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ISASI Forum. That Knowledge, and If You Possess That Tion and Planning Concepts 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
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