Accident Investigations
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The International Society ofAirSafety Investigators Volume 14, Number 4 Winter 1981 Proceedings ofthe Tw e lfth International Seminar ofthe International Society of Air Safety Investigators Hyatt-Regency Hotel Washington, DC September 29-0ctober 1, 1981 Call for Papers The 1982 ISASI International Seminar will be held at the Dan Hotel in Tel-Aviv. Israel, during the period October 11-16. 1982. The Seminar will be devoted to three basic forum themes: Published Quarterly by the First Day: "The Investigation of Avionics and International Society of Air Safety Investigators Electronics Failures" Volume 14, Number 4 Winter 1981 Second Day: "The Investigation of Composite Material Editor - Ira J. Rimson Failures" The Editorial objective is to report developments and Third Day: "Investigation Cases of Special Interest advanced techniques of particular interest to the profes during the Past Year" sional aircraft accident investigator. Opinions and con clusions expressed herein are those of the writers and are (Presentations on other topics will be considered.) not official positions of The Society. The Editoral Staff reserves the right to reject any article that, in its Authors wishing to present papers are invited to submit opinion, is not in keeping with the ideas and/or objec a 200-300 word abstract to: tives of the Society. It further reserves the right to Captain Oded Abarbanell delete, summarize or edit portions of any article when P. O. Box 10094 such action is indicated by printing space limitations. Tel-AViv 61100. Israel Telephone: (03)473530 Editorial Office: c/o Editor. ISASI forum 4507 Wakefield Drive Annandale, VA 22003 (703) 978-2944 CHANGE OF ADDRESS: • • ISaSI West Build ing, 'Room 259 Washington National Airport From th e Mail Washington, DC 20001 U.S.A. After reading "The Editor's Cornered" in the Forum Spring 1981, Volume 14, Number 1, I feel that I should Telephone: (703) 521-5195 share with you some of my feelings on th e adequacy of acci dent investigation by the government investigators, partic ularly those ground installations for which the government is responsible to install, maintain. and operate. As you may be aware, these ground based systems comprise at least 50% of the total system used by most aircraft to navigate from point A to point B. The remaining 50% of the total system is in the aircraft installation. and the ability of the crew to use it. The FAA is charged with the responsibility of plan THE INTERNATIONAL SOCIETY OF ning. installIng. maintaining. operating. a nd certifying all AIR SAFETY INVESTIGATORS air navigation facilities that are used by air carriers. This OFFICERS responsibility within the FAA is shared by the Air Traffic Control. Flight Standards. and Airway Facilities divisions. President John R. McDonald Aircraft Engineering is involved only in investigating the Vice President Charles Mercer air frame and related components of the aircraft for air Secretary Stephan Corrie worthiness. Treasurer Samuel Condon Executive Advisor Laurence S. Edwards The FAA is the sole investigatory body for the investi INTERNATIONAL COUNCILLORS gation of FAA airway facilities that might be involved in. or have contributed to. an aircraft accident. This provides Canada RogerW.Smith some interesting aspects to the investigation of aircraft Australia GeoffSeymour accidents. International S. Olof Fritsch The NTSB uses the FAA findings in their published reports of the cause of the accident. However, the NTSB does not publish the actual FAA technical findings of facil THE JEROME F. LEDERER AWARD 1981 presented to DR. S. HARRY ROBERTSON for Outstanding Contributions to Technical Excellence in Accident Investigation Dr. Robertson has used his extensive experience in accident investigation and crash research to develop improved techniques for investigation which he has taught to over four thousand students in courses on Crash Survival Investigation and in other safety related areas. He has developed new methods and equipment. resulting in crashworthy fuel systems for aircraft and racing cars. His extensive record of publications has served to share this knowledge with the entire safety community. These contributions. through example and leadership, have encouraged and aided others to achieve technical excellence in accident investigation. Table of Contents Methodological Biases which Undermine Accident Investigations 1 .' Ludwig Benner, Jr.; National Transportation Safety Board One Investigator's Attempts to Overcome Methodological 6 Problems in Alrcraft Accident Investigations Stephan J. Corrie; National Transportation Safety Board The Simultaneous Time and Events Process (STEP) Method 10 of Accident Investigation Richard W. Clarke and J. Michael Jobanek; SOCAL Safety Associates Investigations in Small Countries 19 Aage Roed; Board of Accident Investigation, Sweden Human Performance Investigation 21 Gerrit J. Walhout; National Transportation Safety Board Human Performance Factors in Aviation Accidents: 23 An Investigator's Methodology Janis H. Stoklosa; National Transportation Safety Board Human Performance Investigation: The Investigator-in-Charge 28 and Report Writer Roles Ronald L. Schleede; National Transportation Safety Board Video Investigations - A Complementary Source 31 Larry C. Bignall; G.A.B. Business Services, Inc. Investigation of Aircraft Fires 34 Richard H. Wood; University of Southern California Basic Principles of Crashworthiness 38 , David S. Hall; Crash Research Institute Collection of Data on Impact Dynamics 41 William H. Reed; Arizona State University Crash Data on Structures 43 R.K. McLeod, J. W. Hutchinson, A.J. W. Melson and T. W. Heaslip; Aviation Safety Bureau, Transport Canada Data Collection on Seats and Restraint Systems 52 Stan Desjardins; Simula, Inc. Case Study of a Cessna 206 Accident with Crashworthiness 61 Improvements in the Seat Merrill Piper; Jungle Aviation and Radio Service Fire Crashworthiness Investigation 63 S. Harry Robertson; Robertson Research, Inc. Control Cab Video Recorder 66 William V. Shumate; Boeing Commercial Airplane Company Let Microprocessors Help 69 W. Gordon MacSwain; Transport Canada Accident Prevention through Investigation, Reconstruction and Litigation 82 William R. Gaines; W.R. Gaines Associates How Important is Safety Education? 92 . George B. Parker; University of Southern California NTSB Petition Panel Discussion 98 The Great Excuses - Luncheon Address 106 Delfina R. Mott; Association of Flight Attendants List of Attendees 107 -Photoqraphs by Robey J. Green and Ira J. Rimson Methodological Biases Which Undermine Accident Investigations Luduiiq Benner, Jr. M02202 National Transportation Safety Board University of Southern California Strongly differing OpInIOnS about accident causation decisions. Litigation abounds. Investigators quarrel. among conscientious, well-intentioned accident investiga Students bring frequent examples of controversial conclu tors frequently arise in accident investigations. These differ sions from accident investigations to my classes. I regularly ences can complicate investigations, frustrate investigators, encounter views about how accidents should be investi undermine the credibility of investigators' work in the eyes gated and reported that are very different from my own of the public and others, and delay or misdirect safety im even among ISASI members. Jerry Bruggink and I. for ex provements. This paper explores reasons why these differ ample. were unable to reconcile our different professional ences occur. It is a status report of ongoing research into views before he retired. One author describes 20 different accident investigation theory, principles and practices in analytical approaches in a new accident investigation book.s support of advanced accident investigation courses con ducted for the University of Southern California. Every experienced investigator recognizes that differ ences exist. In my view, their consequences can be signifi The research findings reported here indicate ways to cant - in terms ofinvestigations, administration ofjustice to reduce controversy about accident investigations, and im individuals and organizations, money that changes hands, prove their contribution to our nation's well-being. The pur and even public confidence in the results of investigations. pose of this paper is to share my findings in the hope they Investigations can stretch out. Investigative costs can esca will lead to an improved accident investigation methodology late. Recommendations for corrective action can be delayed . that encourages meticulously disciplined, harmonious or misdirected. Blame or fault can be laid on the wrong per- . "win/win" accident investigations, regardless of the subse . sons. Licenses or reputations can be unfairly jeopardized. quent interests of the parties. One party may inappropriately have to bear the accident costs. These are no small matters to the individuals directly The research findings and conclusions reported are involved! solely the author's, and do not necessarily reflect the views of the University, the National Transportation Safety Board Why can't investigative differences be reconciled more or any other organization with which the author is or has easily? Is it solely a matter of the money or reputations at been affiliated. The author accepts all responsibility for the stake? Or is there some technical problem that ISASI mem contents and conclusions reported. bers could attack to overcome these differences? Is There Really My research suggests