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NTSB Chair Deborah Hersman Accepts ISASI Honorary Membership CONTENTS JULY–SEPTEMBER 2011 NTSB Chair Deborah Hersman Accepts ISASI Honorary Membership CONTENTS Volume 44, Number 3 Publisher Frank Del Gandio FEATURES Editorial Advisor Richard B. Stone Editor Esperison Martinez Design Editor William A. Ford 5 Using Commercial Satellite Imagery in Associate Editor Susan Fager Aircraft Accident Investigation Annual Report Editor Paul Mayes By Dr. Matthew Greaves (AO7700) and Professor Graham Braithwaite (MO3644), ISASI Forum (ISSN 1088-8128) is published Cranfield Safety and Accident Investigation Centre, Cranfield University, UK—The quarterly by International Society of Air authors evaluate the current state of the art focusing on the needs and priorities of Safety Investigators. Opinions expressed by authors do not necessarily represent official an accident investigation and reporting on live trials conducted in Cyprus in 2009. ISASI position or policy. Editorial Offices: Park Center, 107 East 10 Safety Reporting and Investigation— Holly Avenue, Suite 11, Sterling, VA 20164-5405. Telephone (703) 430-9668. Cornerstone of SMS Fax (703) 430-4970. E-mail address isasi@ By Paul E. Mayes, Vice President, ISASI—Although the 1979 DC-10 crash on the erols.com; for editor, espmart@comcast. slopes of Mount Erebus occurred long before the concept of an integrated safety net. Internet website: www.isasi.org. ISASI Forum is not responsible for unso- management system, there were elements of SMS already in place. licited manuscripts, photographs, or other materials. Unsolicited materials will be 14 Accident Trends in Asia: returned only if submitted with a self-ad- dressed, stamped envelope. ISASI Forum Major Improvements and Remaining Challenges reserves the right to reject, delete, sum- By Robert Matthews, Ph.D., Senior Safety Analyst, Federal Aviation Administra- marize, or edit for space considerations any submitted article. To facilitate editorial tion, USA—The author uses accident data, exposure data, and other standard avia- production processes, American-English tion measures to document where and to what degree positive change has or has not spelling of words will be used. occurred in Asia and comments on remaining challenges. Copyright © 2011—International Society of Air Safety Investigators, all rights reserved. Publication in any form prohibited without 19 No More Cheese Please: permission. ISASI Forum registered U.S. Accident Modeling from Symptom to System Patent and T.M. Office. Opinions expressed by authors do not necessarily represent of- By John Stoop, Delft University of Technology and Lund University, and Sidney ficial ISASI position or policy. Permission to Dekker, Key Centre for Ethics, Law, Justice, and Governance at Griffith University reprint is available upon application to the —The authors present a framework for safety enhancement based on a new view on editorial offices. human error, a dynamic systems engineering design approach, analytical foren- Publisher’s Editorial Profile: ISASI Forum is printed in the United States sic abilities, and institutional conditions for independent and qualified accident and published for professional air safety investigations. investigators who are members of the In- ternational Society of Air Safety Investiga- tors. Editorial content emphasizes accident investigation findings, investigative tech- DEPARTMENTS niques and experiences, regulatory issues, industry accident prevention developments, 3 President’s View and ISASI and member involvement and 4 V.P.’s Corner information. 26 ISASI RoundUp Subscriptions: Subscription to members 32 Who’s Who—A brief corporate member is provided as a portion of dues. Rate for nonmembers (Domestic and Canada )is profile of Curt Lewis & Associates, LLC US$28; Rate for nonmember international is US$30. Rate for all libraries and schools is US$24. For subscription information, call (703) 430-9668. Additional or replace- ment ISASI Forum issues: Domestic and Canada US$4; international member US$4; domestic and Canada nonmember US$6; and international nonmember US$8. ABOUT THE COVER National Transportation Safety Board Chairman Deborah A.P. Hersman accepts honorary membership in the International Society of Air Safety Investigators from ISASI President Frank Del Gandio. Shown is the certificate plaque presented to Chairman Hersman. Photo: Esperison Martinez, ISASI Forum Editor 2 • ISASI Forum July–September 2011 PRESIDENT’S VIEW NTSB Chair Hersman Accepts ISASI Honorary Membership By Frank Del Gandio, ISASI President On April 14, I was privileged to present and the agency to meet that challenge, which benefits investigators have U.S. National Transportation Safety everywhere. Board Chairman Deborah A.P. Hersman ac- We have seen an elevation of the agency’s transparency by a cept an honorary membership in our Society. more prompt release of factual investigation information to the This is only the eighth honorary membership public both through the news media and through the opening awarded in 47 years. It is our first since 2001, of agency dockets to the public via the NTSB website. Board when Congressman James L. Oberstar was meetings and hearings are now not only open to the public, but presented the award. are also webcast, so anyone can listen and watch. In terms of The significance of this award to our society is embedded in accountability, the NTSB has become stronger, more efficient, ISASI’s creation in 1964 as envisioned by Joseph O. Fluett and and more Truman (Lucky) Finch, Society forefathers. Our first set of nimble in both by-laws established that “It is the policy of the Society of Air its domestic Safety Investigators to offer honorary memberships to those and interna- persons recommended…who have made outstanding contribu- tional roles. tions to air safety.” And while the Our presentation was made in the chairman’s 6th floor office “cooperation of NTSB headquarters in Washington, D.C., which offers a challenge” has view of Ronald Reagan Washington National Airport’s expan- brought closer sive airspace, which is continuously filled with airliners coming coordination and going. It is against this backdrop of our aviation world and support that I took great pleasure in awarding the title of honorary between the member in the International Society of Air Safety Investiga- agency and tors. Hersman is truly one of us, as demonstrated by her tena- accident cious and ever-persistent approach to safety. investigations Many persons may not recall that for five years prior to authorities accepting the chairmanship of the NTSB on July 28, 2009, she from other served as a member of the NTSB. In that time, she oversaw countries, 17 major transportation accident investigations. These events Z it has also covered all modes of transportation: airliners, emergency artine enhanced ex- medical service and sightseeing helicopters, business jets, pri- E. M isting systems vate aircraft, light rail trains, freight trains, container ships, President Del Gandio presents Chairman of keeping recreational boats, school buses, and motor coaches. Since Hersman her certificate of honorary membership. families of ac- being sworn into office, she cident victims ISASI Honorary has become the public face informed and strengthened the agency’s “listening” role. Members of the agency’s investigators Chairman Hersman’s contributions to aviation safety and and investigations. her support of ISASI have been phenomenal. Her ability to HO0001—Alan S. Boyd In addressing our Soci- deal with a myriad of issues and tragedies, coupled with her June 1, 1965 (deceased) HO0002—Najeed E. Halaby ety’s annual seminar in 2009, tenacious approach to safety, identifies her as a true represen- June 1, 1965 (deceased) just seven weeks after being tative of the traveling public. She more than fulfills the lasting HO0003—Charles S. Murphy sworn into office, Hersman code etched on her certificate of membership, which reads: April 1968 (deceased) HO0004—Mike A.S. Monroney spoke of her self-imposed “Deborah A.P. Hersman is an honorary member of ISASI, May 14, 1968 (deceased) challenge to raise the bar of which is dedicated to promote that part of the aeronautical HO0005—Walter Tye three attributes she believed endeavor wherein lies the moral obligation of the air safety Jan. 1, 1969 (deceased) HO0006—Joseph J. O’Connell, Jr. were critical to the NTSB’s investigator to the public.” 1969 (deceased) mission and work: transpar- In presenting the certificate, I said: “You are the most ‘safety HO0007—James L. Oberstar ency, accountability, and motivated’ person I’ve seen in my 30-years of accident investi- April 27, 2001 HO0008—Deborah A.P. Hersman cooperation. It is a mark gation. Your approach to safety mirrors the aims of our Society; April 14, 2011 of her fidelity that she has therefore, I am proud to make you an honorary member of the been successful in leading International Society of Air Safety Investigators.” ◆ July–September 2011 ISASI Forum • 3 V.P. ’S CORNER Reporting on My Washington Visit to the International Council By Paul Mayes, ISASI Vice President The main activity since the previous issue of The Council decided not to make changes at this time. ISASI Forum was my travel to Washington In an effort to retain members, one suggestion was to for the spring ISASI International Council reduce the dues for members who had reached retirement Meeting (ICM) on May 6. I also took the age and were no longer employed. For retired members, a opportunity to visit ISASI’s office in Sterling, 50% reduction in annual dues could be considered. There Va., and spend time with Ann Schull, our was mixed reaction to the proposal, including concern that office manager, and Tom McCarthy, ISASI’s there may be practical difficulties in deciding when a member treasurer. I encourage members to call on Ann in the office if has actually retired. I raised some ideas to reduce our costs, you are in the Sterling area. The office is the center of ISASI which included electronically distributing ISASI Forum operations, and I am sure Ann would be very pleased to meet and reducing the Proceedings to an electronic copy.
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