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