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Proceedings 2008.Pmd VOLUME 12 Publisher ISASI (Frank Del Gandio, President) Editorial Advisor Air Safety Through Investigation Richard B. Stone Editorial Staff Susan Fager Esperison Martinez Design William A. Ford Proceedings of the ISASI Proceedings (ISSN 1562-8914) is published annually by the International Society of Air Safety Investigators. Opin- 39th Annual ISASI 2008 PROCEEDINGS ions expressed by authors are not neces- sarily endorsed or represent official ISASI position or policy. International Seminar Editorial Offices: 107 E. Holly Ave., Suite 11, Sterling, VA 20164-5405 USA. Tele- phone: (703) 430-9668. Fax: (703) 450- 1745. E-mail address: [email protected]. Internet website: http://www.isasi.org. ‘Investigation: The Art and the Notice: The Proceedings of the ISASI 39th annual international seminar held in Science’ Halifax, Nova Scotia, Canada, features presentations on safety issues of interest to the aviation community. The papers are presented herein in the original editorial Sept. 8–11, 2008 content supplied by the authors. Halifax, Nova Scotia, Canada Copyright © 2009—International Soci- ety of Air Safety Investigators, all rights reserved. Publication in any form is pro- hibited without permission. Permission to reprint is available upon application to the editorial offices. Publisher’s Editorial Profile: ISASI Pro- ceedings is printed in the United States and published for professional air safety inves- tigators who are members of the Interna- tional Society of Air Safety Investigators. Content emphasizes accident investigation findings, investigative techniques and ex- periences, and industry accident-preven- tion developments in concert with the seminar theme “Investigation: The Art and the Science.” Subscriptions: Active members in good standing and corporate members may ac- quire, on a no-fee basis, a copy of these Proceedings by downloading the material from the appropriate section of the ISASI website at www.isasi.org. Further, active and corporate members may purchase the Proceedings on a CD-ROM for the nomi- nal fee of $15, which covers postage and handling. Non-ISASI members may ac- quire the CD-ROM for a $75 fee. A lim- ited number of paper copies of past Pro- ceedings and Proceedings 2008 is available at a cost of $150. Checks should accom- pany the request and be made payable to ISASI. Mail to ISASI, 107 E. Holly Ave., Suite 11, Sterling, VA 20164-5405 USA ISSN 1562-8914 ISASI 2008 Proceedings • 1 Proceedings 2008.pmd 1 1/14/2009, 8:22 AM ISASI Information OFFICERS Investigators Training & Education, Finnish Military Aviation Authority Graham R. Braithwaite Flight Attendant Training Institute at Melville College President, Frank Del Gandio ([email protected]) ([email protected]) Flight Safety Foundation Executive Advisor, Richard Stone ([email protected]) Unmanned Aerial Systems, Tom Farrier Flight Safety Foundation—Taiwan Vice-President, Ron Schleede ([email protected]) ([email protected]) Flightscape, Inc. Secretary, Chris Baum ([email protected]) Galaxy Scientific Corporation Treasurer, Tom McCarthy ([email protected]) General Aviation Manufacturers Association CORPORATE MEMBERS GE Transportation/Aircraft Engines COUNCILLORS AAIU Ministry of Transport Bulgaria Global Aerospace, Inc. Accident Investigation Board, Finland Gulf Flight Safety Committee, Azaiba, Oman Australian, Lindsay Naylor ([email protected]) Accident Investigation Board/Norway Hall & Associates, LLC Canadian, Barbara Dunn ([email protected]) Accident Investigation & Prevention Bureau Hellenic Air Accident Investigation ISASI 2008 PROCEEDINGS European, Anne Evans ([email protected]) Aeronautical & Maritime Research Laboratory & Aviation Safety Board International, Caj Frostell ([email protected]) AeroVeritas Aviation Safety Consulting, Ltd. Honeywell New Zealand, Peter Williams ([email protected]) Aerovias De Mexico, S.A.De C.V. Hong Kong Airline Pilots Association United States, Curt Lewis ([email protected]) Air Accident Investigation Bureau of Singapore Hong Kong Civil Aviation Department Air Accident Investigation Unit—Ireland IFALPA Air Accidents Investigation Branch—U.K. Independent Pilots Association NATIONAL AND REGIONAL Air Canada Pilots Association Int’l Assoc. of Mach. & Aerospace Workers SOCIETY PRESIDENTS Air Line Pilots Association Interstate Aviation Committee Australian, Lindsay Naylor ([email protected]) Air New Zealand, Ltd. Irish Air Corps Canadian, Barbara M. Dunn ([email protected]) Airbus S.A.S. Irish Aviation Authority European, David King ([email protected]) Airclaims Limited Japan Airlines Domestic Co., LTD Aircraft Accident Investigation Bureau—Switzerland Japanese Aviation Insurance Pool Latin American, Guillermo J. Palacia (Mexico) Aircraft Mechanics Fraternal Association Jeppesen New Zealand, Peter Williams ([email protected]) Aircraft & Railway Accident Investigation Commission JetBlue Airways Russian, Vsvolod E. Overharov ([email protected]) Airservices Australia Jones Day SESA-France Chapter,Vincent Fave AirTran Airways KLM Royal Dutch Airlines ([email protected]) Alaska Airlines Korea Air Force Safety Ctr. United States, Curt Lewis ([email protected]) Alitalia Airlines—Flight Safety Dept. Korea Aviation & Railway Accident Investigation Board All Nippon Airways Company Limited Kreindler & Kreindler, LLP UNITED STATES REGIONAL Allied Pilots Association L-3 Communications Aviation Recorders American Eagle Airlines Learjet, Inc. CHAPTER PRESIDENTS American Underwater Search & Survey, Ltd. Lockheed Martin Corporation Alaska, Craig Bledsoe AmSafe Aviation Lufthansa German Airlines ([email protected]) Aramco Associated Company MyTravel Airways Arizona, Bill Waldock ([email protected]) ASPA de Mexico National Aerospace Laboratory, NLR Dallas-Ft. Worth, Tim Logan ([email protected]) Association of Professional Flight Attendants National Air Traffic Controllers Assn. Great Lakes, Matthew Kenner ([email protected]) Atlantic Southeast Airlines—Delta Connection National Business Aviation Association Australian Transport Safety Bureau National Transportation Safety Board Los Angeles, Inactive Aviation Safety Council NAV Canada Mid-Atlantic, Ron Schleede ([email protected]) Avions de Transport Regional (ATR) Nigerian Ministry of Aviation and Accident Northeast, David W. Graham ([email protected]) BEA-Bureau D’Enquetes et D’Analyses Investigation Bureau Pacific Northwest, Kevin Darcy ([email protected]) Board of Accident Investigation—Sweden Northwest Airlines Rocky Mountain, David Harper Boeing Commercial Airplanes Parker Aerospace ([email protected]) Bombardier Aerospace Regional Aircraft Phoenix International, Inc. San Francisco, Peter Axelrod Bundesstelle fur Flugunfalluntersuchung—BFU Pratt & Whitney ([email protected]) Cathay Pacific Airways Limited Qantas Airways Limited Southeastern, Robert Rendzio ([email protected]) Cavok Group, Inc. Qatar Airways Centurion, Inc. Qwila Air (Pty), Ltd. Charles Taylor Aviation, Singapore Raytheon Company COMMITTEE CHAIRMEN China Airlines Republic of Singapore Air Force Audit, Dr. Michael K. Hynes Cirrus Design Rolls-Royce, PLC ([email protected]) Civil Aviation Safety Authority Australia Royal Netherlands Air Force Award, Gale E. Braden ([email protected]) Colegio De Pilotos Aviadores De Mexico, A.C. Royal New Zealand Air Force Ballot Certification, Tom McCarthy ([email protected]) Comair, Inc. RTI Group, LLC Board of Fellows, Ludi Benner ([email protected]) Continental Airlines Sandia National Laboratories Bylaws, Darren T. Gaines ([email protected]) Continental Express SAS Braathens Code of Ethics, Jeff Edwards ([email protected]) COPAC/Colegio Oficial de Pilotos de la Aviacion Comercial Saudi Arabian Airlines Membership, Tom McCarthy ([email protected]) Cranfield Safety & Accident Investigation Centre SICOFAA/SPS Nominating, Jayme E. Nichols ([email protected]) Curt Lewis & Associates, LLC Sikorsky Aircraft Corporation Reachout, John Guselli ([email protected]) DCI/Branch AIRCO Skyservice Airlines, Ltd. Seminar, Barbara Dunn ([email protected]) Defence Science and Technology Organization (DSTO) Singapore Airlines, Ltd. Delta Air Lines, Inc. SNECMA Moteurs Directorate of Aircraft Accident Investigations—Namibia South African Airways WORKING GROUP CHAIRMEN Directorate of Flight Safety (Canadian Forces) South African Civil Aviation Authority Air Traffic Services, John A. Guselli (Chair) Directorate of Flying Safety—ADF Southern California Safety Institute ([email protected]) Dombroff Gilmore Jaques & French P.C. Southwest Airlines Company Ladislav Mika (Co-Chair) ([email protected]) Dutch Airline Pilots Association Southwest Airlines Pilots’ Association Cabin Safety, Joann E. Matley ([email protected]) Dutch Transport Safety Board Star Navigation Systems Group, Ltd. Corporate Affairs, John W. Purvis ([email protected]) EL AL Israel Airlines State of Israel Embraer-Empresa Brasileira de Aeronautica S.A. Transport Canada Flight Recorder, Michael R. Poole Embry-Riddle Aeronautical University Transportation Safety Board of Canada ([email protected]) Emirates Airline U.K. Civil Aviation Authority General Aviation, William (Buck) Welch Era Aviation, Inc. UND Aerospace ([email protected]) European Aviation Safety Agency University of NSW Aviation Government Air Safety, Willaim L. McNease EVA Airways Corporation University of Southern California ([email protected]) Exponent, Inc. Volvo Aero Corporation Human Factors, Richard Stone ([email protected])
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