigations.” Northeast Gina T. Pellegrino ([email protected]) issues facing investigators. The ESASI planning committee ex- Pacific Northwest, Kevin Darcy Anne Evans, European councillor, pressed its gratitude for all the local ar- ([email protected]) Rocky Mountain, David Harper reported that “There were presentations rangements to Marc Houalla of ENAC ([email protected]) from EASA on the ongoing European for hosting the event, to Martine Del San Francisco, Peter Axelrod ([email protected]) developments in air safety. Paul Troa- Bono and Nathalie Dandou for all their Southeastern, Robert Rendzio dec, the new head of the French Bureau tireless work, and to Yannick Malinge of ([email protected]) d’Enquetes et d’Analyses (BEA), spoke Airbus. ◆

30 • ISASI Forum July–September 2010 Allied Pilots Association Hong Kong Civil Aviation Department COMMITTEE CHAIRMEN IFALPA Audit, Dr. Michael K. Hynes American Eagle Airlines ([email protected]) American Underwater Search & Survey, Ltd. Independent Pilots Association Award, Gale E. Braden ([email protected]) AmSafe Aviation Int’l Assoc. of Mach. & Aerospace Workers Ballot Certification, Tom McCarthy Aramco Associated Company Interstate Aviation Committee ([email protected]) ASPA de Mexico Irish Air Corps Board of Fellows, Ludi Benner ([email protected]) Association of Professional Flight Attendants Irish Aviation Authority Bylaws, Darren T. Gaines ([email protected]) Atlantic Southeast Airlines—Delta Connection Japan Airlines Domestic Co., LTD Code of Ethics, Jeff Edwards Australian and International Pilots Association (AIPA), Japanese Aviation Insurance Pool ([email protected]) Australia Australian Transport Safety Bureau Jeppesen Membership, Tom McCarthy Aviation Safety Council JetBlue Airways ([email protected]) Aviation Safety Investigations, UK Jones Day Nominating, Tom McCarthy Avions de Transp ort Regional (ATR) KLM Royal Dutch Airlines ([email protected]) AVISURE, Australia Korea Air Force Safety Ctr. Reachout, John Guselli BEA-Bureau D’Enquetes et D’Analyses Korea Aviation & Railway Accident Investigation ([email protected]) Board Seminar, Barbara Dunn ([email protected]) Board of Accident Investigation—Sweden Boeing Commercial Airplanes Kreindler & Kreindler, LLP Bombardier Aerospace L-3 Communications Aviation Recorders WORKING GROUP CHAIRMEN Bundesstelle fur Flugunfalluntersuchung—BFU Learjet, Inc. Air Traffic Services, Scott Dunham (Chair) CAE-Flightscape, Inc. Lockheed Martin Corporation ([email protected]) Cathay Pacific Airways Limited Lufthansa German Airlines Ladislav Mika (Co-Chair) ([email protected]) Cavok Group, Inc. MyTravel Airways Cabin Safety, Joann E. Matley ([email protected]) Centurion, Inc. National Aerospace Laboratory, NLR Corporate Affairs, Erin Carroll Charles Taylor Aviation, Singapore National Air Traffic Controllers Assn. ([email protected]) China Airlines National Business Aviation Association Flight Recorder, Michael R. Poole National Transportation Safety Board ([email protected]) Cirrus Design Civil Aviation Safety Authority Australia NAV Canada General Aviation, Randall S. Mainquist Nigerian Ministry of Aviation and Accident ([email protected]) Colegio De Pilotos Aviadores De Mexico, A.C. Government Air Safety, Marcus Costa Comair, Inc. Investigation Bureau ([email protected]) Continental Airlines Northwest Airlines Human Factors, Richard Stone Continental Express Nova Aerospace, Australia Parker Aerospace ([email protected]) COPAC/Colegio Oficial de Pilotos de la Aviacion Comercial Phoenix International, Inc. Investigators Training & Education, Cranfield Safety & Accident Investigation Centre Pratt & Whitney Graham R. Braithwaite Curt Lewis & Associates, LLC Qantas Airways Limited ([email protected]) DCI/Branch AIRCO Qatar Airways Unmanned Aerial Systems, Tom Farrier Defence Science and Technology Organization (DSTO) Qwila Air (Pty), Ltd. ([email protected]) Delta Air Lines, Inc. Raytheon Company Directorate of Aircraft Accident Investigations— Republic of Singapore Air Force Namibia Rolls-Royce, PLC CORPORATE MEMBERS Directorate of Flight Safety (Canadian Forces) Royal Netherlands Air Force Directorate of Flying Safety—ADF Royal New Zealand Air Force AAIU Ministry of Transport Bulgaria Dombroff Gilmore Jaques & French P.C. RTI Group, LLC Accident Investigation Board, Finland Dutch Airline Pilots Association Sandia National Laboratories Accident Investigation Board/Norway Dutch Transport Safety Board SAS Braathens Accident Investigation & Prevention Bureau EL AL Israel Airlines Saudi Arabian Airlines Administration des Enquêtes Techniques Embraer-Empresa Brasileira de Aeronautica S.A. SICOFAA/SPS (Luxembourg) Embry-Riddle Aeronautical University Sikorsky Aircraft Corporation Aeronautical & Maritime Research Laboratory Emirates Airline Skyservice Airlines, Ltd. AeroVeritas Aviation Safety Consulting, Ltd. Era Aviation, Inc. Singapore Airlines, Ltd. Aerovias De Mexico, S.A.De C.V. European Aviation Safety Agency SNECMA Moteurs Air Accident Investigation Bureau of Singapore EVA Airways Corporation South African Airways Air Accident Investigation Unit—Ireland Exponent, Inc. South African Civil Aviation Authority Air Accidents Investigation Branch—U.K. Federal Aviation Administration Southern California Safety Institute Air Astana (Kazakhstan) Finnair Oyj Southwest Airlines Company Air Canada Pilots Association Finnish Military Aviation Authority Southwest Airlines Pilots’ Association Air Line Pilots Association Flight Attendant Training Institute at Melville College Star Navigation Systems Group, Ltd. Air New Zealand, Ltd. Flight Data Services Ltd., United Kingdom State of Israel Airbus S.A.S. Flight Safety Foundation Transport Canada Airclaims Limited Flight Safety Foundation—Taiwan Transportation Safety Board of Canada Aircraft Accident Investigation Bureau—Switzerland Galaxy Scientific Corporation U.K. Civil Aviation Authority Aircraft Mechanics Fraternal Association General Aviation Manufacturers Association UND Aerospace Aircraft & Railway Accident Investigation Commission GE Transportation/Aircraft Engines University of NSW Aviation Airservices Australia Global Aerospace, Inc. University of Southern California AirTran Airways Gulf Flight Safety Committee, Azaiba, Oman Volvo Aero Corporation Airways New Zealand Hall & Associates, LLC WestJet ◆ Alaska Airlines Hellenic Air Accident Investigation Alitalia Airlines—Flight Safety Dept. & Aviation Safety Board Allianz Aviation Managers, LLC, USA Honeywell All Nippon Airways Company Limited Hong Kong Airline Pilots Association

July–September 2010 ISASI Forum • 31 Non-Profit ISASI Org. U.S. Postage 107 E. Holly Ave., Suite 11 PAID Sterling, VA 20164-5405 USA Permit #273 CHANGE SERVICE REQUESTED ANNAPOLIS, MD

WHO’S WHO Republic of Indonesia’s National Transportation Safety Committee (NTSC)

(Who’s Who is a brief profile prepared KNKT/NTSC, Tatang Kurniadi, was an investigations is to determine when, by the represented ISASI corporate Air Force officer. His appointment was what, who, how, and why transportation member organization to provide a more effective March 5, 2007. accidents occurred. Investigation re- thorough understanding of the organi- The KNKT/NTSC conducts selected ports are provided to promote aviation zation’s role and functions.—Editor) safety; in no case is the report intended to imply blame, judicial process, and he Republic of Indonesia has been liability. a member of the International Based on the new Aviation Act No. TCivil Aviation Organization since 1/2009, dated Jan. 12, 2009, the KNKT/ April 27, 1950. Based on the Aviation NTSC, on Jan. 12, 2011, will be directly Act No. 15/1992, Chapters 34 and 35, responsible to the president of the Re- the Republic’s president formalized the public of Indonesia. establishment of the Komite Nasional Presidential Decree No. 105/1999 Keselamatan Transportasi (KNKT) provides the NTSC chairman with a or the National Transportation Safety secretariat to help with all administra- Committee (NTSC) through Presi- tion and three accident investigation dential Decree No. 105/1999, dated subcommittees Sept. 1, 1999. 1. Subcommittee of Aircraft Accident The KNKT/NTSC is an operation- Investigation, ally independent institution within the 2. Subcommittee of Marine Accident Ministry of Transportation (MOT) and Investigation, and is responsible directly to the minister of investigations of transportation mishaps 3. Subcommittee of Land Transport transportation. As a reflection of its op- (aviation, maritime, railway, and road Accident Investigation. erational independence, the chairperson transportation) and develops research The Subcommittee of Land Transport of the KNKT/NTSC is always selected and studies, as necessary, to identify Accident Investigation is divided into from outside the MOT, even though the possible safety deficiencies and to two sub subcommittees: Sub Subcom- chairperson is appointed by the minister improve transportation safety mittee of Railway Accident Investigation through the Minister of Transporta- performances. and Sub Subcommittee of Road tion decree. The current chairperson of The objective of the Committee’s Accident Investigation. ◆

32 • ISASI Forum July–September 2010