Air Safety Through Investigation OCTOBER-DECEMBER 2016 Journal of the International Society of Air Safety Investigators

“JERRY LEDERER WAS LIKE A FATHER TO TOBY, WHO HAS SPENT A LIFETIME WORKING SELFLESSLY TO ENHANCE AVIATION SAFETY AND HAS DONE SO WITH THE UTMOST PROFESSIONALISM AND INTEGRITY. THERE IS NO ONE MORE DESERVING OF THIS PRESTIGIOUS JERRY LEDERER AWARD THAN TOBY.” —ISASI PRESIDENT FRANK DEL GANDIO

ISASI 2016: Air Accident Investigators Examine Links to Safety Networks—page 5 Advancing Safety Through Multiple Means—page 11 ISASI Presents Eugene “Toby” Carroll Its 2016 Lederer Award—page 14 Another Way to Assess Turbofan Engine Operation During a Crash—page 16 Crash Scene Hazard Management: An Updated Approach—page 22 Five Receive ISASI Scholarships—page 24 CONTENTS Air Safety Through Investigation Journal of the International Society of Air Safety Investigators FEATURES Volume 49, Number 4 5 ISASI 2016: Air Accident Investigators Examine Links to Publisher Frank Del Gandio Safety Networks Editorial Advisor Richard B. Stone By J. Gary DiNunno, ISASI—Delegates to ISASI 2016 meet in Reykjavik, Iceland, on Editor Esperison Martinez October 18–20 for the Society’s annual international accident investigation and Design Editor Jesica Ferry prevention conference to listen to technical presentations and participate in Associate Editor Susan Fager discussions with the overall theme of “Every Link Is Important.” ISASI Forum (ISSN 1088-8128) is published quar- terly by the International Society of Air Safety 11 Advancing Safety Through Multiple Means Investigators. Opinions expressed by authors do By Kristi Dunks, Ph.D., Office of Aviation Safety, U.S. NTSB—After an aircraft ac- not necessarily represent official ISASI position cident occurs, safety issues are identified and safety recommendations are issued or policy. to prevent future similar events. As investigations evolve, so, too, must methods for addressing safety issues. Editorial Offices: Park Center, 107 East Holly Avenue, Suite 11, Sterling, VA 20164-5405. Tele- phone 703-430-9668. Fax 703-430-4970. E-mail 14 ISASI Presents Eugene “Toby” Carroll Its 2016 Lederer Award address, [email protected]; for editor, espmart@ By Esperison Martinez, Editor—The Society’s highest honor goes to one of its most comcast.net. Internet website: www.isasi.org. exceptional investigators ISASI Forum is not responsible for unsolicited manuscripts, photographs, or other materials. 16 Another Way to Assess Turbofan Engine Operation During a Crash Unsolicited materials will be returned only if By Douglas Zabawa (MO5843), Accident/Incident Investigator, Pratt & submitted with a self-addressed, stamped enve- Whitney—Understanding the damage to the engines involved in an aircraft acci- lope. ISASI Forum reserves the right to reject, dent can provide insight into their state of operation at the time of impact. Here, the delete, summarize, or edit for space con- author introduces an alternative to the classic assessment of compressor and turbine siderations any submitted article. To facilitate blade conditions. editorial production processes, American Eng- lish spelling of words is used. 22 Crash Scene Hazard Management: An Updated Approach Copyright © 2016—International Society of Air By Maj. Tyler Brooks, D. Av. Med., Medical Investigator, Canadian Armed Forces Safety Investigators, all rights reserved. Publica- Directorate of Flight Safety; and Capt. Claire Maxwell, Rotary-Wing Investiga- tion in any form is prohibited without permis- tor and Personal Protective Equipment Coordinator, Canadian Armed Forces sion. ISASI Forum registered U.S. Patent and Directorate of Flight Safety—The Canadian Armed Forces Directorate of Flight T.M. Office. Opinions expressed by authors do Safety has developed an updated approach to crash scene hazard management not necessarily represent official ISASI position and welcomes the opportunity to collaborate with other organizations to share or policy. Permission to reprint is available upon best practices and lessons learned. application to the editorial offices.

24 Five Receive ISASI Scholarships Publisher’s Editorial Profile: ISASI Forum is print- By Esperison Martinez, Editor—The ISASI Rudolf Kapustin Memorial Scholarship ed in the United States and published for profes- program has selected five students to receive its benefits. sional air safety investigators who are members of the International Society of Air Safety Inves- tigators. Editorial content emphasizes accident investigation findings, investigative techniques and experiences, regulatory issues, industry ac- DEPARTMENTS cident prevention developments, and ISASI and 2 Contents member involvement and information. 3 President’s View: Aviation Safety’s Remarkable Level Subscriptions: A subscription to members is pro- 4 Editor’s Message: -30- vided as a portion of dues. Rate for nonmem- 32 Who’s Who: The University of Balamand Institute of Aeronautics bers (domestic and Canada) is 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 ABOUT THE COVER replacement ISASI Forum issues: Domestic and Canada US$4; international member US$4; do- ISASI President Frank Del Gandio, left, presents the prestigious ISASI Jerome F. mestic and Canada nonmember US$6; interna- Lederer Award to Eugene “Toby” Carroll, the 2016 recipient (see page 14) before tional nonmember US$8. a banquet audience of more than 250 ISASI delegates and guests.

Photo: Esperison Martinez

INCORPORATED AUGUST 31, 1964

2 • October-December 2016 ISASI Forum PRESIDENT’S VIEW AVIATION SAFETY’S REMARKABLE LEVEL (ISASI President Del Gandio’s opening remarks to the delegates of ISASI 2016 on Oct. 18, 2016, at Reykjavik, Iceland, have been abbreviated.—Editor)

elcome to ISASI 2016 and to dents can understate the overall risk to in countries with marginal or no func- Iceland, a fabulous country to passengers, as nonfatal hull losses can tioning regulators. In addition, nonfatal visit. First, some basic geogra- easily lead to multiple fatalities. An exam- approach-and-landing accidents and Wphy: Iceland is an island about ple is the recent Emirates crash in Dubai high-speed runway excursions involved the size of Indiana, and its population of in which all 300 people exited a burnt-out the usual suspects of losing control 333,000 people is about that of a modest Boeing 777-300. Add to this significant or stalling on approach, landing long, city in many countries. It’s home to multi- impact while landing short of runways landing in tailwinds, failure to go around, ple glaciers and multiple active volcanoes; plus substantial numbers of runway etc. Factors also include poor preflight the former is owed to its latitude, the excursions. planning, poor inflight decision-making, a latter to its location on the fault line be- There is also the challenge of an in- lack of airport and weather infrastructure tween the North American and Eurasian crease in political-criminal acts against in some regions, basic weaknesses among tectonic plates. You actually rode over civil aviation, such as the bombing of a operators, a lack of adequate procedures the edges of those two plates on your trip Russian A321 over the Sinai, killing 224; or crews who fail to follow procedures, a from the airport. the near-disastrous bombing in an A321 lack of flying skills, multiple ground fatal- Today we are here to discuss and learn near Mogadishu in which the person car- ities with housing just off runway ends, about aviation safety, investigative tech- rying the bomb was ejected at 12,000 feet and inadequate regulatory oversight or niques, and the challenges and lessons but everyone else survived; and the shoot simply the absence of oversight. from some recent or ongoing investiga- down of MH17 in July 2014. Then, add sui- We have made huge progress, but such tions. The good news is that year 2015 cide-murder with Germanwings in March old and familiar problems continue to and thus far in 2016 mark the safest era 2015 (150 fatalities) and perhaps the demand attention, especially in certain in air transport history. Measured by fatal disappearance of MH370 in March 2014— regions, and they reinforce the idea accidents in revenue airline operations, though that remains to be seen. And let’s that “Every Link Is Important.” We must and “accident” is a key word here, aviation not forget fatal attacks on airports. continue to focus on and monitor a wide safety has reached a remarkable level. Although the system is incredibly safe range of known safety precursors, but Only 10 fatal accidents occurred world- compared to any time in the past, we’re we also must manage new challenges. wide in revenue airline service since the still a long way from zero risk, which I believe two of the biggest challenges AirAsia crash in Indonesia in December highlights the significance of this year’s will be the growing shortage of qualified 2014. The 10 fatal crashes in two years, seminar theme: “Every Link Is Important.” pilots and mechanics and the continued including four cargo flights, accounted This theme is perfect when we try to integration of unmanned aircraft systems for 278 onboard fatalities and 36 ground understand most of our recent accidents, (UAS) into civil aviation. fatalities, while the world’s airlines moved risks that continue to challenge us, and As the industry continues its explo- nearly 8 billion people, including crew. In newly emerging risks. Let’s start with sive growth, labor shortages may be those same two years, all the OECD (the existing risk. Of the 10 fatal accidents and the biggest long-term problem. These Organization for Economic Cooperation the multiple nonfatal approach-and-land- shortages can be attributed to pay struc- and Development) countries, plus the ing accidents or high-speed runway large economies of Asia, accounted for excursions, only the EgyptAir case may just one fatal accident, a cargo operation include a scenario that we haven’t seen in a CRJ with two fatalities. hundreds of times before. In 1996, airlines had 90 hull losses in For example, both fatal passenger revenue passenger and cargo service, with CFIT accidents involved flying VFR 40 fatal accidents and more than 2,000 in the clouds in mountainous terrain, fatalities, while the world’s airlines were with one crew having ignored multiple moving less than half as many people. Yet, GPWS alerts. Another passenger acci- those numbers already were a major im- dent involved a third attempt to land provement over preceding years. In short, in severe winds. Fatal cargo accidents comparing these past two years to where appear to have included loss of control we were 20 years ago really suggests that on approach, a takeoff accident involving Frank Del Gandio the system is safer than ever. excessive weight, and several with aircraft However, measuring only fatal acci- that were clearly not airworthy, operating ISASI President

October-December 2016 ISASI Forum • 3 tures, especially in the regional industry; fewer pilots and mechanics migrating to the airlines from military organizations; private training costs; the shrinking world -30- of general aviation; and more. Boeing and Airbus both project that worldwide pas- TO A JOURNALIST, THE “-30-” SYMBOL TELLS THE senger numbers will increase about 4.5 EDITOR READING AN ARTICLE THAT IT’S percent per year over the next 20 years. This compounds to nearly 2.5 times to- THE END OF THE STORY. day’s volume. To cope with the expansion, Airbus and Boeing indicate that the world s you are my editors, I mark by the exchange of information. Help will need about 35,000 new widebody and this message with this symbol to broaden professional relationships. single-aisle jets over the next 20 years, because after having been priv- Increase the prestige, standing, and influ- as the world’s fleet nearly doubles from A ileged to serve as editor of ISASI ence of air safety investigators. Project a about 20,000 to 40,000. Forum for the past 80 issues, a total of favorable image of the Society. Somehow we must hire enough quali- 20 years, this is the final issue for which To do this, I set the following editorial fied pilots and mechanics to offset normal I will serve you in that capacity. In that objectives: Be an authoritative source of attrition and to staff this huge expansion. time, I have had the pleasure of working material. Achieve credibility and respect- According to Boeing, about 620,000 new with hundreds of authors whose arti- ability. Reflect the Society’s advocacy, po- pilots and 610,000 mechanics will be cles have brought enlightenment and sitions, and values. Be reader friendly to needed over the next two decades. This knowledge of the accident investigator internal and external audiences. Maintain means hiring 31,000 pilots and 30,500 profession to ISASI members, to the budget constraints. And, most important- mechanics every year at a time when the international air safety community, and ly, establish ISASI Forum as the voice of current labor pool is shrinking. The pilot to the public. aviation accident investigators. shortage and perhaps the shortage of Forum as it exists today is a prod- Has the pledge made so many years mechanics will lead to more automation, uct of former ISASI President Capt. ago been met? One reader of an early edi- even less hands-on flying experience, and Richard Stone’s foresight. In 1996, he tion wrote, “…excellent balance between perhaps even to single-pilot cockpits. envisioned that a change in the Society’s news, organization affairs, future events The rapid expansion of UAS also will communications program would much and plans, and analysis of past accidents accelerate labor shortages for manned better serve the membership in both and hazards that continue within the aircraft. The safety community has performance and financial matters. The i n du str y.” focused most of its attention thus far on then existing print program consist- But only you, the Forum’s current the challenge of safely integrating UAS ed of Forum as a quarterly technical readers, can judge if your magazine has into the civil system of manned aircraft. newsletter, a bimonthly newsletter attained its objectives. I certainly hope This, of course, will continue to be critical, featuring council and chapter news, and you have enjoyed its contents as much but the greater impact may be to accel- published conference proceedings all as I have enjoyed guiding its publication erate the shortage of qualified pilots for distributed by mail to members on an over the years. I thank the authors for the manned aircraft. individual basis. liberties they afforded me in editing their I encourage all to actively participate ISASI’s International Council ap- material and the same thanks to every in this conference. This room has about proved the conversion of the Society’s reader who leafed through Forum pages 7,000 years of experience in aviation safe- two newsletters geared solely at mem- and found the articles sufficiently inform- ty. So whether you’re new to the field or ber interests to a feature-article-styled ative to continue returning to its pages. have been in it 40 years, I will tell you that magazine aimed at members and the I’m sure that Gary DiNunno, your new if you have a question about some topic external public. The start-up of the new editor, will continue to provide you with a in aviation safety, someone in this room publication required the introduction of highly respected, well designed, and very will have real expertise on that topic. Find electronic publishing and new produc- readable ISASI Forum. that knowledge, and if you possess that tion and planning concepts. knowledge, share it with others. In the January–March 1997 issue— Sincerely, Finally, I want to acknowledge the the first edition of the newly conceived Esperison efforts to search for MH370. Authorities ISASI Forum—President Stone wrote, (Marty) have recently decided to continue and “With this issue of ISASI Forum, your In- Martinez extend the search beyond the current ternational Council begins an important zone in a remote part of the southern change in the communications program Indian Ocean. To date, they have searched of our Society. Changes include a new an area of more than 46,000 square miles look, new content, new format, and staff and spent approximately $160 million. changes as well.” ISASI respects the work that has been Along with the issue’s launch, I accomplished and applauds their pledged that Forum would strive to persistence in searching for the aircraft. achieve the following: Promote air safety

4 • October-December 2016 ISASI Forum ISASI AIR ACCIDENT INVESTIGATORS EXAMINE 2016 LINKS TO SAFETY NETWORKS Delegates to ISASI 2016 meet in Reykjavik, Iceland, for the Society’s 47th annual international accident investigation and prevention conference to listen to technical presentations and participate in discussions with the overall theme of “Every Link Is Important.” By J. Gary DiNunno, Editor, ISASI Web News RoundUp and Update

ore than 250 ISASI delegates, 47 gations” and another with a theme of organized and that the organization companions, and 18 guests— “Extending the Networks.” These tutorials changes as military members rotate. representing 43 countries— were separate from the seminar program • Brig. Gen. Bruno Caitucoli, BEAD-Air, Mdescended upon Reykjavik, and required an additional entrance fee. France, talked about lessons learned Iceland, Oct. 18–20, 2016, for the Socie- There were 113 participants who attend- during an investigation of a Hellenic ty’s 47th annual international accident ed the two tutorials. Air Force F-16D mishap. He discussed investigation and prevention conference Jim Roberts, Boeing ASI/ASE, and Wing protocols that France and Greece to listen to technical presentations and Cdr. Neil Bishop, UK Defense AIB, led require for investigations and that a participate in discussions with the overall the military tutorial discussions. Various Spanish judge was also involved as theme of “Every Link Is Important.” As topics were examined. part of a judicial investigation. He delegates arrived and picked up their • Ronald Smits, Dutch Safety Board, suggested that moving forward slowly conference packets and name badges, discussed accident investigation in and ensuring that everyone was discussions about their air safety investi- the middle of a state border con- “happy” with each stage of the inves- tigation was important to being able gations and other work-related matters flict—MH17. Issues included working to proceed without creating conflict commenced and continued throughout in a hostile and dangerous environ- among the numerous parties. the week’s events. ISASI’s annual confer- ment, not being allowed access to the crash site, and the need to adjust the ence is a great networking opportunity • Maj. Stephen Turner, UK Defense AIB, investigation plan to meet changing and a chance for younger air safety in- observed that having fewer aircraft requirements. vestigators to meet and learn from more accidents is good, but this offers fewer opportunities for investigators experienced peers. • Agne Widholm, Statens haverikom- mission (SHK) Sweden, covered 10 to practice and improve their skills. years of experience in Swedish mili- He suggested that military accident Tutorial Workshops tary accident investigation. He noted investigators could share experiences On Monday, October 17, prior to the that there are common investigative across investigative organizations, official opening of ISASI 2016, two all- techniques between commercial modes, nations, and domains. He day tutorials were offered—one looking and military accidents. He discussed urged closer relationships with civil- at “Military Aviation Accident Investi- how the Swedish accident board is ian agencies and industry as they face the same challenges. He also pointed to the use of virtual and synthetic training as a means to hone and up- date investigative skills. • Fahad Masood, squadron leader in the Pakistan Air Force, discussed a different method of learning/edu- cation for “knowledgeable” adults— the K-CAASE methodology, which includes Knowledge, Comprehension, Application, Analysis, Synthesis, and Evaluation. He suggested that this approach emphasizes how to think, not what to think. • Piotr Ptak, Lappeenranta University of Technology, Finland, presented a novel, low-cost method of tracking aircraft using the Doppler Effect phenomenon. Photos: J. Gary DiNunno • Dr. Albert Moussa, BlazeTech Corp., Arriving ISASI 2016 participants register and receive their information packets. October-December 2016 ISASI Forum • 5 SPONSORS discussed two • Marcos Costa, ICAO, discussed • Keith Conradi, chief investigator, The following key ignition ICAO’s Manual on Regional Healthcare Safety Investigation sponsors provided threshold Accident and Incident Investigation Branch, UK, discussed how success- support for ISASI 2016: temperatures Organization. ful air safety investigation tools and in aircraft fires • Olivier Ferrante, ESASI, talked about techniques can transfer to health- involving fuel, GOLD efforts and activities of the European care organizations. Airbus hydraulic fluid, Boeing or oil. He provid- Network of Civil Aviation Investiga- Embraer tion Authorities. ed examples of Seminar Ceremonies which temper- • Thorkell Agustsson, director of the SILVER Tuesday, October 18 ature threshold Islandic Transport Safety Board, pre- Delta Air Lines From the Hotel Grand Reykjavik, the GE Aviation should be used sented efforts of the Nordic Accident largest hotel in Iceland, moderator Peter Rolls-Royce in a particular Investigation Group. University of Southern case and how Swaffer, SRK, Sweden, introduced ISASI’s • Caj Frostell, ISASI international California changes in Site Committee chairman, Thorkell councillor, outlined the work of the environmen- Agustsson, Islandic TSB director, who BRONZE Banjul Accord Group Accident Inves- tal conditions opened the event with a warm welcome IFSA tigation Agency. Frostell is the group’s Parker Aerospace affect these to the international crowd from the commissioner. Pratt & Whitney temperatures. Icelandic ISASI members. Agustsson Southwest Airlines • Chong Chow Wah, AAIB Singapore, • Jeff Kraus, urged all present to pay attention to the NetJets examined regional cooperation with Boeing BT&E technical papers presented (see “Speakers Test Safety/ accident investigations in the Asia and Technical Papers Presented at ISASI EXHIBITORS ASI, examined and Pacific regions. He noted, for 2016,” page 10) and to meet and mingle The following the promising instance, that investigators from with the air safety investigative profes- organizations were technology of Taiwan had to travel to other regions exhibitors for sionals attending the conference. using unmanned that have mountainous terrain to ISASI 2016: Capt. Geirthrudur Alfredsdottir, chair- aerial sys- train for accident investigation at man of the Icelandic TSB, welcomed the Aerobytes tems (UAS) high altitudes. Cranfield University to enhance ISASI delegates to Iceland’s capital city Plane Sciences traditional • Daniel Barafani, director of investi- and looked forward to attending the tech- TU Delft University aircraft accident gations, Junta de Investigations de nical sessions. investigations. Accidentes de Aviation Civil, looked Interior Minister Ragnhildur Hjaltad- He discussed the at the AIG Regional Cooperation ottir, permanent secretary, also warmly efficiency, safety, Mechanism of South America. greeted the gathering and emphasized capabilities, • Rob Carter, AAIB, UK, discussed be- that the seminar theme, “Every Link Is and cost factors of using a UAS as an Important,” was “very descriptive of your investigative tool. ing in accident investigations “for the long run” from Lockerbie to Ethiopi- profession.” She said, “You must find Olivier Ferrante, ESASI, led the tutorial an 787. answers and explanations to accidents “Extending the Networks,” which covered and incidents you are investigating. They a variety of communication, education, • Marion Choude, ATR, and Mike may be caused by different contributing and cooperation techniques that can Gamlin, Roll-Royce, discoursed about factors, which when linked together can enhance air safety investigations. Existing investigation cooperation among lead to the incidents or accidents.” She networks such as the Nordic Accident manufacturers. noted that “your investigations are of vital Investigator Group and the European Net- • Matthew Greaves, Cranfield Univer- importance for international air safety work of Civil Aviation Safety Investigator sity, demonstrated how universities and security…because with your conclu- Group were discussed. The tutorial also and research institutions are expand- sions and recommendations the industry, looked at regional cooperation that ICAO ing networking opportunities for air regulators, and the public can correct any promotes. accident investigators. possible weaknesses and thereby min-

ESASI’s Olivier Ferrante discusses the ISASI 2016 Chairman Thorkell ISASI President Frank Del Gandio agenda for the tutorial “Extending the Agustsson welcomes the ISASI delivers an address to open the Networks.” delegates to Iceland. annual conference.

6 • October-December 2016 ISASI Forum imize the risk of further accidents and try must move toward confidential incidents.” reporting and openness, and this can WE NEED TO ISASI President Frank Del Gandio gave be enhanced by having an investiga- an opening address (see “President’s tion process that works on the same CONTINUE TO PUSH View,” page 3). He noted that, despite an principles. THE BOUNDARIES—OF increase in political-criminal acts against • Annex 13 is extremely valuable to civil aviation, global aviation safety has air accident investigation. Health- OUR KNOWLEDGE, reached a remarkable level in recent care investigations are currently AND OF WHAT WE years. And yet, he observed, “we’re still a conducted by a mismatch of people, long way from zero risk.” As air safety in- not necessarily selected on merit but INVESTIGATE—SO vestigators, he said, “We have made huge more on their availability, with little training. In air safety investigation, THAT ULTIMATELY WE progress,” but problems continue to de- Annex 13 can bring some 190 states mand our attention, especially in certain CAN DO A BETTER into a similar investigative process regions—emphasizing that every link is that we can all recognize. JOB OF ADVANCING important for our global air safety efforts. Acknowledging that “we must continue • Protection of sensitive information SAFETY. during an investigation is important. to focus on and monitor …known safety —KATHY FOX, CHIEF, TSB, CANADA This is a hugely contentious issue in precursors, but we also must manage new health care. That a statement from a challenges,” Del Gandio said two of the clinician might not be made available biggest new challenges that investigators to a family member or patient seek- the industry—as does aviation—to face will be the growing pilot and me- ing retribution is a highly emotional arrive at solutions and then reporting chanic shortages and more UAS in civil experience. Gaining the confidence results as safety actions are taken to aviation airspace. of the health-care staff that a state- fix the problems. Keith Conradi, chief investigator of the ment can be made to an investigator in confidence will take a great deal of Healthcare Safety Investigation Branch, Wednesday, October 19 UK, gave the Tuesday keynote address. time. Understanding that a health- Paulo Soares Oliveira Filho, investiga- Until recently, Conradi was the chief care safety investigation can occur tion manager, air safety, Embraer, was inspector of air accidents with the UK parallel with other investigations, for example, judicial, has helped to begin the keynote speaker for the second-day AAIB. In September 2016, he joined the unlocking this dilemma. session. He said challenges facing air UK’s Healthcare Safety Investigation safety investigators include the size, Branch and became immersed in the • Investigation independence is nec- complexity, and diversity of investiga- health-care industry with a whole new essary. Most investigations in health tions. Filho suggested the key to defeat set of acronyms and meeting with groups care are conducted by colleagues or those who are close to the event. these challenges is effective management and people with very different titles and Adopting the aviation investigation of an investigation. He pointed to two backgrounds. He believes that “there are model and the impartiality that un- successful management programs— five key areas where accident investiga- derpins it should be a major improve- crew resource management and safety tion in aviation can make a real difference ment for the health-care industry. management systems (SMS)—that have in health care.” • Safety action and safety recommen- greatly contributed to air safety since • A no-blame investigation should their inceptions. Effective coordination of become a part of the culture. When dations in health care are often not something goes wrong in health care, effective. Current health-care inves- people among the various safety investi- often the information flow is instant- tigations take place in an isolated, gative teams is the best management tool ly shut down. The current culture is siloed, combative environment. an investigator-in-charge can employ. An more about fear that punitive action Health-care investigations should in- investigative management strategy that will be taken and jobs and careers are clude the concept of working togeth- recognizes every link is important among on the line. The health-care indus- er with individuals, hospitals, and individual professionals, investigation

Keith Conradi, chief investigator HSIB, Paulo Soares Oliveira Filho, Embraer, Kathy Fox, chief, TSB, Canada, during UK, in his keynote address says that discusses challenges facing air safety her day-three keynote address ac- air safety investigation techniques investigators during his second-day knowledges that she is proud of the are useful in other areas, such as keynote address. valuable work air accident health care. investigators perform.

October-December 2016 ISASI Forum • 7 teams, and available resources will ensure is the regulator that is the guardian of better understand why accidents happen, collaborative results. public safety. Because the regulator sets and what needs to be done to make our the rules, determines the playing field, skies, already very safe thanks to your and creates the framework under which good work, even safer. Thursday, October 20 air carriers operate. And then—ideal- Kathy Fox, chief of the TSB Canada, gave ly—it is the regulator that provides the Companion Program the keynote address. She said, “I think we balanced oversight—whether in the form Participants in the first ISASI Companion can be very proud of the valuable work of inspections or audits—to make sure Program on Tuesday took a bus tour of performed by air accident investigators. organizations are abiding by those rules Reykjavik that provided them a glimpse of We’ve become very good at understand- and by that framework. Islandic architecture and some history of ing how accidents unfold, how one event “Over the past decade, [the regulators’] the capital city. They also stopped at the links to another, and how—to invoke the approach to oversight in Canada has Saga Museum to learn about Viking and theme of this conference—every link is moved away from a traditional ‘inspect- Icelandic history. important. and-fix approach.’ The new, preferred Wednesday’s program originally “We’ve become especially good at model is a systems-level approach, where- included a plan to go out to sea on a identifying the operational, technical, by, in addition to verifying a company’s whale-watching vessel, but it was can- and human factors that contribute to compliance with regulations, its internal celled due to weather conditions—rain accidents. Whereas in ‘the old days’ we processes are examined to verify that and cold, high winds that created high sought only to explain what happened, there is also an effective system in place waves. So, instead, they bussed to a whale today we also focus on why. For instance, to proactively manage the risks associ- museum in Reykjavik. There they viewed it has now become standard to look at ated with its operations. The theory [is] 23 to-scale models of whales that hung how people interact with automated that, if this is done properly, such a transi- from the ceiling, giving participants the systems and with one another, or whether tion should result in improved safety— feeling that they were walking among a pilot or crew may have been task-satu- addressing not only any identified prob- swimming whales. Perhaps less dramat- rated, or fatigued, or distracted—because lems, but also the reasons behind them. ic than going out to sea, the museum all of these elements can play a role. But “And I agree—in theory. But that theory, provided an interesting (also warmer and in order to keep improving, we need to and the move away from the traditional dryer) look at all things whale related continue to push the boundaries—of our inspect-and-fix approach, only works if all near Iceland. The tour guide, who has knowledge, and of what we investigate— companies have 1) the ability to proac- experience tagging whales for research, so that ultimately we can do a better job tively identify safety deficiencies, 2) the provided an interesting discussion of of advancing safety. And so today I’d like capability to rectify them, and 3) a top- whale biology and ancestry. The compan- to highlight something else—two some- down, organization-wide commitment ions also traveled away from Reykjavik to things—that we should be looking at. to doing so. Does that sound like any op- see the countryside and stop at a lake. Specifically, I’m talking about the organ- erators you know? Sure. Some. Hopefully izational factors that contribute to acci- a lot. But not all. Because, again, there’s dents and the regulatory environment in Social Events a broad spectrum of capability, compe- President’s Reception which those organizations operate. tence, and commitment when it comes “Let me elaborate. Many companies, for to implementing SMS—despite its track For many ISASI 2016 attendees and example, say that safety is their top prior- record of success. Which brings me back their guests, the president’s reception on ity. However, there is plenty of convincing to my question: when is enough enough? Monday night was their first opportunity evidence that, for many of them, the real Should the regulator wait for an accident during ISASI 2016 to meet professional priority is profitability. That’s not to say before stepping in? Should it wait for op- colleagues with whom they have cor- they consciously choose to be reckless or erators to fix the problems that have been responded and discussed work-related deliberately unsafe. It’s just that, in the identified, or should it adopt a firm hand issues through telephone calls, e-mails, real world, they often have to balance before then? If so, at what point? or Internet video connections. This is an many competing factors: safety, customer “Those are good questions—simple occasion on a global scale to greet long- service, productivity, technological inno- ones, yet perhaps confounding, too. But time friends and former co-workers who vation, scheduling, cost effectiveness, and they need to be asked, and they need to have moved or transferred to other posi- return on shareholder investment. be discussed. If they’re not, we lose out on tions—a time to catch up on events and “That’s a challenge for any business, an excellent opportunity to do what I said life changes. There are hardy handshakes and even though companies generally at the beginning of this speech—to push here, a hug there, a hand on a shoulder, recognize and accept that products and the boundaries of what we know and of and smiles all around. Passing among the services must be ‘safe’ if they want to what we investigate. And this really is clusters of people at the reception seems remain in business, those other priorities such an opportunity. Because the organ- as though the participants are attending a can exert a lot of pressure on manage- izational factors I mentioned today, and school or family reunion. ment. And when that happens, when we the issue of oversight by the regulator, find deficiencies in how organizations are appearing in our work with more and Blue Lagoon Reception identify, prioritize, and manage their more frequency. They are, we have come After a long day of meetings, Tuesday’s risks, we must ask ourselves: where was to learn, important links in the chain— seminar participants and companions the regulator? Because, ultimately, it links that we need to pursue in order to bussed to the Blue Lagoon where many

8 • October-December 2016 ISASI Forum First row top left: Stuart Hawkins, left, receives from President Frank Del Gandio the Award of Excellence for the ISASI 2016 best seminar paper. Seminar participants gather for the president’s reception. Second row: An ISASI 2016 delegate presents a question to the conference speaker. Kapustin scholar Carly Shoemake, left, discusses her presentation with Technical Committee Chairman Brian McDermid, right. An ISASI 2016 delegate presents a question to the conference speaker. Third row: Fabio Bonnett, Embraer, discusses investigating single-pilot accidents. An ISASI 2016 delegate presents a question to the conference speaker.

October-December 2016 ISASI Forum • 9 The president’s table at the awards banquet. SPEAKERS AND TECHNICAL PAPERS PRESENTED AT ISASI 2016 Tuesday, 25 August Wednesday, 26 August Thursday, 27 August 9:00 09:00 09:00 • Opening Ceremonies • Moderator: Jim Roberts, Boeing. • Moderator: Rob Carter, AAIB, UK • Moderator: Peter Swaffer, SRK, Sweden • Keynote address: Paulo Soares Oliveira Filho, • Keynote address—Kathy Fox, Chief, TSB, Manager Air Safety, Embraer Canada • ISASI 2016 Committee Chairman: Thorkell Agustsson, Islandic TSB Director • MH17 Safety Investigation—Kas E. Beumkes, • Germanwings Safety Investigation—Romain Dutch Safety Board Bevillard, Senior Safety Investigator, BEA • Welcome: Geirthrudur Alfredsdottir, ITSB France Chairman • Safety Recommendations: A Foundational Building Block to ESA’s Safety Risk Manage- • An Additional Approach to Establishing the • ISASI President: Frank Del Gandio ment Process—Marion Colavita, Aviation Safe- State of Operation of a Turbofan Engine During • Presentation of Kapustin Scholars ty Officer, European Aviation Safety Agency an Aircraft Accident—Douglas Zabawa, Acci- dent Investigator, Pratt & Whitney • Welcome address: Ragnhildur Hjaltadottir, • Aviation Safety Improvements: Advancing Permanent Secretary, Ministry of Interior Safety Through Multiple Means—Kristi Dunks, • The Effect of Commuting on Pilot Self-Assess- Transport Safety Analyst, NTSB ment of Stress and Performance—Thomas Frie- sacher, Ph.D. Candidate, Cranfield University 09:30 • Accidents During Non-Precision Approach- • Keynote address: Keith Conradi, Chief Inves- es—Still a Recurrent Issue—Thomas Lepagnot, • Investigating Linkages Between an Occurrence tigator of the Healthcare Safety Investigation Airbus Event and an Organization’s Safety System Branch, UK Performance—Heather Fitzpatrick, Senior • Real-Time Data Transmissions—Jaiqi Cao, Transport Safety Inspector, Australian TSB • 10:00 Kapustin Scholarship Winner • AirAsia 8501: Echoes of Air France 447?—An- • Sukhoi Superjet—Airborne Image Recorder • ISASI Business Meeting, Frank Del Gandio, dre Woenardi and Yasmeen Syed, Kapustin Supported Investigation—Ragnar Gudmunds- President; Ron Schleede, Vice President, Bob Scholarship Co-winners son ITSB MacIntosh, Treasurer • Protection of Investigation Records—Marcos Costa, ICAO 13:50 14:00 • Moderator: Martin Pluggaard, AIB, Denmark • Reverse-Engineering the Causal Links Reveals • Moderator, Anthony Brickhouse, Professor, Safety Analysis Issues—David Romat and Embry-Riddle Aeronautical University • * Overview and Images of the MH17 Crash, Sebastien David, BEA, France Ronald Smits, Investigation Manager, Dutch • Using a Drone and Photogrammetry Software Safety Board • Investigating a MD-88 Runway Excursion— to Create Orthomosaic Images and 3-D Models Joshua Migdal, Senior Air Safety Investigator, of Aircraft Sites—Stuart Hawkins, Senior • Alliance or Rebellion: Linking Efforts of State Delta Air Lines Inspector of Air Accidents (Engineering), UK Safety Oversight Agencies—Jeff Guzzetti, AAIB Acting Deputy Director, Office of Accident • Social Media in Crisis Communications—Carly Investigation and Prevention, FAA Shoemake, Kapustin Scholarship Winner • Extend the Network and Exploit Available Resources: Lessons Learned from Two Major • Aircraft Controllability and Primary Flight Dis- Investigations—Michael Guan, Investigation plays: Every Link Is Important—Knut Lande, 14:00 Lab, Aviation Safety Council, Taiwan General Manager/Flight Safety Advisor, Land/ Avia, Ltd. • Moderator: Kaare Halvorson, AIB Norway • Cabin Safety Aspects in Accident Investiga- • Investigation of Single-Pilot Operation Acci- tions: A Crucial Link—Martin Maurino, Safety, • Links for a Successful Investigation—Luis dents—Fabio Bonnett, Air Safety Investigator, Efficiency, and Operations Officer, ICAO Gracia, Head of Product Safety, Airbus Defense Embraer and Space • Collaborative Component Examinations—Eric East, Air Safety Investigator, Boeing 16:10 • ISASI Working Group Meetings * This was a presentation given during ISASI • Feedback from the Tutorial on Military Acci- 2016, not a submitted paper. dent Investigations—Olivier Ferrante, ESASI • New Materials/New Challenges—Taylor Beall, Kapustin Scholarship Winner

16:00 • National Society Meetings (Continued on page 30)

10 • October-December 2016 ISASI Forum After an aircraft accident occurs, safety issues are identified and safety recommendations are issued to prevent future similar events. As investigations evolve, so, too, must methods FOR addressing safety issues. Advancing Safety Through Multiple Means By Kristi Dunks, Ph.D., Office of Aviation Safety, U.S. National Transportation Safety Board (Adapted with permission from the author’s technical paper entitled Aviation Safety Improvements: Advancing Safety Through Multiple Means presented at ISASI 2016 held in Reykjavik, Iceland, Oct. 17–20, 2016, which carried the theme “Every Link Is Important.” The full presentation, including cited references and omitted images to support the points made, can be found on the ISASI website at www.isasi.org under the tag “ISASI 2016 Technical Papers.”—Editor) n Sept. 17, 1908, the first powered that it will not take any actions to ad- Following are case studies of three acci- airplane passenger fatality oc- dress the identified safety issue. When dents in which the NTSB issued safety rec- curred. During a test flight for the this situation occurs, the NTSB cannot ommendations. These investigations also led OU.S. Army at Fort Myer, Virginia, compel the recipient to take action re- to safety accomplishments or safety results. U.S.A., a wooden propeller blade split, garding the recommendation because and pilot Orville Wright was unable to the NTSB is not a regulatory agency. UPS Flight 1354, Birmingham, Alabama, control the airplane. Lt. Thomas Selfridge All safety recommendations issued by U.S.A. sustained a skull fracture as a result of the the NTSB and the related correspond- On Aug. 14, 2013, about 0447 central daylight accident and died hours later. Although ence and classifications are available time, UPS Flight 1354, an Airbus A300–600, aviation history has been full of amazing on the agency’s website http://go.usa. N155UP, crashed short of Runway 18 during achievements, when accidents occur, gov/xKt6k. a localizer nonprecision approach to Run- industry pauses to investigate the cir- The NTSB typically issues safety rec- way 18 at Birmingham–Shuttlesworth Inter- cumstances and learn from these events. ommendations at the conclusion of an national Airport, Birmingham, Alabama. The After the 1908 accident, U.S. Army pilots investigation, but recommendations captain and the first officer were fatally in- were required to wear helmets to prevent are issued sooner when warranted, jured. The airplane was destroyed by impact injuries similar to the one sustained by especially if an urgent safety issue has forces and postcrash fire (see Figure 1, page Selfridge. Even from these early days of been identified. Although the NTSB’s 12). The scheduled cargo flight was operating aviation, the prevention of similar acci- safety recommendations have been the under the provisions of 14 Code of Federal dents through safety improvements was impetus for extensive aviation safety Regulations (CFR) Part 121 on an instrument of primary importance. improvements, a formal recommen- flight rules flight plan. Dark night visual Title 49 United States Code 1131 dation is not always necessary or the flight rules conditions prevailed at the air- authorizes the U.S. National Transporta- most advantageous approach to im- port, and variable instrument meteorolog- tion Safety Board (NTSB) to investigate prove aviation safety, especially if the ical conditions with a variable ceiling were transportation accidents and “establish public and industry call for improve- present north of the airport on the approach the facts, circumstances, and cause or ments immediately after an accident. course at the time of the accident. probable cause.” The NTSB may also issue Other tools that the NTSB uses to safety recommendations aimed at pre- resolve safety issues and prevent future venting future similar accidents. accidents include safety accomplish- Safety recommendations are defined ments and safety results. as a formal request issued as a result of A safety accomplishment is defined investigations or safety studies. Recom- as a positive measureable change mendations address a specific issue iden- within the transportation environment tified during an investigation or a study that is brought about through some Dr. Kristi Dunks and specify actions to correct the issue. direct action of an NTSB employee. Letters containing the recommendations Some safety issues identified during is a transportation safety analyst with are sent to the most appropriate public or investigations, due to their nature, may the Office of Aviation Safety at the U.S. private organization to address the safety be resolved through direct action of the National Transportation Safety Board. She issue. By regulation, the U.S. Federal entity involved. Through meetings and joined the NTSB in 2003. Dunks man- Aviation Administration (FAA) is required correspondence between the investi- to respond to NTSB recommendations. gator and the entity, ideas for resolving ages the aviation safety improvements Since the NTSB’s inception in 1967, the safety issue are identified and then program and works on the identification and as of July 13, 2016, the agency has acted on. and resolution of safety issues. Prior to issued 14,434 safety recommendations, A safety result is defined as a positive becoming an analyst, She worked as a with 5,561 aviation-related safety change within the transportation envi- senior air safety investigator and served recommendations. ronment that is brought about simply as the investigator-in-charge as well as Once a response to a recommendation by the NTSB’s investigation of an the airworthiness group chairman of is received, the NTSB corresponds with accident or incident. The investigator numerous aircraft accidents. She holds a the recommendation recipient until the does not make a suggestion to improve Ph.D. in technical communication from recommended action (or an acceptable safety because the affected party acts Texas Tech, where her research focused alternate action) is completed. However, on its own to resolve the identified on government reports and their role in in some cases the recipient determines safety issue. safety changes following accidents.

October-December 2016 ISASI Forum • 11 reuse of a degraded self-locking nut, (2) the improper or lack of installation of a split pin, and (3) inadequate postmainte- nance inspections, which resulted in the inflight separation of the servo control input rod from the fore/aft servo and rendered the helicopter uncontrollable. Contributing to the improper or lack of installation of the split pin was the mechanic’s fatigue and the lack of clearly delineated maintenance task steps to follow. Contributing to the inadequate postmaintenance inspection was the Figure 1. UPS accident site. inspector’s fatigue and the lack of clearly The NTSB determined that the prob- Independent Pilots Association ad- delineated inspection steps to follow. able cause of the accident was the dressed fatigue reporting and assessment. As a result of the investigation, the flightcrew members’ continuation of an The safety recommendation to Airbus NTSB issued three recommendations unstabilized approach and their failure addressed the need to provide a direct to the FAA. These recommendations to monitor the aircraft’s altitude during cue to flight crews when the flight man- addressed establishing duty-time regula- the approach, which led to an inadvertent agement computer for applicable Airbus tions for maintenance personnel, imple- descent below the minimum approach models is programmed incorrectly. menting best practices for conducting altitude and subsequently into terrain. In addition to these safety recommen- maintenance under 14 CFR Parts 135 and Contributing to the accident were (1) the dations, safety improvements were made 91 Subpart K, and human factors training flight crew’s failure to properly config- outside of the formal safety recommen- for maintenance personnel. ure and verify the flight management dation process. The Birmingham airport During the investigation, several safety computer for the profile approach; (2) authority and the Birmingham control improvements were completed. Sun- the captain’s failure to communicate tower replaced the emergency phone sys- dance Helicopters was a member of the his intentions to the first officer once it tem and updated procedures to provide Tour Operators Program of Safety (TOPS). became apparent the vertical profile was timely notification to emergency response Investigators determined that Sundance not captured; (3) the flight crew’s expec- personnel. Also, controllers received Helicopters did not meet the TOPS tation that they would break out of the refresher training about entering remarks audit requirements but had successfully clouds at 1,000 feet above ground level data into ATIS reports and updating passed the audit. After discussions with due to incomplete weather information; those reports. Thus, the safety recom- the NTSB, TOPS formed a committee to (4) the first officer’s failure to make the mendations addressed the broad safety evaluate its auditing process. TOPS then required minimums callouts; (5) the issues identified during the investigation, revised its audit sampling procedures, captain’s performance deficiencies likely and the safety results implemented at the added the revised information to its an- due to factors including, but not limit- Birmingham airport and control tower nual auditor training and orientation, and ed to, fatigue, distraction, or confusion, addressed local procedures and training. modified its audit-related checklists. consistent with performance deficiencies In addition, due to the maintenance exhibited during training; and (6) the first errors and issues identified during the officer’s fatigue due to acute sleep loss re- Sundance Helicopters, Las Vegas, investigation, the NTSB worked with sulting from her ineffective off-duty time Nevada, U.S.A. the FAA to (1) publish a general avia- management and circadian factors. On Dec. 7, 2011, about 1630 pacific stand- tion maintenance alert on its website to As a result of the investigation, the ard time, a Sundance Helicopters, Inc., highlight recent helicopter maintenance NTSB made 15 recommendations to the Eurocopter AS350–B2 helicopter, N37SH, errors and (2) distribute the information operating as a “twilight tour” sightseeing FAA, two recommendations to UPS, two through the FAA Safety Team (FAAST) trip, crashed in mountainous terrain recommendations to the Independent e-mail registry. The NTSB also provided about 14 miles east of Las Vegas, Nevada. Pilots Association, and one recommenda- accident case study data related to main- The pilot and four passengers were fatally tion to Airbus. The safety recommenda- tenance errors that the FAAST included injured. The helicopter was destroyed in its inspection authorization renewal tions to the FAA addressed areas related by impact forces and postcrash fire. The training for mechanics. to fatigue, dispatcher training, operating helicopter was registered to and operated Although the issues addressed in the procedures and training, the hazards of by Sundance Helicopters as a scheduled safety recommendations could only be dive-and-drive approaches, the need to air tour flight under the provisions of required through regulatory change, include information from the remarks 14 CFR Part 135. Visual meteorological the safety accomplishments improved, section of aviation routine weather re- conditions with good visibility and dusk in a timely manner, the TOPS audit for ports in automatic terminal information light prevailed at the time of the accident, operators and distributed information system (ATIS) reports, ground proximity and the flight was operated under visual to mechanics so that the lessons learned warning system software updates, terrain flight rules. from the investigation could be available awareness and warning system alerts The NTSB determined that the proba- to a wide audience. Notably, the safety and responses, and flight management ble cause of the accident was Sundance accomplishments had been completed computer programming. The safety Helicopters’ inadequate maintenance of before the NTSB’s determination of the recommendations issued to UPS and the the helicopter, including (1) the improper probable cause for this accident. 12 • October-December 2016 ISASI Forum Empire Airlines Flight 8284, Lubbock, accident, Empire Airlines issued training that the investigative team can resolve Texas, U.S.A. guidance on flap anomalies, issued flight identified safety issues in a timely and On Jan. 27, 2009, about 0437 central bulletins addressing airspeed bugs and effective manner. This dialogue may also standard time, an Avions de Transport prohibitions on operating in freezing rain help the team develop unique solutions to Régional Aerospatiale Alenia ATR 42–320, or freezing drizzle, and implemented complex safety issues and determine the N902FX, operating as Empire Airlines special emphasis icing training. FedEx best manner to collaborate with potential Flight 8284, crashed short of the runway held a safety summit to its feeder oper- recipients on ways in which the safety while on an instrument approach to Lub- ators to address the circumstances of issues could be addressed. bock Preston Smith International Airport this accident and facilitate improved Documenting and sharing safety im- in Lubbock, Texas. The captain sustained training, developed “no-go” weather provement information are other impor- serious injuries, and the first officer sus- items that prohibit takeoff or landing tant aspects in improving aviation safety. tained minor injuries. The airplane was operations in known or reported freezing Although official safety recommendations substantially damaged (see Figure 2). The rain or freezing drizzle, and installed ice are well documented and tracked, com- airplane was registered to FedEx Corpora- evidence probes on all company ATR air- prehensive documentation of all related tion and was operated by Empire Airlines, Inc., as a 14 CFR Part 121 supplemental cargo flight. Instrument meteorological conditions prevailed at the time of the accident, and an instrument flight rules flight plan was filed. The NTSB determined that the prob- able cause of the accident was the flight crew’s failure to monitor and maintain a minimum safe airspeed while executing an instrument approach in icing condi- tions, which resulted in an aerodynamic stall at low altitude. Contributing to the accident were (1) the flight crew’s failure to follow published standard operating procedures in response to a flap anoma- ly, (2) the captain’s decision to continue Figure 2. Empire Airlines accident site. with the unstabilized approach, (3) the flight crew’s poor crew resource manage- planes without such equipment. Also, in safety accomplishments and safety results ment, and (4) fatigue due to the time of March 2010, the FAA issued Safety Alert is also needed. Safety improvement infor- day during which the accident occurred for Operators (SAFO) 10006, “Inflight mation is typically included in the NTSB’s and a cumulative sleep debt, which likely Icing Operations and Training Recom- final report of an investigation, similar to impaired the captain’s performance. mendations,” to encourage all operators the documentation of safety actions by As a result of the investigation, the to review and, if necessary, amend their other accident investigation boards. Such flightcrew member and dispatcher train- documentation provides those outside of NTSB issued nine recommendations ing programs to ensure that the programs the investigation with knowledge of the to the FAA. These recommendations address supercooled large droplet (SLD) safety improvements that have occurred addressed (1) improving first officer icing conditions. so that all interested parties may learn assertiveness, (2) prohibiting operations The safety recommendations resulting from the event. in known freezing rain or freezing drizzle from this accident addressed broad oper- Each safety improvement resulting (unless the airplane manufacturer has ational safety issues affecting all opera- from an investigation is important in demonstrated that the airplane model tors and airports, and the safety accom- preventing future accidents and inci- can safely operate in those conditions), dents. Investigative agencies and teams (3) flight training on the dangers of oper- plishments addressed changes made by Empire Airlines and FedEx to prevent fu- should understand and consider the full ating in freezing precipitation, (4) improv- array of safety improvement options and, ing airport emergency response commu- ture similar events from occurring. Also, with the issuance of the SAFO, the FAA based on the needs of the investigation, nications, (5) ensuring airport emergency choose the most effective method for response access, (6) retrofitting aircraft was able to educate and remind operators about SLD icing conditions. Similar to the conveying this information to bring about performance monitoring systems, (7) the desired change. Whether a local safety accomplishments associated with annunciating flap asymmetries, (8) devel- change is instituted by an airport manag- the Sundance Helicopters’ accident, these oping minimum simulator model fidelity er or a significant regulatory change is safety accomplishments were implement- requirements for airplane ice accretion, made within the industry, each safety and (9) providing simulator training ed before the completion of the accident improvement implemented is a step (once the simulator fidelity requirements investigation. forward for aviation safety. are in place) for flight crews of all aircraft certificated for flight in icing conditions. Conclusion Numerous safety accomplishments Potential safety improvements should be (The views expressed in this paper are not those resulted from the work of the investi- included in team discussions from the of the NTSB and are not necessarily endorsed by gative team. In the months after the beginning of an investigation to ensure the NTSB.) October-December 2016 ISASI Forum • 13 Photo: J. Gary DiNunno

ISASI Executive officers congratulate Toby Carroll, the Lederer Award recipient. From left, Robert MacIntosh, treasurer; Frank Del ISASI PRESENTS Gandio, president; Toby Carroll; and Ron EUGENE "TOBY" CARROLL Schleede, vice president. sity, followed by completion of the Army fixed-wing flight school program and then ITS 2016 LEDERER AWARD a tour in South Vietnam. After Vietnam, Toby was then assigned to the Army Avi- THE SOCIETY’S HIGHEST HONOR GOES TO ONE ation School as a committee chief/senior OF ITS MOST EXCEPTIONAL INVESTIGATORS. instructor. After completing active duty, Toby By Esperison Martinez, Editor remained in the military serving in the Reserve and National Guard as a compa- ny commander and operations officer. His he Jerome F. Lederer Award is the In introducing the award winner to last assignment was as brigade aviation highest honor the International the banquet guests, President Frank Del safety officer of the 50th Aviation Brigade, Society of Air Safety Investigators Gandio said, “I have known Toby person- where he established the newly formed Tbestows upon an individual. So ally for approximately 35 years and have Brigade’s aviation and ground safety it is no surprise that the presentation investigated numerous accidents with programs in support of approximately 175 crowns the Society’s annual three-day him with AMSI, the NTSB, and Conti- fixed- and rotary-wing aircraft spread out international conference on air accident nental Airlines. I always considered him over four U.S. states. Toby has served as investigation at its award banquet. Eu- my ‘go to’ person for answers to airline president of three military accident inves- gene “Toby” Carroll, a longtime accident questions. While we attended many tigation boards and as a member of the investigation professional with more than military functions together, we did not aviation standardization board. During 400 investigations to his credit, is the 2016 get to know one another until we met his military career, Toby was awarded the recipient of the award. ISASI, an organi- on accident sites. Toby is undeniably an Distinguished Flying Cross, an Air Medal zation dedicated to enhancing aviation exceptional aviation safety professional with 14 oak leaf clusters, the Bronze Star, safety through the continuing develop- and colleague. Moreover, he is an invalua- and an Army Commendation Medal with ment and improvement of air accident ble mentor to aspiring safety investigators cluster. investigation techniques, only considers and has been a renowned safety advocate In 1985, Toby began his long-lasting for its highest award candidates who have for many decades.” position as the manager, then director, careers of making outstanding lifetime Outlining Toby’s background, Del of flight safety at Continental Airlines, contributions to technical excellence in Gandio noted that Toby’s path in aviation in which he was extremely influential in furthering aviation accident investigation safety began as an ROTC distinguished aviation safety and accident investiga- and achieving ISASI objectives. military graduate from Marquette Univer- tion. Toby was always eager to share his

14 • October-December 2016 ISASI Forum expertise, and he instilled an appreciation caught unaware, so he wondered “What PAST LEDERER AWARD WINNERS of the significance of safety within the now?” Once on stage, he stood aside the organization. He worked with numerous lectern; “Come closer,” said the president. 1977—Samuel M. Phillips interns over the years and took a vested And as he stepped forward, Del Gandio 1978—Allen R. McMahan interest in providing them with men- faced him and announced, “Meet the 1979—Gerard M. Bruggink torship and direction in their respective ISASI 2016 Lederer Award winner.” 1980—John Gilbert Boulding careers. He was also active in the career Stunned, Toby blurted, “Oh my God!” 1981—Dr. S. Harry Robertson development of his colleagues by provid- As he stepped forward on the award 1982—C.H. Prater Houge ing opportunities for them to refine and banquet night to accept the Jerry Lederer 1983—C.O. Miller expand their skills and by enabling them Award plaque, his nervousness was still 1984—George B. Parker to strategically pursue their interests in apparent, but he cradled the award in his 1985—Dr. John Kenyon Mason aviation safety. hands and accepted the well-deserved, 1986—Geoffrey C. Wilkinson At Continental Airlines, Toby was long applause from his peers. When the 1987—Dr. Carol A. Roberts instrumental in implementing the FOQA, room quieted, he moved to the lectern ASAP, IEP, VDRP, and LOSA programs. and said: “On Tuesday morning when 1988—H. Vincent LaChapelle He is a great proponent of proactive Frank announced that I would receive 1989—Aage A. Roed safety programs and was appointed the the Jerome F. Lederer Award tonight, I 1990—Olof Fritsch industry co-chair of the Aviation Safety thought, ‘Wow, what a great honor.’ Later, 1991—Eddie J. Trimble Information Analysis and Sharing (ASIAS) it hit me that I would have to make a 1992—Paul R. Powers program. He also chaired the Issues speech, and I told myself, ‘Keep it short 1993—Capt. Victor Hewes Analysis Team (IAT) and the Air Trans- but meaningful.’ So here it is. 1994—UK Aircraft Accidents port Association’s (ATA) Aviation Safety “From the time I was a child, I knew Investigation Branch Exchange System. Furthermore, he served that I wanted a career in aviation. My 1995—Dr. John K. Lauber as chairman and vice chairman of the plan was to graduate from college, get 1996—Burt Chesterfield ATA (now A4A) Flight Safety Committee my pilot ratings, fly in the military, and 1997—Gus Economy and as an alternate representative to the when my military obligation was ful- ATA safety council. Additionally, for more filled, I would go on to be a pilot at a 1998—A. Frank Taylor than 26 years, Toby served as the Conti- major airline. Things were working out 1999—Capt. James A. McIntyre nental Airlines “party coordinator” during according to my plan until while serving 2000—Nora C. Marshal NTSB investigations and/or as a technical as an Army fixed-wing pilot in Vietnam I 2001—John W. Purvis and the advisor to the NTSB accredited repre- was asked (in military fashion) to partic- Transportation Safety Board of Canada sentatives on International Civil Aviation ipate in an accident investigation. That 2002—Ronald L. Schleede Organization Annex 13 investigations. opened my eyes to a whole new career 2003—Caj Frostell Overall, in his more than 45 years of avi- path that I thought would be interesting 2004—Ron Chippindale ation experience, he has participated or and challenging. I have often told people 2005—John D. Rawson was in charge of more than 400 accident that I became an accident investigator by 2006—Richard H. Wood or significant incident investigations. accident. 2007—Thomas McCarthy Concluding his remarks, President Del “Upon completing active duty, I had the Gandio addressed Toby’s ISASI role: “Toby opportunity to work for a company that 2008—C. Donald Bateman has also been a significant contributory investigated aviation accidents for several 2009—Capt. Richard B. Stone and the member of ISASI since he joined in Oc- manufacturers, and the rest is, as they say, Australian Transport Safety Bureau tober 1982 and has attended every ISASI history. I feel very fortunate that for more 2010—Michael Poole annual conference except two during that than 45 years I have worked not only in 2011—Paul-Louis Arslanian time. He is a former vice president and a field that has enabled me to make con- 2012—Curt L. Lewis treasurer of the Dallas/Ft. Worth Region- tributions to accident investigation, but 2013—Frank Del Gandio and al Chapter and has served as the ISASI also to have been involved in the develop- Myron Papadakis U.S. councillor and U.S. Society president ment and promotion of proactive safety 2014—David King since 2009.” programs such as FOQA, ASAP, IEP, VDRP, 2015—Ladislav (Ladi) Mika “Jerry Lederer would be extremely and LOSA. Once these programs were up proud that Toby is receiving this award. and running, the Aviation Safety Informa- Jerry attended many seminars, and Toby tion Analysis and Sharing program began always arranged his travel. Jerry Lederer in 2007. ASIAS initially began with airlines was like a father to Toby, who has spent and unions sharing de-identified informa- important people in aviation in the 20th a lifetime working selflessly to enhance tion with the FAA to identify trends that century. Jerry truly deserved the title of aviation safety and has done so with the led to significant training, operational, ‘Father of Aviation Safety.’ These are some utmost professionalism and integrity. and maintenance improvements. The of the reasons why I feel so privileged to There is no one more deserving of this program to date has really grown. receive this award that has been named prestigious Jerry Lederer award than “I cannot end tonight without saying a in his honor. To by.” few words about Jerry Lederer. Those of “Finally, I would like to thank the During the first-day opening ceremo- us who were lucky to know Jerry realize person who nominated me; the commit- nies of ISASI 2016 in Reykjavik, Iceland, what a special person he was. Jerry was tee that selected me; Kathy, my support- President Frank Del Gandio, in a surprise humble, he was funny, and, more impor- ive wife of 47 years; and my daughter, move, called Toby Carroll to the speaker’s tantly, he had a wealth of aviation safety Erin—and all of you for making this an platform. Some years earlier, Toby had information that he was willing to share evening that I will always remember. responded to such a call and had been with everyone. He knew many of the most Thank you.”

October-December 2016 ISASI Forum • 15 nderstanding the damage to the was dispatched to the scene to begin the engines involved in an aircraft investigative process. The team arrived on Another accident can provide insight into scene and observed that significant loot- Utheir state of operation at the ing of the wreckage had already occurred. time of impact. In the majority of inves- The majority of the aircraft had been re- Way to tigations, an evaluation is performed moved—including the flight data record- at the accident scene by assessing the er, which was later recovered but was not condition of the blades in the compres- in a useful condition. All that remained Assess sor and turbine sections of the engine. were the two engines midway along, and This classic approach to determining the on opposite sides of, the wreckage path. state of operation of an engine has been Based on observations both on the Turbofan used successfully for many years and has ground and from aerial surveys, it was been widely taught as a fundamental in- determined that the aircraft came in at vestigative tool to generations of aircraft a shallow angle and at a significant bank Engine accident investigators. The fundamental angle with the right wing down (see Fig- premise is that if the blades are bent ure 1). The detailed examination of the ac- Operation against the direction of rotation, the ro- cident site identified both engines. Figure tors were rotating. And if the rotors were 2 shows the engine found on the left-hand rotating, the engines were operating. side of the wreckage. (Figure 7, page 20, During a However, a recent accident involving is of the engine found on the right-hand a large commercial airplane highlighted side of the wreckage. In describing the that this type of assessment has limita- wreckage path, left and right are refer- Crash tions. The on-scene evaluation of one enced looking in the direction of flight). of the engines proved to be mislead- On-scene examination of both engines ing, and the evaluation was changed identified significant differences in the Understanding the following additional assessment. This distress to the fan blades from one engine damage to the engines adapted article will discuss the method to the other. The engine on the right-hand of that assessment. Secondly, it will also involved in an aircraft side of the wreckage path exhibited very describe what information the engines little distress to the fan blades, while the accident can provide yielded about the aircraft ground impact engine on the left-hand side had just the insight into their state sequence, given an absence of the ma- opposite appearance. Further examina- jority of the aircraft. tion of the engine on the right-hand side of operation at the of the wreckage path identified the same time of impact. Here, Accident background lack of distress to the rear-stage turbine the author introduces A twin-engine commercial passenger blades. The on-scene investigation con- jet was reported to have crashed in cluded with a recommendation that the an alternative to the a remote area with thick vegetation engines be examined further to under- classic assessment of similar to what would be found on the stand the differences in their observed compressor and turbine edges of a jungle. A team of investigators levels of distress. blade conditions. Figure 1: View looking against the direction of flight depicting By Douglas Zabawa (MO5843), aircraft bank angle with right wing down. Accident/Incident Investigator, Pratt & Whitney

(Adapted with permission from the author’s technical paper entitled An Additional Approach to Establishing the State of Operation of a Turbofan Engine During an Aircraft Accident presented at ISASI 2016 held in Reykjavik, Iceland, Oct. 17–20, 2016, which carried the theme “Every Link Is Important.” The full presentation, including cited references and omitted images to sup- port the points made, can be found on the ISASI website at www.isasi.org under the tag “ISASI 2016 Technical Papers.”—Editor)

16 • October-December 2016 ISASI Forum Basics of jet hardware was rotating. engine Said differently, the construction faster a rotating part is rotating, the more In simplified energy there is that terms, a jet engine needs to be dissipated. inducts air into This energy dissipa- an intake, com- tion takes the form of presses the air hardware deformation in compressor and distress and thus stages, mixes can provide a measure this compressed as to the state of oper- air with fuel and ation of the engine at then ignites that mixture in the the time of impact. diffuser/combus- Taking this concept tor section, and and putting it to prac- then exhausts the tical application, it is combustion gases worthwhile to examine through turbine a couple of examples. stages that extract Figure 4, page 19, is work to drive the an example of a fan compressor and rotor from an engine that was not rotating/ other ancillary Figure 2: Engine on left-hand side of wreckage path. systems. In a typ- windmilling at the time of impact. (Windmill- ical turbofan en- CIAA Peru Photo credit: gine, the forward ing is a condition of most compression stage(s) is/are called can distort and compromise the struc- unpowered free rotation/spinning, e.g., the fan stage(s). tures involved, including the engines. an unpowered engine.) Note how the The mechanical construction of the This could mean ground impact, water majority of the blades exhibit very little, compressor and turbine sections involves impact, or impact with any other obstruc- if any, deformation. They are straight and the close proximity, usually in an alternat- tions (e.g., trees, buildings, etc.) that were full length. Note also how a sector of the ing pattern, of hardware that rotates and encountered along the wreckage path. blades is buckled. This is interpreted as hardware that remains stationary. The dif- Relating back to the discussion on the meaning that the rotor was not rotating fuser/combustor section, which does not basics of jet engine construction, the dis- at the time of its impact, allowing only contain any rotating hardware, separates tortion of the engine structure itself due the blades that were in the area of the the compressor and turbine sections from to the impact forces brings the rotating deformed case to become deformed. one another. Surrounding all of the static and stationary hardware into contact Figure 5, page 19, is an example of a and rotating hardware are cases that with each other. This contact leaves signa- compressor rotor from an engine that provide the positioning of the rotating tures on that hardware that can then be was rotating at high speed at the time of hardware relative to the static hardware. interpreted by the accident investigator. impact. The blade rows from this example Figure 3, page 18, is a cross-section of an As engine cases distort and intrude into have been liberated completely, folded exemplar turbofan engine. the rotating blades of the compressor over against the direction of rotation or It is this construction, specifically the and/or turbine sections, the blade distress fractured off leaving only stubs of blades close proximity of rotating to stationary is directly related to the rotational speed still attached to the underlying disk. The hardware, that provides the accident of the engine rotors at the time of the in- explanation for this is that the rotor, with investigator with a potentially valuable cursion. As a general rule, the higher the blades attached, was rotating fast enough source of information regarding the state level of damage, the faster the rotating that all of the blades rotated past/into the of rotation of the rotating parts of the engine during the impact sequence. is an accident and incident investigator for Pratt & Whitney. Prior to joining the flight safety investigations group, he was responsible Classic approach to understanding for the planning, execution, and post-test analysis of bird ingestion accident engines and fan blade release tests. Zabawa started his career at Pratt & Due to the dynamics of an accident se- Whitney as a mechanical designer/structures engineer in 1995. He quence, it is typical for an aircraft engine holds a bachelor of science degree in mechanical engineering from to impact the surroundings as opposed Doug Pennsylvania State University (1994), a master of science degree in to coming to rest in a graceful or soft Zabawa mechanical engineering from Western New England College (1999), manner. The dissipation of the energies and a certificate in aviation safety from the University of Southern involved in an aircraft wreckage result in California Viterbi School of Engineering (2008). the generation of significant forces that October-December 2016 ISASI Forum • 17 and low-pressure turbine (LPT) stages of the engine were observed to be in place and intact. No blades fractures in the turbine were identified. There were no findings during the examination of the No. 2 engine that indicated a pre-accident malfunction of the engine. *Examination of the No. 1 engine: Exami- nation of the No. 1 engine did not identify any significant distress to the blades of the first- or second-stage fans. All of these blades were observed to be intact and straight with no significant deformation or distress. Figure 7, page 20, depicts the observed condition of the fan from the No. 1 engine on scene. All of the primary gas path surfaces in the HPC were coated with organic vegetation debris that consisted of dirt and finely chopped wood Figure 3: Cross-section of an exemplar turbofan engine. particles. All of the HPC blades were ob- served to be in place, intact, and straight. deformed part of the engine case. Since as being the No. 2 engine (installed on The combustion chamber outer case all of the blades encountered this intru- the right-hand side of the aircraft) and was noted to be dented inward, con- sion of the case into the rotor, they all the engine on the right-hand side of the sistent with an external impact, from became distressed in a similar fashion. wreckage path as being the No. 1 engine 6:00–9:30 o’clock (clock locations are aft Levels of distress between the extremes (installed on the left-hand side of the looking forward with 12:00 at top dead depicted in Figures 4 and 5 can also be aircraft). center in the installed orientation). The used to infer the state of rotation. Figure *Examination of the No. 2 engine: Exam- domes of the burner cans exhibited a 6, page 20, is an example in which 75 ination of the No. 2 engine identified first- significant deposit/caking of organic percent of the blades are fractured but the stage fan blades that were both fractured vegetation consisting of dirt and finely remainder are full length and straight/ and bent against the direction of engine chopped wood particles. Organic veg- underformed. The energy level of this im- rotation. Additionally, the second-stage etation consisting of a mixture of dirt pact was somewhere between no rotation fan blades that were observable were and finely chopped wood particles was of the engine and high-speed rotation. In all bent against their direction of rota- deposited on the largest diameters along this example, the engine was rotating but tion. Splintered wood was also observed the entire lengths of the individual burner at the low (relative to high-power takeoff) between the blades in both the first- and cans. Figure 8, page 21, depicts the depos- rotational speed of idle. second-stage fans. ited debris on the burner cans. Utilizing the concepts described above Circumferential scoring was observed The inside of the burner cans exhibited to evaluate the accident initially de- on the aft side of the intermediate case. a thin coating of organic vegetation de- scribed, one could come to a potential The forward side of the sixth-stage bleed bris consisting of dirt and finely chopped scenario in which, at the time of impact, cavity was caked with organic vegeta- wood particles. A significant amount the engine located on the left side of the tion debris consisting of dirt and finely of organic vegetation debris, consisting wreckage path was operating while the chopped wood particles. In general, it was of finely chopped wood particles, was engine on the right side of the wreckage observed that the blades in the high-pres- caked around the holes for the burner path was not. sure compressor (HPC) were either cans in the combustion chamber support With the information available from fractured or exhibited damage against the assembly. the on-scene portion of the investigation, direction of rotor rotation. This damage The blades in the HPT and LPT stages and the lack of other definitive data, a consisted of blade bending, leading edge of the engine were observed to be in decision was made to disassemble and and trailing edge breakouts and smearing, place and intact. No blade fractures in examine the engines. and tip curls. The distress within a given the turbines were identified. There were rotating stage was consistent around the no findings that indicated a pre-accident Detailed examination of the engines entire circumference. malfunction of the engine during the examination of the No. 1 engine. During the examination of the engines, All gas path surfaces within the HPC serial numbers permanently marked on were coated with organic vegetation certain engine components were used in that consisted of dirt and finely chopped Engine analysis findings conjunction with the operator’s records wood particles. The domes of the burner *Analysis of No.2 engine findings: The to determine the installed positions of cans exhibited a deposited coating of condition of the fan and compressor stage the engines on the accident aircraft. organic vegetation that consisted of dirt blades in the No. 2 engine were consistent This evaluation identified the engine on and finely chopped wood particles. The with the rotors rotating at the time the the left-hand side of the wreckage path blades in the high-pressure turbine (HPT) engine received its impacts. Furthermore, 18 • October-December 2016 ISASI Forum Figure 4: Historical example of blade damage that occurs at the distress to the fan and com- impact with little or no rotor rotational speed (windmilling). pressor blades as compared to the lack of distress to the turbine blades indicated that the forward portions of the engine were where the initial engine impacts oc- curred, which in turn arrested the rotation of the engine rotors. The circumferential scoring observed on the aft side of the intermediate case was consistent with the HPC still rotating at the time the relative axial positioning of the high-pressure rotor to the intermediate case was lost. This was consistent with the engine ro- tors rotating while the cases were being deformed during the impact sequence. With no findings of pre-impact failure of the No. 2 engine and signs of rotation of the engine rotors at the time of impact of the No. 2 engine, the conclusion was drawn that this engine was oper- ating during the portion of the ac- cident sequence when the engine impacted the trees/ground. *Analysis of No. 1 engine findings: The No. 1 engine did not exhibit the blade distress that is typically associated with an engine that is rotating at the time of its impacts during the accident sequence. The blades also did not exhibit a localized area of distress, such as a quadrant of buckled blades, that could be explained by an engine that was not rotating at the time of its impacts. Both of these points could be explained by the condition of the engine cases. The only significant deformation noted to the engine cases was to the combustion chamber outer case, which does not have any blades in close proximity to it to leave indications as to the state of rotor rotation. With the lack of blade damage to help establish the state of rotor rotation, the investigation focused on understanding the organic debris deposits in the engine. As noted, the debris contained finely chopped wood that was found deep within the engine past all of the compression stages. It was Figure 5: Historical example of blade damage that occurs at determined that for the wood to impact with the rotor at a high rotational speed. have been chopped in the manner

October-December 2016 ISASI Forum • 19 it was, something had to have done work on it, specifically the compressor blades. For this to have occurred, the engine rotors had to have been rotating at the time the engine encountered the trees. It is not feasible to have branches rammed into the front of the engine and still get chopped in the same manner as observed unless that engine was operat- ing under power at the time it encountered the trees. Substantiating further that the engine was operating was the manner in which the debris was deposited on the raised surfaces of the burner cans. The debris was deposit- ed in a manner that was consistent with it being entrained in airflow and then being caught on the high points of the surfaces that the airflow encountered. Again, this pointed to the engine operating and pumping air at the time the wood was being ingested. Finally, as was noted previously, there were some find- ings of finely chopped wood in the No. 2 engine, although significantly less than what was found in the No. 1 engine. Figure 6: Historical example of blade damage that occurs with rotor at low (idle) rotational speed. A qualitative comparison of the wood from both engines assessed that the wood in each engine had been chopped into the conditions of the engines and the aircraft impact sequence. to the same degree. With the mechanical damage to the The relative positions of the engines at the accident site were consist- blades of the No. 2 engine establishing that it was rotating ent with the engines crossing the wreckage path during the accident at the time it sustained its impacts, the finely chopped wood sequence. In other words, the engine installed on the left-hand side of in this engine was determined to be characteristic of what the aircraft (the No. 1 engine) ended up on the right-hand side of the wood would look like when ingested by an engine that was wreckage path, while the No. 2 engine came to rest on the left-hand operating. This provided further substantiation that the No. side of the wreckage path. 1 engine was operating at the time it encountered trees. The knowledge that the engines had crossed the wreckage path was important in further understanding the differences in the observed Understanding engine condition differences levels of mechanical damage within each of the engines. Recalling The determination of the engine installed positions, based that the orientation of the aircraft was right wing down as the aircraft on the operator’s records and positive identification of seri- entered the trees at the accident site, it was recognized that the No. alized components in the engines, provided further insight 1 engine traveled through the thin treetops, while the No. 2 engine encountered the more ro- bust tree trunks that were closer to the ground. The tree trunks pro- vided a more substantial threat to the No. 2 engine in addition to that engine encountering the ground earlier than the No. 1 en- gine during the accident sequence. By contrast, the No. 1 engine traveled through the thin treetops ingesting vegetation as it went along for a relative- ly longer period of time before it came in contact with the ground. This time allowed for the No. 1 engine to ingest the thin debris at the tops of the trees, chop that debris, and deposit it deep within the engine without the engine sustaining the me- chanical damage typically Figure 7: No. 1 engine fan stage as observed at the associated with an engine that is determined to have been operating accident site. at the time it was impacted during the accident sequence. 20 • October-December 2016 ISASI Forum Finally, the dented combus- tion chamber out- er case indicated a significant impact to the No. 1 engine in an area where no blades were present. Thus, there was no incursion of static hardware into rotating hardware within the engine to provide an indication of engine ro- tation, or lack thereof, during the accident sequence. On-scene observation combined with the examination of the engines helped to explain how the engines came to rest on opposite sides of the wreckage path from their installed loca- tions on the aircraft. With the right wing down orientation of the aircraft, it was determined that the No. 2 engine impacted the ground and separat- ed from the aircraft early in the accident sequence. After separation of this engine, it continued to travel in a straight trajectory as the remainder of the aircraft turned to the right and passed the engine. This allowed the No. 2 engine to come to rest on the left-hand side of the wreckage path. The No. 1 engine separated later in time with the aircraft turning right and came to rest on the right- hand side, completing the process of the engines crossing the Figure 8: No. 1 engine burner cans exhibit deposited wreckage path. debris on high spots (largest diameters).

Conclusions the wreckage path during the accident sequence and the The initial on-scene work during this accident investigation observation that the aircraft entered the trees in a right wing- identified differences in the level of mechanical damage be- down attitude, an understanding was reached that the No. tween the No. 1 and No. 2 engines. This difference in mechanical 1 engine (exhibiting no blade damage) entered the tree tops damage suggested the possibility that the No. 1 engine was not and ingested relatively thin vegetation while the No. 2 engine operating at the time of the accident. A disassembly and exam- encountered heavier vegetation and impacted the ground ination of both engines was accomplished to understand the earlier in the accident sequence. The No. 1 engines thus had time to process and accumulate debris before coming to conditions of the engines. rest at the accident site. The manner in which the debris in The examinations confirmed, via the traditional technique of the engine was processed was consistent with having work evaluating the mechanical damage to the compressor blades, (e.g., chopping) performed on it that was consistent with an that the No. 2 engine, located on the left-hand side of the wreck- engine that was operating at the time it encountered trees at age path, was operating at the time of its impacts. Furthermore, the accident site. finely chopped wood deposited within this engine was identified This accident investigation highlighted that the traditional during the examination. method of understanding the state of operation of an engine The examination of the No. 1 engine, located on the right- during an accident sequence can be misleading. An engine hand side of the wreckage path, did not identify the mechanical that was initially suspected of not rotating at the time of its damage signature typical of an engine that was operating during impacts was later determined to have been operating the accident sequence. The examination of this engine did not through a further examination. This examination utilized the identify impacts or distress to the static structure of the engine finding of chopped wood within the engine to establish that that would produce blade distress that could be used to estab- is was operating at the time it encountered trees at the lish the state of rotation of this engine. Detailed examination of accident site. Furthermore, the documentation of the this engine did identify finely chopped wood deposited in the accident scene and positions of the engines were instrumen- burner area of the engine. A qualitative assessment of this wood, tal in understanding why the two engines exhibited different including a comparison with the wood found in the opposite appearances and aided in the explanation of the damage engine, led to the assessment that the engine was operating at observed. the time it encountered trees at the accident site. The positive identification of the installed positions of the engines combined with the survey of the accident scene (The author thanks his colleagues and friends in the Pratt & Whitney further enhanced the understanding of the condition of the Flight Safety Office for their help and support in writing this paper. engines. With the understanding that the engines had crossed Their contributions have been truly valued and invaluable.) October-December 2016 ISASI Forum • 21 CRASH SCENE HAZARD MANAGEMENT: AN UPDATED APPROACH The Canadian Armed Forces (CAF) Directorate of Flight Safety (DFS) has developed an updated approach to crash scene hazard management and welcomes the opportunity to collaborate with other organizations to share best practices and lessons learned.

By Maj. Tyler Brooks, D. Av. Med., Medical Investigator, Canadian Armed Forces Directorate of Flight Safety; and Capt. Claire Maxwell, Rotary-Wing Investigator and Personal Protective Equipment (PPE) Coordinator, Canadian Armed Forces Directorate of Flight Safety n Jan. 21, 2016, an updated Background investigators and CAF aviation medicine approach to crash scene hazard From the early 2000s, crash scene hazard and occupational medicine experts. Thus, management was presented to management in Canada focused largely the previous shopping lists of hazards Orepresentatives of the major air on biohazard protection. This was the were reorganized into five easy-to-re- investigator communities in Canada: the logical consequence of changes in the member categories: 1) Physical, 2) Chem- Canadian Society of Air Safety Investiga- late 1990s to workplace health and safety ical, 3) Environmental, 4) Psychological, tors (CSASI), Transport Canada (TC), the guidelines aimed at protecting the worker and 5) Biological. Transportation Safety Board of Canada from exposure to infectious diseases The DFS then conducted a risk analysis (TSB), and DFS. The updated approach such as Human Immunodeficiency Virus of the five hazard categories using an RM is rooted in the risk-management (RM) (HIV), Hepatitis B, and Hepatitis C. To process. ICAO Circular 315 recommends process recommended by the Interna- emphasize the perceived risk, the annual applying a RM process to crash scene haz- tional Civil Aviation Organization (ICAO) “Personal Protection” training for aviation ards involving the cycle of 1) identifying and is designed as a comprehensive yet accident investigators was specifically hazards, 2) identifying exposure routes, straightforward evidence-based approach called “Blood-Borne Pathogen (BBP)” 3) assessing risk, 4) introducing controls, to managing crash scene hazards. training. and 5) reviewing and revising the risk Unfortunately, the emphasis on biohaz- assessment. Rather than applying RM at ard protection sometimes overshadowed the time of a crash, the DFS decided to other potential hazards at aviation crash take the ICAO recommendations one step scenes. Anecdotally, there was concern further and pre-assess the likely hazards. at the DFS (the independent investigator With primary focus on the CAF aircraft of CAF aircraft accidents) that some CAF fleets, the DFS gathered evidence from flight safety personnel were emerging scientific and medical literature, haz- ardous material safety data, and expert Maj. Tyler Brooks from training with the impression that infectious diseases were the primary haz- consensus to assess the overall risk of is currently the medical and human ards at a crash scene. Over time, the DFS each hazard category. The pre-assessment factors investigator with the Directorate attempted to supplement BBP training was intended to give investigators a “head of Flight Safety. He is a flight surgeon with with instruction on other hazards, such start” when confronting a crash scene, a diploma in aviation medicine (UK) and as chemical, explosive, and radiological allowing faster and more accurate risk is a former tactical helicopter pilot on the hazards. But this led to ever-growing assessment, safer scene hand over, and Griffon helicopter. “shopping lists” of specific hazards that improved safety measures. were difficult to remember and not con- Applying this RM process, the DFS textualized in terms of the actual risks ultimately assessed that there was a low they posed. risk associated with biohazards (e.g., HIV, In 2015, the DFS began a review of Hepatitis B, and Hepatitis C) at a crash its crash scene hazard training pack- site. This assessment was based on reas- age, ultimately leading to this updated suring information from the U.S. Centers approach that is believed to benefit not for Disease Control and Prevention, the Public Health Agency of Canada, and a Capt. Claire Maxwell only Canadian air investigators but also international air investigators. thorough literature search for document- is currently a rotary-wing accident in- ed cases of disease transmission from vestigator with the Directorate of Flight Method aircraft accident sites. Moreover, consid- Safety and coordinates the provision of The DFS reviewed the ICAO guidance eration was given to advances in medi- personal protection equipment for Cana- provided in Circular 315, “Hazards at cal science since the creation of health dian Armed Forces flight safety personnel. Aircraft Accident Sites,” which discusses and safety guidelines in the 1990s. For After graduating from the Royal Military specific crash scene hazards and groups instance, Hepatitis B transmission can be College of Canada with a BSc in space them into categories. The DFS adopted prevented with vaccination, HIV trans- sciences, she served as a combat support this consolidated hazard categorical mission can be prevented with post-expo- and tactical helicopter pilot on the Grif- approach but made slight modifications sure prophylactic treatment, and Hepa- fon helicopter. to the individual ICAO categories after titis C can now be medically cured. Thus, broad consultation with the DFS accident the relatively low risk of biohazards can

22 • October-December 2016 ISASI Forum be put in proper context for accident CSASI, the TC, and the TSB in January 2016. investigators. Coincidentally, each group was considering a periodic review of its own crash scene hazard Authors’ Crash scene hazard matrix management and BBP training packages. Each Comment In the end, the DFS produced the following group subsequently agreed to collaborate We would like to thank matrix describing the minimum expected risk with the DFS to further develop the proposed the following people for level of each of the five crash scene hazard approach and to determine how to best their contributions toward this endeavor: categories. The matrix is intended to serve as incorporate it as the basis for crash scene a quick reference and simple starting point for hazard management within their respective Barbara Dunn, the CSASI; crash scene hazard management. At the same organizations. Nora Vallée, Occurrence time, investigators remain free to modify the Response Analyst, Flight risk levels when necessary based on specific Operations, the TC; Leo Conclusion Donati, Director Opera- crash site circumstances. The DFS has re- This common approach is expected to en- tional Services, the TSB; written the chapter on “Crash Scene Hazard hance interoperability and allow collaboration Susan Greene, Manager Management” (previously entitled “Blood- on future work, such as the rationalization of Multi-Modal Training Borne Pathogens”) in its Airworthiness Inves- PPE. To promote a greater understanding of and Standards, the TSB; tigation Manual (the investigation standards crash scene hazard management, the DFS Beverley Harvey, Senior Investigator International manual for the CAF). The new approach is welcomes the opportunity to collaborate with being taught in the CAF flight safety course for Operations and Major In- other organizations, both nationally and vestigations–Air, the TSB; aircraft accident investigators and the medical internationally, that would like to share their course for aviation medicine providers. Dr. Joan Saary, Occupa- best practices and lessons learned. Hopefully tional Medicine Specialist, our shared knowledge will give our accident Canadian Forces Environ- Collaboration investigators a better idea of the risks that they mental Medicine Estab- The DFS felt that the entire Canadian air may encounter at a crash scene and will result lishment, the CFEME; Maj. investigative community could benefit from its in them being better prepared to protect them- Rachel Morrell, Military work and, as stated earlier, presented it to the selves and others at the site and afterwards. Medicine, the CFEME; Maj. Nathan Nugent, School of Operational Medicine, the Crash Scene Hazard Matrix CFEME; Col. Pierre Moris- sette, Royal Canadian Air Hazard Exposure Route Risk Control Force Surgeon, CF Health • Broken structures • Cuts HIGH • Control access Services Group HQ; Lt. Col. • Carbon fiber (CF) • Punctures Likely probability • Avoid/cordon Helen Wright, 1 Canadian • Stored energy • Crush Critical severity • Disarm • Explosives • Inhalation/ingestion • Severe injury and/or • Apply fixant (CF) Air Division Surgeon, the †

Physical • Radiological • Contact/proximity • Significantly degraded • Decontaminate CAF; Maj. Tarek Sardana, operational capability • No eating on site SO Aerospace Medicine, • Wear PPE the CAF; Maj. Carmen • Petroleum, oil, • Inhalation MEDIUM • Control access Meakin, Clinical Leader for lubricants/fluids • Ingestion Likely probability • Avoid/cordon Mental Health, the CAF; Lt. • Metals/oxides • Contact Moderate severity • Neutralize Col. Martin Leblanc, Chief • Viton (rubber) • Minor injury and/or • Decontaminate

Chemical • Degraded operational • No eating on site Investigator, the DFS, the capability • Wear PPE CAF; MWO Gary Lacour- siere, Technical Investi- • Cold/heat Variable MEDIUM • Control access • Fatigue Likely probability • Implement site security gator, the DFS, the CAF; • Insects/wildlife Moderate severity • Apply work/rest cycles Capt. Roger Dib, Director • Enemy/security • Minor injury and/or • Feeding/hydration Aerospace Equipment • Political situation • Degraded operational • Insect repellent/ Program Management capability sunscreen/tick removal • Wear clothing appropriate (Fighters and Trainers) Environmental for the weather 3-2-2, the CAF; WO Wil • Wear PPE Tyhaar, Director Aero- space Equipment Program • Traumatic exposure†† • Direct exposure MEDIUM • Control access • Indirect exposure Likely probability • Apply work/rest cycles Management (Transport (vicarious trauma, Moderate severity • Monitoring and Helicopters) 2-3-2-3, narratives) • Minor injury and/or • Limit exposure and control the CAF. • Degraded operational information release

Psychological capability • Wear PPE

Blood-borne pathogens • Cuts LOW • Vaccinate††† • HIV • Punctures Unlikely probability • Control access • Hepatitis B/C • Via mucous Critical severity • Decontaminate

Biological membranes • Severe injury • Wear PPE † Although the injury sustained from radiological hazards could be severe, the probability of exposure is considered improbable, and therefore the risk is considered low. †† The potential for severe traumatic exposure may increase the assessed risk level to high in certain circumstances, ††† Advance vaccination is encouraged and could be mandatory for all personnel who attend a crash scene.

October-December 2016 ISASI Forum • 23 FIVE RECEIVE ISASI SCHOLARSHIPS THE ISASI RUDOLF KAPUSTIN MEMORIAL SCHOLARSHIP PROGRAM HAS SELECTED FIVE STUDENTS TO RECEIVE ITS BENEFITS. By Esperison Martinez, Editor

his year’s ISASI Rudolf Kapustin Balentine noted, “It is truly amazing to 1,500 words (+/- 10%). Memorial Scholarship marks a new have received so many outstanding ap- In addition, the requirement remains chapter for this program, which plications for this prestigious scholarship that an applicant must be enrolled as a Twas established in 2002 to memo- that is solely funded through the generous full-time student in an ISASI-recognized rialize all deceased ISASI members. The donations of ISASI members. Designed to education program, which includes cours- scholarship was named in honor of Rudy encourage and attract college students in es in aircraft engineering and/or opera- Kapustin, the former ISASI Mid-Atlantic the areas of aviation safety and investiga- tions, aviation psychology, aviation safety Regional Chapter president, who died in tions, previous winners have ultimately and/or aircraft occurrence investigation, 2002. Throughout his long career, Kapus- found careers as college professors and etc., with major or minor subjects that tin was always a strong safety advocate. manufacturer and accident investigation focus on aviation safety/investigation. After 14 years of dedication to the board investigators. This program truly is An award of US$2,000 is made to each program and the selection of 40 Kapustin working, and I look forward to seeing the student who wins the competitive writ- scholars, Richard Stone and Ron Schleede remarkable contributions that this year’s ing requirement, meets the application have handed the baton to a new selection recipients will bring as they finish their requirements, and who registers to attend committee, chaired by Chad Balentine, education and begin their careers.” the ISASI annual seminar. The award will ISASI’s secretary. Balentine, along with In addition to a new selection commit- be used to cover costs for the seminar Alicia Storey and Erin Gormley, reviewed tee, this year also set forth new schol- registration fees, travel, and lodging/meal the 14 applications submitted and select- arship application criteria. Per the new expenses. Any expenses above and beyond ed the authors of four essays, one with criteria, an applicant the amount of the award will be borne • needs to have demonstrated a gen- dual authorship, to be the 2016 recipients by the recipient. ISASI corporate mem- uine interest in aviation safety and of the scholarship. The new Kapustin bers are encouraged to donate “in kind” accident investigation/prevention. Scholars are services for travel or lodging expenses • Andre William Woenardi, University This includes being an active member to assist student scholarship recipients. of Southern California, Los Angeles, of his or her student chapter (if one California, USA, and Yasmeen Syed, exists). Verification will be conducted Member contributions have provided an University of Southern California, by the professor signing the applica- annual allocation of funds for the scholar- Viterbi School of Engineering, Los tion. ship. Contributions are tax-deductible in the U.S. and may be made in the name of a Angeles, California, USA, dual authors • will be required to obtain a letter of of the essay AirAsia 8501: Echoes of Air recommendation from his or her specific deceased member payable to the France 447? professor, academic tutor, or faculty ISASI Rudolf Kapustin Memorial Scholar- • Taylor Beall, Delft University of Tech- mentor. ship fund and sent to the ISASI main office. Application and scholarship availability nology, the Netherlands, author of • needs to be a student member of New Materials, New notices are posted in some 50 colleges and the essay ISASI to apply for the scholarship Challenges? universities worldwide. ISASI members are (the membership application may ac- • Jiaqi Cao, Cranfield University, UK, company the scholarship application encouraged to promote the scholarship author of the essay The Challenges for submission). to individuals, student groups, parents, Air Safety Investigators: Exploring Po- and applicable departments at their alma tential Link to Achieve Real-Time Data • will be required to submit a profes- maters. Members are also encouraged to sional résumé that includes activities Transmission. assist in securing and completing applica- associated with ISASI’s aims. • Carly Christian Shoemake, Emb- tions for any appropriate student(s). ry-Riddle Aeronautical University, • will be required to sign the applica- The deadline for applications is April 15 Daytona Beach, Florida, USA, author tion, acknowledging that the essay is of each year. Full application details and of the essay Social Media in Crisis his or her “original” work. forms are available on ISASI’s website, Communication. • is required to submit an essay of www.isasi.org.

THE FOLLOWING ARE THREE OF THE FOUR 2016 AWARDEES’ WINNING ESSAYS, AS SUBMITTED. THE FOURTH WILL BE PUBLISHED IN THE NEXT ISASI FORUM.

24 • October-December 2016 ISASI Forum AirAsia 8501: Echoes of Air France 447? An Examination of the Factors that Led to the Fatal Crashes and Their Effects on Aviation Safety By Andre Woenardi and Yasmeen Syed

n June 1, 2009, Air France Flight 447 in aircraft automation have Andre William Woenardi Obound for Paris, France, crashed into dramatically improved airline the Atlantic Ocean, taking the lives of safety, enhanced efficiency 21, born in Singapore, calls Jakarta, Indonesia, 228 passengers. Despite the consequent and performance, increased his hometown, where his parents still reside. improvements to the Airbus automation fuel economy, and reduced He is presently living in Los Angeles, California, system and pilot training, the issues in pilot workload. Conversely, the U.S.A., and attending the University of Southern aviation safety magnified from the Air advent of cockpit automation California. His present course of study, which France crash manifested once again near- has also evolved the role of the he expects to complete in 2017, is industrial ly four and a half years later in the tragic pilot “from manually flying the system engineering. He holds a bachelor of accident of AirAsia Flight 8501. This aircraft to spending a majority science undergraduate degree. Andre plans to essay seeks to explore the critical issues of their time monitoring flight graduate and gain working experience in the shared by both aviation disasters and deck systems.”3 Yet, paradox- U.S. before returning to Indonesia to make a their subsequent impact on the future of ically, pilots are still expected to real difference in his country as he works to aviation safety. Although many factors fly extraordinarily in the face of become a professional in the field of manage- were prevalent in both accidents, the a crisis, given little direct expe- ment consulting, specializing in human factors following research will focus on the loss rience or nonsimulator practice and work design. of situational awareness and its contribu- to do it. Another consequence tion to the downfall of two state-of-the- of the advancement of cockpit art commercial Airbus aircrafts. automation is its increasingly On Dec. 28, 2014, Indonesia AirAsia complex cockpit interface. Pi- Flight 8501, traveling to Singapore, lots, in their new role as system disappeared into the Java Sea after pilots operators, struggle to fully responded incorrectly to a malfunction understand the intricate system Yasmeen Syed in the rudder travel limiter (RTL). Shortly they work with—the “problem” after the first officer, the pilot flying no longer as transparent as it 20, was born in Burbank, California, U.S.A., (PF), requested permission to climb to once was in older mechanical and resides in Glendale, California, where her avoid storm clouds, four master cautions cockpits. parents continue to live. She attends the Uni- activated signaling the failure in the RTL. In the event of an automation versity of Southern California’s Viterbi School The crew performed standard procedures failure, they experience difficulty of Engineering in Los Angeles and is pursuing in response to the first three cautions but fixing a problem they cannot a master’s degree in industrial and systems deviated from procedure after the fourth identify, especially under ex- engineering. She holds a bachelor of science alert by removing and reinserting the cir- treme stress and pressure. Pilots’ degree in industrial and systems engineering. cuit breakers of the flight augmentation skill degradation, coupled by the Yasmeen is currently interning at the NASA computer (FAC). This action disengaged complexity of a highly automat- Jet Propulsion Laboratory for the Asteroid the autopilot and stall protection by ed cockpit, results in the loss of Redirect Mission. Asked about her aspirations shutting off part of the fly-by-wire system situational awareness—defined and future plans, she said, “I would like to mid-flight. As a result, flight control shift- by Airbus as “having an accu- continue developing a deep, comprehensive ed from normal law to alternate law1; and rate understanding of what is understanding of technological systems to for nine seconds, nobody was flying the happening around you and what better identify and mitigate the risks they pose. plane. According to the aircraft accident is likely to happen in the near Given my passion for rock climbing and foren- investigation report released by Komite fu tu re .” 4 The challenges that sic novels, I’ve always had an interest in solving Nasional Keselamatan Transportasiii overreliance on automation and challenging problems. But it wasn’t until I took (KNKT2, Indonesia’s accident investiga- the resulting degradation of situ- a USC course in human factors engineering tion authority), “Subsequent flight crew ational awareness create for avi- and work design that I realized I could apply action leading to inability to control the ation safety have been prevalent my interests toward a career in aviation safety aircraft in the alternate law resulted in and catastrophic since the birth and accident investigation. After immersing the aircraft departing from the normal of cockpit automation. Yet, the myself in the research, I was immediately flight envelope and entering prolonged issue continues to be portrayed drawn to a field where my investigative skill set stall condition that was beyond the ca- time and time again in aircraft could be showcased and my work would have pability of the flight crew to recover.” The accidents such as AirAsia 8501, a lasting impact. Going forward, I hope to use missteps of the flight crew exposed their posing enduring obstacles for my ISASI Kapustin experience as a platform loss of situational awareness after the air safety investigators. to pursue work in the aviation industry as a sudden onset of automation failure. The pilots’ loss of situational system engineer to bridge the gap between Over the past few decades, advances awareness in Flight 8501 was human operators and technological interfaces.

October-December 2016 ISASI Forum • 25 most clearly reflected by the confusion look across to the other side of the flight expert in aviation safety, “Most of the and disunity bred by the cockpit design. deck.”6 Unlike traditional yokes that are training relies on the pilots to look up Radar data showed that the Airbus A320 mechanically connected, this fly-by-wire the solution in a checklist, without giving was climbing at 6,000 feet/minute, more design severs the connection between the them the time in the training program than three times the climb rate commer- pilots, perpetuating the loss of situational to actually practice all the various failure cial airplanes are designed for, before its awareness, which diminishes any hope of modes. In both Air France and AirAsia, crash. The abnormally steep ascent was recovery. there was not enough time to look up explained by the first officer’s operation The same findings were concluded in anything in the checklist. Their train- of the control stick at extreme pitch the 2009 Air France 447 accident. The ing probably didn’t include those types attitude, climbing at a rate of up to 11,000 Airbus A330 crashed into the Atlantic of scenarios.” Moss draws attention to feet/minute and triggering stall warn- Ocean following the pilots’ inappropriate shortcomings of pilot training programs ings. In response, the captain, the pilot response to unreliable airspeed data. Sim- and their inability to evolve with the rapid monitoring (PM), repeatedly instructed ilar to AirAsia, the flight control system progress of automation—the implication the PF to “pull down!” when he actually was misbehaving due to technical fail- of this finding suggesting that insufficient intended for the first officer to push the ures, and the flight crew struggled to un- pilot training breeds the loss of situa- stick forward (pushing the nose down) to derstand what had gone wrong. Possibly tional awareness responsible for recent regain speed and recover from the stall. under the assumption that he was oper- aviation accidents, including Air France The miscommunication may have been ating at low altitude, the PF of Air France 447 and AirAsia 8501. a consequence of high stress and the pulled the sidestick back into a steep A growing threat to the culture of obligation of the pilots, both of different climb for most of the flight—mirroring aviation safety, degraded situational nationalities, to use English—a second the actions of the PF on the Indonesian awareness is cited by the Australian language for both. Confused, the first airline. From bad weather and inadequate Transportation Safety Board (ATSB) to officer continued to pull up and urged the technical maintenance to pilots’ extreme be the cause of 85% of incident reports8. captain to grab his own control and push overcorrection, the similarities between The exorbitantly high statistic reveals a forward. However, the captain overlooked the two Airbus tragedies ensued as the troubling trend of the rise of accidents the fundamentals of CRM5 and failed to pilots of AirAsia failed to acknowledge the involving human factors and pilots’ mis- communicate his action to the PF, result- aircraft was stalling throughout the en- management of the situation, the most re- ing in the pilots’ opposing inputs neutral- tirety of the aircraft’s descent, continuing cent including the 2015 TransAsia crash, izing each other. With an extreme angle to express confusion about its status until where pilots’ loss of situational awareness of attack and inadequate airspeed, the its final moments7. due to the complexity of the engine throt- aircraft continued to stall and descend This trend of diminished situation- tle system led to the flight’s collapse. With until the aircraft disappeared from the al awareness in aviation crashes is the continual advancement of automa- radar. undoubtedly caused by the perpetual tion in the aviation industry, new hazards While miscommunication was a crucial advancement of cockpit automation. quietly emerge and jeopardize the safety factor, the cockpit design prevented the Due to the reliability and convenience and welfare of all those on board. The captain from gaining situational aware- of automation, aircraft are now easier to fatal accidents of Air France 447 and ness of the aircraft’s operation, leading fly and have, in turn, reduced the time AirAsia 8501 urge the need for a harmo- to the stall. Despite reducing pilots’ and scope of pilot training programs. As nious relationship between pilot training responsibility by allowing them to let computers replaced manual operations, and automation to overcome habits of the go of the stick and focus on other tasks, training programs were curtailed from past and drastically improve passenger automation also fosters error by keeping months to weeks. However, the shortened safety. the second pilot’s stick neutral while the training time focuses on learning how to Special thanks to Mr. Daniel Scalese and other is in use. Because the PF’s stick is operate the automated system, neglecting Mr. Tom Anthony of USC Aviation Safety held back for only a few seconds, “it’s not to teach pilots how to manually operate and Security, Capt. Douglas Moss of United immediately apparent to one pilot what aircrafts and work through emergencies Airlines, and Capt. Abdulsalam Sardouk the other may be doing with the control and anomalous procedures. According of Middle East Airlines for their insightful stick, unless he makes a big effort to to Capt. Douglas Moss, an A320 pilot and comments and support of this research.

References 1 “Normal law” is the flight control system that intervenes to protect against 5 Crew Resource Management, a philosophy centered on interpersonal com- stalls, while “alternate law” eliminates stall protection and involves more munication, leadership, and decision making in the cockpit. manual operations. 6 Ross, Nick, and Neil Tweedie. “Air France Flight 447: ‘Damn It, We’re Going to 2 Komite Nasional Keselamatan Transportasi (KNKT). Aircraft Accident Inves- Crash.’” The Telegraph. Telegraph Media Group, n.d. 07 Apr. 2016. tigation Report Air Asia 8501. p.14 Rep. no. KNKT.14.12.29.04. N.p.: n.p., n.d. 7 France. Bureau d’Enquêtes et d’Analyses. Ministère de l’Écologie. Final Report 1 Dec. 2015. Web. On the Accident on 1st June 2009 to the Airbus A330-203. By BEA. N.p.: n.p., 3 United States. Federal Aviation Administration. Department of Transpor- 2012. Print. tation. Enhanced FAA Oversight Could Reduce Hazards Associated with 8 Airbus. “Enhancing Situational Awareness.” Flight Operations Briefing Notes Increased Use of Flight Deck Automation. By Matthew E. Hampton. N.p., 7 (2015): 1490. Web. Jan. 2016. Web. 4 Airbus. “Enhancing Situational Awareness.” Flight Operations Briefing Notes (2015): 1490. Web.

26 • October-December 2016 ISASI Forum New Materials, New Challenges? By Taylor Beall, TU Delft

s time progresses, so do the technol- als, both are currently repaired A ogies used in support of the aircraft in the same way; drilling and industry. One major shift in recent years riveting a metal doubler patch is Taylor Beall is a migration towards new materials, the certified repair for primary particularly fiber reinforced polymer structure. This approved method 24, is a dual U.S./German citizen pursuing a composites. The newest aircraft have seemingly accepts some higher master’s degree in aerospace engineering with large portions of their structure made level of risk due to composites a specialization in structures and materials at from these novel materials; however, it is not behaving ideally when the Delft University of Technology in the Neth- still not completely known how normal drilled. There is a risk of delam- erlands and expects to graduate in 2017. She conditions, or in some cases abnormal ination during drilling and the holds a bachelor of science degree with honors conditions, will affect these lighter, riveting process introducing ar- in general engineering from Smith College in stronger structures. Although the number eas of bearing stress, something the U.S.A., and spent her junior year abroad of major air accidents has continuously that composites are not strong in Hamburg, Germany. Taylor is a member of decreased throughout the years, also not against. Additionally, since the the research society Sigma Xi, German society completely answered is what the effect of thermal behavior of the doubler Delta Phi Alpha, and is an engineer in train- these new materials will be in an accident patch is not the same as the ing (EIT). She has always been interested in scenario. In the 1960s, the typical amount underlying material, changes in quality-control aspects of aviation as well as of composite material on an aircraft environmental temperature will safety in all she does. From the educational was 1% to 3% by structural weight. This introduce additional stresses experience gained at the conference and from amount slowly increased until there into the structure that must be the courses offered, she hopes to work as an air was a major jump in the percentage of taken into account. However, safety investigator or other position in the air composites used in the new Airbus A350 even with the disadvantages safety sector, perhaps after pursuing a Ph.D. or and Boeing 787, which contain more than of this method, maintenance other training/educational programs. 50% composite material.1 The continually groups are well versed in how shifting ratios of metals and composite to properly perform this estab- materials, each with differing thermal lished technique, albeit with and structural properties, might present possible problems when drilling unknown challenges. composites. Another issue with the bonded repair method is Compared to the traditional metals As illustrated by both the that it is not as easily applied in normal mainte- used in aircraft construction, the research Japan Airlines Flight 123 (JAL nance conditions. While a temporary repair can be and knowledge about the long-term and 123)3 and China Airlines 611 a patch8, the permanent repair usually requires a catastrophic behavior of composites are incidents4,5, there have already step-down grinding method, essentially followed still in the beginning phases. Work to fill been repairs that have caused by relaminating the composite in the affected in our knowledge gaps is being done in loss of life. In the case of JAL area. This is not a simple approach to apply, as the many areas, including the effect of fire 123, the repair was properly grinding is done by hand and must be very precise, and impact, as well as others. designed; however, it was incor- and strict environmental controls are required. The U.S. Federal Aviation Administra- rectly installed. As the aviation Some repairs have already failed due to suboptimal tion (FAA) has identified four areas of industry migrates to bonded application conditions9, something if implemented safety concern with using these novel repairs, a major challenge will on a wider scale might end up costing lives. materials: “(1) limited information on be to ensure proper training and This leads to the question of what tolerance the behavior of composite airframe maintenance oversight to reduce margins are acceptable for this type of repair. structures, (2) technical concerns related errors in standardized and tight- For example, some grinding activities require an to the unique properties of composite ly controlled processes. accuracy of a tenth of a millimeter.10 It has not yet materials, (3) limited standardization of The advantage of bonded been firmly established how much error in grind- composite materials and repair tech- repair is that it closely matches ing depth, or applying and feathering the patch, is niques, and (4) level of training and the strength and properties of permitted for the repair to still be effective. Simi- awareness on composite materials.”2 This the original structure.6 Unfortu- larly, the overall effect of different combinations of recognized lack of information and lack nately, this method is still being application variables is not well documented. of standardization presents both systemic evaluated for general use and is Once a repair has been applied, actively used and application-specific challenges to the not yet certified.7 As well, in in- aircraft, such as those in commercial aviation, have aviation industry. troducing a new repair method, an increased probability of repeated impact and Improper repairs can cost lives, and new training and certified stand- damage in the same areas. The effects of multiple the third concern begs a discussion of ards will need to be established impacts have not been extensively explored, par- how composite airframe structures are to ensure that maintenance ticularly on areas that have been repaired. Riveted currently repaired. Despite that fact that operations everywhere can per- doublers on composite materials may actually composites behave differently from met- form a repair of the same quality. make multiple impacts more problematic. The

October-December 2016 ISASI Forum • 27 rivets transfer impact forces to all layers of the Ethiopian Airlines 787, the entire due to the number of plies in the material, of the underlying material, which works upper skin was replaced for the barrel with each added ply requiring the area well with homogeneous materials such section of the fuselage in front of the tail, of the patch to be increased, to provide a as aluminum, but may not be ideal for an area much larger than the exterior sufficiently gradual step-down feathering heterogeneous materials such as fiber visibly damaged section.12 While nonde- area to reach all the damaged plies in the composites. On the other hand, although structive techniques are very important material.10 However, most likely the non- the impact load transfer may be better for in determining the extent of fire damage, destructive inspection techniques will be laboratory-quality “perfect” bonded re- there could be an as yet unknown effect invaluable in reducing risk and confirm- pairs, the chance of slight misalignments or damage type combining short-term ing that repairs are functioning properly. or other small defects may reduce the damage (fire, impact) with longer-term In theory, and in the ideal situation, the effectiveness of the repair. Additionally, it damage (fatigue, aging of materials) benefits of increasing composite material is not known if the effect of normal aging where the nondestructive techniques use vastly outweigh any negative chal- of the material will induce problems, used will be very important. Using the in- lenges. However, there is not yet enough compounded by multiple impacts. With correct method due to the unknown type empirical data about the behavior of the so many factors at play, with quite a few of damage expected could cause damage new composites in all possible situations, still not well studied, it is possible that to grow unchecked and could cause cata- particularly following repair. How the currently accepted repairs to composites strophic failure. materials will age, and the effect of normal could cost lives due to these partially To determine if there is damage within wear, including minor impacts, requires understood effects. a structure and material, nondestructive much more research. With such a large Another area of study is the effect of fire inspection techniques are used. These increase in the use of composite materials on composite materials. During the fires techniques vary in their effectiveness, across the aviation industry, some of these aboard the fledgling Boeing 787 aircraft, depending on the specific situation and unknowns will be established through ac- the composite material was charred, but type of damage. Further research and tual use case studies, and associated certi- the localized damage was not as extreme development of improved standards are fications can expect to be updated accord- as with metal fuselages. The battery fire needed. Also, since composite damage is ingly. As information is steadily gathered, aboard the Ethiopian Airlines plane did not always visible, particularly in the case the challenge for air safety investigators not actually penetrate the composite ma- of physical impacts, more rigorous stand- will diminish. During this initial phase of terial, despite a large amount of damage.11 ardization of techniques to determine widespread composite material imple- However, this improved local perfor- possible damage will most likely need mentation, it is unfortunately likely that mance of the composite material exposed to be pursued. Since an impact normal there will be incidents and accidents that to fire may not tell the entire story. to the fiber is in the weakest strength will improve our understanding. Hopefully There may be possible difficulties when direction for composites, a relatively mi- through experimentation, inspection, and repairing the aircraft, and future failures nor impact for an aluminum skin might data collection, the possibility of these of the structure may result. Since car- produce less visible damage for a com- incidents occurring will decrease over bon fibers are excellent conductors, the posite structure, although the composite time, and our understanding and effec- heat from the fire may not be localized structure might be significantly more tiveness and quality of repairs will vastly and can potentially spread, melting or compromised.9 This can be due to delam- increase. Improper repairs can cost lives, compromising the adhesive layers within inations and other internal interply dam- but through further research the behavior the composite material in adjacent areas. age between composite layers, something of these repairs will be better understood, For repair of fire-damaged aircraft, we that can be very problematic but invisible and the challenge for air safety investiga- need a better understanding of how far to the human eye. A relatively minor im- tors to accurately determine cause and the heat damage can extend. In the case pact may ultimately require a large repair effect, at all levels, will be improved.

References 1 X. Jian and L. Yao, “Study on Airworthiness Requirements of Composite Aircraft for the environmental certification of adhesively bonded repairs,” no. DS- Structure for Transport Category Aircraft in FAA,” Procedia Eng., vol. 17, pp. TO-RR-0282, 2004. 270–278, 2011. 8 M.A. Caminero, S. Pavlopoulou, M. Lopez-Pedrosa, B. G. Nicolaisson, C. Pinna, 2 Gerald L. Dillingham, “Status of FAA’s Actions to Oversee the Safety of Composite and C. Soutis, “Analysis of adhesively bonded repairs in composites: Damage Airplanes,” United States Gov. Account. Off. Rep. to Congr. Requesters, no. GAO- detection and prognosis,” Compos. Struct., vol. 95, pp. 500–517, Jan. 2013. 11–849, 2011. 9 K.B. Katnam, L. F. M. Da Silva, and T. M. Young, “Bonded repair of composite 3 Aircraft Accident Investigation Commission Ministry of Transport, “Aircraft Ac- aircraft structures: A review of scientific challenges and opportunities,” Prog. cident Investigation Report, Japan Air Lines Co., Ltd., Boeing 747 SR-100. JA8119 Aerosp. Sci., vol. 61, pp. 26–42, Aug. 2013. Gunma Prefecture,” 1987. 10 D. Mathijsen, “How to repair composites,” Reinf. Plast., vol. 59, no. 6, pp. 287–290, 4 Aviation Safety Council, “In-Flight Breakup over the taiwan strait northeast of Nov. 2015. Makung, Penghu Island–China Airline Flight CI611–Volume I,” Aviat. Occur. 11 G. Norris and J. Croft, “Boeing’s Latest Challenge Is Repairing Ethiopian’s 787,” Rep., vol. I, no. ASC-AOR-05–02–001, 2002. Aviation Week Intelligence Network, 2013. [Online]. Available: http://awin.avi- 5 Aviation Safety Council, “In-Flight Breakup over the taiwan strait northeast of ationweek.com/ArticlesStory/tabid/975/Status/IPAddress/id/4b0b10ef-b5a7- Makung, Penghu Island–China Airline Flight CI611–Volume II,” Aviat. Occur. 4f32-ae0d-558b282bca27/Default.aspx. Rep., vol. II, no. ASC-AOR-05–02–001, 2002. 12 G. Norris, “Boeing More Than Halfway Through Repairing Fuselage On Ethiopian 6 A.A. Baker, “Repair of cracked or defective metallic aircraft components with 787,” Aviation Week Intelligence Network, 2013. [Online]. Available: http:// advanced fibre composites–an overview of Australian work,” Compos. Struct., awin.aviationweek.com/ArticlesStory.aspx?id=eb8c9380-3078-4347-a6b4- vol. 2, no. 2, pp. *153–181, 1984. 2305ff61aabe. 7 A. Rider, R. Vodicka, and DSTO, “Proposed framework for a risk-based approach

28 • October-December 2016 ISASI Forum Social Media in Crisis Communication By Carly Shoemake

s the demand for air travel has grown or an airport today. There is no Aover the last several decades, the avi- longer the luxury to respond in ation industry is forced to become more two hours, or even 20 minutes.” Carly Shoemake dynamic in order to keep up. The industry (Nigam, SimpliFlying) After a is compensating for this need in the form crash, social media picks the 21, calls Baton Rouge, Louisiana, U.S.A., home of more aircraft, companies, and also story up before the airline even and presently lives in Daytona Beach, Florida, more refined regulations; however, one knows what is going on, making U.S.A., while attending Embry-Riddle Aeronau- area that the industry has neglected to ad- responding to a crash a difficult tical University. Her present course of study is dress has been that of communication— dance acknowledging the event, toward a bachelor of science degree in interdis- specifically, before, during, and after a cri- clearing up rumors, and updat- ciplinary studies with minors in occupational sis. While communicating with the public ing with facts as they are found. safety, human factors, and communications. has always been a task for investigators or With so many social media Carly expects to complete her studies in 2017. even the industry in general, social media outlets and so little time, the She is a student pilot and has worked for sites like Facebook and Twitter have now overwhelming nature of crisis airlines and the FAA. Upon graduation, she become more prominent in the everyday communication can make it very will seek an entry-level position in the field of use of society. Social media is now a main tricky to get it right. It’s impor- accident investigation, preferably with the U.S. source of news for much of the public so tant to recognize that there is a National Transportation Safety Board. when a crisis arises, it is no surprise that wrong way to communicate to many choose to post, share, re-tweet, and the public after a crisis. re-gram their and others’ experiences. The Malaysia Airlines Flight “If the flight is about six hours. Why is the search challenge for air safety investigators arises 370 departed Kuala Lumpur, taking longer to find that plane? [sic]” (Facebook). when the airline or participating party Malaysia, on Saturday, March 8, The lack of response led to public skepticism of does not have an effective social media 2014, and was headed to Beijing, the airline’s integrity and overall safety. However, communication strategy included in their China. Contact was lost with the the crash of Malaysia Airlines Flight 17 provided a emergency response plan to combat the Boeing 777 at 2:40 AM some- perfect opportunity for the airline to try again. speed at which information spreads. where over the Indian Ocean and Malaysia Airlines Flight 17 was due from Am- In order to understand how to respond was never regained. To this day, sterdam, Netherlands, to Kuala Lumpur, Malaysia, to a crisis through social media accounts, what became of the airliner and on July 17, 2014, just a short four months after it is first important to understand how the 239 people on board is still a their company airliner vanished, when the flight quickly information spreads virtually now. mystery. dropped out of the sky killing all 295 people on On July 6, 2013, at 11:28 PDT, Asiana Air- News of the event became board. This time, the airline came back with a lines Flight 214 was flying the approach international news literally much stronger social media presence admitting into San Francisco International Airport over night, and by the time the their loss of contact and, later in the day, establish- from Seoul, South Korea. The flight was sun rose over the Asian Pacific ing a hashtag so that followers could refer to one carrying 291 passengers, 12 flight at- region, it was already too late for place to receive the most up to date information. tendants, and 4 flightcrew members. The the airline to break their silence. Evidence of the airline’s faster response can be aircraft struck the seawall and collapsed, For more than four hours, the found all over news sites that covered the incident, killing three and seriously injuring 49, re- airline was silent and failed unlike that of their sister flight MH370. sulting in the first fatal crash in the United to make an initial statement While Malaysia Airlines did finally catch on, it’s States in more than four years. regarding the loss of contact. safe to say that no one did it better than Southwest. Within 30 seconds of the accident, an When the post finally did come, Southwest Airlines Flight 345 collapsed after their onlooker in the terminal snapped a photo it fell on deaf ears as it was de- nose gear failed upon landing at LaGuardia Airport of the crash and posted it on Twitter. She scribed as cryptic and confusing. in New York on July 23, 2013. The plane skidded was quoted more than 4,000 times in the Much speculation about the more than seven football fields before coming to a media over the next 24 hours. Her post incident also occurred over that stop on the edge of the runway, injuring 10 passen- didn’t just travel through Twitter feeds ei- time that was taken for fact and gers. While the virtual conversation began seconds ther. That post was seen on Facebook but skewed the airline’s chance to after the crash, less than 30 minutes after the inci- also made its way to Path and Sina Weibo speak the truth. dent, Southwest already issued an official hashtag as well as countless other sites. A passen- For those following the inves- in a post recognizing the crash. The timeliness of ger actually live-tweeted the event as it tigation, more questions have the established hashtag, or the presence of one at occurred. His posts were seen re-tweeted been yielded than have been all, is critical to controlling the information spread more than 32,000 times. Shashank Nigam, answered. The public response about the event. an analyst and writer from SimpliFlying, was that of disappointment While every crisis is different and responses agrees that “the lesson learnt is that social heeding distasteful comments, should be catered to the event, waiting for an media needs to be an integral part of any including ones begging the event to happen is already too late to have a social crisis management plan for an airline airline to answer questions like media crisis communication strategy established

October-December 2016 ISASI Forum • 29 in a company’s emergency response plan. Seconds after any crisis, the conversation has already started on social media, so staying ahead of the spread of information matters most ISASI 2016 in those first moments. “You want to have backups and secondaries, and frankly you want to have people who can AIR ACCIDENT INVESTIGATORS give other people relief,” explains Morgan Johnston, manager of corporate communication and social media strategist EXAMINE LINKS TO SAFETY at JetBlue Airways. “A crisis isn’t going to only occur during (Continued from page 10) normal business hours. You need to plan for an emergency NETWORKS response that can last for days, weeks, or even months.” took a pre-dinner plunge into a large outdoor pool with re- In order for a team to respond promptly, a plan of what a laxing, thermally heated water and enjoyed silica mud facials team is supposed to do or even who the team is needs to be for which the site is famous. Bathers walked around in shoul- established before an event and updated frequently as to der-high warm water and under waterfalls into smaller pools as grow with the needs and habits of society. Social media crisis the facial mud dried and cleansed their skin. After they finished communication should involve the response team owning and dressed, the entire ISASI group gathered in the resort’s the conversation. restaurant overlooking the lagoon to socialize, make new ac- With so many different social media platforms, owning the quaintances, and enjoy an excellent meal. conversation can sometimes be difficult. Johnson of JetBlue suggests that crisis communicators need to focus on how Awards Banquet to “limit the amount of places that people think they need At the end of a long day of air safety presentations on Thursday, to look” to find information and providing audiences valid the hotel staff had only a few hours to transform the meeting information while staying empathetic. room from a seminar setting to a fabulous banquet hall that A great way to limit the amount of places people go to seats even more people. The lights were dimmed and tables fash- receive information is by establishing a hashtag early on and ionably set. Meanwhile, seminar participants had a short time encouraging people to check for updates. This customized to catch their breath and then dress for the biggest event during tag provides one quick link for the audience to click on to the week—the ISASI awards banquet. As everyone found their follow the conversation online and find the most recent and seats, waiters poured white or red wine. Bread and salad were factual information only regarding this event. The hashtag served, and the meal began. As desert reached the table, ISASI also allows the party to lead the conversation by posting President Frank Del Gandio took the stage and suggested that updates and answering questions directly instead of people the evening’s program should begin so that all the announce- assuming or falsifying information, or in other words allow- ments and awards could be completed in a timely fashion. ing for the spread of rumors. Even through different social Del Gandio thanked the Islandic team of Thorkell Agustsson media platforms, establishing a centralized location for and Ragnar Gudmundsson for being gracious seminar hosts information can help give crisis communicators the luxury and for their assistance with putting together all the programs. of only posting to a few different places where followers can Recognition was also given to Brian McDermid and Simon Lie, come to you to find answers. Technical Committee; Olivier Ferrante, Tutorials; Alistair Mann, Being linked together is as much a blessing as it is a curse, Technical Support; and Barbara Dunn, Registration. Recogni- but the key for air safety investigators is to begin responding tion is also due for ESASI’s work on the seminar website and to an accident before it happens. Establish an emergency providing an electronic means to collect and categorize all response plan that includes social media releases and of the papers and presentations submitted for ISASI’s identifies teams to create and manage sites. With much of consideration. the world connected through social media, don’t let social Del Gandio then presented new corporate membership certifi- media drowned out the truth or compromise the integrity of cates to the University of Balmand/Balmand Institute of Aero- the company. Social media is and will continue to constantly nautics—Capt. Mohammed Aziz; Asiana Airlines—ISASI Korean change as will the aviation industry. Crisis communication Society Director General Soon Cheol Byeon; Mitsubishi Aircraft can be very tricky, but the most important thing is to join the Corporation—Senior Advisor Hideyo Kosugi; and the Junta de conversation. Investigation de Accidentes de Aviation Civil—Director of In- vestigations Daniel Barafani. Other new corporate members, he said, included Petroleum Air Services, Aegean Airlines, and Delft Resources University of Technology. Bradley, Diana. “Malaysia Airlines Uses Social Media for First Public Stuart Hawkins, AAIB, UK, was awarded recognition for the Comments on Plane Crash in Ukraine.” Malaysia Airlines Uses Social best paper and presentation during the seminar. Hawkins’ Media for First Public Comments on Plane Crash in Ukraine. Haymar- discussion of drones as an investigative tool was riveting and ket Media Group Ltd, 17 July 2014. Web. 11 Apr. 2016. Cohn, Ryan. “How Social Media Is Elevating Airline Crisis Communica- informative with still images and videos of the technology in tion.” LinkedIn. N.p., 13 Mar. 2014. Web. 11 Apr. 2016. action. With a changing of the guard, Esperison (Marty) Mar- Malaysia Airlines. “Malaysia Airlines.” Facebook. N.p., 8 Mar. 2014. Web. tinez was recognized, with a standing ovation, for his 20 years 11 Apr. 2016. of service to ISASI as editor of the ISASI Forum (see page 4). The National Transportation Safety Board. “Board Meeting: Crash of Asiana Flight 214 Accident Report Summary.” National Transportation Safety Kapustin scholarship winners received certificates of recogni- Board. N.p., 24 June 2014. Web. 11 Apr. 2016. tion for their winning essays (see page 24). The highlight of the awards ceremonies was the presentation 30 • October-December 2016 ISASI Forum of ISASI’s highest award, the Jerome F. Lederer Award, to Toby Carroll, U.S. councillor (see page 14) as recognition of a lifetime of selfless work to enhance aviation safety. Following ISASI tradition, at the end of the official seminar 2016 activities, Icelandic host Thorkell Agustsson passed the ISASI cow- bell (used to open the gathering and call delegates to their seats) to the ISASI 2017 North American host, Barbara Dunn.

Post-Conference Tour President Frank Del Gandio, left, presents Toby Carroll ISASI 2016 participants visit the Strokkur A day after the conference settled, the ISASI 2016 Jerome F. Lederer Award, which reads, geyser during a post-seminar optional tour. two busloads of ISASI 2016 “For Outstanding Contributions to Technical Excellence participants willingly became in Aviation Accident Investigation.” tourists and took the Golden Circle Tour to visit some of Iceland’s most stunning geogra- phy. The two busloads traveled the circle in opposite directions so that each site was not over- whelmed with visitors. Despite rain and thick clouds, the groups saw the Geysir geothermal area where the Strokkur geyser can shoot a column of boiling water up to 98 feet (30 meters) into the air every 4–8 minutes. And yes, this area is where the English word geyser originated. They then walked along the Mid-Atlantic Ridge where the European and Kapustin scholarship recipients receive their certificates. Shown from left, Jiaqi Cao, ISASI Presi- North American tectonic plates dent Frank Del Gandio, Carly Shoemake, Taylor Beall, and Yasmeen Syed. Andre Woenardi was not separate about two centimeters available for the photo. per year. The guide noted as the group walked between walls of lava turned to stone that Iceland has hundreds of small earth- quakes every day, but most cannot be felt. The next sight was Gulfoss waterfall, or Golden Falls, where the glacier-fed river, Hvitá, drops into a deep crevice. Finally, the group went to Fontana Wellness in the community of Laugarvatn, where natural, open-air steam baths are located near a much colder lake. By the time the group returned to the hotel, everyone was ready for a rest and dinner in nearby Thorkell Agustsson makes the traditional passing of the ISASI cowbell to Barbara Dunn, chairman restaurants. of ISASI 2017 to be held in San Diego, California, U.S.A. October-December 2016 ISASI Forum • 31 ISASI 107 E. Holly Ave., Suite 11 Sterling, VA 20164-5405 USA

INCORPORATED AUGUST 31, 1964 CHANGE SERVICE REQUESTED

WHO’S WHO The University of Balamand Institute of Aeronautics

(Who’s Who is a brief profile prepared by the represented ISASI corporate member organization to provide a more thorough understanding of the organization’s role and function.—Editor) he University of Balamand is a Leba- or otherwise. numerically based nese institution for higher education Within this global approach to aviation activities. The BIA also has a number of Tthat’s located 75 kilometers north and aeronautics, the BIA has managed flight training devices in addition to an of Beirut. It was established in 1988 and to set up and consolidate a number of advanced high-bypass jet engine resides on a picturesque historic hill that programs within the different faculties. simulator. overlooks the Mediterranean. Examples include the BS/MS aeronautical Despite the hardships imposed by The university is home to some 5,000 engineering programs within the mechan- regional instabilities, the standards set by students in 11 faculties, follows an Amer- ical engineering department and the B. the BIA have made it the focal point for ican system of education, and since its Tech aircraft maintenance engineering aeronautical capacity building in Lebanon inception to date boasts more than 15,000 programs (in airframes, engines, and and the Middle East. The Lebanese Air graduates who act as its ambassadors all avionics) within the faculty of technology. Force, for instance, has entrusted the BIA over the globe. The BIA is currently working on the air with the formation of its technical officers The Balamand Institute of Aeronautics transport management MBA to be an- as well as its recurrent training. Further- (BIA) was established in 2010 as a flexi- chored within the faculty of business and more, many of the Balamand graduates ble academic entity within the faculty of management. are employed by airlines, MROs, training engineering. It’s a unique and pioneering The engineering and technology pro- establishments, service providers, and na- regional structure that has recognized grams are supported by state-of-the-art tional authorities across the Middle East. that aeronautics is a multifaceted and labs and workshops that are intended This has enabled the BIA to build and multidisciplinary sector. Accordingly, to give students genuine opportunities foster strong professional links with many the BIA was conceived with a mission to for experimentation and maintenance of these establishments. advance all aspects of aeronautics in line practice. These labs include wind tunnels, In an effort to expand its scope and with the needs and priorities of the Leb- water tunnels, materials testing machines, international projects, the BIA has anese and regional aeronautical sector. piston and gas-turbine engines, composite become a corporate member of ISASI. This was to be done through the creation, material facilities, as well as a number of Through this step, it seeks to better itself accumulation, and dissemination of fixed-wing aircraft and helicopters. in meeting its institutional objective and knowledge. As such, the BIA now over- In addition to enhancing the students’ delivering quality programs to its students sees all aeronautical academic activities learning experiences, many of these labs and its community. At the BIA, we strive taking place within the various faculties are used in research and are augmented for excellence in aeronautical education of the university—whether they’re related by modern computational facilities that through dedication and commitment to to engineering, technology, management, are used for computational fluid dy- provide our students with the best and regulation, human factors, safety, security, namics, finite element analysis, or other most enjoyable learning opportunities.

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