VOLUME 14 Publisher ISASI (Frank Del Gandio, President) Editorial Advisor Air Safety Through Investigation Richard B. Stone Editorial Staff Susan Fager Esperison Martinez Design William A. Ford Proceedings of the ISASI Proceedings (ISSN 1562-8914) is published annually by the International Society of Air Safety Investigators. Opinions 41st Annual ISASI 2010 PROCEEDINGS expressed by authors are not necessarily endorsed or represent official ISASI posi- tion or policy. International Seminar Editorial Offices: 107 E. Holly Ave., Suite 11, Sterling, VA 20164-5405 USA. Telephone: (703) 430-9668. Fax: (703) 450-1745. E-mail address:
[email protected]. Inter net website: http://www.isasi.org. ‘Investigating ASIA in Notice: The Proceedings of the ISASI 41th annual international seminar held in Sap- Mind–Accurate, Speedy, poro, Japan, features presentations on safety issues of interest to the aviation com- munity. The papers are presented herein Independent, and in the original editorial content supplied by the authors. Authentic’ Copyright © 2011—International Society of Air Safe ty Investigators, all rights reserved. Publication in any form is prohibited with- Sept. 7–9, 2010 out permission. Permission to reprint is available upon application to the editorial Sapporo, Japan offices. Publisher’s Editorial Profile: ISASI Proceed- ings is printed in the United States and pub- lished for professional air safety investiga- tors who are members of the International Society of Air Safety Investigators. Content emphasizes accident investigation findings, investigative techniques and experiences, and industry accident-prevention develop- ments in concert with the seminar theme “Investigating ASIA in Mind—Accurate, Speedy, Independent, and Authentic.” Subscriptions: Active members in good standing and corporate members may ac- quire, on a no-fee basis, a copy of these Pro- ceedings by downloading the material from the appropriate section of the ISASI website at www.isasi.org.