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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 con- siderations 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 permis- sion. 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 profes- sional 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 ac- cident 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; interna- tional 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,
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