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Proceedings of the 41St Annual International Seminar 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. Further, active and corpo- rate members may purchase the Proceedings on a CD-ROM for the nominal fee of $15, which covers postage and handling. Non- ISASI members may acquire the CD-ROM for a $75 fee. A limited number of paper copies of Proceedings 2010 are available at a cost of $150. Checks should accompany the request and be made payable to ISASI. Mail to ISASI, 107 E. Holly Ave., Suite 11, Sterling, VA 20164-5405 USA ISSN 1562-8914 ISASI 2010 Proceedings • 1 ISASI Information Flight Safety Foundation—Taiwan OFFICERS CORPORATE MEMBERS Galaxy Scientific Corporation President, Frank Del Gandio ([email protected]) AAIU Ministry of Transport Bulgaria General Aviation Manufacturers Association Executive Advisor, Richard Stone ([email protected]) Accident Investigation Board, Finland GE Transportation/Aircraft Engines Vice-President, Paul Myers ([email protected]) Accident Investigation Board/Norway Global Aerospace, Inc. Secretary, Chris Baum ([email protected]) Accident Investigation & Prevention Bureau Gulf Flight Safety Committee, Azaiba, Oman Treasurer, Tom McCarthy ([email protected]) Administration des Enquêtes Techniques (Luxembourg) Hall & Associates, LLC Aeronautical & Maritime Research Laboratory Hellenic Air Accident Investigation AeroVeritas Aviation Safety Consulting, Ltd. & Aviation Safety Board COUNCILLORS Aerovias De Mexico, S.A.De C.V. Honeywell Australian, Lindsay Naylor ([email protected]) Air Accident Investigation Bureau of Singapore Hong Kong Airline Pilots Association Canadian, Barbara Dunn ([email protected]) Air Accident Investigation Unit—Ireland Hong Kong Civil Aviation Department European, Anne Evans ([email protected]) Air Accidents Investigation Branch—U.K. IFALPA ISASI 2010 PROCEEDINGS International, Caj Frostell ([email protected]) Air Astana (Kazakhstan) Independent Pilots Association New Zealand, Peter Williams ([email protected]) Air Canada Pilots Association Int’l Assoc. of Mach. & Aerospace Workers United States, Toby Carroll ([email protected]) Air Line Pilots Association Interstate Aviation Committee Air New Zealand, Ltd. Irish Air Corps NATIONAL AND REGIONAL Airbus S.A.S. Irish Aviation Authority Airclaims Limited Japan Airlines Domestic Co., LTD SOCIETY PRESIDENTS Aircraft Accident Investigation Bureau—Switzerland Japanese Aviation Insurance Pool Australian, Lindsay Naylor ([email protected]) Aircraft Mechanics Fraternal Association Japan Transport Safety Board Canadian, Barbara M. Dunn ([email protected]) Airservices Australia Jeppesen European, David King ([email protected]) AirTran Airways JetBlue Airways Latin American, Guillermo J. Palacia (Mexico) Airways New Zealand Jones Day New Zealand, Alan Moselen([email protected]) Alaska Airlines KLM Royal Dutch Airlines Russian, Vsvolod E. Overharov ([email protected]) Alitalia Airlines—Flight Safety Dept. Korea Air Force Safety Ctr. SESA-France Chapter,Vincent Fave Allianz Aviation Managers, LLC, USA Korea Aviation & Railway Accident Investigation Board ([email protected]) All Nippon Airways Company Limited Kreindler & Kreindler, LLP United States, Toby Carroll ([email protected]) Allied Pilots Association L-3 Communications Aviation Recorders American Eagle Airlines Learjet, Inc. NITED TATES EGIONAL American Underwater Search & Survey, Ltd. Lockheed Martin Corporation U S R AmSafe Aviation Lufthansa German Airlines CHAPTER PRESIDENTS Aramco Associated Company MyTravel Airways Alaska, Craig Bledsoe ASPA de Mexico National Aerospace Laboratory, NLR ([email protected]) Association of Professional Flight Attendants National Air Traffic Controllers Assn. Arizona, Bill Waldock ([email protected]) Atlantic Southeast Airlines—Delta Connection National Business Aviation Association Dallas-Ft. Worth, Tim Logan ([email protected]) Australian and International Pilots Association (AIPA), National Transportation Safety Board Great Lakes, Matthew Kenner ([email protected]) Australia Australian Transport Safety Bureau NAV Canada Los Angeles, Inactive Aviation Safety Council Nigerian Ministry of Aviation and Accident Mid-Atlantic, Ron Schleede ([email protected]) Aviation Safety Investigations, UK Investigation Bureau Avions de Transp ort Regional (ATR) Northwest Airlines Northeast, Inactive AVISURE, Australia Kevin Darcy ([email protected]) Nova Aerospace, Australia Parker Aerospace Pacific Northwest, BEA-Bureau D’Enquetes et D’Analyses Phoenix International, Inc. Rocky Mountain, David Harper Board of Accident Investigation—Sweden Pratt & Whitney ([email protected]) Boeing Commercial Airplanes Qantas Airways Limited San Francisco, Peter Axelrod Bombardier Aerospace Qatar Airways ([email protected]) Bundesstelle fur Flugunfalluntersuchung—BFU Qwila Air (Pty), Ltd. Southeastern, Robert Rendzio ([email protected]) CAE-Flightscape, Inc. Raytheon Company Cathay Pacific Airways Limited Republic of Singapore Air Force COMMITTEE CHAIRMEN Cavok Group, Inc. Rolls-Royce, PLC Audit, Dr. Michael K. Hynes Centurion, Inc. Royal Netherlands Air Force ([email protected]) Charles Taylor Aviation, Singapore Royal New Zealand Air Force Award, Gale E. Braden ([email protected]) China Airlines RTI Group, LLC Ballot Certification, Tom McCarthy ([email protected]) Cirrus Design Sandia National Laboratories Board of Fellows, Ludi Benner ([email protected]) Civil Aviation Safety Authority Australia SAS Braathens Bylaws, Darren T. Gaines ([email protected]) Colegio De Pilotos Aviadores De Mexico, A.C. Saudi Arabian Airlines Code of Ethics, Jeff Edwards ([email protected]) Comair, Inc. SICOFAA/SPS Continental Airlines Sikorsky Aircraft Corporation Membership, Tom McCarthy ([email protected]) Continental Express g, Tom McCarthy ([email protected]) Skyservice Airlines, Ltd. Nominatin COPAC/Colegio Oficial de Pilotos de la Aviacion Comercial Singapore Airlines, Ltd. Reachout, John Guselli ([email protected]) Cranfield Safety & Accident Investigation Centre SNECMA Moteurs Seminar, Barbara Dunn ([email protected]) Curt Lewis & Associates, LLC South African Airways DCI/Branch AIRCO South African Civil Aviation Authority WORKING GROUP CHAIRMEN Defence Science and Technology Organization (DSTO) Southern California Safety Institute Air Traffic Services, Scott Dunham (Chair) Delta Air Lines, Inc. Southwest Airlines Company ([email protected]) Directorate of Aircraft Accident Investigations—Namibia Southwest Airlines Pilots’ Association Ladislav Mika (Co-Chair) ([email protected]) Directorate of Flight Safety (Canadian Forces) Spanish Airline Pilots’ Association Cabin Safety, Joann E. Matley ([email protected]) Directorate of Flying Safety—ADF Star Navigation Systems Group, Ltd. Corporate Affairs, Erin Carroll ([email protected]) Dombroff Gilmore Jaques & French P.C. State of Israel Flight Recorder, Michael R. Poole Dutch Airline Pilots Association Transport Canada ([email protected]) Dutch Transport Safety Board Transportation Safety Board of Canada General Aviation, Open EL AL Israel Airlines U.K. Civil Aviation Authority Government Air Safety, Marcus Costa Embraer-Empresa Brasileira de Aeronautica S.A. UND Aerospace ([email protected]) Embry-Riddle Aeronautical University University of NSW Aviation Emirates Airline University of Southern California Human Factors, Richard Stone ([email protected]) Era Aviation, Inc. Investigators Training & Education, Volvo Aero Corporation European Aviation Safety Agency WestJet ◆ Graham R. Braithwaite EVA Airways Corporation ([email protected]) Exponent, Inc. Unmanned Aerial
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