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VOLUME 7, NUMBER 1 Publisher ISASI (Frank Del Gandio, President) Editorial Advisor Air Safety Through Investigation Richard B. Stone Editorial Staff Susan Fager Esperison Martinez Design William A. Ford Proceedings of the ISASI Proceedings (ISSN 1562-8914) is published annually by the International 34th Annual ISASI 2003 PROCEEDINGS Society of Air Safety Investigators. Opin- ions expressed by authors are not neces- sarily endorsed or represent official ISASI position or policy. International Seminar Editorial Offices: 107 E. Holly Ave., Suite 11, Sterling, VA 20164-5405 USA. Tele- phone (703) 430-9668. Fax: (703) 450- 1745. E-mail address: [email protected]. ‘From the Wright Brothers to Internet website: http://www.isasi.org Notice: The Proceedings of the ISASI 34th the Right Solutions— Annual International Seminar held in Washington, D.C., features presentations 100 Years of Identifying Safety on safety issues of interest to the aviation community. The papers are presented Deficiencies and Solutions’ herein in the original editorial content sup- plied by the authors. August 26–28, 2003 • Washington, D.C., USA Copyright © 2004—International Soci- ety of Air Safety Investigators, all rights reserved. Publication in any form is pro- hibited without permission. Permission to reprint is available upon application to the editorial offices. Publisher’s Editorial Profile: ISASI Proceed- ings is printed in the United States and pub- lished for professional air safety investiga- tors who are members of the International Society of Air Safety Investigators. Content emphasizes accident investigation findings, investigative techniques and experiences, and industry accident-prevention develop- ments in concert with the seminar theme “From the Wright Brothers to the Right Solutions—100 Years of Identifying Safety Deficiencies and Solutions.” Subscriptions: Active members in good standing and corporate members may ac- quire, on a no-fee basis, a copy of these Proceedings by downloading the material from the appropriate section of the ISASI website at www.isasi.org. Further, active and corporate members may purchase the Proceedings on a CD-ROM for the nomi- nal fee of $15, which covers postage and handling. Non-ISASI members may ac- quire the CD-ROM for a $75 fee. A lim- ited number of paper copies of Proceed- ings 2002 is available at a cost of $150. Checks should accompany the request and be made payable to ISASI. Mail to ISASI, 107 E. Holly Ave., Suite 11, Ster- ling, VA 20164-5405 USA. ISSN 1562-8914 ISASI 2003 Proceedings • 1 ISASI Information OFFICERS CORPORATE MEMBERS President, Frank Del Gandio Accident Investigation Board, Finland Hall & Associates LLC Accident Investigation Board/Norway Honeywell Executive Advisor, Richard Stone ACE USA Aerospace Hong Kong Airline Pilots Association Vice-President, Ron Schleede Aeronautical & Maritime Research Hong Kong Civil Aviation Department Secretary, Keith Hagy Laboratory IFALPA ISASI 2003 PROCEEDINGS Air Accident Investigation Bureau Independent Pilots Association Treasurer, Tom McCarthy of Singapore Int’l. Assoc. of Mach. & Aerospace Workers Air Accident Investigation Unit—Ireland Interstate Aviation Committee OUNCILLORS Air Accidents Investigation Branch—U.K. Japan Air System Co., Ltd. C Air Canada Japanese Aviation Insurance Pool Air Canada Pilots Association JetBlue Airways United States, Curt Lewis Air Line Pilots Association KLM Royal Dutch Airlines International, Caj Frostell Air New Zealand, Ltd. L-3 Communications Aviation Recorders Australian, Lindsay Naylor Airbus S.A.S. Learjet, Inc. Airclaims Limited Lufthansa German Airlines Canadian, Barbara Dunn Airservices Australia Middle East Airlines European, Max Saint-Germain AirTran Airways National Aeronautics and Space New Zealand, Ron Chippindale Alaska Airlines Administration All Nippon Airways Company Limited National Air Traffic Controllers Assn. Allied Pilots Association National Business Aviation Association UNITED STATES REGIONAL American Airlines National Transportation Safety Board American Eagle Airlines NAV Canada CHAPTER PRESIDENTS American Underwater Search & Survey, Ltd. Northwest Airlines ASPA Mexico Phoenix International, Inc. Arizona, Bill Waldock Association of Professional Flight Attendants Pratt & Whitney Mid-Atlantic, Ron Schleede Atlantic Southeast Airlines—Delta Connection Qantas Airways Limited Alaska, Craig Beldsoe Austin Digital, Inc. Republic of Singapore Air Force Australian Transport Safety Bureau Rolls- Royce Corporation Northeast, David W. Graham Avianca & SAM Airlines Royal New Zealand Air Force Dallas-Ft. Worth, Curt Lewis Aviation Safety Council Sandia National Laboratories Pacific Northwest, Kevin Darcy Avions de Transport Regional (ATR) Saudi Arabian Airlines Belgian Air Force, Air Staff Brussels, VSF Scandinavian Airlines Florida, Ben Coleman Bell Helicopter Textron, Inc. School of Aviation Safety and Management, Rocky Mountain, Richard L. Perry Board of Accident Investigation—Sweden ROC Air Force Academy Great Lakes, Rodney Schaeffer Boeing Commercial Airplanes SICOFAA/SPS Bombardier Aerospace Sikorsky Aircraft Corporation San Francisco, Peter Axelrod Bombardier Aerospace Regional Aircraft/ Singapore Airlines, Ltd. Southeastern, Inactive de Havilland, Inc. Smith, Anderson, Blount, Dorsett, Cathay Pacific Airways Limited Mitchell & Jernigan, L.L.P. Cavok, International, Inc. SNECMA Moteurs NATIONAL AND REGIONAL Civil Aviation Safety Authority, Australia South African Airways SOCIETY PRESIDENTS COMAIR, Inc. Southern California Safety Institute Continental Airlines Southwest Airlines Company Australian, Kenneth S. Lewis Continental Express SystemWare, Inc. SESA-France Chap., Vincent Fave DCI/Branch AIRCO TAM Brazilian Airlines Canadian, Barbara M. Dunn Delta Air Lines, Inc. The Ministry of Land, Infrastructure, Directorate of Flight Safety (Canadian Forces) & Transport, AAIC, Japan New Zealand, Ron Chippindale Directorate of Flying Safety—ADF Transport Canada Aviation European, Ken Smart Dutch Transport Safety Board Transportation Safety Board of Canada United States, Curt Lewis EMBRAER—Empresa Brasileira de U.K.-Civil Aviation Authority Aeronautica S.A. University of NSW AVIATION Russian, V. Venkov Embry-Riddle Aeronautical University University of Southern California Latin American, Marco A. de M. Rocha Emirates Airline Volvo Aero Corporation Era Aviation, Inc. WestJet N EVA Airways Corporation Exponent, Inc. Federal Aviation Administration FedEx Pilots Association Finnair Oyj Flightscape, Inc. Flight Safety Foundation—Taiwan FTI Consulting, Inc. GE Aircraft Engines Global Aerospace, Inc. 2 • ISASI 2003 Proceedings Table of Contents 2 ISASI Information 82 Enhanced Occupant Protection Through Injury 4 Preface Pattern Analysis By Frank Del Gandio By William T. Gormley, Office of the Chief Medical Examiner, 5 Caj Frostell: 2003 Lederer Award Winner Commonwealth of Virginia By Esperison Martinez 85 Forensic Aspects of Occupant Protection: SESSION I Victim Identification By Mary Cimrmancic, Transportation Safety Institute, Oklahoma City, Okla. ISASI 2003 PROCEEDINGS 8 Human Spirit and Accomplishment Are Unlimited 90 Aircraft Accident Investigation—The Role of By Ellen G. Engleman, Chairman, NTSB, USA Aerospace and Preventive Medicine 11 The Practical Use of the Root Cause Analysis System By Allen J. Parmet, Midwest Occupational Medicine, Kansas City, Mo. ® (RCA) Using Reason : A Building Block for Acci- 93 Expansion of the ICAO Universal Safety Oversight dent/Incident Investigations Audit Program to Include Annex 13—Aircraft By Jean-Pierre Dagon, Director of Corporate Safety, AirTran Airways Accident and Incident Investigation 17 From the Wright Flyer to the Space Shuttle: A Histor- By Caj Frostell, Chief, Accident Investigation and Prevention, ICAO ical Perspective of Aircraft Accident Investigation By Jeff Guzzetti, NTSB, USA, and Brian Nicklas, National Air and SESSION V Space Museum, USA 97 The CFIT and ALAR Challenge: Attacking the 26 The Emergency and Abnormal Situations Project Killers in Aviation By Barbara K. Burian, R. Key Dismukes, and Immanuel Barshi, By Jim Burin, Flight Safety Foundation NASA Ames Research Center 100 Flightdeck Image Recording on Commercial Aircraft SESSION II By Pippa Moore, CAA, UK 34 Accident Reconstruction—The Decision Process 105 Flightdeck Image Recording on Commercial Aircraft By John W. Purvis, Safety Services International By Mike Horne, AD Aerospace, Ltd., Manchester, UK 38 CI611 and GE791 Wreckage Recovery Operations— 108 An Analysis of the Relationship of Finding-Cause- Comparisons and Lessons Learned Recommendation from Selected Recent NTSB By David Lee, Steven Su, and Kay Yong, Aviation Safety Council, Aircraft Accident Reports Taiwan, ROC By Michael Huhn, Air Line Pilots Association. Presented by Chris Baum. 43 Application of the 3-D Software Wreckage Reconstruc- 126 Ramp Accidents and Incidents Involving ion Technology at the Aircraft Accident Investigation U.S. Carriers, 1987-2002 By Wen-Lin, Guan, Victor Liang, Phil Tai, and Kay Yong, Aviation Safety By Robert Matthews, FAA, USA Council Taiwan. Presented by Victor Liang. SESSION VI 49 CVR Recordings of Explosions and Structural 133 Accident Investigation in Brazil Failure Decompressions By Col. Marcus A. Araújo da Costa, Chief Aeronautical Accident By Stuart Dyne, ISVR Consulting, Institute of Sound and Vibration Prevention and Investigation Center (CENIPA), Brazil Research, University of Southampton, UK 135 Airline Safety Data: Where Are We and Where Are SESSION III We Going? 54 Learning for ‘Kicking