Air Safety Through Investigation JULY-SEPTEMBER 2017 Journal of the International Society of Air Safety Investigators

Commentary—Air Transport Safety Issues Persist—page 4 Organizing the MH17 Crash Investigation—page 6 Linking State Safety Oversight Agencies—page 15 Aircraft Controllability and Primary Flight Displays—page 18 CONTENTS Air Safety Through Investigation Journal of the International Society of Air Safety Investigators Volume 50, Number 3 Publisher Frank Del Gandio Editorial Advisor Richard B. Stone Editor J. Gary DiNunno Design Editor Jesica Ferry Associate Editor Susan Fager ISASI Forum (ISSN 1088-8128) is published quar- terly by the International Society of Air Safety FEATURES Investigators. Opinions expressed by authors do not necessarily represent official ISASI position 4 Commentary—Air Transport Safety Issues Persist or policy. By Kathy Fox, Chair, Transportation Safety Board of Canada—Despite many successful Editorial Offices: Park Center, 107 East Holly efforts to improve air safety in Canada, the author notes the Canadian TSB has some stub- Avenue, Suite 11, Sterling, VA 20164-5405. Tele- born issues remaining on its WatchList that reoccur in investigation after investigation. phone 703-430-9668. Fax 703-430-4970. E-mail address, [email protected]; for editor, espmart@ 6 Organizing the MH17 Crash Investigation comcast.net. Internet website: www.isasi.org. ISASI Forum is not responsible for unsolicited By Kas E. Beumkes, Senior Investigator/Project Manager, the Dutch Safety Board—The manuscripts, photographs, or other materials. author discusses how and why the MH17 crash investigation was organized and looks Unsolicited materials will be returned only if at how all the different interested parties and exceptional circumstances influenced the submitted with a self-addressed, stamped enve- investigative process. He looks at some of the complex procedures and reports investigators lope. ISASI Forum reserves the right to reject, incorporated into their work to ultimately obtain accurate and independent findings. delete, summarize, or edit for space con- siderations any submitted article. To facilitate 15 Linking State Safety Oversight Agencies editorial production processes, American Eng- By Jeff Guzzetti, Acting Deputy Director, Office of Accident Investigation and Preven- lish spelling of words is used. tion, the FAA—The author examines the importance of cooperation among state air safety Copyright © 2017—International Society of Air agencies that might otherwise rebel against interrelationships under a false premise that Safety Investigators, all rights reserved. Publica- working together is a conflict of interest. He suggests such agencies should find ways to link tion in any form is prohibited without permis- their efforts to accelerate safety improvements in aviation. sion. ISASI Forum registered U.S. Patent and T.M. Office. Opinions expressed by authors do 18 Aircraft Controllability and Primary Flight Displays not necessarily represent official ISASI position or policy. Permission to reprint is available upon By Knut Lande, General Manager/Flight Safety Advisor, LandAvia Ltd.—Although global application to the editorial offices. air accident statistics have improved over the last 50 years, the author suggests loss of control in flight accidents remain a serious issue. He suggests that current accident reports do not Publisher’s Editorial Profile: ISASI Forum is print- address the reasons for pilots losing control, and calling for more pilot training is not the an- ed in the United States and published for profes- swer. The answer, he notes, may be to make primary flight displays more intuitive and easier sional air safety investigators who are members to read. of the International Society of Air Safety Inves- tigators. Editorial content emphasizes accident investigation findings, investigative techniques and experiences, regulatory issues, industry ac- cident prevention developments, and ISASI and DEPARTMENTS member involvement and information. 2 Contents 3 President’s View—ISASI Members Do Make a Difference Subscriptions: A subscription to members is pro- vided as a portion of dues. Rate for nonmem- 28 News Roundup bers (domestic and Canada) is US$28; Rate for 30 ISASI Information nonmember international is US$30. Rate for all 32 Who’s Who—The Air Line Pilots Association libraries and schools is US$24. For subscription information, call 703-430-9668. Additional or replacement ISASI Forum issues: Domestic and Canada US$4; international member US$4; do- mestic and Canada nonmember US$6; interna- ABOUT THE COVER tional nonmember US$8. Ron Smits, left, of the Dutch Safety Board directs recovery of MH17 aircraft parts at one of the crash debris sites in the Ukraine. MH17 aircraft parts, scat- tered over several sites, were later reassembled in a hanger for investigation into probable causes. Photo: The Dutch Safety Board INCORPORATED AUGUST 31, 1964

2 • July-September 2017 ISASI Forum PRESIDENT’S VIEW ISASI MEMBERS DO MAKE A DIFFERENCE

few weeks after you receive this A day prior to the official seminar day this group will go to La Jolla, north of issue of the ISASI Forum, several opening, tutorials for civil air safe- San Diego, for lunch and shopping. After hundred delegates and partic- ty investigators taking place in the the seminar concludes, there is an option- Aipants from all over the world morning, will cover differences between al all-day tour for all participants to the will gather in San Diego, California, on flight data and voice recorder practices San Diego Zoo. August 22–24 for ISASI 2017, the Socie- and in the afternoon will take a look When ISASI 2017 comes to a close and ty’s 48th annual international accident at improvements in cabin safety and we travel back to our homes and jobs investigation and prevention conference. aircraft manufacturing that have led to as air safety investigators and safety The theme for this year’s gathering is “Do increased survivability rates for occu- professionals, there will be no question in Accident Investigations Really Make a pants involved in air accidents. Military our minds that we do make a difference— Difference?” accident investigators will participate what we do makes a difference. Our work ISASI members know the answer to in an all-day session to share knowledge is never done. Successful safety efforts that question, but sometimes it seems and to develop relationships among col- are often hard to quantify in dollars that governments and aviation industry leagues from many parts of the world. and cents, but the cost to do otherwise entities and individuals are confused After day-long technical briefings, about how to best use our investigation there will be time for national society is too dreadful to imagine. Our efforts findings and safety recommendations to business meetings and a chance for ISA- have saved countless lives and mitigat- make aviation safer—on a global, region- SI working groups to meet face-to-face ed the seriousness of countless injuries al, and local scale. In the commentary on to discuss project developments. for crews and passengers of civilian and page 4 of this issue, Kathy Fox, chair of Of course, not all seminar partic- military aircraft involved in incidents and the Transportation Safety Board of Can- ipants’ time will entail formal work accidents. That such events have less- ada, says her agency has had several key discussions and technical presenta- ened in recent years and that the severity items on its Watchlist that have remained tions. There is time for networking with of those that have occurred has been for a long period. The U.S. National Trans- investigators and air safety professionals reduced are evidence that we do make a portation Safety Board (NTSB) doesn’t from many countries who can pass on difference. Are we proud of our accom- new ideas plishments? Certainly. But that makes us WHEN ISASI 2017 COMES TO A CLOSE,… and different more resolved to continue, to improve, to THERE WILL BE NO QUESTION IN OUR MINDS approaches push on—to improve air safety through and who have investigation. THAT WE DO MAKE A DIFFERENCE. air safety I hope to see many long-time friends in expertise in San Diego and to meet many new ones, keep an official watch list as such, but areas that demand to be shared. This too. Our Society requires the constant there are also standing recommendations “unofficial” networking opportunity addition of new, younger investigators for safety measures that have been on is almost more important and useful and safety professionals who are thirsty its agenda for a long time. The seminar’s than the technical side of the seminar. for the knowledge and expertise many of theme of making a difference will weave There are planned dinners and informal us have gained over the years. In that in and out of all the technical presenta- lunches during which hangar talk and regard, ISASI tions. The papers will, of course, be stories hold sway. On Tuesday night, we 2017 is a posted on our website in full and pub- go offsite for dinner at the San Diego Air perfect time lished in edited form in the Forum and Space Museum, and on Thursday and place for throughout the next year. evening we have the ISASI reception and each of us ISASI 2017 participants will also hear awards banquet. from keynote speaker Robert Sumwalt, Companions to seminar participants who have air NTSB vice chairman and ISASI member; will be able to enjoy a ride along the safety each of the 2017 Kapustin Scholarship San Diego Bay in an amphibious SEAL experience to winners, who will present their winning vehicle with a guide providing a history prepare a essays; and an ISASI member given the of the U.S. military facilities in the city solid founda- Jerry Lederer Award—the Society’s high- and then a chance to visit Old Town San tion for the Frank Del Gandio est honor for lifetime achievement in air Diego to explore the city’s heritage in Society’s safety investigation. food, music, and culture. The following future. ISASI President July-September 2017 ISASI Forum • 3 COMMENTARY AIR TRANSPORT SAFETY ISSUES PERSIST

By Kathy Fox, Chair, Transportation Safety Board of Canada (Editor’s Note: This article was edited for space from a speech presented during the ISASI Mid-Atlantic Regional Chapter meeting on May 4, 2017.)

or those in today’s audience who to Runway 14 to take off at the Ottawa/ conduct a go-around. may not be familiar with the Macdonald–Cartier International Airport. Here’s an example. On Feb. 24, 2015, a Transportation Safety Board of A minute after the Dash 8 was cleared de Havilland DHC-8-102, on a scheduled F Canada (TSB), we’re an independ- for departure and began its takeoff roll, a flight from Toronto, Ont., to Sault Ste. ent federal agency whose only goal is to second aircraft, a Piaggio P-180, made an Marie, Ont., touched down 450 feet prior advance transportation safety. It’s been authorized crossing of Runway 14, some to the runway threshold. It was twilight, our job for more than 25 years to inves- 4,400 feet in front. Both aircraft were un- and visibility was reduced due to blowing tigate accidents in the air, marine, rail, aware of the incursion, and they contin- snow. Following touchdown, the aircraft and pipeline modes of federally regulated ued their flight without further incident. struck one of the runway approach lights transportation. At the TSB, we remain concerned that before coming to a stop approximate- Wherever and whenever something similar serious runway incursions will ly 1,500 feet past the threshold on the goes wrong, we find out not just what continue to occur until better defenses runway surface. There were no injuries happened, but also why, in order to make are put in place. Specifically, we’d like to to passengers or crew, though there was recommendations aimed at preventing it see direct-to-pilot alerts that warn of an significant damage to the aircraft. Our from happening again. aircraft or vehicle on the runway being investigation made a number of findings Last October, I spoke at the ISASI annu- used for takeoff or landing—to reduce the as to cause and contributing factors, but al seminar in Iceland. A few weeks after risk of a catastrophic collision. among them was this conclusion: the ap- I gave that speech, the TSB released the The second Watchlist issue I’d like proach was unstable, and the crewmem- latest version of its Watchlist, a document to highlight is unstable approaches. bers didn’t recognize it as such—a fact that identifies the key safety issues that Although international research indicates compounded by the poor visibility—so need to be addressed to make Canada’s that, among commercial operators, just they came in too steep. transportation system even safer. The 3.5 to 4 percent of approaches are unsta- The Flight Safety Foundation has just Watchlist isn’t new; it’s been around since ble, 97 percent of those are continued to a published the final report on the “Go- 2010, but what’s on it is constantly evolv- landing, despite airlines’ stable-approach Around Decision-Making and Execution ing. As old issues and safety deficiencies policies. In other words, only 3 percent Project,” and we welcome such initiatives. are identified and addressed, new ones of the time do flightcrew members who Furthermore, we recommended that take their place. find themselves in an unstable approach Transport Canada require large scheduled In aviation, we’ve seen some evolution, but also a stubborn resistance, as three key Watchlist issues have persisted. All three have shown up in numerous avi- ation investigations over the years, and none have a simple or easy fix. I’d like to look briefly at those three now. The first Watchlist issue I’d like to highlight is runway incursions, which are rare given the millions of takeoffs and landings each year, but their conse- quences can be catastrophic. From 2011 to 2015, incursions averaged a little more than one a day across Canada, and only a small fraction of that, under 1 percent, were considered serious. But this figure is still too high. Here’s just one example. On the evening of Dec. 1, 2013, in darkness, a de Havilland DHC-8-311, with three crewmembers Transportation Safety Board of Canada Chair Kathy Fox addresses the ISASI Mid-Atlantic and 15 passengers on board, was taxiing Regional Chapter.

4 • July-September 2017 ISASI Forum carriers to use FDM programs, or flight old days” we sought only to explain what to verify that there’s also an effective data monitoring, to monitor and reduce happened, today we also focus on why. To system in place to proactively manage the incidence of unstable approaches that keep improving, we need to expand our the risks associated with its operations. are continued to a landing. scope and take a more in-depth look at If done properly, such a transition should The third Watchlist issue I want to the organizational factors that contribute theoretically result in improved safe- highlight is runway overruns. Of course, to accidents, as well as the regulatory en- ty—addressing not only any identified more than 10 years on, few of us can vironment in which those organizations problems, but also the reasons behind forget the powerful images of Air France operate. them. Flight 358, which went off the end of Run- Now many companies say that safety But that theory only works if all com- way 24L at Toronto’s Pearson Internation- is their “top priority.” Yet there is plenty panies have al Airport and burst into flames. of convincing evidence that, for many • the ability to proactively identify The TSB made a number of recommen- of them, the real priority is profitability. safety deficiencies, dations, including that Transport Canada That’s not to imply they’re being deliber- • the capability to rectify them, require major airports to have runway ately reckless or unsafe. It’s just that, in end safety areas that meet International the real world, they often have to balance • a top-down, organization-wide com- Civil Aviation Organization recommend- competing factors such as safety, custom- mitment to doing so, and ed practices or install other engineered er service, productivity, technological in- • balanced regulatory oversight. arresting systems, as well as develop novation, scheduling, cost-effectiveness, Does that sound like any operators you enhanced standards and training for and return on shareholder investment. know? Sure. Some. But not all. Because, conducting approaches in convective And when the TSB finds deficiencies in again, there’s a broad spectrum of ca- weather. how organizations balance those com- pability, competence, and commitment Those are the Watchlist’s three avia- peting factors—specifically, in how they when it comes to implementing SMS— tion issues, and, as I said, they’ve proven identify, prioritize, and manage their despite its track record of success. stubbornly difficult to eliminate. But the risks—we must ask ourselves where was Which—again—brings me back to Watchlist also features two multimodal the regulator? where I started today—to the Watchlist issues that affect other modes of trans- Because, ultimately, it’s the regulator and the stubborn issues that we contin- portation. The first of these is the slow that creates the framework under which ue to see in investigation after investiga- progress that Transport Canada has air carriers operate. And then—ideal- tion. Runway incursions, unstable sometimes made with respect to address- ly—it’s the regulator that provides the approaches, and overruns don’t happen ing certain TSB recommendations. There balanced oversight—whether in the form in a vacuum. And they’re almost never are currently 52 TSB recommendations of inspections or audits—to make sure the result of a single action by one that have been outstanding for 10 years or organizations are abiding by those rules person or organization. But they are in more. And more than three dozen of these and by that framework. part organizational issues. And they’ve have been outstanding for more than 20 In Canada, Safety Management Systems been appearing in our work with years. (SMS) have been mandatory for many persistent frequency. So if a firm hand The other multimodal issue is one the large carriers for more than a decade. and more oversight from the regulator is TSB has been advocating for a while: While that transition hasn’t been seam- what it takes to help organizations the need for the regulator to mandate less, many of these companies have done implement a more robust SMS, then formal safety management processes for a good job, and their SMS—for the most hopefully we’ll begin to see a reduction all commercial operators in the air and part—is fairly robust. in the number of these kinds of acci- marine industries, and then oversee them Many smaller operators, however, dents. Because really, that’s what it’s all effectively. Simply put, too many compa- aren’t required to implement an SMS. about—spot- nies rely solely on regulations to tell them Others have done so only because they ting the what’s safe and what’s not—even though had to. And still more find themselves signals, such an approach can’t possibly foresee somewhere in the middle—trying to making the every contingency. Instead, what’s needed implement it, but with limited experience, connections, is for all companies to demonstrate that expertise, or resources to do it well. It’s a and taking the processes they have are working. And continuum, then—a spectrum. action in if they can’t—or won’t—then the regula- Over the past decade in Canada, the advance so tor must intervene. regulator’s approach to oversight has that the next As you know well, accident investiga- moved away from a traditional “inspect- time you’ll tions have evolved. Over the years, we’ve and-fix approach” to a systems-level find trouble… become very good at identifying the oper- approach whereby, in addition to verify- before ational, technical, and human factors that ing a company’s compliance with regula- trouble Kathy Fox contribute to accidents. Whereas in “the tions, its internal processes are examined finds you. TSB Chair

July-September 2017 ISASI Forum • 5 ORGANIZING THE MH17 CRASH INVESTIGATION

By Kas E. Beumkes, Senior Investigator/Project Manager, the Dutch Safety Board

(Adapted with permission from the author’s technical paper entitled Orgnaizing the MH17 Crash Investigation presented during ISASI 2016, in Reykjavik, Iceland. The full presentation with references can be found on the ISASI website at www. isasi.org in the Library tab under Technical Presentations.—Editor)

he 2016 ISASI seminar theme was those facts, a proven protocol that is used • Ukraine—State of occurrence “Every Link Is Important.” In this worldwide for aircraft accident investiga- • Malaysia—State of registry/operator paper, the Dutch Safety Board tions under the guidelines of the Interna- describes why and how the MH17 tional Civil Aviation Organization (ICAO) • United Kingdom—State of design/ T manufacture (engines) investigation was organized, the involved Annex 13–Aircraft Accident and Incident parties and agencies, and the cooperation Investigation. • United States—State of design/man- with external institutions and experts. The four different investigations were ufacture (airplane) Aviation disasters shock the world. In organized as four different projects, each • Australia—State providing informa- today’s society, an incredible amount of project with its own project manager. For tion (photos) information, including the circumstanc- the investigations that were conducted in es, the possible causes, and who could accordance with Annex 13, one investiga- • Russian Federation—State providing be responsible, is shared immediately tor-in-charge was appointed who worked information (radar data) after a crash. An important objective together with the project managers. Six other states that suffered fatalities of the investigation was to provide the were invited to view the wreckage parts; international community and the victims’ Investigation into the causes of the of these, representatives from Belgium relatives an accurate and truthful picture crash of MH17 and Germany were present. An observer of the causes of the crash of Flight MH17 The investigation into the causes of the of ICAO was present during different on July 17, 2014. Another objective of the crash of Flight MH17 was conducted in phases of the investigation. Dutch Safety Board was to draw lessons accordance with the provisions of Annex for the future, based on the findings of 13 of the Chicago Convention by an in- Investigation into the flight route of this investigation. ternational investigation team in which, MH17 From the start of the investigation, the after the initial phase, the following states The fact that two judicial regimes apply, Dutch Safety Board applied four princi- were represented by an accredited repre- namely the Kingdom Act Dutch Safety ples: maintaining independence, achiev- sentative during progress meetings: Board and Annex 13 of the Chicago Con- ing a high-quality investigation, focusing • Netherlands—State conducting the vention, was especially noticeable in the on determining the causes as accurately investigation investigation into how the decision-mak- as possible to exclude other scenarios, ing related to the flight and achieving as much route of Flight MH17 international acknowl- was organized, and edgment as possible for how decisions about the investigation. flying over conflict are- The investigation as are made in general. was carried out under For the investigation exceptional circum- into flying over conflict stances. The Dutch areas, the Dutch Safety Safety Board was not Board approached var- blind to the geopoliti- ious parties in and out- cal implications of the side the Netherlands to crash but in the inves- request their cooper- tigation deliberately ation in the investiga- kept its distance from tion. It was not always international politics. clear to these parties The facts were leading whether the Dutch in the investigation, Safety Board requested and the views of parties them to cooperate on

Photos: The Dutch Safety Board were evaluated against Figure 1. the basis of Annex 13

6 • July-September 2017 ISASI Forum of the Chicago Convention or on the basis justice to these international devel- of the Kingdom Act Dutch Safety Board. opments and included them in its in- These parties, such as sister organizations vestigation where possible. The Dutch and airlines, provided information to the Safety Board involved representatives Dutch Safety Board and cooperated with of sister organizations where pos- this part of the investigation anonymous- sible and when necessary for the ly and on a voluntary basis. investigation. The investigation into Kas E. During the investigation, it became the general decision-making related Beumkes increasingly clear that parties all over the to flying over conflict areas made it world attach great value to improving the possible to place the outcomes of born in 1964 in the Netherlands, has safety of civil aviation regarding flying the investigation into Flight MH17’s been involved in aviation safety inves- over conflict areas. This was demonstrat- route in an international perspective tigation since 1990. He started as an ed, for example, by a joint declaration (on and created the opportunity to learn aircraft accident investigator for the July 29, 2014) from ICAO, the branches deeper and broader lessons from this Netherlands Aviation Safety Board from air transport (IATA), airports (ACI), tragic accident. and became chief investigator in and air navigation service providers 1998. After the board merged into the (CANSO). Following the crash, various in- Investigation of the occupants of multimodal Dutch Transport Safety ternational initiatives were undertaken to MH17 Board, he became the secretary of the Aviation Commission in 2001. When this board merged into the multisec- toral Dutch Safety Board in 2005, he became senior secretary of aviation. Since 2008, Beumkes has served the board as senior investigator/project manager. Beumkes has two bachelor of science degrees, one in aeronautical engineering (1986) and the other in industrial engineering (1988). He attended the Cranfield Aircraft Accident Investigation Long Course in 1991, the SCSI HFAI in 1999, and the AAAI in 2000. In 2006, he obtained a master’s degree in management of safety, health, and environment at the Technical University Delft, the Netherlands. Figure 2. reduce the chance of an accident, such as According to Annex 13 of the Chicago The investigation into these questions was that involving Flight MH17, from occur- Convention, the investigation should conducted on the basis of the authority ring in the future. In August 2014, ICAO include the injuries suffered by the provided by the Kingdom Act Dutch Safety set up a task force to advise on adapting victims, medical and pathological Board. roles and procedures focused on limiting information, and their chances of sur- risks that conflict areas pose to civil avia- vival, depending on the circumstances Investigation of the passenger tion. On Oct. 27, 2014, ICAO also adopted of the accident. The Dutch Safety information about MH17 a resolution advocating for the investiga- Board decided to conduct a more The investigation into passenger informa- tion into the crash of Flight MH17 to be thorough investigation into the conse- tion looked at the time needed to provide used to improve international standards quences of the crash for the occu- the relatives of the Dutch victims of Flight and to share best practices for the safety pants than is customary on the basis MH17 with official confirmation that their of civil air traffic flying over conflict areas. of Annex 13. Apart from the aspects loved ones were on board the airplane. This The subject was also on the agenda of listed there, the Dutch Safety Board investigation was conducted fully within the ICAO’s high-level safety conference in attempted to answer the question authority granted to the Dutch Safety Board Montreal, Que., in February 2015. Flying as to what conditions the occupants by the Kingdom Act Dutch Safety Board. On over conflict areas and MH17’s flight were exposed to during the crash and the basis of this authority, the Dutch Safety above the eastern part of Ukraine were what the influence of this was on their Board can conduct an investigation into recurring themes in the news media, too. bodies, consciousness, and awareness. the way the Netherlands has managed the In the investigation into the deci- In addition, the Dutch Safety Board consequences of accidents abroad of which sion-making related to flight routes, the investigated how the human remains the impact extends to the territory of the Dutch Safety Board attempted to do were handled following the crash. Netherlands.

July-September 2017 ISASI Forum • 7 In the context must at all times be able to formulate an of an accident autonomous and impartial perspective, investigation, fed by the perspectives of others. independence The investigation into the crash of is not absolute. Flight MH17 took place in an extraor- First, there is dinary context. The large number of always a certain victims, the considerable news media at- interdepend- tention and the public involvement in the ency between crash, the simultaneous occurrence of an the investigator international criminal investigation, and and the subject the geopolitical interests involved made it of the investi- even more important for the Dutch Safety gation, because Board to safeguard its independence. parties directly involved have Reflection meetings knowledge of From the very beginning of the investi- unique facts gation into the crash of Flight MH17, the and circum- Dutch Safety Board was aware that the stances that are risk of political influence could be higher necessary for than usual, given the tense interna- understanding tional relations. To effectively identify the accident. and manage this risk, the Dutch Safety Although the Board held two reflection meetings with Dutch Safety experts having extensive experience in Board benefits conducting investigations in a political from legal pow- playing field. These meetings focused on ers it can use to obtaining advice about the right strategy enforce cooper- for working and interacting with parties ation with its in- in this context. The meetings also aimed vestigation, that to explore what the Dutch Safety Board does not totally could do to ensure that the results and eliminate the recommendations of the investigation op- type of depend- timally matched the expectations of the ency referred to outside world. The Dutch Safety Board above. Second, used the results of these meetings in its due to the scope Figure 3. decision-making processes throughout of its field of the investigation. work, the Dutch Safety Board will always Conducting the investigations depend on the expertise of others to ef- The Dutch Safety Board conducts its fectively conduct its investigations. Third, Stakeholder analysis investigations within the applicable legal in order to arrive at authoritative con- To arrive at independent and authori- framework respecting its core values: clusions, it is important that the Dutch tative conclusions in a complex array of independent, professional, and transpar- Safety Board also takes into account the forces, it is important that the investiga- ent. In the following sections, the Dutch views and interests of others. tive body has an effective understanding Safety Board explains how these terms The Dutch Safety of these forces: what interests do the var- in general are put into practice and what Board therefore can- this meant for the investigation into the not and does not wish crash of Flight MH17. to wholly isolate itself in conducting its in- Independence vestigation. It is rather The Dutch Safety Board’s objective in a matter of the Dutch conducting its investigations is to provide Safety Board guarding a definite answer about what happened its conclusions against and how, and to draw authoritative con- the disproportionate clusions and lessons from this. From that influencing by other objective, it is important that the Dutch parties while Safety Board is able to formulate its own ensuring observance autonomous opinion about the facts and of the aforementioned their interpretation. In this respect, the dependencies. The legal framework offers several guarantees. Dutch Safety Board Figure 4. 8 • July-September 2017 ISASI Forum Figure 5. ious parties have, how could they influ- that is conducting the investigation to course of an investigation and advises the ence the course of the investigation, and organize progress meetings with the par- Dutch Safety Board on the focus and the how can the investigative body best deal ticipating states. The objective is to share findings of the investigation, the com- with those forces? A stakeholder analysis relevant information within the team. ments from the parties concerned on the was performed to systematically answer Holding such meetings is not required, draft final report, the conclusions to be these questions. nor is the number of meetings or their formulated, and the recommendations, frequency set. The investigator-in-charge insofar as applicable. On occasion, guid- International collaboration in aviation invites the accredited representatives and ance committees met jointly when this accident investigation their advisors. In the investigation into was helpful to the investigation. Annex 13 of the Chicago Convention pro- the causes of the crash of Flight MH17, vides for the participation of states hav- this was done on three occasions. Bringing the outside world inside ing a special interest in the investigation During the course of the investigation, the Dutch Safety Board consistently tried into a civil aviation accident. Depending Guidance committee on the nature of their involvement in to keep an open eye to facts, information, To be able to form autonomous conclu- the occurrence, states can participate in investigations, suspicions, and theories the investigation through an accredited sions, the Dutch Safety Board obtained presented by “outsiders” pertaining to the representative or an expert. The rationale advice about the weighting of the findings crash of Flight MH17. It did so with the behind involving various states in the in- drawn up by the investigation team. For conviction that the quality of its conclu- vestigation is that parties with potentially this, it employed a guidance committee. sions would be improved if all kinds of conflicting interests have the opportunity A separate guidance committee was set perspectives were incorporated into its to take note of the facts firsthand and up for each of the four different investi- formulation. The perspectives of parties present their views in the investigation. gations regarding the accident of Flight other than the states and parties already The fact that the interests of the states MH17. For this organized critique, the involved and their experts can add great most involved in the investigation are Dutch Safety Board attempted to incor- value to the process. In order to identify represented in this manner enables the porate all the required expertise in the what statements were circulating about state that conducts the investigation to committees. the causes of the accident and the flight formulate autonomous conclusions based The members of the guidance com- route, the Dutch Safety Board asked on the various views. mittees have relevant expertise and are Publistat, an organization that monitors In international aviation accident appointed in a personal capacity. Each media, to analyze the reports in interna- investigation, it is customary for the state committee convenes several times in the tional social media. This analysis served July-September 2017 ISASI Forum • 9 as the basis for the hypotheses that the Dutch Safety Board included in the investigation. Regarding the results of investigations into the accident conducted by other parties, the Dutch Safety Board examined the sources that formed the basis of these investigations as much as possible. If the sources were accessible, the Dutch Safety Board assessed whether it was useful to incorporate the findings of the other parties in its investigation.

Composition of the investigation teams The Dutch Safety Board strives to have all the necessary knowledge and skills among its own personnel and tries to re- alize this through recruitment, selection, and training. The investigation teams for each project are multidisciplinary and consist of investigators who possess the knowledge and skills required for the in- vestigation at hand. For the investigation Figure 7. into Flight MH17, the Dutch Safety Board called upon investigators having expertise organizations and independent knowl- The following part of this section on the subject of aviation, defense, health, edge institutions such as universities, describes how the Dutch Safety Board, crisis management, administrative pro- when recruiting external investigators. taking into account the limitations cesses, and risk management. mentioned earlier, achieved transparency The investigation into Flight MH17 Transparency in the investigation into the crash of Flight was an exceptionally large and complex The Dutch Safety Board attaches great MH17. project for the Dutch Safety Board. The value to conducting its investigation in project took up a great deal of the availa- a way that is comprehensible to others Preliminary report ble resources: approximately three-quar- so that in turn they can form their own Given the scope of the accident and its ters of the 72 staff members were at some opinion on the investigation’s validity impact on Dutch society and on other point assigned to the investigation or to and reliability. Moreover, it is important nations that suffered fatalities in the activities in support of it. that the Dutch Safety Board informs the accident, the Dutch Safety Board chose different stakeholders (relatives, other to publish the preliminary report after Involving external investigators parties involved, the general public) about a consultation period. In publishing the and support the investigation and its findings in such preliminary report, the Dutch Safety The Dutch Safety Board is an organiza- a way and at such times that they are not Board aimed to provide the relatives of tion with a broad scope of activity. Thus unnecessarily obstructed from coming to the victims, while the investigation was bringing in specific external expertise terms with their grief or drawing lessons still in progress, with factual information is unavoidable, especially for extensive from the event. about the crash and the findings up until investigations such as that into the The extent to which the Dutch Safety that time. crash of Flight MH17. The most relevant Board can practice transparency is limit- Dutch relatives received the prelimi- selection criteria when involving external ed due to the legal obligation to protect nary report an hour before it was pub- staff are relevant exper- its sources. Other than the information in lished on Sept. 9, 2014, under embargo via tise, proven quality, and the final report, the Dutch Safety Board the family liaison officers deployed by the impartiality of the ex- does not release any underlying source in- national police. This allowed the relatives ternal employee. The formation related to the investigation, ex- to become acquainted with the report’s Dutch Safety Board cept in exceptional cases. The purpose of content before it was released by the prefers to use its this source protection is to enable those news media. own network in the involved in an accident to give the Dutch sector related to Safety Board full disclosure without fear- Consultation and review an investigation, ing any disciplinary measures or criminal Both Annex 13 of the Chicago Conven- including con- prosecution. This means that the Dutch tion and the Kingdom Act Dutch Safety tacts in sister Safety Board is in an optimal position for Board include provisions concerning to discovering the true causes of an accident which parties and in what manner the Figure 6. and for drawing lessons from it. draft final report must be presented for 10 • July-September 2017 ISASI Forum consultation, as well as the way in which the moment of publication. In particular, Safety Board by relatives via a dedicat- the resulting comments are to be pro- in cases where information was directly ed forum, family liaison officers, or via cessed. The objective of these provisions related to a (joint) mission carried out by Victim Support the Netherlands were is to ensure that the final report does not (or with) another party, the content of the answered immediately. contain any factual inaccuracies and to news report was shared in advance with be informed of interested parties’ views the party concerned. Other reports on the findings and conclusions that the Part of the transparency policy of the Dutch Safety Board has drawn on the Informing the relatives Dutch Safety Board is to include infor- basis of the facts investigated. The Dutch Safety Board wanted to keep mation about how the investigation is the relatives of the victims informed conducted. Normally one appendix in the Communication policy of the progress of the investigation as final report contains this information. For The needs, expectations, and perceptions effectively as possible. Never before did the MH17 investigations, the Dutch Safety in the outside world have influenced the the Dutch Safety Board have to deal with Board dedicated a separate report to this choices the Dutch Safety Board made such a large group of relatives originating purpose. concerning the type and scope of its from so many different countries during The Dutch Safety Board is obliged to reporting. During the investigation, the an investigation. The Dutch central gov- publish the comments from the consulta- Dutch Safety Board publicized informa- ernment organized information meetings tion phase of the investigation that were tion about the investigation process more for the relatives, and the Dutch Safety not adopted with counter arguments. The than had previously been customary. Board attended these meetings to provide parties concerned are informed of this The Dutch Safety Board also published information about the process of the procedure during the consultation. These a number of relevant documents on its investigation and to answer the questions comments are presented in a table that is website to provide clarity about some of of relatives. appended to the final report. the agreements that were made. This con- During the investigation, the Dutch The Dutch Safety Board also pub- cerns the agreements between the Dutch Safety Board maintained contact with lished a book with the stories behind the Safety Board and other parties with re- the MH17 Aviation Disaster Foundation investigations into the crash of Flight gard to taking charge of the investigation (Stichting Vliegramp MH17), Victim MH17 (see Figure 6). For this purpose, an into the crash of Flight MH17 and with Support the Netherlands (Slachtoffer- investigative journalist and writer was regard to the recovery of the wreckage. hulp Nederland), and the family liaison commissioned to record these stories The press and news reports published officers and sought their advice prior to from inside—from the perspective of by the Dutch Safety Board were not having meetings, publicizing reports, or the board members and some of the shared with other parties in advance, with undertaking other kinds of communica- investigators—to disclose the manner in some exceptions. In certain cases, the tions. The relatives of the victims received which the investigation was conducted, Dutch Safety Board believed it was nec- information via a special forum before it the choices that were made, and how the essary to supply parties with the informa- was shared with the news media. Where investigation was experienced, both as an tion that it was going to publish prior to possible, questions asked of the Dutch organization and as human beings. This book is an “answer” to the long amount of time the investigation was going on with- out releasing information to the families of the victims.

Cooperation with other authorities During the recovery missions, the Dutch Safety Board worked in close cooperation with other Dutch authorities. This was done for security reasons and because the missions for recovering human remains, personal belongings, and wreckage pieces were combined. That is why the Dutch Safety Board joined the operational meetings concerning the missions for as long as deemed necessary to carry out the recovery work. These meetings were organized by the Dutch Ministry of Defense and were attended by the Dutch authorities that took part in the recovery missions, namely the Ministry of Defense, the Royal Netherlands Marechaussee, the national police, the Ministry of Foreign Affairs, and the Dutch Intelligence and Figure 8. Secret Services—the MIVD, the AIVD, and July-September 2017 ISASI Forum • 11 the NCTV. For the purpose of coordinat- seizure of physical evidence and docu- Service, which indicated which pieces ing the activities, there were also bilateral ments, the examination of the pieces of could be relevant to the criminal investi- consultations between the Dutch Safety wreckage, and the fragments and periodi- gation. These pieces were marked. Board and the involved public bodies. cal coordination consultation. After this, the material became availa- ble for examination to both parties simul- Concurrence with the criminal Sharing information related to taneously. Destructive examination (i.e., investigation investigations an examination of an irreversible nature) Following the crash of Flight MH17, an In order to determine the causes of an could only take place once both parties international criminal investigation start- accident or crash, it is of great impor- had investigated the relevant material ed on Aug. 7, 2014. This investigation was tance that those involved can speak freely for damage patterns and traces, and after conducted by a joint investigation team, and are able to provide the Dutch Safety both parties consented. in which police and judicial authorities Board with information without having All pieces of wreckage, parts, or secured from the Netherlands, Australia, Malay- to fear prosecution under criminal law. evidence were only to leave the hangar sia, Belgium, and Ukraine cooperated. Both Annex 13 of the Chicago Conven- in Gilze-Rijen for investigation after the The Netherlands coordinated the inves- tion and the Kingdom Act Dutch Safety Dutch Safety Board and the Dutch Public tigation. The objective of the criminal Board include various provisions on the Prosecution Service had agreed. This investigation differed from that of the subject of maintaining the confidentiality applied, for example, to material analyses investigation conducted by the Dutch of information related to the investiga- that were performed by external agencies. Safety Board. The Dutch Safety Board tion. Insofar as these provisions offered focused on the question of what hap- this possibility, information that was also Examination of the human remains pened and what could be learned, and needed for the success of the internation- The Dutch Public Prosecution Service not on the question of who was to blame. al criminal investigation was shared with seized the human remains when they The joint investigation team, on the other the Dutch Public Prosecution Service. The arrived in the Netherlands, after which hand, focused on the causes of the crash idea was not to withhold information if the injuries and the fragments that were in response to the question of whether that would punishable offenses had been committed hinder the and who could be held responsible in progress terms of criminal law. of the Since both investigations considered criminal the same events, they partly relied on investiga- the same evidence, each from their own tion. Thus perspective. This situation required coor- the Dutch dination between the crash investigation Safety and the criminal investigation to prevent Board both investigations, each responding to continual- a legitimate social need, from frustrating ly con- each other. This necessary alignment sidered was achieved through agreements be- whether tween the Dutch Safety Board, being the sharing accident investigation authority, and the informa- Dutch Public Prosecution Service as coor- tion could dinator of the joint investigation team. in any way The agreements constitute a detailed be detri- elaboration of the existing Dutch Safety mental to Board–Dutch Public Prosecution Service its own Coordination Protocol (Afstemming- investiga- sprotocol Onderzoeksraad voor Veilig- tion. Vice Figure 9. heid–Openbaar Ministerie). This protocol versa, the Dutch Public Prosecution Service also found in the bodies were forensically regulates the coordination between both shared information proactively if it was examined. The Dutch Safety Board was organizations in a general sense if a crim- relevant to the accident investigation. informed of the results of these exam- inal investigation and an investigation by inations and used these for its own the Dutch Safety Board into an occurrence Examination of the investigation. The Dutch Safety Board did are conducted simultaneously. Addition- wreckage not perform its own examination of the al agreements were required given the The Dutch Safety Board was responsi- human remains. complexity of both investigations, their ble for recovering the wreckage pieces concurrence, and the international context and their transport to the Netherlands. Recorders from MH17 in which these investigations took place. The recovered material was inspected During the investigation, the Dutch Safety These agreements related to the reciprocal and sorted at Gilze-Rijen Air Base in the Board provided the Dutch Public Pros- exchange of investigative information, the presence of the Dutch Public Prosecution ecution Service with the data files from 12 • July-September 2017 ISASI Forum the flight data recorder and some of the cution Service. The Dutch Public Prosecu- tion activities and matters related to this. data from the cockpit voice recorder. The tion Service and the Dutch Safety Board Dutch Safety Board was very cautious shared the results of the different analyses Classified information about providing the recordings in order that they had arranged. All the Dutch Safety Board’s investigation to guarantee the cockpit crew’s privacy. material is of a confidential nature. How- In the presence of the Dutch Safety Other evidence ever, in the investigation into the crash Board and the Public Prosecution Service, of Flight MH17, confidential information In addition to the aforementioned specialized staff listened to the sound was used that the Dutch authorities information, the Dutch Safety Board recordings on the Dutch Safety Board’s had categorized as “classified” and that premises, with the objective of determin- provided the Dutch Public Prosecution the Dutch Safety Board was not able to ing what information could be essential Service with the following information: access at all times or could not include to the criminal investigation. The entire photographs of the wreckage area, lists in its reports. The central government of 30-minute recording was found not to be of the parts of the airplane that had the Netherlands adopts different levels relevant in that respect, with the excep- been seized, and information about the of classification, from “departmentally tion of the final milliseconds, the moment damage patterns on the wreckage pieces. confidential” to “top state secret.” It is un- when the airplane was hit. After consul- Statements from individuals as well as usual for the Dutch Safety Board to work tation with the Dutch Public Prosecution medical and private information collect- with this type of material and to not have Service, it was decided, for the above- ed by the Dutch Safety Board were not all the source material in its possession. mentioned reasons, to hand over only shared with the Dutch Public Prosecution This is why additional explanation of the the recording of this working methods short period of time. concerning classified The data carriers information is given themselves were not in the report. handed over. These The Kingdom Act remained in the Dutch Safety Board hands of the Dutch stipulates that the Safety Board. minister of the In- terior and Kingdom Examination of the Relations, the min- fragments ister of Defense, and Both the Dutch the minister of Se- Public Prosecution curity and Justice, or Service and the persons under their Dutch Safety Board jurisdiction, may arranged for the provide confidential fragments found in information to the and on victims’ bod- Dutch Safety Board. ies and in and on the How to handle clas- pieces of wreckage sified information to be analyzed (see in the investigation Figure 9). Both par- Figure 10. into Flight MH17 ties outsourced this was determined process separately to external agencies in consultation with the organizations but jointly coordinated this process since Service. In addition to the results of the that were owners of the information. The the outcomes constituted a substantial forensic analyses of the fragments, the central question in this consideration was source of information for both the crim- Dutch Public Prosecution Service shared whether use of this information could inal investigation and the Dutch Safety other information with the Dutch Safety endanger the security of the Nether- Board’s investigation. Board, such as the autopsy and inspec- lands. An additional consideration was With regard to the fragments found in tion reports of the victims, photographic the extent to which the information was the victims’ bodies, a selection of hu- and video material, and the results of the necessary for arriving man remains was made of which scans analyses concerning the found objects at a conclusion or whether the informa- revealed that they contained “foreign” that probably originated from a missile. tion could also be used in a supporting fragments. The selection included the capacity. human remains of the crew in the cockpit. In the investigation into the crash of The fragments were removed from the Periodic consultation Flight MH17, classified information was bodies by forensic investigators commis- Throughout the investigation, frequent used in several ways: sioned by the Dutch Public Prosecution consultations took place between the • There were classified documents that Service. The fragments were removed Dutch Public Prosecution Service and the the Dutch Safety Board had request- from the wreckage pieces by the Dutch Dutch Safety Board, during which they ed in the context of the investigation Safety Board and the Dutch Public Prose- discussed the progress of the investiga- and that it kept copies of at its The

July-September 2017 ISASI Forum • 13 Hague office. Safety Board was allowed to discuss members of the Dutch Safety Board. classified information under strict The letter also mentioned the agree- • There was classified information confidentiality. Consultation of the ment that the Dutch Safety Board that was available to the Dutch secret information was limited to board would first submit the CTIVD report Safety Board for inspection only. members and a small number of Dutch to both ministers to check it for any The Dutch Safety Board was able to Safety Board employees who had under- state secrets prior to the Dutch Safety see relevant classified information gone an extensive security screening for Board making it public. Before regarding Flight MH17 that was in handling secret information. finalizing its report, the CTIVD the possession of the MIVD and the Lastly, classified information was submitted it with references to AIVD. included in the investigation that the underlying classified sources to the The findings of the Dutch Safety Dutch Safety Board neither had access AIVD and the MIVD for verification of Board as described in the report about to nor was able to see. This concerned the facts. Both intelligence services the crash of Flight MH17 agree with information from the Dutch Intelli- made only a few minor comments, this classified information. Because of gence and Security Services (AIVD and and on April 10, 2015, the CTIVD national security reasons, this classified MIVD) related to the armed conflict handed over the still-classified report information could not be publicized. in the eastern part of Ukraine. At the to the Dutch Safety Board members Since it is unusual for the Dutch Dutch Safety Board’s request, the without any references to classified Safety Board to make use of classified minister of the Interior and Kingdom sources. In conformity with the letter military information, an agreement was Relations and the minister of Defense of Nov. 21, 2014, the Dutch Safety concluded between the Dutch Safety asked the Dutch Review Committee on Board subsequently submitted the Board and the MIVD for this specific the Intelligence and Security Services report to both ministers to have it investigation. This agreement stipulates (CTIVD) in a letter dated Nov. 21, 2014, checked for potentially classified that both organizations may provide to examine this information. information. The ministers did not the other with the information it needs The ministers asked the CTIVD to find any state secrets in the report, to perform its legal tasks. The Dutch report the findings directly to the board which was then declassified.

Figure 11. 14 • July-September 2017 ISASI Forum he United States and many because, by statute, the NTSB must pendence would not be compromised other International Civil assign an investigator-in-charge (IIC) and if the NTSB needs to utilize some of the Aviation Organization (ICAO) determine the cause for every one of the 40,000 FAA employees as force multipliers T nations each have various nearly 1,300 civil aviation accidents that to perform on-scene investigations. agencies inside their borders with occur each year in the U.S. So doing the Looking beyond the “macro” view of overlapping yet differing roles in math determines that for an NTSB IIC an agency’s investigative practices, one regulating, investigating, and eval- to travel to each accident site, let alone must focus on the personal relationships uating the aviation industry. These conduct research and write reports, living between the individuals and personalities interrelationships often produce ten- a normal life is not possible. within the state agencies that are actually sion and “rebellion” under the false Throw in a half-dozen significant and conducting the daily grind of investigative premise that working together is an complex aviation accidents and airline work. If these individuals do not play well unacceptable “conflict of interest” or incidents, and the math becomes more in the investigation sandbox, potential that the authorities of their agency troublesome. In fact, the NTSB travels to life-saving safety improvements may be are being usurped. However, these less than 15 percent of these accidents, delayed. Aviation and accident investi- relationships should be fostered, and therefore it must rely on the vol- gation teams tend to be populated with rather than be allowed to wilt from untary support and expertise from the accomplished experts who may have ignorance, arrogance, or fear. Instead Federal Aviation Administration (FAA)—a oversized egos, assertive personalities, of being predisposed to rebel against massive agency of 40,000 people charged and/or a narrow focus of their mission. each other, these agencies should with regulating and controlling every fac- In most cases, the individual relation- find ways to link their efforts in order et of aviation in the U.S. Refraining from a ships and work efforts of FAA and NTSB to achieve their ultimate objective high level of collaboration with each oth- investigators are productive, but miscom- of accelerating safety improvements er as they develop ideas to improve safety munications, grudges held from previous in aviation. Enlightened managers in the wake of an accident or incident investigations, arrogance, and ignorance LINKING STATE SAFETY OVERSIGHT AGENCIES

By Jeff Guzzetti, Acting Deputy Director, Office of Accident Investigation and Prevention, the FAA (Adapted with permission from the author’s technical paper entitled Linking State Safety Oversight Agencies presented during ISASI 2016, in Reykjavik, Iceland. The full presentation with references can be found on the ISASI website at www.isasi.org in the Library tab under Technical Presentations.—Editor) and staff can and should provide for does not serve either agency. can sometimes cause problems. It is the a culture of enhanced awareness to The U.S. Congress intended to pre- responsibility of the managers and lead- support practical safety actions. vent duplication between investigations ers of these agencies to instill an appro- conducted by the FAA and the NTSB, priate culture and develop guidance that The NTSB and the FAA and therefore established that the NTSB serve to eliminate useless rebellion. In the U.S., the lead agency for all civ- shall always take the lead role. However, il aviation accidents is the National Congress also recognized that the FAA The “Ashburn Accord” Transportation Safety Board (NTSB)—an must participate as a party in all NTSB During the communication chaos that independent and highly credible or- aviation accident and incident investiga- typically occurs after any significant ganization with less than 120 air safety tions, enabling it to obtain safety-critical airline accident or serious incident, the investigators out of a total of about 400 information in a timely manner—to meet NTSB and the FAA can be spring-loaded people. The relatively small size of this its safety oversight needs—during the to rebel against each other when attempt- elite agency is at once its strength and NTSB's fact-gathering activities. As long ing to obtain critical evidence for each of its weakness. The NTSB’s size allows the as longstanding federal ethics and agency their needs. For example, in the wake of agency to be nimble, quick, and focused. policies are followed, and with a healthy a fatal accident in 2010 of a cargo jet that However, being small is also a challenge, dose of transparency, the NTSB’s inde- a U.S. airline operated, the FAA immedi-

is currently the acting deputy director of the Office of Accident Investigation and Prevention at the U.S. Federal Aviation Administration (FAA). He joined the FAA in May 2014 as the manager of the Accident Investigation Division. Guzzetti also served as the assistant inspector general for aviation audits at the U.S. Department of Transportation's Office of the Inspector General for four years, where he led audits of FAA aviation safety programs. His prior experience includes 18 years with the U.S. National Transportation Safety Board's (NTSB) Office of Aviation Safety, where he served as a field- in vestigator, major accident investigator, and the deputy director of regional operations. Guzzetti has also worked as an air Jeff safety investigator with the Cessna Aircraft Company and as a safety engineer with the U.S. Naval Air Systems Command. Guzzetti He earned a bachelor of science degree in aeronautical engineering from Embry–Riddle Aeronautical University, and he holds a commercial pilot license with multiengine, instrument ratings, and seaplane and glider pilot ratings.

July-September 2017 ISASI Forum • 15 ately wanted access to the maintenance tion of timely and relevant data in these Information Analysis and Sharing (ASIAS) records of the accident airline. However, investigations, and the Ashburn Accord system. Implemented in 2007 by the FAA, the airline demurred and initially refused stresses that the FAA may require infor- ASIAS collects and analyzes data from to allow the FAA—the regulatory agency mation in addition to that required by the multiple databases to proactively iden- responsible for its oversight—to gain NTSB. Or the FAA may require informa- tify and address risks that may lead to access to this information. The reason tion more expeditiously than the NTSB accidents. This is a collaborative indus- given was that “the NTSB is in charge” to address urgent unsafe conditions. In try-government information-sharing and and that “the FAA will have to go through these situations, the FAA is clearly author- analysis system that combines, analyzes, the NTSB.” ized to obtain such information directly and disseminates aviation safety data and This did not please the FAA inspectors from the parties. reports. assigned to oversee the airline. However, The Ashburn Accord provides impor- The system is fed by a wide variety of the NTSB was also not pleased that the tant guidance to help ensure that the data sources from both public and pro- FAA attempted to gain access to “evi- appropriate priority is placed on the tected proprietary aviation data. Publicly dence” that the NTSB’s authority clearly collection of investigative information available data include information from indicates has the “priority” to obtain. Was that the FAA needs. If rebellion arises, the many sources such as the NTSB’s accident the FAA trying to sidestep the NTSB? policy states that the NTSB, the FAA, and and incident reports database. Proprie- Was the airline trying to “hide” evidence the operator or manufacturer (or both, as tary and/or confidential sources include behind the guise of an NTSB investiga- appropriate) will conduct an “interagency data from aircraft operators, including tion? Was the NTSB blocking FAA efforts communication call” at the start of an Flight Operations Quality Assurance to ensure “continuing operational safety”? investigation to identify and coordinate (FOQA) extracted from aircraft recorders Should the investigators from the NTSB information requests. Following that call, and voluntary safety reports submitted and the inspectors from the FAA have any information that is provided to the by flight crews. Interactions between the whipped out their badges to see which FAA must be shared with the NTSB. Also, FAA and the aviation industry range from one was bigger in order to settle this if there are any questions regarding an analyzing ASIAS data to identifying and rebellion? Of course, in hindsight, the information request, the assigned NTSB recommending risk mitigations. While answer to all of these questions is no! IIC should be contacted immediately via the NTSB will never have access to the Although the NTSB and the FAA have the NTSB 24-hour Response Operations protected proprietary ASIAS data, a writ- different roles, both share the need for Center. ten agreement was struck in November timely, unimpeded access to operational With regard to conducting interviews, 2012 allowing the NTSB to initiate written safety information. After this incident, the Ashburn Accord stipulates that the requests for de-identified and aggregated and also prompted by previous concerns NTSB will lead interviews of operator and ASIAS data related to aircraft accidents regarding previous engine failure inves- manufacturer personnel and will con- involving U.S. airlines that occur in the tigations, the NTSB, the FAA, aircraft duct them “as soon as practical.” An FAA U.S. The NTSB has agreed it will not manufacturers, engine builders, and party representative, along with other publicly disclose ASIAS information it airline representatives got together in an party representatives, will be invited receives via this process unless the ASIAS attempt to forge an “alliance” of under- to participate in the NTSB interviews. Executive Board agrees. standing. During a two-day meeting in The FAA may conduct its own follow-up The FAA can be a rich source of in- early 2014 at the NTSB Training Center interviews if the FAA needs additional formation for NTSB investigators. For in Ashburn, Va., the FAA and the NTSB information, and the FAA will share the example, on Aug. 14, 2013, an Airbus hammered out the basics for a “joint results of these interviews with the NTSB A300 crashed short of the runway during policy letter” that was later formalized as per their obligations as a party. If the a localizer-only nonprecision approach and signed on June 4, 2014. The policy was NTSB is unable to conduct interviews for to an airport in Birmingham, Alabama. informally dubbed the “Ashburn Accord” its purposes within a reasonable time, the The NTSB determined that the primary and was distributed to the U.S. aviation policy allows the FAA to coordinate with cause of this accident was the flightcrew industry to clarify the roles and respon- the NTSB to conduct its own interviews members’ continuation of an unstabilized sibilities of the NTSB and the FAA during to ensure continuous operational safety approach and their failure to monitor the an incident or accident investigation. and provide the results to the NTSB. aircraft’s altitude during the approach, The Ashburn Accord states that the Now that a written policy exists, poten- which led to an inadvertent descent NTSB and the FAA “both perform critical tially rebellious parties can reference the below the minimum approach altitude roles in maintaining aviation safety,” policy during the chaotic hours following and subsequently into terrain. During the but asserts that the NTSB has “priority” a major accident. Alliances are formed, NTSB-led investigation, recorded data over any other investigation. However, rebellion is crushed, and safety issues are from the FAA’s air traffic system was used the letter also makes clear that the FAA identified and mitigated more quickly. to not only assist with characterizing the has the authority to investigate aviation accident approach, but also to analyze safety-related matters as necessary to An alliance for information sharing other approaches flown by many other ensure continuous operational safety and Another example of collaboration unidentified airlines to similar runways will do so as needed after a significant between similar and competing safety during a three-year period. An analysis accident or incident. The FAA depends on oversight agencies is information shar- was applied to 1.4 million approaches at a the cooperation of the manufacturers and ing. A specific example involves the use subset of 31 U.S. airports that had at least airlines that it certifies to ensure collec- and benefits of the FAA’s Aviation Safety one runway with only a nonprecision ap-

16 • July-September 2017 ISASI Forum proach, a situation similar to that of the the Yellow Book are commonly referred relating to its programs and operations.” accident flight. Approaches to runways to as generally accepted government That means virtually any document that with and without precision approaches auditing standards or GAGAS. GAGAS the DOT OIG wants to obtain from the at the 31 airports were compared with provides a framework for conducting FAA is fair game, including draft reports, respect to vertical speed metrics. The high-quality audits with competence, open investigations, etc. The NTSB and vertical speed of flights on approach to integrity, objectivity, and independence. the GAO do not have this authority. runways with a precision approach at GAGAS also contains requirements and Additionally, the IG has the ear of Con- these airports exceeded a vertical speed guidance dealing with ethics, auditors’ gress and the DOT secretary should any of 1,450 feet per minute at one-third of professional judgment, quality control, of the DOT agencies—such as the FAA— the rate of approaches to runways with- performance of the audit, and reporting. attempt to obstruct audit efforts. Unlike out precision approaches. Based on these Portions of the Yellow Book provide an the NTSB and the GAO, the OIG is also data, the NTSB issued recommendations outstanding template for any aircraft authorized by Congress to report any “se- to the FAA, and awareness was raised in accident investigators to utilize. It is an rious or flagrant problems” to an agency the airline industry about these types of extremely well-written, succinct, and head under the IG act. The agency chief, nonprecision approaches. useful reference that can and should be in turn, must pass on the IG report to applied to our trade. Congress within seven days, thus earning The GAO, OIG, and the “Yellow Book” Perhaps the most rigorous and power- the document its moniker of “seven-day ful GAGAS tenant is the requirement for letter” and guaranteeing a maelstrom Meanwhile, both the FAA and the NTSB the audit organization to establish and of media coverage and congressional are subject to scrutiny by two other maintain a “system of quality control” attention for the agency audited. But do- oversight agencies—the U.S. Government that is designed to provide “reasonable ing so is considered the “nuclear option” Accountability Office (GAO) and the U.S. assurance” that the organization and because it could end the collaborative re- Department of Transportation’s Office its personnel comply with profession- lationship between the IG and his or her of the Inspector General (OIG). These al standards and applicable legal and secretary. Still, it is a powerful tool in the agencies work at the behest of the U.S. regulatory requirements. In order to OIG arsenal, and the mere threat to use Congress and conduct formal, in-depth provide this assurance, the GAO and the it can prompt closed-door negotiations “performance audits” that provide essen- OIG must have an external peer review between the IG and management. tial accountability and transparency over performed by an independent reviewer of Finally, the audit reports that are issued government programs, including FAA’s the audit organization at least once every by the DOT OIG are extremely well-writ- safety oversight efforts and the NTSB’s three years, and the organization should ten, succinct, and coherent, and profes- investigation operations. The rigorous make its most recent peer review report sionals in our trade should readily refer to standards for audits conducted by the publicly available. If the organization fails them for excellent reference on relevant GAO and the OIG are cited in a GAO the peer review, the report serves as a aviation safety topics. Perhaps the only publication known as the “Yellow Book.” scarlet letter to all that the agency is not criticism of an OIG or a GAO audit report Its actual title is Government Auditing credible—a powerful incentive for audit is that the findings and recommenda- Standards. The standards contained in agencies to always strive for competence tions can sometimes lack a practicality and pass their peer review. about them, since they are written by “auditors,” rather than aviation accident The DOT OIG investigators and industry users. How- ever, the FAA and the NTSB can provide The FAA and the NTSB are also subject to comments on the draft audit report, and audits and investigations by the DOT in- the OIG will append those comments spector general (IG). The Inspector Gen- in its final report. The OIG continues to eral Act of 1978 gives the OIG authority monitor FAA and/or NTSB actions taken to conduct performance audits (and sepa- to address any recommendations made in rate criminal investigations) to provide its final report, and the progress on these recommendations that lead to program recommendations is routinely reported to improvements that directly enhance the Congress. safety, efficiency, and effectiveness of the U.S. transportation infrastructure. The act also prevents officials in the scrutinized Investigating the investigators agency from interfering with audits or in- Why are the roles of the GAO and the vestigations, and it requires the IG to keep DOT OIG important for aviation safety the U.S. secretary of the DOT and Con- and accident investigation? The answer gress informed of its findings. Perhaps should be obvious. The primary agency the most powerful authority granted by to conduct all U.S. civil aviation accidents the act is for the IG to “have access to all (NTSB) and the agency that regulates and records, reports, audits, reviews, docu- oversees all aspects of U.S. civil aviation ments, papers, recommendations, or oth- (FAA) are held to the standards that the Figure 1. The GAO “Yellow Book.” er material available to the department public expects of them by the frequent au-

July-September 2017 ISASI Forum • 17 dits conducted by the GAO and the DOT fatigue risks for commuting pilots, using and the OIG attempted to overcome the OIG. Additionally, the recommendations scheduling practices to minimize op- impasse regarding the OIG recommenda- resulting from the work of the NTSB, portunities for fatigue in commuting tions. Building an alliance can sometimes the GAO, and the DOT OIG regarding pilots, and developing or identifying rest take a while. The FAA stipulated that various aviation safety topics can be force facilities for commuting pilots. Later, in commuting can definitely contribute to multipliers to bring pressure to bear, or September 2010, the DOT OIG issued an pilot fatigue and that many pilots com- support, FAA and congressional support audit report entitled FAA and Industry Are mute, but it indicated that a “study” was safety actions. Taking Action to Address Pilot Fatigue, But not needed and would waste precious More Information on Pilot Commuting Is resources. It also indicated that each Creating alliances and accelerating Needed. airline must have a fatigue risk manage- The report independently supported ment plan (FRMP) in place, accepted corrective actions similar findings by the NTSB and cited by the FAA principal inspector for the The ICAO Manual of Aircraft Accident and two similar recommendations to the FAA. airline annually. The DOT OIG appre- Incident Investigation defines the “ideal in- In part, the first recommendation was ciated the FAA’s view that commuting vestigator” as “trained personnel possess- to “ensure the collection and analysis of is widespread in the industry and can ing many qualities, not the least impor- data regarding domicile and commuting contribute to fatigue, and it gave serious tant of which are an inquisitive nature, length for all Part 121 flight crews,” and consideration regarding the role that dedication…, diligence, and patience.” the second was for the FAA to “review FRMPs could play in meeting the intent The definition continues with “Technical and analyze the Part 121 domicile and of this recommendation. skill, perseverance, and logic are the tools commuting data collected to determine After much discussion, the FAA indicat- of the profession; humility, integrity, and if further changes to flight duty and dom- ed a willingness to develop and publish respect for human dignity the guiding icile regulations are needed, or if airlines guidance to its inspectors and/or the rules.” When it comes to building allianc- need to take further mitigating actions in airlines that would essentially compel the es and thwarting useless rebellion, the key their fatigue management systems.” airlines to specifically address commuting words in this definition are the ones that The FAA initially opposed the recom- in their annually updated FRMPs in order describe the characteristics of human mendations, citing that it had just issued to lay out a process by which the airline relationships: patience, humility, and substantial rules that revised and en- could intervene should the commutes of respect for human dignity. hanced crew rest that address fatigue in their pilots become problematic. The OIG Other guidance can be found in a list general, regardless of the cause. The FAA felt that the FAA’s proposal was viable and of principles recently agreed upon by all also stressed its philosophy that pilots met the intent of its recommendations. of the executives within the FAA. Named should take personal responsibility to be after the location of the FAA executive “fit for duty” before each flight. The OIG strategic planning meeting for agency Case study: U.S. helicopter air reiterated its view that these data were ambulance safety operations, these “Shepherdstown Princi- necessary to determine the prevalence Calendar year 2008 was the deadliest year ples” could readily be applied during the of airline pilot fatigue due to commut- rise in tensions between investigators and ing, and it cited its recommendations on record for the helicopter air ambu- auditors in the heat of an inquiry. as a “high priority” in response letters lance industry in the U.S., with eight fatal to Congress. Additionally, the DOT OIG accidents and 29 fatalities, prompting the Case study: U.S. airline pilot indicated that its views on the topic were NTSB to hold a four-day public hearing in February 2009. One month later, the GAO commuting and fatigue consistent with similar recommendations made by the NTSB, giving them more issued an audit report entitled Poten- On Feb. 12, 2009, a Bombardier DHC-8- clout. Yet the FAA continued to rebel. tial Strategies to Address Air Ambulance 400 operated by Colgan Air, Inc. was on an Through several written responses and Safety Concerns. In the report, the GAO instrument approach to Buffalo–Niagara meetings that occurred over the course identified several potential strategies for International Airport in Buffalo, New of about two years, managers at the FAA improving air ambulance safety that were York, when it crashed into a residence about five nautical miles northeast of the airport. The two pilots, two flight attendants, and 45 passengers aboard the airplane were killed, along with one person on the ground. The NTSB’s inves- tigation found that both pilots had not been adequately rested because they had chosen to “commute” from their resi- dences that were far away from their pilot base in Newark, New Jersey. As a result, the NTSB recommended that the FAA “require airlines to address fatigue risks associated with commuting, including Figure 2. Colgan identifying pilots who commute, estab- Air accident site, lishing policy and guidance to mitigate February 2009. 18 • July-September 2017 ISASI Forum similar to what the NTSB had identified. independence of the BFU and permits Transport Agency (FATA), which is the In September 2009, the NTSB issued 10 the director of the BFU to initiate an equivalent of the U.S. FAA, conducts the recommendations to the FAA regarding investigation and appoint an IIC in order government oversight of the day-to-day improved pilot training; collection and to identify safety deficiencies and make Russian aviation operations. All of these analysis of flight, weather, and safety data; recommendations. Reuss cited the BFU’s aforementioned Russian agencies had a and the use of dual pilots, autopilots, and investigation into the tragic midair stake in an accident that occurred on Nov. night-vision systems. collision in July 2002 between a Tupolev 17, 2013, when a Boeing 737-500, operat- The FAA did not rebel against the find- Tu-154 passenger jet and a Boeing 757 ed by a Russian airline, crashed during a ings and proposals because it also imme- cargo jet over the southern German town missed approach at night at the airport in diately recognized that something needed of Überlingen. The official investigation Kazan, Russia. The IAC determined that to be done. The NTSB and the GAO by the German BFU identified the main the cause of the crash was related to the reports and recommendations served to cause of the collision to be a number of flight crew’s failure to maintain control of elevate the issue in the eyes of members shortcomings on the part of the Swiss the airplane, due to spatial disorientation, of Congress, who supported the FAA’s air traffic control service in charge of the inadequate flight crew training, and other issuance of a final helicopter air ambu- sector involved, and also ambiguities in systemic weaknesses in safety, including a lance rule in February 2014. But this case the procedures regarding the use of the lack of adequate oversight by the FATA. study does not stop there. Congress asked onboard aircraft collision-avoidance There were many controversies and the DOT OIG to review the FAA’s progress system. Reuss clearly articulated that some dissention related to the investi- in improving air ambulance safety. One a major investigation in Germany is gation, as noninvestigative members of year later, the OIG issued an audit report effective only if the investigation process the IAC sought to indict the design of the that found that while the FAA’s recently is transparent, safety recommendations aircraft, rather than follow the obvious issued helicopter air ambulance rule was are comprehensible, the safety investiga- facts that led to the official cause. Howev- a good first step toward improving safety, tion authority gives and receives sound er, in the end, dissention was put down, continued delays in finalizing all of the facts about the ongoing investigation, and and alliances among the IAC, the FATA, safety efforts that Congress wanted were licensing and regulating authorities are and others led to a comprehensive and affecting the FAA’s ability to focus its ac- involved in accordance with their nation’s impactful final accident report with rec- cident reduction efforts and limiting the regulations. ommendations that will enhance aviation effectiveness of safety initiatives. safety in Russia. The OIG also stated that the FAA would Case Study: Russia’s accident inves- need to be better positioned to effectively Case study: Iceland oversee a rapidly expanding industry and tigation structure and a Boeing 737 Three years ago, Iceland’s Parliament would need to obtain meaningful safety accident passed Act No. 18.2013, which combined data to analyze for trends. The OIG made Another ICAO-member state that has a three transportation committees into a five recommendations to strengthen the similar “check and balance” aviation safe- single commission of inquiry for trans- FAA's oversight of the industry, and the ty structure is Russia. The Interstate Avia- portation accidents under the Ministry FAA concurred with all of them. This case tion Committee (IAC/MAK) was estab- of the Interior. The act stipulates that in- study shows how all four safety oversight lished in Russia in 1991 pursuant to the agencies came together to improve safety. Interstate Agreement on Civil Aviation vestigations should only aim to reveal the and Airspace Use. The principal aim of the causes of transport accidents and inci- IAC is to ensure safe and orderly develop- dents, not to apportion blame or liability, Case study: Germany’s BFU, BMVI, ment of civil aviation of Russia’s member with the aim to prevent similar accidents. and a midair collision states, specifically to include certifying The Icelandic Transportation Investiga- At the 2015 ISASI seminar in Munich, aircraft, engines, and hardware. Interest- tion Board (ITSB) was born. Meanwhile, Germany, Johann Reuss, the deputy ingly, the IAC has a separate group that the Flight Safety Division of the Icelandic director of the German Federal Bureau of conducts independent investigations of Civil Aviation Administration (ICAA), Aircraft Accidents Investigation (BFU), all civil aircraft accidents that involve the which is also under the auspices of the effectively laid out yet another exam- aircraft of the member states. Ministry of the Interior, acts as Iceland’s ple of the benefits of alliances between Additionally, the work related to air- regulator. Additionally, Iceland is a party safety oversight agencies—this time in craft accident investigation is overseen to the European Aviation Safety Agency Germany. In his paper entitled Independ- by the Aircraft Accident Investigation (EASA), and the Flight Safety Division ence Does Not Mean Isolation: A Practical Commission and the Aircraft Accident participates in its operations. EASA Approach, Reuss explained that the BFU Investigation Scientific and Technical provides oversight and development and is the responsible safety investigation Support Commission. Because of these coordination regarding requirements in authority in Germany for accidents and alliances, the IAC investigators have at flight operations and license issues. serious incidents in civil aviation. The their disposal a modern laboratory that Shortly after the passage of Act No. BFU must adhere to European and na- provides capabilities for flight recorders 18.2013, a prototype Sukhoi RRJ-95B Su- tional requirements, and is subordinate to data recovery, readout and analysis, flight perjet 100 airliner impacted the runway the German Federal Ministry of Transport dynamics analysis, and aircraft and frac- with its landing gear retracted during a and Digital Infrastructure (BMVI). ture analysis. go-around at Keflavik International Air- German law stipulates the professional Additionally, Russia’s Federal Air port in July 2013. (See “Sukhoi Superjet:

July-September 2017 ISASI Forum • 19 BY KNUT LANDE, LANDAVIA LTD/GENERAL MANAGER/FLIGHT SAFETY ADVISOR AIRCRAFT CONTROLLABILITY Figure 3. The Sukhoi Superjet. AND PRIMARY Airborne Image Recorder Supported Investigation,” January–March ISASI Forum, page 19.) The purpose of the flight was to expand the FLIGHT DISPLAYS airplane’s capabilities for CAT IIIA automatic ap- (Adapted with permission from the author’s technical paper entitled proaches. After seven approaches and go-arounds, Aircraft Controllability and Primary Flight Displays—Every Link the objective of the last approach was to assess Is Important presented during ISASI 2016 in Reykjavik, Iceland, Oct. the automatic flight control system performance 18–20, 2016. The full text of this presentation can be found on www. during go-around at a radio altitude of three feet isasi.org in the Library tab under Technical Presentations.—Editor) above the runway, with the right engine shut down and in a crosswind exceeding 20 knots. During he global air accident statistics have gradually this last go-around, the airplane climbed to 27 feet improved over the last 50 years. This has occurred altitude after the landing gear had been selected through gradual improvements in aeronautical engi- to the up position, followed by a loss of altitude. T neering and technological innovations. Examples on The airplane hit the runway with the landing gear this are improved weather radars (WR), navigation displays retracted and skid down and off the runway. The (ND), vertical displays (VD), Traffic and Collision Avoidance crew evacuated the airplane, and during the evac- Systems/Airborne Collision Avoidance System (TCAS/ACAS), uation one crewmember suffered minor injuries. Ground Proximity Warning System/Terrain Avoidance and The ITSB determined the most probable cause of Warning System/Enhanced Ground Proximity Warning the accident to be flight crew fatigue, and it issued System (GPWS/TAWS/EGPWS), Category II/III Landing nine safety recommendations and one safety Systems, etc. The latest technological advancements helped action. The ITSB recommended to EASA to ensure reduce the controlled flight into terrain (CFIT) categories of that necessary changes were made to the emer- accidents. However, the reduction in CFIT accidents led to gency escape slide design of the RRJ-95B aircraft increased focus on loss of control in flight (LOC-I) accident that are EASA-certified to meet the maximum statistics, which seem to remain high. wind requirements specified by EASA. The investi- gation also determined that the use of green color Accidents code during activation of the airport emergency Typical LOC-I accidents plan was prone to causing confusion, prompting The common factors in most LOC-I accidents seem to be the ITSB to issue a “safety action” to the Iceland pilot confusion during unfamiliar flight situations and a lack Ministry of Transport to revise the regulation to of pilot knowledge and piloting skills. From the CAST team change the green color code to another color to report in Figure 1, we see that most LOC-I fatal accidents avoid confusion. are related to attitude and angle of attack (AOA) control. In most LOC-I type of accident reports, the focus is on piloting Conclusion knowledge and skills. No reference is made to possible loss of In the end, just like cases presented in the U.S., spatial orientation contributed by less than optimal prima- Germany, and Russia, the alliances built among ry flight display (PFD) or lack of AOA indication. It is my the ITSB, EASA, the Flight Safety Division of the opinion that the progress in modern glass cockpit and flight ICAA, and the Icelandic Ministry of Transport display design have improved the navigation task but not demonstrated that creating alliances among the contributed to improving pilots’ attitude in space situational state’s safety oversight agencies can lead to awareness. Some of the modern flight displays are not very improvements in aviation safety. Instead of being intuitive or helpful in a loss-of-control situation. predisposed to rebel against each other, these Further, the increased use of cockpit automation seems to agencies should do what is necessary to create a have influenced the education and training of younger pilots. culture of respect and understanding, and to find We have also seen that manufacturers advertise their air- ways to link their efforts in order to achieve their planes as easy to fly (“low workload”) and “unable to stall.” ultimate objective of accelerating safety improve- Such statements are unrealistic and misleading to student ments in aviation. pilots. Any student pilot should have a basic knowledge in 20 • July-September 2017 ISASI Forum physics and be taught from basic training that any heavier-than-air vehicle must always be aerodynamically controlled and may “fall out of the sky” if the flight condi- tions producing a sustainable lift are not maintained, e.g., a minimum airspeed, or more accurately, an AOA below maximum allowable (below the stall AOA). Whether the airplane is stalling or out of control for other reasons does not matter. Even though today’s accident rates in aviation are quite low, the latest LOC-I accidents are avoidable and seem to be caused by a combination of inefficient PFDs and lack of knowledge and basic flying skills among the pilots. We find that LOC-I accidents results from stalls both during high-altitude cruise and during approach. In a typical LOC-I stall accident, the pilots did not recognize the slow-speed/ high-alpha flight condition and were not able to prevent the accidents. We see that these types of accidents are not only relat- ed to fixed-wing aircraft. While airplanes may stall and enter controllable deep stall, helicopters may enter controllable Figure 1. vortex ring state (VRS), which, from a piloting point of view, may be compara- reveal the presence of latent conditions in the system at large.” ble to an airplane stall. The recovery is In modern accident investigation theory, human error is not considered a cause similar—nose down to break the con- of accidents. LOC-I accidents have several underlying cause factors, and most LOC-I dition and increase power. However, a accidents are organizational accidents. safe escape requires altitude, just like an Figure 2 (see page 22) shows the typical operational and training flight envelope of airplane stall at low altitude. today’s commercial pilots. How can we expect pilots to cope with a flight upset sit- Other types of LOC-I accidents are uation involving more than 90 degrees of bank when they have only seen 60 degrees related to pilot spatial disorientation, during their training and are normally limited to 30 degrees during normal oper- which results in pilot confusion and ations? Clearly then, we may label a LOC-I accident as an organizational accident loss of attitude awareness. The spatial and not just human error. disorientation may be caused by somato- gravic, somatogyral, and G-Excess Effect illusions causing the pilots to become is an ISASI member and currently the general manager/flight safety spatially disoriented, and they pitch or advisor for LandAvia in Royneberg, Norway. His experience includes bank too much or in the wrong direction. • aircraft line maintenance/aircraft mechanic/aircraft servicing, Such mistakes may cause loss of control. • aircraft base maintenance/aircraft technician/aircraft and flight systems maintenance, Accident investigations Knut • mechanical engineering/machine design, Historically, most LOC accidents were Lande • mechanical engineering/material laboratory, labeled “pilot/human error.” Professor Dr. Sidney Dekker offers a “new view” on • fighter pilot, human error (2006). • aeronautical engineering/maintenance test pilot, • The old view: “Human error is a cause • experimental test pilot, of trouble” (bad apple theory). • flight operations supervisor/flight test, • The new view: “Human error is a symptom of trouble deeper inside a • offshore helicopter line pilot, sy st e m .” • offshore helicopter operations/project pilot new helicopters, Professor Dr. James Reason (1997) said: • offshore helicopter operations/chief technical pilot, and “The organizational model views human • accident investigation board norway/inspector of accidents/ error more as a consequence than as aircraft accident investigations. a cause. Errors are the symptoms that

July-September 2017 ISASI Forum • 21 primary flight instrument. The wing “stops flying” when the criti- cal AOA is exceeded. The result is a stall; and if not properly educated and trained, the pilot may lose control. An AOA indicator that clearly and intuitively tells the pilot the margin to stall or minimum control may mitigate such loss of control. This is the most fundamental and basic knowledge student pilots are required to know—and that the airspeed indicator is just an “aerodynamic indicator” that does not tell the pilot how much lift margin he or she has, but is related to the forces acting on the aircraft. This has been an item for discussion for several decades. Technically, it is not complicated to in- stall useable and intuitive AOA indicators in airplanes. Pilots used to alpha indicators found these very intuitive and useful, show- ing the lift and performance margin in maneuvering and accelerated flight Figure 2. as well as in approach and slow-speed pilot knowledge and training requirement flight conditions. However, for unknown Areas of concern for decades. However, based on the recent reasons it appears that the FAA, the LOC-I accidents, it seems that the focus European Aviation Safety Agency, Boeing, “Coffin corner” on stall theory and training has dimin- and Airbus have been reluctant to provide When flying at high altitude, the air densi- ty is low; hence, lift and thrust are reduced. ished. pilots with this information. The airplane AOA is increased to compen- Aerodynamic stall occurs when the As a result of the many LOC-I accidents sate for the loss of lift. The Mach number airspeed reduces below stall speed, which in recent years, there is a growing interest increases as a function of lower temper- varies according to flight conditions. in installing AOA indicators as part of the ature and lower speed of sound. Thus the However, it is not the airspeed itself but PFD. I, like many other military-trained maximum cruise true airspeed (VMO) ap- the AOA that is the critical factor. The air- pilots of the Cold War era, have flown proaches the critical Mach number (MMO) speed is an indirect indication of the AOA several aircraft with AOA indicators. The and must be reduced (Mach buffet). Simi- in level flight. During maneuvering flight, experience gained is that AOA is a very larly, the true stall speed/Mach increases. the wing will still stall at the CL max but intuitive primary flight indicator and just As the airplane climbs, the maximum at a higher indicated stall speed. Hence, as valuable as the airspeed indicator. cruise true airspeed is gradually reduced it is only in level flight that pilots have a I have read several comments from and approaches the minimum flying speed good reference to the actual stall speed. pilots not used to AOA indicators, sup- or critical AOA (stall buffet). Hence, the An AOA indicator will give direct indi- plemented by some test pilots’ caution margin between high-Mach buffeting and cation in relation to the stall AOA. This against reliance on AOA indicators, with low-speed buffeting becomes smaller and is basic pilot knowledge; but for some reference to inaccuracies and limita- smaller with altitude. This flight condition unknown reason, the aircraft manufactur- tions. AOA is measured on most modern has been labeled the “coffin corner.” ers and certifying authorities have been aircraft, and the data are used in aircraft Hand flying at high altitude by refer- reluctant to include an AOA indicator as a computers to calculate various flight ence to airspeed only is very challenging. It is very difficult to control the airspeed accurately, and AOA indication is required for better airspeed control. Civilian-trained pilots of today have not had basic training in this area (“pitch and power”) and have limited hand-flying skills.

Aerodynamic stall and lack of AOA indicators Aeronautical knowledge about the rela- tionship between AOA and flying speed Figure 3. and the necessary training has been basic 22 • July-September 2017 ISASI Forum parameters. Further, the AOA indication is of most importance when maneuvering or flying close to the stall AOA. Hence, the indication will be most useful during slow-speed flight or during LOC-I and upset recoveries. However, the AOA must be a prominent and intuitive indication based on human factor and aircraft flight mechanics theory, which is taught in basic pilot training. Boeing is offering AOA indicator as an option (see Figure 3), but this is not the most efficient type of display.

Developments in flight displays LOC-I is not only related to pilot knowl- edge and skill, but also to flight displays, control sticks, and levers (inceptors/ thrust levers)—in other words, the hu- Figure 4. man-machine interface (HMI). It is worth noting that in the early days, fashion. However, it may be argued that that analogue round dial instruments pilots did not have a standby attitude in- even if the scan distance is reduced, so may be easier and quicker to read/ dicator (AI) available. To compensate, the is the instrument readability. Another interpret than digital indications. This military pilots trained partial panel where aspect is the regulated installation of may be important during dynamic flight the AI was covered or disconnected. standby instruments but no associated situations. With the introduction of gyro-stabilized requirement for training in using these A remind- inertial platforms, the standby AI became instruments. er to this standard, but there was still no instru- In an unusual attitude situation, the effect is that ment layout standardization (see Figure old-fashioned round dial AI is easy to most people 4). Note the large instrument sizes that read, with large numbers, a solid white use wrist made situational awareness in unusual needle pointer, and a intuitive indication watches with attitudes easier. (see Figure 5). round dials It is also worth mentioning the large AI With the pointer in the slow-speed and pointers with heading indication. With reference region on the right-hand side of the AI, (an analogue to just one indicator, one got an instant a pull on the stick will increase the AOA round dial “3-D sense” of the flight attitude. This type and reduce the airspeed. The approximate display) in Figure 6. of AI was used in several U.S. aircraft and position of the pointer in relation to the lieu of watches with digits (a digital dis- in the Apollo spacecraft and the Space position and color on the play). Furthermore, most aerobatic pilots Shuttles during the 1960s and 1970s. scale give the pilot an ap- prefer large round dial instruments for Compare this with today’s electronic proximate sense of the quicker scan. altitude director indicator (ADI), airspeed and the lift The round dial analogue airspeed and which does not give the pilot the margin at a glance—in AOA scales may be compared to a typical same 3-D sensation of “attitude addition to giving the analogue wrist watch. It is so intuitive in space,” but only gives a flat 2-D pilot a good rate of that numbers are not required. The user impression of attitude. change in airspeed. may see the approximate time at a glance. FAR 25 specified that the flight The same type of If a more-accurate time reading is re- instruments be arranged in a T-shaped instrument could just as quired, a closer look may be required. This pattern, with the ADI in the center, the Figure 5. well display AOA (see Figure principle works just as fine for aircraft horizontal situation indicator (HSI) 6). The instrument is intuitive in the sense PFD in a cockpit. below, airspeed located to the left of the that pulling on the control stick/yoke in- On the other hand, the present state-of- ADI, altimeter to the right, and the verti- creases/rotates the indicator needle to a the-art AIs are not intuitive, even if they cal speed immediately below the altime- higher digit and vice versa (pull increases have a “speed trend indicator.” This is not ter. This arrangement became known as AOA, push decreases AOA). What can be optimal as a rate indicator, especially in the “basic T.” This standard basic T layout more intuitive to a pilot than pulling on a turbulence. The scale numbers are in- is still a certification requirement for stick that increases the AOA/reduces the creasing upward. This is opposite to rais- modern aircraft in FAR 25 and EASA CS-2. indicatd airspeed (IAS), and pushing on a ing the aircraft nose (pulling on the stick). In Figure 4, we see that the relationship stick that decreases AOA/increases IAS. From basic training, every pilot is taught between the ADI and the other flight The human brain is analogue, and there that raising the nose will decrease the instruments are retained in the basic T seems to be human-factor indications speed and lowering the nose will increase

July-September 2017 ISASI Forum • 23 the airspeed. Furthermore, by raising the scales. Such scales are more suited to The layout is basically the same as nose and hence reducing the airspeed, computers than to aircraft displays. These developed 30 years ago and is also, with a the moving scale should move downward types of displays were introduced during few exceptions, standard in modern heli- with decreasing digits from the top. This the 1980s and were driven by the avionics copter cockpits. Considering the number is in line with human-factor specialist manufacturers. of LOC-I accidents worldwide, it may be recommendations. In its present format, I have seen limited research reports time to reconsider the present PFD layout the state-of-the-art AI is not intuitive, and documenting the benefits and efficiency and do some HMI research and devel- the vertical scale should be reveresed. of the modern PFD indicators, other than opment of flight displays and controls. Pushing the aircraft nose down would engineering and cost benefits. According It may be time to look for new types of then result in increasing airspeed. This is to available literature regarding vertical displays that are more intuitive based also recommended by Don Bateman of scale instruments and movement, the on human-factor considerations and Honeywell. benefits of today’s flight displays in a LOC basic flight mechanics principles. I have The SR-71A was a very challanging situation are doubtful. I am convinced, several hundred flight hours with similar aircraft to fly and demanded good pilot however, that modern glass flight displays types of displays, but was not introduced knowledge and flying skills. It was an have improved the horisontal navigation to any recommended scan pattern. The aircraft that needed continous pilot at- and helped reduce CFIT accidents. And general idea was that all the information tention to attitude and AOA. The SR-71A, yet, they are less intuitive and efficient is included on one display “right in front however, still had a conventional basic-T in resolving the pilots sense of the “3-D of you.” However, several LOC-I accidents layout with round dials. A large portion of attitute in space” in an LOC situation in recent years may indicate that the the instrument panel area was devoted to (unusual attitude or upset situation) and state-of-the-art PFDs are not as efficient the primary flight instruments. In a prom- may have contributed to several of the as thought of in the industry. inent location on the instrument panel recent LOC-I accidents. With today’s These types of PFDs are satisfactory was the AOA indicator close to attitude digital technology, it should be possible only during benign flight conditions and and airspeed. The large round dials with to design more-functional and intuitive autopilot operations, but not during a prominent pointers allowed easy reading flight displays. dynamic or upset flight situation leading and permitted use of the peripheral vision The flight displays in most commercial to an unusual attitude. In such flight con- registering the relative position of the aircraft of today were introduced during ditions, all flight parameters are changing pointer. It allowed the pilot to interpret the flight condition without necessarily reading the exact number. Initially, SR-71 pilots were sceptical about night flying, and there were some incidents where pilots overcontrolled in bank during turning at Mach 3. This was caused by a sensory illusion called G-Excess Effect. To compensate for this, Lockheed developed a device called the peripheral vision display (PVD). It projected a laser-generated, thin red line parallel to the horizon, across the pilot’s instrument panel. The PVD was not in- tended to be part of the pilot’s instrument cross-check. Instead, the pilot perceived the laser line indirectly by peripheral vision and subsconciously supported spatial orientation—just as visible out- side horizon supports orientation during daytime flying. As the aircraft pitched and rolled, the red horizon line also pitched and rolled across the instrument panel and gave the pilot instant orientation. The horizon line flashed to warn the pilot if the pitch or bank angles exceeded certain limits. Figure 7. The digits on state-of-the-art flight the 1980s and have not changed much, and the human brain may be saturated instruments are also smaller than on even though today’s digital technology by changing parameters and digits that previous insturments and not so easy to make most designs possible. Figure 7 is an need direct readings and interpretation. read in a “blurred” and dynamic flight example of a state-of-the-art flight deck Furthermore, today’s PFDs become more (LOC) situation. The same may be said that will be around for the next 20 to 30 and more cluttered with nonflight-con- about the altimeter and vertical speed years. trol-essential indications, which may tend

24 • July-September 2017 ISASI Forum to distract the pilot’s attention. Today’s state-of-the-art instrument panel seems to have lost some of the ben- efits of the older “classic” panel. The panel seems very clean and is certainly saving space (and money). It is quite sufficient during routine benign flight conditions within 15 degrees of pitch and 30 degrees of roll attitude but not optimal during a dynamic unusual attitude (LOC-I) recov- ery situation. It seems that the larger the screens, the more data are included, making the PFD very cluttered. A large screen with a wide horizon line from the synthetic picture of the terrain and transparent round dials with pointers, including AOA indicator, will enhance the pilot’s situational aware- ness. Being an experienced flight and aero- batic instructor, I have seen the reactions of students with limited or no outside references. During such flight conditions, student pilots lose aircraft control very Figure 8. quickly. However, once visual reference with terrain, and weather encounters; to be forgotten by airline pilots who are to the outside terrain and horizon is normally controlling the aircraft through regained, they may regain aircraft control • more personal/business flights; the autopilot. Modern aircraft are within reasonable time and altitude loss. • longer flights; equipped with autopilot and autothrot- It follows that many of the recent LOC-I • more instrument flight rules; and tles. The original intent was that pilots accidents might have been avoided if the should use these automated systems in pilots had visual sight of the underlying • accident pilots were older, with more combination to reduce cockpit work- terrain. flight hours and higher certificates/ load. When flying an autopilot-coupled Therefore, future PFDs should be based ratings. approach, the autopilot controls the pitch on a synthetic picture of the outside and roll, and the autothrottles control world with overlaid prominent and Aircraft controllability the rate of descent. The idea was that the transparent primary round dial flight With reference to the previously dis- pilot flying should disconnect both when instruments, including a prominent AOA cussed accidents, it is also worth men- flying manually. However, some pilots indicator. tioning the role of control sticks (incep- developed the habit of disconnecting Figure 8 shows an advanced flight tors) and handles. These should be even the autopilot and control pitch and roll systems (AFS) type of PFD installed in more intuitive than modern controls. It manually and letting the autothrottle some general aviation (GA) aircraft. The is important that pilots receive feedback maintain speed. Hence, the autothrottle positive features are the display of the ter- cues from the controls that help them controlled the speed, and the pilot con- rain and transparent flight instruments, assess the flight situation and give them trolled the pitch and roll. but the negative features are the strip better situational awareness without total indicators and all the added information reliance on sight and visual readings. making the PFD cluttered. It seems that the knowledge today’s Developments in pilot education and In 2010, the U.S. National Transporta- pilots have about basic aircraft perfor- training tion Safety Board (NTSB) issued a study mance is not adequate. During the 1950s Instrument flying (“blind flying”) was report on accidents in GA airplanes with and 1960s, when the jet aircraft was first introduced by Jimmy Doolittle in the a glass cockpit compared to airplanes introduced, it was focused on “operations United States in 1929. However, it was not with conventional flight instruments. The on the back side of the power curve.” This until World War II that instrument flying report shows that in accidents between was a result of several approach became standard pilot proficiency. After 2002 and 2008 that resulted in fatalities, accidents, both in the military and the war, instrument flying was continu- 16% of the aircraft had conventional flight commercial aviation. ously developed by improved instrumen- instruments whereas 31% had a glass Today’s manufacturers have made tation and pilot procedures. The concept cockpit. flying more complicated than necessary, of attitude flying was introduced. The ba- On average, glass cockpit aircraft had with too many autopilot modes and the sic principle is that the pilot controls the • more accidents during climb, cruise, pilot’s increased reliance on automation. airspeed by lowering or raising the nose and approach; How difficult is it to control an aircraft? attitude of the aircraft. He or she controls • more loss of control in flight, collision Today, basic aerodynamic principles seem the heading by banking in the wanted July-September 2017 ISASI Forum • 25 direction of flight and thus turning to the use his or her peripheral vision allowing pilot is expected to do with the data. required heading. These are the basic and an overall quicker scan. According to Singleton, several ques- intuitive piloting principles both in visual tions must be answered during develop- and instrument flight. In visual flight, the ment of a display: pilot uses the natural horizon as refer- Cockpit displays—test and evaluation • Does the pilot’s need justify the ence, and in instrument flight he or she Richard L. Newman and Greeley Kevin display? W. Greeley in Cockpit Displays: Test and uses the AI (“artificial horizon”). • What data does the pilot need that Evaluation address test and evaluation of This concept was further developed has not been provided? into categories of instruments: control cockpit displays. instruments consisting of attitude and power instruments, performance instru- ments, and navigation instruments. The principle was simple and intuitive—the pilot controlled the attitude of the air- craft by reference to only two instruments (attitude and power) and monitored the performance and navigation instruments for proper response. A special pilot instrument cross-check was developed, where the main instru- ments were the attitude and power indi- cators (control instruments). An improp- er cross-check technique could result in chasing the performance indicators, preventing stabilized flight. Student pilots Figure 9. were trained according to these princi- ples and learned to scan the instruments “There have been a number of papers • Can the average pilot obtain what is in a certain scan pattern, where the AI and articles written about operational required easily? was in the center and the most frequently difficulties with modern display and other • Does the display conform to the scanned instrument. The faster this scan cockpit systems. As we see it, the prob- real world? could be developed, the better situational lem has been a series of discontinuities awareness for the pilot. between the users and the designers, be- —To other cockpit displays? During basic and advanced flight tween the designers and the testers, and —With previous pilot habits and skills? between the users and the testers. training, both in visual and instrument —With required decisions and actions?” flight, it was emphasized that the primary “As a result of the first discontinuity, flight control instruments were the AI between users and designers, inadequate and the RPM/power instrument—pitch design requirements are established. This controlled airspeed, and power controlled is particularly unfortunate as systems can Research on PDF and inclusion of climb and descent according to be (and are being) designed with greater AOA indicator R/C = (T – D)V/W R/D = (D -T)V/W and greater capabilities in terms of auto- Figure 10 shows the results of a re- This knowledge was also the fundamen- matic flight and guidance and flight con- search program related to readability of tal basis for controlling an aircraft during trol. Without adequate requirements, it is different types of airspeed and altitude any emergency or upset flight condition hardly surprising that there are problems displays on head-up displays (HUDs). • maintain aircraft control—Aviate, encountered in operational use. We see that a pointer is more intuitive • analyze the situation—Navigate, and “The second discontinuity, between and quicker to read and to interpret at designers and testers, reduces the oppor- a glance. This indicates that the round • take proper action—Communicate. tunities for feedback to the designer. In dial and pointer are more human adap- Today’s pilots seem to forget this, pos- fact, with today’s economic setting, many tive than tapes and digits. sibly because authorities and manufac- systems are practically committed to pro- Initial results of a Ph.D. study re- turers allow design and operational use of duction by the time they reach flight test. garding the way pilots look at digital conflicting control laws and operational Only if there are very serious problems, and analog instruments conducted at practice. will these systems be corrected. the Swinburne's Aviation Simulation Figure 9 shows the T-shape instru- “The third discontinuity, between users Laboratory, Swinburne University of ment scan of the modern strip PFD. This and testers, results in inadequate test Technology, Australia, suggest experi- scan will take longer as the eyes must be criteria. As a result of this discontinuity, enced pilots facing an emergency will directed to one focal point at a time, and we are left with highly subjective criteria spend twice as much time looking at the pilot fails to see more than one pa- which vary from tester to tester. Or we their instruments as novices. The study rameter at a glance as opposed to round have inappropriate criteria.” is testing volunteers in the university’s dial instruments and pointers. With larg- “The display design must consider why flight simulators to see how pilots cope er round dials and pointers, the pilot may the pilot needs the data and what the with the switch between digital and

26 • July-September 2017 ISASI Forum Conclusion Several recent LOC accidents indi- cate that the human-factor-related aspects of PFDs, lack of AOA displays, flight control and inceptor design, and pilot education and training play a significant role in a pilot’s handling of an aircraft. Using today’s technol- ogy, flight displays could be made more intuitive and easier to read in an unexpected and blurred flight sit- uation. Also, by making flight control inceptors and autopilot modes more intuitive, and thus improving tactile feedback cues, pilots may be kept in the loop and be more prepared to take control in an unexpected situation. Figure 10. Regardless of how ideal the analog cockpits. to develop new PFDs based on human- aircraft’s handling qualities are, it is of There is evidence indicating that pilots factor research and technological limited value if the handling pilot who have trained on analog instruments advancements. becomes confused and disorientated generally find it easier to move to a digital In the future, there might be novel during an unusual attitude (UA) or cockpit than vice versa. I have not seen any aircraft control systems available to help upset recovery (UR). It may be time research data supporting the pilots in a LOC-I situation, but so far the for the manufacturers to focus on human-factor benefits of the state-of-the-art most rational solution is to make the PFD, PFDs in addition to autopilot modes PFDs of today with strip indicators. However, autopilot modes, and control inceptors and aircraft handling qualities during there are indications that digital round dial more human-factor-centric and intuitive, test and evaluations. I recommend indicators are more intuitive and quicker to combined with a prominent AOA indica- that the industry initiate more read at a glance than strip indicators. The tor and relevant pilot training in stall and human-factor-based research within PFDs of today are 30 years old, and it is time upset recovery. these areas. Figure 11.

July-September 2017 ISASI Forum • 27 NEWS ROUNDUP

touring the Delta safety management systems to reduce Flight Museum and aviation risks. “Because really, that’s what Delta Tech Ops, the it’s all about—spotting the signals, mak- largest airline ing the connections, and taking action in maintenance, repair, advance so that the next time you’ll find and overhaul facility trouble…before trouble finds you,” she in North America concluded. and the third largest During the MARC business meeting, worldwide. The day ISASI President Frank Del Gandio called ended with a group dinner at a midtown Atlanta restaurant. On Sunday, students visited the Georgia Aquarium before heading back to Daytona Beach. Spe- Embry–Riddle Aeronautical University students visit the headquarters of Delta cial thanks goes out Air Lines in Atlanta, Georgia. to Capt. Bill Klein, Student ISASI Members Shannon Masters, Joshua Alber, David Hahahan, Taylor Smith, Greg Masters, and Tour Delta Air Lines Maryam Gracias. Treasurer Bob MacIntosh to the podium Anthony Brickhouse, an ISASI student to honor him with ISASI Fellow member- coordinator, reports that 23 members of Mid-Atlantic Regional Chapter ship status. An ISASI Fellow is a senior membership class, established to recog- the Embry–Riddle Aeronautical Univer- Holds Annual Dinner sity (Daytona Beach, Florida, campus) nize extraordinary professional achieve- Student Chapter of ISASI visited Delta Air Nearly 80 ISASI members and guests at- ment and contribution to ISASI. The Lines headquarters in Atlanta, tended the Mid-Atlantic Region Chapter’s ISASI Board of Fellows, which Curt Lewis Georgia, USA, on February 18. Delta’s (MARC) annual gathering in Herndon, chairs, confers this honor by election. flight safety team, which includes sev- Virgina, USA, on May 6 to greet friends There are currently 41 ISASI Fellows. eral ISASI members, hosted the student and conduct chapter business. Del Gandio provided participants with group. The day began with a quick over- success sto- view of the agenda, and then the students ries about the formed smaller groups to tour various Rudy Kapus- aspects of the operation. tin Memorial During the tour, the students experi- Scholarship enced a B-777-200LR full-motion simula- winners, tor. They also saw the various tools used many of to train Delta flight crews. Another part of whom now the tour took students to the facilities for work in the training Delta inflight service crewmem- aviation bers, including cabin trainers and the industry. water evacuation pool. While touring the Fifteen indi- Flight Operations Customer Center, stu- viduals and dents received a real-time briefing from a two regional dispatcher working a developing situa- chapters tion. Another exciting and educational donated more than $2,000 to the scholarship fund, part of the morning featured an exercise Participants listened to Canadian which provides an award to cover costs that allowed students to don personal Transportation Safety Board Chair Kathy protective equipment, get covered in sim- Fox, the keynote speaker, discuss current for the ISASI seminar registration fees, ulated bloodborne pathogens, and then issues and concerns facing the agency. travel, and lodging/meals expenses. Any safely duff the gear. The students quickly Fox described the board’s WatchList, expenses above and beyond the amount learned how important it is to always which includes “the key safety issues that of the award are to borne by the recipient. follow accepted industry practices. need to be addressed to make Canada’s In addition, the following are offered to Members of the Delta flight safety team transportation system even safer.” (See the winner(s) of the scholarship: briefed the students during lunch, and “Commentary,” page 4.) • A one-year membership to ISASI. then the students spent the afternoon She discussed the need for more robust • Tuition-free attendance to any South- 28 • July-September 2017 ISASI Forum NEWS ROUNDUP

ern California Safety Institute (SCSI) ship Committee chairman, submitted a ISASI International regularly scheduled SCSI course. This written report that 130 new individual includes the two-week Aircraft Acci- members and eight new corporate mem- Activities Coordination dent Investigator Course or any other bers joined ISASI in 2016. He also noted ISASI International Councilor Caj Frostell investigation courses. Travel to/from that as of May 1, 2017, there were 29 met and discussed the upcoming ISASI the course and accommodations are corporate members and 272 individuals annual seminar and ISASI activities with not included. More information is who had not yet paid their annual dues. A representatives of some 35 African civil available at www.scsi-inc.com/. list of delinquent members was provided aviation administrations and aircraft • A tuition-free course provided by to all Council officers to take appropriate remedial action. accident investigation authorities in the Transportation Safety Institute. connection with a mission to Swaziland. Travel to/from the course and accom- A final report on ISASI 2016 was given Frostell represented the regional Banjul modations are not included. More to the Council that showed total registra- information is available at www.tsi. tions were 318 and that net revenues were Accord Group Accident Investigation dot.gov/. positive. Plans for ISASI 2017 in San Agency (BAGAIA) at the European Diego, California, USA, taking place Aviation Safety Agency (EASA)–Interna- • Tuition-free attendance to the August 22–24, are set, and information tional Civil Aviation Organization (ICAO) Cranfield University Safety and Acci- is posted on the Society’s website. ISASI Safety Forum on Regional Safety Over- dent Investigation Centre’s five-day 2018 will be in Dubai, the United Arab sight Organizations for Global Aviation Accident Investigation Course, which Emirates, and will be held in 2019 in The runs as part of its master’s degree Safety in Swaziland, which took place on Hague, the Netherlands. March 22–24. program at the Cranfield campus, 50 National councils and regional chapters miles north of London, UK. Travel to/ presented reports on their activities for from the course and accommodation the last six months. A report by Erin are not included. Further information Carroll, ISASI’s Corporate Affairs Working is available at www.csaic.net/. Group chair, noted that seven organiza- • Free-attendance and room during tions joined ISASI since October 2016. the RTI seminar on Kent Island, She reviewed delinquent corporate Maryland. members and organizations that do not wish to renew. Tom Farrier, UAS Working Group chair, noted that the International Civil Aviation Organization (ICAO) International Councilors incorporated ISASI’s investigation guidelines for UAS events into a new UAS Gather for Meeting Attending the EASA–ICAO Safety Forum on chapter in ICAO Document 9756. He Regional Safety Oversight Organizations, from the The Society’s international councilors added that the working group will have a left, are Herbert Jow, finance and administration full briefing on the investigation guide- manager, BAGASOO (Banjul Accord Group Aviation gathered in Herndon, Virginia, USA, fol- Safety Oversight Organization); Caj Frostell, ISASI lowing the Mid-Atlantic Region Chapter’s lines at ISASI 2017. Anthony Brickhouse, international councilor representing the BAGAIA; dinner to conduct ISASI’s semi-annual ISASI’s Student Outreach and Mentoring and Emmanuel Akatue, BAGASOO. business meeting. Following ISASI Presi- coordinator, said that 45 Society mem- dent Frank Del Gandio’s opening remarks, bers are signed up to serve as student mentors. There are currently 14 students Treasurer Bob MacIntosh reviewed the International Safety Society’s finances. He noted that 2016 participating in this program. He also income from individual member dues discussed ISASI’s participation during the Courses Held in Prague was down slightly from the previous year, recent Women in Aviation Conference ISASI member Ladi Mika reports that and visiting the booths of aviation schools but new and renewed corporate member- in April and May a series of four inter- ship dues made up most of the difference. and universities with aviation programs at the conference. national courses for safety experts and MacIntosh observed that safety aviation investigators were organ- ISASI 2016 was a success and ized in Prague in the Czech Republic by that the overall financial con- the Southern California Safety Institute dition of ISASI for 2016 was (SCSI) in cooperation with the Ministry of positive. He urged the coun- Transport of the Czech Republic and the cilors to continue positive Czech Aviation Training Centre (CATC). actions to keep ISASI 2017 The traning included the Aircraft Acci- and future seminars within dent Investigation Course, Flight Safety budget, to actively seek do- Officers Course, Operational Risk Man- nations designated for ISASI educational programs, and to agement Course, and Unmanned Aircraft recruit new members while Systems Course. Attending the courses retaining current members. were 37 safety experts and safety aviation Tom McCarthy, Member- investigators from Italy, the Republic of July-September 2017 ISASI Forum • 29 NEWS ROUNDUP ISASI INFORMATION Korea, Norway, the United Arab Emirates, Latvia, Luxembourg, Kosovo, Malay- OFFICERS sia, Montenegro, Austria, Israel, the Czech Republic, Hungary, Portugal, Kenya, President, Frank Del Gandio Denmark, the Netherlands, Findland, Uruguay, the Central African Republic, ([email protected]) Executive Advisor, Richard Stone Mauritius Island, and Romania. ([email protected]) In 16 years, more than 700 experts from different parts of world have partici- Vice President, Ron Schleede pated in these corses. Mika, who cofounded these sessions, noted that the ([email protected]) Secretary, Chad Balentine courses in Prague are very attractive due to the expertise of the instructors and ([email protected]) excellent conditions prepared by CATC. Treasurer, Robert MacIntosh, Jr. ([email protected]) COUNCILORS Australian, Richard Sellers ([email protected]) Canadian, Barbara Dunn ([email protected]) European, Rob Carter ([email protected]) International, Caj Frostell ([email protected]) New Zealand, Alister Buckingham ([email protected]) Pakistan, Wg. Cdr. (Ret.) Naseem Syed Ahmed ([email protected]) United States, Toby Carroll ([email protected]) NATIONAL AND REGIONAL SOCIETY PRESIDENTS AsiaSASI, Chan Wing Keong ([email protected]) Training course participants gather at the Czech Aviation Training Center in Prague. Australian, Richard Sellers ([email protected]) Canadian, Barbara Dunn ([email protected]) European, Olivier Ferrante ([email protected]) Australian, New Zealand Societies Hold Annual Seminar Korean, Dr. Tachwan Cho (contact: Dr. Jenny Yoo—[email protected]) Latin American, Guillermo J. Palacia (Mexico) The New Zealand Society hosted the annual Australian and New Zealand (AN- Middle East North Africa, Khalid Al Raisi ZSASI) regional seminar in Wellington, New Zealand, on June 10–11. The annual ([email protected]) New Zealand, Alister Buckingham event is held alternately on either side of the Tasman. In an associated event, the ([email protected]) Asia–Pacific Cabin Safety Working Group meeting was hosted by the Civil Avia- Pakistan, Wg. Cdr. (Ret.) Naseem Syed tion Authority of New Zealand on June 9 and was attended by some 45 delegates, Ahmed ([email protected]) Russian, Vsvolod E. Overharov many of whom also attended the ANZSASI seminar. ([email protected]) A high-quality program of technical papers, and a good turnout of members United States, Toby Carroll and other interested parties, ensured that the 2017 ANZSASI seminar was a huge ([email protected]) success. Apart from the usual eastward migration from Australia, three overseas presenters, one from Germany and two from the USA, participated at the semi- UNITED STATES REGIONAL nar. Approximately 90 delegates were in attendance, with an additional 20 or so CHAPTER PRESIDENTS companions attending the social events, including the welcome reception and Alaska, Craig Bledsoe the seminar dinner. ([email protected]) Between the end of the presentations and the dinner, each society held its Arizona, Bill Waldock ([email protected]) business meeting—the ASASI AGM and the NZSASI BGM. At the New Zealand Dallas-Ft. Worth, Erin Carroll ([email protected]) Society’s meeting, the executive appointments mentioned in the June edition of Great Lakes, Matthew Kenner Update were ratified, with President Alister Buckingham stepping down to make ([email protected]) way for new appointee Graham Streatfield; Russell Kennedy moving from secre- Mid-Atlantic, Ron Schleede ([email protected]) tary/treasurer to vice president; and with Siobhan Mandich taking over as secre- Northeast, Steve Demko tary/treasurer. Buckingham will continue in the role of New Zealand councilor. ([email protected]) At the conclusion of the session, ASASI President Rick Sellers announced the Northern California, Kevin Darcy next ANZSASI seminar, to be held in Melbourne, Victoria, on June 2–3, 2018. ([email protected]) Pacific Northwest, Anna Bernhardt Most of the technical papers presented at the 2017 seminar are now available ([email protected]) on the ASASI website, www.asasi.org, with the exception of those that contained Rocky Mountain, David Harper material of a restricted or proprietary nature. ([email protected])

30 • July-September 2017 ISASI Forum NEWS ROUNDUP ISASI INFORMATION

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

July-September 2017 ISASI Forum • 31 ISASI 107 E. Holly Ave., Suite 11 Sterling, VA 20164-5405 USA

INCORPORATED AUGUST 31, 1964 CHANGE SERVICE REQUESTED

WHO’S WHO

The Air Line Pilots Association—“Schedule with Safety” Department of Transportation and the FAA in 1994, which (Who’s Who is a brief profile prepared by the represented ISASI corporate member organization to raised the standards for FAR provide a more thorough understanding of the organization’s role and function.—Editor) Part 135 small airlines to those of FAR Part 121 airlines; n July 1931, a group of 24 airline Air Safety Department’s 23 staff investigations. pilots, meeting in secret so that members who are devoted to up- An astute observer would be • involvement with the FAA they wouldn’t be fired, formed holding the highest possible level of hard pressed to find an aspect of and industry to set rational, the Air Line Pilots Associa- aviation safety. Of that larger group the airline industry not improved science-based flight- and I duty-time limits and mini- tion (ALPA) out of fear of losing of pilot safety representatives, nine by ALPA’s dedicated efforts to their lives to pilot pushing in bad seasoned accident investigators enhance safety during the last mum rest requirements for weather and other operational serve on the ALPA Accident Inves- eight-plus decades. From the passenger airline pilots, and safety hazards. They established tigation Board. cockpit to the elevator, from the • the push for more-stringent the motto “Schedule with Safety,” ALPA routinely participates in air traffic control tower to aircraft minimum qualifications for which remains a foundation for accident and incident investiga- rescue and firefighting and runway all airline first officers. ALPA members’ efforts to the pres- tions conducted by the NTSB and safety areas, ALPA’s partnerships ALPA continues its dedication to ent day. ALPA’s founders knew that the Transportation Safety Board of with government agencies, airlines, safety work in a variety of areas, they would be the ones who would Canada (TSB), and in other coun- airports, and manufacturers have including “arrive first at the scene of the acci- tries through the process outlined resulted in safety improvements dent.” Half of ALPA’s founders did in International Civil Aviation large and small. ALPA has received • the safe integration of un- just that despite their best efforts— Organization (ICAO) Annex 13. three Collier Trophies for its work manned aircraft systems into they died in aviation accidents. Moreover, ALPA is routinely asked with Boeing on the development of the national airspace system; Today, more than 86 years later, to provide engineering and acci- the B-777, for its innovative work • the safe shipments of hazard- ALPA represents the collective bar- dent investigation expertise to pilot on Automatic Dependent Surveil- ous materials and reducing gaining, professional, and work life groups in other countries through lance-Broadcast (ADS-B), and for shipments of undeclared interests of more than 57,000 pilots the International Federation of Air its contributions as a member of dangerous goods; at 33 airlines in the United States Line Pilots’ Associations (IFALPA). the Commercial Aviation Safe- and Canada. It’s the largest labor ALPA maintains a state-of-the- ty Team, producing the safest • strengthened voluntary safety union of airline pilots in the world art facility for analyzing flight data commercial aviation system in the reporting programs; and the oldest and most effective recorder information, as well as world. • improved cargo safety and non governmental organization air traffic control recordings and Over its 86-year history, some security, and working for aviation safety. ALPA recorded radar data. The Asso- of ALPA’s larger contributions to representatives participate on ciation also trains pilot accident aviation safety have included • air traffic control moderni- numerous governmental commit- investigators twice a year through • the promotion of TCAS for zation. tees and aviation safety working its long-established Basic Accident FAR Part 121 operations; To learn more about ALPA’s groups. Investigation and Advanced Acci- • work to get FAA approval for ongoing efforts to improve aviation The Association boasts some dent Investigation Courses. NTSB, crew resource management safety, visit the Association’s 400 pilot safety representatives TSB, and FAA representatives take (CRM) training; website at www.alpa.org. To read under the auspices of its Air Safety part in these courses to provide more about ALPA’s Air Safety Organization (ASO). The ASO is attendees with their perspective • the One Level of Safety Organization, visit www.alpa.org/ supported by the Engineering & on participating in accident campaign, embraced by the asodirectory.

32 • July-September 2017 ISASI Forum