JANUARY–MARCH 2008 International Cooperation Paves Safer Sky Runways (Page 5) Standardizing International Taxonomies (Page 8) Small Plane Search in Atlantic Waters (Page 14) Safety and Cultural Challenges (Page 17) ISASI Council Completes Heavy Agenda (Page 21) ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ CONTENTS

FEATURES Volume 41, Number 1 Publisher Frank Del Gandio 5 International Cooperation Paves Safer Sky Runways Editorial Advisor Richard B. Stone By Guo Fu, East China Regional Administration, CAAC—Through examples, Editor Esperison Martinez the author demonstrates the importance of international cooperation in accident/ Design Editor William A. Ford Associate Editor Susan Fager incident investigation, and how investigation and safety management benefit Annual Report Editor Ron Schleede from international cooperation. ISASI Forum (ISSN 1088-8128) is pub- lished quarterly by International Society of 8 Standardizing International Taxonomies Air Safety Investigators. Opinions ex- By Corey Stephens, Oliver Ferrante, Kyle Olsen, and Vivek Sood—Common pressed by authors do not necessarily rep- taxonomy is an indispensable tool to define common safety issues and complemen- resent official ISASI position or policy. tary ways to globally enhance aviation safety. Editorial Offices: Park Center, 107 East Holly Avenue, Suite 11, Sterling, VA 20164- 5405. Telephone (703) 430-9668. Fax (703) 430-

○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ 4970. E-mail address [email protected]; for edi- 14 Small Plane Search in Atlantic Waters tor, [email protected]. Internet website: By Joseph Galliker—An example of how cooperation among an accredited www.isasi.org. ISASI Forum is not responsible investigation team , local authority, local marine professionals, and the general for unsolicited manuscripts, photographs, or other materials. Unsolicited materials will be public helped bring closure to an investigation and to the pilot’s family. returned only if submitted with a self-ad- dressed, stamped envelope. ISASI Forum reserves the right to reject, delete, summa- 17 Safety and Cultural Challenges rize, or edit for space considerations any sub- By Alexey Morozov, IAC (Interstate Aviation Committee), Russia and Sylvain mitted article. To facilitate editorial produc- tion processes, American-English spelling of Ladiesse, BEA (Bureau d’Enquêtes et d’Analyses pour la sécurité de l’aviation civile)— words will be used. The key to successful cooperation is certainly the capacity and the will to listen to Copyright © 2008—International Society one’s interlocutors, to understand the cultural and historic differences, of Air Safety Investigators, all rights re- and to make compromises. served. Publication in any form prohibited without permission. ISASI Forum regis- tered U.S. Patent and T.M. Office. Opinions 21 ISASI Council Completes Heavy Agenda expressed by authors do not necessarily rep- resent official ISASI position or policy. Per- Compiled from the Council’s Singapore meeting minutes prepared by Secretary mission to reprint is available upon applica- Chris Baum and Council member written reports. tion to the editorial offices. Publisher’s Editorial Profile: ISASI Fo- rum is printed in the United States and pub- DEPARTMENTS lished for professional air safety investiga- tors who are members of the International 2 Contents Society of Air Safety Investigators. Edito- 3 President’s View rial content emphasizes accident investiga- 4 VP’s Corner tion findings, investigative techniques and experiences, regulatory issues, industry ac- 24 ISASI RoundUp cident prevention developments, and ISASI 30 ISASI Information and member involvement and information. 32 Who’s Who—A brief corporate member profile Subscriptions: Subscription to members is of Raytheon Company provided as a portion of dues. Rate for non- members is US$24 and for libraries and schools US$20. For subscription informa- tion, call (703) 430-9668. Additional or re- placement ISASI Forum issues: members US$3, nonmembers US$6. ABOUT THE COVER Scene of an MD-11 cargo accident on April 15, 1999, in Shanghai, China. The aircraft departed Shanghai Hongqiao International Airport with two pilots and one flight technician on board. It crashed at a construction site 3 minutes after takeoff (see article on page 5). Photo by Wu Yibing, CAAC.

2 • ISASI Forum January–March 2008 PRESIDENT’S VIEW

A Decade of Progress By Frank Del Gandio, President

The past 10 years have been phenomenal for ○○○○○○○○○○○○○○○○○○○○○○○○ The development of the ISASI website is our newest line of ISASI. Our individual membership has in- communication to you. The site gives members access to the creased by 150 members. Our corporate membership database, ISASI Forum articles, Reachout reports, members have significantly increased, bringing ISASI Proceedings dating back to 1970, annual seminar the active total to 129. In 2000, we purchased updates, and other important information relative to your office space for ISASI headquarters for Society. The ISASI Forum continues as the premier publication $101,000. The office condominium unit is now of your Society. valued at $250,000. The purchase has saved ISASI approxi- Our numerous “working groups” have been productively mately $240,000 over the past eight years. A portion of our total active. The Cabin Safety, Air Traffic Services, and Investigators office space is leased to other agencies. The income generated Training and Education Working Groups have published reduces our expenses by $8,760 per year. Due to the financial success of our recent seminars we have been able to retire our mortgage, which reduced our annual expenses by another ur Society has indeed been very active $9,600. In addition, ISASI lobbied for and successfully acquired Oover the past decade, accomplishing many a “nonprofit” tax exemption from Virginia state personal property and real estate taxes. This further reduced our yearly effective programs to improve aviation safety expense by $10,000. To sum up, our Society’s financial situation ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ worldwide. While I have been your president has changed from a negative status to a financially secure for the past 10 years, our success has been a position. What have we accomplished in the world of aviation safety? collaborative effort of your Executive officers, I’ll start with our “Reachout Workshops” program, which has your international councilors, office manager, successfully brought knowledge and expertise regarding and most importantly the continued support accident investigation and safety management to many persons around the world. We have completed 24 Workshops attended by of you, the membership. 1,141 participants. Statistics show that delegate participation at ISASI annual guidelines that have been approved by your national Council. seminars has increased. I attribute this to the excellent quality The guidelines have been mailed to all governmental investiga- of the presentations. ISASI 2002 Taipei, Taiwan, and ISASI 2007 tive agencies in ICAO. The guidelines are also available on the Singapore opened the door to the Asian air safety population. ISASI website. And most recently, ISASI has been granted Thanks to an anonymous donor, in 2005 we initiated a program observer status at ICAO, and we have been invited to participate to identity the “Best Paper” presented at the annual seminar. in the 2008 AIG Meeting in Montreal. The author(s) receive an Award of Excellence in the form of a ISASI has assumed sponsorship of the international plaque and a monetary award. Industry Human Factors Working Group, which aims to The founding of the ISASI Rudolph Kapustin Memorial develop better guidance for investigating human performance. Scholarship Fund is still another significant endeavor. It These experts will produce a series of training modules was established in 2002 and honors all ISASI deceased emphasizing state-of-the-art human factors considerations in members. The Scholarship’s purpose is to encourage and accident investigation. assist aviation students enrolled in the studies of aviation Our Society has indeed been very active over the past decade, safety and aircraft accident investigation. The program has accomplishing many effective programs to improve aviation been so financially successful that we were able to select and safety worldwide. While I have been your president for the past provide funds for three recipients for 2007. Generosity is 10 years, our success has been a collaborative effort of your contagious—the recipients of the Award of Excellence for Executive officers, your international councilors, office manager, “Best Paper” for ISASI 2007 donated their $500 award to the and most importantly the continued support of you, the member- Fund. Since its inception, $18,875 has been donated to the ship. I constantly receive accolades from individuals attesting to Fund, and nine students have been named recipients. As a the professionalism exhibited by ISASI and its members. ISASI result of the program, two scholarship recipients have gained is truly an international society covering a broad spectrum of the positions in the aviation safety field. All ISASI Rudolph aviation safety community. Kapustin Memorial Scholarship Fund donations are fully I thank you for the honor to serve as president. It is truly a tax-deductible in the U.S. rewarding and gratifying experience. ◆

January–March 2008 ISASI Forum • 3 V.P.’S CORNER Aircraft ‘Accident’ Investigators or Aircraft ‘Incident’ Investigators? By Ron Schleede, Vice-President While thinking about a theme for my comments, ○○○○○○○○○○○○○○○○○○○○○○○○ Here is one example in which it is obvious that a more- I noticed an item on the Internet about the aggressive approach to examining incidents most likely would Eastern Airlines L-1011 that crashed in the have prevented a major fatal airline accident. On Aug. 14, 2005, Everglades near Miami, Fla., on Dec. 29, 1972. Helios Flight 522, a Boeing 737-300, crashed near Grammatiko, Several memories came flooding back. It seemed Greece, killing all 121 persons aboard. That investigation to me that only three-and-a-half years had revealed scores of precursor incidents worldwide that had passed, not 35 years! exhibited virtually identical circumstances to those identified in As I thought about the “old” days, I pondered how the work of the Helios accident. an air safety investigator has changed in those 35 years. Why hadn’t the air safety investigators of the world been able I had just begun my career with the U.S. NTSB in October to turn findings from scores of incident investigations into 1972. It seemed very quiet until Dec. 8, 1972, when a United Airlines Boeing 737-200 crashed on approach to Midway Airport in Chicago, Ill. Forty-three of the 61 occupants and two persons believe that air safety investigators must on the ground were killed. I was assigned to the go-team as a Iconsider virtually every incident a precursor human factors investigator trainee, my first on-scene accident investigation for the NTSB. to a fatal accident. Consequently, senior We were still on scene at Midway, on Dec. 20, 1972, when a ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ aviation safety officials (government and North Central Airlines DC-9-31, taking off at Chicago O’Hare industry) must ensure that adequate resources Airport, collided with a Delta Air Lines Convair 880 that had are available and are applied to incident just landed. Ten occupants of the DC-9 were killed in the accident. A second NTSB go-team was sent to Chicago. Nine investigations, commensurate with those days later, the Eastern L-1011 crashed killing 100 of the 176 applied to fatal accident investigations, to occupants. A third NTSB go-team was dispatched. further improve the safety record. An Internet search revealed an additional five fatal airline accidents outside of the U.S. in December 1972, killing 239 corrective actions before the Helios crash? Perhaps, because persons. Worldwide, there were about 70 airline accidents in “incident” investigators had not delved into the precursor 1972, killing about 2,500 persons. Fortunately, those numbers incidents as aggressively as past “accident’ investigators have were the highest for the next 35 years (excluding the 9/11 done. Perhaps, it was a lack of resources to conduct comprehen- events). Another Internet search revealed only about 10 fatal sive incident investigations. airline accidents worldwide in 2007, with none in the U.S. It Dick Wood, who was awarded the 2006 ISASI Jerome would seem that the honed skills of professional air safety Lederer Award, said in his paper Defining and Investigating investigators are in much less demand. Incidents, “There is evidence we have ignored incidents… Indeed, the investigative landscapes, along with technologies [because] we haven’t adequately defined ‘incidents.’ An incident, and techniques of the air safety investigator, have changed properly defined, should be a precursor of a future accident. considerably since 1972. But that doesn’t mean the “honed If you consult the various lists of incidents, you will see that skills” need be blunted because of inactivity. almost none of them are precursors of accidents all by them- Perhaps what needs to be done is a full transition from being selves. They may be an initiating event or even a key factor in primarily “accident” investigators to primarily “incident” an accident, but there is always more to the accident than just investigators. I am fully aware that major strides are taking that single event.” place to identify and reduce risk before accidents occur, includ- I believe that air safety investigators must consider virtually ing government and industry efforts related to Safety Manage- every incident a precursor to a fatal accident. Consequently, ment Systems concepts to deal with risk in aviation operations. senior aviation safety officials (government and industry) must However, why not investigate incidents with the same vigor that ensure that adequate resources are available and are applied to has been applied to accidents in the past? Why not use the go- incident investigations, commensurate with those applied to fatal team concept and commit comprehensive and dedicated re- accident investigations, to further improve the safety record. sources to examine incidents? The NTSB actually considered I had a very fulfilling career as an accident investigator. I this concept several years ago, but it failed because of lack of sincerely hope that today’s incident investigators are given the resources. It was easy to get resources to investigate a fatal opportunity to look back 35 years from now and feel equally airline accident, but not for incident investigations. fulfilled. ◆

4 • ISASI Forum January–March 2008 International Cooperation Paves Safer Sky Runways

Through examples, the author demonstrates the Case 1: An MD-11F cargo flight importance of international accident in Shanghai, China. cooperation in accident/ incident investigation, and how investigation and safety management benefit from international cooperation. By Guo Fu, East China Regional Administration, Civil Aviation Administration of China (This article was adapted, with permission, from the author’s presentation entitled In- ternational Cooperation Paves the Runway for a Safer Sky, presented at the ISASI 2007 seminar held in Singapore, Aug. 27-30, 2007, which carried the theme “Interna- tional Cooperation: From Investigation Site to ICAO.” The full presentation includ- to take action. And it is obvious that an in- ment, concurrent management, and feed- ing cited references index is on the ISASI vestigation is one of the most effective ways back management. website at www.isasi.org.—Editor) to improve safety. • Feedforward management prevents an- With an annual average growth rate of ticipated unsafe events from happening by t is common sense that the purpose of more than 16% of total air traffic volume establishing certification criteria, policies, an accident/incident investigation is to within the last 20 years in China, the num- operational standards, procedures, manu- Iprevent the same occurrence from re- ber of occurrences is increasing accordingly. als, training programs, maintenance pro- peating—so to promote safety, it’s impor- In addition to the routine preventive mea- grams, budgets, etc., that are mainly based tant that the investigation can locate or as- sures adopted, we take investigation as one on previous experiences or lessons learned, sess the cause(s) and reveal findings in or- of the most critical means in safety man- and sets guidelines or processes for imple- der to enable the entire system or industry agement and investigate both accidents and menting a plan, or achieving organizational incidents. While we may not be experienced objectives. Guo Fu is an accident enough in investigation aspects, China is • Concurrent management monitors or investigator with the one of the fastest-growing aviation markets. oversees operational activities in processes general Civil Aviation Annex 13 provides us with not only stan- and ensures that immediate, corrective ac- Administration of China dards or basic principles and guidelines for tions be taken if any below-standard condi- (CAAC) and is now the investigation, but also with a cooperative tion, deviation from the standard, or any deputy director of the mechanism. Our investigation practices fol- violation is observed during operation so Aviation Safety Office of low both international and domestic regu- that performance is back on track and the East China Regional Administration of lations and standards. Therefore, our inves- plans are properly implemented or objec- CAAC. Guo Fu graduated in 1982 from tigation benefits a great deal from interna- tives achieved. Thus, it can also be called the Civil Aviation University of China, tional cooperation. simultaneous management. with a major in avionics and in 2000 from • Feedback management examines the re- Shanghai No. 2 Polytechnic University The role of investigation sults or consequences of operation, finds, (with a major in computer technology According to the basic management and analyzes the causes of deviation from application). He also has a master’s theory, aviation safety management ac- standards, and then makes guidelines for degree in public administration from tivities can be classified into three differ- corrective actions or suggestions. Mean- Shanghai Jiaotong University. ent areas or phases: feedforward manage- while the lessons learned will be fed back

January–March 2008 ISASI Forum • 5 for modifying or adjusting standards, pro- cedures, policies, and programs, even regu- lations to prevent reoccurrence. All these activities provide a safe opera- tion platform, which acts as a solid founda- tion for a safe operation. Symbolically speaking, the foundation is supported by the feedforward, concurrent, and feedback management tripod. It will collapse if one of the supports fail. From the aviation point of view, a solid foundation can be seen as a concrete runway for safe flight. Therefore, Case 2: A CRJ-200 you can never image that a flight would passenger flight safely takeoff or land if a section or part of that crashed in the runway fails. Baotou, China. Aviation safety investigation is a type of safety management that falls into the feed- back management category. The purposes guidelines for investigation, but also a co- from organizations with special investiga- and functions of the investigation are just operative mechanism. So, it sends a strong tion equipment or facilities—otherwise, we the same as those of feedback management. signal that investigation cooperation is the couldn’t have a good investigation. Hence, the investigation activities are as international standard for aviation safety equally important as other safety manage- investigation. Investigation practices in China ment measures and play a major role in In the conduct of an investigation, many Investigation practices in China benefit aviation safety management. reasons exist for the need for cooperation. from international cooperation in terms of In an investigation, we collect evidence, Though ICAO plays a key role in enhanc- technical support and coordination. We have check all the relevant aircraft systems and ing cooperation, there are many other fac- many rules to follow when we conduct an related operational support equipment and tors that drive the investigation itself to seek air safety investigation in China. They in- facilities, gather all the information associ- international cooperation. Aviation is a com- clude both international and domestic stan- ated with an incident or accident, review all plex system that is an interacting combina- dards. In addition to Annex 13, our investi- the relevant documents, procedures, stan- tion, at any level of complexity, of people, gation will be in compliance with the follow- dards and regulations, and try every means material, machines, tools, software, facili- ing regulations: to find out, or assess, the causes of an event. ties, and procedures. Furthermore, with • Law of Civil Aviation of PRC We make safety recommendations in order globalization and the rapid development in • Law of PRC on Work Safety to alert the whole system or industry to take aviation, the investigation will be influenced • Civil Aircraft Flight Accident & Incident actions to prevent or improve on the basis by different factors, such as new technolo- Investigation (CCAR395) of findings, including any defect or latent gies, technical expertise or know-how, dif- • Civil Aircraft Flight Incident (MH2001- unsafe condition found in the fields of man- ferent cultural backgrounds, language, po- 2004) agement, design, manufacturing, equip- litical systems, etc. It is evident that an in- • Procedure of Civil Aircraft Accident In- ment, operation and maintenance, and hu- vestigation has become a global challenge vestigation (MD-AS-2001-001) man factor issues or lessons learned from that needs global cooperation and solutions. • Classification Standard for Aircraft an event. With all these measures practiced, One nation’s resources sometimes are not Flight Accident (GB14648-93) the investigation functions as one of the adequate to fulfill the requirements of an • Classification for Ground Accidents of most effective tools of safety protection. investigation. Only when an internationally Civil Aviation (GB18432-2001) cooperative relationship is established can • Response to Aircraft Accident and Fam- Cooperation in investigation an efficient and beneficial investigation be ily Assistance (CCAR-399) In Annex 13 to the Convention on Interna- achieved. • Civil Aviation Safety Information Man- tional Civil Aviation, the most frequently To investigate an occurrence, we need agement (CCAR-396) used words are the state of occurrence, the help and assistance from A two-leg investigation system is adopted state of registration, the state of the opera- • investigation authorities with re- in our investigation practices. According to tor, the state of design, and the state of sources and power to help coordinate and our regulations, an investigation will be con- manufacture. This language shows very communicate, ducted by different organizations depend- clearly that an aviation investigation is a • investigators and experts from other na- ing on the consequences of an event. Tradi- multinational endeavor. We can also find in tions with knowledge of their nation’s safety tionally speaking, the investigation function Annex 13 that obligations and the rights are regulations and policies, operational stan- is shared between the Civil Aviation Admin- shared among all these nations. From these dards, expertise or know-how of the aircraft istration of China (CAAC) and the State points of view, the Annex provides us with and its equipments or systems, and Council or its authorized department. More not only standards or basic principles and • other operational supportive facilities, specifically, the State Council is responsible

6 • ISASI Forum January–March 2008 for the investigation into a significant ma- quires the investigation of both accidents analyze and determine factors that are not jor air transport accident, while CAAC in- and incidents. Although definitions of the directly related to the accident, but have vestigates major air transport accidents and accident and incident are almost the same potential impact to flight safety and related incidents. Usually a significant major acci- as those in Annex 13, there are more-de- issues. dent investigation used to be organized by tailed classifications for the levels of acci- a temporary organization set up by the dent and incident, and items are explained. Investigation practices State Council, but things have changed For instance, Civil Aircraft Flight Incident In most cases, an investigation team will be since the State Administration of Work (MH2001-2004) gives the definition of inci- formed immediately upon receiving an oc- Safety (SAWS) was established in 2001. currence accord- The SAWS is an affiliated organization ing to the authori- of the State Council, and it acts as the ex- zation. The size of ecutive office of the Work Safety Commit- the team will de- tee of the State Council. One of its major pend on the conse- functions is to supervise the national work quence and signifi- safety and conduct or coordinate investiga- cance of the occur- tion of significant major accidents, and ma- rence. A full jor accidents occurring within the territory go-team will be of mainland China. However, its actual in- comprised of in- vestigation activities involve other accident vestigators from investigations, including general aviation flight operation, accident investigation and ground aviation airworthiness, accident investigation. SAWS will conduct ATS, aeronautical these types of investigation when it has meteorology, avia- enough professionals to do so. tion security, air- The aviation geographical purview of port management, mainland China is divided by seven re- flight recorders, gional administrations. Within CAAC, the failure analysis, investigation is arranged according to the dent and lists items considered as the pre- ground handling, weight and balance, avia- geographical purviews of the regional ad- cursor of the accident. There are two dif- tion medical, survival factors, human fac- ministrations. Each regional administra- ferent types of accidents in our classifica- tors, safety management, and some periph- tion is responsible for conducting an inves- tions—one is flight accident and the other eral groups involved—for example, site pro- tigation when the following has occurred is ground aviation accident. Classification tection, site clean, and aftermath assistance in its region: Standard for Aircraft Flight Accident need to be coordinated. • an incident involving a commercial air (GB14648-93) defines and classifies the The investigation process usually has transport or a general aviation aircraft. flight accident and as does the Classifica- three phases, from notification through fi- • a ground accident. tion for Ground Accidents of Civil Aviation nal report. We may describe them as rescue For a major accident, or foreign carrier (GB18432-2001). and evidence collection; facts, preliminary accident investigation, it is the general Basic principles for investigation—Our ba- report, and analysis; conclusion and recom- CAAC’s (headquarters) responsibility to sic principles must be followed if an investi- mendation. The requirements of the notifi- investigate. It can also delegate its investi- gation is conducted. cation, preliminary report, and format final gation authority to relevant regional admin- • Independent: Investigation shall be con- report are the same as those of Annex 13. istrations accordingly. ducted independently—no other organiza- We must inform the authorities of the tion or individual is allowed to interfere. state of manufacture, the state of registry, Investigation regulations • Objective: Investigation shall be fact the state of the operator, and ICAO accord- Civil Aircraft Flight Accident & Incident driven, objective, fair, and scientific and can- ingly, even though the field representatives Investigation-CCAR395 outlines all the re- not have any intent of subjectivity. of the manufacturer are ready to offer help quirements for the investigation. The main • Detailed: Investigation shall analyze and under most cases. And most of the time we contents are organization of investigation, determine the causes of the accident or in- have speedy responses with willingness to investigator, notification, investigation, and cident and contributing factors, including provide assistance from the relevant au- report. One of the most important features any defect concerning aircraft design, thorities. In our practices, we have received of the regulation is cooperation, which re- manufacture, operation, maintenance, per- assistance from many foreign investigative flects the spirit of Annex 13. Actually, the sonnel training, and company’s manage- authorities both in accident and incident main contents of the regulation are quite ment policies, and regulator’s rules and investigation. There is no doubt that we similar to those of Annex 13. The follow- regulations and implementation. have shared a good experience working to- ing is the important information of the • Thorough: Investigation shall not only gether with our international partners dur- regulation. analyze and determine the cause of the ac- ing an investigation. It is obvious that re- Scope of investigation—Regulation re- cident and contributing factors, but also (continued on page 29)

January–March 2008 ISASI Forum • 7 Standardizing International Taxonomies taxonomy, the data become even more valu- prevention. Also discussed is some work on able to investigators. Each investigator new taxonomies to be standardized, espe- Common taxonomy is an studying worldwide data is relying on these cially for incident investigation. These new indispensable tool to standardized definitions. In addition, the taxonomies will help answer the following investigation results can be exchanged questions: How do we know that our safety define common safety among organizations and with the Interna- strategies prevented an accident from hap- issues and complementary tional Civil Aviation Organization (ICAO). pening, and how often? Finally, the paper The standardized data also forms the core addresses the last important question: How ways to globally enhance of the data in the ADREP reporting scheme can taxonomies help safety investigators aviation safety. (ICAO, 2001). This operational framework and vice-versa? illustrates investigation cooperation, from By Corey Stephens (MO3790), the investigation site to ICAO. CAST/ICAO common taxonomy Olivier Ferrante (MO4749), This article will emphasize how interna- team history Kyle Olsen, and Vivek Sood tional cooperation in taxonomies can help Comprised of industry and government prevent accidents. Some CAST/ICAO Com- safety experts, the Commercial Aviation (This article was adapted, with permission, mon Taxonomy Team (CICTT) taxonomies Safety Team (CAST) came together in a from the authors’ presentation entitled Stan- will be presented, as will some examples of unique industry-government partnership dardizing International Taxonomies for their applications that have helped facilitate in 1997 and set a goal to reduce the U.S. Data-Driven Prevention, presented at the data collection and analysis for accident commercial aviation fatal accident rate by ISASI 2007 seminar held in Singapore, Aug. 27-30, 2007, which carried the theme “Inter- Corey Stephens at the Kyle Olsen joined the national Cooperation: From Investigation time of this presentation FAA Aircraft Engineer- Site to ICAO.” The full presentation includ- was a senior staff engineer ing Division in 1970 and ing cited references index is on the ISASI with the Air Line Pilots is now manager of website at www.isasi.org.—Editor) Association (ALPA)’s Continued Operational Engineering & Air Safety Safety for the FAA he development of an industry- Department. He has Transport Airplane accepted taxonomy, defined as a classi- assisted the Inter-national Federation of Directorate. He has been deeply involved T fication scheme of keywords and defi- Air Line Pilots Associations (IFALPA) with CAST since 1997. Kyle was the nitions and which can also be considered the with technical expertise on international FAA certification project manager for the “safety language” of information systems, accidents. Corey Stephens was the indus- L-1011 and MD-11 and was manager of plays an essential role in safety. It goes be- try co-chair to the CAST/ICAO Common the Propulsion Branch in the FAA Los yond just identifying occurrence categories. Taxonomy Team (CICTT) and served as Angeles Aircraft Certification Office. He As more data sources and systems become an ALPA representative to the Commer- has a bachelor’s degree in aerospace available for use in reactive (post-accident) cial Aviation Safety Team (CAST)—Joint engineering from the University of and proactive safety programs, the impor- Implementation Monitoring Data Southern California. tance of well-developed and agreed-upon Analysis Team (CAST—JIMDAT). standards becomes very apparent for data- Vivek Sood is the manager of FAA’s driven safety initiatives. Industry-accepted Olivier Ferrante joined the Bureau Aviation Safety (AVS) Aviation Safety standards aid in data sharing and analysis. d’Enquêtes et d’Analyses pour la sécurité Information Analysis and Sharing Common taxonomies and definitions estab- de l’aviation civile (BEA) in 2000 and has (ASIAS) center. He holds commercial, lish a standard industry language, thereby been working with the Federal Aviation flight instructor, and dispatcher certifi- improving the quality of information and Administration (FAA) (Continued cates. He has worked in the aviation communication. With this common lan- Operational Safety) since November 2005 sector for the last 18 years, particularly guage, the aviation community’s capacity under a BEA-FAA cooperation agree- in the area of safety analysis. Vivek is a to focus on common safety issues is greatly ment. Before that, he worked with the member of the CICTT and is the govern- enhanced. The safety issues are commonly Transportation Safety Board of Canada. ment co-chair of the Runway Confusion defined, which facilitates tracking the effec- Olivier holds a master’s degree in aviation Study Group sponsored by CAST. He has tiveness of their mitigation solutions. engineering from the French National a master’s degree in aviation and The investigation site can be the start- Civil Aviation School (ENAC) and a post- aerospace operations and a bachelor’s ing point for data collection. When data are graduate degree in human factors from degree in aeronautical science from collected and recorded using a standard Paris University. Embry-Riddle Aeronautical University.

8 • ISASI Forum January–March 2008 80% over the next 10 years. tion accident and incident reporting systems. tions for its annual statistical summary of Though CAST has focused primarily on CICTT includes experts from ICAO, several accidents (Boeing, 2006). the U.S. aviation system, throughout its his- air carriers, airframe and engine manufac- The CICTT Occurrence Categories are tory CAST has reached out internationally turers, pilot associations, regulatory au- also used by the Safety Indicator Study to help improve aviation safety around the thorities, transportation safety boards, and Group (SISG)—a group formed by ICAO world. A large number of international or- members from North America and Eu- after the 1999 Accident Investigation and ganizations are members and observers of rope, and indirectly from more countries. Prevention Divisional Meeting (AIG 99). CAST, including the European Aviation CICTT is co-chaired by one representa- Since 2001, SISG has met annually to ex- Safety Agency (EASA), the Joint Aviation tive from ICAO and one from CAST. change, review, and jointly classify accident Authorities (JAA), and other ICAO member states. CAST’s impact and leadership ex- tends to regional safety alliances around the world, and its principles have been incor- porated into the newly released ICAO glo- bal safety roadmap. CAST has developed an integrated, data- driven strategy to reduce the commercial aviation fatality risk in the United States. To date, CAST has completed 40 of the 65 most promising safety enhancements iden- tified to reduce the leading causes of fatal commercial aviation accidents in the United States. Adoption of these enhancements has been a major factor in the substantial re- duction of the fatal accident rate over the past 10 years. CAST is redirecting its ef- forts to the analysis of incident data to iden- tify emerging safety risks. To continue to achieve reductions in the accident rate, it is necessary to expand into analysis of incident and normal operation data to unearth changing and emerging Figure 1. Boeing statistics based on CICTT Occurrence Categories. threats in a proactive manner. Access to the data is a vital component of this risk analy- The original taxonomies established by and incident data to produce consistent sis. The use of CICTT taxonomies by all or- the CICTT activity were Occurrence Cat- safety statistics. ganizations will be critical to further advance- egories, Phase of Flight, Aircraft Make/ Figure 2 (page 10) illustrates the down- ments in aviation safety. The absence of a Model/Series, and Engine Make/Model. The ward trend of controlled flight into terrain common taxonomy and the lack of industry Occurrence Categories and Phase of Flight (CFIT) accidents. This example shows a data-sharing initiatives greatly diminishes definitions were completed in 2002. The Air- “common taxonomy benefit” for CFIT pre- the ability to recognize emerging risks and craft Make/Model/Series values were estab- vention since a common understanding of increasing threats before their manifestation lished in 2004, and the Engine Make/Model this issue was needed before tackling it. in an accident or serious incident. values activity started in 2006. Both the Air- The efforts undertaken these past years Before the formation of the CICTT craft and Engine taxonomies are updated to prevent CFIT accidents (the acronym (CAST/ICAO Common Taxonomy Team), quarterly. The establishment of these origi- CFIT was less known 20 years ago) intro- there was no universal standard for safety nal taxonomies lays the foundation for duced new safety nets to successfully address data. A focus on safety worldwide at that time • worldwide sharing of common accident/ this accident category. The common catego- resulted in the startup of many disparate incident data, rization of a problem and its coding greatly efforts. This in turn made the development • focused, data-driven, coordinated safety helped to better identify it and monitor its of a common worldwide safety agenda ex- agendas, trend. Above all, it contributed to gathering tremely difficult. It was decided that an in- • common investigation, reporting, and a global consensus. The different stakehold- ternational industry and government stan- post-accident analysis, and ers (industry and government) could “talk” dard must be developed, made up of com- • shifting from reactive to proactive safety about the same issue and consequently act mon and “non-proprietary” standards. assessments. in a coordinated manner. Non-proprietary standards were needed since proprietary or patented taxonomies CICTT product applications ASIAS in the United States had contributed to stovepiping of data. ICAO examples The FAA promotes the open exchange of and CAST jointly chartered the CICTT in Industry has been gradually implementing safety information to continuously improve 1999. The Team is charged with developing CICTT products. Figure 1 shows how the aviation safety. To further this basic objec- common taxonomies and definitions for avia- Boeing Company adopted CICTT defini- tive, the FAA established the ASIAS (Avia-

January–March 2008 ISASI Forum • 9 tion Safety Information Analysis and Shar- tems. Through the ASIAS web-based por- rective database. This new compatible data- ing) center. tal (see Figure 3), users are able to query base should facilitate investigations and en- A fundamental problem faced by ASIAS multiple systems in a single query. hance continued operational safety. For ex- is the heterogeneous nature of the data sys- The global query search can mine sev- ample, while working on a given occurrence, tems that have been developed by the vari- eral databases by entering a unique aircraft an investigator should easily be able to verify ous organizations. The systems typically model thanks to the CICTT Aircraft Make/ pending issues in the airworthiness direc- feature text blocks that are not governed Model/Series standard. Figure 4 depicts a tives system in relation with the Aircraft by controlled vocabularies and contain data single query for a Boeing 737-800 and its Make/Model/Series mentioned in the notifi- values that do not conform to any common associated results. cation. This verification would be done elec- tronically with a high degree of confidence because of the common standard.

Interconnecting safety information systems Common taxonomies are enabling tools that can accelerate the collection and consolida- tion of facts during an investigation. This can be done by interconnecting safety informa- tion systems (at national or international lev- els) or by making them interoperable like ASIAS. Studies have demonstrated the fea- sibility of interconnecting, for example, U.S. and European safety systems, by combin- ing information technologies and common taxonomies. The efforts undertaken by CICTT enable safety information systems Figure 2. Worldwide evolution of CFIT accidents (Source: ICAO SISG 2007). to talk to one another (or to be cross-visible) and safety data to have the same meaning in standard (aircraft make/model codes). In ECCAIRS in Europe respective systems. addition, the systems store data in database The ASIAS “portal” approach and the Eu- Investigators soon will have easier and structures that have little in common. As a ropean Coordination Center for Aviation faster access to a growing number of data result, safety analysts are faced with a mo- Incident Reporting Systems (ECCAIRS) systems for their searches of similar inci- saic of data that can only be viewed one piece share objectives. The European Commis- dents. The challenge is to avoid being bur- at a time. ASIAS addressed these problems sion provides a common tool for users across ied by the exponential increase of electronic by implementing a data-management strat- Europe to encode accidents and incidents data. “Intelligent” classification schemes egy known as the Advanced Data Architec- into compatible repositories. ECCAIRS is are needed more than ever. ture (ADA). The principal objective of the based on the ICAO ADREP (Accident/In- During ISASI 2006, Dick Wood strategy was to enhance the analytical value cident Data Reporting) 2000 taxonomy stressed that “an incident, properly de- of existing data sources by creating an op- (Menzel, 2004). This common tool facilitates fined, should be a precursor of a future erational environment that supports the electronic exchanges and data integration accident.” He also added that if we con- rapid and cost-effective integration of data among organizations from different coun- sult the current lists of incidents, none of from multiple sources. tries (not necessarily from the European them are precursors to accidents by them- The development of ASIAS has allowed Union). Safety analyses can then be based selves. They may be an initiating event the FAA to standardize data-management on larger data sets. or even a key factor in an accident, but practices and address data quality issues. The ADREP taxonomy has adopted there is always more to the accident than Having developed and deployed a data-man- CICTT products throughout the years. just a single event. The majority of these agement framework, ASIAS is focusing its ADREP implemented the Occurrence predefined lists of incidents (or taxono- efforts on the development and adoption of Categories in 2004 and will adopt the mies) deal with “visible” incidents. This common taxonomies and definitions and ana- CICTT Aircraft Make/Model/Series stan- means we already know what they are, lytical methodologies. ASIAS has made sig- dard in its next release. Taxonomy their causal factors, and their solutions. nificant progress in developing analytical changes take time as they generally re- Because they are generally isolated capabilities by establishing internal data quire changing the structure of existing events caught by the redundant safety standards and using CICTT taxonomies. systems. Such a migration has to be nets, they do not degenerate into acci- By focusing on standardizing key data planned and coordinated among the vari- dents. There is a tendency to ignore them. elements initially, like aircraft make and ous organizations involved. The “real” precursor is a situation that is model, airport names, state names, coun- The European Aviation Safety Agency, not “single error safe.” Consequently, it try names, and operator names, ASIAS is which operates ECCAIRS, directly imple- becomes crucial to better understand the able to link databases and establish mented the CICTT Aircraft Make/Model/ safety nets of the system and their effec- interoperability among multiple source sys- Series standard in its new airworthiness di- tiveness in preventing accidents.

10 • ISASI Forum January–March 2008 “Hard” and “soft” safety nets safety net (a new system or regulation) is and Warning System (TAWS), standard ECCAIRS allows investigators to record added because of an accident, whereas the operating procedures (SOPs), and training technical safety nets as well as to keep track successful human interventions have not yet are examples of “hard” and “soft” safety of the failure of the expected function of these been recorded in a standardized way through nets that prevent accidents. However, the “hard” barriers. On the other hand, when a common “positive taxonomy.” effectiveness of these safety measures is analyzing incidents and human defenses, it The aviation system has indeed achieved difficult to assess. Our safety statistics are is not yet possible to keep track of those fac- an impressive safety level across time by presently only using negative indicators, tors that saved the day, such as a successful creating redundant systems and adding such as accident or fatality numbers. third-party intervention or the application safety layers for prevention and mitigation. We need to develop an easy-to-use target taxonomy that would enable “rough” trend analyses of some key safety nets (both “soft” and “hard”) of the aviation system. Having better indications of the coverage of these safety nets should facilitate their monitor- ing and should contribute to reinforcing the resilience of the aeronautical system.

Positive taxonomy sub-team CICTT has chartered a sub-team to develop a positive taxonomy that aims at better identifying the safety nets and assessing their effectiveness, with emphasis on the successful human interventions. Human factors have generally been considered in relation to accident causes or as perfor- mance limitations. The sub-team will— • consider the human factor as a safety factor, • record successful human interventions in databases, and • capitalize on positive taxonomy to increase the resilience of the aeronautical system. This shifting from a reactive to a proac- Figure 3. Access to global query search—by aircraft. tive focus is not new. For example, L. Benner and I. Rimson, in 1995, suggested in the fol- lowing situations • To redirect data acquisition concentration from accidents (which identify causes or operational failures) to incidents (which identify both operational failures and suc- cessful recoveries). • To try to find answers to the question “What went right to prevent it?” instead of “What went wrong to cause it?” • To acknowledge both the ubiquity of hu- man error and the human capability to re- cover from errors. Redirect resources to- Figure 4. Global query and results for ward successful intervention processes that Boeing 737-800. thwart accident progression, thereby focus- ing on adaptation to error rather than er- of the relevant procedure. These successful The “single error safe” system started with ror perpetuation. human interventions that prevented an inci- the airplane itself. Much of the airplane de- • To expand the focus of investigations to dent from turning into an accident or mini- sign criteria are meant to provide a redun- include positive factors. mized accident outcomes are not currently dancy wherein the failure of any system or The positive factors mentioned more than uniformly recorded in databases, probably part of a system does not lead to an acci- 10 years ago are included in the Terms of because taxonomies illustrate the recent ef- dent. This concept has been extended to the Reference of the positive taxonomy sub-team. forts in enhancing safety through the addi- other components of the aeronautical sys- tion of technical safety nets like those avail- tem. The Airborne Collision Avoidance Sys- CICTT concept banks able in the ADREP taxonomy. This is more tem (ACAS), Minimum Safe Altitude Warn- Another major challenge faced by aviation in line with a reactive paradigm where a ing System (MSAW), Terrain Awareness safety analysts is the extensive use of free text

January–March 2008 ISASI Forum • 11 to capture important information related to vestigation organizations do not have the 4. What prevented the accident/incident accidents and incidents. Simple facts, such as time or resources to investigate everything from being more serious? For example, if a date, time, operator, altitude, and location, are that might be reported under the current passenger is injured, is it worth consider- easily collected using structured data fields. reporting rules. This brings up the “seri- ing that his environment (seat, seat belt, Acquiring a thorough understanding of what ous incidents” that should be the outcome etc.) contributed to his survival? happened, how, and why, however, requires a of this sifting process. 5. Are the results of this occurrence only a subject matter expert to interpret the narra- As a result of the ICAO Accident Investi- matter of circumstances? tive component of the report if there are no gation and Prevention Divisional Meeting 6. Was there any human (positive) factor structured data fields. Accident narratives can 1992, the term “serious incident” was in- that reduced the seriousness of the accident/ be lengthy and complex. Depending on the cluded in Annex 13 and defined as “an inci- incident? nature of an analysis, subject matter experts dent involving circumstances indicating that The answer to the last question should may be required to read thousands of reports. an accident nearly occurred.” This paved the be very helpful in classifying an occurrence As a result, a safety analysis can be a very way for the investigation of serious incidents. as a serious incident. In other words, if the time-consuming and expensive undertaking. How can reality be assessed 15 years after consequences appear to be merely a mat- One approach to addressing the free-text AIG 92? In some countries, serious incidents ter of circumstances, meaning that no hu- issue is to develop text-mining concepts. A are treated like accidents by the investiga- man positive intervention was identified, concept, simply stated, is a collection of tion authority. Even the flight safety depart- then the occurrence could be considered a words that have been related to a subject. ments of many airlines investigate incidents serious incident and investigated in depth. Concepts can be combined to form complex and serious incidents. Nevertheless, not all It could help identify causes that are more concepts that include word strings and use incidents that should be defined as serious difficult to observe than effects. text-mining techniques, such as stemming incidents are investigated. It is clear to any- The introduction of such a taxonomy, as and word proximity rules, to assess the one that the investigation of a serious inci- well as the six questions previously men- strengths of relationships among words. dent can contribute as much to flight safety tioned, would help analysts and investigators In a recent study using the concepts for as the investigation of an accident with a fa- classify, consider, investigate, and analyze automation and confusion, analysts were tal outcome. It is equally clear that it is nearly occurrences. It would mean an alteration to quickly able to search 5.4 million records to impossible to spend as much time and effort the overall framework that should be dis- identify 800 reports for further analysis. on this kind of investigation. cussed during the next ICAO Accident In- Figure 5 illustrates some concept banks in Investigation authorities have stressed vestigation and Prevention Divisional Meet- relation to another study on Boeing 737 the need to bring more consistency to the ing (AIG 2008 tentatively scheduled for Sep- pressurization events. interpretation of a serious incident. Re- tember 2008 in Montreal). Some proposals The objective of the CICTT Text-Mining sources would be well spent to identify se- could include Concepts Taxonomy is to develop a share- rious incidents that avoided becoming acci- • for the short term, guidance material able collection of concepts (concept banks) dents because of luck. These serious inci- such as a checklist of questions. and structure them within a taxonomy that dents should highlight the gaps and • for the medium/long term, common fields will facilitate easy retrieval by the aviation weaknesses of the system. in databases to better assess the resilience community. The development of concept of the overall system. banks greatly helps exploit the current da- How taxonomies help If we want to be more proactive, we tabases that do not operate a common safety The introduction of a positive taxonomy could should collect data that would help assess language yet. A next step could be merging help safety investigators in classifying inci- the resilience of the existing safety nets. If, the concept banks within new structured dents and Annex 13 serious incidents by put- for example, the first elements of an in- fields for improved trend analyses. ting more emphasis on causes rather than vestigation cannot highlight a safety net, on consequences. Most incident lists describe that is, there was no damage nor injury Better defining “serious known outcomes whose causal factors (and thanks to luck, then the occurrence should incident” solutions) are also known. Considering “posi- be investigated in depth. Common taxono- These sub-teams are part of a wider effort tive” factors should change the way occur- mies are tools that help shift focus from that has been trying to address the challenge rences are being considered and could help consequences to causes. presented by ISASI’s President Frank Del address the challenge of finding new acci- Gandio in his opening speech of ISASI 2006 dent precursors. The following short check- Weighing pros and cons (“Incidents to Accidents—Breaking the list of questions from “Towards a Human The image of a balance leveraging produc- Chain”): “To do this right, we will need to Factor ‘Positive’ Taxonomy for Occurrence tion goals versus safety goals is commonly sharpen traditional investigative and analyti- Analysis” paper by B. Boudou, Y. Pouliquen, used by Safety Management System (SMS) cal skills to understand visible, high-risk in- and O. Ferrante could also be useful: programs. The positive taxonomy aims at cidents that come to our attention.” 1. Why did this incident not turn into an completing this tool with a “safety balance” Braking the chain requires having tools accident? that would leverage the “new” positive fac- to sift through the increasing number of re- 2. Was there equipment, a decision, and/or tors versus the “usual” negative ones. This ported occurrences in order to “find that a procedure that prevented an accident should help decision-makers better assess needle in a haystack that might really be from occurring? the pros and cons of a safety decision. For worth understanding...,” as noted by Del 3. In the case of an accident, could it have example, regarding the language issue for Gandio. These tools are needed because in- been more serious? air traffic control, authorities in some coun-

12 • ISASI Forum January–March 2008 tries may have to decide about implement- strengths and weaknesses of the system. dents. As we are moving toward incident ing the systematic use of the English lan- The next step could be to combine inci- investigations, why not have successes guage for radio communications in areas dent, serious incident, and accident data to tied to incidents? with significant international traffic. In such establish enhanced “reading grids” to bet- The rise of the Internet and powerful da- cases, a risk analysis should also take into ter diagnose the risks. This can currently tabases like Google have been under- account the times when the use of the local be done in hindsight. Foresight capabilities exploited for accident and incident investi- language prevented a misunderstanding of are on the horizon if we all apply the same gations. The resources offer promising safety a non-native speaker from turning into a approach to serious incidents. Safety inves- prospects if everybody shares the same hazardous situation. To have a more com- tigators could thus mine more similar inci- safety language and if taxonomies are tran- scribed into user friendly tools. The efforts already undertaken by CICTT enable safety information systems to talk to one another and safety data to have the same meaning in respective systems. This common taxonomy is an indispensable tool to define common safety issues and complementary ways to globally enhance aviation safety. Looking into the future, emerging infor- mation technologies will greatly improve our ability to collect data but, at the same time, make it even more difficult to conduct safety analyses. This is because the data- management environment is simply not equipped to handle an exponential growth of data. For example, low-cost, sensor- equipped processors are starting to be de- ployed on everything from aircraft parts to produce in the grocery stores. These sen- sors can measure and regularly report over Figure 5. Examples of “concept banks” applied to various text-based data sources. wireless networks various attributes such as locations, performance factors, or envi- plete picture of the reality of operations, the dents (precursors?) and build complete and ronmental conditions that are of interest to reporting systems must flag and record the convincing safety cases powered by more us. A single airliner equipped with thou- safety nets (that is, positive factors), such and better data. With more and more docu- sands of these low-cost sensors could report as the use of another language, which pre- ments in electronic format and numerous various parameters every second. A fleet vented accidents. If we generalize this ex- reporting systems, there is a great poten- of these aircraft could generate terabytes ample, we need to have a global and com- tial for enhanced tools (based on common of data per day and give new meaning to mon approach to ultimately producing con- taxonomies) having foresight capabilities. the expression “information overload.” sistent data to give decision-makers a more The safety investigators who provide the The technology to enable these capabili- complete picture of the aviation system. facts and data that will ultimately feed these ties is on the horizon. However, if it is diffi- analytical tools should be involved in these cult to manage aircraft accident/incident re- Safety investigator roles expanding new activities. Participation in ports, how will the information systems Safety investigators are the end-users of the newly founded international working adapt to the new technologies and their po- data systems in one way or another—either groups is more than welcomed from both tential impact? How will value be derived by entering data or by querying it for in- industry and government representatives. from the new data? How will analyses be vestigation or analytical purposes. They are The challenge consists of jointly develop- conducted and new safety hazards identified? instrumental as they collect and provide the ing a universal set of simple tools, accepted The CICTT is addressing standardiza- facts on which the safety data are based. and used by all for data-driven prevention. tion issues by developing an industrywide When the Annex 13 tools and resources CICTT could ultimately have an impact on consensus as to what business rules and are applied to serious incidents, safety in- the investigation framework if supported by naming conventions should be applied to vestigations can explore more in-depth the the various stakeholders, especially by key aviation descriptors and data elements. causal factors with clear cause and effects ISASI and its members. The long-term goal of this effort is the de- relationships, especially from a human fac- velopment of a core universal aviation lan- tors standpoint, because all actors survived The future guage that will maximize the industry’s ca- and can recollect the circumstances of the Taxonomies have evolved in line with the pability to analyze and share aviation safety hazardous buildup. More investigations on scope of investigations (technical failures data and information. The CICTT is near- serious incidents shared through the exist- in the 1950s/1960s, human failures in the ing the completion of the first phase of the ing ADREP framework could provide qual- 1970s/1980s, and organizational failures effort and will be moving on to subsequent ity data, ideally data also recording the in the 1990s). Failures are tied to acci- phases. ◆

January–March 2008 ISASI Forum • 13 Small Plane Search in Atla An example of how cooper- ation among an accredited One of the two remaining aircraft in investigation team, local the hangar at Narsarsuaq. authority, local marine profes- sionals, and the general public helped bring closure to an investigation and to the pilot’s family. By Joseph Galliker (M03322) (This article was adapted, with permission, from the author’s presentation entitled In- ternational Investigation: General Aviation Accident in Atlantic Waters, presented at the ISASI 2007 seminar held in Singapore, Aug. able to reach the coastal waters of the first The pilots of the remaining two aircraft 27-30, 2007, which carried the theme “Inter- rock islands in southern Greenland (ap- had already been telephone interviewed by national Cooperation: From Investigation proximately 45 nautical miles southwest of the investigator-in-charge. As both of these Site to ICAO.” The full presentation includ- Narsarsuaq near the “SI” NDB). The pilot pilots had communicated with the aircraft ing cited references index is on the ISASI ditched the aircraft but drowned outside the in distress, and searched for and located the website at www.isasi.org.—Editor) aircraft. pilot and the aircraft, they became prime witnesses. The two pilots stated they found n Feb. 2, 2007, three identical factory- Site investigation in Greenland their colleague floating about 70 meters new Cirrus SR20s were enroute In Greenland, aviation accident investiga- from the aircraft. The aircraft itself was Ofrom Goose Bay, Canada, to Reykja- tion falls into the jurisdiction of the Acci- afloat with the tail broken (but still at- vik, Iceland. While diverting to Narsarsuaq, dent Investigation Board of Denmark. The tached) protruding above the surface of the Greenland, due to weather ahead, the en- investigator-in-charge (IIC) proceeded to water. The sea had waves and swells (5-7 gine of one of the aircraft failed twice due Greenland to conduct the field investigation. feet). Water temperature was -1 to +1 C. to low engine oil pressure and loss of en- On arrival in Narsarsuaq, he met up with The alarm and mobilization of the local gine oil. Engine oil appeared on the wind- the representative of the aircraft manufac- emergency response plan had also been ini- shield. The engine could not be restarted. turer, engine manufacturer, and the repre- tiated immediately, and the first helicopter Gliding from cruising altitude, the pilot was sentative for the next of kin of the pilot. (AS350) reached the area within about 10 minutes. Shortly after, the first rescue heli- Joseph Galliker is the with Air Canada, Galliker developed the copter was joined by a second one (Sikorsky president of ASC Inter- first-ever seminar on emergency response S-61). The S-61 retrieved the lifeless pilot and national, Inc., and management for airlines in 1984, which flew him to the Qaqortoq hospital (30 kilo- develops customized provided an incentive for airlines meters), where he was pronounced dead. The airline emergency re- worldwide to improve their emergency S-61 helicopter “froze” the location of the sponse and family response plans and their liaison with the floating aircraft on GPS. The next day it was assistance plans. Previ- accident investigator-in-charge. He is reported that the aircraft had sunk. ously, he worked for Air Canada as a providing training to airlines and civil The days following the arrival of the IIC flight safety officer. His experience covers aviation authorities in Africa, the Carib- were plagued by extremely cold, wind, and flight safety management, aircraft inci- bean, Asia, and Europe on airline emer- snowy weather conditions. Proceeding to dent and accident investigation and hand- gency response planning and liaison with the accident site was postponed by the IIC ling, the development of airline emergency the investigation agency. He lives in the pending safe flying weather for the AS350 response and family assistance plans, as Montreal area and is married with two helicopter. well as liaison with the investigator-in- grown children. His hobbies are private The two remaining aircraft were placed charge on behalf of the operator. While flying, sailing, and snowshoe trekking. in the only hangar in Narsarsuaq, in nice

14 • ISASI Forum January–March 2008 antic Waters and cozy 20 degrees Celsius temperature. white chunks of glacier ice, fairly calm sea, the island. We returned to Narsarsuaq, Going to the hangar from the hotel was a at a distance of about 200 meters from the somewhat disappointed, but appreciating different story. High winds (100 kilometers/ shore of an approximately 50 by 100 meters what nature is like out there. hour) and cold temperatures prevailed for solid-rock island. We realized boats with sonar and barges days. The effects were, for example, that We thought it would be best to check the with cranes would be required for the next reading glasses were blown off one of the shore of the nearest island for any debris step to determine the depth of the seabed team member’s face and promptly flew or other evidence of the aircraft. Anxiously at the ditching location, then search for the “straight and level” until later the next day scanning the steep, rocky shore, we could aircraft and, if found, to lift it and bring it they were found by a search party 50 meters not see a single shred of anything but crys- ashore in the nearest town (Qaqortoq). downwind. The two aircraft were checked tal clear water (would qualify as premium But where in Greenland is such equipment for fuel level and balance, as well as service bulletin status. The days following the arrival of the IIC were plagued by Two service bulletins were of interest, extremely cold, wind, and snowy weather conditions. “Oil Breather Tube Insulation” and “Engine Winterization Kit.” They had not been in- mineral soda water in any big city). Sud- available and at what cost? By speaking with corporated for the flight. denly one team member shouted, “I see it. local fishermen, they expressed the follow- Finally, on a Saturday, the sky cleared I see it!” We all turned to his side of the ing concerns about the aircraft location and and the wind was calm. This was the time helicopter, and indeed could see the shape what could happen to the aircraft itself: to fly to the site. The intention by all was to of what looked like a white airplane under • Strong currents (north/south and tidal see if the aircraft could be seen under wa- water. A minute later, big disappointment; east/west). ter, if any debris could be spotted on the on closer investigation it turned out to be a • Icebergs in March to May to crush the shores of the nearby small rocky islands, sand patch in about 20 meters of water. We aircraft on the seabed (icebergs can reach and have the helicopter pilot comment on learned from that, as later there were simi- depths of 30 meters or more). the location of the aircraft. Equipped with lar sightings. • Angle at which the aircraft sunk to the three GPS units, we set off. One of the GPS Flying further out from the shore of the bottom of the seabed. units was a Garmin 295 with maps for island, another call “for stop it” occurred. • Seabed surface could be anything from Greenland. This time it was clearly a paper page like a large rock boulders to sand or steep inclines On the way, the pilot showed us some flight plan or chart, floating horizontally or crevasses. earlier crash sites—all well preserved, about a meter under the surface of the wa- • The depth at the site. There are some re- some dating back to the second World War. ter. The location was about 300 meters far- cent charts that show general and sparsely The coastal islands were clearly visible on ther out to sea from were the aircraft had measured depths farther out (~241 the maps of the GPSs, and we soon found been ditching. We searched for an amount meters). the spot matching the coordinates taken of time but could not find anything else, but at the site on the day of the rescue opera- we were getting a feel for the ditching and Aircraft search tion. The site was open water, with some pilot rescue locations and their reference to The investigator-in-charge discussed the search for the aircraft with Greenland and Danish authorities. It became clear that the cost would be prohibitive. The wife of the pilot asked her representative to the inves- tigation to explore a “low-cost solution,” to find and raise the aircraft. She felt she needed to see the aircraft for closure. In June, with permission and cooperation of the IIC, the representative for the pilot began to contact the local police (Qaqortoq), which provided contacts to local owners of boats. It became soon clear that the re- sources were limited. The representative One of the two remaining aircraft—oil breather tube. proceeded to Narsarsuaq then to Qaqortoq

January–March 2008 ISASI Forum • 15 LEFT: Trawler with drag net. MIDDLE: summarized: “We can find the aircraft as our anchor, we felt a net could do a better job Danish Navy charting ship—SKA-12. drag net can trawl to 300 meters. Also at a and began the trip back to Qaqortoq (2.5 RIGHT: The two ships surveying the depth of around 100 meters, we can snag it hours). seabed in the site area. with the net and lift it and bring it right into We were satisfied with the work we had this harbor.” He then showed and explained performed and the information we were to inquire and speak with local professionals the gear and the measuring and navigation able to bring back. The following is a list: in person. The plan was to find someone who equipment—latest state of the art. • Checked the shore of the island for evi- could scan the seabed at the site with an echo He suggested that I go with the diver and dence—nil found. sounder, then if the aircraft was spotted, try survey the seabed in the area around the • Measured and recorded the depths and to lift it. How, was not clear yet. Speaking to crewmembers of the Dan- This experience is a good example of cooperation among an ish Ice Patrol Unit based in Narsarsuaq investigation team with accredited members, local brought forward good maps of the site area. authority, local professionals, and general public to help the They had checked the site from time to time by flying over it with their helicopter. They investigation (cause) and the pilot’s family (closure). also suggested contacting the only diver in GPS coordinates of the aircraft last seen, make up of the seabed in the greater site the area, as he had lots of experience find- to provide him a feel for the make up of the area. ing “things” under water. They also sug- ground (level sand, boulders, or crevasses, • Confirmed witness statements by heli- gested contacting two Danish Navy ships, etc.) as well as the exact terrain depths a copter and two Cirrus aircraft pilots as to which were on a mission to chart the south- few hundred meters around the site. the distance from shore to aircraft and pi- ern Greenland seabed out of Qaqortoq. The diver was available the next day, and lot, which was measured. They had been docking in Qaqortoq harbor with good planning we went off to the site • Checked performance of a certain type for the last few weeks. “How lucky can one (25 kilometers from Qaqortoq). On the way, of immersion suit by wearing it while float- get,” I thought to myself. one of the Danish Navy ships, the SKA-12, ing in the sea or a period of time. It took a while to find the diver (Kaj), as appeared on the horizon. Our captain con- • Marked the point of “interesting returns” he was held in a remote location by bad tacted it by radio to ask about exact depths by the echo lot. weather. His wife, however, provided good in the site area. In a cooperative tone of voice, • The feeling of actually having been at the information of his capabilities. Not only was an officer came back and asked for the site site. he a diver, but he also owned two 10-meter coordinates. Ten minutes later we received The investigator-in-charge was briefed. boats, well equipped with echo lots (as they depths of several locations in the site area. The next step should now be the dispatch are called locally). In the meantime, wan- We proceeded and found the exact site of the trawler, fully staffed and accompa- dering around the harbor in Qaqortoq and with the help of the GPS coordinates taken nied by the diver and his staff. The cost speaking with people also provided hope for last February. Scanning the seabed with should be reasonable, as the trawler is ex- finding the aircraft and lifting it. No sight echo lots on each of the ships, the seabed pected to complete the search in 1 or 2 of Danish Navy ships though. They had left showed up as a level plateau bordered by days. in the morning, bound to be at sea for a few the rock island on one side, by a rise in ter- This experience is a good example of co- days. rain (42 meters depth) on the north/east operation among an investigation team with Walking one evening on the pier, I saw a side, and a plateau of about 300 meters accredited members, local authority (Ice 20-meter trawler come in and moor. Look- length, parallel to island (depth 70 meters), Patrol, Police, Danish Navy), local profes- ing at the net, it seemed massive with steel then a shallow drop to the open sea. Boat sionals, and general public to help the in- balls and huge grommet-like rubber rings. No. 2 was searching the south end of this vestigation (cause) and the pilot’s family “What can you do with this net?” plateau when he called on the radio, “I got (closure). ◆ “What do you have in mind?” the cap- something unusual here. I can not identify tain/owner asked. it, but there is something here.” Editor’s note: The Danish AIB has since “Looking for an aircraft out in the We began to drag with the anchor for a contracted the trawler for the recovery of Niaqornaq Island area.” while in the area, recording the tracks of the aircraft. The recovery operation is “How big is the aircraft?” After he under- the ships at the same time. pending weather conditions and iceberg stood the situation and possible depths, he After about an hour of dragging with an movements.

16 • ISASI Forum January–March 2008 Safety and Cultural Challenges

The key to successful cooperation is certainly the capacity and the will to listen to one’s interlocutors, to understand the cultural and historic differences, and to make compromises. Sochi accident By Alexey Morozov, IAC (Interstate Aviation Committee), Russia and Sylvain Ladiesse, BEA (Bureau d’Enquêtes et d’Analyses pour la sécurité de l’aviation civile)

(This article was adapted, with permission, consequently, to a common agreement on operation in case of an accident. However, from the authors’ presentation entitled Rus- working methods. Investigators applying this framework leaves wide scope for inter- sia/France: Safety and Cultural Challenges basic human values such as adaptability and pretation as to the concrete outcome of this in International Investigations, presented at the capacity for dialogue can overcome cooperation. In practice, there are many the ISASI 2007 seminar held in Singapore, these impediments. cases where the various participants work Aug. 27-30, 2007, which carried the theme Annex 13 to the Chicago Convention sets in isolation without any interaction. Equally, “International Cooperation: From Investi- out the international standards for techni- at times, reports arrive at the destination gation Site to ICAO.” The full presentation cal investigations, and thus provides a with no warning, or comments issued by an including cited references index is on the framework for bilateral or multilateral co- investigative body are not taken into ac- ISASI website at www.isasi.org.—Editor) Alexey N. Morozov, 36, responsible for all IAC activities in the lobalization has created many chal- graduated from Moscow field of accident investigation. lenges to society in terms of the Aviation University as a Gtransfer of knowledge and know-how. specialist in flight dynam- Sylvain Ladiesse, 31, It has highlighted the need for humans to ics, aircraft control received a master’s degree in adapt themselves to systems and activities systems, and flight tests. aerospace engineering and outside their usual orbit, and to understand He joined the Interstate Aviation aviation operations from the cultural differences in order to further in- Committee (IAC) in 1994. In 1997 he French National Civil ternational cooperation. Aviation accident became the head of the FDR Research Aviation School (ENAC). He investigations require close international Division, and in 1998 the vice-chairman joined the BEA in 1999 and acted as cooperation between states, whether they of the IAC Air Accidents Investigation investigator-in-charge, accredited are involved in design, manufacture, opera- Scientific and Technical Support representative, or group leader on many tions, registration, or through the passen- Commission. In 2005 Alexey became the investigations. As of September 2007 he is gers on board. chairman of the Air Accident Investiga- resident twinning advisor in Ukraine in Language barriers and cultural differ- tion Commission and from 2006, the framework of a European project ences are the main obstacles to a correct keeping the previous position, he was aimed at implementing the JARs. Sylvain understanding of the approach taken, and promoted to IAC vice-chairman, holds a commercial pilot’s license.

January–March 2008 ISASI Forum • 17 Irkutsk accident count. Such cases compromise the mutual confidence necessary between investigative bodies and fail to meet our goal of improv- ing safety. During 2006, the Commonwealth of In- dependent States (CIS) suffered three ma- jor accidents, two of which involved Airbus airplanes. The first occurred in May near Sochi and the second in July at Irkutsk. The Interstate Aviation Committee (IAC) con- ducted the investigations, and the French BEA (Bureau d’Enquêtes and d’Analyses pour la sécurité de l’aviation civile) partici- pated as state of design. The two states had signed a memoran- dum of understanding in 1993, which was renewed in 2005. They worked together in the context of an A310 accident investiga- tion in 1994. This collaboration brought to light different working methods. Neverthe- (pitch attitude, altitude, vertical speed) by The Interstate Aviation less, the two events that occurred in 2006 the copilot and the absence of proper reac- Committee (IAC) conducted allowed the IAC and the BEA to get to know tion by the crew to the EGPWS warnings. each other better, to develop a climate of The high degree of cooperation between the investigations, and the confidence, and to overcome cultural differ- the French and Russian investigators en- French BEA (Bureau ences. The progress of the investigation into sured that the lessons learned in the course d’Enquêtes and d’Analyses the Irkutsk accident reflected this positive of this investigation, both in technical and pour la sécurité de l’aviation state of mind and showed a strong desire to human terms, could subsequently be ap- work together for the benefit of safety. plied in case of another accident. These les- civile) participated as state of sons were able to be applied only 3 months design. The two events that The events later at Irkutsk. occurred in 2006 allowed the Sochi—On May 2, 2006, at 22 hours 13 min- Irkutsk—On July 8, 2006, at 22 hours 44 IAC and the BEA to get to utes UTC, an A320, registered EK-32009 minutes UTC as it was landing at Irkutsk and operated by Armavia Airlines, was un- Airport, an A310, registered F-OGYP and know each other better, to dertaking a passenger flight from Yerevan, operated by OAO Aviakompania Sibir, develop a climate of Armenia, (CIS) to Sochi, Russia, (CIS) at landed, overran the runway end at approxi- confidence, and to overcome night in instrument meteorological condi- mately 180 kilometers/hour and at a dis- cultural differences. The tions and crashed into the Black Sea near tance of 2,140 meters and on a magnetic Sochi Airport. The IAC was advised of the bearing of 296° from the aerodrome refer- progress of the investigation accident on May 3, 2006, at 02 hours 15 min- ence point and collided with the perimeter into the Irkutsk accident utes Moscow time. fence. The aircraft broke apart and burst reflected this positive state of The IAC’s final report concluded that the into flames. One hundred twenty five people mind and showed a strong crash resulted from controlled flight into died, including both pilots and three cabin terrain while attempting a climbing maneu- crew. Sixty passengers and three cabin crew desire to work together for the ver after an aborted approach to Sochi Air- suffered physical injuries of various degrees benefit of safety. port at night, with weather conditions be- of severity. low the established minima. While perform- A commission appointed by the IAC con- as their advisers from Airbus and P&W, ing the climbout with the autopilot ducted the investigation into the accident. participated in the investigation. disengaged, the captain, while under stress, Specialists from the Federal Transport During the course of the investigation, made nose-down control inputs due to a loss Oversight Authority, Rosaviatsia, Rosaero- the Commission requested information of pitch and roll references. navigatsia, Irkutsk Airport, the airlines about the cabin reconfiguration carried out Subsequently the captain’s pitch inputs Aeroflot, Rossiskiye avialini, and Sibir, as by Lufthansa Technik (Germany). In accor- were insufficient to prevent the accident. well as the accredited representative from dance with ICAO Annex 13, this informa- Along with the inadequate control inputs the BEA as state of design, manufacturer, tion was provided via the BFU (Bundes- by the captain, contributory factors to the and registry (France), and from the NTSB, stelle für Flugunfalluntersuchung), which accident were the lack of necessary moni- who represented the state of the engine also appointed an accredited representative. toring of the aircraft descent parameters developer and manufacturer (U.S.), as well The IAC completed the technical inves-

18 • ISASI Forum January–March 2008 tigation in May 2007 and concluded— international agreements. IAC activities as a bridge to the safety recommendations “The cause of the accident to the A310 related to investigations fully conform to that follow. F-OGYP operated by Siberia airlines was recommended international practices, in In the case of a major investigation, the erroneous and uncontrolled actions by the particular Annex 13. government Commission that is usually cre- crew during rollout after landing in a con- The BEA was created in 1946 and is at- ated to deal with the aftermath of an acci- figuration with one thrust reverser deacti- tached to the Ministry of Transport. The dent and to arrange support for the fami- vated. After touchdown, the captain, while BEA carries out investigations and issues lies of the victims has to be informed rela- acting on the reverse thrust lever of the its reports in a completely independent tively rapidly on the causes of the accident. right engine, inadvertently and in an manner. Its offices and technical services Thus, the IAC has to provide the “Conclu- uncontrolled manner moved the throttle are located in the Paris region at Le Bourget sion” of the investigation report before the lever of the left engine, whose thrust re- Airport. It also has regional offices in consultation procedure on the whole draft verser was deactivated, from the ‘idle’ to Toulouse, Bordeaux, Rennes, and Aix-en- final report is fully completed by foreign significant forward thrust position. Provence. parties to the investigation. Inadequate monitoring and call-outs of air- In addition, in the context of Annex 13, The IAC’s reports are mainly intended craft speed and engine parameters by the the BEA represents France in investiga- for those in the aeronautical world, and it copilot did not allow the crew to perform tions carried out abroad for any accident or organizes a conference specifically for them the necessary actions, either of moving the incident involving at the end of the investigation. Only the fi- left throttle back to idle or of shutting down • an aircraft of French design or manufac- nal sections of the report are usually made the engine. The crew had enough time to ture or registry (for example Airbus and public. The rest of the report is supplied recognize the situation.” ATR airplanes, Eurocopter helicopters). upon request. • an aircraft operated by a French airline For the investigation into the accident that IAC—BEA: Two organizations, (Air France, Corsair...). occurred at Irkutsk, the BEA nominated an two approaches • French passengers. accredited representative in its capacity as The IAC was established in December 1991 The European directive on aviation acci- state of design, manufacture, and registry. pursuant to the Intergovernmental Agree- dent investigations specifically forbids that Airbus provided technical advisers for the ment on Civil Aviation and Use of Air Space, investigations aim to apportion blame or li- accredited representative. In addition, since which was concluded by 12 newly indepen- ability to persons or companies involved in the responsibility for continuing airworthi- dent states (CIS) with a view to the event. ness for A310s had been transferred from • preserving common aviation rules and the DGAC to the European Aviation Safety airworthiness standards, Different working procedures Agency, the BEA kept the Agency informed • maintaining a unified system for certifi- The IAC and the BEA work according to throughout the investigation. cation of aviation equipment and its manu- the standards and recommendations set by facturers and international categorized Annex 13 as well as to internal procedures, Environmental challenges aerodromes and their equipment, which may differ. Some examples of these In an international investigation involving • conducting independent investigation of specific features include: five investigative bodies (IAC, BEA, NTSB, aircraft accidents, and The IAC designates a Commission of In- AAIB, and BFU), there were numerous • coordinating the efforts in the area of civil quiry that plays the role of investigator-in- challenges. Initially they were environmen- aviation development and harmonizing the charge in a collegial manner. Its members tal, especially during the first few days of national programs development of air traf- may or may not come from the IAC, but they the investigation. The accident site (Irkutsk, fic organization systems. are generally chosen for their specialized in eastern Siberia) was a long way from the The IAC operates on the basis of, and in technical knowledge. The investigator-in- headquarters of each of these investigative full compliance with, applicable interna- charge directs this Commission, which itself bodies, which complicated communications. tional law and national laws of the member supervises sub-commissions and working As an example, the distance between states, exercising the powers vested in it by groups. The latter work independently and Irkutsk and Moscow, where the IAC’s head- presidential and governmental decrees and provide reports to the Commission. quarters is located (and thus the laborato- appropriate legislative acts. Its headquar- Accredited representatives have access ries where the CVR was read out), is 8,000 ters is located in Moscow. to all of the information gathered by inves- kilometers and there is a 5-hour time dif- The principal aim of the IAC is to ensure tigators, but they are not invited to work ference. safe and orderly development of civil avia- within the sub-commissions or working Further, Russia is a country where Eu- tion and efficient use of air space by the groups. ropean Union and U.S. citizens can only states that are party to the Agreement. The final report includes an additional enter with a visa. Having a dozen visas is- The IAC investigates all aircraft acci- paragraph, compared with the format rec- sued on a Sunday was one of the challenges dents that involve aircraft from its mem- ommended by the ICAO, which is entitled that the IAC had to overcome in order to ber states whether they occur on their ter- “Shortcomings” and groups together all of bring in the accredited representatives and ritories or elsewhere, as well as other air- the failings identified by the Commission their advisers. craft accidents covered by the appropriate in the course of the investigation and acts Russian is one of the six official ICAO

January–March 2008 ISASI Forum • 19 A desire for cooperation and consensus was present languages and was naturally the working throughout the investigation. ments relating to the investigation, were language in Irkutsk during work on gath- It made it possible to done on the basis of a consensus reached ering the facts. Within the BEA-Airbus complete the investigation among Airbus, the IAC, and the BEA. The team, few investigators spoke any Russian, and publish the report within final report was then considered at a pre- and among the members of the Commis- paratory meeting in the presence of the sion and sub-commissions present in 10 months of the accident. All accredited representatives before being Irkutsk, few investigators spoke English. of the participants reached a sent out for consultation. Finally, at the Lots of the difficulties in communication common understanding of the request of the BEA, the IAC organized a and in comprehension were caused by this event and, in addition, the review meeting with the accredited repre- absence of a common language. For ex- sentatives and the advisers from Airbus in ample, the evening work progress meetings BEA and the NTSB had no order to discuss the integration of the vari- were held in Russian, and even if the BEA- further comments to make on ous comments. Airbus team members were invited to at- the final report following the Both the BEA and the IAC remained tend, they could not understand the infor- various consultations. patient and open-minded throughout the mation shared by the members of the Com- investigation—initially, during the fact- mission of Inquiry. to take into account all of the comments made gathering phase in Irkutsk, then when faced on both the Russian and English versions. with the BEA’s supposed “slowness” and Cultural challenges Communicating facts to outside organiza- the IAC’s supposed “overlooking” things, During 2006, in the space of 4 months, the tions was also a major challenge in this in- and finally during the various revisions to IAC had to investigate three major acci- vestigation. After the FDR readout, the air- the final report. dents that caused the deaths of more than plane manufacturer relayed to the IAC and The difference in culture implied long 400 people. The IAC and the CIS aviation to the BEA the pressure that it was under meetings, during which certain paragraphs system were subjected to enormous media from operators to communicate data. The could be discussed for several hours, but all pressure, which obliged them to keep up a IAC was not yet ready to communicate this of the participants maintained their desire very demanding pace. This pressure was data. Equally, the IAC, due to public pres- for a consensual approach. In fact, the key naturally passed on to the BEA, which thus sure, had to communicate the “conclusions” to successful cooperation is certainly the had to respond to the pace. The IAC some- of the investigation very early on, and the capacity and the will to listen to one’s inter- times had the impression that the BEA was BEA had to comment on the findings and locutors, to understand the cultural and his- slow in responding to its requests, which the conclusion of the report before having toric differences, and to make compromises. seemed to it to be urgent, while for its part access to the factual and analytical sections. This desire for cooperation and consen- the BEA sometimes had the impression Investigative cultures differ, and these sus was present throughout the investiga- that this sustained pace implied that some differences came to light in the final report tion. It made it possible to complete the in- things were being overlooked. and the comments that the BEA made dur- vestigation and publish the report within 10 Understanding a different aeronautical ing the consultation phase. The report in- months of the accident. All of the partici- system was also a challenge that had to be cludes, for example, in the part entitled “Ad- pants reached a common understanding of taken up by both sides. For the IAC, this ditional Information,” some points of view— the event and, in addition, the BEA and the meant understanding the relationship be- thus not factual—expressed by specialists NTSB had no further comments to make tween Airbus, the DGAC, and the EASA, as who participated in the investigation. On the on the final report following the various con- well getting to grips with the A310’s systems, other hand, some comments made by the sultations. The IAC published the most its documentation, and its ergonomics—so BEA were quite unexpected and presented important parts of the report (the analysis, different from that of Russian airplanes. For the IAC with some difficulties in integrat- the findings and the conclusion, the short- the BEA it meant understanding the rela- ing or adding them to the report. comings, and the safety recommendations) tionship between Sibir, Rosaviatsia, and the on its website. FTOA, as well as the airplane’s operational Cooperation The best example of this cooperation environment in Russia. The approach decided on from the very concerns the safety recommendations. The report had to be translated into En- beginning of the investigation was complete The BEA proposed several improvements glish and the translation validated by the openness. Each investigative body had ac- to the safety recommendations written by IAC in order to have a common document to cess to all the data. The investigators passed the IAC, so as to extend the application work with. Some concepts essential to an on any new data significant to the under- of some of them to operators outside the understanding of the report turned out to standing of the event as soon as they got it. CIS and for others to be addressed to all be very hard to translate, such as, for ex- Subsequently, the IAC took the time, airplane manufacturers, underlining the ample, the Russian word “Kontrol,” which despite heavy media pressure and the ur- fact that some themes were specific nei- simultaneously means “observation, moni- gency of publishing the report rapidly, to ther to the CIS nor to the Airbus A310. toring, and feed back.” Using an English consult the BEA before communicating In the final wording of its safety recom- version as a basis for discussion also meant any facts relating to the event. Airbus com- mendations, the IAC took into account all that the IAC duplicated its work, since it had munications, with its operators on ele- of the comments. ◆

20 • ISASI Forum January–March 2008 ISASI Council Completes Heavy Agenda PHOTOS: E. MARTINEZ (Compiled from Council meeting minutes prepared by Secretary Chris Baum and agenda, there was a brief review of the cur- Council member written reports.—Editor) rent seminar plans and programs with no problems noted. Also included was a review he ISASI International Council meet- of the potential for a monetary grant by the ing in Singapore on Aug. 26, 2007, set Singapore Tourism Board. Seminar regis- Tthe 2008 budget, affirmed the cash tration figures were also reviewed. award to accompany the annual seminar In conjunction with the review of min- “Best Paper” selection, gave the National utes from the May 2007 meeting, several Societies permission to waive the late dues discussions of unresolved issues and items payment fee and the delinquent member re- took place. The question of copyrighting the instatement fee, and disbanded the Posi- terms “Reachout” and “Forum” was revis- tions Working Group. In addition, reports ited. However, no further determination of were received from Council executives, TOP: Council in session, left to right, the feasibility of, or process for, copyright- working groups, and committees. C. Baum, D. King, R. Chippindale, ing these terms had been achieved. Inves- President Frank Del Gandio called the R. Stone, F. Del Gandio, R. Schleede, tigation into the matter continues. meeting to order. Attendees included Dick A. Schull (guest), L. Naylor, J. Purvis, There was a continuation of the discus- Stone, Executive advisor; Ron Schleede, and B. Dunn. ABOVE: President sion begun in May regarding waiving late vice-president; Chris Baum, secretary; Del Gandio makes his report as and reinstatement fees for delinquent mem- Toby Carrol, proxy for Curt Lewis, U.S. R. Schleede looks on. bers. This in turn led to further discussion councilor; Ron Chippindale, New Zealand about the lack of growth in membership in councilor; Barbara Dunn, Canadian coun- general. Existing bylaws do not address late cilor; Caj Frostell, international councilor; fees, but a proposed revision to bylaws cur- Lindsay Naylor, Australian councilor; David rently under review would cancel the rein- King, European National Society president; statement fee. Current common practice is John Purvis, chairman, Corporate Affairs to waive late fees on a case-by-case basis; Working Group; Chan Wing Keong (with most, but not all, fees are being waived in guests), chairman, ISASI 2007 seminar; this manner. Discussion showed that be- Marty Martinez, editor, ISASI Forum; and cause late fees stay at the local level, waiver Ann Schull, ISASI office manager. authority, should any be granted, should be Prior to discussing items on the published at that level as well. It was then moved and

January–March 2008 ISASI Forum • 21 seconded that late fees be waived at the dis- proceeds are listed as $10,000 in accordance cretion of the National Societies. That mo- with existing guidelines….” He noted, how- tion passed, with the notation that reinstate- ever, that profits from the past three semi- ment fees are likely to be eliminated with nars have been well over the projected neg- the pending bylaws revision. ative figure. The Council approved the bud- Continuing his report, Frank com- get as submitted. mented that ISASI issued formal seminar Executive Advisor Dick Stone an- invitations to government investigating nounced the Kapustin Scholarship win- and/or regulating bodies of 87 countries ners: Phillip Gregory (Embry-Riddle and asked if the Council felt this practice Aeronautical University), Marissa Liquori should be continued. The consensus was (Pottsdam University of New York), and that it should. Frank then briefed the Ruth Martin (Cranfield University). There Council on concerns that had been ex- was additional discussion on the Scholar- pressed by some presenters at the current ship in general. The suggestion was made seminar that their papers, if selected as to solicit donations for the Fund at semi- backups, would not be published in the nars. It was pointed out that US$1,500 ISASI Proceedings. He reiterated the ex- doesn’t go far in supporting seminar at- Chan Wing Keong provides isting general policy that all papers will be tendance by the winners. Possible ways to last-minute details on ISASI 2007, on the conference CD-ROM provided to address this were raised, including using of which he was chairman, as attendees, but only those actually pre- a complimentary corporate registration or B. Dunn listens. sented will be published in the ISASI Pro- being more innovative in soliciting airline ceedings. Regarding the Kapustin schol- support. arship awards, he clarified that the free Dick also commented on the process TSI and SCSI courses awarded to winners used to select the best seminar paper. A do not need to be used within a year. committee comprised of Dick Stone, Gra- Frank related a question that had arisen ham Braithwaite, and two others makes regarding a corporate member’s represen- the selection. Dick pointed out that the tative who is not an individual member be- Council had not acted on a monetary award ing selected as an ISASI Fellow. It was for the best paper. It was moved and sec- pointed out that such a representative is onded that a US$500 award should be entitled to free individual membership, but given to the author(s) of the winning pa- that the individual must nevertheless ap- per. It was further clarified that the award ply for the membership for it to be acti- would be for the paper and the total vated. The discussion revealed that there amount awarded would remain US$500 re- is a need for a briefing to the Council on gardless of the number of authors. The what past practice has been and what writ- motion passed. ten guidance exists regarding the status Regarding the status of the Human Fac- of the primary and alternate representa- tors Working Group (HFWG), of which he tives of a corporate sponsor vis-à-vis their is chairman, Dick will give a status report individual membership status. Tom at AIG 08. At that time, he hopes the HFWG McCarthy and John Purvis will brief the has several modules completed. Council in May. Treasurer Tom McCarthy provided a National Societies/Councilors written report and comprehensive 2008 Lindsay Naylor, ASASI, reported a mem- budget outline for the Council’s review and bership of 146 and announced the resigna- approval. In his report, Tom projected a tion of President Ken Lewis and that he had negative cash flow of $29,700. He added, been elected to the position. ANZSASI 2008 “While our negative net income figure is a will be held in Adelaide to coincide with the bit frightening, remember that seminar net 30th anniversary of ASASI.

22 • ISASI Forum January–March 2008 Barbara Dunn, CSASI, reported no quent, 133 current corporate members, and change had occurred in the Society since 15 with past-due accounts. Newly recruited May. members for 2007 were 154 individual and David King, ESASI president, supple- 11 corporate. The goal remains to achieve mented Anne Evans written report and 200 new individual members and 10 corpo- added that the proposed spring 2008 Euro- rate members per year. The program to pean seminar may be done in collaboration waive processing fees for new individual with Cranfield and will use the university members joining in conjunction with an as its venue. The format is expected to be a ISASI seminar is considered successful. 1½-day technical program. A companion However, the program to increase Latin program is not being planned, although American membership by reducing fees has there may be a tour after the seminar. The not resulted in any increase in membership goal is to develop an event with zero regis- applications. Both programs will continue tration cost. to be monitored. Ron Chippindale, NZSASI, reported as Ron Chippindale, Board of Fellows, noted the main activity the hosting of the that the Committee determined the US$100 ANZSASI seminar in Wellington in June, application fee should remain and be paid which drew 127 registered participants. Ten “up front” with half of the fee (US$50) be- participants presented membership applica- ing returned if the applicant is unsuccess- International councilor C. Frostell tions. The Society will support the 2008 ful. There have been no new applications. discusses the ISASI Reachout ANZSASI. Also, NZSASI is considering bid- Tom McCarthy, Nominating, reported program. ding for the 2012 or 2013 ISASI annual semi- that 2008 is an election year. Deadline for nar. Ron submitted a written report. nominations is April 1. He said the Council Caj Frostell, international councilor, re- needs to revitalize the Nominating Commit- ported on upcoming Reachout Workshops: tee, as he intends to resign as chairman and May 2008 in Kiev and Pakistan and Abu will not be able to serve on the Committee. Dhabi in November 2007 [occurred Novem- He recommended that a society or chapter ber 25-28]. He said the next Reachout will president be appointed as Committee chair mark more than 200 people trained in pro- and that each society/regional chapter grams. He noted that ICAO has not pro- should have a representative as a member. vided financial support for the Reachout He also noted that affected international effort since an initial contribution. The gen- Council members should decide if they wish eral concept (as opposed to specific to run again and make the chairman aware amounts) of ICAO funding can be addressed of their decision. at AIG 08. Caj noted that it would be help- Barbara Dunn, Seminar, reported that ful to have an education campaign to help preparations for the 2008 seminar in Halifax ICAO members understand what ISASI is are in good shape. The hotel contract is and does. Dave King asked for a Reachout signed and the technical program is form- in Malawi to be considered. ing. There have been no significant devel- opments in the preparations for the 2009 ISASI Committees seminar in Orlando or 2010 in Sapporo. Darrren Gaines, Bylaws, reported the by- The Positions Working Group put for- laws revision is complete. Voting instruction ward the question whether a standing WG has been sent to the membership to allow a is necessary or if positions should be devel- vote on accepting the revised bylaws. Vot- oped on an as-needed basis. Following ing may be done by paper ballot or elec- Council discussion, the standing Positions tronically. WG was dissolved and the Council directed Tom McCarthy, Membership, reports that issues will be dealt with as the need 1,409 members in good standing, 118 delin- arises. ◆

January–March 2008 ISASI Forum • 23 ISASI ROUNDUP

ISASI 2008 Set for Halifax, Canada

The International Society of Air Safety ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ Hotel, 1919 Upper Water Street, Halifax, ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ The schedule for submission of paper Investigators 39th annual international Nova Scotia. The hotel is located on proposals for ISASI 2008—indication of conference on air accident investigation, Halifax harbor in the center of historic interest and subject matter (for readers “ISASI 2008,” will be held in Halifax, downtown. The Marriott is close to shops, of the Forum) March 1. A detailed Canada, September 8-11. The conference historical sites, and nightlife. The city itself abstract is due May 1, and the final paper theme is “Investigation: The Art and the was established in 1749 and is one of the in electronic format is due July 1. Science.” The event is being hosted by the world’s most strategic harbors, having All submissions may be made to Canadian Society of Air Safety Investiga- been an integral part of the Allied war Stewart electronically at e-mail: tors. Members of that group are serving effort during both World Wars. Known as [email protected], and in hard copy to as the workforce for organizing the event. “A Navy Town,” Halifax, as well as the 307-1500 Riverside Dr., Ottawa, ON, The Seminar Committee consists of province of Nova Scotia itself, has a strong Canada, K1G 4J4. ◆ Chairperson Barbara Dunn, who also civil and military aviation history. As the serves as the Society’s president; home of Maritime Command for the ISASI Executive Technical Program, Jim Stewart and Nick Canadian Forces, Halifax has been host to Stoss; Sponsorship, Ron Schleede and Joe members of the military from five conti- Nominations Due April 1 Jackson; Companion Program, Gail nents. The Maritime Provinces have also Nominations for election to the ISASI Stewart and Paula Demone; and seminar been an essential component in the offices of president, vice-president, registration is being handled by Sharon development of transatlantic and interna- secretary, treasurer, U.S. councilor, and Morphew and Gary Morphew. tional civil aviation. international councilor for the term 2009- Dunn says the Seminar Committee will Seminar details as to costs and 2010 are due to the Nominating Commit- honor the 100th anniversary of the programming are now in the reconcilia- tee by April 1. construction of the Silver Dart at tion stages and will be posted in the next Each potential candidate whose name Baddeck, Nova Scotia, in late 1908. Built issue of ISASI Forum, as well as on the is submitted to the Nominating Commit- by the Aerial Experiment Association, seminar website, which is also nearing tee must have consented to the submis- chaired by Dr. Alexander Graham Bell, completion. sion. The nominator must submit a short the Dart first flew on Feb. 23, 1909. John In announcing the seminar’s Call for biographical sketch of the nominee. A.D. McCurdy took off from a frozen lake Papers, in support of the theme “Investi- Nominees must be at least a full member completing the first controlled power gation: The Art and the Science,” Jim in good standing to be eligible for office flight in Canada and the British Empire. Stewart said, “We are looking for papers within ISASI. Nominations should be sent Made of steel tube, bamboo, friction that will deal with the hard and soft to the ISASI office, attention Nominating tape, wire, and wood, the Dart was aspects of investigation, in particular, Committee. ◆ powered by a V-8 engine, supplied by new ideas that will lead us to improved Glenn Curtis, which developed 35 ○○○○○○○○○○○○○○○○○○○○○○○○○○ investigation, whether it be techniques, ○○○○○○○○○○○○○○○○○○○○○○○○○○ horsepower at 1,000 rpm. The Canadian management, process, technology, CORRECTION Army looked upon the aircraft with factual analysis, high tech, or low tech. skepticism, believing that airplanes would The subject matter can be as broad as never amount to much in actual warfare. the imagination or expertise of the The Silver Dart was flight tested at presenter. The Technical Committee Petawawa, Ontario. On its fifth flight, wants to reach beyond the normal while trying to land on sandy terrain, one papers and explore new ideas. We are wheel struck a rise in the ground and the also very interested in hearing from full- craft was wrecked. On the 50th anniver- time investigators or agencies that have In the October/December issue of sary, a replica was flown at Baddeck to recent experience with new techniques or Forum, the caption of this photo of commemorate that first flight. The legacy processes and their experiences in an ISASI 2007 speakers’ panel of the Silver Dart continues to live on, and applying them. For the art side, we are incorrectly identified N. Athiniotis the replica is on constant display in the interested in subjects ranging from as L. Anthinotas (first person on Canadian Aviation Museum in Ottawa. dealing with the news media and relatives left). We apologize for this over- The 3-day technical program will be to interview techniques. The art of sight.—Editor held at the Halifax Marriott Harbourfront communication may also be worthwhile.”

24 • ISASI Forum January–March 2008 2007 Annual Seminar Proceedings Now Available

Active members in good standing and page at http://www.isasi.org. The seminar US$75 fee. A limited number of paper corporate members may acquire, on a papers can be found in the “Members” copies of Proceedings 2007 are no-fee basis, a copy of the Proceedings section. Alternatively, active members available at a cost of US$150. Checks of the 38th International Seminar, may purchase the Proceedings on a CD- should accompany the request and be held in Singapore Aug. 27-30, 2007, by ROM for the nominal fee of $15, which made payable to ISASI. Mail to ISASI, downloading the information from the covers postage and handling. Non-ISASI 107 E. Holly Ave., Suite 11, Sterling, appropriate section of the ISASI web members may acquire the CD-ROM for a VA USA 20164-5405.

Preface: Welcome to Singapore Using Checklists as an Investigator’s Tool SESSION 5—Moderator Danny Ho By Frank Del Gandio, President, ISASI By Al Weaver International Cooperation and Challenges: Opening Address: Importance of Interna- Understanding Cross-Cultural Issues tional Cooperation in Aircraft Accident SESSION 3—Moderator Alan Stray By Dr. Wen-Chin Li, National Defense Investigation Finding Nuggets: Cooperation Vital in Efforts University; Dr. Hong-Tsu Young, Taiwan, By Raymond Lim, Minister for Transport to Recover Buried Data ASC; Thomas Wang, ASC; and Dr. Don and Second Minister for Foreign Affairs, By Christophe Menez and Jérôme Projetti, BEA Harris, Cranfield University Singapore International Investigation: General Aviation Very Light Jets: Implications for Safety Keynote Address: Sharing Experience Accident in Atlantic Waters And Accident Investigation And Knowledge By Joseph Galliker, ASC International, Inc. By Dr. Robert Matthews, Ph.D., FAA By Mark V Rosenker, Chairman, U.S. Standardizing International Taxonomies for Enhanced Airborne Flight Recorder National Transportation Safety Board Data-Driven Prevention (EAFR)—The New Black Box Lederer Award Recipient: ‘Independence By Corey Stephens, Air Line Pilots Association; By Jim Elliot, G.E. Aerospace and Integrity’ Mark Tom McCarthy Oliver Ferrante, BEA; Kyle Olsen, FAA; and RSAF: Analysis and Investigation; Tools By Esperison Martinez, Editor Vivek Sood, FAA and Techniques Midair Collision Over Brazilian Skies— By Lt. Col. Suresh Navaratnam, Republic of SESSION 1—Moderator David McNair A Lesson to Be Learned Singapore Air Force (RSAF) Royal Australian Navy Sea King Accident By Col. Rufino Antonio da Silva Ferreira, José Wet Runway Accidents—The Role of Investigation—Indonesia April 2, 2005 Mounir Bezerra Rahman, and Carlos Eduardo Fatigue and Coercive Habits By Nicholas Athiniotis and Domenico Magalhães da Silveira Pellegrino, Brazilian By Capt. A. Ranganathan Lombardo, Defence Science and Technology Aeronautical Accident Investigation Commis- Organization, Australia sion (CENIPA); William English, NTSB; and SESSION 6—Moderator David King Russia/France: Safety and Cultural Nick Stoss, TSB Canada ISASI International Working Group on Challenges in International Investigations Human Factors: A Progress Report By Alexey N. Morozov, Interstate Aviation SESSION 4—Moderator Richard Breuhaus By Capt. Richard Stone, ISASI and Dr. Committee and Sylvain Ladiesse, BEA Convair 580 Accident Investigation: A Study in Randy Mumaw, Boeing International Cooperation Paves the Synergy International Coorperation During Recent Runway for a Safer Sky By Ian McClelland, TAIC, New Zealand Major Aircraft Accident Investigations in By Guo Fu, East China Administration, Tenerife to Today: What Have We Done in Nigeria CAAC 30 Years To Prevent Recurrence? By Dennis Jones, NTSB By Ladislav Mika, Ministry of Transport, Czech Critical Aspects of International Incident SESSION 2—Moderator Sue Burdekin Republic, and John Guselli, JCG Aviation Investigations Winter Operations and Friction Measure- Services By Deborah J. Lawrie, Robert N. van Gelder, ments Flight Data: What Every Investigator and Jan Smeitink, Independent Safety By Knut Lande, Accident Investigation Should Know Investigation & Consultation Services Board, Norway By Michael Poole, Flightscape, Inc., and Simon National Transportation Safety Commit- Utilization of the Web-Based GIS to Assist Lie, Boeing tee of Indonesian Presentation Aviation Occurrence Investigation Sound Identification and Speaker Recogni- By Tatang Kurniadi, Chairman, National By Tien-Fu, Yeh, Wen-Lin Guan, and Hong tion for Aircraft Cockpit Voice Recorder Transportation Safety Committee, Indonesia T. Young, Aviation Safety Council By Yang Lin, Center of Aviation Safety Going the Extra Mile Use of Reverse Engineering Techniques to Technology, CAAC and Wu Anshan and Liu By Donald F. Knutson (Accepted for Generate Data for Investigations Enxiang, General Administration of Civil presentation, but not orally delivered due to By Peter Coombs, AAIB, UK Aviation of China, CAAC exigent circumstances.) ◆

Members Approve Bylaws ○○○○○○○○○○○○○○○○○○○ ○ ○ or altered in whole or in part by a two- ○○○○○○○○○○○○○○○○○○○ ○ ○ directed Bylaws Committee Chairman thirds (2/3) majority of the members Darren Gaines “to revise our bylaws that Amendments voting. Voting shall be by letter ballot sent have been in effect since our founding in Ninety-nine percent of members voting in to all eligible voting members. A minimum 1964. The revisions will allow us to use the recent bylaws amendment voting of sixty (60) days shall expire between the modern-day tools and programs for process voted to approve the changes mailing and closing of ballots which everyday Society administration at made to the bylaws by the Society’s concern amendments to the bylaws.” significant monetary savings and will International Council. During the open In early August 2007, President Frank provide guidelines for responsible voting period of Aug. 25-Oct. 25, 2007, for Del Gandio mailed to each member in fiduciary and business practices.” The all eligible members, 190 members cast good standing information regarding the IC approved the revisions and had them votes, with 188 approving the amend- voting process, which involved both the posted on the ISASI website, ments noted on the ISASI website. U.S. mail system and electronic voting www.isasi.org, for members’ perusal. The Society’s bylaws state: “11.2— through the ISASI website. He noted that The final eligible vote tally return was These bylaws may be amended, repealed, the International Council (IC) had U.S. mail 138, electronic votes 52. ◆

January–March 2008 ISASI Forum • 25 ISASI ROUNDUP Continued . . . In Memorium

David W. Berger (LA1208), Westlake Village, Calif., U.S.A., Nov. 12, 2007

Harold D. Hoekstra (LM0263), Arlington, Va., U.S.A., 2007

Dale C. Jepsen (MO2765), Cape Coral, Fla., Lederer Award ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ nomination letter when they identify ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ U.S.A., 2007 someone they consider qualified for this Dr. Henry A. Rowe (LM2735), Santa Maria, Ca- Nominations Due May 1 outstanding Award.” lif., U.S.A., Sept. 12, 2007 The ISASI Awards Committee is seeking Nominations should be mailed, or e- nominations for the 2008 Jerome F. mailed, to the ISASI office or directly to Lederer Award and reminds all that the the Awards Committee chairman, Gale interactive case studies, including a Boeing deadline for receipt of the nomination Braden, at 13805 Edmond Gardens Drive, 747 overrun in Bangkok, a Boeing 737 letter is May 1. Established in honor of Edmond, OK 73013-7064 USA. His e-mail accident near Athens, Greece, and a video “Jerry” Lederer, one of the foremost address is [email protected]. He can of a Boeing 737 investigation in Panama. A innovators in the field of aviation safety, also be reached by phone at 405-242-4815 brief half-day module as an introduction to the purpose of the Award is to recognize (home), 405-517-5665 (cell). ◆ Safety Management Systems (SMS) was outstanding contributions to excellence in also conducted. Sponsors for the event air safety accident investigation. The Reachout Closes 2007 with included AeroSvit Ukrainian Airlines and Award is presented each year during Ukraine International Airlines, SAA, and ISASI’s annual international seminar to a Multiple Workshops some workshop participants. recipient who is recognized for positive The months of October and November In November 2007, the Santiago advancements in the art and science of air 2007 saw three Reachout Workshops program was hosted by the Circulo de safety investigation. completed in Kiev, Ukraine; Santiago, Pilotos de Chile. Chilean sponsors Gale Braden, Committee chairman, says Chile; and Abu Dhabi, United Arab included the Universidad del Pacifico, the “The nomination process is quite simple. Emirates, under the auspices of ISASI Direccion General de Aeronautica Civil de Any member of ISASI may submit a and local airlines and authorities. Chile (DGAC), and Air Comet, Chile. nomination. The nominee may be an ISASI instructors Caj Frostell and Exponent Failure Analysis Associates of individual, a group of individuals, or an Bryan Stott worked with 34 participants Menlo Park, Calif., Tri-Logic Solutions organization. The nominee is not required through a 5-day Workshop program in International, Inc. of Ottawa, Ontario, to be an ISASI member. The nomination Kiev. The attendees were from different Canada, and AeroPlus STM Services of may be for a single event, a series of departments within the State Aviation Winnipeg, Manitoba, Canada, also events, or a lifetime of achievement. The Administration (SAA) in Kiev. The provided support for instructor travel and ISASI Awards Committee considers such program began on October 15 and was participation. traits as duration and persistence, opened by Aleksander Ignatiev, deputy The 5-day Workshop, which began on standing among peers, manner and chairman of SAA in Ukraine, as well as Nov. 5, 2007, included sessions on occur- techniques of operating, and of course Azerbaijan, Kazakhstan, and Romania. rence investigation and Safety Manage- achievements. Once nominated, a nominee Simultaneous interpretation (English- ment Systems. Jim Stewart, chairman of ○○○○○○○○○○○○○○○○○○○○○○○○○○ ○○○○○○○○○○○○○○○○○○○○○○○○○○ is under consideration for three years and Russian and Russian-English) was ISASI Reachout, and Claudio Pandolfi if not selected in that period is then provided throughout the length of the taught the SMS portions. Occurrence dropped. After an intervening year, the program. investigation was taught by Vic Gerden candidate may be re-nominated for The accident investigation module and Dr. Joseph Rakow. All instructors another three-year period. The nomination contained presentations on the interna- were ISASI members. Pandolfi is credited letter for the Jerome F. Lederer Award tional requirements and obligations in with being the driving force behind the should be limited to a single page.” ICAO Annex 13, planning and organization Workshop and serves as manager of Over the years, this Award has become for a major investigation, procedures and Safety Prevention DGAC, Chile. recognized as one of the most significant checklists, wreckage recovery, field More than 85 persons attended. The honors an accident investigator can investigation, collecting evidence, flight professional makeup of the attendees receive; therefore, the Jerome F. Lederer recorders, technical investigation, flight included senior aviation managers, safety Awards Committee exercises consider- operations investigation, crashworthiness, investigators and managers, members of able care in determining the recipient. human factors, witness interviewing, the pilots’ union LAN, flight attendants, Braden, “asks ISASI members to handling the news media, family assistance air traffic controllers, and dispatch and thoughtfully review their association with programs, writing the final report, maintenance personnel. All participants air safety investigators and submit a identification of safety deficiencies, making were awarded completion certificates safety recommendations, and several following closing remarks by the general

26 • ISASI Forum January–March 2008 LEFT: Reachout Workshop opening, left to right, Ron Schleede, Capt. Richard Hill, vice-president of Flight Operations, Etihad Airways; Caj Frostell; and Greg Janelle, manager of Emergency Response, Etihad Airways. BELOW: Workshop participants as they engage in lessons.

of the Chilean Air Force, Jose Huepe ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ Kapustin Scholarship ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ Fund is through donations, which in the Perez, director general DGAC. United States are tax-deductible. An award From Nov. 5-19, 2007, Elaine Parker Administrators Issue of US$1,500 (this may be increased by the and John Guselli managed a Reachout Application Call International Council in May) is made to Workshop in Karachi, Pakistan. Repre- each student who wins the competitive sentatives of the civil aviation authority The ISASI Rudolf Kapustin Memorial writing requirement, meets the application and the aviation industry were in atten- Fund administrators, Richard Stone, requirements, and registers to attend the dance. The Workshop focused on Safety ISASI Executive advisor, and Ron ISASI annual seminar. The award will be Management System implementation Schleede, ISASI vice-president, have used to cover costs for the seminar registra- and, although outside the normal ISASI issued the call for scholarship applications tion fees, travel, and lodging/meals. Any Reachout mandate, proved to be worth- to universities and colleges whose expenses above and beyond the amount of while in fostering safety improvements in students are eligible to participate in the the award will be borne by the recipient. Pakistan. program. According to the Fund’s ISASI corporate members are encouraged In the closing week of Nov. 25-28, 2007, administrators, the deadline for applica- to donate “in kind” services for travel or Caj Frostell and Ron Schleede conducted tions is June 1. lodging expenses to assist student scholar- the Abu Dhabi Reachout program. It was Given the lead time to the application ship recipients. Students granted a opened by Capt. Richard Hill, vice- deadline, the Fund administrators encour- scholarship also receive president of Flight Operations, Etihad age all ISASI societies, chapters, working • a 1- year membership to ISASI. Airways, which hosted the event and groups, and individual members to promote • tuition-free attendance to ANY sponsored instructor travel costs. the availability of the ISASI scholarship and regularly scheduled Southern California The Workshop’s content mirrored that its application procedures to students, Safety Institute (SCSI) course. This provided in the Ukraine program but was student groups, and education centers includes the 2-week Aircraft Accident tailored to the region from which 22 whenever the opportunity presents itself. Investigator Course or any other investi- attendees came. In all, safety profession- The purpose of the Scholarship is to gation courses. Travel to/from the course als from 11 airlines in the Middle East encourage and assist college-level and accommodations are not included. participated. As was to be expected, the students interested in the field of aviation More information is available at http:// Workshop became a very interesting safety and aircraft occurrence investiga- www.scsi-inc.com/. forum for exchanging experiences, tion. Eligible applicants must be enrolled • tuition free course from the Transpor- different ways of implementing safety as full-time students in a recognized (note tation Safety Institute. Travel to/from the strategies, catering to emergency ISASI recognized) education program, course and accommodations are not situations, and ideas for the future. which includes courses in aircraft included. More information is available at A Workshop record 18 attendees (out of engineering and/or operations, aviation http://www.tsi.dot.gov/. 22) applied for ISASI membership. Three ○○○○○○○○○○○○ psychology, aviation safety and/or aircraft ○○○○○○○○○○○○ The Fund is administered by an of the participants were already members occurrence investigation, etc., with major appointed committee, and oversight of and Emirates and Qatar Airways were or minor subjects that focus on aviation expenditures is done by the ISASI also already ISASI corporate members. safety/investigation. A student who has treasurer. The committee ensures that the Several of the other airlines represented once received the annual ISASI Rudolf education program is at an ISASI- at the Workshop are also considering Kapustin Memorial Scholarship is not recognized school and applicable to the ISASI corporate membership, according eligible for a second award. aims of the Society, assesses the applica- to the ISASI instructors. ◆ Continued funding for the Memorial tions, and determines the most suitable

January–March 2008 ISASI Forum • 27 ISASI ROUNDUP Continued . . .

New Members

CORPORATE Holland, Dennis, A., Northamptonsire,

○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ Curt Lewis & Associates, LLC United Kingdom candidate(s). Donors and recipients will Curtis L. Lewis, President/CEO Houston, Mark, D., Havelock North, New be advised if donations are made in honor Joe Oyler, Principle Associate Zealand of a particular individual. Korea Air Force Safety Ctr. Husain, Muhammad, M., Arad, Kingdom of Cdr Eung-Kyun Shin Bahrain Students who wish to apply for the Jae-Hoon Jung, ATC Investigator Jay, Susan (Sue), M., Orange Park, FL, USA Scholarship may acquire the application National Aerospace Laboratory, NLR Kelman, Sarah, J., Cambridge, United form and other information at the ISASI A.D.J. Rutten, manager, Air Transport Kingdom Safety Institute Kunteson, Randall, R., Deatsville, AL, USA website: www.isasi.org. Students may also Qatar Airways Kwajan, Francis, A., Forest Hills, NY, USA request applications by e-mail to isasi@ Capt. Abdulla Ali Johar, general manager, Labrucherie, Stephan, Abu Dhabi, United erols.com. The ISASI office telephone Flight Operations Arab Emirates ◆ Capt. Dharamraj Rebbapragada, Flight Mayfield, Richard, F., Renton, WA, USA number is 1-703-430-9668. Safety manager Miranda, Ray, M., Kajang, West Malaysia Moussa, Ali, M., Beirut, Lebanon INDIVIDUAL Naseer, Ahsan, Abu Dhabi, United Arab ANZSASI 2008 Plans Adedoyin, Tosin, A., Lagos, Nigeria Emirates Seminar in Australia Al Marzouqi, Fouad, B., Abu Dhabi, United Nitta, Takashi, Toyonaka, Osaka, Japan Arab Emirates Pinzón Müller, Eduardo, Bogota, Colombia The Australian Society of Air Safety Al Said, Saud, T., Dubai, United Arab Qarashi, Baha, G., Abu Dhabi, United Arab Emirates Emirates Investigators, in conjunction with the Al-Awadhi, Kamil, H., Quadsiah, Kuwait Rigby, Kevin, T., Pensacola, FL, USA New Zealand Society, will co-host Alegado, Jaime, V., Doha, Qatar Rivera-Martinez, Alimael, Prescott Valley, ANZSASI 2008 in the Stamford Grand Balentine, Chad, J., Winchester, VA, USA AZ, USA Barros, Andrés, Santiago, Chile Ronaldson, George, Aberdeen, United Hotel, Glenelg, Adelaide, South Australia Boyd, Rodney, L., Wylie, TX, USA Kingdom May 30 to June 1, according to a joint Cabel (Engr.), Francis, Abu Dhabi, United Ross, Cameron, C., Southlake, TX, USA announcement by the two Societies. Arab Emirates Satti, Juan, A., Castelar, Argentina Chen, Felix, S.K., Singapore, Singapore Savage, Eric, R., Prescott, AZ, USA Seminar registration costs will be Chiang, Vin, C., Daytona Beach, FL, USA Schonhardt, Carlos, F.G., Rio De Janeiro, similar to the rates of last year’s seminar De Waal, Johan, G., Abu Dhabi, United Arab Brazil (around $350 Australian, and the room Emirates Senthil, M.S., Gopalakrishnan, Seeb Int’l Elgindi, Hisham A. Aziz, Abu Dhabi, United Airport, Sultanate of Oman rates are expected to be in the $150-170 Arab Emirates Shappee, Eric, H., Salina, KS, USA range, Australian). Engroba, Juan, D., Buenos Aires, Argentina Skoor, Erich, J., Prescott, AZ, USA Theme for the 15th Australasian safety Franklin, Ryan, H., Ormond Beach, FL, USA Smith, Sean, J., Daytona Beach, FL, USA Gipson, Paul, Scottsdale, AZ, USA Stauffer, Kent, M., Stow, OH, USA seminar is “Transport Safety—Past, Goetz, Jean-Baptiste, Abu Dhabi, United Talay, James, E., Mission Viejo, CA, USA Present, and the Future.” The seminar Arab Emirates Trono, Peter, J., Pearblossom, CA, USA will also see a celebration of the Austra- Graydon, Mike, Abu Dhabi, United Arab Yusof, Mohd Hisham Md., Abu Dhabi, United Emirates Arab Emirates lian Society’s 30th anniversary of its Hahn, Robert, G., Gulf Breeze, FL, USA Zwager, Finn, Dubai, United Arab Emirates ◆ establishment. A Call for Papers was issued earlier. ○○○○○○○○○○○○○○○○○○○○○○○○○○ The Call asked for papers on contempo- that the Society will host a 2008 inaugural ○○○○○○○○○○○○○○○○○○○○○○○ ○ Presentations will address current rary transport safety (road, rail, marine, regional air safety seminar, “Air Accident issues in the European environment, aviation) on the issues facing the safety Investigation in the European Environ- challenges of modern air safety investiga- investigators of the future and on recent ment,” on April 24-25, with an optional tions, and operational developments. investigations. Abstract are due by social program on April 26, at Cranfield Further details of the seminar are February and should be sent to Paul University, which is located 50 miles north scheduled to be made available via the Mayes at e-mail Paul.Mayes@ of London (nearest airports Luton, ISASI website, www.isasi.org. Cobham.com.au. ◆ Birmingham and Heathrow). For further information, contact With emphasis on current European seminar organizer Anne Evans— issues in the investigation and prevention telephone: (44) 1252 510300, e-mail: European Society of accidents and incidents, the 2-day [email protected]. Bookings: A.L. Inaugurates Regional seminar is aimed at accident investigation Roff, academic operations manager, Seminar professionals and will provide an opportu- Cranfield University, Cranfield, Bedford, nity to update professional knowledge and MK43 0AL; telephone: (44) 1234 754176, European Society of Air Safety Investiga- skills, as well as to meet other active air fax: (44) 1234 751206, e-mail: tors President David King has announced safety investigators. [email protected]. ◆

28 • ISASI Forum January–March 2008 International Cooperation Paves Safer Sky Runways (from page 7) sults of the cooperation are fruitful and ben- ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ The team made a thorough search of the ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ was wing contamination due to frost. At the eficial to the aviation industry. crash site and found the memory circuit beginning of the investigation, it was very Usually, several different kinds of reports board of the solid-state cockpit voice re- hard for most of us to believe that frost con- will be finished and submitted during the corder (SSCVR) and pieces of tape from the tamination would result in such a tragedy, investigation, but four are commonly quick access recorder (QAR) and recovered though we knew that ice or snow would im- adopted. They are the group report, the the engines, control systems and surfaces, pair the wing’s performance if it was con- preliminary report, the draft final report, and other most important components. taminated with either one. and the final report. Each group must fin- The SSCVR’s memory circuit board, all Through the discussion and demonstra- ish its group report after the field investi- collected pieces of QAR tape, and the Elec- tion of performance of supercritical airfoils gation. It is done by the group chairman tronic Engine Controllers (EEC) were sent without leading edge devices by the experts with the signature of every participant of to the United States for data retrieval. The of the manufacturer, we understood why the group, and a different opinion will be whole contents of the SSCVR and EEC contamination is so critical to those airfoils. attached if there is any. The preliminary were successfully retrieved in the NTSB lab A nationwide cold weather operation train- report is compiled by the team leader and and engine manufacturer’s lab, respectively, ing campaign was adopted with the help of is based on all the group reports and con- which helped investigators understand our Canadian colleagues, and the cold tains the factual information associated with what happened in the cockpit and the en- weather operation program was revised and the event. The preliminary report submis- gines’ performance before the crash. A joint implemented to prevent the same disaster sion within 30 days after the occurrence is bulletin of the accident, signed by the three from happening again. All these corrective requested. The team leader approves the parties, was released in three nations on measures have raised both management’s draft final report before it is sent to relevant April 27, 1999, and excluded the possibili- and frontline personnel’s concentration on organizations for review. Before the final ties that the accident was caused by any the contamination issues. report is released, all the comments or sug- explosion, sabotage, or ATC mishandling. Engine IFSD incident investigation—On gestions received will be reviewed and cor- Members of the joint investigation team March 3, 2007, a Boeing 747-200, enroute rections or amendments to the report will and their advisors gathered at the Boeing (continued on page 30) be taken if they are accepted, or attached if flight safety facilities in Long Beach, Calif., denied. for flight simulation tests. The simulation We have received much valuable assis- was performed more than 100 times. tance and international cooperation from The accident scenario was at last under- MOVING? our foreign partners in safety investiga- stood on the basis of all the analyzed, col- tions, which have made our investigations lected factual information; tests conducted; Please Let Us Know successful. The following case introduc- recorded information retrieved; and key Member Number______tions will show how valuable cooperation systems, parts, or components examined. is in a safety investigation and for safety The probable cause of the accident was Fax this form to 1-703-430-4970 or mail to ISASI, Park Center improvement. the flight crew’s loss of altitude situational 107 E. Holly Avenue, Suite 11 awareness resulting from an altitude clear- Sterling, VA USA 20164-5405 Cases ance wrongly relayed by the first officer and Old Address (or attach label) MD-11 cargo accident—On April 15, 1999, the crew’s overreaction with abrupt flight Name ______an MD-11F departed Shanghai Hongqiao control inputs. International Airport, operating as a regu- With all the help and assistance from our Address ______larly scheduled international cargo flight foreign partners, we could then reconstruct City ______with two pilots and one flight technician on the accident scenario and better understood State/Prov. ______board. It crashed at a construction site 3 the accident. Zip ______minutes after lifting off. The airplane was CRJ-200 accident—On Nov. 21, 2004, a ○○○○○○○○○○○○○○○○○○○○ ○○○○○○○○○○○○○○○○○○○○ totally destroyed by high-energy impact CRJ-200 aircraft departed Baotou Airport Country ______force and a post-crash fire. at 08:21 (Beijing local daylight time) for a New Address* After the accident, the CAAC forwarded scheduled passenger flight from Baotou to Name ______notification of the accident to the state of Shanghai, and 1 minute later it crashed in a Address ______manufacture, the state of registration, the park near by. operator, and ICAO. A joint investigation The investigation was instituted and or- City ______team was formed in accordance with the ganized by SAWS. CAAC was on the tech- State/Prov. ______provisions of Annex 13. The investigation nical investigation team since it was a sig- Zip ______received technical support from the rel- nificant major accident. The technical inves- Country ______evant investigation authorities, aircraft tigation team was comprised of the state of manufacturer, engine manufacturer, air- occurrence, the state of aircraft manufac- E-mail ______lines, and component manufacturers dur- ture, and the state of engine manufacture. *Do not forget to change employment and ing the investigation. One of the probable causes of the accident e-mail address.

January–March 2008 ISASI Forum • 29 International Cooperation Paves Safer Sky Runways (from page 29) ISASI Information from PVG to KIX, experienced No. 2 en- which account for a large amount of occur- gine IFSD followed by an audible loud boom rences. That is why we need the whole com- and a drop in engine parameters. The air- munity to work hard to provide an opera- craft returned to PVG and landed unevent- tional environment that will reduce human- fully. This event is considered to be an inci- factors-related issues to the greatest extent. dent as per Civil Aircraft Flight Incident of In some cases, one nation’s competence is CAAC. not enough to resolve problems confront- OFFICERS Since we focus on aircraft with a rela- ing us since they are global challenges. President, Frank Del Gandio ([email protected]) tively long time of service, this aircraft had The cockpit meter/feet change-over Executive Advisor, Richard Stone experienced three IFSD within 4 months. switch offers a very successful solution to ([email protected]) Vice-President, Ron Schleede In order to investigate the cause of this different ATC altitude assignments adopted ([email protected]) IFSD event, a notification was sent to the in different nations to prevent a flight crew’s Secretary, Chris Baum ([email protected]) state of engine manufacture, and an inves- confusion while flying between nations us- Treasurer, Tom McCarthy tigation team was formed with the experts ing different altitude assignment systems. ([email protected]) from the engine manufacturer since the In addition, language is another worldwide state of manufacture appointed a non-travel issue for those pilots whose native tongue COUNCILLORS Australian, Lindsay Naylor accredited representative. is not English, since it is the aviation lan- ([email protected]) In the investigation, we found that one guage. Though we can train pilots and stan- Canadian, Barbara Dunn ([email protected]) cluster of the fourth stage LPT stator of dardize radiotelephony in air-ground com- European, Anne Evans the engine exhibited displacement and outer munication, we still have some occurrences ([email protected]) International, Caj Frostell shroud forward OD hook fracture, which associated with language difficulty. ([email protected]) resulted in the cluster’s rubbing against the Therefore, it is strongly recommended New Zealand, Ron Chippindale ([email protected]) fourth stage LPT rotor blades and conse- that the international aviation community United States, Curt Lewis quently rupturing some of the blades, and step up and widen cooperation to take ef- ([email protected]) the ruptured fly-away blades cut away all fective measures to improve the operational the blades/vanes on the fourth, fifth, and environment with both software and hard- NATIONAL AND REGIONAL sixth stages. Several other fourth stage ware. We need to not only rationalize the SOCIETY PRESIDENTS Australian, Lindsay Naylor LPT blades displayed fatigue in the airfoil standards, procedures, and policies, but ([email protected]) fracture just above the root platform. Fur- optimize technologies in order to find tech- Canadian, Barbara M. Dunn ([email protected]) ther lab examination revealed that the vane nical solutions as well. We share informa- European, David King cluster’s displacement/fatigue fractures re- tion, experience, knowledge, and lessons ([email protected]) Latin American, Guillermo J. Palacia sulted from their sharp radii at the OD for- learned by seminars, conferences, training, (Mexico) ward foot due to improper engine overhaul. and Reachout programs. We can resolve big New Zealand, Peter Williams ([email protected]) The advantages of the manufacturer’s issues by creating small gadgets or new Russian, Vsvolod E. Overharov involvement were not only that it knew its technologies. ([email protected]) SESA-France Chap.,Vincent Fave product and was able to provide expertise There can be no doubt that safety inves- ([email protected]) in the investigation, but also that it took tigation lays a solid foundation for the safe United States, Curt Lewis ([email protected]) immediate actions or gave professional in- operation and safe flight of aircraft, along structions if problems were found. with other safety management activities, UNITED STATES REGIONAL Though incident investigation seems not and thus plays a significant role in improv- CHAPTER PRESIDENTS as urgent as accident investigation to some ing aviation safety. As its scope is being wid- Alaska, Craig Bledsoe extent, we can still promote aviation safety ened, international cooperation will play an ([email protected]) Arizona, Bill Waldock by revealing defects found in the system and increasingly active role in promoting inves- ([email protected]) making safety recommendations. We also tigation efficiency by sharing expertise, ex- Dallas-Ft. Worth, Curt Lewis ([email protected]) can prevent the accident from happening perience, and information. As a result, no Florida, Ben Coleman by investigating the incident since we de- matter what type of investigation (accident ([email protected]) Great Lakes, Matthew Kenner fine an incident as a precursor to an acci- or incident) it is, we will make a huge dif- ([email protected]) dent in Chinese. ference to our aviation safety record if we Los Angeles, Inactive Mid-Atlantic, Ron Schleede embrace the globalization trend and strictly ([email protected]) The challenges ahead follow the international standards in inves- Northeast, David W. Graham ([email protected]) Through cooperative efforts, the aviation tigation with a cooperative attitude. The Pacific Northwest, Kevin Darcy community has resolved many problems whole aviation community will surely ben- ([email protected]) Rocky Mountain, Gary R. Morphew that impair safety, but we still have to face efit from investigation cooperation, which ([email protected]) those safety-related challenges. From the will function as one of the powerful driving San Francisco, Peter Axelrod ([email protected]) investigator’s point of view, the biggest chal- forces to move the aviation industry in a Southeastern, Inactive lenge now is human-factors-related issues, favorable direction. ◆

30 • ISASI Forum January–March 2008 COMMITTEE CHAIRMEN All Nippon Airways Company Limited Independent Pilots Association Audit, Dr. Michael K. Hynes Allied Pilots Association Int’l Assoc. of Mach. & Aerospace Workers ([email protected]) American Eagle Airlines Interstate Aviation Committee Award, Gale E. Braden American Underwater Search & Survey, Ltd. Irish Air Corps ([email protected]) AmSafe Aviation Irish Aviation Authority Ballot Certification, Tom McCarthy Aramco Associated Company Japan Airlines Domestic Co., LTD ([email protected]) ASPA de Mexico Japanese Aviation Insurance Pool s, Ron Chippindale Board of Fellow Association of Professional Flight Attendants Jeppesen ([email protected]) JetBlue Airways Bylaws, Darren T. Gaines Atlantic Southeast Airlines—Delta Connection ([email protected]) Australian Transport Safety Bureau Jones Day Code of Ethics, John P. Combs Aviation Safety Council KLM Royal Dutch Airlines ([email protected]) Avions de Transport Regional (ATR) Korea Air Force Safety Ctr. Membership, Tom McCarthy BEA-Bureau D’Enquetes et D’Analyses Korea Aviation & Railway Accident Investigation Board ([email protected]) Board of Accident Investigation—Sweden Kreindler & Kreindler, LLP Nominating, Tom McCarthy Boeing Commercial Airplanes L-3 Communications Aviation Recorders ([email protected]) Bombardier Aerospace Regional Aircraft Learjet, Inc. Reachout, James P. Stewart Lockheed Martin Corporation ([email protected]) Bundesstelle fur Flugunfalluntersuchung—BFU Seminar, Barbara Dunn Cathay Pacific Airways Limited Lufthansa German Airlines ([email protected]) Cavok Group, Inc. MyTravel Airways Centurion, Inc. National Aerospace Laboratory, NLR WORKING GROUP CHAIRMEN Charles Taylor Aviation, Singapore National Air Traffic Controllers Assn. National Business Aviation Association Air Traffic Services, John A. Guselli (Chair) China Airlines ([email protected]) Cirrus Design National Transportation Safety Board Ladislav Mika (Co-Chair) ([email protected]) Civil Aviation Safety Authority Australia NAV Canada Cabin Safety, Joann E. Matley Colegio De Pilotos Aviadores De Mexico, A.C. Nigerian Ministry of Aviation and Accident ([email protected]) Comair, Inc. Investigation Bureau Corporate Affairs, John W. Purvis Continental Airlines Parker Aerospace ([email protected]) Continental Express Phoenix International, Inc. Flight Recorder, Michael R. Poole COPAC/Colegio Oficial de Pilotos de la Aviacion Comercial Pratt & Whitney ([email protected]) Qantas Airways Limited General Aviation, William (Buck) Welch Cranfield Safety & Accident Investigation Centre ([email protected]) Curt Lewis & Associates, LLC Qatar Airways Government Air Safety, Willaim L. McNease DCI/Branch AIRCO Qwila Air (Pty), Ltd. ([email protected]) Defence Science and Technology Organization (DSTO) Raytheon Company Human Factors, Richard Stone Delta Air Lines, Inc. Republic of Singapore Air Force ([email protected]) Directorate of Aircraft Accident Investigations— Rolls-Royce, PLC Investigators Training & Education, Namibia Royal Netherlands Air Force Graham R. Braithwaite Directorate of Flight Safety (Canadian Forces) Royal New Zealand Air Force ([email protected]) RTI Group, LLC Positions, Ken Smart Directorate of Flying Safety—ADF ([email protected]) Dutch Airline Pilots Association Sandia National Laboratories Dutch Transport Safety Board SAS Braathens EL AL Israel Airlines Saudi Arabian Airlines CORPORATE MEMBERS Embraer-Empresa Brasileira de Aeronautica S.A. SICOFAA/SPS Sikorsky Aircraft Corporation AAIU Ministry of Transport Bulgaria Embry-Riddle Aeronautical University Skyservice Airlines, Ltd. Accident Investigation Board, Finland Emirates Airline Singapore Airlines, Ltd. Accident Investigation Board/Norway Era Aviation, Inc. SNECMA Moteurs Accident Investigation & Prevention Bureau European Aviation Safety Agency South African Airways Aeronautical & Maritime Research Laboratory EVA Airways Corporation South African Civil Aviation Authority AeroVeritas Aviation Safety Consulting, Ltd. Exponent, Inc. Southern California Safety Institute Aerovias De Mexico, S.A.De C.V. Federal Aviation Administration Southwest Airlines Company Air Accident Investigation Bureau of Singapore Finnair Oyj Southwest Airlines Pilots’ Association Air Accident Investigation Unit—Ireland Flight Attendant Training Institute at Melville College Star Navigation Systems Group, Ltd. Air Accidents Investigation Branch—U.K. Flight Safety Foundation State of Israel Air Canada Pilots Association Flight Safety Foundation—Taiwan Transport Canada Air Line Pilots Association Flightscape, Inc. Transportation Safety Board of Canada Air New Zealand, Ltd. Galaxy Scientific Corporation U.K. Civil Aviation Authority Airbus S.A.S. GE Transportation/Aircraft Engines UND Aerospace Airclaims Limited Global Aerospace, Inc. University of NSW Aviation Aircraft Accident Investigation Bureau—Switzerland Gulf Flight Safety Committee, Azaiba, Oman University of Southern California Aircraft Mechanics Fraternal Association Hall & Associates, LLC Volvo Aero Corporation Aircraft & Railway Accident Investigation Commission Hellenic Air Accident Investigation WestJet ◆ Airservices Australia & Aviation Safety Board AirTran Airways Honeywell Alaska Airlines Hong Kong Airline Pilots Association Alitalia Airlines—Flight Safety Dept. Hong Kong Civil Aviation Department IFALPA

January–March 2008 ISASI Forum • 31 WWHO’SHO’S W WHOHO

Raytheon, a Company of Innovation ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ ○ ○ ○ ○ ○ ○ ○ ○ (Who’s Who is a brief profile of, and pre- ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ advances. Emerging from the depths of a batteries. The tube would overcome the pared by, the represented ISASI corporate severe post-war depression that wiped out need for two expensive, short-lived A and member organization to enable a more jobs and forged a widening chasm between B batteries, the greatest shortcoming to thorough understanding of the organiza- the privileged and the poor was a breed of widespread radio use at the time. By tion’s role and functions.—Editor) entrepreneurs with a driving ambition to devising a way to replace the B battery succeed and willingness to gamble on it. with a tube, the small company beat out he Raytheon of today is the result of Against this backdrop the founders of the army of researchers and engineers of 80 years of continuous innovation… Raytheon became business partners. Two RCA, Westinghouse, and other corporate Tincluding the impressive legacies of former college roommates, Laurence K. giants to produce a device that forced the the businesses Raytheon has joined with Marshall and Vannevar Bush, formed the entire radio industry into a new direction over the years, like Beechcraft, E-Systems, and made radios affordable and accessible Texas Instruments Defense Systems and to every household. Perfected and Electronics business, and Hughes Air- introduced to the public in 1925, the tube, craft’s Defense Electronics business. All known technically as a gaseous rectifier businesses brought complementary skills company with Charles G. Smith, a young and marketed under the brand name and expertise, which have combined to scientist who had developed the prototype Raytheon, brought in more than $1 make Raytheon a global leader in defense, for a home refrigerator that used artificial million in sales by the end of 1926 and government and commercial electronics, coolants. Marshall, an engineer, business- positioned the company as a major and business and special-mission aircraft. man, and trained physicist, and Bush, a contributor to the fast-growing radio tube As a world-class supplier of space and scientist and professor of electrical market for nearly two decades. airborne products, safety and mission engineering at the Massachusetts In the more than 80 years since, the assurance are always at the forefront. Institute of Technology, along with several company has become known for many Raytheon provides state-of-the-art elec- other financial backers, dreamed of more major technological advancements tronics, mission systems integration, and prosperity and a potential market for that have changed the course of American other capabilities in the areas of sensing; their newly developed refrigerator. culture and world history. Among these effects; command, control, communications However, as is the case with so many innovations are the first commercial

and intelligence systems; and a broad ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ other entrepreneurs, the product that microwave ovens, miniature tubes for range of mission support services. The launched the company was a bust and hearing aids, the Fathometer depth company branded and trademarked the never left the laboratory. Facing failure, it sounder, the mass production of magne- term “No Doubt,” pledging to customers was Marshall and Bush who suggested tron tubes, early shipboard radar, the first that Raytheon products will work as revisiting an earlier idea young Smith had successful missile guidance system, a advertised, are safe, and are supportable. experimented with: a new kind of gaseous space communications system, mobile Raytheon is stepping out to lead the tube that would allow radios for the first radio telephones, the first combat-proven industry in mission assurance and to make time to be plugged into a wall socket and air defense missile system and terminal assurance a key market differentiator. operate on electricity rather than doppler weather radar. ◆ Raytheon Company was founded in Cambridge, Mass., as the American Appliance Company in 1922, a pivotal time ISASI NON-PROFIT ORG. in American history. The first decade of 107 E. Holly Ave., Suite 11 U.S. POSTAGE PAID modernism, the 1920s saw the advent of Sterling, VA 20164-5405 USA Permit #273 automobiles, radios, and refrigerators. The ANNAPOLIS, MD electrical industry was extending power lines across the United States, and telephones were linking every hamlet and home. In the aftermath of World War I, the nation was in flux, disillusioned at the end of a bitter war that brought no real peace or economic security and energized by the prospects of modern technological

32 • ISASI Forum January–March 2008