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Proceedings of the 37Th Annual International Seminar VOLUME 10 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 37th Annual Society of Air Safety Investigators. Opin- ions expressed by authors are not neces- ISASI 2006 PROCEEDINGS sarily endorsed or represent official ISASI International Seminar position or policy. Editorial Offices: 107 E. Holly Ave., Suite 11, Sterling, VA 20164-5405 USA. Tele- phone: (703) 430-9668. Fax: (703) 450- ‘Incidents to Accidents— 1745. E-mail address: [email protected]. Internet website: http://www.isasi.org. Breaking the Chain’ Notice: The Proceedings of the ISASI 37th annual international seminar held in Cancun, Mexico, features presentations on Sept. 11–14, 2006 safety issues of interest to the aviation com- munity. The papers are presented herein Cancun, Mexico in the original editorial content supplied by the authors. Copyright © 2007—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 Pro- ceedings is printed in the United States and published for professional air safety inves- tigators who are members of the Interna- tional Society of Air Safety Investigators. Content emphasizes accident investigation findings, investigative techniques and ex- periences, and industry accident-preven- tion developments in concert with the seminar theme “Incidents to Accidents— Breaking the Chain.” 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 2005 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 2006 Proceedings • 1 ISASI Information OFFICERS CORPORATE MEMBERS President, Frank Del Gandio ([email protected]) Accident Investigation Board, Finland Flight Attendant Training Institute at Executive Advisor, Richard Stone ([email protected]) Accident Investigation Board/Norway Melville College Vice-President, Ron Schleede ([email protected]) Aeronautical & Maritime Research Laboratory Flight Safety Foundation Secretary, Chris Baum ([email protected]) Flight Safety Foundation—Taiwan Treasurer, Tom McCarthy ([email protected]) Accident Investigation & Prevention Bureau AeroVeritas Aviation Safety Consulting, Ltd. Flightscape, Inc. Air Accident Investigation Bureau of Singapore Galaxy Scientific Corporation COUNCILLORS Air Accident Investigation Unit—Ireland GE Transportation/Aircraft Engines Australian, Lindsay Naylor ([email protected]) Air Accidents Investigation Branch—U.K. Global Aerospace, Inc. Canadian, Barbara Dunn ([email protected]) Air Canada Pilots Association Hall & Associates, LLC ISASI 2006 PROCEEDINGS European, Anne Evans ([email protected]) Hellenic Air Accident Investigation International, Caj Frostell ([email protected]) Air Line Pilots Association New Zealand, Ron Chippindale ([email protected]) Air New Zealand, Ltd. & Aviation Safety Board United States, Curt Lewis ([email protected]) Airbus S.A.S. Honeywell Airclaims Limited Hong Kong Airline Pilots Association NATIONAL AND REGIONAL Aircraft Accident Investigation Bureau—Switzerland Hong Kong Civil Aviation Department Aircraft Mechanics Fraternal Association IFALPA SOCIETY PRESIDENTS Aircraft & Railway Accident Investigation Independent Pilots Association Australian, Kenneth S. Lewis Commission Int’l. Assoc. of Mach. & Aerospace Workers ([email protected]) Airservices Australia Interstate Aviation Committee Canadian, Barbara M. Dunn ([email protected]) AirTran Airways Irish Air Corps European, David King ([email protected]) Latin American, Guillermo J. Palacia (Mexico) Alaska Airlines Japan Airlines Domestic Co., LTD New Zealand, Peter Williams ([email protected]) Alitalia Airlines—Flight Safety Dept. Japanese Aviation Insurance Pool Russian, Vsvolod E. Overharov ([email protected]) All Nippon Airways Company Limited JetBlue Airways SESA-France Chap.,Vincent Fave Allied Pilots Association KLM Royal Dutch Airlines ([email protected]) L-3 Communications Aviation Recorders United States, Curt Lewis ([email protected]) American Eagle Airlines American Underwater Search & Survey, Ltd. Learjet, Inc. ASPA de Mexico Lockheed Martin Corporation UNITED STATES REGIONAL Association of Professional Flight Attendants Lufthansa German Airlines CHAPTER PRESIDENTS Atlantic Southeast Airlines—Delta Connection MyTravel Airways National Air Traffic Controllers Assn. Alaska, Craig Beldsoe Australian Transport Safety Bureau ([email protected]) Aviation Safety Council National Business Aviation Association Arizona, Bill Waldock ([email protected]) Avions de Transport Regional (ATR) National Transportation Safety Board Dallas-Ft. Worth, Curt Lewis ([email protected]) BEA-Bureau D’Enquetes et D’Analyses NAV Canada Florida, Ben Coleman ([email protected]) Board of Accident Investigation—Sweden Nigerian Ministry of Aviation and Accident Great Lakes, Rodney Schaeffer ([email protected]) Investigation Bureau Los Angeles, Inactive Boeing Commercial Airplanes Mid-Atlantic, Ron Schleede ([email protected]) Bombardier Aerospace Regional Aircraft Parker Aerospace Northeast, David W. Graham ([email protected]) Bundesstelle fur Flugunfalluntersuchung—BFU Phoenix International, Inc. Pacific Northwest, Kevin Darcy ([email protected]) Cathay Pacific Airways Limited Pratt & Whitney Rocky Mountain, Gary R. Morphew Cavok Group, Inc. Qantas Airways Limited ([email protected]) Qwila Air (Pty) Ltd. San Francisco, Peter Axelrod Centurion, Inc. ([email protected]) China Airlines Republic of Singapore Air Force Southeastern, Inactive Cirrus Design Rolls-Royce, PLC Civil Aviation Safety Authority Australia Royal Netherlands Air Force COMMITTEE CHAIRMEN Colegio De Pilotos Aviadores De Mexico, A.C. Royal New Zealand Air Force Audit, Dr. Michael K. Hynes Comair, Inc. RTI Group, LLC ([email protected]) Continental Airlines Sandia National Laboratories Award, Gale E. Braden ([email protected]) Continental Express SAS Braathens Ballot Certification, Tom McCarthy ([email protected]) Saudi Arabian Airlines Board of Fellows, Ron Chippindale ([email protected]) COPAC/Colegio Oficial de Pilotos de la Bylaws, Darren T. Gaines ([email protected]) Aviacion Comercial SICOFAA/SPS Code of Ethics, John P. Combs ([email protected]) Cranfield Safety & Accident Investigation Centre Sikorsky Aircraft Corporation Membership, Tom McCarthy ([email protected]) DCI/Branch AIRCO Skyservice Airlines Ltd. Nominating, Tom McCarthy ([email protected]) Delta Air Lines, Inc. Singapore Airlines, Ltd. Reachout, James P. Stewart ([email protected]) SNECMA Moteurs Seminar, Barbara Dunn ([email protected]) Directorate of Aircraft Accident Investigations— Namibia South African Airways Directorate of Flight Safety (Canadian Forces) South African Civil Aviation Authority WORKING GROUP CHAIRMEN Southern California Safety Institute Air Traffic Services, John A. Guselli (Chair) Directorate of Flying Safety—ADF ([email protected]) Dutch Airline Pilots Association Southwest Airlines Company Ladislav Mika (Co-Chair) ([email protected]) Dutch Transport Safety Board Star Navigation Systems Group, Ltd. Cabin Safety, Joann E. Matley ([email protected]) EL AL Israel Airlines State of Israel Corporate Affairs, John W. Purvis ([email protected]) EMBRAER-Empresa Brasileira de Transport Canada Flight Recorder, Michael R. Poole Transportation Safety Board of Canada ([email protected]) Aeronautica S.A. General Aviation, William (Buck) Welch Embry-Riddle Aeronautical University U.K. Civil Aviation Authority ([email protected]) Emirates Airline UND Aerospace Government Air Safety, Willaim L. McNease Era Aviation, Inc. University of NSW AVIATION ([email protected]) University of Southern California Human Factors, Richard Stone ([email protected]) European Aviation Safety Agency EVA Airways Corporation Volvo Aero Corporation Investigators Training & Education, Graham R. ◆ Braithwaite ([email protected]) Exponent, Inc. WestJet Positions, Ken Smart ([email protected]) Federal Aviation Administration Finnair Oyj 2 • ISASI 2006 Proceedings Table of Contents 53 The ATSB Approach to Improving the LATIN AMERICA DAY—Tuesday, September 12 Quality of Investigation Analysis By Michael Walker, ATSB, Australia 2 ISASI Information 58 An Investigation as to How Aviation Safety 4 Preface: Welcome to ISASI and Cancun Will Be Maintained in the Light of the Major By Frank Del Gandio, President Change Processes Taking Place in the Norwegian Civil Aviation Sector 6 Keynote Address: Safety Cannot Be Seen; It Must Be Felt By Dr. Kaare Halvorsen and Dr. Grete Myhre, ISASI 2006 PROCEEDINGS By Capt. Gilberto Lopez Meyer, DGCA Mexico AIB, Norway 8 ‘Dick’ Wood Reaps Lederer Honors 66 Incident Investigation: A Diversion
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