OCTOBER-DECEMBER 2019 Journal of the International Society of Air Safety Investigators

Air Safety Through Investigation OCTOBER-DECEMBER 2019 Journal of the International Society of Air Safety Investigators

ISASI Goes to the Netherlands page 4

ISASI Honors Capt. Akrivos Tsolakis with 2019 Jerome F. Lederer Award page 12 Comparing UA232 and AA383 Uncontained Events page 15 ISASI Kapustin Scholarship Essay—Applying Human Factors to Commercial Space Operations page 20 LAMIA Flight 2933: Who Lived, Who Died, and Why page 23 CONTENTS

Air Safety Through Investigation Journal of the International Society of Air Safety Investigators FEATURES Volume 52, Number 4 Publisher Frank Del Gandio 4 ISASI Goes to the Netherlands Editorial Advisor Richard B. Stone By J. Gary DiNunno, Editor, ISASI Forum—ISASI holds its 50th annual seminar in The Editor J. Gary DiNunno Hague, the Netherlands September 3-5. Participants attended technical presentations, Design Editor Jesica Ferry social events, and the traditional awards banquet. The ISASI 2020 host committee discussed Associate Editor Susan Fager plans for the next seminar to be held in Montreal, Que., Canada. ISASI Forum (ISSN 1088-8128) is published quar- terly by the International Society of Air Safety 12 ISASI Honors Capt. Akrivos Tsolakis Investigators. Opinions expressed by authors do with 2019 Jerome F. Lederer Award not necessarily represent official ISASI position or policy. By J. Gary DiNunno, Editor, ISASI Forum—During the ISASI 2019 awards banquet, held in The Hague, the Netherlands, the Society presented its highest recognition for lifetime air Editorial Offices: Park Center, 107 East Holly Ave- safety achievement to Capt. Akrivos Tsolakis, Hellenic Air Accident Investigation & Aviation nue, Suite 11, Sterling, VA 20164-5405. Telephone Safety Board. 703-430-9668. Fax 703-430-4970. E-mail address, [email protected]; for editor, jgdassociates@ 15 Comparing UA232 and AA383 Uncontained Events starpower.net. Internet website: www.isasi.org. ISASI Forum is not responsible for unsolicited By David Chapel, Flight Safety Director, and Dan Klemme, Aviation Safety Lead, GE manuscripts, photographs, or other materials. Aviation—The authors describe and compare two uncontained engine separation events. Unsolicited materials will be returned only if They found some key similarities and two differences worth noting. This paper received submitted with a self-addressed, stamped enve- recognition as the best paper presented during ISASI 2019. lope. ISASI Forum reserves the right to reject, delete, summarize, or edit for space considerations any submitted article. To facilitate 20 ISASI Kapustin Scholarship Essay—Applying Human Factors to editorial production processes, American Eng- Commercial Space Operations lish spelling of words is used. By F/O Stacy Jackson (WestJet), Embry-Riddle Aeronautical University—The author Copyright © 2019—International Society of Air discusses the importance of applying human factors strategies developed from other Safety Investigators, all rights reserved. Publica- industries into future commercial space operations. tion in any form is prohibited without permission. ISASI Forum registered U.S. Patent and 23 LAMIA Flight 2933: Who Lived, Who Died, and Why T.M. Office. Opinions expressed by authors do not necessarily represent official ISASI position By Anthony T. Brickhouse, Embry-Riddle Aeronautical University, U.S.A.; Diego M. Garcia, or policy. Permission to reprint is available upon Embry-Riddle Aeronautical University, U.S.A.; and Julian E. Echeverri, Aviation Accident application to the editorial offices. Investigation Group, Colombian Civil Aviation Authority—The authors examine an AVRO 146-RJ85 accident when charter flight LAMIA 2933 impacted a hillside near Medellin, Colum- Publisher’s Editorial Profile: ISASI Forum is print- bia. Only six of 77 occupants survived. ed in the United States and published for professional air safety investigators who are members of the International Society of Air Safety Inves- tigators. Editorial content emphasizes accident investigation findings, investigative techniques and experiences, regulatory issues, industry accident prevention developments, and ISASI and DEPARTMENTS member involvement and information.

2 Contents Subscriptions: A subscription to members is pro- 3 President’s View vided as a portion of dues. Rate for nonmem- 28 News Roundup bers (domestic and Canada) is US$28; Rate for 30 ISASI Information nonmember international is US$30. Rate for all 32 ISASI 2020 Set for Montréal, Canada libraries and schools is US$24. For subscription information, call 703-430-9668. Additional or replacement ISASI Forum issues: Domestic and Canada US$4; international member US$4; do- ABOUT THE COVER mestic and Canada nonmember US$6; international nonmember US$8. ISASI President Frank Del GandiO, left, presents the 2019 Jerome F. Lederer Award to Capt. Akrivos Tsolakis, Hellenic Air Accident Investigation and Avia- tion Safety Board, during the 2019 ISASI awards banquet.

INCORPORATED AUGUST 31, 1964

2 • October-December 2019 ISASI Forum PRESIDENT’S VIEW

ISASI: ADVANCING AVIATION SAFETY THROUGH THE DECADES

SASI recently established duced its fatal accident rate by of accidents since ISASI start- and consultants, have issued a committee within our a third to a half every decade. ed. From 1963 through 1965, thousands of aviation safety International Council to The only change in that long- CFIT into high terrain acci- recommendations that have Ireview the Society’s official term trend is that the rate of dents accounted for 28 of the directly and indirectly im- Positions on Air Safety Inves- improvement has accelerated 89 fatal passenger hull losses proved air safety. tigation Issues to determine if in the past two decades. with just more than 1,000 The aviation industry con- any required an update. The I will not try to convince you fatalities. Add CFIT into water, tinues to rapidly accelerate committee reported that the that ISASI and its members obstacles, or the ground, and into the age of automation. Society’s adopted policies, have been the only factor in the numbers jump to 43 fatal ISASI members know well that practices, and concepts are that century-long achieve- hull losses with more than a primary driver for increased current. This document can be ment, but ISASI members 1,600 fatalities. In contrast, automation is often efficiency found on our website under can claim their share of the over the past three years, the rather than safety. So we can- the Guidelines tab. ISASI credit. Since it was established world’s airlines suffered just not rest on our past accom- recently offered members in 1964, ISASI has tried to one fatal accident involving plishments. We individually the option of receiving their advance aviation safety by pro- CFIT into high terrain, a and collectively must continue Forum only in a digital format. viding a professional forum in DHC-6 with 23 occupants on to maintain and improve avia- If you are interested in partic- which air safety professionals a scheduled domestic flight in tion’s safety record. The areas ipating in this option, contact can exchange ideas, experienc- Nepal. of future concern—in my opin- Ann Schull, our headquarters' es, and knowledge. I believe it ISASI and its members can ion—are labor shortages both office manager, and provide a has succeeded admirably in take a lot of credit for virtually in pilots and maintenance, valid e-mail address. Another this goal. eliminating CFIT accidents. cargo accidents, automation, activity of note is our ongoing Some basic numbers help Don Bateman, a long-time managing rapid growth, unmanned aircraft systems, Reachout Workshops program to tell the story. From 1963 ISASI member, developed the commercial space operations, that provides training to air through 1965—spanning the first of several generations of and suicide. safety professionals through- year before, the year of, and GPWS equipment, and profes- Shortly after ISASI’s early out the world. We recently the year after ISASI’s found- sional investigators continued members established the held our 55th Reachout ses- ing—the world’s then much to make the case for requiring Society, they chose a motto: sion. The Pakistan Society held smaller commercial airline GPWS equipment. In fact, Don Safety Through Investigation. a series of training sessions in industry suffered 89 fatal hull Bateman also was instrumen- Even with notable past that country during June 2019. losses in passenger operations tal in developing TCAS. Major success, that motto continues Since this program began in with nearly 3,200 fatalities. breakthroughs in safety like to guide our future path. 2001, nearly 2,900 air safety Let’s compare those numbers GPWS and TCAS are rare, professionals and government to the past three years for but ISASI members played officials have participated in which we have complete data, important roles in other sud- ISASI Reachout Workshops. 2016 through 2018. During den advances. They have been ISASI is now 55 years old, that time, the world’s airlines especially important in the and this is an appropriate time had just 10 fatal hull losses in steady improvement in areas to evaluate the effectiveness of passenger operations with 760 such as stronger operating the Society over the preced- fatalities. procedures, adherence to and ing five decades. Despite two Do the math and you will quality of checklists, and other high-profile accidents in 2018 discover that the risk of fatal incremental enhancements involving the B-737 MAX, avia- injury to anyone on board a that, over time, add up to ma- tion safety has persistently im- passenger airliner today is jor improvements in aviation proved since the beginning of about 0.5 percent of the risk safety. Our members, while air travel. For its first 80 years when ISASI began. Equally employed by governments, air- Frank Del Gandio or so, commercial aviation re- striking is the change in types lines, manufacturers, unions, ISASI President October-December 2019 ISASI Forum • 3 early 400 delegates, 30 companions, and invited guests gathered in the World Forum Auditorium in ISASI Goes to the NThe Hague, the Netherlands, Sep- tember 1–6 for ISASI’s 50th international accident investigation and prevention conference to attend tutorials and a special class about the Dutch Safety Board’s Netherlands investigation of the MH17 event in 2017, By J. Gary DiNunno, Editor, ISASI Forum to listen to 34 technical programs, to tour the city and surrounding areas, and to meet and greet long-time and new colleagues. The theme for this year’s program was “Future Safety: Has the Past Become Irrelevant?” By the end of the seminar, that question was answered—a definite “no.”

MH17 master class ing ISASI 2019. Sixty selected delegates and a fee separate from the seminar. On July 17, 2014, a Malaysia Airline participated in the class and viewed the B-777/200, traveling from Amsterdam to reconstruction at Gilze-Rijen Air Base. General tutorial—The Dutch Safety Board Kuala Lumpur as Flight MH17, crashed in “Dutch Safety Board investigator Ron hosted this tutorial, which was held in the eastern part of Ukraine. The accident Smits, who coordinated recovery and re- two parts (A morning and B afternoon). was fatal to all 298 persons on board; 193 construction of MH17 aircraft parts, gave A. Two sections: Aviation Safety Versus occupants were citizens of the Nether- a presentation on the process of recov- Medical Confidentiality and Balancing lands. ering the wreckage in an area where an Medical Confidentiality and Flight Safety Ukraine delegated the investigation armed conflict was going on and on the Implementation Challenges (morning). to the Netherlands. The Dutch Safety reconstruction itself. I spoke with the at- Since the Germanwings Flight 9525 acci- Board launched an investigation and tendees, and everyone was truly amazed. dent, a new debate has started on pilots’ determined that the aircraft was brought They learned of all the problems and costs medical privacy. The investigation showed down by a surface-to-air missile (see associated with such an undertaking.” that the copilot had visited several private ISASI Forum, July–September 2017, page Del Gandio noted, “ISASI is highly physicians and health-care professionals, 6.) The Dutch Safety Board reconstructed appreciative of the Dutch Safety Board for including a psychiatrist and a psycholo- the nose section of the aircraft to further the great job it did and making the MH17 gist, before the accident. Why did none of prove its hypothesis. reconstruction available to the selected them inform the civil aviation authority ISASI President Frank del Gandio said, Society seminar delegates.” or his employer? The reporting of unfit “The Society seminar in The Hague, the pilots is a deliberate breach of medical Netherlands, was fortunate in that the Monday tutorials and the president’s confidentiality, but it’s intended to pre- Dutch Safety Board made the recon- reception vent an unfit pilot from flying. Hence pre- structed portion of MH17 available to a Preceding the three-day ISASI seminar, venting a potential accident and, in the number of the seminar delegates through participants were able to choose one of case of commercial aircraft, possible loss a ‘master class’ held on Sunday preced- three tutorials. They required registration of many lives. As in the case of the Ger- manwings accident investigation, public investigation authorities might encoun- ter difficulties in obtaining information to rule out the pilot’s medical condition as a contributing factor. Although both reporting an unfit pilot and investigating aircraft accidents are aimed at improving flight safety, the legal considerations for allowing medical professionals to breach medical confidentiality for these different purposes can vary greatly. This tutorial provided an insight into various existing international and national legal provisions and policies with regard to medical confidentiality and the use of pilots’ medical information From the left, ISASI President Frank Del Gandio, Treasurer Bob MacIntosh, and Seminar in relation to reporting unfit pilots and

Photo credit: J. Gary DiNunno Photo credit: Host Committee Chair Dann Zwart view the reconstructed MH17 fuselage. accident investigation. Attendees were 4 • October-December 2019 ISASI Forum ISASI 2019 delegates attend seminar presentations in the World Forum Auditorium. provided with tools derived from this legal framework analyses to help find a balance between aviation safety versus medical confidentiality. B. Communications with Victims and Relatives (afternoon). A crash has an enormous impact on society, especially on victims and their relatives. Often, they go through a life-changing process of emotions and questions, which they have to deal with in a complex media landscape. In this tutorial hosted by the Dutch Safety Board, the basics and latest developments concerning communication with victims and their relatives was presented. With insights from the field of crisis communication, the media landscape, and victim support, the tutorial aimed to increase confidence when deal- ing with these contacts.

Military accident investigations—The Military Air Safety Investigators (MASI), which is a subset of ISASI, hosted this tutorial. The all-day session was a forum for international military accident investigators to share knowledge on their respective capabilities, experiences, processes, and procedures with a view to develop future relationships and common prac- The stage and podium are ready for ISASI 2019 to begin. tices. The MASI forums/tutorials drew numerous military investigators from across Europe, Australia, North America, and Asia seeking to share accident investigation simulation, has attracted their safety lessons. press and professionals for more than five years while providing problem-based-learning for aerospace Hands-on “crash day”—The faculty of Aerospace Engineering Delft Univer- students. The aerospace engineering faculty firmly sity of Technology hosted this tutorial at its campus. Crash day, a real-life believes in problem-based-learning and strives to inspire students to go beyond what’s learned in text books. For the first time, this real-life accident simulation was provided for ISASI tutorial attendees. Following the tutorials, seminar participants attended the traditional president’s reception during which ISASI’s president welcomed delegates and their guests to The Hague and set the stage for the next several days of ISASI 2019.

ISASI 2019 opening day On Tuesday, September 3, Host Committee Chair Dann Zwart welcomed ISASI 2019 participants to the World Forum King Willem Alexander Auditorium. He then introduced ISASI’s president to address the gathering. Del Gandio said, “Good Morning everyone, and welcome to ISASI’s 50th international seminar here in The Hague.” He noted that 374 delegates registered ESASI President Olivier Ferrante leads a discussion during the military tutorial. for ISASI 2019, 126 participants attended Monday’s October-December 2019 ISASI Forum • 5 Compare those numbers to the past three years for which we have complete data—2016 through 2018. In that period, the world’s airlines had just 10 fatal hull losses in passenger operations with 760 fatalities. “Run the arithmetic and you will find that the risk of fatal injury to anyone on board a passenger airliner today is about 0.5 percent of the risk when ISASI began. Equally striking is the mix of accidents when ISASI started. From 1963 through 1965, controlled flight into terrain [CFIT] accounted for 28 of the 89 fatal passenger hull losses with just more than 1,000 fatalities. Add CFIT into water, obstacles, or the ground, and the numbers jump to 43 fatal hull losses with more than 1,600 fatalities. In contrast, over the past three years, the world’s airlines suffered just one fatal accident involving CFIT into high ISASI President Frank Del Gandio delivers the seminar opening address. terrain, a DHC-6 with 23 occupants on a tutorial program, and that 45 companions aircraft, most people in this room recog- scheduled domestic flight in Nepal. were scheduled for tours on Tuesday and nize that aviation safety has improved “ISASI and its members in fact can take Wednesday. Del Gandio observed that consistently for its entire history. For its a lot of the credit for virtually eliminat- representatives from 48 countries gath- first 80 years or so, commercial aviation ing CFIT accidents. A long-time ISASI ered for ISASI 2019. He introduced ISASI’s reduced its fatal accident rate by a third member, Don Bateman, developed the executive officers—Chad Balentine, secre- to a half every decade. The only change first of several generations of GPWS tary, and Bob MacIntosh, treasurer—and in that long-term trend is that the rate of equipment, and professional investigators ISASI councilors and Society presidents improvement has accelerated in the past continued to make the case for requiring who were in the meeting auditorium. two decades. GPWS equipment. In fact, Don Bateman “Fifty-five years ago, three investigators “I will not try to convince this audience also was instrumental in developing from the U.S. Civil Aeronautics Board, that ISASI and its members have been the TCAS, which could have averted three now known as the National Transporta- only factor in that century-long achieve- more of the fatal accidents from 1963 tion Safety Board [NTSB], said let’s form ment, but ISASI and its membership can through1965. a fraternal organization. Six years later, claim their share of the credit. Since it “Major breakthroughs in safety like they held their first seminar in Washing- was established in 1964, ISASI has worked GPWS and TCAS are rare, but ISASI ton, D.C. This is now our golden anniver- to advance aviation safety by providing members played important parts in sary. ISASI has come a long way. a professional forum for the exchange of other sudden advances, and they have “We are celebrating other milestones ideas, experiences, and knowledge ac- been especially important in the steady here in the Netherlands. KLM [Royal quired by air safety professionals. I believe improvement in areas like stronger Dutch Airlines] is celebrating 100 years. it has succeeded admirably in that goal. operating procedures, adherence to and The only airline to become 100 years old “In ISASI’s early years, major fatal ac- Dutch Safety Board Chair Jeroen with the same name. Congratulations to cidents were almost a routine affair, and Dijsselboem delivers the opening day KLM. Ten years after KLM began flying, that was in an era of a far smaller system keynote address. the KLM pilots organized to become than we have today. In the interim, of Dutch ALPA. Ten years later, Delft Univer- course, the system has expanded expo- sity of Technology-Faculty of Aerospace nentially. Today’s system manages about Engineering was founded. Twenty years 10 times as many passenger aircraft and ago, the Dutch Safety Board, formerly the about 15 times as many flights, each of Dutch Transportation Safety Board, was which carries twice the number of seats founded. The Netherlands has an ex- and three times as many passengers on tremely rich history of service to aviation average. and the flying public. ISASI is proud to be “Some basic numbers help to tell the here and help everyone celebrate their story. From 1963 through 1965, spanning anniversaries and to continue to enhance the year before, the year of, and the year aviation safety through our various pres- after ISASI’s founding, the world’s much entations and global networking. smaller commercial airline industry “Despite two recent and high-profile suffered 89 fatal hull losses in passenger accidents involving the Boeing-737 MAX operations with nearly 3,200 fatalities. 6 • October-December 2019 ISASI Forum quality of checklists, and other incremental improvements that, over time, add up to major improvements. Our members, while employed by governments, airlines, Kapustin manufacturers, unions, and consultants, scholarship have issued thousands of aviation safety recipient NTSB Vice Chair recommendations that have directly and Nur Amalina Jumary Bruce Landsberg indirectly improved air safety. presents her gives the afternoon winning essay “However, ISASI cannot rest on its past keynote address. accomplishments. We individually and in Human Factors to Commercial Space collectively must continue to maintain Operations (see page 20). and improve the aviation safety record. ISASI 2019 adopted a new format for ISASI 2019 Sponsors The areas of future concern, in my opin- technical presentations to accommodate The following organizations were ion, are labor shortages both in pilots and the large number of selected submissions: sponsors of ISASI 2019. maintenance, cargo accidents, automa- presentations began simultaneously in tion, managing rapid growth, unmanned both the main auditorium and an Platinum aircraft systems, and suicide. We must adjacent conference room. Delegates all remember that the aviation industry chose which presentation to attend. (See TU Delft continues to rapidly accelerate into the page 10 for a complete list of presenta- Vereniging Nederlandse age of automation and that the primary tions.) Verkeersvliegers (Dutch ALPA) driver for increased automation is often efficiency rather than safety.” Another keynote address Del Gandio concluded, “I hope that you Gold During Tuesday afternoon, Bruce Lands- enjoy the seminar and that you enjoy the Airbus berg, the NTSB vice chair, provided a Netherlands, a beautiful country.” Boeing second keynote address. He discussed extending the time for CVR recordings Embraer Opening day keynote address beyond the current two hours and the GE Jeroen Dijsselboem, Dutch Safety Board need to simplify the current NOTAM NTR chair, outlined the history of aviation in system—specifically providing pilots Schiphol Group the Netherlands that began with man- better notices about runway closures and The Hague ufacturing at Fokker and commercial system management problems. Looking flights with KLM in 1919. He discussed at automation, Landsberg examined how the creation and structure of the Dutch pilots deal with disengaging automatic Silver Safety Board and some of the activi- aircraft functions during an emergency Delta Air Lines ties and investigations that could be He observed that the collection and prop- Lockheed Martin disclosed. He observed that the safety er investigative use of “big data” leads to LVNL (Air Traffic Control of the investigation agency in various forms was air accident prevention. now 20 years old. Netherlands) Ministry of Infrastructure and Water Kapustin scholarship presentations Management (the Netherlands) Following the keynote address, Nur Transavia Amalina Jumary, a 2019 Kapustin scholar- University of Southern California ship recipient from the University of New South Wales, Australia, presented her Bronze paper Air Safety Cyber Security: Why Cyber Security Is a Threat for Air Safety. Next to Air Line Pilots Association the podium was Kapustin scholar Stacy Gulfstream Jackson from Embry-Riddle Aeronautical NetJets University (ERAU), who urged air safety Parker Aerospace professionals to Apply Lessons Learned Exhibitors Cranfield University Kapustin Scholarship CGE Risk Management Solutions recipient Stacy FlightDataPeople Jackson discusses Plane Sciences investigating human factors in Southern California Safety Institute commercial space Delegates and companions enjoy a buffet operations. dinner held at the Louwman Car Museum. October-December 2019 ISASI Forum • 7 gation” followed the keynote address to discuss how safety and accident investigators might become necessary participants in global space flight programs. Delft University professor Jacco Kapustin scholarship presentations Hoekstra presents Kapustin scholarship recipient Elise Von- the final keynote address about dra presented her winning essay Remem- the concept of bering Before the Crash: How Nonvolatile “free flight.” Aviation Organization meetings, ISASI’s financial status, and other ongoing administrative matters. Following the lunch break, at 1300 Elise Vondra delegates again broke into two groups to gives her essay attend simultaneous technical presenta- selected for a tions. They rejoined in the auditorium at Kapustin Dutch physician and European Space 1500 to hear the two final presentations Agency astronaut Andre Kulpers provides scholarship. the second day opening keynote address. of the day. At 1600, the overall conference disbursed so that ISASI working groups ISASI national societies conducted could hold informational meetings for business meetings at 1600 to discuss re- Kapustin scholar interested participants. That evening, gional and local activities, introduce new Alex Hall observes the Seminar Host Committee held a “pub officers, and review other organizational that language differences quiz” in the World Forum cafe to engage matters as needed. can cause a friendly competition among teams to Delegates, companions, and guests miscommunication correctly answer trivia questions. were then bussed to the nearby Louwman that leads to aviation accidents. Car Museum for an informal buffet dinner Day 3, Thursday, September 5 and a chance to view classic and antique Memory Can Change the Course of an The day began at 0900 with a keynote automobiles from all over the world, Investigation. She was followed by Kapus- address. Jacco Hoekstra, a Delft University period dioramas of auto mechanic repair tin scholar Alex Hall who discussed The professor, discussed the concept of “free shops, and a collection of antique fuel Challenges of Investigating Language in flight” in congested airspace. He suggest- pumps. Aviation Accidents: How Applied Linguis- ed that aircraft separation could be pos- tics Can Reveal Subtle Communications sible using an independent surveillance Day 2, Wednesday, September 4 Errors. system such as the Airborne Separation The conference opened with keynote Assurance System (ASAS) with a central speaker Andre Kulpers, a Dutch physician Technical presentations control at airports. ASAS could lead to increased airspace capacity and reduced and a European Space Agency astronaut, ISASI 2019 delegates divided into two congestion. who discussed accidents and incidents groups at 1100 to attend simultaneous occurring during space flights and what technical presentations. They then gath- investigations and remedies space agen- ered in the main auditorium at 1130 for Technical presentations cies and suppliers conducted to mitigate an ISASI business meeting during which Following the keynote, delegates lis- or correct problems. A technical pres- ISASI executive officers discussed Society tened to presentations covering SMS at entation titled “Do We Need an Annex 13 working group and committee actions, Amsterdam’s Schiphol Airport and the for Commercial Space Accident Investi- representation at International Civil importance of high-load event reporting. Seminar participants then broke into two From left, ISASI President Frank Del Gandio, Treasurer Bob MacIntosh, and groups to attend parallel sessions until Secretary Chad Balentine during a “business meeting” provide Society members information and news about ISASI’s financial position and 1600. current activities. Vice President Ron Schleede didn’t attend ISASI 2019. Closing session Del Gandio thanked the delegates for participating in ISASI 2019, hoping they had an enjoyable and productive week and wishing them a safe journey home. Zwart, ISASI’s 2019 Host Committee chair, introduced Barbara Dunn, ISASI 2020 Host Committee chair, who discussed plans for the next seminar to be held Sept. 1–3, 2020, in Montréal, Qué., Canada, at the 8 • October-December 2019 ISASI Forum Seminar participants attend the annual ISASI awards banquet at the Kurhaus Scheveningen, a magnificent beachside hotel on the North Sea.

Le Centre Sheraton Montréal and provided a promotional video shown to all seminar attendees. That evening, delegates and their guests attended the traditional reception and awards dinner held at Kurhaus Scheveningen, a palatial hotel on the shores of the North Sea. The highlight of the evening was the presentation of the Jerome F. Lederer Award, ISA- SI’s highest honor for lifetime contributions to air safety, to Capt. Akrivos D. Tsolakis of the Hellenic Air Accident and Aviation Safety Board (see page12).

Companion Activities Tuesday, September 3: Old and New Holland Upon meeting their professional guide in front of the World Forum, the ISASI 2019 “companion” participants traveled to Delft, a picturesque town with one of Hol- land’s most perfectly preserved city centers that has not changed since Vermeer painted his View of Delft. The group walked through the historic city center viewing many almshouses and along the canals. Afterwards, the tour visited the Royal Dutch Delftware manufacture De Porceleyne Fles. Established in 1653, it is the last remaining Delftware factory from the 17th century. Delftware is still hand painted according to a century-old tradition. The companion tour includes a visit to the royal Dutch The group them traveled to Rotterdam, the city that Delftware manufacturer, De Porceleyne Fles. was destroyed in World War II and later rebuilt—now with the largest harbor in Europe. The companions also visited Euromast, an observation tower that offers a spectacular view of Rotterdam center, the port area, and nearby cities. At the top of the tower is the Euroscoop, a rotating glass elevator that takes visitors 185 meters into the air, turning slowly while providing a 360-degree view of the city and information about Rotterdam. After lunch, the companions embarked on a tour of the harbor.

Wednesday, September 4: Water, Windmills, and Cheese On this day, the ISASI companions discovered some unique sights of Holland. First, they traveled to Zaanse The seminar companions gather for a photo during the Schans, a 40-house community on the banks of the river awards banquet. Zaan that in the 18th century had more than 700 windmills Now only five remain. The group then went to the city of Edam, famous for its cheese. For centuries, the well-known round Edam cheeses have been sent from this town to all corners of the world. The cheese market, once again restored to its place of honor, is open weekly on Wednesdays during the summer months. Neighboring cheese warehouses keep alive the memory of a colorful past. Edam is a city with a rich history. In the early afternoon, the group continued on to Monnickendam, a former fisherman’s village with a long history. During the city walk, the companions visited the historic city hall and De Waag, where shiploads coming in from overseas used to be weighed. Companions visit a working windmill.

October-December 2019 ISASI Forum • 9 ISASI 2019 Technical Program Tuesday, September 3 1800–2145 1100 Offsite Dinner: Louwman Museum Breaking Airlines’ Flight Data Monitoring 0900 Barriers—A Pilot’s Perspective, Capt. B. de AM Moderator: Dann Zwart, Dutch ALPA Courville, Air France (Ret.) Welcome Speech: ISASI President, Frank Del Wednesday, September 4 1100 Gandio; Dutch Safety Board Chair Jeroen 0900 Dijsselbloem New Safety Investigator Profile, E. Zambonini, AM Moderator: Mario Colavita, EASA LARSA Council, JIACC, Argentina 0930 Keynote Speech: Dutch Physician and Euro- 1130 Small Country/Big Accident, PNG AIC Chief pean Space Agency Astronaut A. Kulpers Commissioner H.H. Namani Themes and System Safety Investigation— 0930 Proactively Investigating for System Safety 1000 Do We Need an Annex 13 for Commercial Improvements, D. Foley, CAA, New Zealand Kapustin Scholarship Presentations Space, J. Sedor, NTSB 1130 1100 1000 Competency-Based Education and Frame- Black Swan Events—Examples from Airbus Kapustin Scholarship Presentation work for a More Efficient and Safer Aviation History, S. Cote, Airbus SAS 1100 Industry, F.A.C. Mendonca, Purdue Universi- ty; J. Keller; B. Dillman 1100 Improving the Investigation of Takeoff and The Head Injury Criteria and Future Accident Landing Incidents/Accidents, D. Gleave, chair 1300 Investigations, J.M. Davies, University of ISASI Airport Working Group, Loughbor- PM Moderator: Chong Chow Wah, Trans- Calgary, Canada; W.A. Wallace; C.L. Colton; ough University; D. Pitfield portation Safety Investigation Bureau of O. Tomlin; T. Payne 1100 Singapore 1130 Investigation of the In-Flight Failure of the Research-Based Insights: The Importance Comparisons and Lessons Learned from Stratos III Sounding Rocket, R. Wubben, TU of Lightweight Data Recorders for General UA232 Sioux City and AA383 Chicago Uncon- Delft University; E. Gilleran; M. Van Heijnin- Aviation Aircraft, B. Harvey, TSB of Canada; tained Events, David Chapel, GE Flight Safety gen, et al C.M. Rudin-Brown Director, and Dan Kemme, Aviation Safety Lead, GE Aviation 1130 1300 1130 ISASI Business Meeting Accidents Past, Accidents Future: Safety in 1300 the Age of Unmanned Aviation, T.A. Farrier, LAMIA Flight 2933: Who Lived, Who Died, Chair, ISASI Unmanned Aircraft Systems and Why, Anthony Brickhouse, ERAU; D.M. PM Moderator: Frank Hilldrup, NTSB Working Group Garcia; and J.E. Echeverri Takeoff Performance Incidents: Do We Need 1330 1300 to Accept Them or Can We Eliminate Them? Does What Happened in the Aircraft Matter PM Moderator: Nuno Aghbassi, NETJETS G. van Es, Netherlands Aerospace Centre; M. Nijhof; B. Bernard Anymore? N. Boston, ATSB Australia Airmanship 2.0: Innovating Aviation Human 1330 Factors Forensics to a Necessarily Proactive 1300 Role, F. Mohrmann, Netherlands Aerospace Human Factors Panel Discussion Evolution of Mishap Prevention: Application Centre; J. Stoop William Bramble, NTSB, Chair ISASI Human of Human Factors Evaluation Techniques for 1300 Factors Working Group; M. Walker, Austral- UAS, E. Lagerstom, Insitu, Inc., U.S.A. Analysis of Aviation Accident Videos at NTSB, ian Transport Safety Board; Fanny Rome, 1400 D.T. Horak BEA; T. Flint, AAIB, UK Flying Over Conflict Zones—Follow-up Rec- 1330 1500 ommendations MH17 Crash, M. van Hijum, Dutch Safety Board The Paradox of Intuition—A Neuroscience Updating the Concept of Cause in Accident Approach to Training Pilots for Unexpect- Investigation, N. Leveson; Capt. D. Straker, 1400 ed Events, L. Earl, Coventry University; J. Hong Kong Review of Aviation Safety Regulation and Sheffield 1530 Practices of Remotely Piloted Aircraft Systems 1330 Investigating Accidents in Highly Automated in China, L. Yang, China Academy of Civil Aviation Science and Technology, P.R. China Why Did the Helicopter Collide with Trees? Systems—Systemic Problems Highlighted by Approach the Cause from Analysis of Images Analysis of AF 447, Capt. S. Malmquist, RAeS, 1500 and Sounds, K. Fukuda, Japan Transport Florida Institute of technology; N. Leveson Safety Promotion at the Manufacturer—Ac- Safety Board 1600 knowledging the Past Helps Establish the Fu- 1400 ISASI Working Group Meetings ture, E.J. East, Boeing Commercial Aircraft, Inattentional Blindness During Visual Ap- 1700–1900 U.S.A. proach, Capt. A. Singh, Royal Aeronautical Pub Quiz 1500 Society, India Flying Over or Near Conflict Zones—The Way 1400 Forward, K. Beumkes, Ministry of Infrastruc- Analyzing Large and Complex Image Collec- Thursday, September 5 ture and Water Management, Civil Aviation tions During a Safety Investigation, F. Gisolf, 0900 Directorate, Aviation Safety and Security Dutch Safety Board Division, the Netherlands AM Moderator: Pablo Soares Oliveira Filho, 1500 Embraer 1530 Challenges of Accident Investigation in Africa, Keynote Address: Professor K. Hoekstra, How to Achieve a High Safety Level with Aircraft Accident and Incident Division, Delft University of Technology Dual-Mode Fly & Drive Vehicles, M. Stekeler- Rwanda, Manager C. Bagabo; J. Smeitink burg, PAL-V, the Netherlands 0930 1530 1600–1630 Integral Safety Management System Schiphol, Keynote Speech, NTSB Vice Chair B. Lands- J. Daams, Schiphol Closing Remarks and Looking Forward to berg 1000 ISASI 2020 1600 The Importance of High-Load Event Report- 1800–2200 National Society Meetings ing, A. Dika, AAIC, Republic of Kosovo President’s Reception and Awards Dinner 10 • October-December 2019 ISASI Forum Optional Tour Friday, September 6: Amsterdam Following the close of ISASI 2019, conference participants and companions had an optional opportunity to visit Amsterdam. First, they toured the national museum of Amsterdam, the Rijksmuseum. This museum is world famous and includes the largest collection of paintings by the Dutch “Old Masters,” including works by Frans Hals, Jan Steen, and Rembrandt (The Night Watch). Following a quick lunch on the museum’s square, participants either took off on their own itinerary or joined hosts Dann and Karen Zwart for a walking tour of the city—including sites that tourists do not normally frequent. At the end of the afternoon, tour participants rejoined at Haesje Claes for a typical Dutch dinner. Afterwards, the group met for an evening canal cruise to see Amsterdam in its full glory from the water.

The high point of the awards banquet is the presentation of the Jerome F. Lederer Award, ISASI’s highest recognition for contribution to air safety, to Capt. Akrivos Tsolakis. Recognition for the best presentation during ISASI 2018 went to Kåre Halvors- en and Tor Nørstegård, AIB Norway, for their paper The EC 225 LP Accident Near Turøy in Norway (see ISASI Forum, April–June 2019, page 4). The best presentation for ISASI 2019 went to David Chapel and Dan Kemme for their paper Comparison and Lessons Learned from UA232 Sioux City and AA383 Chicago Among the sights of a postseminar optional tour are Amsterdam’s national museum, the Uncontained Events (see page 15). Del Rijksmuseum. Gandio welcomed and gave plaques to representatives from new ISASI corporate members: the Netherlands Defence Safety Inspectorate, Ministry of Infrastructure (Rwanda AAIB), Bell, EUROCONTROL, and the University of Management Technology (Pakistan). ISASI’s president gave Kapustin scholarship certificates to the four 2019 recipients: Alexander P. Hall, ERAU; Stacey Jackson, ERAU; Nur Amalina Jumary, University of New South Wales; and Elise Maria Vondra, University of Southern California Aviation Safety Program. He observed that ISASI 2019 From left, delegates from the Nigerian Accident Investigation Board are engineer Francis Odita, participants had donated nearly $2,900 commissioner/CEO engineer Akin Olateru, engineer Mohammed H.I. Wali, and engineer Henry to the 2020 Kapustin Memorial Scholar- Nwanyanwu. ship Fund. At the end of the evening, Del Gandio thanked everyone present “for attend- ing and participating in the 2019 seminar.” He added, “I hope you enjoyed and benefited from our program, the tutorials, and the social activities. I look forward to seeing you in Montréal, Québec, Canada, next year for ISASI 2020. Good night and have a safe trip home.” A scenic view of Rotterdam from the Euromast, a 185-meter-high observation tower. October-December 2019 ISASI Forum • 11 ISASI Honors Capt. Akrivos Tsolakis with 2019 Jerome F. Lederer Award By J. Gary DiNunno, Editor, ISASI Forum Photo credit: J. Gary DiNunno Photo credit:

Capt. Akrivos Tsolakis, right, accepts the 2019 Jerome F. Lederer Award for lifetime excellence in promoting air safety from Frank Del Gandio, ISASI president.

12 • October-December 2019 ISASI Forum uring the ISASI 2019 annual awards banquet, held in The Hague, the Netherlands, on September 5 (see page 4), the Society presented PAST LEDERER AWARD WINNERS its highest recognition for lifetime air safety achievement to Capt. 1977—Samuel M. Phillips DAkrivos Tsolakis. Frank Del Gandio, ISASI’s president, noted that 1978—Allen R. McMahan Tsolakis has had “a unique aviation and aviation safety career over the last 70 1979—Gerard M. Bruggink years.” 1980—John Gilbert Boulding The Hellenic Air Accident Investigation & Aviation Safety Board (AAIASB) was established in 2001. From 2001 to 2011, Tsolakis was its first president. 1981—Dr. S. Harry Robertson And from 2014 through 2023, he’s serving as a senior member of the board 1982—C.H. Prater Houge to guide his younger colleagues and is still actively involved in promoting 1983—C.O. Miller aviation safety within Greece and the Balkan region. Under the leadership 1984—George B. Parker of Tsolakis, the Hellenic AAIASB was organized as an independent accident 1985—Dr. John Kenyon Mason investigation agency with full capacity to investigate major accidents with 1986—Geoffrey C. Wilkinson a well-trained investigator staff. Throughout his terms with the AAIASB, Tsolakis has been dedicated to improving aviation safety in Greece, the Bal- 1987—Dr. Carol A. Roberts kans, Europe, and throughout the world. 1988—H. Vincent LaChapelle “Under the leadership of Capt. Tsolakis,” Del Gandio said, “the AAIASB 1989—Aage A. Roed investigated over 250 accidents and serious incidents, and over 250 safe- 1990—Olof Fritsch ty recommendations were made. The Hellenic AAIASB became an ISASI 1991—Eddie J. Trimble corporate member, and Capt. Tsolakis became an individual ISASI member 1992—Paul R. Powers and subsequently a life member. Recognizing that not many safety investigators from the Balkan region had the opportunity to attend ISASI seminars to 1993—Capt. Victor Hewes learn from and network with world-class safety experts, Capt. Tsolakis host- 1994—UK Aircraft Accidents ed three ISASI Reachout Workshops, two in Athens—in 2005 and 2015—and Investigation Branch one in Cyprus in 2006. He facilitated an ISASI Reachout in Istanbul, Turkey, 1995—Dr. John K. Lauber in 2010. 1996—Burt Chesterfield “Capt. Tsolakis worked closely with the Flight Safety Foundation [FSF] 1997—Gus Economy and attended 43 FSF international seminars. He hosted five FSF seminars in 1998—A. Frank Taylor Athens and became a friend of Jerry Lederer. He became an FSF life member 1999—Capt. James A. McIntyre in 2009. He was also president of FSF South Eastern Europe, and he founded the Greek Flight Safety Organization. 2000—Nora C. Marshal “Capt. Tsolakis received his military flight training in the U.S.A. at Ran- 2001—John W. Purvis and the Transportation dolph Field, Texas, in 1949 and Nellis Air Force Base, Nevada, in 1950. He flew Safety Board of Canada 160 combat missions in the Korean War from 1950–1953 with the Greek unit. 2002—Ronald L. Schleede He retired from the Hellenic Air Force in 1965 as a lieutenant colonel with 2003—Caj Frostell several air medals and decorations for distinguished service. 2004—Ron Chippindale “Capt. Tsolakis joined Olympic Airways in 1965. He flew 18,200 hours 2005—John D. Rawson in 24 types of aircraft, including the DC-3, Comet 4B, B-727, B-707, Airbus A300, and B-747. During his time with Olympic Airways, he established the 2006—Richard H. Wood flight safety department, a safety magazine, an anonymous safety reporting 2007—Capt. Thomas McCarthy program, wind shear prevention programs, CRM, and LOFT. He retired from 2008—C. Donald Bateman Olympic Airways in 1990. For Athens International Airport, he established 2009—Capt. Richard B. Stone and the Australian a flight safety department in 2000, a council for flight safety, and a ‘foreign Transport Safety Bureau object’ day, as well as an airport safety manual. 2010—Michael Poole “During his 70 years in aviation safety, of which 11 years [were] as head 2011—Paul-Louis Arslanian of the AAIASB and another 10 years as senior member of the board, Capt. 2012—Curt L. Lewis Tsolakis has been and continues to be a strong visionary supporter of international cooperation, including ISASI activities. He developed the Hellenic 2013—Frank Del Gandio and Myron Papadakis AAIASB into a professional accident investigation agency respected by 2014—David King colleagues all over the world. 2015—Ladislav (Ladi) Mika “The aviation safety achievements of Capt. Tsolakis, and his encourage- 2016—Eugene (Toby) Carroll ments and support to others,” Del Gandio concluded, “have been tremen- 2017—Chan, Wing Keong dous and outstanding on an international scale and dimension. ISASI is 2018—Capt. Mohammed Aziz proud to have such a truly internationally spirited, worldwide recognized

October-December 2019 ISASI Forum • 13 accident investigation expert as a life significant results, saving lives, reputations, friendly—even festive—voice would change member. Capt. Akrivos Tsolakis is…a most and equipment. After leaving the air force, to an angry, ominous, tone. He said, ‘In deserving recipient of the prestigious ISASI I joined the national Hellenic air carrier, the beginning everyone was blaming the Jerry Lederer Award.” Olympic Airlines, during its golden era pilots, but young man remember that In accepting the Lederer Award, Tsolakis under the leadership of Aristotle Onassis. there are many who are involved in this said, “This night is for me and my family full I found him to be a very strong proponent miracle called flight. Beware the designers, of intense feelings of gratitude and pride for of air safety. Aware of my background, he the builders, the regulators, and the stock the unique honor you have bestowed on me directed me to establish a modern safety market—on both sides of the Atlantic. Be and my beloved country.” He acknowledged department at the airline. I was ecstatic for ready to face complicated accidents. Every the presence of Vassilki, his wife; Constan- the opportunity to use my experience and accident has its deep causes that at times tine, his son; Gen. Antonios Athanasiou, ideas with his full, no-nonsense support. In are latent. So always go deep in your inves- board president; and Nikolaus Tika, board a short time, Olympic became a flight safety tigation.’ member. operator and a very active member of the “In half a century,” Tsolakis observed, “I Tsolakis said, “It was the summer of 1959, Flight Safety Foundation. have never forgotten that advice. Through a day in August, when I stood at attention, “It was during those years at an early the years, while investigating some of facing USAF Gen. Joseph Caldara, the first Flight Safety Foundation seminar that I met the, thankfully, few aviation accidents, I deputy inspector general, USAF, in front of Jerry Lederer. He was medium height, with frequently had an opportunity to remember the entrance of the University of Southern deep blue eyes, white hair, and had a strong Jerry’s angry manner and words. And now, California. He was holding a small model of handshake. He was an outstanding speaker you have also heard him. a republic F-84 Thunderstreak, a plane the and communicator. For me, he was and still “Tonight, we are here, during ISASI 2019, Hellenic Air Force was flying in Greece. The is the only prophet I have ever met. In every to celebrate the Society’s 50th international model was a special award for me as the top gathering where he was present, everyone seminar. With feelings of appreciation and graduate from a class of 32 officers—the was trying to engage him to ask for advice gratitude to all those brave souls who class of 1959. The course we had completed and to sit next to him. He was what young created and have nurtured this magnificent was designed to teach us, according to the people today call a ‘rock star.’ I noticed that Society, I raise a glass to wish ISASI many general, how to prevent airplanes from he particularly preferred to speak with the more successful seminars and Reachouts— falling from the sky.” Tsolakis observed that younger participants. With me, he specif- our most effective programs to spread the this was when he became “infected with ically liked to hear about the exploits and word of flight safety to committed aviation the incurable virus of flight safety—60 long ideas of my legendary boss, Onassis. professionals in every corner of the world. years ago, which, I confess to you, has gone “But when our discussion turned to flight Aviation needs ISASI, and we will always be by too fast for my taste.” safety matters, he would immediately stop there when that call comes in. Let us He noted that “during the subsequent what he was doing, close his eyes, and stay remain as our Founding Father wanted, ‘the six years with the Hellenic Air Force, we silent for a few seconds. When he opened Conscience of Aviation Safety.’ Thank you applied many of those USC lessons with his eyes, you saw fire, and his normally from my heart.”

The 2019 Lederer Award recipient, Capt. Akrivos Tsolakis, right, addresses attendees during the annual ISASI awards banquet.

14 • October-December 2019 ISASI Forum COMPARING UA232 AND AA383 UNCONTAINED EVENTS

By David Chapel, GE Flight Safety Director, and Dan Kemme, Aviation Safety Lead, GE Aviation (Adapted with permission from the authors’ technical paper Comparisons and Lessons Learned from UA232 Sioux City and AA383 Chicago Uncontained Events presented during ISASI 2019, Sept. 3–5, 2019, in The Hague, the Netherlands. The theme for ISASI 2019 was “Future Safety: Has the Past Become Irrelevant?” The full presentation can be found on the ISASI website at www.isasi.org in the Library tab under Technical Presentations. This paper received recognition as the best paper presented during ISASI 2019.—Editor) David Chapel Dan Kemme Nomenclature The notation UA232 refers to United Airlines Flight 232, which crash landed at the Sioux Gateway Airport in Sioux City, Iowa, on July 19, 1989. AA383 refers to American Airlines Flight 383, which conducted an aborted takeoff at Chicago O’Hare International Airport on Oct. 28, 2016. Reference to the “UA232 disk” refers to the fractured Stage 1 fan disk, and reference to the “AA383 disk” refers to the fractured high-pressure turbine (HPT) Figure 1. Event images. second-stage disk. The UA232 disk was made of a titanium alloy (Ti-6-4), and the On Oct. 28, 2016, a B-767-323 powered postevent survival aspects for those on AA383 disk was made of a nickel-based by two CF6-80C2B6 engines suffered an board. alloy (Inconel 718), both workhorse alloys uncontained separation of the Number for the gas turbine engine business. 2 (right-hand) engine high-pressure tur- Purpose bine second-stage disk during takeoff. A There are many aspects of these two Background segment of the disk penetrated the right wing, severing a fuel line and breach- events that could be compared: crew On July 19, 1989, a DC-10-10 powered by ing the wing fuel tank. The flight crew resource management, emergency three CF6-6 engines suffered an uncon- rejected the takeoff and quickly stopped checklists, evacuation procedures, and tained separation of the Number 2 (tail) the aircraft on the runway. There was a disaster preparedness to name a few. This engine Stage 1 fan disk during cruise, ground fire on the right-hand side of the paper will strictly focus on the UA232 which compromised all three aircraft hy- aircraft. The passengers and crew exited and AA383 disks themselves from their draulic systems. The only control that the the left-hand side of the aircraft. The original fabrication to actions taken after flight crew had over the aircraft was by Chicago O’Hare International Airport Fire their respective failures. It is important modulating the throttles for the Number Department responded rapidly and extin- to note that with these events occurring 1 and Number 3 wing-mounted engines. guished the fire. All 170 people survived, roughly 27 years apart, there are some key The DC-10-10 attempted to land at the most with no injuries. differences in the industrial, media, and Sioux Gateway Airport, but the right Figure 1 shows two snapshots of the regulatory environments in which they wing dropped at the last moment causing respective events. These events reflect occurred. In addition, we will discuss the the aircraft to tumble down the runway two very different scenarios. UA232 was importance of cross-enterprise safety in- resulting in the fuselage breaking apart. at altitude (37,000 feet) when the initial itiatives, which are critical to ensure that Of the 296 people on board, there were disk burst occurred. The remainder of this lessons learned are applied across the 111 fatalities yet 185 survived. The inves- flight was a struggle to maintain control entire business enterprise and industry. tigation later found that a hard-alpha of the aircraft. The AA383 event flight was inclusion in the fan disk forging served as over in a matter of seconds with an abort- U.S. National Transportation Safety a crack initiation site on the bore surface. ed takeoff and subsequent evacuation. Board (NTSB) Investigations This led to fatigue propagation, which AA383 was fortunate to have the wind Table 1 (see page 16), summarizes the ultimately resulted in the disk failure. In blowing in the right direction or it could key parameters related to the two event addition, it was determined that a liberat- have been reminiscent of the Manchester, engines. There are several things worth ed disk fragment severed the two backup UK, 1985 accident. A similarity of UA232 noting. hydraulic systems, which combined with and AA383 is that both events occurred in 1. The UA232 engine was in for main- the Number 2 engine failure resulted in direct proximity of emergency personnel tenance inspection less than a year no available hydraulics to fly the aircraft. and equipment, which was critical to the before the event. The investigation October-December 2019 ISASI Forum • 15 Table 1: Comparison of Event Engine Parameters would conclude that the crack in tive “anomalies.” mined when the crack broke the surface the disk was of sufficient size that The UA232 disk developed a crack due of the disk bore. it should have been detected using to a melt-related hard-alpha inclusion on the fluorescent penetrant inspection the bore surface. This inclusion was not Producing titanium and nickel (FPI) process. detected during manufacture due to its UA232 disk: The titanium used to man- subsurface nature and likely uncracked 2. Both disks did not reach their re- ufacture the CF6-6 fan disk in the Sioux spective life limits before failing. The and nonvoided condition, making detec- City event was produced in the early UA232 disk was short by 1,101 cycles, tion difficult. The AA383 disk developed a 1970s using the Kroll process. In this and the AA383 disk was short by crack due to an anomaly called a discrete 4,016 cycles. dirty white spot (DDWS). Like the UA232 process, titanium dioxide, called rutile, is reacted with chlorine to produce titani- 3. While rotating component lives are disk hard-alpha inclusion, this DDWS was not detected during manufacture because um chloride. This is reacted with sodium measured in cycles (every takeoff is a to form titanium and salt. The mixture cycle), it is interesting to note that in it was subsurface and likely was not is mechanically broken down into small terms of calendar time the UA232 and cracked or voided. pieces, and the salt is leached out leaving AA383 engines had initial installa- The UA232 disk was subjected to FPI tions that went back 17 and 18 years, six times during its service life. It was pure titanium—which is often called tita- respectively. determined that the crack had broken the nium sponge due to its appearance. The surface of the fan disk and should have titanium sponge is mixed with alloying Disk anomalies been detectable at least at the last FPI. elements and compacted into bricks. The In both events, nearly all of the fractured The AA383 disk underwent FPI and eddy bricks are welded together into sticks pieces of the disks were recovered (see current inspection (ECI), inspection in an argon atmosphere to prevent the Figure 2), and most importantly these techniques used primarily to detect titanium from reacting with oxygen. The pieces included the primary fracture surface cracks, twice after entering sticks are then melted into an ingot in a surfaces. Figure 3 (see page 17) shows the service. Multiple cracks were observed vacuum oven in a process called vacuum fracture surface of each disk, and Figure emanating from the DDWS propagating arc remelt (VAR). At the time that the 4 (see page 17) shows the close-up of the at various rates with unknown initiation UA232 disk was made, the VAR procedure fracture areas highlighting their respec- times. Therefore, it could not be deter- was then repeated in what is commonly referred to as a double VAR process. If the argon atmosphere present during the welding process described above is not pure and there is any oxygen present, the oxygen may react with the titanium forming hard-alpha. A hard-alpha inclusion in titanium can be a source for the initiation of a fatigue crack in a highly stressed part such as a fan disk. Hard-alpha can be formed during other parts of the manufacturing process, but in this instance it was believed to have been Figure 2. Disk side-by-side comparison. formed during the welding of the bricks. 16 • October-December 2019 ISASI Forum results in another ingot—the VAR ingot. The purpose of this step is to establish the desired microstructure and serves to further refine the cleanliness. The ingot then undergoes a billet con- version process, including homogeniza- tion and forging. The billet produced from these processes is subjected to immersion UTI. The Chicago event billet passed this inspection. The billet was then cut into mults. The mult for the Chicago HPT disk was then forged, heat treated, and machined into a sonic shape. The part then underwent immersion UTI, which it passed. After that, the HPT disk went through final machin- Figure 3. Failure surface comparison. ing and processing. It was then inspected The ingot formed after the double VAR UA232 disk. using an FPI process, which it passed. process is then extruded into a billet. The extrusion process works the material AA383 Disk: The Inconel 718 alloy used and may cause any hard-alpha inclusions for the CF6-80C2 HPT Stage 2 disk in the Manufacturing processes to crack or void. Subsurface cracks and Chicago event was produced in 1997. Both the titanium and Inconel processes voids are detectable during ultrasonic The Inconel material was made using a were considered state-of-the-art at the inspection (UTI). The billet was subjected triple-melt process consisting of vacuum time the parts were manufactured. The to contact UTI during which a UTI probe induction melt (VIM), electroslag remelt titanium alloy was manufactured using was moved along the surface of the billet. (ESM), and VAR. In the VIM step of the a double VAR process. The industry had The billet passed this inspection. process, the raw material, consisting of since determined that the triple VAR pro- The billet was then cut into mults, the elemental nickel material, master cess produced parts that were much less which is short for multiples. The mult alloy, revert (scrap or chips from previ- likely to have inclusions such as hard-al- for the UA232 disk was then forged and ous melts and processes), and reactive pha than the those produced using the rough machined into a sonic shape that material is melted in a vacuum furnace double VAR process. As shown in Figure was ready for UTI. The part was then and is poured into ingots. The purpose 5 (see page 18), the rates of hard-alpha subjected to immersion UTI. In this of this step is to produce the desired inclusions and high-density inclusions im- process, the part is immersed in water chemistry and remove impurities. These proved dramatically from the early 1990s and the UTI probe is moved around the VIM ingots are then remelted in the ESR to the early 2000s “driven by incorporat- part but does not contact the surface of process. In this step of the process, the ing prior lessons learned and continuing the part. Immersion UTI is more sensitive VIM ingot is lowered into a layer of ac- to pay great attention to detail in the than contact UTI. The UA232 disk passed tive/reactive slag. As the VIM ingot melts, manufacture of premium quality Ti used the immersion UTI. the molten droplets sink through the slag in critical rotating aircraft engine applica- A macroetch (ME) inspection was also removing impurities. The droplets collect tions.” Since then, the industry has moved performed on the UA232 disk in the sonic into another ingot, the ESR ingot. The to a cold hearth melt + VAR process that shape as opposed to the final machined purpose of this step is cleanliness of the has proven to be much better than even shape. This inspection highlights micro- material. The ESR ingot is remelted again. triple VAR as shown in Figure 6 (see page structural changes or anomalies on the The process takes place in a vacuum and 18). It should be noted that double VAR surface. The UA232 disk passed the ME inspection. The hard-alpha inclusion located on the bore surface would have had a greater chance of being detected if the part was macroetched in the final machined shape. The part then went through final machining and was inspected using FPI. In this inspection, the part is immersed in or wetted with FPI fluid. The fluid is then gently rinsed from the surface of the part. The part is then inspected with ultraviolet light. If there are any surface cracks, the fluid should remain in the cracks and glow under the ultraviolet light. No crack indications were found on the Figure 4. “Anomaly” comparison. October-December 2019 ISASI Forum • 17 the aggressiveness of the rinsing process, surface cleanliness, and the ability of the inspector to get a clear view of the surface due to factors such as part geometry, lighting, and inspector fatigue (human factors). Also, ME is often used following some manufacturing processes. ME is a chemical treatment of a metal surface to accentuate structural details and anomalies for visual observation. For titanium, GE Aviation uses a process called blue etch anodize (BEA), which, like ME, accentu- ates differences on the surface of the part for visual detection of anomalies. FPI, ECI, ME, and BEA inspections are effective at detecting surface or near-surface cracks and voids. UTI inspections are effective in detecting subsurface cracks and voids. Figure 5. Hard-alpha and high-density inclusion rates from 1990 through 2016 in premium quality Table 2 (see page 19) summarizes the titanium. key parameters related to the event disks in terms of the forging and inspection is still in use by some manufacturers in Inspection processes processes used. Figure 7 (see page 19) is a relatively low-stress applications. Both the UA232 disk and the AA383 disk schematic showing the various titanium Prior to the 1980s, Inconel was produced were subjected to UTI and FPI during the and Inconel melt processes and high-level using the double-melt VIM + VAR process. manufacturing process. Both were also manufacturing and inspection steps and The industry developed the ESR process, subjected to FPI and/or ECI after entering their rough timing of implementation. which greatly improved cleanliness of the service. The UTI process can detect cracks material. Around the time of the Sioux and voids that are subsurface. FPI can City event, GE Aviation converted to the detect cracks on the surface, and ECI can NTSB recommendations triple-melt VIM + ESR + VAR process for detect surface and near-surface cracks Table 3 (see page 19) shows a side by side all Inconel critical rotating parts. This and voids. The probability of detection of recommendations from the two NTSB process produced high-quality parts. In (POD) for each process is less than 100 accident investigation reports. Both events fact, the AA383 event was the first time percent. UTI depends on the orientation of had many more recommendations than that a critical rotating nickel part had the crack or void relative to the ultrasonic shown but the ones shown provide some failed across the industry. The triple-melt wave. Contact UTI is affected by part ge- interesting talking points. nickel process was refined, and lessons ometry, cleanliness, and the couplant used. 1. Both events generate a recommen- learned were incorporated so that the Following the UA232 event, multizone UTI dation that effectively request an inclusion rate improved even though the was introduced, which allowed inspec- evaluation of the state-of-the-art basic triple-melt process did not change. It tions of much higher sensitivity. Phased inspection techniques and whether they can be enhanced. should be noted that the inclusion rate for array and circ-shear UTI are later methods Inconel is much higher than for titanium; that also improve the POD. 2. Both events spawn a recommen- however, Inconel is also more inspecta- For FPI, there are many factors that can dation to revise Advisory Circular ble and more tolerant to anomalies than affect the POD, including the length and 20-128(A) “Design Considerations titanium. This is in part due to differences tightness of the crack at the surface (which for Minimizing Hazards Caused by in crack initiation and growth rates. affects the amount of FPI fluid retained), Uncontained Turbine Engine and Auxiliary Power Unit Rotor Failure.” 3. The UA232 report recommends cre- ating a historical database of rotary part failures that can be used in design assessments and safety analysis. This could be considered a precursor to the initiative to create AC39-8, “Continued Airworthiness Assess- ment Methodology,” released in 2003. This guidance provides the historical- ly based hazard potential for power- plant components and systems.

Discussion Figure 6. Premium quality titanium hard-alpha and high-density inclusion rates for hearth melt At the time of UA232, capturing a video vacuum arc remelt (VAR) and triple VAR. of a commercial aviation accident was 18 • October-December 2019 ISASI Forum that there has only been a single fatality on a U.S. domestic airliner since the Colgan Air event just more than 10 years ago. The manufacturing processes for both Inconel and titanium have seen improvements, but the focus by industry on titanium after UA232 has resulted in a process that minimizes hard-alpha inclusions to a level unimagined in 1971 when the UA232 disk was first forged. This success was driven by a collaborative approach of industry and regulatory agencies. In the Table 2: Comparison of Disk Forging/Inspection Parameters wake of UA232, nine U.S. Federal Aviation Administration (FAA)/industry teams focused on the recommendations that the NTSB made as part of the investigation. Of note are the Jet Engine Titanium Quali- ty Committee (JETQC) and the Aerospace Industries of America (AIA) Rotor Integ- rity Subcommittee (RISC). Inconel has also improved, but its higher tolerance to inclusions, crack initiation, and growth rate made it a lower-risk priority than the titanium activities. On Nov. 7, 2018, the FAA sent a request to the AIA to consider addressing the NTSB recommendations by chartering the longstanding and ongoing JETQC and RISC teams to apply their Figure 7. Side-by-side premium quality titanium and nickel processing. lessons learned from titanium to nickel alloys. These teams indicated that they would support the effort.

Safety management system In 2010, the International Civil Aviation Organization (ICAO) released Annex 19, which defines the safety management system (SMS) framework. As of March 2018, all U.S. domestic airlines were required to have an SMS (14 CFR Part 5). In December 2018, GE Aviation was the first original equipment manufacturer (OEM) in the U.S. to receive FAA acceptance of its SMS, an SMS that was in place since January 2013. Within GE’s SMS, one of Table 3: Comparison of NTSB Recommendations (Abbreviated and Emphasis Added) the key learnings as it evolves is to ensure that lessons learned on one program unprecedented. By the time of AA383, the improvements during this timeframe in- are communicated to other programs. A airport tower had complete footage of the clude ground proximity warning systems, formal process driving this cross-program event, and passengers disembarking were the advent of crew resource management review was implemented in mid-2017. As taking videos of the aftermath. Newspa- (a key success factor in the UA232 event), more operators and OEMs move toward pers told the story of UA232; the Internet and wind shear systems and detection SMS implementation and have internal captured the images of AA383. training. Contrast this to the AA383 en- lessons learned, the question should be In an evolving aviation system, techno- gine, which throughout its 18 years in ser- asked: What forum ensures sharing of logical advances and product enhance- vice only two major U.S. domestic airliner these respective findings on an industry, ments are always being made. The 17-year events occurred: in 2001, AA Flight 587, an regulatory, global stage? span of the UA232 engine has as its back- Airbus A300, in Queens, N.Y.—the second drop the worst U.S. aviation accident (AA worst U.S. aviation disaster; and in 2009, Summary and conclusions Flight 191, crash of a DC-10 after takeoff Colgan Air Flight 3407, a Bombardier Dash This paper has reviewed the UA232 and from Chicago O’Hare on May 25, 1979) as 8 that crashed on approach to Buffalo, N.Y. AA383 accidents from an engine perspec- well as a string of other major events in the Aviation safety within the U.S. national U.S. throughout the 1970s and 1980s. Key airspace system has improved to a level (Continued on page 30) October-December 2019 ISASI Forum • 19 ISASI Kapustin Scholarship Essay APPLYING HUMAN The following article is the first of four essays from the 2019 FACTORS TO Kapustin scholarship winners that were presented during COMMERCIAL SPACE ISASI 2019. The number of scholars selected each year OPERATIONS depends upon the amount of money ISASI members donate By F/O Stacey Jackson (WestJet), annually to the scholarship fund. Embry-Riddle Aeronautical University Details about scholarship applications and additional informa- ircraft accident investigation is sions as evidenced during the in-flight tion can be found on the ISASI a well developed, yet dynamic, breakup of the reusable suborbital website at www.isasi.org. Appli- part of the aviation industry. rocket SpaceShipTwo on Oct. 31, 2014. cation and essay deadlines are A It exists in a constant balance As a result of the investigation, the U.S. mid-April of each year.—Editor between reactive and proactive actions; National Transportation Safety Board reactive in the conclusions and rec- (NTSB) identified seven safety issues ommendations that are derived from that contributed to the accident, one an investigation and proactive in the of which was a “lack of human factors development and implementation of guidance for commercial space oper- the various mitigation strategies aimed ators” (National Transportation Safety at preventing a reoccurrence. Board, 2015, p. vii). The future of aviation is attaining new The term human factors is often used heights, as the commercial space indus- to describe an exceptionally broad try continuously achieves unprecedent- topic that incorporates a vast subject ed successes. Even with exceptional array, including ergonomics, human technological advancements, and an cognition, sensation and perception, evolution in operational environment, aeronautical decision-making, crew spacecraft operators must remember resource management (CRM), human that at least one element has remained physiology, effective communication, constant: the human. and threat and error management, for Human error mitigation strategies example. All of these elements have that have been previously developed been incorporated into commercial for other industries, including aviation, aviation operations, through the Code have been established through decades of Federal Regulations (CFR) Part 121 of data gathering and analysis. Failure and 135, as preventative methods to to implement these strategies will reduce human errors and improve per- result in the genesis of latent and active formance (pilots and flight engineers, errors that when combined with other 2019; crewmember training require- operational oversights will develop an ments, 2019). error chain (Reason, 1990; Wiegmann & Unfortunately, the CFR guidance on Shappell 2003). pilot licensing for commercial space Commercial space operators must in- operations does not mandate a com- corporate the lessons learned through mercial or airline transport license, past experiences in related fields to which could result in a pilot command- improve future operational safety. ing a spacecraft with substandard human factors training, if any at all Human factors and commercial (crew qualifications and training, 2019). space operations The application of different human The commercial space industry is one factors concepts has greatly improved that demands exceptional precision, aviation safety, while improving synergy with little room for errors, and yet it and teamwork among crewmembers. must include the human element that These concepts will provide a similar remains fallible in nature. Failing to benefit to commercial space operations incorporate error mitigation strategies if they are incorporated into regulatory F/O Stacey Jackson has severe and often fatal repercus- provisions.

20 • October-December 2019 ISASI Forum Oversight and accident prevention execute their duties with zero human er- itative data, the latter being subject to Title 14 CFR §460 provides federally ror (Helmreich, Merritt & Wilhelm, 1999; bottom-up and top-down information regulated guidance on training elements Maurino & Murray, 2010). Fortunately, processing errors (Gibb, Gray & Scharff, that must be incorporated to satisfy the this erroneous thought process was, for 2010). Information recalled through licensing requirements for human space the most part, corrected in the subse- human memory is never perfect and, as flight (aeronautics and space, 2019). Title quent generations of CRM, and appropri- such, cannot be considered a fact. But it is 14 C.F.R. §460.15 identifies the necessity ate provisions have been in place for the still valuable for the sake of data mining of human factors training to incorporate past several decades. and accident prevention. Third, databases elements that could “affect a crew’s ability Unfortunately, the assumption that are incomplete as not every incident or to perform safety-critical roles” (human training could result in perfect human accident is reported. factors, 2019, para. 1). This four-item list performance was one of the primary Furthermore, there are situations in primarily discusses ergonomics, in an failures in the hazard analysis that was which an intervening action caused effort to improve the flight crew’s oper- conducted by Scaled Composites LLC the cessation of the accident sequence, ational efficiency and decrease disso- prior to the launch of SpaceShipTwo leaving the crew unaware of the potential nance when liveware interfaces with the (National Transportation Safety Board, disaster that would have occurred. These hardware and software of a spacecraft 2015). The Transportation Safety Board of scenarios are almost impossible to track, (International Civil Aviation Organiza- Canada has identified that the majority simply because it is exceptionally difficult tion, 1993.) of accidents, regardless of size, can be to document an event that did not hap- Although important, ergonomics is attributed to the failure of an organiza- pen. Clearly, data collection and mining only one small aspect of human factors. tion to identify and mitigate hazards and are not perfect but even so provide valua- The lack of federally regulated guidance manage risk (Fox, 2016). ble predictors of future behavior. on the additional aforementioned compo- The aviation industry has spent the bet- nents is a severe detriment to the future ter part of 50 years analyzing the limita- How the past predicts the future of spaceflight safety. Unfortunately, U.S. tions of both cognitive and physiological Using the central limit theorem, behav- law has limitations on the authority of the human performance and from this was ioral and social scientists specializing Federal Aviation Administration (FAA) able to develop and implement mitiga- in inferential statistics often witness a when it comes to regulating the commer- tion strategies. These conclusions were normal distribution pattern in the major- cial space industry. The U.S. Congress developed from previous accident inves- ity of populations in nature (Aron, Coups established a dedicated learning period tigations, incidents, voluntary reporting, & Aron, 2011). This results in 68% of the that was extended from Oct. 1, 2015, to and other forms of data gathering. Even population falling within one standard Sept. 30, 2023, resulting in the moratori- though operations in space likely con- deviation of the average and 96% within um on the development and implementa- tain unique elements, the foundation of two standard deviations. The distance tion of new safety regulations for com- human performance and error prevention from the average for any value is derived mercial space operations (Ward, 2016; that have been established in the aviation from a variety of factors, including envi- Reimold & Sloan, 2017). industry is transferrable. ronmental and educational, as well as the It would be irresponsible to rely solely physiological and cognitive abilities of on perfect compliance with federal regu- Data application the participant. Values that are found on lations to mitigate the industry from risk, The purpose of aircraft accident investi- the extreme of the population curve are and, as such, commercial space operators gation is to develop an understanding of referred to as outliers but are rare in pop- must identify the gaps in regulations the actions and decisions that led to the ulations that follow a normal distribution and mitigate the associated risks. Risk unfavorable outcome, and to apply that (Aron et al., 2011). identification and mitigation is a com- information to the development of miti- Understanding that human perfor- bined effort between several participants, gation strategies (Wiegmann & Shappell, mance is likely to follow the normal including, but not limited to, the federal 2003; Wood & Sweginnis, 2006). Approx- curve, given that the fluctuation of regulator and the operator. The creation imately 80% of all aircraft accidents have influential variables remains relatively and implementation of federally regulat- some element of human-related error, consistent, future human performance ed requirements provides the necessary and it is imperative to apply the lessons can be predicted with relative accuracy foundation upon which operators can learned to future actions in an effort to based on previously acquired behavioral build their own defences; however, when prevent a reoccurrence (Campbell & Bag- data (Aron et al., 2011). With relative this foundation has not yet been devel- shaw, 2002). The aviation industry is well simplicity, the commercial space industry oped, it behooves operators to build it versed with data mining and has identi- could implement mitigation strategies themselves. fied relationships, links, and trends that to improve human performance during have already benefitted aviation safety; operations in space. Operator involvement in accident but this, too, has its shortcomings. avoidance First, there is not a singular database Conclusion In the late 1970s, it was identified in the that contains all of the related informa- Even though commercial spaceflight is a first generation of CRM that the aviation tion, and as such not every relationship unique and attractive mode of transporta- industry had an unrealistic expectation or trend can be identified. Second, the tion, there are exceptional risks involved. of human performance and incorrectly databases that do exist are built on a Human spacecraft operators are fallible, assumed that humans could be trained to combination of quantitative and qual- and their performance is comparable to

October-December 2019 ISASI Forum • 21 References

Aeronautics and space, 14 C.F.R. §460 (2019).

Aron, A., Coups, E.J. & Aron, E.N. (2011). Statistics for the Behavioral and Social Sciences: A Brief Course (5th ed.). Upper Saddle River, NJ: Prentice Hall/ Pearson.

Campbell, R.D. & Bagshaw, M. (2002). Human Performance and Limitations (3rd ed.). London, England: Blackwell Science.

Crew member training requirements, 14 C.F.R. §135.329 (2019).

&UHZTXDOLƬFDWLRQVDQGWUDLQLQJ&)5

Fox, K. (2016, April 26). Keynote Address to the Northern Air Transport Asso- ciation Annual General Meeting. Speech presented at Northern Air Transport Association Annual General Meeting, Whitehorse, YT. Retrieved from http:// www.tsb.gc.ca/eng/medias-media/discours-speeches/2016/04/20160426. html.

*LEE5*UD\5 6FKDUƪ/ 6HQVDWLRQDQGSHUFHSWLRQIRXQGDWLRQV In Aviation Visual Perceptions: Research Misperception and Mishaps (pp. 21- 59). Retrieved from http://site.ebrary.com.ezproxy.libproxy.db.erau.edu/lib/ erau/reader.action?docID=10376614.

Helmreich, R.L., Merritt, A.C. & Wilhelm, J.A. (1999). The evolution of crew resource management training in commercial aviation. International Journal of Aviation Psychology, 9(1), 19-32. doi: 10.1207/s15327108ijap0901_2.

Human factors, 14 C.F.R. §460.15 (2019).

International Civil Aviation Organization. (1993). Human factors digest No. 7: Investigation of human factors incidents and accidents. Circular 240-AN/144. Montreal, QC: International Civil Aviation Organization.

Maurino, D.E., & Murray, P.S. (2010). Crew resource management. In J. Wise, V. Hopkin & D. Garland (Eds.), Handbook of Aviation Human Factors (pp. 10- 1–10-20). Boca Raton, FL: CRC Press. highly trained aircraft pilots. As such, the lessons that have been previously learned National Transportation Safety Board. (2015). In-Flight Breakup During Test in aviation-centered human factors Flight Scaled Composites SpaceShipTwo, N339SS, Near Koehn Dry Lake, Califor- should be evaluated and adapted for nia, October 31, 2014. Retrieved from https://www.ntsb.gov/investigations/ flight in space. Furthermore, federal regu- AccidentReports/Reports/AAR1502.pdf. lations must eventually evolve to develop a satisfactory level of safety that protects 3LORWVDQGƮLJKWHQJLQHHUV,QLWLDOWUDQVLWLRQDQGXSJUDGHJURXQGWUDLQLQJ C.F.R. §121.419 (2019). the operating crew and passengers from avoidable risks. Reason, J. (1990). Human Error. New York, NY: Cambridge University Press. In addition, research must be conducted to develop specialized oversight for Reimold, D. & Sloan, J. (2017). Commercial space transportation overview the commercial space industry, as well >3RZHU3RLQWVOLGHV@)HGHUDO$YLDWLRQ$GPLQLVWUDWLRQ2ƯFHRI&RPPHUFLDO as additional education for investigators Space Transportation (AST). Retrieved from https://www.faa.gov/about/ of spacecraft accidents. Regulations and RƯFHBRUJKHDGTXDUWHUVBRƯFHVDWRVHUYLFHBXQLWVV\VWHPRSVDWRBLQWOGRF- uments/cross_polar/CPWG23/CPWG23_Brf_Commercial_Space_Transporta- policies must be created to facilitate data tion_Intro.pdf. gathering and mining, specific to operations in space, as well as a process for Ward, E.L. (2016). Is It a Space Plane or Rocket? ISASI Forum. Retrieved from implementing risk mitigation strategies. KWWSVZZZLVDVLRUJ'RFXPHQWV)RUXP0DJD]LQHVIRUXPƬQDOOU The development of safe and efficient web.pdf. commercial space operations is entirely dependent on the ability of industry Wiegmann, D.A., & Shappell, S.A. (2003). A human error approach to aviation accident analysis. Burlington, VT: Ashgate Publishing. leaders to remember the past and apply this wealth of knowledge to the creation Wood, R.H., & Sweginnis, R.W. (2006). $LUFUDƱDFFLGHQWLQYHVWLJDWLRQ QGHG . of future safety measures. Casper, WY: Endeavor Books.

22 • October-December 2019 ISASI Forum

Julian E. Anthony T. Diego M. Echeverri Brickhouse Garcia LAMIA FLIGHT 2933: WHO LIVED, WHO DIED, AND WHY

By Anthony T. Brickhouse, Embry-Riddle Aeronautical University, U.S.A.; Diego M. Garcia, Embry-Riddle Aeronautical University, U.S.A.; and Julian E. Echeverri, Aviation Accident Investigation Group, Colombian Civil Aviation Authority, Colombia

(Adapted with permission from the authors’ technical paper LAMIA Flight 2933: Who Lived, Who Died, and Why presented during ISASI 2019, September 3–5, in The Hague, the Netherlands. The theme for ISASI 2019 was “Future Safety: Has the Past Become Irrelevant?” Thell fu presentation can be found on the ISASI website at www.isasi.org in the Library tab under Technical Presentations.—Editor)

Introduction (container, restraint, environment, energy aviation accidents are crucial for crash- An Avro 146-RJ85, performing charter absorption, and postcrash factors) meth- worthiness design, but also for education, flight LAMIA LMI2933 for the Brazilian odology to assess the different factors research, and safety enhancements of Chapecoense football team, was de- that influence survivability in a crash (see current aerospace systems. A compre- Table 1, page 25). Actual flight data, crash stroyed after impacting a wooded hillside hensive survival analysis, especially when scene analysis, medical and forensic in- occurrence circumstances diminish the south of José María Córdova International formation, and personnel interviews from Airport in Colombia. The official accident this accident were gathered to determine odds of survival for occupants as in this investigation board included more than acceleration loads, magnitude and dura- case, becomes paramount. Research can 20 experts from five states. At the end tion, aircraft structural collapse, and en- contribute to enhanced aircraft design of the investigative process, the board ergy absorption. Injury causation, search and restraint systems, improved emergen- determined that fuel exhaustion was and rescue, and health-care services for cy services, advanced accident inves- the cause of the crash. Of the 77 occu- the aircraft occupants were also explored. tigation techniques, and in general an pants on board, only six survived. Five All five CREEP factors were depicted and augmented awareness and understanding occupants suffered serious injuries, and weighted for each one of the six survivors of safety promotion and accident/injury one sustained minor injuries. Crashwor- in order to evaluate what specific condi- prevention for the general public, operations contributed to survivability. thiness and survivability analyses were tors, and regulators. performed to assess the conditions that allowed these occupants to survive the Results Background crash. CREEP elements played different roles The aerospace industry nowadays is for each of the surviving occupants of labeled as an ultrasafe industry given the the accident aircraft. Energy absorption Methodology safety performance indicators assessed by and restraints were decisive for all six It is taught in academic circles around the International Civil Aviation Organi- survivors. The container was a protective the world that for occupants to survive zation (ICAO) and the International Air factor for three of them, while environ- an accident, specific stipulations must mental factors during the crash dynamics Transport Association (IATA). According be met. Occupants must have occupiable were also important as a protective ele- to recent research, accident rates were in living volume during the dynamic portion ment. In contrast, postcrash factors were between 12.2 fatalities per billion passen- of the crash. Decelerative (G-forces) must detrimental for all of the six survivors. gers in 2017 for the former and 1.35 per be within human tolerances. And occu- billion in 2018 for the latter. Even though pants must survive all postcrash factors these indicators are near their historical until rescue and medical treatment occur. Discussion best, high-profile accidents involving Air safety investigators use the CREEP Occupant survival analyses derived from commercial aviation operators bring October-December 2019 ISASI Forum • 23 high-impact consequences for the general • Inappropriate planning and execu- ments for the specific occurrence and the public in terms of trust and willingness tion of the flight by the operator in specific conditions that each accident to use airline transportation services. Re- regard to the amount of fuel required presented to occupants. This depends on cent studies described a survival percent- for the safe completion of the intend- their position in the airframe, the energy age of 81% for all aircraft occupants of ed flight. amount and dynamics of the crash, the commercial passenger aircraft accidents, • Sequential flameout of the four correct and effective use of different types and in 90% of accidents there was at least engines as a consequence of fuel of restraining systems, their opportuni- one survivor. exhaustion. ty to egress the scene, and the support According to different aspects and ele- • Inadequate decision-making on the received after the event, among other ments unique for each one of the occur- part of the aircraft operator in terms factors. When the investigation process rences, the outcomes in terms of surviv- of the implementation of operational determines that all these elements were ability of an accident are dichotomously safety in its processes. against occupant survival, yet one or categorized as survivable or nonsurviva- • Loss of situational awareness and more occupants survived, other analysis ble. It is not unusual that, in spite of the wrongful decision-making by the and factors should be considered. This is theoretically exceeded human tolerance flight crew because of the fixation of the case with LAMIA Flight 2933. The ob- capabilities in certain crash events, there continuing the intended flight with jective of the present study is to analyze are one or more surviving occupants an extremely limited amount of fuel. the different elements of CREEP method- in the aftermath of an accident. This is ology for the six survivors of the flight. precisely the case regarding LAMIA Flight There was no postimpact fire, and the 2933 that crashed near Medellin, Colom- aircraft was destroyed as a result of the Kinematics bia, in November 2016 (see Figure 1). crash. Of the 77 occupants, 71 perished For the survival factors analysis specific According to the Colombian Aviation and six survived with serious and/or to the crash of LAMIA Flight 2933, the Accident Investigation Authority (GRIAA), minor injuries. Despite the high-energy authors of this study referred to the offi- the accident aircraft, an AVRO 146-RJ85, impact, the almost complete destruction cial final report published by the Colom- registered with the tail number CP 2933, of the airframe, the rough environmental bian Civil Aviation Authority (CAA) and was conducting a chartered flight from conditions after the crash, and the limited GRIAA, where crucial data are depicted Viru Viru International Airport in Santa first responders’ assistance secondary to and analyzed. Data included weight and Cruz de la Sierra, Bolivia, to José María the geographic conditions of the acci- balance, speed, distances, accelerations Córdoba International Airport (SKRG) dent site and the accessibility from there that were mainly retrieved from the in Rionegro, Colombia. The aircraft was to health-care services, eight survivors flight data recorder (FDR), cockpit voice carrying the Brazilian football team were found among the wreckage at the recorder (CVR), and operational records Chapecoense and some journalist and accident site. Unfortunately, one of these and forms. The final report included pho- administrative directives from the team. survivors was lost at the crash site before tos, diagrams, formulas, and calculations During a holding pattern waiting to be the evacuation, and another died from his for relevant information related to injury authorized to intercept the localizer for injuries at the regional hospital shortly causation to occupants. Other publicly the approach to Runway 01 of José María after arrival. available resources such as interviews, Córdova International Airport, the air- After taking into account these differ- expert analysis, documentaries, press craft suffered a sequential flameout of its ent factors, accident investigators can releases, and reports were also taken into four engines and impacted the southern point to one or more of these elements as account. slope of a mountain located 10 nautical the potential source(s) of injuries to oc- Following the procedure for CREEP miles south of the threshold of Runway cupants and the different levels of injury analysis, the authors weighted and mod- 01 of SKRG at 02:59 Zulu time at night severity generated by their interaction. eled all the available information in order during rainy weather conditions. After an accident investigation, fatal- to build a general, unified model for the The investigation process identified the ities and both severe and minor injuries entire airframe and for all occupants. Af- following causal factors: are explained in terms of CREEP ele- terward, a detailed analysis for each one of the surviving occupants was conducted in terms of energy absorption, container preservation, restraint elements, and environmental and postcrash factors. This was done to explain the potential conditions and factors that determined the survivability of six of the 77 occupants of the ill-fated flight. The first approach for the analysis was energy calculations. This was accom- plished using the FDR data, crash scene distances, wreckage distribution, and Figure 1. An Avro 146-RJ85. forensic analysis for specific injuries evi- Source: GRIAA. Final Report. Accident. COL-16-37-GIA Fuel Exhaustion AVRO 146-RJ85, denced in both fatal and nonfatal victims Reg. CP 2933 Nov. 29, 2016, La Unión, Antioquia, Colombia. of the crash. This was done to determine 24 • October-December 2019 ISASI Forum Results of kinematics Acronym Factor Explanation For energy calculations, estimated The available living space for occupants resulting weights, distance, and speeds were de- C Container during and after the accident dynamics. rived from dispatch records and FDR-re- Seats, seat belts, and other restraint systems lated elements. This was done in order protecting occupants from being injured by other to replace available terms of the energy R Restraint structures and elements, and preventing them magnitude and duration equations. Based from being projected inside and outside of their on the data and scene and impact dy- living space. namics reconstruction, it was determined that after the initial impact at the top of The deceleration forces experienced by occupants the hill, a descending energy dissipation during the crash; since occupants are not a fixed E Energy trajectory (approximated 55-degree slope) part of the airframe, energy can be either attenuat- was generated along a magnetic course ed or amplified. of 296 degrees, continuing for around 140 All the surrounding factors created by the crash meters (462 feet) downhill on the north- that can injury occupants, like fumes, extreme heat ern slope of the ridge. This is where the E Environment or cold, toxic materials, or fast-moving objects majority of the aircraft wreckage came within their living space. to rest almost completely destroyed. The only recognizable sections of the airframe All the different situations and elements that can were the tail and empennage section affect occupant survival after the dynamic portion Postcrash (which was preserved and found at the P of the accident. Postcrash fire and smoke, wreck- Factors top of the hill slightly behind the initial age evacuation, and search-and-rescue systems impact site) and the right wing with a are the most relevant elements under this domain. small fuselage section attached directly Table 1. CREEP survivability methodology below it (see Figure 2). Final distribution and destruction level of the debris also the acceleration pulse shape and duration and recovery. suggested that the main wreckage dissi- and the onset rate and the magnitude Finally, a resulting model based on an pated the remaining postimpact energy for energy vectors (horizontal and ver- analog scale comparing the estimated in a snowball-like pattern, with its center tical acceleration) using the following contribution of each one of the CREEP in the front portion of the fuselage, which equations: elements was consolidated for each one was also the most badly destroyed. This fi- of the surviving occupants. nal distribution pattern also explains the

Where the following: GH = Horizontal G loading VH1 = Initial impact velocity VH2 = Secondary impact velocity g = Acceleration of gravity SH = Horizontal deceleration distance Gv = Vertical G loading SV = Vertical deceleration distance

The second approach for the analysis was the CREEP study for estimating the resulting living space during and after the dynamic portion of the crash, the restraining systems’ characteristics, usa- bility and effectiveness for the surviving occupants, and factoring environmental and postcrash aspects affecting the Figure 2. Postimpact path and main wreckage location. occupants’ possibilities of receiving Source: GRIAA. Final Report. Accident. COL-16-37-GIA Fuel Exhaustion AVRO 146-RJ85, Reg. CP timely medical assistance, treatment, 2933 Nov. 29, 2016, La Unión, Antioquia, Colombia. October-December 2019 ISASI Forum • 25 from the other four occu- Restraint pants since their seats were The restraint element, along with energy rear facing and supported absorption, was factored into the type by a structural wall dividing and relatively low severity of the inju- the galley from the rest of the ries of occupants 1 and 2. As previously passenger cabin. The con- mentioned, these two occupants were tainer element for these two rear facing, wearing four-point restraint occupants was protective at systems. These restraints offered extra least for the initial sequence of protection and prevented further inju- events, after which they were ries from decelerating forces and during likely ejected from the airframe the dynamic part of the accident. For and were recovered near the occupant 3, rescue personnel stated that empennage section according he was attached by his two-point seat to rescuer statements and their belt to the middle seat of a row of three, where the occupants to his left and right Figure 3. G loads and onset time modeling. own narratives. Occupant 3 was recovered side were found fatally injured and also final location of most of the deceased passengers, outside of the main wreckage attached to their respective seats. These especially those who probably were not using any on higher ground compared to findings indicate that the restraint sys- restraint system at the moment of the initial impact. the rest of occupants and main tems might have played a crucial role in The resulting energy calculations for a triangular wreckage. For this occupant, the survival of this occupant. pulse showed a peak around 70 Gs in the vertical there was not enough evidence Occupants 4, 5, and 6 were using axis at approximately 0.6 seconds, with an initial to determine if the container two-point restraint systems like the rest rapid deaccelerating force until around 0.8 seconds played a protective role, but the of the passengers. According to their and then a more steady deceleration until around 4 statements, they were using the seat belts seconds after the initial impact (see Figure 3). probability is low given the injuries received by the close and at the time of the initial impact. This Moving forward into the model, the approxi- most definitely contributed to their final mate location of the six surviving occupants in the immediate passengers around him and the condition of the survival. For all the seats on the ill-fated aircraft at the moment of the initial impact was aircraft, the G loads encountered by the container at the section where assessed to determine the container’s integrity, the airframe and the attaching structures he was estimated to be seated. restraint conditions, and environmental aspects were well beyond the threshold that they For occupants 4, 5, and 6, such as potential blunt and penetrating trauma can support by design (usually 16 Gs for it is highly probable that the produced by fast-moving and high-energy elements passenger seats). Most of the recovered surrounding them during the dynamic portion of container aspect was the most bodies from the crash site were found the crash. To perform this assessment, the approxi- protective element, since evi- restrained to their respective seats, but a mate occupant distribution within the aircraft cabin dence from the final wreckage significant number of bodies were recov- and type of injuries were taken into account (see revealed that the upper section ered outside the main wreckage, along Figure 4). of the fuselage, below the the path of postimpact energy dissipa- For occupants 1 and 2, the initial impact was attachment to the right wing, tion. This is a good indicator that those estimated to have occurred right below and behind was the only fuselage section occupants might not have been wearing their seats. The energy affectation and dynamics that was almost intact after the their respective restraint systems at the experienced by these two occupants was different crash impact. moment of the accident.

Energy absorption The energy absorption and dynamics for the six surviving occupants represent special difficulty for a general modeled assessment. It is highly probable that all six of them received high decelerating G forces at the moment of the first impact (around 70 Gs on the vertical axis). Be- cause of the direction of the higher G peak, the seat design, and according to Eiband curves, this energy load might have been survivable for most of the occupants. Unfortunately, energy dissipation and injury prevention that would have Figure 4. Approximate distribution and injuries of surviving occupants. allowed them to survive the dynamics of Adapted from GRIAA. Final Report. Accident. COL-16-37-GIA Fuel Exhaustion AVRO 146-RJ85, Reg. the crash were decidedly influenced by the CP 2933 Nov. 29, 2016, La Unión, Antioquia, Colombia. other four elements of the CREEP model. 26 • October-December 2019 ISASI Forum Environment Environmental aspects during the dynamic portion of the crash behaved differently for the six surviving occupants. For occupants 1 and 2, due to their facing toward the rear of the aircraft, the container and restraint factors, and ejection outside of the main wreckage, the other elements moving with very high energy did not represent any injury risk for them. This was also true for occupant 3. A different scenario existed for the other three surviving passengers, since they were seated in the middle section of the fuselage, where most of the occupants received fatal blunt injuries from the heavy and fast-moving elements inside their occupiable space. These elements were seats, lug- gage, interior cabin structures, and other passenger bodies. For occupants 4, 5, and 6, this element was most likely attenuated by the fact that during the crash dynamics, the fuselage broke into three main sections: one containing the front part of the fuselage, including the flight deck, which was destroyed and mostly disintegrated; the middle section, which included their location and which was fairly preserved around the right wing, precisely where they were seated; and a third section right behind the seats of passengers 4, 5, and 6, which was also completely destroyed.

Postcrash factors Postcrash factors were determined to be detrimental for all six surviving occupants. Eight occupants survived the dynamic portion of the crash, but unfortunately two perished either during the evacuation or shortly after arriving at an appropriate medical facility. This was the result of persistent rain and cold temperatures, the high altitude, and the long response times for rescue teams because of the relative remoteness of the Figure 5. Surface graphs for CREEP element analysis for each surviving occupant. crash site. The rescue efforts were complicated by questions will be a resounding yes, emergency services, and the advancement the nonexistent access roads to the site and the but this will not happen automat- of accident investigation techniques. In unavailability of air rescue services. Despite those ically. Occupant survival analysis general, an augmented awareness and adverse factors, rescue teams evacuated all survi- derived from aviation accidents is understanding of safety promotion and vors on stretchers by foot for at least one kilom- crucial for crashworthiness design, accident/injury prevention for the general eter (0.6 miles) to a narrow unpaved road where but also for education, research, public, operators, and regulators can also ambulances and rescue vehicles could pick them and safety enhancements to current occur. up for an approximately hour-long drive to the aerospace systems—not to men- CREEP analysis presents a comprehen- nearest health-care facility. Also noteworthy was tion search-and-rescue teams and sive inventory of factors to take into that occupant 4 was rescued from the wreckage first responders for events of such account when evaluating the different with serious injuries approximately four hours magnitude. circumstances that contribute to occupant after the crash. The safety performance of the injury causation and severity in an aircraft Figure 5 shows the summary model for all aerospace industry is currently at accident. Yet more research is needed CREEP-related elements for all six surviving its best, but when accidents occur, regarding possible redesign or reevalua- occupants. survivability of occupants is still a tion of the CREEP model to assess new and topic with significant opportunities developing factors. Some of the factors Survivability and future safety for improvement. A comprehensive that could influence the future of the Future safety is the aim of any aircraft accident survival analysis, especially when current CREEP model include newer investigation. For survival factors, investigators occurrence circumstances diminish aircraft seats and pitches, composite must ask: If the same accident occurs again, the odds of survival for occupants materials, and supersonic air transport. A will the outcome for occupant survivability be like those in this particular case, redesigned CREEP model should also improved? If a similar accident to LAMIA Flight can contribute to the enhancement account for personnel variability and 2933 occurs again, will more than six passengers of aircraft design and restraint individual conditions such as age, fitness, survive? Hopefully the answer to each of these systems, the improvement of physical condition, and gender. October-December 2019 ISASI Forum • 27 NEWS ROUNDUP

SERC Meeting Held in Atlanta prior to immigrating to the U.S. in the mid-1960s. He joined Boeing Com- mercial Airplane Company and made The Southeast Regional Chapter (SERC) of ISASI recently held his mark as Boeing’s chief engineer its annual meeting with Delta Air Lines as a cosponsor, reported for the B-747/-767/-757/-737 Airplane SERC Secretary Alicia Storey. This meeting, which marked SERC’s Performance & Airworthiness Group. 10th anniversary of holding annual meetings, included a half day Latter’s presentation, “Design and of hands-on enrichment education and a full day of presentations Operation for Flight Safety,” provid- given by world-class speakers. The 2019 event was held August ed a review of the historic origin of 2–3 in Atlanta, Georgia, U.S.A., at the Delta Air Lines training Boeing’s “lessons learned” philoso- center. Forty-six SERC members attended, representing about a phy drawn from early accidents to third of the SERC membership. establish a design process that gives Barry Latter gives a an assurance of built-in safety from the The Flight Safety Division of Delta Air Lines orchestrated Friday presentation during the afternoon activities that included various tours of the Delta Air Paciﬁc Northwest Regional outset. Guidance from FAA regulations Lines training complex. SERC attendees were divided into three Chapter’s fall meeting. and their significance were discussed, groups and were given comprehensive tours of Delta’s in-flight along with changes brought about by training school, Delta’s Simulation Division (where SERC attend- composite airplane structure and the introduction of digital elec- ees were able to command an MD-88), and received an overview tronics. Latter pointed out that one major change in safety design and tour of Delta’s operations customer center where all world- philosophy occurred in the 1970s with the advent of digital elec- wide operations and movements are tracked 24/7. tronics, a subject he was personally involved with through B-747, Delta Air Lines dedicated no less than nine professionals to -767, and -757 propulsion system design, test, and certification. ensure SERC attendees were given a comprehensive experience A highlight of Latter’s remarks involved his personal experience that spanned from 1:00 p.m. to past 5:00 p.m. The National Air in investigating several specific accidents and the lessons learned Disaster Foundation (NADF) hosted a Friday evening dinner for as a result. These remarks brought forth a healthy exchange of all attendees at Lickety Split near the hotel. The restaurant closed Q&As at the conclusion of his remarks. exclusively for the group. The meeting also included a secretary-treasurer’s report that On August 3, SERC meeting attendees participated in a full day summarized the chapter’s financial status, along with an update of presentations at the Delta training center. These presentations on membership. PNRC President John Purvis provided further included remarks relating to membership retention and recruitment. • “The Importance of High Load Event Reporting” by Arben Participants agreed that the chapter’s goal for 2020 should focus Dika, Aeronautical Accident and Incident Investigation Com- on stronger partnerships in the aviation community represented in Seattle and the promotion of ISASI to increase membership mission, Republic of Kosovo. numbers and involvement. The chapter’s program schedule for • “An Overview of the NADF” by Matt Ziemkiewicz, NADF pres- 2020 is currently under review. ident, and Gail Dunham, NADF executive director. • “Fire and Explosion Investigations” by Anthony Brickhouse, Embry-Riddle Aeronautical University. • “Daylight Black Hole Approaches” by Glenn Grubb, deputy director, international aviation safety, JAARS, Inc. • “Accident Investigation/Engine Examination” by Bryan Lari- more, accident investigator, Safran Helicopter Engines. • “Investigation Discoveries: The Party System Effectively Un- raveling Causality” by Tom Huff, senior aviation safety officer, Gulfstream Aerospace. • “Taxonomy of Language as a Factor in Aviation Safety” by Elizabeth Mathews, Embry-Riddle Aeronautical University. The Museum of Flight near Seattle, Washington, U.S.A. Speakers came from near and far for this 10th anniversary event. The day ended with a dinner at Malone’s Steak and Seafood. ESASI Seminar Set for June 2020 in Budapest SERC will be evaluating a 2020 location for its annual meeting, including Memphis, Tenn.; Charleston, S.C.; or Mobile, Ala. Steve Hull, European SASI (ESASI) secretary, announced that the 10th ESASI seminar will take place in Budapest, Hungary, on PNRC’s Fall Meeting Featured Barry Latter June 3–4, 2020. The seminar will be held in conjunction with the European Civil Aviation Conference Air Accidents and Incidents ISASI’s Pacific Northwest Regional Chapter (PNRC) held its fall Investigations that will be scheduled on June 2, 2020. meeting October 16 at the Museum of Flight in Seattle, Washing- The aim of the seminar is to keep the European air safety ton, U.S.A., reported Jeanne M. Elliot, PNRC secretary-treasurer. investigation community abreast of current developments and The featured speaker was Barry Latter, a well-known aeronautical evolving best practice in aircraft safety investigation. As in engineer, aviation historian, and museum docent. Latter, born previous years, the seminar will include presentations on case and educated in Britain, worked for the Hawker Siddeley Group studies, the European environment, challenges of modern air 28 • October-December 2019 ISASI Forum Annual Dues Notice Please note that ISASI annual dues payments are due by Jan. 31, 2020. Pay- ments to the ISASI office can be made by check or credit card. Members in Austraila, Canada, and New Zealand should direct annual dues payments to their respective national society offices. Members who are not current are no longer eligible to partici- pate in Society elections, meetings, and nominations for special recognition. In addition, they will not re- On October 23–24, ISASI International Councilor Caj Frostell, left, met with Dr. Abdallah Falah Alsamarat, director ceive Society publications of the Aircraft Accident Investigation Department, Jordan Civil Aviation Regulatory Commission in Amman, Jor- and other communications. dan. The trip also included a visit to Mount Nebo and the city of Madaba. ISASI and Middle East North Africa SASI seminars were discussed and promoted as inexpensive additional training activities. safety investigations, and human factors in aircraft accidents and Lederer Awards Applications Due Mid-April 2020 incidents. The Jerome F. Lederer Award is ISASI’s highest recognition for air Scholarship Applications Due Mid-April 2020 safety. Any member of ISASI in good standing may submit a Lederer Award nomination to the 12-person selection committee, which The deadline for applications and essays for ISASI’s 2020 Ru- considers such traits as persistence, standing among peers, manner dolph Kapustin Memorial Scholarship comes in mid-April of and techniques of operating, and achievements. Nominations for each year. Scholarship recipients are eligible for the Lederer Award are limited to a single-page submission. Nomi- • funded attendance at ISASI’s annual seminar. A award of nees not receiving the award are reconsidered for three years and $2,000 will be made to each student who wins the compet- itive writing requirement, meets the application require- may be nominated again after an intervening year. ments, and registers for the ISASI seminar. The award will be Nomination statements should emphasis an original and remark- used to cover costs for the seminar registration fees, travel, able contribution and personal effort beyond normal duty require- and lodging/meals expenses. Any expenses above and be- ments. The award may be given to an individual, group, or organi- yond the amount of the award will be borne by the recipient. zation and may recognize a single event, series of events, or lifetime ISASI will assist with coordination and control the expendi- achievement. The nominee does not have to be an ISASI member. ture of funds. Nomination forms and additional information can be found on the Awards tab at www.isasi.org. • a one-year membership to ISASI. • tuition-free attendance to ANY regularly scheduled Southern In Memoriam California Safety Institute course. This includes the two- DFRC Member Bryan Roberts Passes Away week Aircraft Accident Investigator Course or any other ISASI recently received notice that member Bryan Roberts passed investigation courses. Travel to/from the course and accom- away on Sept. 14, 2019, in Fort Worth, Texas, U.S.A. He will be remem- modations are not included. More information is available at bered as a loving husband, father, friend, and colleague to all who www.scsi-inc.com. knew and loved him. • a tuition-free course from the Transportation Safety Insti- Bryan was a professional air traffic controller and a proud member tute. Travel to/from the course and accommodations are not of the National Air Traffic Controllers Association at the time of his included. More information is available at www.tsi.dot.gov. death. His interest in aviation began in high school when he received his private pilot’s license. Shortly after high school, Bryan entered the • tuition-free attendance at Cranfield University Safety and U.S. Army, proudly serving his country in the states and in Korea as Accident Investigation Center’s five-day Accident Investiga- an air traffic controller. It was in Korea that he met his wife, Hannah. tion Course, which runs as part of the university’s master’s After they were married and Bryan had separated from the Army, he degree program at the Cranfield campus, 50 miles north of was hired by the U.S. Federal Aviation Administration. He then com- London, UK. Travel to/from the course and accommodation pleted his bachelor’s degree at Embry-Riddle Aeronautical University are not included. Further information is available at www. and became one of the most respected and admired air traffic con- csaic.net. trollers. He also represented NATCA as a member of the U.S. National Transportation Safety Board accident investigation team. He always For details, application forms, and additional information, go had a ready smile for those he worked with and everyone he encoun- to the Awards tab at www.isasi.org. tered in his professional life. October-December 2019 ISASI Forum • 29 COMPARING UA232 AND AA383 UNCONTAINED EVENTS OFFICERS President, Frank Del Gandio ([email protected]) (Continued from page 19) Executive Advisor, Richard Stone ([email protected]) Vice President, Ron Schleede tive. Key similarities include ([email protected]) • Initiation of both events was the crack propagation of a disk defect to the Secretary, Chad Balentine ([email protected]) point of disk fracture. Treasurer, Robert MacIntosh, Jr. • The disk failures subsequently impacted aircraft systems. For UA232, the ([email protected]) hydraulics system and for AA383 a puncture of the right-wing fuel tank. COUNCILORS • Both disks fractured before their designated life limit. Australian, Richard Sellers ([email protected]) • Production and operational inspections did not find the defects/cracks. Canadian, Barbara Dunn ([email protected]) European, Rob Carter • The introduction of the anomalies in the disks was during the forging pro- ([email protected]) cess. International, Caj Frostell ([email protected]) • Recommendations from both accidents are similar regarding engine rotat- New Zealand, Alister Buckingham ing part processing and inspection—they need to be improved/enhanced. ([email protected]) Pakistan, Wg. Cdr. (Ret.) Naseem Syed Several differences are worth noting Ahmed ([email protected]) United States, Toby Carroll • UA232 was a fatal accident with 111 fatalities, AA383 had 21 injuries ([email protected]) (1 serious, 20 minor). NATIONAL AND REGIONAL • The AA383 event was the first time that a critical rotating nickel part had failed across the industry. Hard-alpha issues with titanium disks had SOCIETY PRESIDENTS occurred multiple times prior to UA232. AsiaSASI, Chan Wing Keong ([email protected]) • Post UA232, the industry/regulatory collaboration in activities related to Australian, Richard Sellers understanding, improving, and enhancing titanium forging and inspection ([email protected]) Canadian, Barbara Dunn ([email protected]) processes is the model for addressing complex issues. However, the European, Olivier Ferrante comparison here does show that it is critical that lessons learned in one ([email protected]) part of our industry need a forum to communicate learnings in support of Korean, Dr. Tachwan Cho (contact: Dr. Jenny SMS activities. Yoo—[email protected]) Latin American, Daniel Barafani, PTE ([email protected]) Middle East North Africa, Khalid Al Raisi ([email protected]) New Zealand, Graham Streatfield ([email protected]) Pakistan, Wg. Cdr. (Ret.) Naseem Syed Ahmed ([email protected]) Russian, Vsvolod E. Overharov ([email protected]) United States, Toby Carroll ([email protected]) UNITED STATES REGIONAL CHAPTER PRESIDENTS Alaska, Craig Bledsoe ([email protected]) MOVING? NEW E-MAIL ACCOUNT? Arizona, Bill Waldock ([email protected]) Dallas-Ft. Worth, Erin Carroll ([email protected]) Do you have a new mailing address? Have you recently Great Lakes, Matthew Kenner ([email protected]) changed your e-mail address? Then contact ISASI at isasi@ Mid-Atlantic, Frank Hilldrup ([email protected]) erols.com to ensure that your magazine and other ISASI Northeast, Steve Demko ([email protected]) materials are delivered to you. Please include your previous Northern California, Kevin Darcy address with your change request. Members in Canada, New ([email protected]) Pacific Northwest, (Acting) John Purvis Zealand, and Australia should contact your national society. ([email protected]) Rocky Mountain, David Harper ([email protected]) Southeastern, Robert Rendzio ([email protected]) 30 • October-December 2019 ISASI Forum ISASI INFORMATION

Southern California, Thomas Anthony Air Canada Pilots Association de Aviación ([email protected]) Air Line Pilots Association Gulfstream Aerospace Corporation Airbus Hall & Associates LLC Airclaims Limited Hawaiian Airlines COMMITTEE CHAIRMEN Air New Zealand HNZ New Zealand Limited Audit, Robert Cox Airways New Zealand Hogreen Air ([email protected]) All Nippon Airways Co., Ltd. (ANA) Honeywell Aerospace Hong Kong Airline Pilots Association Award, Gale E. Braden ([email protected]) Allianz Allied Pilots Association Human Factors Training Solutions Pty. Ltd Ballot Certification, Tom McCarthy Aloft Aviation Consulting Independent Pilots Association ([email protected]) Aramco Associated Company Insitu, Inc. Board of Fellows, Curt Lewis ([email protected]) Asiana Airlines Interstate Aviation Committee Bylaws, Darren T. Gaines Asociación Nicaragüense de Investigación de Irish Air Corps Accidentes Irish Aviation Authority ([email protected]) Japan Transport Safety Board Code of Ethics, Jeff Edwards ([email protected]) ASPA de Mexico ASSET Aviation International Pty. Ltd. Jones Day Membership, Ron Schleede ([email protected]) Association of Professional Flight Attendants Junta du Investiación de Accidentes Aviación Mentoring Program, Anthony Brickhouse Australian and International Pilots’ Association Civil (JIAAC) ([email protected]) (AIPA) KLM Royal Dutch Airlines Nominating, Troy Jackson Australian Transport Safety Bureau Korean Air Korea Aviation & Railway Accident ([email protected]) Aviation Accident and Incident Investigation Division/Ministry of Infrastructure, Rwanda Investigation Board Reachout, Glenn Jones ([email protected]) L-3 Aviation Recorders Scholarship Committee, Chad Balentine Aviation Investigation Bureau, Jeddah, Learjet/Bombardier Aerospace Kingdom of Saudi Arabia Lion Mentari Airlines, PT ([email protected]) Avisure Seminar, Barbara Dunn ([email protected]) Lockheed Martin Aeronautics Company Azure Aero Ltd Middle East Airlines Becker Helicopters Pty. Ltd. Midwest University WORKING GROUP CHAIRMEN Bell Military Air Accident Investigation Branch Air Traffic Services, Darren T. Gaines (Chair) Bundesstelle fur Flugunfalluntersuchung (BFU) Military Aircraft Accident & Incident Bureau d’Enquêtes et d’Analyses (BEA) Investigation Board ([email protected]) CAE Flightscape Ladislav Mika (Co-Chair) ([email protected]) Ministry of Transport, Transport Safety Cathay Pacific Airways Limited Investigation Bureau, Singapore Airports, David Gleave ([email protected]) Centurion Aerospace Ltd. National Aerospace Laboratory, NLR Cabin Safety, Joann E. Matley Charles Taylor Aviation National Institute of Aviation Safety and ([email protected]) China Airlines Services Corporate Affairs, Erin Carroll Civil Aviation Authority, Macao, China National Transportation Safety Board Civil Aviation Department Headquarters ([email protected]) National Transportation Safety Committee- Civil Aviation Safety Authority Australia Indonesia (KNKT) Critical Incident Stress Management (CISM), Civil Aviation Safety Investigation and Analysis NAV CANADA David Rye--([email protected]) Center Netherlands Defence Safety Inspectorate Flight Recorder, Michael R. Poole Colegio Oficial de Pilotos de la Aviación Ocean Infinity ([email protected]) Comercial (COPAC) Pakistan Air Force-Institute of Air Safety General Aviation, Steve Sparks Commercial Aircraft Corporation of China Pakistan Airline Pilots’ Association (PALPA) ([email protected]) Cranfield Safety & Accident Investigation Pakistan International Airlines Corporation (PIA) Centre Papua New Guinea Accident Investigation Co-Chair, Doug Cavannah Curt Lewis & Associates, LLC Commission (PNG AIC) ([email protected]) Dassault Aviation Parker Aerospace Government Air Safety Facilitator, DDAAFS Petroleum Air Services Marcus Costa ([email protected]) Defence Science and Technology Organisation Phoenix International Inc. Human Factors, William Bramble (DSTO) Plane Sciences, Inc., Ottawa, Canada ([email protected]) Defense Conseil International (DCI/IFSA) Pratt & Whitney Delft University of Technology PT Merpati Nusantara Airlines Investigators Training & Education, Delta Air Lines, Inc. Qatar Airways Graham R. Braithwaite Directorate of Flight Safety (Canadian Forces) Rademan Aviation ([email protected]) Discovery Aur Defence Republic of Singapore Air Force (RSAF) Military Air Safety Investigator, James W. Roberts Dombroff Gilmore Jaques & French P.C. Rolls-Royce PLC ([email protected]) DRS C3 & Aviation Company, Avionics Line of Royal Danish Air Force, Tactical Air Command Business Royal Netherlands Air Force Promotion of ISASI, Daniel Barafani (Chair) Royal New Zealand Air Force ([email protected]) Dubai Air Wing Dubai Civil Aviation Authority RTI Group, LLC Unmanned Aerial Systems, Tom Farrier Dutch Airline Pilots Association Saudia Airlines-Safety ([email protected]) Dutch Safety Board Scandinavian Airlines System Eclipse Group, Inc. Sikorsky Aircraft Corporation CORPORATE MEMBERS Education and Training Center for Aviation Safety Singapore Airlines Limited AAIU, Ministry of Transport EL AL Israel Airlines Southern California Safety Institute Abakan Air Embraer-Empresa Brasileira de Aeronautica S.A. Southwest Airlines Company Accident Investigation Board (AIB) Army Aviation Embry-Riddle Aeronautical University Southwest Airlines Pilots’ Association Etihad Airways Spanish Airline Pilots’ Association (SEPLA) Accident Investigation Board Norway State of Israel Accident Investigation Bureau Nigeria EUROCONTROL Statens haverikommission Administration des Enquêtes Techniques European Aviation Safety Agency (EASA) Swiss Accident Investigation Board (SAIB) Adnan Zuhairy Engineering Consultancy EVA Airways Corporation Taiwan Transportation Safety Board (TTSB) Aegean Airlines Executive Development & Management Advisor The Air Group Aer Lingus Finnair Plc The Boeing Company Aero Republica Finnish Military Aviation Authority The Japanese Aviation Insurance Pool (JAIP) Aerovias De Mexico, S.A. De C.V. Flight Data Services Ltd. Transportation Safety Board of Canada Agenzia Nazionale Per La Sicurezza Del Volo Flight Data Systems Pty. Ltd. Turbomeca Air Accident Investigation Authority of Hong Kong Flight Safety Foundation Ukrainian National Bureau of Air Accidents and Air Accident Investigation Bureau of Mongolia Fugro Survey Middle East Ltd. Incidents of Civil Aircraft Air Accident Investigation Bureau of Singapore Gangseo-gu, Republic of Korea UND Aerospace Accident Investigation Committee of Thailand GE Aviation United Airlines Air Accident Investigation Unit-Ireland General Aviation Manufacturers Association United States Aircraft Insurance Group Air Accident Investigation Sector, GCAA, UAE German Military Aviation Authority, Directorate of University of Balamand/Balamand Institute of Air Accidents Investigation Branch-UK Aviation Safety Federal Armed Forces Aeronautics Air Asia Group Global Aerospace, Inc. University of Southern California Air Astana JSC Grup Air Med S.A. Virgin Galactic Air Canada Grupo Regional de Investigación de Accidentes WestJet October-December 2019 ISASI Forum • 31 ISASI 107 E. Holly Ave., Suite 11 Sterling, VA 20164-5405 USA

INCORPORATED AUGUST 31, 1964 CHANGE SERVICE REQUESTED

ISASI 2020 SET FOR MONTRÉAL, CANADA

arbara Dunn, ISASI 2020 • Thursday—Technical pro- Host Committee chair, gram and awards banquet. reports that the Society’s • Friday—Optional tour of Bannual international Montréal. accident investigation and prevention conference will be held Sept. 1‒3, 2020, in Montréal, Hotel registration and site Qué., Canada, with optional facility information will soon tutorials on August 31 and an be posted on ISASI’s website, optional tour on September www.isasi.org, as well as a call 4. The Canadian Society of Air for papers with procedures and Safety Investigators is the host submission deadlines. organization. The committee selected Le Centre Sheraton Travel information includes: • Currency—Most Canadian September in Montréal can the largest in the province of Montréal, a nonsmoking facili- be warm and humid with Québec. The city occupies ty, as the site of the conference. businesses accept major credit cards and U.S. and temperatures at 20°C/68°F about 75 percent of Montréal The theme for the meeting is during the day and cooler Island, the largest of 234 “2020 Vision for the Future.” Canadian dollars, although the exchange rate will be during the evening. islands of the Hochelaga Technical presentations will Archipelago. The city began as address the theme as well as better at a bank or ATM. • Language—English and French are the two official a French missionary settle- relevant air safety investigation • Taxes and tipping—For all ment in the 16th century and processes, case studies, and purposes, purchases show languages of Canada. Montréal is a cosmopolitan became a fur-trading center techniques. prices without local taxes. that grew in size and com- Goods and services tax and city and both languages are available, but signs and merce after the British A preliminary program provincial sales tax will conquest of New France in includes: be added to the final bill. conversation are predomi- nately in French. 1763. Its advantageous • Monday—Tutorials on Tipping restaurant service location on the St. Lawrence winter operations and providers is expected and • Voltage—120V with a River allowed the city to military investigations and can range from 15 to 20 frequency of 60 Hz; power become a transportation, a welcome reception. percent depending on the plugs and sockets are Type manufacturing, and financial • Tuesday—Technical pro- level of service. A, mainly used in North center. At the time of the gram, companions tours • Visa information—For Ca- and Central America, confederation of Canada of Montréal, national and nadian visa requirements, China, and Japan; and B, (1867), Montréal was Canada’s society meetings, and an go to https://www.canada. similar to A but with a largest city until Toronto off-site dinner. ca/en/immigration-refu- ground prong. claimed that title in 1970. • Wednesday—Technical gees-citizenship/services/ program, companion tours visit-canada/entry-require- About Montréal of Montréal; working group ments-country.html. Montréal is the second-most meetings, and a free night. • Climate—August and populous city in Canada and

32 • October-December 2019 ISASI Forum