JANUARY–MARCH 2012

ISASI Members Earn Year-End Recognition Page 5 Impact Dynamics—Cases and Cautions Page 8 Ensuring Safety in Aviation’s Second Century Page 12 Building Partnerships in Unmanned Aircraft Systems Page 16 Major Investigations, ‘NextGen’ Thinking Ahead Page 20 CONTENTS

Volume 45, Number 1 Publisher Frank Del Gandio FEATURES Editorial Advisor Richard B. Stone Editor Esperison Martinez Design Editor William A. Ford 5 ISASI Members Earn Year-End Recognition Associate Editor Susan Fager Presidential, royal, and agency honors are awarded to three ISASI members Annual Report Editor Paul Mayes and one ISASI corporate member at year’s end. ISASI Forum (ISSN 1088-8128) is pub- lished quarterly by International Society of Air Safety Investigators. Opinions 8 Impact Dynamics—Cases and Cautions expressed by authors do not necessarily By Robert Carter, Air Accidents Investigation Branch; Anne Evans, Air Accidents represent official ISASI position or policy. Investigation Branch; and Andrew Walton, Cranfield Impact Centre (CIC). The Editorial Offices: Park Center, 107 East authors look at the British Airways B-777 crash at London Heathrow Airport on Holly Avenue, Suite 11, Sterling, VA 20164-5405. Telephone (703) 430-9668. Jan. 17, 2008, and report the resulting investigative computational impact dynam- Fax (703) 430-4970. E-mail address isasi@ ics work concerning the rupture induced by loads from the main landing gear. erols.com; for editor, espmart@comcast. net. Internet website: www.isasi.org. ISASI Forum is not responsible for unso- licited manuscripts, photographs, or other 12 Ensuring Safety in Aviation’s Second Century materials. Unsolicited materials will be By NTSB Chairman Deborah A.P. Hersman—This adapted presentation describes returned only if submitted with a self-ad- accident investigation’s past and present, and how it must adapt in order to play an dressed, stamped envelope. ISASI Forum even more pivotal role in creating civil aviation’s safer and stronger future. reserves the right to reject, delete, sum- marize, or edit for space considerations any submitted article. To facilitate editorial production processes, American-English 16 Building Partnerships in Unmanned Aircraft Systems spelling of words will be used. By Thomas A. Farrier, Chair, ISASI, Unmanned Aircraft Systems Working Group— Copyright © 2012—International Society of As UAS use propagates, the established mutually supporting investigative and Air Safety Investigators, all rights reserved. Publication in any form prohibited without regulatory processes for manned aircraft that have evolved and exist today must be permission. ISASI Forum registered U.S. given the opportunity to perform those functions for UAS operations. Patent and T.M. Office. Opinions expressed by authors do not necessarily represent of- ficial ISASI position or policy. Permission to 20 Major Investigations, ‘NextGen’ Thinking Ahead reprint is available upon application to the editorial offices. By Robert M. MacIntosh Jr., National Transportation Safety Board, Retired—New Publisher’s Editorial Profile: ISASI and revised thinking is the challenge for the air safety investigators of tomorrow. Forum is printed in the United States and published for professional air safety investigators who are members of the In- ternational Society of Air Safety Investiga- DEPARTMENTS tors. Editorial content emphasizes accident investigation findings, investigative tech- 2 Contents niques and experiences, regulatory issues, 3 President’s View industry accident prevention developments, 4 V.P.’s Corner and ISASI and member involvement and information. 26 ISASI RoundUp Subscriptions: Subscription to members 30 ISASI Information is provided as a portion of dues. Rate for 32 Who’s Who—A brief corporate nonmembers (Domestic and Canada )is US$28; Rate for nonmember international member profile of Airbus is US$30. Rate for all libraries and schools is US$24. For subscription information, call (703) 430-9668. Additional or replace- ment ISASI Forum issues: Domestic and Canada US$4; international member US$4; About the Cover domestic and Canada nonmember US$6; C. Donald Bateman receives the National Medal of Technology and Innovation from and international nonmember US$8. President Obama at White House ceremonies. The Medal is the nation’s highest honor for technological achievement. Bateman, the 2008 ISASI Jerome F. Lederer Award recipient, is being recognized for developing and championing critical flight safety sensors now used on aircraft worldwide, including ground proximity warning systems and windshear detection systems. Photo: Ryan K Morris/National Science & Technology Medals Foundation

2 • ISASI Forum January—March 2012 PRESIDENT’S VIEW

Invest in ISASI’s Future; Mentor a Student By Frank Del Gandio, ISASI President January is National Mentoring Month, so it aim is to encourage the development of a flexible relationship is with a bit of serendipity that I write this that responds to both the mentor’s and the student’s needs. column during the opening days of the New Year to announce ISASI’s initiation of a hybrid Why should you become a mentor?—Our industry, like others, is student mentoring plan as a natural outgrowth changing. Many of us are retired or are contemplating retiring in of our highly successful memorial scholarship the near future. However, we all have one thing in common. We program. have a wealth of knowledge and experience in the aviation indus- The program has awarded 22 scholarships since 2002, the try. This knowledge would be a valuable addition to any student’s year of its inception. For the past two annual seminars, the education and decision-making regarding a career path. awardees have presented their winning essays to the seminar President Del assembly. And at last year’s seminar, we recorded more than WhatGandio is in opensit for me? —To begin with, you will probably provide 20 students in attendance. thisISASI student 2011. with a vision of real-life experiences from your histo- In the International Council meeting last September, we ry. You will get a sense of accomplishment by providing informa- discussed the mentoring concept. We determined that a full- tion to these students. In a way, your legacy may go on through fledged program, such as one that may be found in a company someone else. You will be a great asset to someone who will prob- or corporation, would be less attractive to potential mentors ably hold a position somewhere in the aviation industry that will than one that merely brings together a student who seeks a maintain and improve the high standards we have established. mentor and an ISASI member who wishes to share knowledge and experiences with a student on an ongoing basis. What would be expected of me? —A commitment to communi- Still, even a minimized program requires organization, form, cate with the student on an agreed-upon basis. This can be in and direction. Anthony Brickhouse, a professor at Embry-Riddle person, by phone, or through e-mail. Be passionate about your Aeronautical University and an ISASI member, has volunteered profession and the aviation community. Be a good listener and to be the lead on this program. He will develop the workings of communicate your experiences and knowledge. the program, which will include securing a roster of students Should you wish early involvement in this very worthy effort, seeking a mentor and maintaining a list of members who wish to contact Anthony at [email protected]. I promise that you mentor. The details of the mentoring plan will be announced in a will not regret it. ◆ future edition of ISASI Forum. In the meantime, here are a few thoughts:

Benefits of mentoring—A mentor is a caring adult friend who devotes time to a student. Although mentors can fill any number of different roles, all mentors have the same goal in common: to help young people achieve their potential and discover their strengths. Mentors should understand that they are not meant to replace a parent, guardian, or teacher. A mentor is not a disciplinarian or decision- maker for the student. Instead, a mentor echoes the positive values and cultural heritage of our profession. A mentor is part of a team of caring adults.

Mentor’s purposes—A mentor’s main purpose is to help a student find ways to achieve individual goals. Since the expec- Embry-Riddle Aeronautical University (Daytona Beach, Fla.) students attend tations of each student varies, a mentor’s ISASI 2011 in Salt Lake City, Utah. All are student members of ISASI.

January—March 2012 ISASI Forum • 3 V.P.’S Corner

Analyzing the Safety Data By Paul Mayes, ISASI Vice President There are several organizations that publish There are various technological solutions to reduce the aviation safety statistics and analyze the risk of runway incursions (for example, ground surveillance safety trends. While the numbers and trends radar, conflict recognition, barrier systems, onboard taxi path can be revealing, they do not reflect the actual displays, and conflict warnings), but as yet many of these are impact of a serious accident or fatality. For not mandated. Should we as an air safety organization be more every victim, there can be dozens of family active, and proactive, in lobbying for greater risk manage- and friends who are affected by the suffering. ment and the implementation of technological solutions to this However, the best measure of the success of our air safety threat to aviation safety? work is by these statistics. Similarly, the aviation safety analysts are highlighting loss The initial reviews are showing that the year 2011 was a of control as a major accident finding. Although there are very safe year for civil aviation. Last year was the second safest year by number of fatalities and the third safest year by number of accidents. Also, at the end of 2011 there was the he initial reviews are showing that longest period without a fatal airliner accident in modern avia- the year 2011 was a very safe year tion history. for civil aviation. Last year was the There were a total of 28 fatal airliner accidents, resulting in T 507 fatalities and 14 ground fatalities. The number of fatali- second safest year by number of fatalities ties is lower than the 10-year average of 764 fatalities. When and the third safest year by number of these numbers are quoted as rates, the results are even more encouraging due to the increases in passenger numbers and accidents. Also, at the end of 2011 flights every year. there was the longest period without Seven out of 28 accident airplanes were operated by airlines a fatal airliner accident in modern on the European Union’s (EU) “black list” as opposed to six out of 29 the year before. The EU added a total of nine airlines aviation history. to the black list and removed three airlines based on improved many factors in this type of accident, it can be related to the safety records. standards of pilot training and lower levels of pilot experience In 2011, Africa showed a continuing decline in accidents: 14 as the so-called “baby boomers” retire. On the positive side, percent of all fatal airliner accidents happened in Africa. This there was the example of an Airbus A380 that had an uncon- is still a county that needs a great deal of help to get its safety tained engine failure during the initial climb from Singapore. in line with North America. The major accident rate in North The skill and team work of the crew resulted in a safe landing America, for example, has remained flat at about one in 10 mil- after a very hazardous loss of systems. lion flights, while in Africa the rate is roughly 40 times greater, Therefore, even though the accident rate in North America, according to the International Air Transport Association. Rus- for example, is very low, we must not relax our safety efforts. sia suffered a very bad year with six fatal accidents. ISASI can play an important part in ensuring the continuing While the year’s airline accident statistics are very welcome, safety of aviation. The majority of our members are based all of us in safety know that we cannot rest on our laurels. One in North America, and many have influential positions in the accident involving a widebody aircraft could reverse these government and as regulators. But ISASI is an international trends. And there are worrisome factors that could impact organization, and we can make a difference through ICAO and these trends. in our own countries. Airport and runway incursions are still high on the risk As the current vice president and the only non-North scale. For example, a B-777 and an Airbus A340 had a close American on the ISASI Executive, I feel I can add an extra call at JFK International Airport last year when the B-777 dimension to the ISASI Executive and assist with the wider in- entered the active runway. The incident in June was the most ternational role. We have members in most countries, although dangerous near miss of the year at the New York City airport, many countries are only represented by one or two ISASI according to a news report from the Federal Aviation Admin- members. The Executive is here to provide what support we istration. The A340 carried 286 passengers bound for Munich can to all our members. while the B-777 carried 346 passengers headed to Cairo. If As individuals, we must conduct our business with the utmost they had collided, it could have been the worst commercial air integrity and do what we can to make aviation even safer. disaster in history. Perhaps that should be a part of our New Year goals. ◆

4 • ISASI Forum January—March 2012 ISASI Members Earn Year-End Recognition Presidential, royal, and agency honors are awarded to three ISASI members and one ISASI corporate member at year’s end.

(This material was compiled from related news releases and a contribution from Nancy Wright.—Editor)

oneywell engineer and 2008 ISASI Jerome F. Lederer Award honoree C. Donald Bateman is a recipient of the nation’s highest honorH for technological achievement, the National Medal of Technology and Innovation from the U.S. Department of Commerce Patent and TradeMark Office. President Barack Obama presented him the National Medal on Oct. 21, 2011, in a White House ceremony. Bateman was honored for developing and championing critical flight safety sensors now used on aircraft worldwide, including ground proximity warning systems and winds- F oundation M edals S cience & T echnology K M orris /N ational yan hear detection systems. The FAA man- R dated the installation of these systems President Obama prepares to present Don Bateman the National Medal for all commercial aircraft. of Technology and Innovation. The National Medal of Technology and Innovation was created by statute the late 1960s. Additional innovations in- was named a Pathfinder by the Museum in 1980. It is administered for the White volve systems for heads-up display, speed of Flight in Seattle and was inducted into House by the U.S. Department of Com- control autothrottle, stall warning, angle the National Inventors Hall of Fame in merce’s Patent and Trademark Office. of attack, automatic flight control, weight 2003. He won the Laura Taber Barbour The Award recognizes those who have and balance, radar, and others. He con- Air Safety Award from the Flight Safety made lasting contributions to America’s tinues to be actively involved improving Foundation and is a Honeywell Corporate competitiveness and quality of life and aviation safety and is currently working Fellow. He is also a Fellow of the Royal helped strengthen the nation’s techno- on improving his runway aural awareness Aeronautic Society. logical workforce. Nominees are selected system, which reduces the risk of runway About his selection, Don said to Forum, by a distinguished independent commit- incursions and overruns. “I have been fortunate to have a patient, tee representing the private and public Born in Canada, Don is a U.S. citizen encouraging wife and family. Also, I have sectors. educated at the University of Saskatch- had the privilege of working with some Don was among 11 others who were ewan. He has been with Honeywell and very special colleagues, the support of a recognized in the fields of science, en- its predecessors since 1960. He has been few key friends from my upper manage- gineering, and invention. Of these men, a strong supporter of ISASI for more than ment, from the airlines, the FAA, aircraft President Obama said: “Each of these ex- four decades, supporting the organization manufacturers such as Boeing, Airbus, traordinary scientists, engineers, and in- with his knowledge and by presenting Gulfstream, the Flight Safety Founda- ventors is guided by a passion for innova- papers and speaking at industry events. tion, the International Russian Flight tion, a fearlessness even as they explore Over the years, Don has been recog- Safety Foundation, the Royal Aeronautical the very frontiers of human knowledge, nized for his achievements worldwide. Society, and especially ISASI. Many of and a desire to make the world a better He won the Admiral Luiz de Florez my accomplishments have been our ac- place. Their ingenuity inspires us all to Award from Flight Safety Foundation complishments. All have been my friends reach higher and try harder, no matter twice. He’s been an Aviation Week Lau- making flying safer.” how difficult the challenges we face.” reate and received the New Zealand Air Kevin Darcy, president of the Pacific Don began his initial work on GPWS in Safety Foundation Award in 1992. He Northwest Regional ISASI Chapter in

January—March 2012 ISASI Forum • 5 “Don is a giant in his field. I don’t believe it is an overstatement to say that his work has which Don holds membership, comment- added, “Don’s recognition should come probably saved more ed, “Those of us who have had the good as no surprise to his peers and fellow lives than any other fortune to watch Don in action over the members. Don is a giant in his field. I single person who has years congratulate him for his remarkable don’t believe it is an overstatement to say ever worked in the achievements. He has been a key player in that his work has probably saved more the success of our Chapter and has often lives than any other single person who has field. His recognition arranged events at Honeywell.” ever worked in the field. His recognition is richly deserved.” ISASI President Frank Del Gandio is richly deserved.” ◆ Royal honors

ISASI’s United Kingdom corporate tigious form of national recognition member Cranfield University is being open to a UK academic or vocational awarded a Queen’s Anniversary Prize institution. The honor is distinctive in for Higher and Further Education for recognizing the institution rather than its “world-leading work in aviation an individual or team. The scheme was safety through research and training established in 1993 with the approval in air accident investigation.” The of the queen and all-party support in Safety and Accident Investigation Parliament. Centre has a worldwide reputation Cranfield University will be pre- for excellence. The UK’s Department sented with a medal and certificate by for Transport, the Civil Aviation Au- Her Majesty the Queen and His Royal thority, and the Ministry of Defence Highness the Duke of Edinburgh at a (MOD) turn to Cranfield with its deep ceremony to be held at Buckingham knowledge of the aviation sector to Palace in February and will be al- spearhead critical research and train- lowed to use the Queen’s Anniversary ing across the UK’s aviation fleet. The Prize crest for four years. facilities give students the opportunity Professor Graham Braithwaite, to experience practical “real life” situ- head of the University’s Department ations. Students gain skills in evidence of Air Transport and chair of ISASI’s collection and witness interviewing recognize and celebrate outstanding work Investigator Training & Education and analysis through simulated ac- within UK higher, further education institu- Working Group, said: “We are abso- cidents staged on the University’s tions and the impact that they have. lutely delighted with this prestigious own airport. Entries undergo a rigorous process of award in recognition of the role our Over the last 30 years, the University independent external assessment. This work has played in ensuring the safety has trained more than 1,000 air acci- includes review by national and interna- of travelers worldwide. The industry as dent investigators and safety managers tional experts and specialists covering the a whole has benefited from the Univer- for national investigation agencies, the relevant disciplines, reference to govern- sity’s work in aviation safety, including military, airlines, regulators, and manu- ment departments and UK devolved gov- passenger behavior and fire evacuation facturers. Past students have gone on ernments with a particular interest in the procedures. to investigate some of the most serious fields of work under consideration, and to “We are enormously proud of this aviation accidents in every continent professional and other bodies and sources. achievement, which represents the including, most recently, the Qantas The final decisions on recommendations hard work of many staff and visitors Airbus A380 engine failure of late 2010. for the queen’s approval are made by the over at least 30 years. I hope that all of In all, 21 institutions are winners Awards Council of the Trust. the past students and staff of Cranfield of the Queen’s Prizes. A total of 130 The Prizes are a biennial award scheme and those in industry who have either institutions entered submissions to the within the UK’s national honors system. helped us or utilized our work will join Royal Anniversary Trust. The Prizes As such, they are the UK’s most pres- us in celebrating this achievement.”◆

6 • ISASI Forum January—March 2012 Top Champion of Safety

Robert “Bob” Matthews snared “Top Champion of Safety” honors in the Federal Aviation Administration’s 4th annual AVS National Awards ceremony in late October. FAA Associate Administrator Peggy Gilligan and the senior executive management team honored members of AVS for their contributions to aviation safety. Out of 62 nominations, seven individuals and three teams were recognized. Tagged “The Top Champion of Safety,” Bob is a senior aviation safety analyst and special assistant to the director in the Office of Accident Investigation and Prevention. An internationally renowned aviation safety expert, Bob is respected for his historical analysis of safety trends and his identification of emerging safety challenges. He has had a hand in every critical FAA rule currently under consideration—providing effectiveness Top safety measures for pilot flight, rest, and duty requirements and safety management systems—just to name a few. champion Bob Over the course of his career, Bob earned a Ph.D. in public administration, taught as an assistant professor, Matthews helped develop national transportation legislation for the Federal Highway Administration, and served under the Secretary of Transportation as an aviation analyst. His most recent work involved an instrumental role in helping establish the next generation of aviation safety enhancements by transitioning FAA’s focus from analyzing accidents to monitoring national airspace system operations so that AVS can proactively identify and address emerging threats before they lead to serious inci- dents or accidents. Bob has now retired from government service and, along with Frank Del Gandio, who has also retired from the FAA, is exercising his entrepreneurial spirit by operating the newly formed company Legend Aviation, doing safety and analytical work. ◆

International Recognition

The International Federation of Airworthiness (IFA) has announced that the 2011 honoree of the Whittle Safety Award is ISASI member Dr. William B. Johnson, chief scientific and technical advisor for human factors in aviation maintenance for the Federal Aviation Administration. The Award, which honors the co-inventor of the jet engine, Sir Frank Whittle, is the highest and most prestigious award the Federation can confer to recognize an advance in aviation safety. The citation reads, “In recognition of his dedication, research, leadership, and promotion of human factors in aviation maintenance and engineering and his many publications exemplified by the ‘Maintenance Human Factors Presentation System’ and the video production Grounded. In making the Award, IFA said: “Safety specialists, worldwide, first observed that attention to human Dr. William factors on the flight deck and on flight crew behavior had a positive impact on safety. The same attention and “Bill” Johnson programs were initiated for maintenance/engineering personnel by the mid-1980s. From the early national plans for human aviation human factors to a 25-year legacy of international maintenance human factors symposia, Dr. Johnson has been a key planner and contributor. At the international level, in his corporate and government roles, Dr. Johnson has influenced attitude, procedures, tools, training systems, and policy regarding human factors in maintenance. Johnson has successfully evoked an applied scientific approach that combines the fundamentals of human performance, psychology, and learning to the daily requirements of operational aviation maintenance.” Upon notification of the Award, Johnson said, “Industry and government attention factors have impacted not only continuing flight and worker safety, but also operational effectiveness and efficiency. We are off to a very good start on maintenance human factors. Our collective activity shall evolve as it is inte- grated with other safety management systems. I accept this Award as it acknowledges the importance of maintenance human factors and the many maintenance human factors proponents in government and industry worldwide.” ◆

January—March 2012 ISASI Forum • 7 (This article is adapted, with permission, The accident on Jan. 17, 2008 Cabin crashworthiness/survivability from the authors’ paper entitled Impact While on approach to London (Heathrow) Despite a high rate of descent at impact, Dynamics—Cases and Cautions presented from Beijing, China, at 720 feet AGL, there were only 16 passengers identified at the ISASI 2011 seminar held in Salt the right engine of Boeing 777-236ER G- with “minor injuries” and one serious inju- Lake City, Utah, Sept. 13–15, 2011, which YMMM ceased responding to autothrottle ry in the accident. There were a number of carried the theme “Investigation—A commands for increased power and in- crashworthiness and survivability issues Shared Process.” The full presentation, stead the power reduced to 1.03 Engine identified in the cabin, and these are fully including cited references to support the Pressure Ratio (EPR). Seven seconds described and analyzed in the AAIB final points made, can be found on the ISASI later, the left engine power reduced to 1.02 accident report (AAIB AAR 1/2010, pub- website at www.isasi.org under the tag EPR. This reduction in thrust led to a loss lished February 2010), with detailed safety “ISASI 2011 Technical Papers.”—Editor) of airspeed, and the aircraft touching down recommendations. These issues concerned some 330 meters [1,082 feet] short of the cabin lighting, emergency lighting, and hen a British Airways B-777 paved surface of Runway 27L at London the seatback video monitors attached to crashed at London Heathrow Heathrow. The investigation identified the business-class seats; they were all WAirport on Jan. 17, 2008, after a that the reduction in thrust was due to dealt with by the AAIB investigation in a rapid loss of thrust on both engines, the restricted fuel flow to both engines. It conventional investigation process.

Fuel tanks crashworthiness/ survivability The major crashworthiness work in this accident, however, concerned the impact- Impact Dynamics related damage to the aircraft fuel tanks, which had been compromised in the impact and ground slide sequence. The initial Cases and Cautions impact of the aircraft was approximately The authors look at the British Airways B-777 crash at London 120 meters [393 feet] inside the airfield’s Heathrow Airport on Jan. 17, 2008, and report the resulting perimeter fence (see Figure 1). The first ground marks were made by the rearmost investigative computational impact dynamics work concerning wheels, followed by all the main wheels as the rupture induced by loads from the main landing gear. the trucks tilted forward, at which time By Robert Carter, Air Accidents Investigation Branch; the maximum vertical acceleration spike Anne Evans, Air Accidents Investigation Branch; and of 2.9g was recorded on the DFDR. The Andrew Walton, Cranfield Impact Centre touchdown into soft soil produced impact gouges with a depth of up to 0.45 meters [1 foot] from the right main landing gear safety investigation led by the United was determined that this restriction oc- (MLG) and 0.36 meters [1 foot] from the Kingdom Air Accidents Investigation curred on the engines at the Fuel Oil Heat left gear. There was contact with the rear Branch (AAIB) concentrated principally Exchanger (FOHE). fuselage as the aircraft continued forward. on the causal and contributory issues The investigation identified the causal The aircraft then rebounded and briefly concerning the powerplants, fuel system, factors that led to the fuel flow restric- became airborne again. On the second and icing in the fuel. [See ISASI Forum tions as being the release of accreted impact, approximately 53 meters [174 feet] April-June 2011, page 5]. ice from within the fuel system, caus- from the first impact, the ground marks In parallel to the investigations into ing a restriction to the engine fuel indicated that the right MLG had moved the root causes of the accident, the AAIB flow at the face of the FOHE on both inboard. There was contact by the engine conducted a further investigation into the the engines. This ice had formed from nacelles and the nose landing gear, which crashworthiness and survival aspects of water that occurred naturally in the immediately collapsed. As the weight of the accident. There were, fortunately, only fuel while the aircraft operated with the aircraft transferred onto the engine relatively minor injuries in the accident low fuel flows over a long period and nacelles, the engine cowlings and engine and no ground fire, despite a substantial the localized fuel temperatures were in accessories were damaged and the engines rate of descent at impact and rupture of a an area later described as the “sticky dug into the ground. major fuel tank. In this article, we will dis- range.” The FOHE, while compliant During the ground slide, both the en- cuss the computational impact dynamics with the applicable certification require- gines scooped up soft soil, which increased work concerning this rupture, which was ments, was susceptible to restriction the aircraft’s retardation. Approximately induced by loads from the main landing when presented with soft ice in a high 152 meters [498 feet] after its initial gear. Also to be considered are the advan- concentration, with a fuel temperature contact, the right engine struck the thick tages and disadvantages of computational below -10°C and a fuel flow above flight concrete cover of an inspection pit. This impact dynamics studies in accident inves- idle. The certification requirements did caused damage to the lower part of the tigations, including previous instances in not take into account this phenomenon as engine and assisted the deviation of the which the AAIB has been involved. the risk was unrecognized at that time. aircraft’s ground slide to the right, with

8 • ISASI Forum January—March 2012 the aircraft coming to rest on the tarmac area near the threshold of Runway 27L, approximately 372 meters [1,220 feet] from the first impact (see Figure 2). The nose landing gear had separated from the aircraft; damage to its attach- ments was consistent with both a high vertical load and side load to the left. The left MLG had partially separated due to overload but remained attached to the fuselage by the drag and side braces. During the initial impact, the gear beam outboard end fuse pin had fractured, which allowed the gear beam to rotate upward. The trunnion housing fuse pins then also fractured, allowing the forward trunnion to move upward. The significant vertical load had also resulted in a piece of top wing skin being removed. There were witness marks on the aft trunnion outer bearing race, consistent with the aft trunnion then Figure 1 (above). G-YMMM, Runway 27L having been pulled out. The attachment of at London Heathrow. Figure 2 (left). the inboard end of the gear beam was dam- G-YMMM ground impact marks. aged but remained intact; the drag strut Figure 3 (below). Right main gear with fuse pin had “crankshafted” in a direction rear spar web. indicating that a load had been applied in tension but this had also remained intact. Of greater interest was the damage to also fractured, and witness marks on the the right MLG. During the initial impact, lower housing support indicated that the H the fuse pins in the right MLG gear beam block, together with the forward trunnion, outboard end fractured, which allowed it had been pulled aft and down. There was to rotate upward in the same manner that no evidence of any crankshafting or dam- had occurred on the left MLG. The lower age to the drag brace fuse pin. Witness housing (“H block”) fuse pins had then marks on the upper surface of the truck n Robert Carter is a principal inspector and investigator-in-charge (IIC) with the beam indicated an over-travel in both the Air Accidents Investigation Branch (AAIB). He is a graduate of Imperial Col- truck pitch-up and pitch-down directions. lege, London, and Cornell University, New York. He joined the AAIB in 1985. His During the subsequent ground slide, civil and military accident field investigations include the Boeing 747 at Lockerbie the right MLG had separated from the

(1988), the Boeing 737 at Kegworth, UK (1989), the Airbus A300B4 near Medan, aircraft, rupturing the rear wing spar web. Sumatra (1997,) and the Concorde at Gonesse, France (2000). In November 2008, he The drag brace support fitting, together assumed IIC duties for the Boeing 777 G-YMMM investigation, having the respon- with portions of the rear spar web, rear sibility for completing the investigation and preparing the final reports. terminal fitting, and the internal back-up n Anne Evans was a senior inspector (engineering) with the Air Accidents Investiga- fitting, remained attached to the right tion Branch in the UK. She joined the AAIB in 1987 and specialized in the analysis of main landing gear (see Figure 3) around FDR and CVR data. In 2000 she began work as an engineering investigator and has the drag brace fitting. Examination of the participated in a range of civil and military accident investigations, including the Boe- fracture surfaces indicated an overload in ing 747 at Lockerbie, UK (1988), the Boeing 737 at Kegworth, UK (1989), and the A320 the aft direction. in Ibiza (1998). She was responsible for investigation of crashworthiness aspects on the During the separation, the remaining accident to the Boeing 777 G-YMMM at Heathrow in January 2008. Ann was gradu- section of the right MLG had impacted the ated from Imperial College, London, and is the ISASI European Councillor. fuselage, damaging the wing-to-body fair- n Dr. Andrew Walton joined Cranfield Impact Centre in 1983, having graduated ing and penetrating the rear cargo hold. from Loughborough, Cambridge, and Cranfield Universities. His major interest This impact had caused damage to and is in analytical crash simulation methods, working in the aerospace and automo- leakage from the passenger oxygen cylin- tive sectors. He first worked with the AAIB in the simulation of the Boeing 737-400 ders, which are located in the rear cargo accident at Kegworth, UK in 1989. Subsequently, he has worked with the AAIB and hold. This section of MLG then became other authorities in some 20 or so accidents as part of formal accident investiga- airborne and impacted the right horizontal tions. The case reported in this presentation represents his most recent work with stabilizer as the aircraft continued to slide. the AAIB involving the accident of Boeing 777 at Heathrow in 2008. This was confirmed by the presence of an

January—March 2012 ISASI Forum • 9 eration signals to allow comparison with impact area. The aircraft and ground mod- certification levels. els were combined to simulate the dynamic The classic AAIB case was the B-737 behavior of the aircraft during the impact, G-OBME accident at East Midlands in and the aircraft model was projected at the January 1989. For this exercise, relatively ground at the velocity and attitude derived crude compared with recent work, air- from the recorded data. More detail on the frame and ground modelling were used analysis by the CIC, and the results, are as a supplement to other investigation contained in the AAIB accident report. work in order to generate seat load and Figures 5 and 6 show static images from deceleration levels. This was followed by the dynamic impact modelling. further work using these deceleration sig- In addition to a simulation of the ac- nals levels in modelling a typical passenger cident conditions, a number of test cases in a typical seat. The AAIB was involved were also run to investigate the factors in in a similar exercise in support of the SAS MD-81 OY-KHO accident near Stockholm in December 1991 in which there was a particular interest in the strength of over- head bin attachments as well as passenger seats. In September 1999 the AAIB used Figure 4. Right rear spar and center impact modelling in investigating a Cessna fuel tank structure. 404 Titan G-ILGW accident in which the plane crashed shortly after takeoff from Figure 5. Impact Glasgow Airport, with the emphasis again X embedded portion of horizontal stabilizer modelling, impact on airframe and seat strength. leading edge material (see Figure 4). with hard surface. The two front wheels of the right MLG, Another interesting case was the BEA Z Y together with the forward section of the investigation of the Concorde accident in truck beam ahead of the center axle, be- 2000. In this instance the impact of inter- came detached and impacted the right side est was between a large mass of detached of the fuselage, resulting in the injury to tire and the lower skin of a main fuel tank, X and the computational simulation ran the passenger seated in seat 30K. Y For the investigation, Boeing generated alongside a series of tank impact tests. Z a clear and useful graphical account of this It was the experience gained from these MLG sequence, and it is reproduced in the cases that brought about the confidence AAIB accident report. to undertake impact modelling in this G- YMMM accident. Previous impact modelling Over the previous 20 years, the AAIB had G-YMMM crashworthiness modelling been involved in a number of exercises Regarding the accident to the BA B-777 Figure 6. Impact where state-of-the-art computational im- G-YMMM, study was carried out by the modelling, soft ground deformation. pact dynamics has been used within an Cranfield Impact Centre (CIC) to simulate accident investigation. The scenarios had the impact in order to investigate the fail- the impact; these included the impact sur- been varied, but in each case the funda- ure of the right MLG and the consequent face (soft soil and hard ground) and yaw/ mental purpose of the computational work fuel tank rupture. A Finite Element (FE) roll angle at impact. A “normal” landing had been to deepen the understanding model of the aircraft, based on data from case was also simulated using data sup- of the conventional “field investigation” the manufacturer, was combined with a plied by the manufacturer to validate the work and, in particular, to compare the FE model of the accident site. For this model. The nature of the ground surface impact, principally in terms of impact structural impact analysis, LS-DYNA was found to have a significant effect on decelerations and loads, with values used software was used for its capability to the outcome of the simulation. in the aircraft design and certification predict the dynamic behavior of nonlinear processes. This is rather different from materials under transient loads and vary- The fuel tank rupture the use in industry of impact dynamics as ing boundary conditions. The AAIB analysis in the final report a “predictive” tool in which the modelling The FE model for the right main land- used both the conventional investigation takes the place of expensive and highly ing gear and its attachment to the aircraft examinations and the results of the Cran- instrumented hardware impact tests. model was derived from engineering data field Impact Centre FE simulation work. Instead, the use within the investigation supplied by the manufacturer and supple- Both main landing gears had partially takes place after the hardware exercise mented by additional data from other separated at the initial impact, which oc- (the accident, which is always unplanned, sources. The model of the accident site was curred with a vertical rate of descent of uninstrumented, and uncontrolled!) but created from a detailed site survey, which 25 ft/s immediately before impact. The aims, for instance, to quantify seat decel- included soil properties measured at the ground marks showed that, at the second

10 • ISASI Forum January—March 2012 impact, the main landing gear legs were to a post-impact fire. As the fuel tank transferring loads into the rear spars and unable to sustain vertical load and that the rupture represents a significant hazard resulted in distortion in the region of the aircraft contacted the ground on its engine in a survivable accident, the following rec- drag brace attachment. nacelles and its nose landing gear, which ommendation was made: “Safety Recom- It was concluded that the difference in immediately collapsed. mendation 2009-094—It is recommended outcome in the simulation from that of the The separation of the left gear attach- that Boeing apply the modified design of accident was due to the soil characteristics ments followed the design breakaway the B-777‑200LR main landing gear drag in the model being different to those of sequence, leaving the fuel tanks intact brace, or an equivalent measure, to pre- the soil at the accident site. Had the soil except for a small gap between the upper vent fuel tank rupture on future Boeing strength in the model been greater, it is wing skin and the rear spar. The gear 777 models and continuing production of probable that more fuse pins would have remained with the aircraft as it continued existing models of the type.” failed and the rear spar distortions would to slide along the ground. Analysis of the The rupture of the rear spar resulted have been less. However, the analysis did sequence of failures indicated a very heavy in a breach in the center fuel tank. Based indicate that landing gear interaction with vertical impact, with the fracture of all six fuse pins in the upper and lower housings of the forward trunnion. The drag brace Use of can fuse pin showed some evidence of crank- computer-based impact tools shafting but did not fracture. add real value to the accident investigation. This The right gear showed a similar initial breakaway sequence following the frac- is as a supplement to other approaches, not as ture of the outboard end of the gear beam attachment; however, only the four fuse a substitute, and compared with other investigation pins in the lower housing for the forward costs, it . trunnion failed, leaving the two upper can be expensive housing pins intact. The forward trunnion on the knowledge at the time, the design soft ground can substantially modify the was then forced down and aft. The ground breakaway scenario was accepted when breakaway sequence. marks at the second impact indicated that the aircraft was certificated and found to Dynamic FE modelling is a novel and the right MLG had been displaced inboard be in compliance with the requirements. complex task. The analysis carried out by during the initial impact. The current CS 25.721 (a) require- the CIC had a number of limitations and As the aircraft continued the ground ments stated that “…The overloads must ultimately did not accurately reproduce slide, the right MLG moved aft allowing be assumed to act in the upward and aft the accident outcome. Further research the shock strut to contact the truck beam. directions in combination with side loads is required in order to fully understand This resulted in the separation of the for- acting inboard and outboard. In the ab- the effects of soft ground on the landing ward portion of the truck beam together sence of a more rational analysis, the side gear breakaway and the dynamics of the with two wheels. This piece then struck loads must be assumed to be up to 20% of fuse pin loading. the right side of the fuselage causing the vertical load or 20% of the drag load, The current requirements do not ex- damage within the cabin and leading to whichever is greater.…” plicitly differentiate between landings the passenger injury. As the remainder of Although, as part of the B-777-200 certi- on different types of surfaces and the the gear assembly continued to move aft, fication, this criteria was met as part of the resulting dynamics. Emergency landings the inboard wheels contacted the fuselage EASA Certification Review Item (CRI), may be performed on soft surfaces either behind the MLG bay. The rear spar web, there is no such requirement in the FARs. outside the airfield boundary or beside the together with the back-up fitting and This generated a safety recommendation: runway itself. To consider different types terminal fittings, ruptured, which caused “Safety Recommendation 2009-095—It of surfaces in the landing gear design the right MLG to separate. This became is recommended that the Federal Aviation requirements, this safety recommenda- airborne and struck the right horizontal Administration amend its requirements tion was made “Safety Recommenda- stabilizer before coming to rest. for landing gear emergency loading tion 2009-096—It is recommended that The possibility of the landing gear being conditions to include combinations of the Federal Aviation Administration, in displaced inboard had been considered in side loads.” conjunction with the European Aviation the certification of the B-777-200LR, as The analysis by the CIC also showed Safety Agency, review the requirements this variant has a fuel tank located aft of very different failures resulting from for landing gear failures to include the the main landing gear bay. As a result, the landing on soft ground as opposed to a effects of landing on different types of manufacturer introduced a rotational tab hard runway surface. In the soft ground surface.” and reduced the cross-sectional area on accident simulation, the results showed the drag brace to protect the additional that only one of the fuse pins failed. A Lesson learned fuel tank in the event of an overload con- delayed build-up of shear forces in the Within this accident investigation the im- dition. On G-YMMM, this area contained pins (when compared to impact with hard pact dynamics work was limited in scope the passenger oxygen bottles, which ground) prevented most of them from but was, overall, successful and helped were disrupted by the MLG during the reaching their failure loads. This delaying to formulate a number of safety recom- ground slide; this could have contributed action allowed the fuse pins to continue (continued on page 31)

January—March 2012 ISASI Forum • 11 Ensuring Safety in Aviation’s Second Century By NTSB Chairman Deborah A.P. Hersman

Accident investigation’s improvements in safety through standard- And, that’s what I will talk about: acci- ization. And that is my theme—fostering dent investigation—its past and present, past and present, and how it improvements in aviation safety. and how it must adapt in order to play an must adapt in order to play As I look out at the audience and see even more pivotal role in creating civil so many of you from all around the world, aviation›s safer and stronger future. an even more pivotal role I am reminded that global diversity and Jureybon did exactly what the 185 del- in creating civil aviation’s international perspective are what make egates from 52 states intended two-thirds safer and stronger future. aviation so strong. of a century ago at the 1944 Chicago Con- Growing up, I spent most of my child- vention that created ICAO. Investigating, (The following article is presented for hood overseas. I lived in Spain, England, learning, and adapting from accidents the historical and future perspective it and Amman, Jordan. I got to see other so that the deadly past would not be re- provides to the profession of air safety countries—their challenges, their suc- peated. And that’s what all of us and all of investigator. It is adapted from remarks cesses, and their diversity. I learned that you are doing every day. delivered by National Transportation one size does not fit all. Thanks to the vision in 1944—and to the Safety Board Chairman Deborah A.P. In Jordan, I saw goat and sheepherd- efforts of so many more—today’s global Hersman at the 8th annual Assad Kotaite ers, which brings me to a story I want to airline accident rate is at its lowest ever. Lecture in Montreal, Quebec, on Dec. 8, tell. It’s a Lebanese tale in homage of Dr. The Air Transport Association reports 2011.—Editor) Kotaite’s heritage. Once upon a time, three that last year the global rate was one ac- goats—Siksik, Mikmik, and Jureybon— cident for every 1.6 million flights. t is my honor to be here with so many were grazing on a stony hill. Scenting That’s a 42 percent improvement since people who do so much for civil avia- them, a hyena lopes up. “Siksik,” calls the 2000. How did we get to this low rate? Ition and for aviation safety. And it is hyena. “Yes, sir,” says the goat. “What are What did we see? What did we learn? And, a privilege to be invited to give this talk those points on your head?” “These are how did we adapt? and be here with Assad Kotaite, a giant my little horns, sir.” “What is that patch Here are three key areas that helped in internation- on your back?” the hyena asks. “My hair, get us to that low rate: data, technology, al aviation. sir.” “Why are you shivering?” roars the and design. Those Chicago pioneers recog- Dr. Kotaite’s hyena. “Because I am afraid, sir.” With nized the importance of data. Their plan: leadership that, the hyena gobbles him up. ICAO was to be a center for the collection, has advanced The hyena turns to Mikmik, who an- study, and distribution of information on cooperation swers just as his brother, with the same all significant aircraft accidents. among ICAO, tragic result. They did early work to define common its contracting Next, the hyena approaches Jureybon. terms and develop a standard method to states, and the As the hyena draws near, Jureybon bel- present accident statistics. And they laid global aviation lows, “May a plague be on you!” The hyena important groundwork to develop an ac- community, asks, “What are those points on your cident investigation manual. and dramati- head?” “Why, those are my trusty sabers!” This focus was essential. For one, Deborah A.P. Hersman, cally fostered “And the patch on your back, what is that?” between 1946 and 1950, on average, U.S. chairman, NTSB improvements “My sturdy shield!” Jureybon replies. To carriers had a major aviation accident in safety through standardization and the hyena’s last question, “Why are you every 16 days. Think about that: Every technical leadership. shivering?” Jureybon snarls, “Shivering? 16 days. I have not had the privilege to know Dr. I’m shaking with rage to throttle you!” Here’s another way our forebears rec- Kotaite for as long as many of you. But Jureybon advances on the hyena, who ognized the importance of data. A report in speaking with my colleagues, they all runs for his life. Jureybon springs after from the 1947 meeting of the Accident credited him with the success of ICAO— him, slits open his belly, and frees his Investigation Section noted that flight its lack of politics and its focus on doing brothers. recorders had proven valuable. The re- the technical work and being an efficient You could say that Jureybon was the port recommended, “These instruments and effective organization. He excelled at world’s first accident investigator. He saw should ideally record indicated air speed leadership of an organization, of people, what happened, learned from it, and adapted and acceleration as well as altitude.” Those and of ideas. He dramatically fostered to prevent it from happening again. early foil flight recorders, followed by their

12 • ISASI Forum January—March 2012 Ensuring Safety in Aviation’s Second Century By NTSB Chairman Deborah A.P. Hersman

second- and third-generation descendants, greater challenges in investigating ac- vide investigators with critical real-time contributed significantly to today’s out- cidents and ensuring safety. This is be- information. standing global safety record. cause while modern technology has made And, we’re seeing an immense amount aircraft more efficient, they are also far of video data from surveillance cameras Solved accidents more complex. and personal cameras, as well as informa- I could fill an entire book with examples of No one knows that better than you do. tion from GPS devices and electronic flight accidents solved—and countless accidents Look at the changes. Old “steam bags. In fact, over the last seven years, prevented—thanks to information ob- gauges” have been replaced by electronic there has been a 200 percent increase in tained from data recorders. Much of that displays. Hand flying has been supplanted the number of recording devices that come information led directly to technological by increasing automation. Many flight into our lab. All of this comes together to improvements. controls now rely on electronic actuators provide key pieces of the investigative In fact, just last month, Honeywell’s compared with control cables. And, of puzzle. Don Bateman was recognized by Presi­dent course, there are more and more compos- Yet, even with all the data sources, we Obama with the National Medal of Technol- ite structures. continue to deal with the most complicated ogy and Innovation for his breakthrough While these all provide advantages, piece of equipment in aviation for which work developing ground-proximity warn- they require adjusting how accident inves- there is no data recorder—the human. ing and windshear detection systems. [Mr. tigators acquire evidence and information. For example, in the August 2006 ac- Bateman is ISASI’s 2008 Jerome F. Lederer The evidence and failure signatures we cident in Lexington, Ky., the pilots tried Award winner.] relied upon in yesterday’s investigations to take off from the wrong runway—one Bateman’s EGPWS has all but solved are not always available today. intended for GA aircraft. This investiga- CFIT accidents. And with Doppler radar For example, in 2001, when we pulled tion highlighted issues of communication, and so much more, aircraft now fly more the vertical fin of the Airbus A300 out of runway signage, and the importance of safely in all kinds of weather conditions. the waters in the New York area, it took us cockpit discipline. Traffic Alert and Collision Avoidance a long time to figure out where the failure Likewise, it was not a mechanical issue Systems, or TCAS, have helped eliminate began and why—and what the forces op- that caused the February 2009 crash near mid-air collisions. Those are just the tip of erating on it were because we didn’t have Buffalo, N.Y. This investigation shed fur- the technology iceberg. typical overstress signatures that we used ther light on pilot professionalism, fatigue, Through aviation’s first century, to see with metal. and pilot training. the community learned a tremendous Or, before glass cockpits, investigators Unlike the early accidents in which amount—the hard way—about aircraft could determine an airplane’s airspeed at investigators identified a structural or design issues from a number of accidents, impact because they could see the slap of component failure, human factors acci- including the DC-10 with its poorly de- a needle on the face of the gauge. These dents are even harder to investigate. We signed cargo door latches and the Boeing concrete physical traces are no longer can figure out why a component failed, 737 and metal fatigue. there. we can’t always figure out—especially in As we ended that first century, we saw The good news is that investigators a fatal accident — why humans made the further design improvements on the work- have access to more data sources. To- decisions they made. horses of the airline industry—remedies day’s flight recorders collect thousands It’s important to identify the decision- for the rudder design issues in the 737 of parameters. And investigators are making process that got them there so and the inflammability of the 747 center able to retrieve information from non- we can prevent it from happening again. fuel tank. Today, we find fewer and fewer volatile memory sources, which can be Yet, unlike airplanes that come off the equipment and design failures. recovered from electronic components, assembly line, that are intended to be ex- Why? including digital engine controls, flight actly the same every time, and perform to We investigated. We learned. And we control and maintenance computers, and predictable and repeatable specifications, adapted. much more. human beings are not always predictable. Even when these devices are severely As the mother of three boys, I can tell you Second century challenges damaged, we’ve had successes with chip- that humans are not predictable. So, what are we seeing in aviation’s level data extraction. There’s also data And there’s only so much data on the second century? Today, there is greater transmitted from onboard reporting CVR, often the most scrutinized piece of safety. Yet, at the same time, there are systems, such as ACARS, which can pro- equipment on an accident airplane. Inves-

January—March 2012 ISASI Forum • 13 No matter how proud we are of the safety record we have achieved, we cannot—we must not—be complacent. tigators listen for inflections in the pilots’ Many states have instituted family in Beijing 10-and-a-half hours earlier, was voices—yawns, straining on the controls, assistance programs. Most recently, the on short-final approach at 720 feet AGL and many other subtle changes in speech European Union passed family assistance when the right engine and then the left to determine why pilots responded the legislation for its member states. We ap- engine stopped responding to autothrottle. way they did...or did not. plaud ICAO for its family assistance lead- Through outstanding airmanship, over One of the most frustrating things our ership. At the NTSB, we were honored, at busy roadways and dense population, investigators encounter is listening to a ICAO’s request, to participate in a task the pilots brought the plane to land just CVR and hearing a pilot say, “Look at force to revise ICAO Circular 285, first beyond the perimeter fence at Heathrow. that!” It can take years of painstaking ef- published 10 years ago. The UK’s AAIB led the investigation, fort to finally determine what “that” was As I mentioned in the beginning of my which the NTSB joined as an accredited and its relevance to the accident. speech, we recognize that one size will representative. Unfortunately, there are no FDRs in not fit all cultures. In March [2011], the The FDR, CVR, and quick access re- pilots’ heads. NTSB held a family assistance confer- corder were recovered, and there were Adding to the complexity of accident in- ence attended by representatives from some 1,400 parameters on the data record- vestigation in aviation’s second century is more than 30 countries—from North and ers. The pilots gave extensive interviews. the increasing globalization of aviation. No South America, from Africa, and from None of this told the team precisely why longer is there a clear distinction between Asia. Clearly, there is a widespread need both engines failed. Nor did tests of the domestic and international accidents. Ac- for consistent principles for governments fuel, of water content, examining where cidents involving U.S. operators and U.S. and air carriers. We are hopeful the Coun- the airplane was last serviced, and more. equipment can and do occur anywhere cil and Assembly will embrace this issue. Everything came up blank. in the world. Likewise, accidents may Because in the aftermath of an accident, Yet, with a rich store of data, the team happen in the United States but involve a we have seen what happens, we’ve learned reviewed thousands of similar flights. foreign-operated or foreign-manufactured about what needs to be done, and, now we One key finding was that the accident aircraft. need to adapt. plane flew longer at a low fuel flow in cold And, truly, what does “foreign-manu- With air travel’s dynamic worldwide temperatures than other flights. Tem- factured” mean today? Look at the Boeing growth, projected to be some 3.6 billion peratures on the accident flight’s routing 787 supply chain, which stretches from passengers by 2014, we know that as we reached as cold as minus 74º C. Japan to Italy. The Airbus A380 has 100- plan we must be very intentional in how This, in turn, led to scrutiny of fuel plus suppliers in more than 20 countries. we work together, which is why the ICAO delivery to the engines. Lab tests looked This is why the accident investigation structure and Annex 13 are so important. at the effect of extreme cold temperatures framework provided by Annex 13 is so How are we going to investigate, learn, and long idle times. Of particular interest crucial. Annex 13 provides the founda- and adapt in order to prevent accidents in was the fuel oil heat exchanger, which tion—the protocols, the rights, and aviation’s second century? uses cold fuel to take heat away from the responsibilities—for the states to work It’s clear that accident investigation will oil and leads to the engine running cooler, together. depend far more on data and cooperation especially the bearings. One of the challenges is when the ac- than in the past. While time-honored tin- The investigative team performed tests cident investigation protocols defined in kicking will never go away, it is increas- running a fuel system mockup for hours Annex 13 collide with the local political ingly being joined by sophisticated data with cold fuel. They saw ice crystals collect and judicial systems. This is where data analysis. on the face of the fuel oil heat exchanger. If and cooperation are so essential. The data, And the amount of data is growing the engine throttle was applied, the newly most often on the recorder, are needed every day. formed ice broke up. But, with no throttle first since for safety investigations the applied, the ice continued to form. [See data lay the foundation for all the activi- New Investigation model “Investigative Data Mining: Challenges ties to follow. Those activities enable us to Let me tell a story that illustrates the new and Innovative Outcomes,” page 5, ISASI investigate, to learn, and to adapt. Today, model of accident investigation...and the Forum, April-June 2011.] as we work together across boundaries importance of data and cooperation. It turned out that this perfect flight— to learn what caused an accident, we are On Jan. 17, 2008, a British Airways Boe- with minimal throttle usage to conserve doing even more to help those whose lives ing 777 crash landed at London Heathrow. fuel—led to slushy ice forming within the are affected by them. The plane, on a flight that had originated fuel system. When throttle was applied

14 • ISASI Forum January—March 2012 No matter how proud we are of the safety record we have achieved, we cannot—we must not—be complacent.

during the later stages of approach, the ac- crosswinds. The simulator could provide up essential in setting standards of protection cumulated ice traveled to the fuel oil heat to 30 knots of crosswinds but was unable to for the use of data in accident investiga- exchanger and restricted the fuel flow. replicate gusts while on the runway. tions. The NTSB looks forward to con- Corrections included interim proce- Sometimes it can be difficult to reach tinuing the conversation on cooperation dures that were followed by a redesign a simple finding. That was the case with next year when we host an international of the fuel oil heat exchanger. We investi- this accident. Our investigation revealed conference to share experiences, address gated, learned, and adapted. Safety was that the pilots were being trained on a the challenges with conducting Annex 13 served through data and cooperation. constant wind and no gusting. Yet, pilots investigations, and identify best practices. Here’s another story about the impor- are more likely to see crosswinds gusting We will also address training needs for tance of data to accident investigation. In to 40 knots than engine failure on takeoff. investigators on new and advanced equip- late 2008, a Continental Airlines 737 They are trained in engine-out procedures ment as well as follow up on the work un- crashed on takeoff at Denver Interna- and not gusts. der way on international family assistance. tional Airport. It was a windy day, as it Just like with the British Airways I began my remarks with a Lebanese is so often on Colorado’s high plains. In Heathrow crash landing, the aviation com- story. Let me close with another tale. It’s Continental’s operation, the 737 has a munity investigated, learned, and adapted one of my favorites: Cinderella. crosswind limit of 33 knots. A Denver to improve safety. None of which would You know the story about the maiden tower controller told the flight crew that have been possible without data. outfitted in fine clothes by her fairy god- the winds on the runway were from their Yes, data are key. And, in this era of mother who captivates the prince at the left at 27 knots. dynamic growth and greater complexity, ball. Yet, when she races to leave before The crew, assessing they were well data are more important than ever. As the stroke of midnight—as she was in- within Continental’s limits for operating Alan Mulally famously, and frequently, structed—she loses one glass slipper. That in crosswinds, prepared for takeoff. Yet, said when he was with Boeing: “The data lone slipper is how the prince —himself a when they rolled down the runway they will set you free.” clever investigator like Jureybon—finds were hit by 90-degree crosswinds that In our work, the data do much more the girl of his dreams. exceeded 45 knots. This resulted in the than that. Today, with sophisticated data analysis, plane, full of holiday travelers, departing Data save lives. the prince would not have to try the glass the side of the runway at about 90 knots. In aviation’s second century, accident slipper on every female in the kingdom. The airplane sustained substantial dam- investigators need all the data available He could run a software program, com- age during the roll over uneven ground to put together the big picture of what pare all the shoe sizes, avoid the wicked and post-crash fire. Fortunately, no one happened. Some of that data—as we saw stepsisters, and quickly find his princess. was killed or seriously injured. at Heathrow and at Denver—are from And live happily ever after. Just as with the BA flight, the inves- routine flights that can be compared with How will we in aviation fly more safely tigative team downloaded recorders, the accident flights. ever after? examined equipment, and interviewed the I applaud the agreement reached last No matter how proud we are of the crew, dispatchers, meteorologists, Boeing year at the 37th Assembly to foster data safety record we have achieved, we can- aircraft performance engineers, and con- sharing through the creation of the Global not—we must not—be complacent. We trollers. From this information, the team Safety Information Exchange. This infor- must make a constant commitment to could not tell what was so unusual about mation can be vital to learning what really further improve aviation safety—by ob- this day, this flight, or this flight crew. happened and determining what can be serving, learning, and adapting. And by The data revealed that frequently done to improve safety. using the data and increased international Denver’s major airport experiences much Data and cooperation. These are how cooperation through ICAO. stronger crosswinds than expected on we will continue to investigate, learn, and But when the inevitable accident occurs, takeoff. That led to the first key finding: adapt. we must also recognize our responsibilities the method ATC used for reporting winds And, these are how aviation will main- to those who are left behind. Because life to flight crews did not provide the best tain—and enhance—its strong safety is not always a fairytale ending. There possible information to flight crews. Then, record into the second century of powered are accidents and there are families and questions about crew training took investi- flight. friends who are left behind. gators to Continental’s simulator training The recent General Assembly initiated Like Jureybon, we are our brothers’ and facility to see how it trained its 737 pilots on this dialogue about data sources. This is our sisters’ keepers. ◆

January—March 2012 ISASI Forum • 15 Building Partnerships in Unmanned Aircraft U.S. AIR FORCE Systems As UAS use propagates, the established, mutually supporting investigative and regulatory processes for manned aircraft that have evolved and exist today must be given the opportunity to perform those functions for UAS operations. By Thomas A. Farrier, Chair, ISASI Unmanned Aircraft Systems Working Group

(This article is adapted, with permission, cordance with standardized right-of-way tives of UAS safety as a sector. As UAS from the author’s paper entitled Build- rules. In a 2008 report (GAO-08-511) to the use propagates, the established, mutually ing Partnerships in Unmanned Aircraft U.S. Congress, the Government Account- supporting investigative and regulatory Systems presented at the ISASI 2011 ability Office (GAO) made the following processes must be given the opportunity seminar held in Salt Lake City, Utah, observation: “Routine UAS access to the to perform the functions for which they Sept. 12–15, 2011, which carried the theme national airspace system poses a variety of evolved and exist today. “Investigation—A Shared Process.” The technological, regulatory, workload, and co- full presentation, including cited refer- ordination challenges. Technological chal- Today’s UAS community ences to support the points made, can be lenges include developing a capability for The principal UAS stakeholders—and found on the ISASI website at www.isasi. UASs [sic] to detect, sense, and avoid other thus the main holders of or gatekeepers org under the tag “ISASI 2011 Technical aircraft; addressing communications and to useful information about the operation Papers.”—Editor) physical security vulnerabilities; improving and safety of the broad constellation of UAS reliability; and improving human fac- unmanned aircraft systems—fall into a nmanned aircraft systems (UAS) tors considerations in UAS design.” few major categories. increasingly are finding their way In other words, UAS “integration”—the • Operators—Current operators of UAS Uinto shared airspace, flying side by preferred term for the desired end state in the U.S. national airspace system (NAS) side with manned aircraft throughout the advocated by most current public-use UAS include traditionally aviation-oriented United States. In some instances, this operators—has to address not only the components of the military that are adding is being orchestrated on a case-by-case lack of an onboard pilot to perform see- basis. In others, it is due to increased lati- and-avoid duties, but also issues arising Tom Farrier has been tude granted to military and other public- from the remote location of the pilot, dif- an ISASI member since use UAS operators by the Federal Avia- ferent certification strategies, and a lack 1995. He began his tion Administration (FAA) under pressure of broad-based expertise in UAS-oriented aviation safety career from UAS users, interest groups, and in human systems integration. with the U.S. Air Force, some cases the U.S. Congress. The only way to systematically address serving as an on-scene For a variety of reasons, advocacy of the needs of regulators trying to chart the investigator as well as unmanned aircraft systems is outpacing future directions of unmanned aircraft performing prevention and program- a knowledge-based approach to bringing systems in shared airspace is for today’s matic duties at wing, major command, them into the current aviation system. A UAS users to allow them far greater ac- and headquarters Air Force levels. After near-universal perspective exists regard- cess to the practical operational and safety retiring from the military, he was na- ing data related to UAS operations and knowledge they have built and continue tional safety coordinator for the National safety that is completely at odds with how to build. At the same time, the amount Air Traffic Controllers Association, later similar data on manned aircraft have come and quality of data available to accident becoming director of safety for the Air to be regarded. investigators trying to foster a UAS Transport Association. Since 2005, Tom By their nature, unmanned aircraft regulatory structure are sorely lacking, has been a government contractor ad- systems have the potential to be extremely and the findings of investigations being dressing aerospace safety matters rang- destabilizing in an operational environment conducted by various UAS operators and ing from heliport design to space tourist that evolved from the basic principle of manufacturers are not being leveraged safety to his current work in the emerging seeing and avoiding other aircraft in ac- effectively to support the broad objec- field of unmanned aircraft systems.

16 • ISASI Forum January—March 2012 UAS to their fleets. Also, public agencies where the setbacks have been marked by Beyond imposing operational controls with defined missions that are taking ad- aircraft losses. to mitigate various recognized hazards vantage of the economic efficiencies associ- • Interest groups—There are at least associated with UAS operations, a key ated with UAS to expand their capabilities three major trade associations support- component of both approval processes is in the aviation environment, and a handful ing UAS interests: the Association of a requirement for operational and safety of new entrants into the community of Unmanned Vehicle Systems International reports documenting authorized flights in flight pursuing entrepreneurial ideas for (AUVSI); UVS International; and the the NAS. Monthly reports include basic using the UAS platform commercially. British-based Unmanned Aerial Vehicle data regarding flight hours and operations In the U.S., the umbrella term “public Systems Association (UAVS). To vary- to aid in normalizing reported data. Indi- use” UAS operators includes military or- ing degrees, these and other nationally vidual occurrences are reported as they ganizations, federal agencies performing oriented UAS associations, such as UVS happen. In addition, a new template for a variety of missions, state and local law Canada, the Russian Unmanned Vehicles COAs is about to be released, which will enforcement entities, and state-owned uni- Association, and the Japan UAV Associa- significantly expand the types of nonhull versities. Regardless of size, capabilities, tion (JUAV), all serve as advocates for the loss events of interest to regulators in or missions, however, under public law UAS manufacturing sector while engaging developing system and pilot certification all of these organizations have the right criteria for eventual civil use. to certify the airworthiness of their own unmanned aircraft systems and, to a large The needs of UAS investigators extent, the pilots who fly them as well. Given that little current hard data are In contrast to the public-use sector, since available to regulators regarding UAS ac- there are no regulations currently in place cidents, incidents, and malfunction trends, establishing UAS aircraft, ground control air safety investigators face a host of new system, or pilot certification standards for challenges as unmanned aircraft systems civil operators, there is no provision for become more widespread, especially in UAS to be flown as general aviation aircraft nongovernmental use. The three most with typical airworthiness certificates. critical are likely to be 1) Knowing how This has served as a brake on some—but Facing page: MQ-9 Reaper control link to investigate an unmanned aircraft ac- not all—UAS flying aimed at developing deliberately severed due to ground emer- cident, 2) Knowing what can go wrong (to capabilities and markets. So, for now, just gency; does not follow its preprogrammed understand what the investigation uncov- about the only “civil” operators of UAS are “lost link” profile. U.S. Air Force declines ers), and 3)Having a common language manufacturers of UAS, as discussed below. to investigate as a safety event. with which to describe findings and make • Manufacturers—As with the opera- Above: July 27, 2011, Lockheed Martin recommendations. tors, the UAS manufacturers’ sector is an HALE-D airship launches from Akron, Ohio; • The mechanics of investigation—To interesting blend of the old and the new, fails to achieve planned altitude, forced break down the investigator’s problem to including long-standing aerospace cor- to make uncontrolled descent. U.S. Army, a manageable level, one must recognize porations, existing companies diversify- which sponsored the test as the HALE- that unmanned aircraft systems consist of ing into aviation to support other lines D’s operator for the purposes of its COA, multiple, noncollocated components—some of business, and purely UAS-oriented declined to investigate, citing it as “not exactly the same as manned aircraft, some start-ups. If one scans recently published an Army aviation accident.” similar to those used in manned aircraft but lists of current (announced) unmanned employed differently, and some unique to aircraft manufacturers, familiar names in varying degrees of interaction with their remotely piloted aircraft. Equally impor- appear, like Boeing, EADS, Northrop national airspace regulators. tant is the need to understand that dif- Grumman, Thales, and IAI. For those ferent manufacturers choose to solve the with at least a nodding familiarity with Current FAA data collection various technical challenges associated with unmanned aircraft systems, you’re likely Given the limitations of unmanned aircraft unmanned aircraft in very different ways. to recognize names like General Atomics, in terms of both see-and-avoid and the Special Committee 203 of RTCA (“Un- AAI, AeroVironment, and InSitu as well. undesirability of control link loss in some manned Aircraft Systems”) has concep- However, for every established aerospace locations and classes of airspace, the gap tualized unmanned aircraft systems as company engaged in UAS development between UAS capability and the needs consisting of three basic, interconnected or production, there are at least a dozen of the NAS as a whole is bridged in the components: the “control segment” (the or more small businesses or individual U.S. by two separate processes: the “Cer- pilot and associated hardware and soft- entrepreneurs in search of part of the tificate of Waiver or Authorization” (COA) ware needed to effect control), the “air- burgeoning UAS market. The presence of process, managed by the FAA Air Traffic craft segment” (the unmanned aircraft such enterprises complicates addressing Organization (ATO) in cooperation with proper), and the national airspace system two fundamental challenges: identifying the FAA’s Unmanned Aircraft Program (which incorporates the communications, current and emerging UAS manufactur- Office (UAPO), and the “Special Airworthi- navigation and surveillance capabilities ers and encouraging them to document ness Certificate–Experimental Category” that support flight operations). progress (and setbacks) encountered (SAC-Exp) process, managed by the UAPO A typical NTSB investigation may in their development efforts, especially with the participation of the ATO. involve nine or more groups working on in-

January—March 2012 ISASI Forum • 17 Standards Development Initiatives RTCA Special Committee 203 • Developing UAS minimum aviation system performance standards, minimum operational performance standards, etc. EUROCAE WG-73 • Established to create six key products, including —Framework for civil UAS to operate safely within shared airspace based on existing ATM regulations, infrastructure, and procedures dividual aspects of the accident, including —Catalog of UAS normal and abnormal operations requiring special air traffic • Air traffic control, management consideration • Airplane Performance, ASTM International Committee F38 • Human Performance, • Minimum safety, performance, flight proficiency, and quality assurance require- • Maintenance, ments • Meteorology, • Production acceptance tests/procedures, continuing airworthiness • Operations, requirements • Powerplant, • Structures, and • Systems. the observed failure or failures leading to tion developed through aircraft loss Mapping the NTSB areas of concen- the accident. investigations. The availability of this tration against the “segments” described • Existing taxonomies and unmanned privilege in turn led to the evolution of above, most of the basic areas of inquiry aircraft system accidents—Finally, mak- two distinct processes to document each readily suggest themselves. The inves- ing a worthwhile preventive recommenda- such loss: 1) The “mishap investigation,” tigator’s path seems straightforward tion depends upon being able to answer governed by individual service safety at this point; however, in the absence of such questions as: Has this failure been directives, and 2) The “accident investi- specific knowledge about the exact sys- observed before? If so, how frequently? gation” (sometimes called the “collateral tem involved in the accident, or historical Is a similar failure possible in other un- investigation”), which is conducted in knowledge to draw upon, the picture manned aircraft systems? And is the out- accordance with service legal directives quickly becomes much murkier. come of a similar failure in similar systems that conform to certain requirements of • Developing theories of the sequence comparable to this accident? U.S. public law as well as the Uniform of events—The RTCA architecture is a Regulators and investigators alike need Code of Military Justice. brilliant simplification of the raw compo- a much greater level of insight into what To oversimplify the differences between nents that must be in place to make an is normal and abnormal for unmanned these two processes, the first does not unmanned aircraft system work. However, aircraft systems in general and individual make use of sworn testimony, may offer for investigators, its utility fades rapidly types of UAS in particular to be able to do witnesses a promise of statement confi- once basic investigative requirements are their jobs effectively. dentiality, and results in a report created figured out and a broad sense has been solely for preventing the recurrence of developed of the segment or segments Cross-communication is lacking similar losses in the future. most likely to have played a part in a given Public-use UAS operators represent the The second process uses the body of accident’s sequence of events. single-best source of the kinds of opera- factual information gathered by the mishap The investigator’s task is greatly com- tional and safety data needed to support investigators as a starting point. It obtains plicated when you walk onto an accident the safe growth of commercial UAS activ- sworn testimony from either the same set scene with no perspective on the safety ity, since they are far ahead of virtually all of witnesses or others identified as needed, record of the type of aircraft involved. It other users in the development of certifica- and generates a report, including a legally becomes that much more so when you real- tion criteria (especially with respect to sys- protected “statement of opinion” by the ize that, for example, you may not have any tem reliability), safe operating protocols, lead investigator regarding the cause or idea as to the precise way that the UAS and UAS-specific accident investigation causes of the accident, that may be used pilot’s control inputs reach the unmanned procedures. However, the challenges as- for any purpose (prosecution, civil litiga- aircraft’s control surfaces. sociated with obtaining and leveraging tion, etc.). In other words, for every new accident, such information are different based on The fruits of accident investigations investigators have to become experts not the entities involved, because each has a generally are available to the FAA, but only on the accident at hand but on the pre- different set of core concerns associated only on the same basis that any member of cise operation of and relationships among with its release and exploitation. the public can obtain them. Mishap inves- all of the notional “segments” embodied in • Military UAS operators—In the tigation results based on candid testimony the accident UAS. Even having done so, U.S., the uniformed military services and expert interpretation of the factual the most difficult challenge is yet to come: have the option of asserting what is fa- data by those best qualified to render it are describing what happened in such a way miliarly known as the “safety privilege” never made available to the FAA. Absent as to support an actionable judgment on in controlling the release of informa- explicit legislation aimed at compelling

18 • ISASI Forum January—March 2012 their release, they never will be. Why? Because all mishap investigation reports Unmanned aircraft have for both manned and unmanned aircraft come a long way. accidents must be protected uniformly to preserve their privileged nature. • Law enforcement agencies—Similar sensitivities arise in law enforcement or- ganizations operating unmanned aircraft systems. For example, the largest nonmili- tary user of the Predator family of UAS is the U.S. Customs and Border Protection (CBP) Office of Air and Marine. Although the CBP was the operator of the Predator whose 2006 crash marked the NTSB’s first UAS investigation, it has matured into a responsible and effective user of both the because they tend to provide essential of considerations known to be challenges resource and the airspace. The CBP has context for understanding how a given to the safe operation of UAS, especially established a well-earned reputation for event took place. However, the underlying when “innovation” is the watchword in clear communications with the FAA on issue is the same: all incident information UAS development. all UAS-related matters, including the is kept close because some of that informa- occasional operational anomaly. tion must be protected. The way forward The main constraint on the use of the • Manufacturers and developers—In- There really is no option: more and bet- CBP’s incident information is that, in terestingly, although UAS experimental ter data regarding UAS in general, and many cases, the only way the agency can certificates are intended to meet the safety-related data in particular, are es- describe a sequence of events is by refer- needs of marketing and testing, not one sential if UAS users want greater access to ring to a specific mission profile or route. currently valid certificate of this type has shared airspace than they have today. John This information frequently tends to be been issued for a small UAS. The most Allen, director of the FAA’s Flight Stan- “security sensitive information” (SSI), likely reason for this is that the regulatory dards Service, observed, “What level of which is defined as “information obtained gray area associated with model aircraft trust do we give this technology? We just or developed in the conduct of security is being used to test small UAS concepts. don’t yet have the data.… We are moving activities, including research and develop- Hence, no established structure exists that cautiously to keep the national airspace ment, the disclosure of which would requires anomalous events to be reported system safe for all civil operations. It’s the “(1) Constitute an unwarranted invasion to the FAA. FAA’s responsibility to make sure no one is of privacy (including, but not limited to, This doesn’t mean that the manufac- harmed by [an unmanned aircraft system] information contained in any personnel, turers are unaware of the types of occur- in the air or on the ground.” medical, or similar file), rences that could be highly undesirable Clearly, then, it is the stakeholders who “(2) Reveal trade secrets or privileged or if encountered in controlled airspace. It will have to develop a framework within confidential information obtained from means that nothing obliges them to talk which they are comfortable sharing data any person, or about such occurrences. UAS market com-­ of varying degrees of value to different “(3) Be detrimental to the security of petitiveness makes it is most unlikely that users. Given the unfortunate and ongo- transportation.” any manufacturer is likely to do so in a ing willingness of many legal systems to A related type of information—like SSI, public forum where the advantages and favor prosecution over protection, any also considered “sensitive but unclassi- defects of different systems could be more data exchange architecture intended to fied”—is “law enforcement sensitive.” easily compared. advance the safety of unmanned aircraft While not presenting identical obstacles Several efforts aimed at developing systems almost certainly would have to be posed by the military’s “safety privilege,” standards for UAS manufacture and op- explicitly protected by law to be attractive SSI and law enforcement sensitive in- erations are in progress (see sidebar, page to submitters. This is a worthwhile goal, formation often are difficult-to-separate 18). However, it is not at all certain such and one that the air safety investigator components of UAS incident reporting standards will account for the entire range (continued on page 30)

January—March 2012 ISASI Forum • 19 Major Investigations, ‘NextGen’ Thinking Ahead New and revised thinking is the challenge for the air safety investigators of tomorrow.

By Robert M. MacIntosh, Jr., National Transportation Safety Board, Retired

(This article is adapted, with permission, from the author’s I would offer that the answer to that premise is a very quali- paper entitled Major Investigations, NextGen Thinking Ahead fied perhaps—maybe—sometimes! We can cite some past cases presented at the ISASI 2011 seminar held in Salt Lake City, where the wreckage is still up on the mountain or down on the Utah, Sept. 12–15, 2011, that carried the theme “Investigation— seabed. Events in the 1990s, such as the Thai Airways A310 near A Shared Process.” The full presentation, including cited refer- Kathmandu, Nepal, or the Berginair B-757 off the north coast ences to support the points made, can be found on the ISASI of the Dominican Republic, are examples of the ability of the air website at www.isasi.org under the tag “ISASI 2011 Technical investigation team to proceed toward reliable conclusions and Papers.”—Editor) recommendations without (lacking) the on-scene documentation. However, let’s look at a situation where existing data alone did uccess in any business endeavor calls for constant review not allow the investigation team to arrive at substantive conclu- and revision of processes and technology. There is no sions: the Jan. 17, 2008, B-777-200ER, British Airways accident exception to this premise in the global aviation environ- at London-Heathrow Airport, United Kingdom. The UK Air ment. To remain current and relevant, the time-honored Accidents Investigation Branch (AAIB) did a tremendous job practicesS of aircraft accident investigation need constant revi- providing details of the ongoing investigation through interim sion. Today’s journeymen air accident investigators can quickly reports and a superb final report published in January 2010. find themselves rendered noncurrent by the technical, organi- Many of the details of the AAIB investigation were presented zational, and political advances of tomorrow. at the ISASI 2010 annual seminar in Sapporo, Japan, in papers As the reliability of our airframes, powerplants, and infrastruc- by Senior Inspector Brian McDermid, Heathrow 777, regard- ture has improved, the perspective of our accident investigation ing the extensive fuel system testing, and by Senior Inspector focus has certainly shifted. In past decades, operators could Mark Ford, Investigative Data Mining, regarding the challenges expect an engine failure about every 1,000 hours of operation. presented by that evidence. It is that preponderance of evidence Avionics components had even shorter time between failures. that should be notable to all of us involved in the investigation of Thankfully, those times are past, and today’s challenges result accidents and incidents in large transport aircraft. in a more proactive approach aligned with safety management The B-777 was certificated in April 1995. It is equipped, per concepts and a much more broad and effective approach toward ICAO Annex 6, with an extensive list of flight recorder pa- risk identification and reduction. So where will the wings of rameters derived from fly-by-wire mediated flight and engine change take formal investigations and practicing air safety controls. Since its entry into commercial service, the B-777 fleet investigators in the future? accumulated more than 17 million accident-free flight hours over

Data—the insatiable quest Robert MacIntosh has recently retired from One place to look at “NextGen” ideas and new thinking is in the a career of more than 55 years in the avia- area of recorded data. With the preponderance of data available tion industry, including positions of NTSB from the multiple parameters on aircraft flight recorders and the investigator-in-charge, airline director of data further available within the nonvolatile memory (NVM) of safety, airplane manufacturer staff engineer/ various components and subsystems, how much time and effort accident investigator, and 22 years as a U.S. do the investigators really need to exert on scene? How much Air Force officer pilot and safety director. on-site documentation is enough? Can we expect to effectively He has more than 8,000 hours of flying experience and holds investigate major accidents with the recorded data alone? bachelor of arts and master of business degrees.

20 • ISASI Forum January—March 2012 LEFT—Figure 1: Fuel tube and FOHE ice. BELOW—Figure 2: Iron bird test rig.

from those millions of accident-free flights that took place over the prior 12 years. AAIB Senior Inspector Mark Ford tells us in the [April-June 2011] ISASI Forum article “Investigative Data Mining: Chal- lenges and Innovative Outcomes” that their group got an early start with immediate access to the operator’s flight data moni- toring (FDM) of 13,500 flights. The data mining team eventually incorporated minimum fuel temperature snapshots from 191,000 flights from the northern hemisphere, the tropics, and the south- ern hemisphere based on many operators’ data. The point here is not to review the details of data mining pro- vided in the AAIB’s investigation, but rather to recognize the initiative taken by the AAIB to rally together the wide-ranging sources of FDM data in order to analyze and share that data in a meaningful way. There is industry consensus that this data mining initiative provided an important catalyst leading to the more than 12 years prior to this hull loss. Also, regarding data full understanding of the event. Further, similar data mining available in the Heathrow event, recall that the aircraft remained strategies may very well be the NextGen thinking required for relatively intact at the end of Runway 27L. All the crew and pas- future serious and complicated investigations. sengers survived, there were many credible witnesses, and data Are you ready to “data mine”? Can you (or your investigation were available from both of the required onboard flight recorder agency) arrange for access to very privately held FDM data? systems, from a QAR quick access recorder, and from the air Can you analyze it for your specific purposes and at the same traffic and ground servicing organizations. time protect it from unauthorized users, such as overzealous The UK AAIB final accident report provides clearly worded or misguided judicial advocates? To clarify, the subject is raw probable cause factors of the event—when the engines ceased data, not summarized or aggregate information derived from responding to commands for increased power—including that raw data. And the question posed is, Can your investigation get accreted ice released in the fuel delivery pipes caused a restric- timely access to all the data that may sometimes be needed in tion at the engine fuel oil heat exchangers (FOHE) during the a complicated investigation, similar to the data analyzed by the critical landing stage of the flight. But did the data alone lead AAIB. An investigator’s need for such raw data may very well the AAIB to these probable cause factors? be the “NextGen challenge” for the air safety investigators of I would suggest that many more resources and expertise tomorrow. went into that investigation: the field investigation, the compo- nent examinations, the interim actions for airline operators, the Testing—collaborative efforts engineering testing and analysis, and, of course, the final report Another investigative vignette from the Heathrow event that and safety recommendations. Most will agree this extensive and deserves special recognition within our investigation commu- detailed work was necessary to make the whole investigation nity is the fuel rig testing. How did the investigation replicate process and results credible to the professional aviation com- the conditions of the accident to confirm the hypothesis that munity and the public. there were some unique factors of the flight that contributed to Further, we should ask ourselves, as state investigation au- the formation of ice in the fuel pipes and then contribute to the thorities and industry investigation professionals, how we can subsequent release of a quantity of ice (slush) in the fuel delivery best be prepared for any similar undertaking in the future. For stream? As many of our ISASI members have seen, just like the this accident, though, the vast amount of data that was available carburetor ice conditions of the general aviation fleet, the suspect both from the accident airplane and from thousands of other ice obstruction/restriction usually seems to have melted before flights led investigators to develop a hypothesis about what oc- the inspector arrives to see the evidence. curred in this accident. That lack of physical evidence provides an opportunity to Within the UK AAIB, the air safety investigators recognized review the details of the trail toward a final decision to test a a need for some very specific expertise. It fell to a group of major portion of the airplane fuel system. We know now that statisticians with the support of the air safety investigators to the B-777 has more than 110 feet of fuel tubes and lots of turns determine what may have been unique about this accident flight and twists valves, filter units, and a fuel-oil heat exchanger unit

January—March 2012 ISASI Forum • 21 (FOHE) that makes up the complete system in the tank to engine thrust fuel circulation procedures prior to descent. This AD was setup. There was hardly an investigator on the planet who did superseded in March 2009 with some limited modifications, and, not suspect fuel system icing from some source as he or she read concurrently, the Trent FOHE received a subsequent engineer- the initial details of the BA accident, but where to look? ing design improvement. The AAIB final report also contained AAIB senior Inspector Brian McDermid in his [April-June safety recommendations to FAA and EASA authorities to un- 2011] ISASI Forum article “Heathrow 777: Investigation Chal- dertake joint research to identify the root causes of fuel system lenges and Problems” presents a fascinating story of starting icing that should encompass the airframe, the engine, and the out thinking that small-scale laboratory testing would be environment to address future aircraft design and certification sufficient. Then there was a consideration for the possibility requirements. of flight testing and further consideration for the use of a full- What is the takeaway from these unique experiences of the scale climatic hangar with either a single pass of fuel or with Heathrow B-777 investigation? Ask yourself, does your agency a reticulating source of fuel. Finally, a decision was made to (and state) have the capability to investigate a complex accident assemble a full-sized test rig with components of the crashed event? Are you prepared to offer sufficient elements of trust to airplane at the North Boeing Field facility in the U.S. The UK those outside your close sphere of control? Will the independence AAIB and participating agencies came to this highly engineered of the investigation allow you to reach out for similar additional and costly conclusion that an “iron bird” test rig was needed to expertise? Are you able to recognize the parallel air safety in- accurately replicate the mechanical and environmental condi- terests of those other concerned participants? Can a sufficient tions and to ensure that credible results would be fully available level of trust be cultivated between government and industry for all aviation industry stakeholders. representatives to go forward in a productive arrangement to Broad-based aviation industry cooperation and communica- share FDM data? Are you prepared and functionally able to tion were necessary to make this endeavor fully representative put mechanisms in place to meld these common interests? To of the flight conditions. Recall that the Boeing 777 has an op- repeat—These are the NextGen challenges for the air safety tion for engine installations offered by all three large engine investigators of tomorrow. manufacturers: Rolls-Royce, Pratt & Whitney, and GEAE. The Rolls-Royce Trent engine involved in the Heathrow event is also Civil/military issues installed on both Boeing and Airbus transport airplanes. Within In keeping with the ISASI 2011 theme, “Investigation—A Shared the strict interpretation of Annex 13, hence, any similar event Process,” let’s look at a recent example of civil/military coopera- affecting an engine type common to different airframes remains tion in the field of investigation. This accident occurred on April a challenge to the airframe manufacturers. Therefore, a broad 10, 2010, to a Tu-154M Polish Air Force (PAF) flight providing scope of early industry interest in the details of this investigation transportation for the president of the Republic of Poland and a existed. Further, state investigative agencies probably should party of distinguished visitors. conclude that with limited agency resources they cannot conduct The military mission was to deliver a group of military and such complex investigations alone. civilian dignitaries and their wives, politicians, businesspersons, ICAO Annex 13 standards and recommended practices and clergy to a ceremony in the Russian Federation at a memo- place the state of occurrence in the leadership position and in rial complex intended to heal some of the wounds of World War full control and responsible for air accident investigations. But II. The destination was Smolensk “Severny” Airfield, a military without the collaborative knowledge and collective resources of facility slightly more than 1 hour from Warsaw. The mission other investigative agencies and industry, an investigation of this ended in a very tragic controlled flight into terrain (CFIT) magnitude cannot move forward. To do less creates a credibility scenario just 600 meters short of the destination runway. All 88 gap that would do a disservice to all involved. Further, any muted passengers, 3 cabin crew and 4 flight crew, and 1 security officer effort could stop well short of the desired goals of identifying the were fatally injured. causal factors and mitigating the safety risks. As might be expected, old political wounds resurfaced along The Heathrow investigation results are well known. Follow- with the turmoil from the death of the president of the Republic ing an in-depth analysis of the occurrence by the participating of Poland and many of the leading cabinet members, military agencies, with major participation from the engine and airframe hierarchy, and social and political leaders. manufacturer, the FAA issued an airworthiness directive (AD) ap- Of interest to ISASI members is what happened next. What plicable to B-777/Trent 800 airplanes effective Sept. 29, 2008, for agency would investigate the crash of a Polish Air Force VIP interim mitigating actions to prevent recurrence. It introduced transport aircraft within the territory of the Russian Federation? on-ground fuel circulation procedures along with inflight high- This was a “state aircraft,” clearly outside the ICAO convention

22 • ISASI Forum January—March 2012 Figure 3: Tu-154M glide slope versus flight path.

conclusions: • The FMS terrain database did not contain data for the definition of civil air transport activity. The bilateral diplomatic Smolensk “Severny” military Airfield. The crew constructed agreement authorizing this international nonscheduled flight to an approach in the FMS using waypoints superimposed on the carry passengers did not address the eventuality of accident or physical location of the published 2 RBN approach procedure. incident, and there was no provision for insurance coverage of • The weather was below minimums upon arrival. The crew re- the passengers. quested and was granted approval to conduct a “trial” approach Upon notification of the crisis, the president of the Russian to the published minimum of 100 meters. Federation provided an initial response at the accident site • The crew flew the approach with the autothrottle and autopilot supervised by the head of the flight safety agency of the Rus- engaged in lateral nav mode and used the autopilot climb/descend sian Armed Forces. However, from the onset, it was obvious to wheel for the glide path. all concerned that, in this very highly charged atmosphere, the • The crew continued descent below the published minimums traditional military leaders should not be in a position to inves- and took no action in regard to the TAWS terrain alerts and tigate themselves. warning, ultimately colliding with trees and terrain in a valley With some astute diplomacy on both sides, three days follow- before the runway threshold. The aircraft was destroyed. All ing the accident, the governments of the Russian Federation aboard were fatally injured as a result of deceleration, blunt and the Republic of Poland concluded a bilateral agreement force trauma, and destruction of structure. that the regional international independent safety investigation • Further, the presence and discussions in the cockpit during organization, the Interstate Aviation Committee (IAC), would the approach of the commander-in-chief of the Polish Air Force conduct the investigation in accord with the existing ICAO Annex and the protocol director of the Polish government influenced the 13 standards and recommended practices. Acting as the state of crew to continue the approach in conditions of unjustified risk. occurrence, the IAC appointed an investigator-in-charge, and The investigation was completed in January 2011 (nine months the Polish government appointed an accredited representative after the occurrence), and the final report and supporting docu- within the protocols of the state of the operator and state of ments are available to the public and posted on the IAC website. registration. The Polish Air Force participated as an advisor to This brief accident résumé illustrates the necessity of the IAC the accredited representative of Poland. investigation group to gather much more information than was The various participants formed the traditional investigation available on the flight recorders. This action is not always prudent groups and set about to investigate the accident at the crash site or appropriate in every case due to the labor-intensive process and at the Warsaw dispatch point and crew base. Early readout requirements. However, in order to fully understand this accident of the CVR indicated conversations related to the setup of a flight scenario, it was necessary to proceed in much more expanded management system (FMS), and several audible warnings could detail to determine the navigation performance of the FMS and be heard from a terrain alert warning system (TAWS) prior to the warning capabilities of the TAWS. This effort required what the crash. The FDR readout indicated that, for most of the flight, we should call “the physical presence test.” That is, the investiga- the autopilot was engaged and coupled in lateral navigation tors traveling directly to the component manufacturing facility, mode with the FMS. Evidence from the accident site identified jointly developing an investigation protocol, and proceeding to the FMS and TAWS components as manufactured by Universal examine each subcomponent and circuit board to extract the bits Avionics Systems Corporation of Redmond, Wash., in the U.S. A of data necessary to understand the overall component function maintenance records examination confirmed that these units had and performance. been installed as an upgrade of the PAF Tu-154 fleet. What does this action say to you and your fellow investigators? The investigator-in-charge notified the U.S. National Trans- Are you prepared, when necessary, to identify equipment with portation Safety Board (NTSB) of the U.S.-manufactured and nonvolatile memory sources and seek out methods to extract certificated navigational equipment and requested U.S. participa- raw data? Are you willing to invest the time and resources for tion in the investigation. Ultimately, despite significant mechani- forensic component examination? And on the other hand, are cal damage, with the assistance of the design and manufacturing you capable and willing to determine when it may be sufficient engineers, much of the nonvolatile memory data was retrieved for practical purposes to terminate searches that may appear to at the manufacturing facility. The examination and analysis of waste resources and delay timely conclusions? To repeat—these the FMS and TAWS and conventional flight recorders revealed are the NextGen challenges for the air safety investigators of several important crew actions and led to the following general tomorrow.

January—March 2012 ISASI Forum • 23 VH-QPA A300-303 Inflight Upset Oct. 7, 2008

RIGHT—Figure 4: Flight data re- corder information. BELOW— Figure 5: Travel distance and time zone dif- ferences between participants.

The sharing process Again recognizing the “Investigation—A Shared Process,” theme, let’s address the issues of sharing proprietary data and the obstacles that investigators meet in attempting to accomplish that end. As an example, a multi- faceted case involving different nation states can best illustrate the difficulties presented to an investigator-in-charge. On Oct. 7, 2008, an Airbus A330- 300 operated by Qantas Airways departed Singapore en route to Perth, Australia. On board were 303 passengers, 9 cabin crew, and 3 flight crew. While in cruse flight at Flight Level 370, the autopilot disconnected. At about the same time, there were various aircraft system failure indications; and, while the crew was evaluating the erator information telex to Airbus operators. They were asked situation, the airplane abruptly pitched nose down. The airplane to distribute it to all A330/A340/A340-500/A340-600 flight crews reached a maximum pitch angle of about 8.4 degrees nose down immediately. The telex provided brief details known about the oc- and descended 650 feet during the event. The passenger cabin currence and provided operational recommendations applicable experienced minus 0.8 to minus 1.3g. for A330/A340 aircraft fitted with Northrop Grumman ADIRUs. After returning the airplane to the assigned flight level, the An operations engineering bulletin (OEB) followed, and subse- crew began to deal with multiple failure messages and cabin quently the European Aviation Safety Agency (EASA) issued an injuries. About three minutes later, the airplane began a second emergency AD, effective Nov. 19, 2008, to mitigate the potential pitch-down event, reaching a maximum pitch angle of about hazard of a pitch excursion. Similar OEBs were issued by Airbus 3.5 degrees nose down, 0g and descending about 400 feet. One for A340 airplanes, and an EASA AD followed for the A340. The flight attendant and 11 passengers were injured during the two results of the ATSB investigation, the interim reports, and the upset events. The Australian Air Transportation Safety Board final report are available on the ATSB website. (ATSB) initiated an investigation and quickly identified two What is different about this flight path upset event from those significant safety factors related to the pitch-down movements. of the past? Simply put, the past days of a flight control cable First, immediately prior to the autopilot disconnect, air data hang up or a stuck hydraulic servo or iced elevator tab have given inertial reference unit (ADIRU) No. 1 started to provide er- way to new technology. roneous data (spikes) on many parameters fed to the aircraft Today’s modern fly-by-wire, computer-assisted flight control systems. The other two onboard ADIRUs continued to function systems are highly sophisticated and unique to the manufacturer. correctly. Second, some of the spikes in angle-of-attack data Control laws, design concepts, and aerodynamic performance were not filtered by the airplane’s flight control computers, and data are generally regarded as trade secrets of a proprietary those flight management computers subsequently produced the nature. Each airframe manufacturer’s fly-by-wire concept, pitch-down movements. failure mode analysis, and flight control logic are not something The ADIRUs were subject to detailed examination and test- to be readily shared outside the confidence of the manufacturer ing at the Northrop-Grumman Corporation facilities in the and the certification authority. Therefore, during an independent U.S. The download, examination, and testing were attended by investigation intended to improve flight safety, in-depth negotia- representatives of the ATSB, the French Bureau d’Enquêtes et tion among participants is required to share and protect data d’Analyses pour la sécurité de l’aviation civile (BEA), the U.S. that is specific and relevant to the investigation. NTSB, the U.S. Federal Aviation Administration (FAA), the The investigation of the A330 pitch excursion of Qantas Air- airplane manufacturer, and the operator. ways was defined as an ICAO Annex 13 “accident” by virtue of Following a preliminary analysis of the occurrence, Airbus the occupant serious injuries. The investigation presented some published interim operational procedures in the form of an op- unique challenges in coordination due to a number of multina-

24 • ISASI Forum January—March 2012 tional participants. The Australian ATSB had the responsibility lomatic service departments to be aware of the political issues to conduct an investigation representing the state of occurrence, that may be an obstacle to the investigation? The Qantas upset operator, and registration. As expected, the Airbus A330 brought event serves as an excellent illustration of the added aspects of into the investigation the organizations of Europe, including the distance and proprietary data that present the NextGen chal- Airbus factory team in Toulouse, the BEA, and the EASA, the lenge in multinational investigation management. aircraft certification authority in Cologne, Germany. Further, the ADIRUs installed on this A330 were Northrop Grumman Cor- Takeaway conclusions poration products, manufactured in the U.S. and certificated to There are 190 ICAO member states, and per the ICAO conven- standards set by the FAA. Therefore, U.S. participation included tion and the standards and recommended practices of Annex an NTSB accredited representative and advisors from the FAA 13, each member state is obligated to either investigate accident and Northrop Grumman. Importantly, the ATSB was able to and serious incident occurrences or to delegate the investigation negotiate the issues of limited access with the manufacturers and responsibilities to another state. other participants to fully accomplish its safety goals. From the preceding examples, the B-777 of British Airways, Also, in some countries there may be additional constraints the Tu-154 of the Polish Air Force, and the A330 of Qantas Air- and legal restrictions that limit technology transfer of safety ways, we can observe some exemplar agency accomplishments relevant data on a national level. For example, in the U.S. there by the UK AAIB, the IAC of Russia, and the Australian ATSB in are a broad set of regulations that control the import and export the area of investigation and the associated safety recommenda- of defense articles, commercial items, technical data, and defense tions to identify and reduce risks for future flights. As members or commercial services. of the investigative community, are you and your state prepared These regulations sometimes extend to the participation of with the experience and resources to manage or participate in ac- foreign entities or the import/export of parts. Further, the regula- cident/incident investigations similar to the scope and complexity tions may extend to target commercial items that can be termed outlined above? If your state does not have the capability to do a “dual use,” those items having both commercial and military ap- complete and credible investigation, do you know where to reach plications. Also, most countries in the international community out for necessary guidance and support? Hopefully investigators maintain foreign policy and national security goals and technology will recognize the wake-up call for greater cooperation neces- exchange rules that apply to specifically designated countries, sary to work toward identifying and reducing risk in a timely regimes, terrorist organizations, illegal traffickers, and other and efficient manner. nefarious groups. Although exceptions can be made for certain Due to the increasing engineering complexity of the aircraft, air safety initiatives, the accident investigation community must the availability of additional data sources, the changing human operate within the confines of the respective governmental policies. factors operational environment, the global nature of the aviation The intent of discussing the details of the specific A330 upset industry, and the advances of air traffic and airport interface, our event and the causes and safety actions to mitigate risk is to future successes in investigation will be measured by how well we recognize the international coordination necessary to effect the can adjust and accept the emerging challenges of mutual trust investigation and to alert our colleagues of the varying organiza- and support among all participants. tional needs that may be present in similar future investigations. Whether the accident/incident event is a four-seat glass Setting up foreign travel arrangements or even telephone cockpit airplane such as the Cirrus model; a new corporate busi- conferences in this multinational environment presents global ness jet; the new regional entrants from China (Comac), Japan management challenges and unique demands on resources. (Mitsubishi), or Russia (Sukhoi); or a large commercial transport Turning again to the A330 example, in addition to the number of airplane from Airbus, Boeing, Bombardier, or Embraer, inves- participating agencies already mentioned, it is also appropriate tigators must be motivated to accept a shift to new realities for to note the travel distance and time zone differences involved data sources and cooperative analysis to facilitate a timely and among the participants. efficient investigation and risk mitigation process. Once again we should ask ourselves to consider how best to The same can be said for a data search of a hand-held GPS, an meld an investigation group to function in the global environ- EFB, or notepad. This updated approach will require a revised ment. Do you have an infrastructure in place and ready to ad- level of trust and professional respect among all participants dress the challenges of distance among participating agencies? and an increased reliance on the manufacturing state accredited Are you prepared to recognize the rationale and impediments representative team and the manufacturers’ investigative advi- of technology transfer concerns? Have you cultivated channels sors. Such new and revised thinking is the NextGen challenge of communications with your foreign relations ministry and dip- for the air safety investigators of tomorrow. ◆

January—March 2012 ISASI Forum • 25 ISASI ROUNDUP

ISASI 2012 Opens Registration

The ISASI 43rd annual international member, $660; non-member, $710; stu- a degree in metallurgical and materials conference on air accident investiga- dent member, $220; and companion $360. engineering, specializing in forensic tion is now open for hotel and seminar If registration is made after August 5, metallurgy, failure analysis, and aircraft registration. The event is being held in the fees are $720, $780, $250, and $400, investigation. His career began in 1983 Baltimore, Md., USA, Aug. 27–31, 2012. respectively. Day pass fee for any of the as a materials engineer with the U.S. “Evolution of Aviation Safety—From three days is $200, and $225 after Au- Air Force’s Oklahoma City Air Logis- Reactive to Predictive,” the theme of the gust 5. The member fee for the one-day tics Center in the Materials Engineer- seminar, is designed to address several tutorial by August 5 is $175, and student ing Laboratory. There he conducted areas of interest: 1) The historical evolu- $125. After August 5, member tutorial forensic metallurgy, failure analysis, tion from reactive to predictive; 2) the fee is $200, and student $150. Fee for a and aircraft accident investigation of interaction between accident or incident investigation and accident prevention single event: Tuesday night dinner $120, Air Force aircraft, aircraft components, or analysis; 3) Analytical processes that awards banquet $125. and aircraft engines. identify, monitor, or assess emerging Two tutorials are planned for seminar McMinn says of his tutorial, “Basic risks; and 4) the practical application of day one. Anna Cushman of the FAA will failure analysis/failure mode identifica- those processes to minimize the risk of present “When Animation Doesn’t Tell tion of fractured aircraft components at accidents. the Real Story…Flight Data Recorders the accident site is a skill needed by all The four-day program consists of a for Accident Investigation and Beyond.” air safety investigators and is consid- day of tutorial workshops and a three- Cushman is a flight data analyst and ered by many to be ‘black magic’ when day technical program. The annual event program manager of the FAA’s Flight it needn’t be. The black magic of failure will be held at the Baltimore Marriott Data Lab. She provides flight data mode identification is based on scientific Waterfront, which is only eight miles technical support to the FAA accident principles that are easily learned when from Baltimore Washington Internation- investigation team during NTSB ac- condensed down to basic structure and al (BWI) Airport and only one mile from cident investigations and data analysis metallurgy, i.e., what the component Baltimore Penn Station (Amtrak). Lo- and policy guidance in support of the was made of, how it was made, how it cated in the heart of Baltimore, the hotel FAA’s aviation safety responsibilities. was treated, and what its normal service sits on the water’s edge in Baltimore’s Anna is an instrument-rated private conditions are? All of these determine East Harbor. The hotel is hailed as the pilot. She holds a BS degree in mechani- how a component fails whether in flight most sophisticated and upscale destina- cal engineering and an MS degree in due to abnormal service conditions or in tion in Baltimore, only steps away from mechanical engineering, with a concen- an accident due to impact forces with the the city’s finest dining, shopping, and tration in aero-fluid dynamics. ground/water.” entertaining attractions. Her tutorial will explain how data Seminar program technical details The guest rooms feature many high- products can help in the evaluation of and the companion’s program are now tech and luxurious amenities offered an event and what the real story is on in the reconciliation stages and will be at the special seminar room rate of FDR data quality and decoding. Topics posted in the next issue of ISASI Fo- US$159.00 (plus taxes) based on single of discussion include sources of flight rum, as well as on the seminar website. or double occupancy. This rate includes data on board an aircraft, FDR decod- daily room Internet access and use of ing—document control quality issues, the hotels fitness facilities. This rate is data limitations—the effect of sampling Reminder available for three days pre- and post- and other issues, and how flight data seminar (Aug. 24 to Sept. 3, 2012). The regulations affect you as an investigator, ISASI annual dues were due in cutoff for reservations is Aug. 4, 2012. operator, and regulatory inspector. January. For those members who To make your hotel reservations, please Andy McMinn will present “Basic may not yet made the payment, go to the link posted on the seminar’s Failure Analyses: Failure Mode Iden- please contact Ann Schull at website, which may be accessed via the tification at the Accident Site.” He is [email protected] or call 703-430- ISASI site, www.isasi.org. an air safety investigator/instructor 9688 to make payment arrange- Also available on that site is the who has worked at the Department of ments. If payment is not received, seminar registration application. The Transportation’s Transportation Safety the affected member will be placed seminar program registration fee (in Institute for 12 years. Andy is a gradu- in an inactive status. ◆ U.S. dollars) by midnight August 5 is ate of the University of Oklahoma with

26 • ISASI Forum January—March 2012

NEW MEMBERS

Individual Beshoy A. Mishriky, Tampa, FL Matthew R. Harris, Wellington, Ralph L. Wilson, Dallas, GA Jason S. Minns, Kevalla Beach, QLD New Zealand Jeffrey P. Weiherer, Moorpark, CA Michael A. Miles, Brooklyn, NY David T. Hamblin, Knoxville, TN Sam J. Watson, Canberra, ACT James D. Mercereau, Haslet, TX David K., Hall Big Rock, IL Stephen W. Tignor, Daytona Beach, FL Brannon D. Mayer, Hermantwon, MN Zachary J. Gualardo, Ormond Beach, FL Bret W. Tesson, Hazelwood, MO Travis R. Matthews, Annapolis, MD Robert G. Grubb, Waxhaw, NC Carol L. Stone, North East, MD Shannon M. Masters, Atlanta, GA Fred B. Grantham, San Tan Valley, AZ Chad M. Sneve, Senoia, GA George Mashababe, Harare, Zimbabwe David J. Goddard, Northgate, QLD Taylor S. Smith, Dayton, OH Lloyd G. Mais, Cairns, QLD Robert J. Gallagher, Meridian, MS Mark A. Shelly, Bel Aire, KS Amber M. Macchia, Daytona Beach, FL Frank W. Fischer, Lueterkofen, Switzerland Jonathan M. Schwartz, Prescott, AZ Jeffrey Luong, Daytona Beach, FL Crystal L. Ferguson, Palm Coast, FL Christoph Schlueter, Lorgues, France Christopher O. Lowenstein, Monroe, CT Sam I. Drummond, Corinda, QLD Shivani A. Rudradat, Daytona Beach, FL Katrina E. Lewis, Archefield, QLD Paul G., DanDan, Daytona Beach, FL Joe D. Rucker, Tucson, AZ Evan, C. Lee, Auckland, New Zealand Yailet Cruz Galardy, Daytona Beach, FL Mike S. Richards, Washington, DC Eric C. Launer, Sanford, FL Tammy L. Crowell, San Jose, CA Jason A. Ragogna, Atlanta, GA Kristina R. Larson, Prescott Valley, AZ John B. Carey, Sandwich, IL John P. Quinlan, Burraneer, NSW Betty S. Koschig, Fredericksburg, VA Paul B. Breuilly, Lower Hutt, New Zealand Stephen P. Quigg, Perquea, PA Robert A. Kopko, Pensacola, FL Carlos E. Bravo Guarello, Vina Del Mar, Joy Premraj, Daytona Beach, FL Robert B. Kelly, Ormond Beach, FL Chile Raymond J. Pearson, Fadden, ACT Edwin F. Kelly, Oranjestad, Aruba Richard T. Blackwell, Ormeau, OLD Rizwan S. Nasir, Perth, WA Ryan T. Joseph, Daytona Beach, FL Hugh H. Belle, Port Orange, FL Kelvin (Kel) L. Morton, Cotton Tree, QLD Justin A. Jaussi, Chesterfield, MO Daniel J. Bartlett, Alexandria, VA Mitchell A. Morrison, Sacramento, CA Gary A. Janelli, Anchorage, AK Thomas R. Anthony, Palos Verdes James M. Morrison, Ogden, UT Marc J. Hookerman, Lake Saint Louis, MO Peninsula, CA ◆

Committee members for the seminar member. The Award may recognize FAA, “Are We Really Asking the Right are Frank Del Gandio, Seminar chair; a single event, a series of events, or a Investigative Questions about Fatigue,” Barbara Dunn, Registration chair; lifetime of achievement.” 2) Dr. Paul Schuda, NTSB, “Volun- Robert Matthews, Technical Committee The ISASI Awards Committee consid- teer Pilot Accident Briefs,” 3) Major chair; Ron Schleede, Sponsorship chair; ers such traits as duration and persis- Hunter Larimore, Turobmcca, “Engine and Candy Del Gandio, Companion tence, standing among peers, manner, and Powertrain Examination,” and 5) Program chair. ◆ and techniques of operating, and of Blake Kelly, Embry-Riddle Aeronauti- course achievements. cal University, “ADS-B and Flight Data Jerome F. Lederer Award Each nominee competes for three Monitoring in the Accident/Incident years unless selected. If not selected Investigation Program.” Nominations Sought during that time, the nominee can be The registration fee is $75, and $35 Nominations for the prestigious ISASI nominated after an intervening year for students. To register for the event, annual Jerome F. Lederer Award are for another three-year period. This is a contact Alicia Storey at 334-598-8893 or now open. Awards Committee Chairman prestigious award that usual results in e-mail [email protected]. Hotel reserva- Gale Braden urges ISASI members to good publicity for the recipient and one tions are made directly with the hotel at look for deserving candidates in the vari- that might be beneficial in advancing 1-800-535-9177. Callers should ask for ous fields of aircraft accident investiga- a recipient’s career or standing in the the ISASI group. tion and nominate those meeting the community. Online registration for the meeting is criteria. For consideration, the Commit- Nomination letters for the Lederer also available through the ISASI web- tee chair must receive the nomination Award must be limited to a single page. site, www.isasi.org. Click onto the SERC letter by May 31, 2012. Nominations should be mailed, or e- 2012 spring meeting flyer. ◆ Braden said, “Each year, at our an- mailed, to the ISASI office or directly nual seminar, we recognize positive ad- to the Awards Committee chairman, SF Chapter Reactivates; vancements in the art and science of air Gale Braden, 13805 Edmond Gardens safety investigation through the Jerome Drive, Edmond, OK 73013, USA; e-mail: Holds ‘Kickoff’ Meeting F. Lederer Award. The criteria for the [email protected]. ◆ After many years of inactivity, ISASI’s Award are quite simple. The Lederer San Francisco Chapter held a kick- award recognizes outstanding contribu- SERC Sets Spring Meeting off meeting October 28 that was well tions to technical excellence in accident attended and featured three ISASI investigation. In New Orleans, La. leaders. U.S. Society President Toby “Any member of the Society may ISASI’s Southeast Regional Chapter Carroll and Lederer Award winners Ron submit a nomination, and the nominee will hold its spring meeting at the Mai- Schleede and John Purvis conducted a may be anyone in the world. The Award son Dupuy Hotel in New Orleans, La., two-hour roundtable discussion titled may be given to a group of people, an on March 17, 2012. “Investigating Major Aviation Acci- organization, or an individual, and the The full-day program will include dents.” In addition to the Chapter mem- nominee does not have to be a Society presentations by 1) Dr. Bill Johnson, bers, the presentation was well attended

January—March 2012 ISASI Forum • 27

ISASI ROUNDUP In Memoriam Continued . . . A.G. William Harvey (LM0294), Silver Spring, Md., USA, January 2010 Robert F. Hunt (LM2193), Annapolis, Md., USA, August 2010 James E. Dougherty (LM0518), McLean, Va., USA, September 2011 ◆

by a number of aviation enthusiasts from credit, was held in the Oakland Aviation +44 (0) 7860516763 or e-mail: anne_e_ev- the area. Museum located at Oakland Interna- [email protected]; or ESASI Secretary The program introduced the audi- tional Airport. The Museum proved an John Dunne—Tel: +44 (0) 7860 222266 or ence to the investigation process from excellent venue for the meeting. “It was e-mail: [email protected]. ◆ the viewpoint of the NTSB, the manu- great being in the Museum’s hangar sur- facturer, and the operator. For most rounded by vintage and home-built air- Luke Schiada Named attendees, it was their first broad look at planes, with a Rutan VariEze suspended a process that for them has been cloaked overhead while hearing from these three NERC President in mystery. Even those familiar with incredibly experienced investigators,” Luke Schiada has been appointed presi- the process benefitted from hearing the Darcy said. The meeting also allowed dent of the Northeast Regional Chapter viewpoints other party members. the attendees to tour the Museum. (NERC). He is a senior “We were delighted by the number The Chapter plans to begin regularly air safety investigator of attendees and the degree of group scheduled quarterly meetings reach- with the National Trans- participation for this kickoff meeting,” ing out to current and future ISASI portation Safety Board Kevin Darcy, newly designated Chapter members. ◆ and has been involved president, said. in numerous domestic The seminar, which also entitled Amsterdam Is Site of and foreign accident attendees to FAA Wings program Schiada investigations as the ESASI Regional Seminar investigator-in-charge (IIC) or United The European Society of Air Safety States accredited representative during Investigators announces that its 5th air his more than 14-year career. Moving? safety seminar will be held in Amster- Luke is a graduate of Farmingdale Please Let Us Know dam, the Netherlands, April 19–20. State University of New York with Member Number______“With emphasis on current European is- degrees in aerospace technology and sues in the investigation and prevention aviation administration, holds FAA Fax this form to 1-703-430-4970 or mail to ISASI, Park Center of accidents and incidents, the two-day commercial pilot and airframe and pow- 107 E. Holly Avenue, Suite 11 seminar is aimed at accident investi- erplant mechanic certificates, and has Sterling, VA USA 20164-5405 gation professionals and will provide been an active ISASI member for more an opportunity to update professional than 10 years. Old Address (or attach label) knowledge and skills, as well as to meet He believes the objective of the reacti- Name______other active air safety investigators,” vated regional chapter is to promote air Address______said ESASI Councillor Anne Evans. safety via the exchange of aircraft accident City______Under the seminar theme “Air Accident­ investigations and aviation safety infor- Investigation in the European Envi­ mation on a local level with the additional State/Prov.______ronment,” presentations will address cur- benefit of providing networking opportuni- Zip______rent issues in the European environment ties to members in or aspiring to join the Country______and the challenges of modern air safety aviation safety field. Chapter meetings New Address* investigations. The two-day program will will be held biannually featuring interest- take place at the Dutch National Aero- ing and informative speakers. Interested Name______space Laboratory (NLR), which is the members are encouraged to contact Luke Address______center of expertise for aerospace technolo- directly with thoughts, suggestions, and City______gy in the Netherlands. Hotel accommoda- advice at [email protected]. ◆ State/Prov.______tion will be arranged near the city center and transportation provided to the NLR. Zip______Canadian Society Issues Event activity includes a dinner cruise Country______reception that companions may attend. Remembrance E-mail______For details, please check the Society Jim Stewart, on behalf of the Cana- *Do not forget to change employment and website, www.esasi.eu. For bookings, con- dian Society, reports the “flying west” e-mail address. tact ESASI Councillor Anne Evans—Tel: of Rayne “Joe” Dennis Schultz at age

28 • ISASI Forum January—March 2012 Royal Honors

89. He served as the director of Flight in Sydney at the Mercure Hotel, George among all participants. Safety for the Canadian Forces, which is Street, June 1–3, 2012. Registration The meeting was well an ISASI corporate member. details will be released shortly, but in the attended by representa- Jim, in his remembrance writes, “Joe meantime the hosting Societies are issu- tives from all areas of was an amazing leader who developed ing their “Call for Papers.” aviation accident investi- and led the Canadian military avia- A representative for the event noted, gation from general avi- tion safety and accident investigation “We would like offers of papers address- ation to suborbital space programs into the modern age. I was ing contemporary air safety investiga- Anthony travel. The keynote always amazed at how far ahead of tion and air safety issues. Please submit speaker was Jon Turnipseed, the chief of his time Joe really was in terms of the an abstract and short bio by March 1, safety for Virgin Galactic. Jon detailed safety business. The ideas and programs 2012, to Paul Mayes at ropadofelix@ the development of the Virgin Galactic he introduced have been so absorbed hotmail.com. Paul may also be contacted space program, the Spaceport America into our safety work that I doubt we re- for further seminar information. in New Mexico, and construction of the ally remember that much of what we do The seminar hotel, the Mercure, is ad- Virgin Galactic Spaceship and the White came from the mind of one very talented jacent to Sydney’s Central Station and Knight delivery vehicle. Jon detailed the man. He will be greatly missed.” easily accessed by train from the airport mission profile and prototype testing Joe’s obituary noted, “After a fighter or by public transport. For partners, the that is ongoing. The presentation was pilot’s struggle, Joe slipped the surly Mercure is very central, close to Darling greeted with great interest. bonds of earth…. His love of flying Harbour and to the Sydney attractions. Plans for the future include dinner carried over a distinguished 37-year The seminar will follow its usual for- meetings with presentations from manu- career with the RCAF and beyond. A mat with a welcome reception on Friday facturers detailing the specific technical well-documented WWII Mosquito night evening, two full days of presentations considerations that would be involved in fighter pilot with 410 Squadron, he went on Saturday and Sunday, and a dinner investigations that concerned their prod- on to fly over 40 different aircraft includ- on the Saturday night. ◆ ucts and reports from members about ing the CF-18 twice in his later years. recent investigative developments. ◆ Over many years in cooperation with the LA Chapter Renamed; military and the civilian agencies associ- Reachout Program ated with aviation, his vision, dedication Reactivated as and pursuit of excellence resulted in Remains Ready significant advancement in air opera- SoCal Chapter “The ISASI Reachout program re- tions generally and flight safety accident The ISASI Los Angeles Regional Chap- mains prepared to deliver the services prevention programs in particular.” ◆ ter has been in an inactive status for of expert volunteers in diverse areas of some time. Recently, Thomas Anthony, the aviation world,” says John Guselli, ANZSASI Sets Seminar; the director of the USC Aviation Safety chair of the program. He adds, “We have and Security Program, volunteered and recently fielded inquiries from New Zea- Issues Call for Papers was appointed president of the re-estab- land, Hungary, and Pakistan; however, The 2012 Australian/New Zealand Soci- lished SoCal Regional Chapter by ISASI these are all at the preliminary stage.” eties Australasian seminar will be held President Frank Del Gandio. The process relies upon “host” Thomas reports that a meeting was organization(s) specifying the particular held in Los Angeles, Calif., in Novem- areas of expertise that are sought for Correction ber 2011 to re-establish ISASI in the their location. This enables the Reachout southern California area. Previously, due Committee to then match the necessary Forum incorrectly reported in its to the high level of aerospace activity skills with the available volunteers. October-December 2011 issue that in the area, there had been two ISASI Additionally, the “host” rganization(s) Michael Lemay was the creator chapters in southern California, eventu- are expected to provide a training venue of the ISASI 2011 logo. Credit for ally reduced to one. Now, however, it was that permits interactive learning for the the superb work should go to Mar- decided to re-establish the Chapter to attendees. “This is not unlike any airline jorie Chartier. Our apologies. ◆ cover all of southern California. Sup- or government agency training facility,” port for the re-establishment was strong notes Guselli. ◆

January—March 2012 ISASI Forum • 29 ISASI ROUNDUP Continued . . .

Sumwalt Gains the Board, as well as the NTSB staff.” cation to our mutual goals of enhanc- Member Sumwalt was first designat- ing aviation accident investigation and Second Term as NTSB ed as Board member on Aug. 21, 2006, prevention. The professionalism of your Board Member by President Bush and served as vice organization is widely recognized, and chairman of the Board for a two-year I know that will continue in the future. Robert L. Sum- term. His ISASI membership precedes Congratulations once again and know walt has been his NTSB service. ◆ that ISASI is proud to have you as a sworn in for his member of our organization.” ◆ second five-year term as a Board Russia Interstate Aviation US Safety Chiefs Outline member of the Na- Committee Celebrates tional Transporta- Ambitious 2025 Strategy tion Safety Board. 20-Year Anniversary Ken Hylander, responsible for safety Nominated by The Interstate Aviation Committee of at Delta Air Lines, and Peggy Gilligan, President Obama, Russia, an ISASI corporate member, the Federal Aviation Administration's Sumwalt his term of office was sent a letter of congratulations on top safety official, spoke recently about will run until Dec. 31, 2016. its recently celebrated 20th anniversary. a new goal to halve the current low ac- “Public service is truly one of the ISASI President Frank Del Gandio, cident risk by 2025, as reported by Air highest callings in the land. I have been writing to Dr. Tatyana Anodina on Traffic Management magazine. honored to serve on the NTSB for the behalf of the Society, said, “We send our The article noted that attaining that past five years, and I am humbled and best wishes and heartfelt congratula- goal would mean approximately one appreciative that President Obama has tions upon this noteworthy occasion. The fatality for every 22 million flights, which asked me to serve for an additional Committee has been a long-time sup- equates to one death roughly every two- term,” said Sumwalt. “I am grateful to porter of ISASI activities and programs and-a-half years, a period in which more the Senate for their positive action on and for that, we are truly grateful. I than 1.4 billion passengers will have this nomination. I look forward to con- personally appreciate your participation boarded scheduled flights operated by tinuing to work with my colleagues on in the Society and your long-time dedi- U.S. airlines. ◆

Building Partnerships in Unmanned Aircraft Systems continued from page 19 community can and should pursue. Final word “While the path for [UAS] develop- The quality and availability of relevant The need for effective “sharing” of knowl- ment in the military, civil, and commercial data are likely to be the most difficult is- edge and resources is a critical prerequi- sectors domestically and internationally sue to overcome. Many UAS operators, site to figuring out how to safely operate seems clear, the saying that ‘the sky’s especially in the military, do not as read- manned and unmanned aircraft in shared the limit’ may literally be true as [UAS] ily acknowledge UAS as being aircraft so airspace. The information available in the increasingly become part of the national much as high-end equipment. If detailed many scattered, proprietary, or otherwise airspace system (NAS). After all, the information regarding operational issues protected UAS investigations that have national airspace is already occupied is not being collected systematically, the taken place over the past decade must by aircraft manned by general, com- problem of access to existing records be gathered, analyzed, and exploited mercial, and military interests, and it is may be overshadowed by the far greater to improve both the safety of UAS and not entirely clear whether, when, how, or problem of there being no relevant records their operations and the quality and ef- if [UAS] of every type can or should be in the first place. fectiveness of future UAS-related safety incorporated into the busy NAS environ- Overcoming that hurdle, and oblig- investigations. ment. Whether [UAS] can be integrated ing UAS operators to think about their Attorney Timothy Ravich, writing in into the national airspace without also unmanned aircraft as aircraft instead the North Dakota Law Review in 2009, posing a safety or national security issue of simply as equipment providing aerial offered this succinct summary of the is an open question.” vantage points, may be the biggest chal- broad issues surrounding successful UAS Safety professionals of all stripes will lenge of them all. integration: play a defining role in answering the

30 • ISASI Forum January—March 2012 ISASI Information

OFFICERS New Zealand, Alan Moselen Ballot Certification, Tom McCarthy President, Frank Del Gandio ([email protected]) ([email protected]) ([email protected]) Russian, Vsvolod E. Overharov Board of Fellows, Ludi Benner Executive Advisor, Richard Stone ([email protected]) ([email protected]) ([email protected]) SESA-France Chapter,Vincent Fave Bylaws, Darren T. Gaines Vice-President, Paul Mayes ([email protected]) ([email protected]) ([email protected]) United States, Toby Carroll Code of Ethics, Jeff Edwards Secretary, Chris Baum ([email protected]) ([email protected]) ([email protected]) Membership, Tom McCarthy Treasurer, Tom McCarthy UNITED STATES REGIONAL ([email protected]) ([email protected]) CHAPTER PRESIDENTS Nominating, Troy Jackson Alaska, Craig Bledsoe ([email protected]) COUNCILLORS ([email protected]) Reachout, John Guselli Australian, Lindsay Naylor Arizona, Bill Waldock ([email protected]) ([email protected]) ([email protected]) Seminar, Barbara Dunn ([email protected]) Canadian, Barbara Dunn Dallas-Ft. Worth, Tim Logan ([email protected]) ([email protected]) WORKING GROUP CHAIRMEN European, Anne Evans Great Lakes, Matthew Kenner Air Traffic Services, Scott Dunham (Chair) ([email protected]) ([email protected]) ([email protected]) International, Caj Frostell Mid-Atlantic, Ron Schleede Ladislav Mika (Co-Chair) ([email protected]) ([email protected]) ([email protected]) Cabin Safety, Joann E. Matley New Zealand, Peter Williams Northeast, Luke Schiada ([email protected]) ([email protected]) ([email protected]) Corporate Affairs, Erin Carroll United States, Toby Carroll Pacific Northwest, Kevin Darcy ([email protected]) ([email protected]) ([email protected]) Flight Recorder, Michael R. Poole Rocky Mountain, David Harper ([email protected]) NATIONAL AND REGIONAL ([email protected]) General Aviation, Open SOCIETY PRESIDENTS San Francisco, Kevin Darcy Government Air Safety, Marcus Costa ([email protected]) ([email protected]) ASIASASI, Chan Wing Keong Human Factors, Richard Stone ([email protected]) Southeastern, Robert Rendzio ([email protected]) ([email protected]) Australian, Lindsay Naylor Investigators Training & Education, ([email protected]) Southern California, Thomas Anthony ([email protected]) Graham R. Braithwaite Canadian, Barbara M. Dunn ([email protected]) ([email protected]) COMMITTEE CHAIRMEN Unmanned Aerial Systems, Tom Farrier European, David King ([email protected]) ([email protected]) Latin American, Guillermo J. Palacia Audit, Dr. Michael K. Hynes (Mexico) ([email protected]) Award, Gale E. Braden ([email protected])

questions posed by Mr. Ravich. It seems inevitable that accidents involving UAS Impact Dynamics Cases and Cautions will form part of the backdrop against continued from page 11 which they will be considered. Only honest data describing both the context within mendations. The exercise was undertaken clear decisions on technical alternatives. which such accidents take place and the with the experience of previous cases and, 3) There is no substitute for the helpful co- factors surrounding their root causes will indeed, the G-YMMM experience under- operation of the aircraft manufacturer—it lead to the safe integration of unmanned lined the lessons that over 20 years have is pretty much essential. (If there are aircraft systems throughout the world’s been remarkably consistent in applying injuries involved, a cooperative medical airspace systems, and to the development computational impact dynamics: investigator is essential, too). of regulatory controls consistent with the 1) Use of computer-based impact tools 4) The accident investigator must work risks that UAS pose to the other users of can add real value to the accident inves- closely and frequently with the spe- those systems. ◆ tigation. This is as a supplement to other cialist impact analyst throughout the approaches, not as a substitute, and com- investigation. (The views expressed in this paper are pared with other investigation costs, it can 5) Accidents lending themselves to compu- the author’s, and do not reflect official be expensive. tational impact approach are infrequent, positions of the Federal Aviation Ad- 2) The modelling process must fit into the but the lessons are widely applicable and ministration, ClancyJG International, timescale of the accident investigation, so add substance to safety recommenda- or its clients.) it is important to start early and to make tions. ◆

January—March 2012 ISASI Forum • 31 Non-Profit ISASI Org. U.S. Postage 107 E. Holly Ave., Suite 11 PAID Sterling, VA 20164-5405 USA Permit #273 CHANGE SERVICE REQUESTED ANNAPOLIS, MD

WHO’S WHO Airbus

(Who’s Who is a brief profile prepared Airbus draws together the skills and family. Across all its fly-by-wire aircraft by the represented ISASI corporate expertise of 15 sites in France, Germany, families, Airbus’s unique approach en- member organization to provide a more Spain, and the UK. Each site produces sures that aircraft share the highest pos- thorough understanding of the organi- a complete section of the aircraft, which sible degree of commonality in airframes, zation’s role and function.—Editor) is then transported to the Airbus final onboard systems, cockpits, and handling assembly lines in Toulouse, Hamburg, characteristics, which significantly re- irbus is a leading aircraft manufac- or Tianjin. Airbus’s industrial network duces operating costs for airlines. turer whose customer focus, com- Furthermore, in anticipation of market Amercial know-how, technological growth, Airbus is extending its portfolio leadership, and manufacturing efficiency of freighter aircraft, which will set new have propelled it to the forefront of the standards in the general and express industry. With revenues of more than 29 freight market sectors. Airbus’s latest billion euros in 2010, Airbus today con- addition to its family of freighter aircraft sistently captures about half of all com- is the A330-200F, a mid-sized, long-haul mercial airliner orders. The company cargo aircraft that benefits from the ex- also continues to broaden its scope and cellent economics and fly-by-wire technol- product range by applying its expertise ogy of the popular A330-200 airliner. to the military market. Airbus has sold more than 10,000 Headquartered in Toulouse, France, aircraft to more than 400 customers/ Airbus is owned by EADS. It is a truly operators and has delivered more than global enterprise of some 52,000 em- has been expanded to include a regional 6,500 aircraft since it first entered ployees, with fully owned subsidiaries design office in North America, a joint service in 1974. Sensitive to its position in the United States, China, Japan, and venture engineering center in Russia, as an industry leader, Airbus strives to the Middle East; spare parts centers in and further engineering centers in the be a truly eco-efficient enterprise. To Hamburg, Frankfurt, Washington, Bei- People’s Republic of China and India. that end, Airbus is the first aeronautics jing, and Singapore; training centers in Airbus’s modern and comprehensive company in the world to have earned Toulouse, Miami, Hamburg, and Beijing; product line comprises highly successful the ISO 14001 environmental certifica- and more than 150 field service offices families of aircraft ranging from 107 to tion for all production sites and products around the world. Airbus also relies on 525 seats: the single-aisle A320 family for the entire lifecycle. Airbus seeks to industrial cooperation and partnerships (A318/A319/A320/A321), the widebody, ensure that air transport continues to with major companies all over the world long-range A330/A340, the all-new next- be an eco-efficient means of transport, and a network of some 1,500 suppliers in generation A350 XWB family, and the delivering economic value while minimiz- 30 countries. ultra-long-range, double-decker A380 ing its environmental impact. ◆

32 • ISASI Forum January—March 2012