Air Safety Through Investigation OCTOBER-DECEMBER 2015 Journal of the International Society of Air Safety Investigators

“Many thanks to ISASI for awarding me this honor and to Jerry for dedicating his life to aviation safety. I accept this award in appreciation of my entire life’s professional activities in aviation safety….” —Ladislav Mika, Jerome F. Lederer Award Recipient

Augsburg, Germany: ISASI 2015 ‘Independence Does Not Mean Isolation’ Page 5 Ladislav Mika Is ISASI’s 2015 Lederer Award Recipient Page 11 Divorcing the Regulator: The Establishment of an Independent Investigative Authority Page 14 ISASI Scholarship Recipients Receive Awards Page 16 Towards the Next Generation of HUMS Sensor Page 19 Change Point Analyses Applied to SMS Page 26 CONTENTS

Air Safety Through Investigation FEATURES Journal of the International Society of Air Safety Investigators 5 Augsburg, Germany: ISASI 2015 ‘Independence Volume 48, Number 4 Does Not Mean Isolation’ Publisher Frank Del Gandio Editorial Advisor Richard B. Stone By Esperison Martinez, Editor—Hosted by the ISASI European Society of Air Editor Esperison Martinez Safety Investigators, the annual ISASI conference drew 344 delegates and guests Design Editor Jesica Ferry from 43 countries. Associate Editor Susan Fager ISASI Forum (ISSN 1088-8128) is published quar- 11 Ladislav Mika Is ISASI’s 2015 Lederer terly by the International Society of Air Safety Award Recipient Investigators. Opinions expressed by authors do not necessarily represent official ISASI position By Esperison Martinez, Editor—The 2015 presentation marks the 39th year that or policy. ISASI has presented the award. Editorial Offices: Park Center, 107 East Holly Avenue, Suite 11, Sterling, VA 20164-5405. Tel- 14 Divorcing the Regulator: The Establishment of an ephone 703-430-9668. Fax 703-430-4970. E-mail address [email protected]; for editor, espmart@ Independent Investigative Authority comcast.net. Internet website: www.isasi.org. By Capt. Ibrahim S. Koshy, Director General, Aviation Investigation Bureau, ISASI Forum is not responsible for unsolicited manuscripts, photographs, or other materials. Kingdom of Saudi Arabia—This paper received the Best of Conference Award of Unsolicited materials will be returned only if Excellence for technical papers presented at ISASI 2015. submitted with a self-addressed, stamped enve- lope. ISASI Forum reserves the right to reject, delete, summarize, or edit for space con- 16 ISASI Scholarship Recipients Receive Awards siderations any submitted article. To facilitate By Esperison Martinez, Editor—ISASI 2015 awards banquet attendees loudly rec- editorial production processes, American Eng- ognized the four recipients of the ISASI Kapustin memorial scholarships. lish spelling of words will be used. Copyright © 2015—International Society of Air 19 Towards the Next Generation of HUMS Sensor Safety Investigators, all rights reserved. Publica- tion in any form is prohibited without permis- By Dr. Matthew Greaves (MO5700), Head, Safety and Accident Investigation sion. ISASI Forum registered U.S. Patent and Centre, Cranfield University—The author describes a research program that T.M. Office. Opinions expressed by authors do not necessarily represent official ISASI position aims to inform the next generation of helicopter health and usage monitoring or policy. Permission to reprint is available upon systems (HUMS) by identifying and proving feasibility for new and newly applied application to the editorial offices. sensing technologies, with a specific focus on internal sensors for rotating systems of helicopters. Publisher’s Editorial Profile: ISASI Forum is print- ed in the United States and published for profes- sional air safety investigators who are members 26 Change Point Analyses Applied to SMS of the International Society of Air Safety Inves- By Paulo Manoel Razaboni, Embraer Air Safety Department—The author offers tigators. Editorial content emphasizes accident investigation findings, investigative techniques a method to better understand the behavior of safety-related items, using a statisti- and experiences, regulatory issues, industry ac- cal approach to support strategic decisions like resources assignment or product cident prevention developments, and ISASI and change requests. member involvement and information.

Subscriptions: A subscription to members is pro- vided as a portion of dues. Rate for non-mem- bers (domestic and Canada) is US$28; Rate for nonmember international is US$30. Rate for all DEPARTMENTS libraries and schools is US$24. For subscription 2 Contents information, call 703-430-9668. Additional or 3 President’s View—Aviation’s Global Impact on Improving Air Safety replacement ISASI Forum issues: Domestic and 32 Who’s Who—Flight Data Systems: A Multi-Avionics Product and Service Provider Canada US$4; international member US$4; do- mestic and Canada nonmember US$6; interna- tional nonmember US$8. ABOUT THE COVER ISASI President Frank Del Gandio, right, presents the prestigious ISASI Jerome F. Lederer Award to Ladislav (Ladi) Mika, the 2015 recipient (see page 11), before a banquet audi- ence of 280 ISASI delegates and guests. INCORPORATED AUGUST 31, 1964 2 • October-December 2015 ISASI Forum PRESIDENT’S VIEW

Aviation’s Global Impact on Improving Air Safety By Frank Del Gandio, President

(ISASI President Del Gandio’s opening re- All this and more about Augsburg likely emerging chal- marks to the delegates of ISASI 2015 on Aug. is well known by every German in the lenges that really 25, 2015, at Augsburg, Germany, have been audience and by many other Europeans do not recognize abbreviated.—Editor) here today. However, I really cannot hope national borders to do justice to this city’s long history, so and that are elcome back to Europe. This I will excuse myself from this topic and shared in varying is the first ISASI accident move on to the reasons for which we are degrees by all of investigation and prevention here: to share our knowledge and insights us. This is simply Wconference on the European about accident and incident investiga- my shopping list, continent since Barcelona, Spain, in 1998 tion and to continue improving aviation and the items and the first anywhere in Europe since safety. are not in any Shannon, Ireland, in 2000. The good news The theme of this year’s seminar is a particular order. for ISASI is that we have returned to one good one: “Independence Does Not Mean of Europe’s oldest cities whose story can- Isolation.” At a minimum, the theme Labor Shortage. not be outlined in just a few minutes; but reminds us that aviation is among the A serious pilot shortage has been pre- I will try at least to offer a sense of what oldest of truly global industries, and it dicted for years, and it has arrived. The this city has witnessed in its long history. becomes more globalized every day. same shortages were developing on the Keep in mind that I come from a rela- For example, most major accidents to- maintenance side, and those shortages tively young country, the United States. day remind us that nationals from all over also have arrived. The entire industry In my country, people often fight hard to the world can be found on any interna- faces significant shortages in both fields. save buildings that are 100 years old or tional flight or long-haul domestic flights. Most people in this room can list several less because they are thought to be inher- Several recent crashes illustrate this reasons to explain the shortages: (1) ently “historic.” Compare this kind of per- point. The 150 fatalities from the German- pay structures, especially in the regional spective to a community like Augsburg. It wings Fight 9525 accident were from 18 industry; (2) fewer well-trained pilots and was named after Roman Emperor Augus- countries. Malaysia Airlines Flight MH17 mechanics migrating to the airlines from tus, and its origins date to at least 15 BC had fatalities from at least 12 countries, military organizations; (3) the cost of pri- when it was founded by the Romans as a while Malaysia Airlines Flight MH370 car- vate training; (4) the challenges and costs military base. Augsburg was established ried people from at least 14 countries. of training employees with no experience; as a provincial capital of the Roman Em- Even if a major accident is a rare event (5) the shrinking world of general aviation pire 1,900 years ago. It was sacked by the for a country or especially if a country has and more. Huns 1,600 years ago and by Charlemagne persistently high accident rates, all of us Some of the causes, such as pay 1,300 years ago. It became an imperial city can be affected. Our aircraft operate to structures, have fairly obvious solutions, nearly 750 years ago, which means it was and from other countries, fly over third at least in theory. Other causes are not essentially autonomous and subject only countries, and can have a major accident so easily fixed. Either way, shortages of to the emperor. in any one of those locations. Even a skilled workers could raise serious chal- Like many cities in Germany, Augsburg domestic flight is likely to carry nationals lenges for regulators and operators. also was a central player in the Protestant from more than a single country. Reformation, and it lent its name to the In short, though each country may Cargo Accidents Treaty of Augsburg, which temporarily indeed be independent, the nature of Most of us recognize the enormous ended religious conflict in Germany in aviation means that we really are in this improvements that have been achieved 1555. The city then was a central player together. No one operates in isolation, in safety over the past 15 years or so, in the 30 Years War. It also is home to the and safety risks or problems are not con- especially in passenger transport. The first effort to establish what we today tained by national borders. One country’s story is less impressive in the cargo world. would call social housing, with the walled chronic problems or newly emerging Though rates also have improved in cargo district of Fuggerei—which was estab- challenges are everyone’s problems and operations, accident rates by any measure lished almost 500 years ago and is still challenges. remain far too high. Depending on who is part of this city. Here is my short list of chronic or newly counting, the cargo hull loss rate is rou-

October-December 2015 ISASI Forum • 3 may arise. The good reason is that things Rapid expansion of this technology “No one operates in usually work out because the automa- poses challenges for accident investiga- tion really is remarkable. The down side tion authorities, but especially for regula- isolation, and safety is that when crews need to intervene, tors who face contradictory challenges. risks or problems they may simply fail to recognize that Regulators are being told to get out of the they need to do so, or they may wait too way—but make sure nothing goes wrong. are not contained long to take action, or they mishandle the The demand to make sure nothing goes by national borders. transition to manual flight. wrong helps to explain caution by many This is not an easy problem to solve. regulators. Yet regulatory decisions need One country’s chronic It suggests that changes are needed in to be made, and soon. Some decisions problems or newly the type and quantity of training. It may have been made, but many more remain. mean changing routine flight regimes In short, integrating this new technology emerging challenges are to ensure at least some hands-on flying, is imperative, but it will require a difficult everyone’s problems and and it might require more line flying balancing act. and more hands-on time for instructors. challenges.” Whatever the appropriate fixes might be, Suicide ISASI President Del Gandio they will not come cheaply, but some- Finally, at least in my estimation, pilot thing has to change. suicide has become the new issue of the tinely computed to range between 10 to day. Germanwings and speculation about 20 times higher than the rate in passenger Managing Rapid Growth MH370 are the obvious sources of this transport. That has to change. The shortage of skilled pilots and skilled new issue. The aviation community is The cargo industry often cites older mechanics is coming at a time in which hearing demands that we figure out how fleets, back-side-of-the-clock flying, and much of the aviation world is experi- to identify pilots who are vulnerable to flights into remote and ill-equipped encing amazing growth rates. Even if suicidal behavior. I recognize that more airports. Older fleets have an obvious if the world economy slows down a bit in than a little work has been done in this costly cure. The argument about remote the next couple of years, many markets area, and I fully understand that every- locations has some merit, but most cargo already have grown so much that even one could benefit from identifying those hull losses in fact occur in typical airspace slower growth will continue to put severe pilots. But I simply do not see how the and at the same airports that are fre- pressure on the labor pool. It also will aviation community is to become the first quented by passenger operators. Back- put pressure on operators who may lack sector of society to successfully screen side-of-the-clock also has some merit, but experience in managing large fleets, large everyone. it’s overstated. The bottom line is that the workforces, and so on. It also will add This short list is not comprehensive nor commonly cited factors cannot hope to pressure to an urgent need to improve the is it likely the best short list around. Every- explain tenfold to twentyfold disparities. competence and the de facto authority one in this room could add to the list or Something needs to change. of regulatory bodies in some countries, find good reason to delete one or more of and the need to improve the capacity and my items. I also recognize that more than a Automation independence of accident investigation few folks here might strongly disagree with Automation has produced huge net gains authorities in some cases. a comment or two that I’ve made. in safety. However, the very success of My real point is simple. We cannot get automation has introduced new risks. As Unmanned Aerial Systems complacent with the success of the recent automation becomes ever more sophis- Unmanned aerial systems (UAS) have past. We still have challenges to address, ticated and effective, pilots have less and huge promise for entire economies, and and we will continue to have some ac- less experience flying by hand. This has they should deliver significant improve- cidents. Our job is to minimize those acci- been recognized for years, but changes ments in safety. For example, UAS might dents, and I hope this conference makes at in the pilot population and changes in replace a lot of high-risk flying in aerial least a modest contribution to that effort. how we learn to fly and how we structure applications, surveillance, traffic moni- I close with a few short remarks. First, recurrent training have brought the issue toring, news coverage, and a host of other please participate fully in this conference. front and center today. Though major ac- low and slow flight regimes. I suspect Share your knowledge and be willing to cidents have become rare events, several none of us can yet imagine all the applica- learn from the knowledge and expertise of those rare events over the past eight tions of UAS that may seem routine in just that everyone else brings here. If you are a years or so have involved software that 20 years or even 10 years from now. student or if you are new to the field, take flight crews did not fully understand or However, the technology is still in its full advantage of the knowledge that you displayed pilots’ inability to transition to relative infancy. UAS has come a long way see walking around here. Ask questions. manual flying. quickly, but the aviation community is Whatever question you might have, For good reason, pilots tend to rely struggling to incorporate the technology someone here can give you an authorita- extensively and, in practice, sometimes because that technology still has some tive answer. Finally, enjoy this conference, exclusively on automation to handle not distance to go before it is ready for full enjoy this beautiful city, and enjoy its just normal flight but any emergency that integration into civil airspace. environs.

4 • October-December 2015 ISASI Forum Photos: Esperison Martinez

Conference committee members. Left to right, A. Mann, K. Ardey, O. Ferrante, M. Greaves, J. Friedmann, M. Del Bono, and K. Conradi. Augsburg, Germany: ISASI 2015 ‘Independence Does Not Mean Isolation’ Hosted by the ISASI European Society of Air Safety Investigators, the annual ISASI conference drew 344 delegates and guests from 43 countries. By Esperison Martinez, Editor

f the 344 delegates and guests Augsburg, the city venue for the confer- program followed those of past years: a attending the 46th annual ence, is the third-largest city in Bavaria full day of two tutorial workshops, three international accident investiga- and one of Germany’s oldest cities. It was days of technical paper presentations, Otion and prevention conference founded by the Romans in 15 BC under three evening social events, three days of in Augsburg, Germany, on Aug. 24–27, Caesar Augustus, after whom the city is companion tours, and a full day of sight- 2015, 119 were first-time attendees. The named. It also has an equally long tradi- seeing after the conference closed follow- annual conference, featuring the theme tion as a city of aviation and aerospace ing the awards banquet. The sightseeing “Independence Does Not Mean Isolation,” technology, as its Lord Mayor Dr. Kurt day is an add-on and at an additional cost. was the first to be held on the European Gribl told conference attendees at a wel- The hosting European Society’s Plan- continent since Barcelona, Spain, in 1998 coming reception held in the Golden Hall ning Committee stayed involved over a and the first anywhere in Europe since of City Hall. two-year effort to locate and confirm the Shannon, Ireland, in 2000. It was only at social functions such as venue, hotel, and conference center and the lord mayor’s develop the budget and technical and reception that del- social programs, review and adopt techni- egates were able cal papers, and oversee registration tasks. to see and enjoy The committee members included Keith the flavors of the Conradi, society president and confer- city and its attrac- ence chairman; Alistair Mann (IT); Klaus tions. Their days Ardey (Augsburg liaison); Olivier Ferrante, at the cavernous Simon Lie, and Brian McDermid (Techni- convention center cal Committee); Matt Greaves (treasurer); were steady labor Jens Friedemann (German liaison); and from 9 a.m. to 5 Martine Del Bono (public relations). p.m., with official social functions Tutorial workshops following in the The conference’s tutorial workshops keep evening. growing in popularity. The workshops Registration morning was busy. The conference generated an attendance of 173 individu-

October-December 2015 ISASI Forum • 5 is conducted by the national acci- dent investigation authority (or by an ad-hoc investigation commission if the state does not have a permanent investigation authority) to prevent future accidents. (This is also known as the Annex 13 investigation.) • An investigation may arise from civil litigation, the results of which are intended to compensate victims. • A judicial/criminal investigation may be opened with the aim of adminis- tering justice to punish wrongdoers. “Victims and their relatives need to be informed about the respective objectives of the different processes (safety versus civil litigation versus judicial investiga- tions). It must be emphasized that the sole objective of a safety investigation is the prevention of accidents and Some of the 90 attending the Social Dimension of a Safety Investigation Workshop. incidents.” Turning to the issues and challenges, he als. Of this total, 90 attended the Social social aspects are the “nontechnical” ones said, “Despite policies and procedures, it Dimension of a Safety Investigation Work- that complement the technical actions remains quite difficult to meet the needs shop, and 83 attended the Military In- conducted by safety investigation au- of the victims and their relatives after a vestigations Workshop. Both workshops thorities after an accident. They notably major air accident, as well as to anticipate shied away from audience interactive encompass victims/families (relatives)/ the political dimension all of this entails. activities and instead relied upon speaker colleagues; politicians; news media/the It is important to remember that the PowerPoint presentations. The social public; and legal/insurance—individuals families have a very limited understand- dimension workshop had eight speakers, and organizations. ing of what the many different agencies while the military workshop had 12. From a global framework, Ferrante said are doing, who is in charge, and what is Presenters at the social dimension that states that have faced major civil expected from them [the families.] They workshop included Marcus Costa, chief, aviation disasters have, based on their want to know what happened; they want Accident Investigation Section, Interna- experience, reinforced their procedures to visit the crash site and get their loved tional Civil Aviation Organization (ICAO); in relation to their national emergency ones back. Olivier Ferrante, European Commission; plans, most notably regarding the assis- “The new ICAO guidance details roles Barbara Crolow, HIOP AF447; Martine tance to the victims and their relatives. for governmental and nongovernmental Del Bono, BEA France; Wieslaw Jedynak, He went on to say: “ICAO recently re- organizations with emphasis on the role SCAAI Poland; Linda Tavlin, LJT Associ- leased its Policy on Assistance to Aircraft of a national coordinator, which should ates, Inc.; Capt. Adrian Jenkins, Air Asia; Accident Victims and their Families and interface with all entities. However, when and Michel Guerard, Airbus. updated other related documents (as well dealing with the progress of the safety Speakers at the Military Investigations as a number of SARPs in Annex 9 and An- investigation, it is essential that, where Workshop included Mike Gamlin, Rolls- nex 13). In Europe, member states have possible, families are directly informed Royce; Jens Friedemann, the BFU; Mike the obligation to establish civil aviation about the safety investigation by the Buran, Lockheed; Andreas Kern, German accident emergency plans at the national safety investigation authority. Organiz- military; Maciej Lasek, SCAAI Poland; level. These plans must cover assistance ing a visit to the accident site can pose a Luis Garcia, Airbus military; Robout to the victims of civil aviation accidents number of difficulties. Wever, RNLAF; Pete McCarthy, Cranfield and their relatives. EU air carriers also “The wave of solidarity triggered by University; Jim Roberts, Boeing military; have the obligation to adopt a plan, which the tragedy and embraced by the politi- Dave Harper, U.S. Air Force; Bret Tesson, must be audited by the member states, to cal world through the various steps of Boeing military; and Wing Commander assist the victims of civil aviation acci- an investigation contributes to raising Neil Bishop, UK military, AAIB. dents and their relatives. different levels of expectations and may In summarizing the papers presented “After fatal civil aviation accidents, lead to frustration in the long run. The at the Social Dimension of a Safety Inves- there are generally two, and sometimes final report prepared by safety investiga- tigation Workshop, Ferrante noted that three, separate investigations that need tion authorities generally describes and the social dimension has grown in impor- to be closely coordinated since they share explains a complex chain of events, and tance and has become more and more de- the same evidence: remains primarily addressed to aviation manding with each succeeding year. The • An accident (or safety) investigation professionals for prevention purposes.

6 • October-December 2015 ISASI Forum Communicating the results of an inves- • They need access to psychological on the part of victims and their families, tigation to victims and their relatives, as and legal support as well as access as well as the public. well as to the public, remains challenging. to a victims’ family association for “Through the judicial investigation and “In some cases, alternative [or con- as long as necessary. More guidance also through civil litigation, operators, spiracy] theories can dispute the official [psychological and legal] is required. manufacturers, and sometimes regula- tors can be placed in a defensive mode report. These theories, which some- • They need demonstration of the inde- and face indirect attacks from parties not times can be quite sophisticated, may pendence of the safety investigation governed by Annex 13. Such a situation sometimes be triggered and spread by and the results. individuals with specific motivations not can impact the credibility of operators, necessarily linked to improving aviation • They want those individuals having manufacturers, and regulators as com- safety.” An example of political motivation a role in the accident to be account- munication about the accident and its was given during the tutorial. able in accordance with their level of safety investigation belongs to the state of “Factors such as geographic loca- responsibilities. occurrence.” tion and language barriers can become • They want the judicial investigation In summarizing the workshop pres- challenges when the authorities interact to be easier to follow, especially when entations dealing with social challenges with victims and their relatives of various considering all the victims’ nationali- from a number of perspectives, Ferrante noted, “A major air accident is a human nationalities and religious/cultural back- ties. grounds. Communicating with victims tragedy. Operators’ communication “The operator is on the front line deal- and their relatives often must be under- people should be prepared for the envi- ing with passengers, families, and crew taken in more than the six ICAO lan- ronment of a safety investigation. They and can sometimes struggle to survive guages. In the aftermath of an accident, should incorporate this aspect in their the accident, especially when faced with victims and their relatives have various communication strategies. If or when operational factors. Families have formal an operator seeks emergency response needs and wants, which are related to relations with authorities and the opera- support from a service provider, it should the different phases of the safety and the tor but not with the manufacturer, which not hire away its responsibility in the judicial investigations: nevertheless has a role in the Annex 13 handling of an accident. If the operator is • They need to have their privacy re- investigation for prevention purposes. part of an alliance, as the main operating spected, and this must be considered This lack of relationship and the manufac- partner, it should still maintain its duty a question of ethics and integrity. turer’s role may contribute to suspicions to provide primary support and com-

A portion of the 299 delegates who filled the plenary session.

October-December 2015 ISASI Forum • 7 munication. The credibility of the safety changes that result from an accident welcome to Augsburg, which is “interna- investigation authority conducting the investigation.” tionally known for its aerospace compe- investigation is essential, especially when tence.” She went on to outline the past operators, manufacturers, or regulators Technical program and present status of the city’s aerospace become targets after an accident. The in- The conference center’s huge convention endeavors, saying its “success is the net- dependence and competence of the safety hall presented a very large center screen working of research and business.” Speak- investigation authorities involved in the for PowerPoint presentations. Acoustics ing directly about the ISASI conference, investigation contribute to reinforce the proved to be adequate, holding the atten- she said, “In addition to the exchange credibility of the final report.” tion of back-row attendees, and the room of experiences, this conference is also a Speaking about the communications temperature was always comfortable. In networking source for those authorities aspects, Ferrante noted, “Developing all, the 299 delegates who filled the hall and industry representatives who have to additional communication expertise and paid rapt attention to the 20 technical cooperate effectively on cross-border in- skills in handling the aftermath of a major papers presented and to the 3 keynote vestigative activities…to increase aviation accident is essential, as well as encourag- speakers as well as the welcoming ad- safety in the future.” ing liaison between authorities and better dress from Eva Webber, the city’s deputy First-day keynote knowing each other’s roles. The accident lord mayor. speaker Ulf Kramer, investigation authority responsible for head of the BFU and the investigation should immediately be Day one president of ENCASIA, in charge of communication about the Chairman Conradi began the program said the conference investigation. This is vital for long-term promptly at 9 a.m. by welcoming the theme of “Independence credibility. Planning and conducting Does Not Mean Isolation” is “much more regular training and exercises involving delegates and covering the housekeep- ing details pertinent to the program. complicated” than it sounds. He pointed support and communication staff in that out that the word “independence” has process is paramount. Planning must ISASI President Frank Del Gandio then mixed meanings in various dictionar- anticipate and be based on what other welcomed all; but before making his ies, but that the term “independence of agencies will be doing to avoid duplica- welcome address, he asked Ladislav investigation authorities” may only be tion or contradiction.” (Ladi) Mika to join him on stage. Obvi- found in related laws. Still, he said that in Concluding his summary of the ously wondering why, Ladi was greatly general the word independence almost workshop, he said, “The tutorial/work- surprised when Del Gandio announced, has a positive connotation. He added that shop recommends the development of a “Meet the ISASI 2015 Jerome F. Lederer in looking at the dictionary definition of practical guide in the form of a manual recipient.” Thunderstruck, but smiling or leaflet for frequent or regular use. This broadly, Ladi shared a congratulatory the word “isolation” and its many uses, guide should be specifically prepared for embrace with the president, who next it almost has a negative connotation. victims and their relatives to facilitate introduced the four students who were He delved into the many examples that their understanding of the role and the awarded the 2015 ISASI Kapustin memo- investigators may encounter that involve different phases of a safety investigation, rial scholarships. independence and isolation and the as well as its relationship to the other In his opening remarks (see page 3), Del ensuing results. entities involved in dealing with the Gandio spoke of Augsburg history, about He concluded, saying, “If we work to- accident.” the pilot shortage that is upon the indus- gether and do our work impartially with The objective of the military acci- try and the reasons for is existence, about some included self-isolations, we will dent investigations tutorial was to have the need for change in the commonly reach good results; we will not be isolated international military accident investiga- cited factors causing the high accident and stay [independent within] our enti- tors share knowledge on their respective rate of air cargo carriers, and about how ties, companies, and authorities….” capabilities, experiences, processes, and automation has brought both “huge net procedures with a view to the develop- gains in safety and introduced new risks” Day two ment of future relationships and common through the reduced hand-flying experi- The keynote speech practices and to benefit from the experi- ence of pilots. He also addressed the is- from Rémi Jouty, direc- ence gained by the civil counterparts over sues involved in managing the industry’s tor of the BEA of France, the years. A sampling of the workshop’s rapid growth in light of labor shortages. also addressed the words presentations shows that both objectives Unmanned aerial systems, he said, independent and isolation were amply met: “Military/civil coopera- hold economic promise and significant based on the BEA’s experience. He noted tion and industrial partnerships.” “Pre- improvements in air safety, but regula- that judging by BEA’s recent news media parations to support multinational mis- tory decisions need to be made soon. And exposure, the agency does not work in hap investigations.” “Accident/major inci- lastly, he spoke of how pilot suicide has isolation. Referencing independence, he dents investigation process within Airbus become the “new issue of rhetorically asked, “Why should a safety DS and its relationships with Airbus the day.” investigation be independent?” adding, commercial.” “Flight data monitoring as a Guest speaker “Is there a difficulty or some issue in hav- proactive approach to improving safety.” Deputy Lord Mayor ing an independent safety investigation?” “Practical application of incorporating Webber bid all a great Noting that the Annex 13 charge to

8 • October-December 2015 ISASI Forum Some of the delegates who posed questions to the speakers. a safety investigation is to “prevent ac- nonaffected operators, with passengers’ ing with a known person rather than a cidents,” he posed three questions: “What relatives, and most notably with the news stranger. could the obstacles to an independent media and its speculation-filled “buzz” investigation be?” “Could anybody want that follows an accident. Business meeting to oppose the goal of preventing future Malinge concluded, saying: “Commu- A short ISASI business meeting was also accidents?” and “Who could want to nicating the big picture in the shortest conducted. Del Gandio reported that influence our investigation activity and possible time seems to be the sole means membership numbers were holding why and how?” that has proven to be efficient to bring steady—as many new members are re- The remainder of his presentation back a reasonable noise level during an cruited as are lost. He urged each member (which will appear in the January–March investigation. Communicating is also a to promote the society’s achievements 2016 issue of ISASI Forum) provided required means to ensure the families and and to work at retaining members. insight into those questions. the public will keep trust in the official He singled out corporate members for investigation agencies by showing trans- special praise, noting that new members Day three parency in a timely manner.” have been recruited. Two ISASI programs Keynote speaker Yan- are in need of new applicants: ISASI Fel- nick Malinge, vice Program content low and the Lederer Award. He recounted president and chief The three-day technical program, which the importance of both, asking members product safety officer was filled with the presentations of 20 to consider applying for Fellow status and of Airbus, addressed the technical papers, flowed evenly between to make a nomination for the Lederer topic of “communication,” subjects that directly addressed the Award. noting that for those involved in major theme and those that discussed specific Vice President Ron Schleede spoke investigations communication was found investigations and investigation issues. of the need to raise funds for the ISASI to be “the biggest challenge we all face, All presented technical papers will be Kapustin Scholarship Fund. He outlined whatever our role.” He went on to briefly posted on the ISASI website, www.isasi. the fundraising procedures used by the outline what the term may mean to air- org. The attendees’ interest in the techni- Mid-Atlantic Chapter. craft manufacturers, to authorities, and cal subjects was noted by the conference Chad Balentine, secretary and newly to investigators. He took the audience hall being filled to capacity throughout appointed chair of the Scholarship Com- back to the time when communicating the presentations and by the questions mittee, reported that the scholarship se- was done by phone, fax, or a pager, noting posed to each speaker following a pres- lection process is being revised and that how then everything moved much slower entation. Each day allowed for two tea/ details will be made available soon. and quieter. That time contrasts with to- coffee breaks, which provided much- Treasurer Robert MacIntosh said the day’s digital world of communication that needed time for the attendees to stretch society’s financial health was good and brings “a new era of investigation; the and interact with each other. One of the that the annual audit was done by a pro- required level of reactivity becomes more prime benefits of the conference is the fessional firm. The last report showed no and more demanding due to the com- opportunity to make new professional issue with bookkeeping procedures. munication means becoming faster and acquaintances and renew old friendships. open to a far bigger audience.” Through The importance of this interaction is Program social events examples, he showed the challenges often revealed through the experience of Three conference-sponsored special in communicating with affected and arriving at an accident scene and work- social events were held: a welcome recep-

October-December 2015 ISASI Forum • 9 Following the reception, the and a Bavarian-style meal was served. dinner venue was Bahnpark Thursday’s event was a walking tour of Augsburg, a rail locomotive mu- Augsburg’s historic section, which is filled seum. It was a fascinating place, with many sidewalk cafes and specialty with many full-size vintage en- shops that line the street. Except for the gines available for viewing. The heat of the day, the group’s exposure to most eye-catching element was the very historic location was greatly the great many model railroad enjoyed. trains that moved about the Two choices were available for the entire span of the dining room. Friday post-conference program. The first The entire setting made for a was a visit to Bavarian castles complete very relaxing evening. with interior and garden visits. The sec- The third social event was the ond tour was a visit to Airbus Helicopters, awards banquet. Its role is to which included an insight into the final A networking event during the seminar. give peer recognition to those who have assembly of the EC135 helicopter, the tion, a casual dinner, and the awards achieved a deed that merits presentation Military Support Center, and manufactur- banquet. Each has a specific role. The of an award. Because of the peer-to-peer ing of helicopter doors. welcome reception is held the evening be- recognition aspects, it is the most awaited fore the conference starts. It is intended and most formal of all the social events Awards banquet to help attendees get rid of jet lag and to (see “Awards banquet). The technical program closed on Thurs- make new friendships and rekindle old day, and the hotel staff wasted no time ones. This year rain intruded into what Special events getting the banquet hall ready for the was to be an outdoor event, so mingling The conference program included two evening’s awards dinner banquet and its was done in close quarters. But that did special events: the companion program 280 guests. As they filled the room and not deter attendees from enjoying the and the extra-cost, post-conference one- took their seats, six Bavarian perform- evening, as was evident by the group clus- day excursion. ers, complete with lederhosen dress and ters throughout the room. Companions boarded their first bus at feathered hats, played their gigantic The highlight of the Tuesday even- 9:00 a.m. for a full day of touring the city Alpenhorns, much to the delight of the ing event was a reception hosted by of Munich with time to stop at selected audience. Many had never seen such an Augsburg’s Lord Mayor Dr. Kurt Gribl shops. Also included was a visit to the array of musical instruments, so photo and held in the Golden Hall of City Hall. Lenbachhaus, which houses the world’s taking was much in order. Attendees were taken with the splendor largest collection of the Blauer Reiter (the Immediately after dinner, President Del of the ballroom’s gilded ornamentation, Blue Rider). An “on-your-own” lunch was Gandio quieted the room and began the marvelous ceiling and wall painting, and taken at the art center’s restaurant. formal part of evening designed to rec- stained windows. In his welcoming talk, Wednesday was monastery day, with ognize individuals who have contributed Gribl related some of the city’s history: visits to the monasteries in Ottobeuren to the well-being of the society. He first Founded by the Romans in 15 BC and and Irsee. At each location, the group was expressed appreciation for the seminar’s source of religious freedom via its 1555 provided a full explanation of the history success by recognizing the many people Peace of Augsburg document that ena- and purpose of the religious facility. Com- who were responsible: organizers, confer- bled Christianity to take a decisive turn in panions had lunch at a neighboring town, (Continued on page 31) its development—giving birth to a unique public holiday known as the High Peace Festival. He then turned his attention to the city’s long tradition in aviation and aero- space technology: In the early 1600s, a failed flying machine attempt by Salomon Idler; in 1931, the launch of an air balloon by Auguste Piccard to record altitude; and later Professor Willy Messerschmitt’s development of aircraft, followed in 1989 by Deutsch Aerospace, now EADS and part of the Airbus group. In closing, he said, “I wish you an intensive and produc- tive conference, as the topic of air safety that you are dealing with is of interest and importance for everyone in these times of mobility. A warm welcome to all.” Table one of the 28 that filled the banquet hall and provided seating for280 guests.

10 • October-December 2015 ISASI Forum The 2015 presentation marks the 39th year that ISASI has presented the award. LADISLAV MIKA IS ISASI’S 2015 LEDERER AWARD RECIPIENT By Esperison Martinez, Editor

he International Society of Air Safety Investigators (AAB), and EUROCONTROL Provisional Council. crowns its annual three-day international conference • ISASI—as vice chairman of the ATS Working Group. on air accident investigation by presenting its highest • Southern California Safety Institute (SCSI)—as co- honor, the Jerome F. Lederer Award, at the Society’s T founder and instructor for international safety courses award banquet. Ladislav Mika (Ladi), senior officer of the and workshops in Prague for the past 13 years with more Air Operation Technology and Development Division of the than 600 worldwide participants. Czech Ministry of Transport, is the year 2015 recipient of the award. ISASI, an organization dedicated to enhancing In 1987, Ladi established the Helicopter Emergency Medi- aviation safety through the continuing development and im- cal Service (HEMS) in Czechoslovakia. He also served as provement of air accident investigation techniques, only con- the former president of the Association of the Air Rescue siders candidates for its highest award whose careers reflect Services in Czech Republic. Since its founding, more than outstanding lifetime contributions to technical excellence 200,000 people have been saved because of HEMS. in furthering aviation accident investigation and achieving Ladi was one of the founders of the ISASI Reachout ISASI objectives. Workshop program. He facilitated the first ISASI Reachout In introducing the award winner to the banquet guests, Workshop held in Prague in 2001, at which more than 100 President Frank Del Gandio said, “Ladi stands out for his aviation safety specialists attended. They represented all dedication, perseverance, energy, professionalism, and leader- Eastern European countries and Russia. He was instrumental ship among the world’s experts in aviation safety, particularly in bringing the SCSI training courses to Prague, beginning regarding accident/incident investigation and prevention. ” with aircraft accident prevention and accident investigation Outlining Ladi’s background, Del Gandio noted that in courses in 2002. The SCSI courses have expanded and are 2014 Ladi received the International Civil Aviation Organiza- ongoing to this day, with offerings of various aviation safety tion (ICAO) Award of Certificate of Outstanding Achieve- subjects each year. ment for 30 years of activities and outstanding personal He was also instrumental in bringing the European Cabin contribution to the sustainable development and safety of Safety and Security and Health Symposium to Prague in 2004 international civil aviation within the framework of ICAO’s and 2006. These programs provided a new venue for those European Air Navigation Planning Group (EANPG). His unable to travel far distances from their country for their experiences in aviation encompass 44 years, including 7 continued safety training. He has also brought to Prague years with Czechoslovak Airlines and 37 years with the Czech a number of other safety-related courses and workshops, Ministry of Transport. During his time with the ministry, Ladi including ramp and maintenance, operational risk manage- was also a member of the Permanent State Commission for ment, safety management systems, and air traffic control the Investigation of Aircraft Accidents. investigation. Ladi was instrumental in the preparations to establish the Air Accident Investigation Institute in the Czech Republic in 2002, an independent aircraft accident investigation agency set up to meet Euro- pean Union requirements. During his career, Ladi has worked very closely and successfully with a number of key organizations, such as • ICAO—as the chief delegate representing the Czech Republic at the first High Level Safety Con- ference in 2010 (HLSC 2010) and at HLSC 2015 in February 2015. • European Civil Aviation Conference (ECAC) Group Experts on Accident Investigation (ACC)—as a member of the group that meets annually to resolve safety matters related to international aviation safety within Europe. • EUROCONTROL—as a member of the CNS/ATM Consultancy Group (ACG) and Stakeholder Con- President Del Gandio (left) presents the Jerome Lederer Award plaque to 2015 sultation Group (SCG), Agency Advisory Body receipient Ladislav (Ladi) Mika.

October-December 2015 ISASI Forum • 11 Ladi’s nomination submission important and unexpected infor- states, “Ladi’s gifts are his energy, mation about his father, who was professionalism, leadership, and born and studied at the medical organizational abilities. Through facility at the Charles University in dedication and perseverance in his the Czech Republic. He also men- work, he has gained the respect of tioned that his father taught him his colleagues in the field. He has the Czech language. Jerry said that the unique ability to bring together he still remembered one sentence people of many nationalities, the and said in perfect Czech: ‘Pretty Central and Eastern European girl kiss me. ’ I was the only person countries in particular, in order who understood what he said, and to work harmoniously toward the we both smiled. Jerry’s father de- common goal of worldwide aviation parted Prašný Újezd in 1890 to the safety. He was one of the first active U.S.A., where Jerry was born in New ISASI members from the Central/ York City in September 1902. Eastern Europe region and has “This experience motivated me to expanded ISASI membership in this learn more about Jerry’s heritage. region.” First, I had to research his father’s In closing his comments, Presi- first name, which with the help dent Del Gandio said, “ISASI is of Frank Del Gandio led me to his indeed blessed to have such an daughter Nancy and the discovery outstanding individual in its ranks. of the name Zygmund. I then visited His contribution to global aviation the Charles University archives, safety is outstanding, and there is no where past examination records doubt that the contributions made proved that Zygmund Lederer, by Ladi have improved aviation Jerry’s father, had studied at the safety through accident/incident medical facility in Prague. investigation and prevention in “When I first met and talked to Central/Eastern Europe. His native Jerry, he was happy to meet some- Czech Republic has an excellent one who was from the same coun- An exuberent Ladi holds his award high. aviation safety record—no fatal try his family came from. I invited accidents with transport-category ceremony.” him to visit these places personally aircraft for more than 39 years. Ladislav He continued, “It is a great honor for together. The idea excited him, and he Mika is uniquely qualified to receive the me to be here today with you and hold was keen to visit the homeland of his honor of being named the Jerry Lederer the prestigious award bearing the name father. Unfortunately, at the age of 101 in Award recipient. We are very proud to of Jerome Fox Lederer in my hands. It February 2004 he flew west, and his visit have such a widely recognized aviation might be a suprise for you, as it was for never materialized. But Jerry’s daughter safety expert among our membership. He me, to learn that the Lederer family has Nancy Cain visited Prašný Újezd last July; is a most deserving recipient of the ISASI roots in the Czech Republic. We are situ- it was the first return of a member of Jerry Lederer Award.” ated about 300 kilometers from the place Jerry’s family to his father’s homeland. Throughout President Del Gandio’s where Jerry’s father was born. The place “I also recall that we spoke about introduction, Ladi, calm faced, stood is called Prašný Újezd, a small village Jerry‘s inspection of Charles Lindberg’s nearby. But upon being presented the located about 30 kilometers from the city Spirit of St. Louis before crossing the award and after the handshake, his exu- of Pilsen, where for a long time one of North Atlantic in May 1927. I asked him berance burst through with a huge smile. the best beers in the world is produced. whether he knew that then Czechoslo- Holding the award plaque high, he quick Another important person in American vakia also participated in the success of stepped to the center of the stage as a aviation, with roots in the Pilsen region, this flight. He replied that he did not. I photo of himself with Jerry Lederer filled is Jim Lowell—thanks to his grandfather then explained that the crankshaft—the the stage’s large screeen. The 280 banquet from his mother’s side. Also the ancestors heart of the aircraft’s engine—was made guests responded to his enthusiasim with of Kim Novak, the actress, come from this in Czechoslovakia. Coincidently, I was a resounding standing ovation. region. born on the same day, 20 years later, that Taking the lecturn, Ladi, after acknowl- “How did I discover the evidence and Charles Lindberg completed his flight edging the assembled group, turned his facts about Jerry’s ancestors? When Jerry across Atlantic Ocean. head, looked at the large screen behind was celebrating his 100th birthday in “When I look at the past Lederer Award him, and began his acceptance address in 2002 at that year’s ISASI conference, he winners, I note that the majority have a unique way: “Good evening Mr. Avia- stepped up on the stage and made a short participated in dozens of aviation ac- tion Safety. Dear Jerry, I am very happy reflection on the professional as well as cident and incident investigations in their that you can be with us during this award a personal part of his life. He brought up professional lives. For me, the situation

12 • October-December 2015 ISASI Forum is completely different. I participated in “I am glad I could devote my entire Past Lederer Award Winners the investigation of only two aviation ac- professional life of 44 years to increasing 1977—Samuel M. Phillips cidents of transport aircraft. The first one the level of safety and training of the new 1978—Allen R. McMahan in 1975, an accident of a Czechoslovak aviation safety experts. That’s why I was 1979—Gerard M. Bruggink Airlines aircraft IL-62M near Damascus very pleased when I received the Cer- 1980—John Gilbert Boulding [Syria] and the second one in 1976 of the tificate of Outstanding Achievement in 1981—Dr. S. Harry Robertson IL-18 aircraft at the airport of Bratislava recognition of 30 years of continous and 1982—C.H. Prater Houge [Slovakia]. It is a true that since then, for unconditional support to ICAO activities 1983—C.O. Miller 39 years, no fatal accident of transport and outstanding personal contribution to 1984—George B. Parker aircraft in the Czech Republic has oc- the sustainable development and safety of 1985—Dr. John Kenyon Mason curred. I am proud to have been able to international civil aviation in particular 1986—Geoffrey C. Wilkinson 1987—Dr. Carol A. Roberts contribute to this great result. within the European Air Navigation Plan- 1988—H. Vincent LaChapelle “During my professional career I have ning Group from the regional office of 1989—Aage A. Roed focused on improving aviation safety, ICAO EUR/NAT in Paris in October 2014. 1990—Olof Fritsch accident prevention, and education of “Millions of people now fly safely to vast 1991—Eddie J. Trimble investigators and safety professionals in and far reaches of the world. The number 1992—Paul R. Powers aviation. When I first met ISASI’s Ron of passengers travelling on schedule ser- 1993—Capt. Victor Hewes Schleede and Jim Stewart at the annual vices has grown by more than 3.3 billion. 1994—UK Aircraft Accidents conference in Barcelona, Spain, in 1998, This figure represents almost half of the Investigation Branch I suggested that an ISASI conference be world’s population being carried by air- 1995—Dr. John K. Lauber organized in Prague. But I had no idea craft in 2013, on just more than 32 million 1996—Burt Chesterfield how complex the organization of such departures. 1997—Gus Economy 1998—A. Frank Taylor an event is and that venues are chosen “All of us here and hundreds of other 1999—Capt. James A. McIntyre several years in advance, much like the aviation specialists share the same goal: 2000—Nora C. Marshal Olympics. So I then suggested organizing to improve the level of aviation safety. 2001—John W. Purvis and the a seminar, local to Prague, for safety ex- Like Jerry, we believe that flight without Transportation Safety Board perts and investigators with the empha- risk was flight without progress—we all of Canada sis on keeping the costs low in order to must minimize this risk. 2002—Ronald L. Schleede provide the greatest number of experts “I thank all my colleagues and friends 2003—Caj Frostell the opportunity to participate. From that who have supported me in the effort to 2004—Ron Chippindale idea sprang ISASI’s Reachout Workshop increase the level of international aviation 2005—John D. Rawson program, which took firm form during safety. A deep appreciation goes to my 2006—Richard H. Wood the ISASI conference in Boston [Massa- parents who gave me the opportunity to 2007—Thomas McCarthy 2008—C. Donald Bateman chusetts] where we began organizing the study the wonderful field of aviation, and 2009—Capt. Richard B. Stone and the first Reachout Workshop in Prague. It was at last but not least my thanks goes to my Australian Transport Safety held in 2001, with 100 participants from family for their understanding and sup- Bureau 14 countries attending. port throughout the years. I am grateful to 2010—Michael Poole “The workshop’s feedback was very those who nominated me as a candidate 2011—Paul-Louis Arslanian positive, resulting in the decision to for this very prestigious international 2012—Curt L. Lewis continue with this very important in- aviation award. I highly appreciate being 2013—Frank Del Gandio and Myron ternational ISASI activity. Key persons the first one from the countries of Central Papadakis were Ron Schleede, Jim Stewart, and Caj and Eastern Europe to be awarded ISASI’s 2014—David King Frostell. To the present day, the Reachout Jerome F. Lederer Workshop program has been conducted Award. in 46 locations. “Many thanks to “Another important moment in my ISASI for awarding me professional life was meeting Dr. Peter Gar- this honor and to Jerry diner, director and CEO of the Southern for dedicating his life California Safety Institute. We immediately to aviation safety. I “hit it off ” and initiated the launch of the accept this award in international courses for the investigators appreciation of my and safety experts. Peter, Ron, Caj, and I entire life’s profes- delivered in 2002 the first international sional activities in aircraft accident investigation and safety aviation safety and at course in Prague. It has now been coduct- the same moment in ed 13 times, with more than 600 aviation appreciation of the safety experts from different countries and civil aviation in my continents attending. country.“ Ladi in coversation with Jerry Lederer during the 2003 ISASI conference.

October-December 2015 ISASI Forum • 13 DIVORCING THE REGULATOR: THE ESTABLISHMENT OF AN INDEPENDENT INVESTIGATIVE AUTHORITY By Capt. Ibrahim S. Koshy, Director General, Aviation Investigation A lesson learned is “Don’t Bureau, Kingdom of Saudi Arabia isolate yourself. To be (This paper received the Best of Conference eral. A very important first step was the effective, you need to go Award of Excellence for technical pa- establishment of the AIB regulation. The pers presented at ISASI 2015 in Augsburg, AIB regulation was required to define the out and work with others Germany, Aug. 24–27, 2015. The conference authorities officially for operators, service locally, regionally, and theme was “Independence Does Not Mean providers, pilots, air traffic controllers, air- Isolation.”—Editor) ports, and other regulators to understand internationally.” who the AIB was and to understand the ike the majority of the International authorities of the AIB. The AIB regulation home of the AIB. In the first year, the of- Civil Aviation Organization (ICAO) was approved in January 2013 and became fice walls were covered with many project signatory states, the Kingdom of effective in November 2013. charts that were being run simultane- LSaudi Arabia assigned the authority ously. There were many late nights at the and responsibility of investigating aviation Challenges office as well as working outside of the occurrences to the regulator, the General Getting the right people on board in any office during the first year. Authority of Civil Aviation (GACA). To be startup, including a government agency, in line with ICAO standards and recom- is very important. Not only do they have Actual levels of independence and mended practices, a decision was made in to know how to do it right, but they have priorities 2009 to transfer the authority for aviation to know how to build it. In addition to Although independence was very im- occurrence investigation to an agency investigating occurrences, the team being portant, it was also important to decide independent from the regulator; this was put together would be responsible for how to achieve the appropriate levels the impetus for the birth of the Aviation building a system, policies, procedures, of independence that would serve the Investigation Bureau (AIB). and processes. interest of the AIB. The strategy looked at Many actions took place before the The first person brought on board was three areas in detail: functional independ- AIB was born, including the senior Serge Lemire, who had years of experience ence, administrative independence, and government decision in the form of a as an investigator with the Transportation financial independence. royal decree for the establishment of an Safety Board (TSB) of Canada. Lemire was A five-year strategy was set by the AIB independent aviation occurrence inves- also familiar with aviation in Saudi Arabia, in which 100% functional independence tigative agency, the regulator (the GACA) as he had been assigned to GACA aviation was required from day one. In relation to amending articles of the Civil Aviation safety through ICAO. Lemire was brought financial and administrative independ- Act transferring the authorities from the on board as the first AIB director of inves- ence, however, it was decided by the AIB regulator, and the GACA making internal tigations, and bringing other investigators that in order to concentrate efforts in amendments by resolutions. on board created a core team that could building the desired investigative and lab In 2012, Capt. Ibrahim S. Koshy was conduct occurrence investigation in a capabilities, the AIB would utilize finan- tasked to establish and head the AIB and professional manner. cial and administrative support that was was appointed as its first director gen- Having a team “look inside” and “tend available initially from the GACA while the house” allowed the director general the AIB gradually built its own financial Capt. Ibrahim S. Koshy to “look outside” and determine required and administrative department in ac- is the director general of regulatory changes, determine desired cordance with the government’s require- the Aviation Investigation capabilities, determine a long-term ments. This was still considered by the Bureau (AIB) of the strategy, and define an organizational AIB to have a level of independence as the Kingdom of Saudi Arabia, structure that would be effective for the administrative authority resided with the a member of the board current situation as well as fit in with the AIB while the execution of administrative of the newly established projected level of aviation activity in the functions would be with another govern- MENASASI Chapter. He is kingdom. ment agency (the GACA). The AIB strat- an IOSA senior lead audi- Many tasks were required, includ- egy calls for developing its own financial tor and evaluator with more than 25 years as ing getting an approved organizational and administrative capabilities in 2018. an airline pilot with experience in E170, G-IV, structure, getting job descriptions and B-737, A300-600, B-777, and A330 types. He authorities for each position, applying for has served in various management positions in Working together—investigative airline flight operations safety and corporate a budget, getting financial authorities for authorities safety. He is a graduate in aeronautical science the office and staff, getting a budget for While building an organization, it’s not (aviation safety and accident investigation) from the desired lab facilities, getting vehicles enough to just do it the way you think it ERAU in the United States and is working on and equipment, and most importantly a should be done; you need to get out there an MSc in safety and accident investigation at temporary facility as well as an approval and see how others are doing business. Cranfield University in the United Kingdom. for a permanent facility that would be the Take time to visit others who have been

14 • October-December 2015 ISASI Forum dle East and North Africa (MENASASI) be underestimated. has brought aviation safety professionals and investigators together on a regular Working together—coast guard, re- basis in another forum to discuss cur- search institutes, and universities rent issues and improve cooperation and Getting to know what capabilities were understanding of current issues among available in the country that the AIB might safety investigators. require in the course of an investigation was necessary. The AIB reached out to Working together—Saudi Arabia universities, colleges, and research centers The theme of ISASI 2015 was “Independ- and found the following capabilities: ence Does Not Mean Isolation,” and the • Supercomputers—which with data Capt. Koshy (left) accepts the Award of Excel- realization of how closely the AIB found it lence from ISASI President Frank Del Gandio. could be used for predicting wreck- was required to work with the GACA to be age scatter patterns in the event of a in this business for a while. The AIB had effective is a perfect example of how the mid-air collision or an explosion in a familiarization project that entailed investigative authority and the regulative flight (like the Lockerbie event). This visiting various investigative authori- authority cannot work in isolation if they capability was also found to be ben- ties. From 2013 through 2015, the project are to be effective. eficial to assist in locating underwater entailed visits to the the AAIB–UK, the One of the main challenges the AIB wreckage by using sea current data BEA–France, the TSB–Canada, the ATSB– initially faced was in spite of press releases and mathematical formulas. These Australia, the NTSB–U.S.A., and the BFU– and circulars issued to the operators, ser- supercomputers could also be used Germany. vice providers, and the aviation communi- in safety studies for visualization of Sitting down to hear what worked for ty, there was a problem with notifications airway and an analysis in visualization the various agencies as well as what didn’t and awareness of who the AIB was. Coor- labs (the cave). work helped the AIB in deciding several dination with the GACA through frequent reminders on the new requirements and • Material and fluid analysis—the AIB changes to what its organizational struc- also identified other capabilities in reachout programs at 28 airports in the ture should look like. The visits also let the the country where material and fluid country with all stakeholders—including AIB better understand the processes they analysis was available and to what airlines, service providers, airport manage- used to stay on top of things, which gave standards the labs were being oper- ment, air traffic control, fire rescue ser- us additional insight into some capabili- ated. This allowed the AIB to identify vices, civil defense, police, airport security, ties that we felt should be established in areas where it could either use the our ops room design as well as in our customs, etc.—raised the awareness level facilities or would have to develop its recorder labs. of who the AIB was, and the notifications own in-house capability. A strategic There are a large number of interna- situation improved considerably. partnership is in the making with a tional carriers overflying Saudi Arabia due The concept of first responders, which European world-class certification to the size and geographical location of appeared to be working well for the BEA of and inspection company for bring- the state as well as the political develop- France, was appealing to the AIB. Working ing material-analysis capabilities and ments and economic and aviation growth with the GACA, the AIB created its own competency, including technology and in the region. The reachout to other safety “first responders” by utilizing safety and skills transfer. quality personnel at each airport who were boards helped the AIB build a good rap- • Marine search and recovery—In port quite fast. briefed and trained in the requirements of the AIB in the event of an occurrence until reaching out to the faculty of marine science in Jeddah, we found that it had Working together—regional the AIB arrived on site. Furthermore, the AIB now participates in all airport emer- projects like mapping the floor of the cooperation gency drills to give its input in regards to Red Sea and studying sea currents and Reaching out and coordinating with preservation of evidence and investigative that it had some of the most-advanced our regional counterparts has been very requirements and to continue the reach equipment and teams available in beneficial for the AIB. States like the out. The GACA had previously developed a the field that could be utilized in the United Arab Emirates (UAE) have taken software database for occurrence tracking event of an aviation occurrence in our initiatives and reached out to bring other that the AIB now utilizes for its own occur- waters to help locate wreckage. investigative authorities in the region rence tracking. We reached out to the Coast Guard to together in a way that has helped the in- Establishing memorandums of under- come to an understanding on roles in vestigative authorities in the region better standing (MOUs) with other agencies that wreckage recovery. We also realized that understand each other’s capabilities. This an investigative authority requires to coor- the experience and capabilities to locate has allowed the AIB to better understand dinate with in an accident investigation is recorders wasn’t adequate and would have what capabilities and resources to invest an important task. The GACA previously to be built. The AIB plan to build the expe- in. The initiatives by the UAE have also had entered into MOUs with agencies, and rience and capabilities to locate recorders improved regional coordination in train- utilizing those MOUs, rather than starting begins in late 2015, with the first exercises ing by offering seats to states. This is now from scratch, as a basis for some of the expected to be conducted in 2016. being reciprocated by other states in the AIB’s required MOUs was quite helpful. A lesson learned is “Don’t isolate region, including the AIB of Saudi Arabia. There are many MOUs that still require up- yourself. To be effective, you need to go out The lead initiative by the UAE in estab- dating, including those between GACA and and work with others locally, regionally, lishing a local ISASI chapter for the Mid- the AIB. The importance of MOUs cannot and internationally.”

October-December 2015 ISASI Forum • 15 ISASI Scholarship Recipients Receive Awards ISASI 2015 awards banquet attendees loudly recognized the four recipients of the Kapustin memorial scholarships. By Esperison Martinez, Editor

SASI awarded four ISASI Kapustin memorial scholarships in Take, for example, Schiphol airport located near Amsterdam 2015. Recipients included Nicolaus Dmoch, Berlin, Germany, in the Netherlands. Although serious accidents do not often Emery-Riddle Aeronautical University (ERAU), Berlin cam- happen at this airport and other airports, there are regular Ipus; Mario Pierobon, Conegliano, Italy, Cranfield University, occurrences of incidents that could be classified as risky. Two UK; Kiki Faber, the Netherlands, Delft University of Technology, such regular incidents are runway incursion and collisions/taxi Delft, Netherlands; and Amy LaRue, Los Flores, California, Uni- incidents during ground traffic. versity of Southern California, Los Angeles, California, U.S.A. In 2010, the Dutch Safety Board, Onderzoeksraad voor Veilig- The July–September issue of the Forum (see page 28) intro- heid, did an extensive investigation into a runway incursion, duced all the winners and published the essays authored by focusing on the incident of Dec. 18, 2010, and similar incidents. Micolaus Dmoch and Mario Pierobon. The remaining two essays These incidents involved incursion of aircraft that had been by Kiki Faber and Amy LaRue follow this introductory text. cleared for takeoff or landing and bird controller vehicles with permission to operate on the runway. The conclusion of this investigation was that the method of communication between Kiki Faber , 24, is pursuing a master of aero- bird controller and ATC was insufficient to avoid dangerous space engineering degree with a specializa- situations. Also, the communication between the runway tion in aerospace control and operations at controller and ground controller, as in the case of December Delft University of Technology. She holds a 18, was insufficient to convey the needed awareness of the bird bachelor’s degree in aerospace engineering controller to the runway controller. A technical issue within this and expects to graduate in 2016. Kiki calls problem was the runway system that shows the occupancy of Hoorn, Netherlands, home. Her hobbies and the runway; it only indicates if the runway is empty or occupied. interests include classical and jazz music and No information is provided regarding the number of occupants singing. She sings in the Delft student choir and enjoys traveling on the runway. As a result, it is incapable of giving a warning in and experiencing other cultures. After graduation, Kiki will seek case of runway incursion. This investigation called for a real- work in the aviation safety investigation arena. She said, “I hope istic and practical way to safely operate runways and stop the to become a specialist on aircraft safety and be able to work on insufficient risk control. However, on Jan. 12, 2014, a similar case challenging projects on international teams to improve aircraft of runway incursion with a bird controller occurred, indicating and aviation.” that the problem is not yet fully solved. Other runway incursion cases at Schiphol airport involve mul- The Challenges for Air Safety Investigators: tiple aircraft (e.g., incidents on Apr. 18, 2012, Dec. 11, 2012, and Dangers of Busy Airports—Schiphol Dec. 6, 2013). In these incidents, communication between the By Kiki Farber, Master of Aerospace Engineering Candidate, ATC and pilots resulted in the pilots’ believing they were cleared Delft University of Technology, Delft, Netherlands for takeoff, while in fact they were not. This led to runway The demand for air travel is growing worldwide. The rapid incursions between crossing traffic and the arriving/departing economic growth in regions such as China and South America flights. These cases illustrate the need for a system in which the is fueling the greatest increases in demand; however, substantial pilots can get clearer information and/or a way to check if they growth is also expected for regions such as Europe and the Unit- understood the information correctly (DSB 2014 & DSB 2013-4 ed States with already established markets. The negative impact & DSB 2014-1). of this growth is more traffic. This will increase the demand on In addition to safety, preventable ground traffic incidents can current airport infrastructure, resulting in the potential for over- also cost a lot of money. One of these cases at Schiphol airport is crowding. What will be the impact of increased traffic on the the collision between two Boeing aircraft on Dec. 13, 2013. This safety of airports? And what can we do to maintain and improve case was a gate management problem: a B-737 was delayed at upon current airport ground safety? its designated gate while a B-757 came in for docking. The B-757 Increasing traffic usually also means increased risks of was designated a gate adjacent to the delayed B-737. Docking incidents and accidents. These dangers at large airports can of a B-757 at its designated gate, however, is only possible if result in high damages and in the worst cases even loss of lives. its dock and one of its neighboring docks are empty. The Gate The challenge for air safety investigators is to prevent this from Management System showed the dock of the B-737 planned happening without stifling the growth of the air travel industry as unoccupied, and bad weather conditions limited visibility, (Okwir 2014 & Airbus 2014). making it impossible for the gate planner to see the B-737. This

16 • October-December 2015 ISASI Forum resulted in the B-737 losing its winglet and the B-757 having Navigation and Surveillance (ICNS) Conference, 2014, p.1-15. http://ieeex- severe wing damage. plore.ieee.org/xpls/icp.jsp?arnumber=6819989. De Arruda, A.C., Weigang, L. & Milea, V., 2015. A New Airport Collaborative Deci- Another case is the use of an unavailable runway by multiple sion Making Algorithm Based on Deferred Acceptance in a Two-Sided Market. aircraft in sequence (e.g., June 16, 2012). Luckily the runway was Expert Systems with Applications, 42(7), pp.3539–3550. http://linkinghub. cleared of debris and birds, but an incident like that could also elsevier.com/retrieve/pii/S0957417414007593. have made a turn for the worst. This was also a simple matter of European Airport CDM, 2015. Airport Collaborative Decision Making. http:// www.euro-cdm.org/index.php. miscommunication (DSB 2014-2 & DSB 2012-2). Airbus, 2014. Global Market Forecast: Flying on Demand 2014–2033. Airbus All of these cases allow us to evaluate the current safety at http://www.airbus.com/company/market/forecast/. airports and find ways to improve it—not only at Amsterdam Schiphol airport but also at other busy airports around the world. Air safety investigators evaluate incidents and accidents Amy LaRue, 20, is pursuing a bachelor’s of in order to identify ways to improve the safety of the current aerospace engineering degree at the Viterbi systems, but also to help with implementing these changes. The School of Engineering at the University of recommendations given by the Dutch Safety Board are about Southern California. She expects to graduate changing the current system to improve safety. The current in 2016. Amy plays a trombone in the universi- ground control system at many airports has grown from smaller ty’s marching band. Her other interest include starting airport systems into bigger systems—without a cen- volunteering at an all-women’s community tral information system and with its functions scattered over service organization and participating in the different disciplines, allowing for miss communication. What aerodesign team where she is helping build a radio-controlled could greatly improve the communication and safety of ground airplane for the AIAA Design, Build, and Fly competition. Amy is control at airports is the introduction of a centralized airport also taking flying lessons and enjoys exploring Los Angeles and vehicle monitoring system. reading. Currently there are new developments around airports About her future, she said, “Aviation safety is a field that I called collaborative decision making (CDM) where airports encountered as a result of my participation on the AeroDesign centralize information to improve the operational speed of the Team. USC’s Aviation Safety and Security Program was avail- airport. In this development, mainly the ATC and airlines are in- able as a resource to undergraduate students from our team, cluded while recommendations are urging for using more input particularly emphasizing the ISASI scholarship. I jumped at the of the air traffic flow management. Further improvements on opportunity to learn more about aviation outside of the field of harmonization, situational awareness, collaboration, and opera- engineering. I hope to carry the educational experience of the tions in adverse conditions can be made. As a result, this system ISASI Kapustin scholarship through to my senior year of school has not yet reached its full potential for improving airport safety. as well as into my career. Having a well-rounded view of all fac- European Airport CDM is an initiative that includes IATA, ets of aviation will allow me to be more versatile as well as fulfill EUROCONTROL, the European Union, and Airports Council my personal curiosities.” International (ACI). Air safety investigators can make a valuable contribution The Tactical Use of Camera-Equipped UAVs in by using their knowledge to take on the challenge of incident The Field of Aviation Safety prevention, collaborating and proposing ways to include safety By Amy LaRue, Undergraduate Degree in Aerospace Engineer- developments in this new initiative. The system, which is al- ing, University of Southern California, U.S.A ready partially implemented in Europe and America, can then The current system in use for investigating crash sites, seen most be developed to be safe and solve some of our current safety recently in the Germanwings Flight 9525 tragedy in the French issues. An association as ISASI, or any national safety board, can Alps, emphasizes the use of human capital, which requires large be involved in the project evaluation and in pointing out the amounts of personnel, resources, and money—challenges better improvements that can be made to create a safe system. These met by expanding use of unmanned air vehicles (UAVs) to air entities could also help to develop the safety of the system as a safety investigation. Drones can endure harsher conditions, fit partner. By collaborating and acting proactively on these new in smaller spaces, and report back to the command center with developments, they can prevent dangers in the future and con- presumably more accuracy than an investigation performed tribute to safe flying, arrival, and departure of aircraft at airports without them. The use of drones would have been incredibly throughout the world (Okwir 2014 & De Arruda 2015 & Europe- beneficial in the case of Flight 9525 as sources of aerial pho- an Airport CDM 2015). tography to better understand the site before ground-level in- References formation gathering happened. Helicopters, the primary means Dutch Safety Board, 2013. Runway incursion baan 24, Amsterdam Airport of accessing the site, were once the most modern technology Schiphol. Onderzoeksraad voor Veiligheid. http://onderzoeksraad.nl/nl/ available; however, the natural progression of technology has onderzoek/977/runway-incursion-baan-24-boeing-737-18-december-2010/ led drones to now be most practical. The FAA, the EASA, and fase/1386/onduidelijkheid-leidde-tot-runway-incursion-op-schiphol. the BEA will be conquering the age-old challenges of time and Dutch Safety Board, year-quarter. Quarterly reports of the Dutch Safety Board Aviation Department. Onderzoeksraad voor Veiligheid http://onderzoeksraad. money by using UAVs to support their aircraft investigations. nl/Okwir, S., 2014. Though drones have already been introduced as a means Collaborative Decision Making (CDM) in Airport Surface: Europe vs. U.S.A. of observation, they are not yet being fully capitalized in the Implementations, Challenges, and Best Practices. Integrated Communication field of aviation safety. In the United States, their capabilities October-December 2015 ISASI Forum • 17 Kapustin scholarship recipients receive banquet attendees’ applause after accepting scholarship cer- tificates. Shown, left to right, are Nicolaus Dmoch, Mario Pierdon, Amy LaRue, Kiki Faber, and ISASI President Frank Del Gandio.

concerns stating, “Currently the expansion of the RPAs market is inhibited by the absence of an adequate regulatory framework.”2 Sharing the same sentiment, the FAA has recently launched research

Photo: Esperison Martinez initiatives in six areas of the United States to test the technology. are continually being explored and defined. Law enforcement Nevada has been assigned to “look at how air traffic control agencies, such as the Grand Forks Police Department (GFPD) in procedures will evolve with the introduction of UAS into the North Dakota, have taken it upon themselves to use drones to civil environment and how these aircraft will integrate with the mitigate dangerous situations in which suspects are believed to modernization of the national airspace system,”3 which address- pose threats. Rather than sending officers into a potentially dan- es the concern of the lack of definition regarding shared air- gerous situation with little background on the area, the police space. Ideally, pending the completion of the two-year program, send in a Qube quadcopter to procure all applicable information the FAA will have a defined system of rules for unmanned flight beforehand. Using the thermal imaging capabilities of the Qube, that all regulated airspaces can follow. the police department searched for suspects: “The field was The best way to move forward with the utilization of drones in quickly traversed and found to be empty. Though the suspects aircraft investigations is to establish a set of guidelines for their were not there, the automated search freed up police officers to use, similar to what is being done in Nevada. This set of guide- look elsewhere, and the suspects were soon picked up in the sur- lines needs to be all-encompassing and specific to the field of 1 rounding area.” The efficiency of the GFPD should be something aviation safety by including a clause about what protocol is for that other agencies strive for. This forward-thinking approach to the drone’s activity when personnel arrive on scene. To have the urban observation can, with extended-range capabilities, also be operations run smoothly, it would be best to have the controller applied to the search for downed aircraft. fly to the scene with the other professionals who traditionally Drones’ systematic observance is more thorough than the attend to the crash. This would allow the person most familiar human eye, as can be proven by capabilities such as thermal with the drone to operate it safely around others and review imaging, and can more quickly identify hard-to-find wreckage in footage as necessary. If space in the aircraft flying to the site is places such as the French Alps or a forest. Though Flight 9525’s an issue, the drone’s flight capabilities can be shut down when A320 remains were found relatively quickly via manned helicop- the investigation team is on site, but video can remain enabled. ter search, this cannot always be counted on. The use of cameras The safety of the interactions among the UAVs, manned aircraft, will positively benefit the search mission as a supplementary and personnel cannot be overlooked, as one problem will investigation technique. For instance, Malaysia Flight 370 has quickly result in another. spent upwards of $100 million dollars on reconnaissance mis- Humans will always be involved in rescue operations, but the sions, which have been unsuccessful thus far. These costs could deployment of a drone in advance of their arrival can minimize be greatly reduced if unmanned vehicles were sent. their time on scene. An argument can be made for retaining the In addition to search missions, quadcopters have been proven current system of gathering a team upon notification of a crash, in the field at hand. USC’s Aviation Safety and Security Program setting a mental plan, and executing each specialized job that is has been making strides toward investigating aircraft wreckage assigned, but that kind of wait time can be deadly to any with drones by recording videos of wreckage in its aircraft in- survivors. To alleviate the delay of search-and-rescue operations vestigation lab. Signs of human life and location of the aircraft’s arriving on site and the funds that it currently takes to back such data recorders are time-critical pieces of information that need operations, the largest problems that exist in aviation safety, it’s to be determined as soon as possible. Sending a drone with the readily apparent that UAVs should be used. endurance required to fulfill the mission and the visual capa- bilities to do so would speed up the recovery and investigation References process once people arrive on site, which benefits everyone 1. Pilkington, Ed. “’We See Ourselves as the Vanguard’: The Police Force Using involved. These drones are equipped to provide an equivalent, Drones to Fight Crime.” The Guardian. Oct.1, 2014. Web. Apr. 4, 2015. if not greater, amount of information regarding the investiga- 2. Brussels. “Communication from the Commission to the European Parliament tion than the human eye, and can do so in conditions not fit for and the Council.” European Commission, Aug. 4, 2014. Web. Apr. 3, 2015. 3. Dorr, Les, Jr., and Alison Duquette. “Research to Examine UAS Integration human search-and-rescue operations. with Air Traffic Control Procedures and NextGen.” Press Release—FAA An- The FAA, the EASA, and the BEA recognize that drones play nounces Nevada UAS Test Site Now Operational. Federal Aviation Administra- a large role in the future of aviation safety. The EASA voiced its tion, June 9, 2014. Web. Apr. 5, 2015.

18 • October-December 2015 ISASI Forum Towards the Next Generation By Dr. Matthew Greaves (MO5700) Head, Safety and Accident Investigation Centre, Of HUMS Sensor Cranfield University

The author describes a research program that aims to inform the next generation of helicopter health and usage monitoring systems (HUMS) by identifying and proving feasibility for new and newly applied sensing technologies, with a specific focus on internal sensors for rotating systems of helicopters.

his adapted article describes work Puma, registration G-REDL, in the North (Adapted with permission from the undertaken as part of European Sea in 2009, have raised questions about the author’s technical paper entitled Aviation Safety Agency (EASA) project efficacy and limitations of HUMS. In light of Towards the Next Generation of EASA.2012.OP.13 VHM and outlines technological advances since the develop- HUMS Sensor presented at ISASI T the project phases, the work undertaken, and ment of the early HUMS, it is appropriate that 2014 held in Adelaide, Australia, some of the achievements. The project was the issue of detecting incipient failure is reex- Oct. 13–16, 2014, which carried the theme “Investigations and Safety initiated in response to two recommenda- amined. The research program described here Management Systems.” The full pres- tions from the UK Air Accidents Investigation aims to inform the next generation of HUMS entation, including cited references Branch (AAIB), namely: by identifying and proving feasibility for new to support the points made, can be 1. UNKG-2011-041: It is recommended that and newly applied sensing technologies, with found on the ISASI website at www. EASA research methods for improving the a specific focus on internal sensors. isasi.org under the tag “ISASI 2014 detection of component degradation in heli- Technical Papers.”—Editor) copter epicyclic planet gear bearings. Overview of vibration health monitoring 2. UNKG-2010-027: It is recommended that (VHM) systems EASA, with the assistance of the Civil Avia- HUMS was developed in North Sea op- tion Authority, conduct a review of options erations, motivated in part by the crash of a Matthew for extending the scope of health and usage Boeing Vertol 234 in 1986 that was caused by Greaves is the head of monitoring systems (HUMS) detection into disintegration of the forward main gearbox. the Safety the rotating systems of helicopters. After HUMS development in the 1990s, the and Accident UK Civil Aviation Authority (CAA) mandated Investigation Background that HUMS be fitted to certain helicopters. Centre at Since the 1980s, the use of onboard sen- A Rotor & Wing article suggests that HUMS Cranfield sors for helicopter HUMS has been increas- “successes” are found at a frequency of 22 per University. Prior ingly popular for benefits of enhanced safety. 100,000 flight hours. to joining Cranfield, he worked for Through the years, a wide range of sensors Several surveys have been carried out by the science and technology organiza- and methodologies have been developed for different authors and agencies into the ef- tion QinetiQ. He holds an engineer- ing degree and a Ph.D. in aircraft monitoring and fault detection across heli- fectiveness of HUMS sensors and analysis engine noise and vibration. His copter rotor, drivetrain, and engine systems. methods. The FAA carried out one of the first research deals with the application Vibration health monitoring equipment is surveys for helicopter HUMS in an effort to of technology to aviation safety and now commonplace on large helicopters, and develop certification requirements. NASA the accident investigation process. the technology has matured and can claim a performed several surveys examining the He is an ESASI committee member. number of successes with respect to accident application of HUMS in areas ranging from prevention. gearbox to engine health monitoring. The UK However, despite these successes, ac- CAA has also conducted a review of extend- cidents, such as the one involving a Super ing HUMS to rotor systems. Those surveys

October-December 2015 ISASI Forum • 19 level, rather than on improved process- Safety Analysis Team (EHSAT) database The main aim of any ing of existing signals. However, as the used different criteria, aiming to capture project progressed, both aspects were any significant accidents that had been signal-processing explored. missed. However, no new accidents were discovered, thereby providing some con- technique is to Accident review and failure modes—A fidence that the earlier sort process did review of accidents and failure modes not miss any significant accidents. “expose” the signal was conducted to understand the types Detailed fault-tree analysis was of degradation that cause catastrophic performed to identify various primary that characterizes failures and to help select case studies for and secondary failures of the MGB and the degradation or benchmarking candidate technologies. transmission systems for each of the se- The fundamental generic degradation lected cases. The fundamental aim of the incipient failure from and failure mechanisms for gears and fault-tree analysis was to develop detailed bearings are well understood and include understanding of triggers, causes, and the general noise effects such as wear, spalling, adhesion, event sequences for the selected acci- fretting, etc. dents and incidents. of the platform and Roberts, Stone, and Turner, in “Deriv- The analysis showed no general pat- ing Function-Failure Similarity Informa- tern or sequence to the accidents. Some ordinary gear meshing tion for Failure-Free Rotorcraft Compo- similarities may exist between events, but nent Design,” analyzed more than 1,000 the overall sequence, nature, depth, or and bearing noise. accident reports for the Bell 206. They importance of each event was found to be discovered 29 accidents involving engine different either up- or downstream of the provide a good overview of existing sen- and powertrain failures, involving 10 dif- accident. The key failure modes identified sor technology and methods and their ferent failure types. These were listed as from the above analysis were implementation in a HUMS program. bond failure, corrosion, fatigue, fracture, • Small corrosion pits as triggers of fretting, galling and seizure, human, cracks. Signal processing—There is an extensive stress rupture, thermal shock, and wear. • Small machining defects as triggers range of possible signal processing tech- For this project, a thorough search was of cracks. conducted, via various available databas- niques available with which to analyze • Subsurface cracks. HUMS vibration signals. Over the years, es and data sources, to form a compre- processing has evolved from simple indi- hensive population of relevant helicopter • Possible spalling of gears/bearings. cators such as root mean square (RMS) accident and incident formal reports. • Material defects/manufacturing to more developed techniques such as Candidate accident reports were selected anomalies. data mining. Another development is the according to strictly specified criteria: • Galling of studs/bolts. implementation of an advanced anomaly • Final official formal reports. • Wear due to load variations/move- detection algorithm, developed by Gen- • Of sufficient technical detail to estab- ments. eral Electric under a UK CAA-sponsored lish an adequate sequence of events. program. This algorithm expands the • Fracture/rupture under overload. • Either of events within the main concept of condition indicators to estab- gearbox (MGB) and transmission • Deformation under overload of lish a “normal” vibration set that allows systems or of external events that bearing rollers/raceways/gear teeth/ alerts to be raised using a data-mining influence these systems (including shafts/splines. approach. human input). • Internal residual hoop/tension/tor- The main aim of any signal-processing • Of relevance to existence and appli- sion/compression/buckling stresses. technique is to “expose” the signal that cation of HUMS. • Permanent distortion (creep) of characterizes the degradation or incipi- casings. ent failure from the general noise of the • Written in English (there was no platform and ordinary gear meshing and access to the whole group of Eastern • Seizure of roller bearing. helicopters for instance or to West- bearing noise. However, the ultimate • Improper coating of hard metal ern reports written in other languag- success of any signal-processing strategy (carbide grains size, porosity, coating es due to time limitations). depends on the quality of the signal un- thickness, etc.). der analysis. If the signal-to-noise ratio is Applying the above criteria, a total of • Lamination of the hard metal coating. too small then no amount of processing 12 reports were selected out of an initial will allow detection. screening input of 413. The selected acci- • Defective bonding between hard metal and coating. The initial aim of this research project dents can be summarised by registration was to focus on the sensing technolo- as G-REDW/CHCN, C-FHHD, G-REDL, Given the difference of each examined gies available for fault detection, with a G-BJVX, C-GZCH, G-BBHM, G-CHCF, accident, an argument could be made for particular emphasis on increasing the GASNL, G-PUMI, 9M-SSC.G-JSAR, and using all of the accidents as test cases. signal-to-noise ratio of the “defect signal” LN-OPG. To support these selections, However, available time and funding measured against the background noise interrogation of the European Helicopter made this impracticable. It also risked di-

20 • October-December 2015 ISASI Forum luting the focus of the research. Instead, it was necessary to establish baseline With the selection of a potential sensing the focus centered on the monitoring of operating requirements for any proposed technology, it was necessary to ensure planetary gears and bearings as moti- sensor. Precise conditions differ on each that a suitable wireless transmission vated by the recommendation stemming platform so, in general, a “worst case” as- technique that could operate successfully from the accident to G-REDL (UNKG- sessment was used. To limit the possible inside the gearbox could be found or de- 2011-041). This accident is considered solution, a number of constraints were veloped to complement the technology. to be the most complex case; hence, any imposed: monitoring solution that can be effective- • No mechanical signal connection Existing systems—There are a range of ly applied to this scenario stands a good (e.g., slip rings)—wireless only. established technologies that might pro- chance of being successful in monitoring, • Limited space (of the order of cm at vide a starting point for such a system, say, bevel gear shafts or possibly being most). including Wi-Fi, Bluetooth, and ZigBee. transferred to other rotating systems on Table 1 details some of the key param- • Useful temperature range -10˚C to the aircraft. +130˚C. eters of these three protocols. One key feature of AE is the frequency Sensing technology review and selection • Sensor weight below 10g. range of interest, typically around 100 In order to review the potential sensing • Tolerant of gearbox mineral oil. kHz to 1 MHz. Therefore, to produce technologies, all options were initially • Power inside MGB is generated—no an unaliased signal at 16-bit resolution considered. Opinions and technologies battery. would require a data rate of 32 Mbps. were sought from a range of subject ZigBee offers low power consumption • Guaranteed attachment or no risk areas, including wind turbines, mot- and short join time, which are useful in from sensor if detached. orsport, rail, and marine. While some this application, but it also has a limited innovative practices were discovered, no Based on these requirements, AE was network speed that will not handle sam- entirely new technologies were discov- selected as the sensing technology. AE pling rates in the order of MHz (ZigBee ered. A down-selection process was then measurement is the capture of high- can support around 16 kHz sampling undertaken, leaving vibration, strain, frequency (hundreds of kilohertz) surface rates at 16-bit resolution). Bluetooth can stress waves that are produced in struc- temperature, acoustic emission (AE), and offer higher transmission rates and hence tures by applied forces. The potential of audible acoustics as potential sensing this technology has increased dramatical- support higher sampling rates (64 kHz at technologies. ly over the last 10 years, due to improve- 16-bit resolution), although this would ments in sensor and data-acquisition still not permit real-time MHz sampling Operating conditions—Clearly any solu- technology, so that it is now established rates. The 32 Mbps (2 MHz at 16-bit tion will need to function correctly in as a condition-monitoring tool. resolution) would be challenging for even an operational environment. Therefore, Wireless transmission Wi-Fi standards. Therefore, any of these wireless protocols will require preproc- Wi-Fi Bluetooth ZigBee essing or caching to work at high AE sam- pling rates. However, typical vibration sampling rates can be easily supported. Standard IEEE 802.11 IEEE 802.15 IEEE 802.15 There is an additional factor of shield- ing that greatly complicates the use of Max range 50-100m 10-100m 10-100m wireless transmission. The MGB casing acts as a Faraday cage, defeating attempts to pass an electromagnetic wave through the casing. This means that placing an an- 868 MHz Europe tenna outside the gearbox will not allow a Frequency 2.4 and 2.5 GHz 2.4 GHz 900 - 928 MHz US signal to be transmitted into the gearbox. 2.4 GHz World There will also be shielding and modu- lating effects from the rotating metallic components inside the gearbox, mean- ing that any transverse electromagnetic Power consumption High Medium Low (TEM) field may be affected or defeated inside the gearbox. Within an enclosed metal cavity, the use of high frequencies 700 kbps – produces a standing wave pattern, where Max network speed >11 Mbps 1 Mbps 20 kbps -250 kbps the field falls to zero at regular intervals, typically every half wavelength (about 6 cm at 2.4 GHz). If the receive coil passes Network join time 3 s 30 ms through these standing wave nulls, the recovered power will vary and unwanted modulation will be superimposed on the Table 1. Candidate wireless communication protocols recovered baseband signal.

October-December 2015 ISASI Forum • 21 As previously discussed, digital trans- mission of sensor data up to 1 MHz band- width would occupy too much bandwidth for a back-scatter technique and would make the sensor circuitry quite complex. A better analogue approach is to modu- late the resonant frequency of the loop using a varactor diode. Such a diode is a variable capacitor controlled by a “tun- ing” voltage and has a linear response over a certain voltage range. The electrical change so induced by the varactor diode produces a combination of amplitude and phase modulation of the back-scattered signal. The back-scattered signal can be “tapped off ” the illuminating coil, so a Figure 1. Lab-scale gear rig. single coil functions both as transmitter and receiver simultaneously. Using a high- Alignment in the gearbox also intro- munications link to pass the analogue quality (low-noise) crystal oscillator as duces complexity. Using a high-gain signal across the wireless link. Operation both transmit source and receiver refer- antenna would produce a spot beam at 13.56 MHz allows the use of magnetic ence enables the use of homodyne receiv- where the power density is very high, so coupling, where the “antennas” are two er architecture. A portion of the transmit- the rotating part must remain in the spot tuned loops of wire or pipe. Such cou- ted signal (which is free of modulation) is at all times. Additionally, unless circular pling is termed “near field” and relies multiplied with the back-scattered signal polarization is used on both transmit and purely on magnetic coupling, as seen in a from the tap at the same carrier frequen- receive antennas, the recovered power conventional transformer for AC mains. cy in a coherent demodulator. The output will vary at the rotation rate. The magnetic loop does not produce a of the demodulator, which responds to A further consideration is the avail- TEM propagating wave, as in a normal both amplitude and phase modulation, is ability of power; it would be preferable if broadcast transmitter. By using two paral- filtered to remove the RF signal at 13.56 power were transferred wirelessly along lel, coaxial coils in close proximity, the MHz leaving the baseband signal. with the data. RF scavenging to supply DC coupling remains consistent as one coil power wirelessly in tags has been carried rotates with respect to the other. Lab-scale sensor test out at the relatively high RF frequencies of In order to understand, test, and vali- 800 MHz and 2.4 GHz. Using an antenna Method of operation—Modulated back- date the performance of AE as a sensing with high gain allows useful power to scatter is a technique that relies on technique, a range of lab-scale tests were be transmitted over a long range, in the periodic damping of the resonant circuit performed. By seeding faults in a repre- order of many tens of meters, using a few of the rotating loop. When magnetically sentative setup, it was possible to identify watts of RF. Note that these systems are coupled to a receiving loop, the modula- the detection potential of AE, for a range termed “far field” and energy transfer is tion can be detected. In contactless cards, by TEM wave. Huang, Paramo, and Desh- the data are transmitted mukh, in “Unpowered Wireless Transmis- digitally by modulating a sion of Ultrasound Signals” demonstrated carrier signal with a square the transfer of AE signals and power using wave. However, in this ap- far-field waves at 2.4 GHz. plication, there is a need to A final consideration is the genera- transmit a linear analogue tion of sufficient RF power and licensing. signal over a bandwidth For these reasons, it was decided to use extending from 100 kHz to the 13.56 MHz ISM band, used by other 1 MHz, to preserve the time near-field, short-range devices, such as domain waveform generated ISO14443 contactless cards, e.g., Master- by the sensor. Card PayPass and TFL Oyster cards. Contactless cards use a “load” modulation scheme, Newly developed system—In an attempt where a damping resistor to meet the demands outlined in the is switched periodically in previous section, a new approach was parallel with the coil. This is developed to wireless transmission of accomplished with a simple AE signals. The system uses a so-called on/off transistor switch, but “homodyne” (same–frequency) receiver the technique is not suitable Figure 2. Triaxial accelerometer and AE sensor mounted on idler with a “modulated back-scatter” com- for a linear system. shaft.

22 • October-December 2015 ISASI Forum with the outer race defect (ORD) fre- quency shown.

Lab wireless system In order to test the approach described in the above wire- less transmission section, a proto- type system was constructed. This consisted of two coils (to replicate a fixed and rotating coil) with one at- tached to a sensor Figure 3. Enveloped spectrum of AE signal with small bearing defects. conditioning board, which accepts a of faults, in a controlled condition, par- wide, 1 mm deep slot in the outer race), signal input, and ticularly in comparison with more-estab- marginal (2 mm diameter spot, 0.5 mm the other attached to a demodulator pro- lished vibration techniques. To provide deep), and slight (1 mm diameter spot, ducing an output signal. the most representative test conditions 0.25 mm deep). A high-stability oscillator is used as the with which to study a helicopter gearbox, transmit source. And to ensure that the Enhanced signal processing oscillator is not adversely loaded, a buffer While the gross damage was easily amplifier is used to drive a power ampli- detected using traditional techniques, fier producing approximately 1 watt of the more subtle damage was much more RF output into the illuminator coil. The difficult to detect. The use of taper roller buffer amplifier is also required to ensure bearings may have limited the detect- that the carrier signal has no back-scatter ability of the small damage because of modulation present on it, as a pure sine the capacity of the roller to bridge the wave carrier is needed as a reference in “hole.” In addition, the use of EDM may the coherent demodulator. This testing have removed the rough edges, often showed that both power and signal could seen in damage, that can help to provide be transferred wirelessly. AE events. As a result, enhanced signal processing was used to try and extract Full-scale testing useful information, using signal separa- To test and validate the approach out- tion and spectral kurtosis. lined by the lab-scale testing, it was nec- Spectral kurtosis was employed to essary to perform full-scale testing of the Figure 4. Sensor position on dish of planet carrier. extract the filter characteristics that AE and wireless transmission concept. were used for envelope analysis on the While the lab-scale approach tentatively an existing rig was heavily modified as nondeterministic component of the AE proved the concept, many of the issues shown in Figure 1. signature. A comparison of the vibration surrounding new techniques are only The rig uses three gears—an input gear, and AE analysis showed both measure- an idler gear, and an output gear—to ap- ments were able to identify the presence proximate a single planet of an epicy- of the large bearing defect based on clic setup. The input gear is driven by a observations in the enveloped spectra. fixed-speed motor, and the output gear is For the small defect condition, however, loaded by a variable dynamometer. The the enveloped spectrum was dominated idler gear was allowed to rotate about a by the gear mesh frequencies and their fixed idler shaft by two taper roller bear- harmonics—hence, the bearing defect ings. frequencies were not evident in the vibra- A miniature triaxial accelerometer was tion signal. However AE analysis was able mounted on the idler shaft next to a min- to identify both the small and large defect iature AE sensor as shown in Figure 2. conditions. Detection of the small bearing Three levels of damage were introduced defect gives the AE measurement a diag- to one of the bearings using electro-dis- nosis advantage over the vibration signal. charge machining (EDM): gross (a 2 mm Figure 3 shows the enveloped spectrum Figure 5. Moving coil mounted on the planetary carrier.

October-December 2015 ISASI Forum • 23 try was approximated as a rectangle with fixed depth and width. The fault-to-rolling element length ratio dictates whether the fault is extended (major) or not (minor). The defect length for the major damage was 30 mm and 10 mm for the minor damage and around 0.3 mm deep for both cases. In its current form, the wireless transfer system is only able to support a single sensor; therefore, it was necessary to select a single location at which to attach the sensor. One of the restrictions to the Figure 6. Coils in position before rejoining top cover. positioning of the sensor was the need to keep the sensor clear of the main upper revealed when implemented at full scale. mm diameter, 4 mm height) AE sensor face of the planet carrier to allow it to For this phase of testing, an SA 330 weighing less than 1 gram. This was the be used as pressure face when changing Puma gearbox was acquired. While this sensor used in the lab-scale testing and is the planet gears. The sensor was bonded gearbox is an older design, it was the shown in Figure 2 (see page 22). in a position on the “dish” of the planet basis of the design of the current EC225 There was a need to balance reliabil- carrier, as shown in Figure 4 and Figure 5 main gearbox and shares many of the ity and stability against the potential (see page 23). same design features. Most importantly damage if released. The PICO is a reliable For the full-scale wireless system, the for this project, it has a final two-stage commercial off-the-shelf (COTS) sensor prototype system was modified and epicyclic reduction utilizing a combined but would cause significant damage if rebuilt for operation inside the Puma planet gear/outer bearing race design. released into a planet bearing. The micro gearbox. While the principles and transfer Airbus Helicopters provided technical sensor is the smallest of the sensors but mechanisms of the lab-scale design support and access to its test bench facili- is experimental and susceptible to noise. remained the same, there were changes ties and testing was conducted in May/ Therefore, a comparison between the to most aspects of the system. One of June of 2014 (see Figure 7). PWAS and s9225 sensors was conducted the most significant changes from the on the lab-scale rig. With the PWAS prov- lab-scale system was that the space avail- AE sensor selection ing to be more effective, this sensor was able to mount coaxial coils on the planet Having selected AE as the detection used for the full-scale test program. An carrier and the gearbox casing is limited. mechanism, it was necessary to select a additional feature of the PWAS sensor is The full-scale system comprised two sensor for use inside the MGB. All of the its very broadband performance (from single-turn brass coils of approximately sensors considered required signal con- low kilohertz up to megahertz). This 400 mm diameter, which were cut to size ditioning and/or pre-amplification. Ph.D. means that it is able to research by A. Pickwell in “Design and function to detect more Development of Micro-electromechanical traditional vibration Acoustic Emission Sensors” showed frequency ranges as that the development of a functioning well as AE ranges. micro AE sensor (approximately 20 µm thick) was possible, and comparison with Experimental setup commercial AE sensors provided some For full-scale testing, a confidence in the performance of the sen- program was devised sor. However, this research work focused consisting of tests in more on the design and physical produc- three conditions—an tion of these sensors than on the detail of undamaged planet their performance. bearing, a heavily dam- The piezoelectric-wafer active sen- aged planet bearing, sor (PWAS) is a small sensor often used and a slightly damaged for nondestructive evaluation (NDE) planet bearing. The dif- testing and condition monitoring. A 7 ferent conditions were mm diameter, 0.2 mm thick sensor was achieved by swapping selected for comparison. The s9225 sen- a planet gear between sor is a miniature (3.6 mm x 2.4 mm) AE each test. Each of these sensor from Physical Acoustics weighing three conditions was less than 1 gram, with an operating range tested at a range of from 300 kHz upwards. The Physical loads. Acoustics PICO sensor is a miniature (5 The damage geome- Figure 7. MGB installed on the test bench.

24 • October-December 2015 ISASI Forum Figure 8. Power spectrum for enveloped random signal for minor damage. using water jets for accuracy. The station- of the resonance at 13.56 MHz. varied enormously with frequency; typical ary (upper) coil was suspended from two Once installed in the gearbox, it was Fourier amplitudes at 10 kHz are four clamping rings that were attached to possible to temporarily attach a signal orders of magnitude larger than those at the top case of the gearbox with a spacer generator to the sensor boards. The 1 MHz. It is unusual to be able to make through the holes to retain location. The time delay of the system was measured these comparisons since many AE sen- moving (lower) coil was attached to a by comparing the input signal with the sors are only useful in a limited frequency circular mounting ring, which in turn was output signal of the system transmit- range. However, the broadband sensitivity mounted on top of the oil caps on the ted through the coils. From 100 kHz to 1 of the PWAS sensor also presents chal- planet carrier (see Figure 5, page 23). MHz, there was very little delay variation lenges since the large energy levels at low Figure 6 shows the two coils in position with frequency. The system behaved as a frequency present within the gearbox can before the top cover was pressed onto the length of cable, providing about 1 µs delay affect the sensor. planet carrier. at all frequencies. This means that in this Figure 8 shows the enveloped random Electrical isolation of the coils from range it is linear phase and nondispersive, signal for the case of minor damage at the mounts and surrounding metallic i.e., there is no variation in wave speed 110% maximum takeoff power. The outer structure was achieved through the use with frequency. Below 100 kHz, there is race defect frequencies and harmonics of nylon washers and bushes. The main significant dispersion. But since most are clearly visible, whereas the undam- electrical difference between the lab- “low frequency” analysis techniques aged case contained no such harmonics. scale coils and the full-scale coils is their ignore phase, this is not a significant It can be concluded from this that the proximity to metal and, in particular, limitation. sensor is providing useful information the mounting ring that forms a “shorted To replicate a typical HUMS setup, ac- across the wireless link at a wide range turn.” The proximity causes a drastic celerometers were attached to the case of frequencies, opening the potential for reduction in inductance, which then re- of the gearbox, including on the ring gear, improved detection. quires an increase in loading capacitance using a mixture of bonded and bolted to maintain tune at 13.56 MHz. attachments. Conclusion In addition to the reduction in induct- This research program has resulted in ance comes a large reduction in the Q Preliminary results successful proof of concept of broadband factor of the coupled circuit. Fortunately, The rig was run at power settings ranging wireless transmission, including power the electrical power transfer requirement from 80% of maximum continuous power scavenging, coupled with small-scale in the gearbox was significantly reduced (936 kW) to 110% of maximum takeoff broadband sensors, working successfully compared to the prototype, as the spacing power (1760 kW) for 20 minutes at each in an operational environment. This result between the coils was relatively close. setting. During testing, the maximum oil presents a new range of potential fault This meant that even with reduced Q, temperature was 97.6 °C. diagnosis opportunities for the future of there was enough power transferred to The low-frequency portion of the signal HUMS. Future publications will release run the opamp buffer circuit. One advan- from the internal sensor (of the order of further results from the testing. tage of reduced Q factor is that dispersion kilohertz) contains clear peaks at typical Acknowledgements: The work described in this is reduced in the baseband signal. This is gear mesh frequencies, showing that a paper was conducted as part of EASA.2012.OP.13 because the steepness of the phase/fre- meaningful signal is being transferred VHM. The support of Airbus Helicopters in the quency response is reduced in the vicinity from the sensor. Signal energy levels full-scale testing is gratefully acknowledged.

October-December 2015 ISASI Forum • 25 The author offers a method to better Change Point Analysis understand the behavior of safety- Applied to SMS related items, using a By Paulo Manoel Razaboni, Embraer Air Safety Department statistical approach to support strategic (Adapted with permission from the author’s technical paper entitled Change Point Analysis Applied to SMS presented at ISASI 2014 held in Adelaide, Australia, Oct. 13–16, 2014, which carried the decisions like resources theme “Investigations and Safety Management Systems.” The full presentation, including cited refer- ences to support the points made, can be found on the ISASI website at www.isasi.org under the tag assignment or product “ISASI 2014 Technical Papers.”—Editor) change requests.

ealing with on-site accident of control or to the positive effect of an Paulo Razaboni has a investigation will always be a applied countermeasure. In the first case, degree in electronic engi- significant part of every safety an alert can be issued. In the second case, neering, with a specializa- system. Nevertheless, as aircraft the effectiveness of the actions can be tion degree in air safety, D production management, systems become even more precise and better understood and measured, and a and administration. reliable, thus pushing safety performance very accurate index can be assigned to a He is a certified mem- indexes to higher standards, the need for safety performance key indicator. ber of the Aeronautical ways to improve event precursor’s detec- Embraer, as do other aircraft manu- Accidents Prevention and tion becomes paramount in order to keep facturers, gathers information about Investigation System (SIPAER–Brazil). After absolute numbers within an acceptable events related to air safety from opera- joining Embraer in 2007 in the technical support limit despite the ever-increasing volume tors’ reports and other sources, such as area, he moved to the Air Safety Department in of flight operations. government authorities and specialized 2010, where he is the Safety Programs manager. Since no one could wait for an accident companies. These reports are grouped by His team is responsible for analyzing flight data either on a regular basis or providing support to occur to start fighting its contributors, their nature—for example, ATA chapter to investigations. Other roles include generating a proven way to cut these rates is to work or FAA nature of condition codes. safety-related statistics for the fleet and helping in the “base of the pyramid,” exploring Monthly, or as per some special in the development of specifications for future incidents, reports, or even routine opera- requirement, the information is summa- aircraft data recorders. SMS implementation tions in search for the so-called “lower- rized and sent to a distribution list, which and safety officers’ support are also part of the consequence indicators.” includes mainly people from customer team’s role. The present challenge is how to share support, systems engineering, and an air the always limited efforts among all safety team responsible for “safety health” probable issues and, especially inside the monitoring. These summaries include, safety management system (SMS), how besides the data grouped in Pareto and to generate reliable safety performance indexes related to the “never happened” events. While the experience gathered in the field is very relevant to the preven- tion job, monitoring selectively identified items is essential to ensure adequate risk mitigation, which in turn collaborates in achieving an acceptable level of overall safety performance. In this adapted article, an objective tool to monitor selected events rates will be shown, using statistical ways to positively identify changes in their behavior, spe- cially focused on “low occurrence” events. Detected changes may be assigned to the Figure 1. Typical data input, as a rate against time (in months). Vertical axis data were negative effect of some factor getting out intentionally hidden.

26 • October-December 2015 ISASI Forum chosen as outlined by Tim Stapenhurst in Mastering Statistical Process Control—A Handbook for Performance Improvement Using Cases, using symbols and colors to make it friendly enough for all users. Average and deviation lines are drawn for each data segment, thus evidencing the changes detected, as well as short- and long-term trend lines. A distribution profile helps support the process chart analysis. Seasonality can be assessed by calculating the monthly stratified average for the last Figure 2. Cumulative sum of differences to the average for the data set. three years, then interpolating a sinusoidal curve that would better fit to data. pie charts, the history and a statistical trend analysis, developed Methodology specially for these kinds of data. This analysis eliminates the For the change points detection, an algorithm “cumulative sum subjective interpretation of data, supporting resource alloca- of differences” to the average, outlined in John S. Oakland’s Sta- tion for crucial tasks, as well as confirming the effectiveness of tistical Process Control, was used. Then for a particular data set, some corrective action taken, thus closing the loop for a change one could get a typical history chart as shown in Figure 1. initiative. Although seemingly simple, determining a change point from The techniques were chosen among several sources as per the above data can be very challenging. Several trend analyses the specific data nature as a way to gather the information that may be tried—for instance, some points sequentially above or would better fit the decision process. The main tool is a “change below the average. Although all techniques could be implement- point analysis” approach, as described by Wayne A. Taylor in ed by software, some of them would result in different outcomes, “Change-Point Analysis: A Powerful New Tool for Detecting and a numeric value for the change itself would be hard to get. Changes.” This analysis allows estimating the precise point Calculating the cumulative sum would produce the output where the “process” represented by the input data changed its shown in Figure 2. behavior, thus calculating representative figures for the average The chart (see Figure 2) begins with the difference between and deviations for each segment (before and after the change the first reading and the average and necessarily ends at zero itself). because by definition the sum of all differences to the average is Each confirmed change point found brings up another ques- zero. The x-coordinate where the value is the farthest from the tion: Could there be another “minor” change point that would average (last “Mar” month) defines a change point candidate. become relevant after isolating the primary one? So each seg- Conceptually, from this point on, readings shall contribute in an ment can be recursively checked for the presence of a secondary opposite way to the average. point that fulfills the same requirements. During the analysis It then becomes necessary to check whether the original validation, it was assumed that only the change points with readings present a distribution pattern of enough significance, at least a 95% confidence level would be considered, with the not just a mere sequence of random values that might produce method for calculating this index to be explained also. a peak somewhere. The most straightforward way to do so is to To summarize this information, a process-like chart was force this situation, shuffling the data and determining if some

Figure 3. Cumulative sum of differences to the average, shown here for the original data set (the thicker line with markers) and for 20 other calculations. Amplitude of each curve should be compared to the original one for confidence level determination.

October-December 2015 ISASI Forum • 27 (before/after it), as represented in Figure 4. Then the same proceeding is applied to each segment, recursively. Assuming that data revealed a be- havior change, a similar analysis can twice be run—as now two distinct data segments exist, one before and, another after the change point. Applying the same technique recursively will reveal other change points, if any, up to a practical limit, which may be one of the two following cases: no more candidates Figure 4. Initial data set, now showing two different averages, as identified by the change point detection algorithm. could be found with at least 95% confi- dence or there are not enough points left random distribution would be able to generate comparable in the segment to drive a significant analysis. From the knowl- results (in this case, a higher amplitude in the cumulative sum edge about change points for the parameter under study, one curve). As per Taylor’s “Change-Point Analysis: A Powerful New can better decide about resources allocation as well as check the Tool for Detecting Changes,” proceeding this way a thousand effectiveness of some action taken. times would be fair enough to classify the candidate as a change This technique, according to Taylor, is resilient enough against point or not. For example, if data are randomly shuffled and spurious readings. To help evidence the behavior, a process the cumulative sum curve amplitude is calculated 1,000 times, chart called “u-chart” allows variable opportunity for the events and for 950 times the amplitudes remain below the original to happen (as flight hours usually vary from month to month). one, the candidate can be considered a change point with 95% The deviation “s” as devised by Stapenhurst in Mastering Sta- confidence. In an analog way, if no other distribution was able to tistical Process Control—A Handbook for Performance Improve- produce higher amplitudes, the candidate would be considered ment Using Cases can be calculated as below: a change point with 100% confidence. In this example, a change is the average for the data segment (as point could positively be assigned to the process, as shown in identified from the change point analysis); Figure 3 (see page 27). “n” are the flight hours for that specific As the candidate was positively classified as a change point, month. As “n” may vary, 2-s and 3-s limit an average calculation is performed for both data segments curves are not purely horizontal, but they show amplitude

Figure 5. Proposed chart containing all elements with a brief description for each one. Styles were chosen to be intuitive, using standard representation when practical.

28 • October-December 2015 ISASI Forum a measure for the seasonality fitness and de- pendence for each parameter. This would help someone take countermeasures in advance, as a bonus. Putting all information together may seem challenging so the correct choice for colors and symbols is evident. As it is usually not required for all the recipients to deal with such level of details, a brief comment in plain text from the analyst for each plot would be ap- preciated. The curves will remain an analysis Figure 6. Real data plotting, along with a short-term trend line based on the rolling average for tool for the specialists and a source for deeper the last three readings. Although some visual clues may suggest trends, the subjectivity must be information, if required (see Figure 5). taken away in order to get an accurate analysis. The main advantage is that calculations are made automatically and the analyst expertise variation that is inversely proportional to the hours flown dur- is focused on data interpretation supported by statistical tools, ing each month. These two limits are usually called “warning assertively documenting the process already done and gener- threshold” (2-s) and “action threshold” (3-s) for processes under control. ating targets for the next improvement cycle. Actions can be In order to provide a consistent view over the “process chart” requested inside the company or from suppliers in an unam- (as it is valid only for “normal-like” distributions), it is neces- biguous way. In the case of SMS implementation, performance sary to know the readings’ frequency distribution, which may indexes can be tracked to achieve established levels. be done by plotting a histogram, in this case drawn 90 degrees While the results for the manufacturer are clear and the rotated and placed aside the control graph using the same verti- documentation would be concise enough to attend to SMS cal scaling, a very common practice for simultaneous viewing, requirements, the final client would also have benefits, as safety as outlined by Stapenhurst. as a whole would be closely monitored and improved. The same In order to evidence seasonality, a sinusoidal interpolation technique may also be applied for monitoring items not directly with a fixed 1-year period can be plotted over monthly-stratified related to safety­—such as the ones related to maintenance, average readings. This means that three Januarys, three Febru- which can give expressive payback, like engines, landing gears, arys, and so on are averaged representing one typical month as avionics subsystems, etc. a way to get rid of long-term trends. A correlation coefficient All processing can be implemented by software using dedicat- is calculated as well as the sinusoidal interpolation amplitude ed routines in a database system, or even an ordinary spread- referred to as the global average, which together will serve as sheet for proof-of-concept evaluation where macro routines can

Figure 7. Same data set plotted using change detection algorithm. One “level 1” change was detected in February 2013 (with 96% confidence). Short-term behavior has become more stable (less scattering), while long-term curve presents a downtrend. Distribution is not normal for the whole set, but the peak is under the average, probably due to the recent readings. No seasonality was evidenced, as correlation factor is very poor (R=0.10).

October-December 2015 ISASI Forum • 29 proach to support strategic decisions like resources assignment or product change requests. A spreadsheet with macro routines for fast data processing is avail- able from the author. It was created to fit specific data characteristics, which are a common sense for commercial aircraft operations, and has its own benefits and limitations. Although it is a belief that this is a valuable tool, the suitability for solving Figure 8. Again, real data plotting. How many changes would be assigned to this data set? specific tasks, related or not to safety, must be adequately evaluated by the be programmed (macros are necessary, suggest deviations or improvements, analyst. Statistical methods, if adequately mainly because of the intense and recur- while seasonality might be associated implemented, will provide reliable sive calculation, but will take only a few with climate changes. The decision for as- indicators that can be used to keep seconds to run). signing engineering resources or sending processes under control and, of course, to communications (service bulletins, news- document the relevant actions taken in Examples letters, etc.) to the operators would be any quality system, including SMS. As it is impossible to control something facilitated and supported. This would also that is not known, looking at the behavior happen to the negotiations with suppliers Acknowledgements: This work is part of of selected monitored items over time can as a way for enforcing corrective actions, Embraer’s permanent commitment to the give a rough idea about whether an inter- product safety at all levels, from concept writing dispositions, or even evaluating vention is necessary, as well as whether to operation. I wish to acknowledge the contract clauses. some action was successful (see Figures 6 opportunity provided by ISASI for sharing this information, believing this can offer and 7 on page 29 and Figures 8 and 9). Conclusion a means to help improve aviation safety People with knowledge of the subsys- levels worldwide. My special thanks are tem would be able to illustrate this analy- This adapted article offers a method extended to the staff of Embraer for the sis with elements from product history. to better understand the behavior of valuable feedback on the reports that my As an example, average changes might safety-related items using a statistical ap- team has provided.

Figure 9. Using the above data set, the algorithm reveals three changes, the latest one in July 2013 (96% confidence), earlier ones in October 2011 and in July 2012. Short-term behavior is stable, and long-term presents a downtrend. Distribution is not normal, considering the whole set. Some level of season- ality may be assigned as the sinusoidal curve roughly fits the data; the worst month identified as August (42% above the average).

30 • October-December 2015 ISASI Forum Augsburg, Germany: ISASI 2015 ‘Independence Does Not Mean Isolation’

(Continued from page 10) ence committee members, fundraisers, presentation of the Jerome F. Lederer In accepting the Lederer plaque, Ladi transportation providers, behind-the- Award to Ladislav (Ladi) Mika, senior said, “It is a great honor for me to be here scene workers, and hotel management officer of the Air Operation Technology today with you and hold the prestigious and staff. He gave special attention to and Development Division of the Czech award bearing the name of Jerome Fox the 13 cohost corporate sponsors, the Ministry of Transport and the ISASI Air Lederer in my hands.” companies that exhibited product booths, Traffic Service Working Group co-chair. He went on to share his quest to affirm and the companies that contributed Ladi had earlier been introduced during the birthplace of Jerry’s father in the Czech door prizes. The highlight of the evening the opening plenary session, but this was Republic, then known as Czechoslovakia. would be the presentation of the Jerome the first opportunity for his peers to give He also shared parts of the 44 years he has F. Lederer Award. him full recognition, which they did with experienced in the aviation safety field. In He then began the presentation of a standing ovation. closing he said, “I thank all my colleagues plaques and certificates. New corporate Del Gandio spoke of Ladi’s accomplish- and friends who have supported me in the member representatives came on stage ments and contributions to air safety effort to increase the level of international and accepted a specially designed plaque: and ISASI, concluding by noting that aviation safety. A deep appreciation goes to Luis Garcia with Airbus Defence & Space “ISASI is indeed blessed to have such an my parents who gave me the opportunity outstanding individual in its ranks. His and Alister Buckingham with Massey to study the wonderful field of aviation, contribution to global aviation safety is University. New corporate members not and at last but not least my thanks goes to outstanding, and there is no doubt that represented included Human Factors my family for their understanding and sup- the contributions made by Ladi have im- Training Solutions Pty Ltd, Executive proved aviation safety through accident/ port throughout the years. I am grateful to Development & Management Advisory, incident investigation and prevention in those who nominated me as a candidate and ATR Airlines. Central/Eastern Europe. His native Czech for this very prestigious international The surprise recognition of the even- Republic has an excellent aviation safety aviation award. I highly appreciate being ing was the announcement of the Best of record—no fatal accidents with trans- the first one from the countries of Central Seminar Award of Excellence for techni- port-category aircraft for more than 39 and Eastern Europe to be awarded ISASI’s cal papers presented at ISASI 2015. The years. Ladislav Mika is uniquely qualified Jerome F. Lederer Award.” selected paper, Divorcing the Regulator: to receive the honor of being named the With the room stilled, Conradi made the The Establishment of an Independent Jerry Lederer Award recipient for 2015. traditional passing of the “cow bell” to Investigative Authority, was authored by We are very proud to have such a widely Thorkell Agustsson, chair of ISASI 2016 to Capt. Ibrahim S. Koshy, director general recognized aviation safety expert among be held in Reykjavik, Iceland. The passing of the Aviation Investigation Bureau of our membership. He is a most deserv- of the bell signaled the close of the the Kingdom of Saudi Arabia. In its tenth ing recipient of the ISASI Jerry Lederer banquet. The crowd then milled about year of existence, the Award of Excel- Award.” (See page 11.) saying their farewells until 2016. lence carries with it a $500 stipend, which Koshy contributed to the ISASI Kapustin Memorial Scholarship Fund. The best paper selection was made by members of the conference Technical Committee (see page 14). The next group to be recognized was the inductees into the society’s Fellow membership class. Graham Braithwaite and Alan T. Weaver, two long-term ISASI members, were pinned on stage by Presi- dent Del Gandio. Then Del Gandio introduced the indi- viduals he calls “ISASI’s future.” The four ISASI Rudolph Kapustin Memorial Schol- arship recipients came on stage one by one, as their names were called. Receiving certificates of scholarship were Nicolaus Dmoch, ERAU-Berlin; Kiki Faber, Delft University of Technology; Amy LaRue, University of Southern California; and Mario Pierobon, Cranfield University, UK. Closing the awards ceremony was the Thorkell Augstsson accepts from Keith Conradi the “cow bell,” which will open ISASI 2016. October-December 2015 ISASI Forum • 31 ISASI 107 E. Holly Ave., Suite 11 Sterling, VA 20164-5405 USA CHANGE SERVICE REQUESTED

INCORPORATED AUGUST 31, 1964

WHO’S WHO

Flight Data Systems: A Multi-Avionics range located in Victoria, Australia. The Product and Service Provider UAV range has a CASA-designated perma- nent danger zone of 316 kilometers². (Who’s Who is a brief profile prepared by the represented ISASI corporate member organization to FDS offers defense and aerospace provide a more thorough understanding of the organization’s role and function.—Editor) customers the ability to design, qualify, and light Data Systems (FDS) is an avion- laboratories; airlines; maintenance, repair, manufacture rugged and complex electron- ics product manufacturer and service and operations facilities (MROs); flight ics-based systems in one facility. Further Fprovider with facilities located in recorder original equipment manufacturers strategic expansions include establishment Melbourne, Australia; London, United (OEMs); and defense organizations. of our environmental testing laboratory Kingdom; and Sarasota, Florida, USA. FDS recently expanded its military to qualify products to military and civilian FDS’s core business centers on all areas of unmanned aerial systems (UAS) business standards. flight recorder systems, including product to the civil market. We offer online remotely The FDS environmental testing labora- manufacture such as flight data acquisition piloted aircraft systems (RPAS) theory train- tory includes units and quick access recorders currently ing as a registered training organization • impulse shock and vibration systems operating on military and civil aircraft. Our with practical flight training at the FDS (up to a 500 kilogram payload). flight recorder ground support equipment, dedicated flight range and UAS subsystem • three-meter-diameter centrifuge for such as the popular handheld multipur- design as well as manufacturing. In col- sustained shock testing up to 50 g’s. pose interface unit and return to service laboration with universities, FDS conducts • temperature and humidity controlled automatic test equipment products, have development of UAS-related products to environmental chambers. become the industry standard for many aviation standards and leverages our avion- • altitude chamber and rapid decompres- major airlines, maintenance organizations, ics design, manufacturing, and qualifica- sion testing. aircraft manufacturers, and investigation tion facilities to meet the more demanding • highly accelerated life testing and stress authorities. aviation standards currently not required screening for products (HALT & HASS). FDS’s flight data services include flight in the UAS industry. A recent development • lightning test facility. data monitoring and analysis for airline project working with an Australian uni- Our Melbourne-based electronics and corporate aircraft operators through versity through a government-sponsored In- manufacturing facility uses advanced a web-based FDM service. In addition, novative Manufacturing CRC grant includes automated electronics assembly and FDS performs in excess of 1,500 manda- development of a UAS-specific crash flight production equipment with quality-control tory flight data recorder (FDR) and cockpit recorder system that meets current Euro- processes targeted to niche defense and voice recorder (CVR) readouts through our pean and FAA standards. aerospace products. Major customers three locations using our FDR and CVR FDS operates a fleet of Elbit Skylark un- include aircraft manufacturers, interna- replay software product sensor test and manned aerial vehicles (UAV) along with its tional military electronics systems manu- replay system (STARS). Our products are own multi-rotor units and conducts flight facturers, mining industry suppliers, and a used worldwide by many leading aviation testing and training at our Civil Aviation number of diverse industry component organizations, such as crash investigation Safety Authority (CASA) approved flight suppliers.

32 • October-December 2015 ISASI Forum