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Proceedings of the Thirteenth International Seminar of the International Society of Air Safety Investigator

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Proceedings of the Thirteenth International Seminar of the International Society of Air Safety Investigator The International Society ofAirSafety Investigators Volume 15 1982 Proceedings of the Thirteenth International Seminar of the International Society of Air Safety Investigator. Dan Hotel Tel Aviv, Israel October II-October 15, 1982 Call for Papers forum The 1983 ISASI International Seminar of the International Society of Air Safety Investigators Published Quarterly by the will be held at the Chicago Marriott Hotel in International Society of Air Safety Investigators Chicago, Illinois Volume 15 #2,1982 October 11-14, 1983 Editor-Ira J . Rimson The theme of the seminar will be: The Editorial objective is to "report developments and ad­ vanced techniques of particular interest to the professional "The Air Safety Investigator: aircraft accident investigator. Opinions and conclusions Meeting the Future Challenge of Aerospace Technology" expressed herein are those of the writers and are not of­ ficial positions of The Society. The Editorial Staff reserves (Presenta tions on other topics will be considered) the right to reject any article that, in its opinion, is not in Authors wishing to present papers are invited to keeping with the ideas and!or objectives of the Society. It submit a 200-300 word abstract to: further reserves the righ t to delete, summarize or edit por­ tions of any article when such action is indicated by prin­ J ack J. Eggspuehler ting space limitations. 24 N. High Street Dublin, Ohio 43017 Phone: (614) 889-0715 Editorial Offi ce: Abstracts must be received by April 30, 1983. c/o Editor, ISASI forum Final Papers will be required by August 15, 1983. 4507 Wakefield Drive Annandale, VA 22003 CHANGE OF ADDRESS isasi West Building, Room 259 The Jerome F. Lederer Award Washington National Airport Washington, DC 20001 The aw ard is given for outstanding contributions to U.S.A. technical excellence in accident investigation. Not more than one award will be made annually and presentation is Telephone: (703) 521-5195 at the ISASI Seminar. The recipient is selected by an ISASI Board of Award. Any ISASI member may submit a nomination for this award. It must be sent to the Chairman of the Board of; Award not later than 15 May 1983, and must include ~ statement describing why the nominee should be con-, THE INTERNATIONAL SOCIETY OF sidered. This statement should be sufficiently descriptive AIR SAFETY INVESTIGATORS to justify the selection but no more than one typewritte page in length. This award is one of the most significant honors an ac­ OFFICERS cident investigator can receive, and so considerable care i President John R. McDonald given in determining the recipient. Each ISASI mernbef should thoughtfully review his or her association with pro~ Vice President Charles Mercer fessional investigators, and submit a nomination when Secretary ................... Stephan Corrie they can identify someone who has really been outstanding Treasurer. .................. Samuel Conlon in increasing the technical quality of investigation. Executive Advisor Laurence S. Edwards Mall to: David S. Hall Chairman, Board of Award, ISASI INTERNATIONAL CoaNCILLORS 8202 E. Vista Scottsdale, AZ 85253 Canada .................... Roger W. Smith Australia ................... Geoff Seymour International. ................ S. Olof Fritsch TABLE OF CONTENTS Jerome F. Lederer Award ii Accident to British Aerospace 748 at Nailstone ............................... .. 1 P.J. Bardon; UK AlB Psychological Stresses in the Lives of Pilots which can Predispose Fatal Accidents . .. 3 Richard K Brown, Ph.D.; USC Problems of Large Aircraft Accident Investigation in Antarctica . .. .. 8 Ron Chippendo1e; N.Z.MOT The Use of Air Traffic Control Radaras a Tool in Accident Investigation 12 Stephan J. Corrie; USNTSB Flight Crew Education: Fact vs. Rumor 18 Capt Henry A Dykhuis; UAL Manufacturers' Responsibility to Communicate Safety Information 19 Daniel R Gerard; Airbus Industrie Prevention of Death and Injury in Aerial Spraying 22 Milton Gordon, MD and Michael HaJomish; Israel MOT E.D. Richter, MD; B. Gribetz, MD & B. Cohen,' Hebrew University & Hadassah Medical School Y. Yacob; M.D.; Ichilov Hospital Aircraft and Thunderstonns Don't Mix Well ' 27 William Jennings; Safety Advocate!VISTAS Electronic Interference with Airbome Navigation Systems 30 James Francois Leggett, Esq.; Attorney Control Cab Video Recorders: A Pilot's Viewpoint 41 Capt Dale L Leppard; ALPA Classification of Pilot Errors As Needed by the Cockpit Designer 44 J.P. Manor; IAI Engine-Out Flight Training Revisited 46 Harold F. Marthinsen; ALPA Development of the ISASI Code of Ethics and Conduct 64 CO. Miller; System Safety, Inc. Electromagnetic Interference in Aircraft 70 J. Rosenzweig; IAI Eliminating Dangers of Lightning Strikes on Aircraft 72 P. Slezinger and J. Rosenzweig; IAI Microwave Landing System (MIS):The New Approach Aid 77 Capt Douwe W Stool; IFALPA Diagramming the Wreckage Scene 81 Richard H w~ P.E; USC list of Attendees 86 i THE JEROME F. LEDERER AWARD 1982 .presented to H. PRATER HOGUE for Outstanding Contributions to Technical Excellence in Accident Investigation Mr. Hogue has been involved in aviation for his entire professional life and has spent the past 25 years in the field of accident investigation. He pioneered the team concept of investigation at The Boeing Company, and freely shared his expertise with others through committee work, ISASI and university teaching. He has participated in the investigation of accidents on all Boeing models since the B-17, and has assisted various agencies on other military and civil aircraft. By leadership, example, and teaching he has produced outstanding contributions to technical excellence in accident investigation. ii Accident to British Aerospace 748 at Nailstone P..l. Bardon Deputy Chief Inspector ofAccidents UK Accidents Investigation Branch Bramshot, Fleet, Hampshire My reason for selecting this accident for my talk to you is loss of a cabin door and severe control problems. We also knew, not only because the circumstances were somewhat bizarre, of course, that the aircraft had broken up in flight. The wreck­ but more particularly because I wanted to detail the investiga­ age in the area furthest down the flight path consisted of small tion techniques we employed which I thought would be of fragments of plastic which were identified as having come interest to this audience. from the rear starboard baggage door. However at the main site, all significant components of aircraft structure were The accident happened in the UK to a British Aerospace found, including the starboard baggage door, though this was 748 twin turboprop aircraft which was operating a mail run a few metres further from the main wreckage than were all the from Gatwick to the East Midlands Airport, a relatively short other doors. Examination of these other doors and hatches con­ flight of just under one hour. There were on board just three firmed that they were closed at the time of impact. It was also persons, namely the two pilots and someone designated as a apparent from the wreckage examination that the two wings postal assistant. From the FDR and CVR, we were able to and the port tail plane had failed in up-load and that the star­ establish that the flight was quite routine for the first half board tail plane had also failed in up-load, but had separated hour. About 30 minutes before the accident, the aircraft began from the fuselage somewhat later in the sequence than the its descent, and shortly after that the PA could be heard to say other components and had done so shortly before the fuselage that the rear cabin door was showing red. The pilot was obvi­ had struck the ground. ously worried about the door coming off, and he was heard to say that he hoped that by reducing the cabin pressure, it would lessen the risk of this happening. He also hoped that by reduc­ Itcould be seen from an examination of the starboard bag­ ing speed, any impact damage to the tailplane by the door com­ gage door aperture that it had been extensively damaged dur­ ing off would be minimised. (How wrong he was on both ing impact whereas the damage to the door itself indicated that counts.) The airacraft was then given further descent Clearance it had not been in position when the fuselage hit the ground. and the sound of the engines could be heard to decrease. The The door itself appeared to have been struck at approximately speed was 150 kts. As the aircraft was passing through 5,200 mid height and partly folded over. Deposits of rubber in the feet a noise could be heard consistent with a sudden loss of fold clearly indicated that it had been struck by the leading cabin pressure. edge of the starboard tailplane, since the rubber deposits matched the deicing boot material. Therefore, fairly early on in Thereafter, from the pilots' comments it was clear that the investigation, without positive evidence that it had in fact something very violent was happening to the aircraft. This is happened, the manufacturer was asked to carry out a wind tun­ confirmed by the FDR read out. I should digress here to say nel test to determine the effect on the stability and control of that the refined FDR output was displayed on a VDU in the the aircraft of the starboard baggage door becoming impaled form of flight instrument indications, which is the first time we on the leading edge of the starboard tail plane. have used this technique. It conveys, as no digital or analogue read out can convey, a dramatic reconstruction of the accident sequence. In fact, what we were able to observe was the addi­ The results were as startling as they were unexpected. The dent sequence in real time. The crew put out a Mayday call and tests showed that with the door in a stable position on the lead­ at the same time reported severe control problems, and that ing edge there was a marked discontinuity in the relationship they thought they had lost the rear cabin door.
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