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APRIL-JUNE 2017 Journal of the International Society of Air Safety Investigators

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APRIL-JUNE 2017 Journal of the International Society of Air Safety Investigators Air Safety Through Investigation APRIL-JUNE 2017 Journal of the International Society of Air Safety Investigators Nonprecision Approaches: Status and Evolution—page 5 Investigation of Single-Pilot Operation Accidents—page 8 Links for a Successful Investigation: C-212 Robinson Crusoe Island Accident Case—page 14 Reverse Engineering the Causal Links Reveals Safety Analysis Issues—page 19 The Effect of Commuting on Pilot Self-Assessment of Stress and Performance —page 22 CONTENTS Air Safety Through Investigation Journal of the International Society of Air Safety Investigators FEATURES Volume 50, Number 2 5 Nonprecision Approaches: Status and Evolution Publisher Frank Del Gandio By Thomas Lepagnot, Accident and Incident Investigator, Airbus—The author looks at Editorial Advisor Richard B. Stone recent nonprecision approach events and how they still can be a major causal factor for Editor J. Gary DiNunno aircraft accidents and incidents. He notes that nonprecision approaches are becoming safer Design Editor Jesica Ferry with new technology but pilot adherence to procedures and respect for minima are crucial. Associate Editor Susan Fager 8 Investigation of Single-Pilot Operation Accidents ISASI Forum (ISSN 1088-8128) is published quar- By Fabio Couto Bonnett, Air Safety Investigator, Embraer Air Safety Department—The terly by the International Society of Air Safety author compares air accidents involving one-pilot versus two-pilot business jet operations Investigators. Opinions expressed by authors do not necessarily represent official ISASI position over a 37-year period. He notes that even though the number of two-pilot accidents was or policy. higher, single-pilot accidents resulted in more fatalities. Editorial Offices:Park Center, 107 East Holly 14 Links for a Successful Investigation: Avenue, Suite 11, Sterling, VA 20164-5405. Tele- C-212 Robinson Crusoe Island Accident Case phone 703-430-9668. Fax 703-430-4970. E-mail By Luis Gracia, Head of Product Safety, Airbus Defense and Space–Military Aircraft—The address, [email protected]; for editor, espmart@ author discusses how a successful investigation of a complex accident can be accomplished comcast.net. Internet website: www.isasi.org. ISASI Forum is not responsible for unsolicited by merging scientific technologies and linking information and data from other sources. manuscripts, photographs, or other materials. 19 Reverse Engineering the Causal Unsolicited materials will be returned only if submitted with a self-addressed, stamped enve- Links Reveals Safety Analysis Issues lope. ISASI Forum reserves the right to reject, By Sébastien David and David Romat, Senior Safety Investigators, BEA—The authors exam- delete, summarize, or edit for space con- ine the safety assessment process for complex aircraft systems and design and conclude that siderations any submitted article. To facilitate the process can be vulnerable to errors or inaccuracies that may arise at various stages and editorial production processes, American Eng- lead to aircraft component or system failure. lish spelling of words is used. 22 The Effect of Commuting on Pilot Copyright © 2017—International Society of Air Safety Investigators, all rights reserved. Publica- Self-Assessment of Stress and Performance tion in any form is prohibited without permis- By Thomas M. Friesacher, a Ph.D. candidate at Cranfield University, UK, and an active sion. ISASI Forum registered U.S. Patent and senior airline pilot and instructor, and Dr. Matthew Greaves, Head of the Safety and T.M. Office. Opinions expressed by authors do Accident Investigation Center, Cranfield University, UK—The authors are conducting re- not necessarily represent official ISASI position search on stress exposure and susceptibility to error among cockpit crews in relation to pilot or policy. Permission to reprint is available upon application to the editorial offices. commuting practices. They note that pilot commuting to and from work can be stressful and fatiguing and therefore can have a significant negative effect on air safety. They suggest that Publisher’s Editorial Profile: ISASI Forum is print- a sound industry-level fatigue risk-management program rather than assigning responsibil- ed in the United States and published for profes- ity to individual pilots could enhance flight safety. 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 3 President’s View: A Global Air Safety Advocate Subscriptions: A subscription to members is pro- 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 Who’s Who: Aegean Airlines 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- mestic and Canada nonmember US$6; interna- ABOUT THE COVER tional nonmember US$8. Not many instruments were recovered from the wreckage of a Chilean C-212 military aircraft near Robinson Crusoe Island (see page 14), but the most relevant information was provided by the g’s indicator, where the needle was pointing to a negative vertical acceleration of -1.6 g’s. The aircraft was flying in inverted position with a significant downward acceleration. INCORPORATED AUGUST 31, 1964 2 • April-June 2017 ISASI Forum PRESIDENT’S VIEW A GLOBAL AIR SAFETY ADVOCATE SASI has a number of new members countries participated in technical pres- Virginia, and is managed by our one full- who may not be fully aware of our entations, social events, a business meet- time employee, Ann Schull, who is our organization’s accomplishments, the ing, and networking with colleagues. office manager. Ann handles commu- Iscope of our global efforts, and what ISASI 2017 is scheduled to take place nications, inquiries and requests from we do to enhance air safety investi- August 22–24 in San Diego, California. members, and mailings to members, gation. Even those of us who’ve been ISASI 2018 will be held in Dubai in the among other duties. This office is located around our Society for some time could United Arab Emirates October 29– five minutes from Washington Dulles probably use a refresher. So I want to November 1. International Airport, near Washington, give all ISASI members an update on the The Society’s publications and website D.C., and can be accessed by telephone Society’s status and activities. have a global audience. ISASI publishes a during normal business hours or by fax ISASI will turn 53 this summer. The quarterly magazine, ISASI Forum, which and e-mail at any time. Society was founded in the United States provides Society news and events and There are now 11 societies around under articles of incorporation in the includes edited versions of the techni- the world that are mostly active with District of Columbia on Aug. 14, 1964. At cal papers presented during the annual their own seminars, communications, the organizational meeting, the govern- seminars. ISASI Update is a periodic networking resources, and more. These ing bylaws of the Society were adopted newsletter covering news and events societies elect officers, hold meetings, and the first slate of officers elected. A that is e-mailed to all Society mem- and set agendas for their respective more thorough history can be found in bers. ISASI’s website provides members members. These societies also serve as the July-September 2014 issue of ISASI electronic access to ISASI information, ISASI seminar hosts when the event is Forum posted to the library on ISASI’s publications, events, activity reports, held in their region. website. The Society currently has 1,369 guidelines, and additional information These regional societies are the Asian WE ARE AN OFFICIAL OBSERVER DURING MEETINGS OF THE INTERNATIONAL CIVIL AVIATION ORGANIZATION—A UNITED NATIONS-SANCTIONED ENTITY THAT ESTABLISHES RULES AND PROCEDURES FOR AVIATION. individual members and 138 corporate that members may find useful as air Society of Air Safety Investigators, Civil members who are based in 80 countries. safety investigators. Aviation Department of Hong Kong, ISASI—a U.S.-based 501(c)(3) tax-exempt ISASI’s International Council admin- president; the Australian Society of Air organization—is financially sound, and isters the Society’s business. The Inter- Safety Investigators, Rick Sellers, presi- an outside accounting firm conducts an national Council members include the dent; the Canadian Society of Air Safety audit and reports on the Society’s financ- Society’s president, vice president, sec- Investigators, Barbara Dunn, president; es on a yearly basis. retary, treasurer, executive advisor (the the European We’re an official observer during meet- immediate past president), and coun- Society of Air ings of the International Civil Aviation cilors representing the affiliated nation- Safety Inves- Organization—a United Nations-sanc- al societies and international members. tigators, Oliv- tioned entity that establishes rules and As the current ISASI president, I sit on ier Ferrante, procedures for aviation. ISASI represent- the Society’s International Council along president; the atives participate in numerous ICAO with Ron Schleede, vice president; Bob
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