JULY–SEPTEMBER 2009

Meet The 2009 ‘Kapustin’ Scholars (Page 3) Why Do Emergency Evacuation Slides Fail? (Page 8) Accident Investigation—A Complete Service? (Page 13) Cockpit ‘Conversations’: Pilot Error or Communications Failure (Page 18) Council Meets in Spring Session (Page 22) CONTENTS

Volume 42, Number 3 FEATURES Publisher Frank Del Gandio Editorial Advisor Richard B. Stone 3 Meet The 2009 ‘Kapustin’ Scholars Editor Esperison Martinez Incorporated into “President’s View” are the three 1000-word essays selected Design Editor William A. Ford as the best of the 12 submitted in the competition to win the 2009 ISASI Rudolph Associate Editor Susan Fager Kapustin Memorial Scholarship award, which memorializes all ISASI members Annual Report Editor Ron Schleede who have “flown west.” ISASI Forum (ISSN 1088-8128) is pub- lished quarterly by International Society of Air Safety Investigators. Opinions ex- 8 Why Do Emergency Evacuation Slides Fail? pressed by authors do not necessarily rep- By Gerard van Es, Senior Consultant, NLR-Air Transport Safety Institute, resent official ISASI position or policy. Amsterdam, the Netherlands—The author presents an analysis of historical Editorial Offices: Park Center, 107 East emergency evacuations in which slides were used. The factors that have hampered Holly Avenue, Suite 11, Sterling, VA 20164- the use of emergency evacuation slides are identified from these data and are 5405. Telephone (703) 430-9668. Fax (703) analyzed in-depth. 430-4970. E-mail address isasi@erols. com; for editor, [email protected]. Internet website: www.isasi.org. ISASI Forum is not responsible for unsolicited 13 Accident Investigation—A Complete Service? manuscripts, photographs, or other ma- By Phil Taylor, Senior Inspector of Air Accidents, UK AAIB—Using examples from terials. Unsolicited materials will be investigations to illustrate the article’s content and to confirm or challenge the returned only if submitted with a self-ad- dressed, stamped envelope. ISASI Forum notion of completeness, the author discusses improvements that could be made to reserves the right to reject, delete, sum- enhance the investigation process, including advances in technology. marize, or edit for space considerations any submitted article. To facilitate editorial production processes, American-English 18 Cockpit ‘Conversations’: spelling of words will be used. Pilot Error or Communications Failure Copyright © 2009—International Society of Air Safety Investigators, all rights re- By Noelle Brunelle, Field and Production Safety, Sikorsky Aircraft Corporation— served. Publication in any form prohibited The author asserts that the automation installed in today’s advanced aircraft has without permission. ISASI Forum regis- assumed the role of a crewmember and explores the conversations between the tered U.S. Patent and T.M. Office. Opinions expressed by authors do not necessarily aircrew and the aircraft. represent official ISASI position or policy. Permission to reprint is available upon ap- 22 Council Meets in Spring Session plication to the editorial offices. Compiled from submitted reports and Council meeting minutes. Publisher’s Editorial Profile: ISASI Forum is printed in the United States and published for professional air safety investigators who are members of the EPARTMENTS International Society of Air Safety In- D vestigators. Editorial content emphasizes 2 Contents accident investigation findings, investiga- 3 President’s View tive techniques and experiences, regula- 24 ISASI RoundUp tory issues, industry accident prevention developments, and ISASI and member 30 ISASI Information involvement and information. 32 Who’s Who—A brief corporate member profile Subscriptions: Subscription to members of Baines Simmons Americas is provided as a portion of dues. Rate for nonmembers is US$24 and for libraries and schools US$20. For subscription informa- tion, call (703) 430-9668. Additional or re- placement ISASI Forum issues: members US$3, nonmembers US$6. About the Cover A 1998 emergency evacuation using exists on the right side of the aircraft. The 3R door did not open fully, and the slide did not deploy. Twenty-eight passengers reported minor injuries from the evacuation. (Photo courtesy of NLR-Air Transport Safety Institute)

2 • ISASI Forum July–September 2009 PRESIDENT’S VIEW

Meet the 2009 Kapustin Scholars By Frank Del Gandio, ISASI President

You have heard me speak or have read the nent to the economy, and there is a need to ensure optimization words of praise I have often written about the of safety to the general public. Since the air transportation ISASI Rudolf Kapustin Memorial Scholarship system has a very dynamic infrastructure, it is paramount that program we instituted in 2002 to memorialize a continuous effort is made to also provide new concepts in all deceased ISASI members. It is a program design.” Already he has trained with the NTSB; functions as a that we can all be proud of, for it has suc- graduate research consultant, Transportation Research Board ceeded well beyond our initial expectation (TRB), National Academies, Aviation Safety Issues; has ex- of awarding an annual scholarship to a college-level student perience with the airline industry working as a safety special- interested in the field of aviation safety and aircraft accident ist within the confines of the ASAP program and regulatory occurrence investigation. Our hope in initiating the program compliance; and serves as a part-time instructor/professor at was to entice a greater number of students to our Society, ERAU, Worldwide. He also holds a private pilot license and is which is becoming increasingly aged. obtaining a commercial rating. The initial award was $1,500. It has since grown to $2,000. Brian hails from Charleston, S.C, Carolina, U.S.A. He holds The award’s intent is to grant a student membership in ISASI an undergraduate degree in business aviation and is enrolled and to allow the recipient to attend the respective year’s in a masters of science in aeronautics (MSA) program with a ISASI annual international seminar on air accident investi- course of study in safety. He expects to graduate in December gation. No dues funds are used to support this program. It 2009. He believes that his 10 years’ experience in air traffic is totally dependent upon voluntarily [tax free in the U.S.] control and airport operations and past training in aircraft ac- contributions. And in that, you, the membership, have been unselfishly generous. Since the program’s inception, more than $35,500 have been donated. Much of the funding has come o dues funds are used to support from donations made by our chapters and societies [see “Mid- the Rudolf Kapustin Memorial Atlantic Council Conducts Spring Meeting,” page 24]. Scholarship. It is totally dependent Not only have we been able to increase the monetary award, N but for the past 2 years we have been able to select three upon voluntarily [tax free in the U.S.] recipients. Since inception, 15 students have received awards contributions. and 4 of them are now working in fields related to aviation cident investigation provides a solid foundation to work as an safety and investigation. Indeed, our first two recipients of aviation consultant. He is married and has two children. the award—Michiel Schuurman and Noelle Brunelle—have Murtaza is from Mumbai, India. He is a third-year student delivered papers at our annual seminar. Michiel at ISASI 2005 seeking an undergraduate degree in aviation management. He [see Proceedings 2005, “3-D Photogrammetric Reconstruction expects to graduate in 2010. At this time, his aspirations are to in Aircraft Investigation,” page 118] and Noelle at ISASI 2008 become a professional in fields related to airline/airport man- [see Proceedings 2008, “Conversations in the Cockpit: Pilot agement or human factors. In explaining his hopes, he said, Error or a Failure to Communicate,” page 67]. “ I initially aspired to become a pilot, but after gaining 100+ It is with great pleasure that I introduce to you the three hours of experience, I decided to switch to the aviation man- recipients of the 2009 scholarship: Dujuan B. Sevillian, Cran- agement program at Massey University, which specializes in field University, School of Engineering, Human Factors and various aspects of aviation such as aviation psychology, airline Systems Engineering, Bedfordshire, United Kingdom; Brian management, air traffic design, etc.” He holds a New Zealand Dyer, Embry-Riddle Aeronautical University, Daytona Beach, CAA private pilot license and lists as hobbies reading, hiking, Fla.; and Murtaza Telya, Academic Institute, Massey Univer- photography, swimming, and using flight simulator software. sity, Palmerston North, New Zealand. His main interests are aviation, history, and soccer playing. Dujuan is a product of Atlanta, Ga., U.S.A., and an alumnus Adjoining this introduction, you will find the essay that each of Embry-Riddle Aeronautical University, Extended Campus. of these students submitted and was judged to be of sufficient He is in his second year of graduate study for his Ph.D. in superiority, each in its own right, to be declared a top submission. flight deck design aviation safety. His professional goal is to be The theme of the essay was restricted to subject matter that an aviation safety expert, and to “work within the field of hu- addressed “The Challenges for Air Safety Investigators.” I am man factors and aircraft incident/accident occurrence because sure you will agree that each one of them did an outstanding job. there is constant need to improve aviation safety throughout And as you read the essay, think about the breadth and the world. The air transportation system is a critical compo- vitality of thought presented, think of those other students at-

July–September 2009 ISASI Forum • 3 tending an aeronautical institution who hunger for a career in penses to our seminars or to gifted training courses. Corpo- aviation but who may not realize our Society exists. Then, con- rate members in particular might consider donation of in-kind sider if any of your annual contributory dollars could or should services such as air tickets or lodging expenses to travel to be directed toward nurturing your profession and Society. the seminar location or to redeem a training gift. Again, let Remember, our selectees are students: no expense accounts, me remind you that in the U.S., contributions to the ISASI no jobs, no extra cash to pay for related travel and living ex- scholarship fund are tax-deductible. ◆

around the world. According to the study, Africa and the Middle East maintained an accident rate of 1.54 fatal accidents The Continuous Challenge for U.S. per million flight hours and 3.62 per million flight departures. Several other agencies have conducted studies to determine Air Safety Investigators Assisting in why there are so many aircraft accidents in other areas of International Investigations the world (NTSB, 2003). U.S. investigators have assisted the African continent with improving aviation safety. The United By Dujuan B. Sevillian States Congress mandates that the NTSB promote aviation TSB investigators support the standards within ICAO safety across the world, and it would seem pertinent that the Annex 13 and have assisted international investigators NTSB would be an integral part in continuous aviation-safety- Nwith aircraft accidents for several years. Sending U.S.- related improvement strategies. accredited representatives to aircraft accidents builds rapport with international investigators. The various methods of exchanging technical expertise, he various methods of exchanging technical the willingness of investigators to serve, and Texpertise, the willingness of investigators the continuous exchange of information to im- to serve, and the continuous exchange of prove aviation safety around the world are just a couple ways that can improve communica- information to improve aviation safety around tion within aviation safety. In 2003, the NTSB the world are just a couple ways that can conducted a study regarding aircraft accidents improve communication within aviation safety.

On April 1, 1998, a “Safe Skies of Africa” program was DONATION FORM initiated by the U.S. Department of Transportation (DOT) and focused on aviation safety and airline security between Each year ISASI invites worldwide university students the U.S. and nine African nations, including Angola, Mali, enrolled in aviation engineering or safety programs to apply for a grant to attend the ISASI annual seminar. You can Namibia, and Tanzania. According to statistics, most of the help educate students in and direct them to aircraft accident accidents in Africa are related to maintenance human factors investigation by making U.S.-tax deductible contributions to (FAA, 2004). Since the FAA regulates the continuous analysis the ISASI Rudolph Kapustin Memorial Scholarship Fund (in and surveillance of maintenance programs within the U.S., memorial to all ISASI members who have died). Mark your it would seem practical to assist the international aviation donation in memory of a deceased friend and comrade. Help support the future. You can make a difference. community of Africa within these confines. From an FAA air safety investigator perspective, and beyond just investigating Name______accidents, areas of concentration in Africa should be the de- Phone number______velopment or the continuous support with facilitating effective Company/organization______air carrier internal evaluation programs, aviation safety action Address______programs, and continuous analysis and surveillance systems ______within Africa’s air transportation system, just to name a few. These programs could assist their government and airlines to City______State______continuously improve aviation safety. These types of oversight Zip/Postal code______Country______systems and the active management of these programs have Donation is made in the name of ______helped improve the United States air transportation system In the amount of______considerably over the past 10 years thus reducing the number

Credit card: l American Express l MasterCard l Visa Card Code______of aircraft accidents and incidents. Card number______Expiration date______Recently, the Air Transportation Oversight System (ATOS) initiative was developed by the U.S. FAA to enhance the Make check payable to: overall system safety aspect of air carrier programs and the ISASI Rudolph Kapustin Memorial Scholarship Fund Mail this completed form to: ISASI; 107 E. Holly Ave. associated departments that require oversight by the FAA for Suite #11; Sterling, VA, USA 20164 the airline industry. As air travel increases and new aircraft Contact information: (703) 430-9668, Fax (703) 430-4970 are developed, there is a demand for continuous surveillance E-mail: [email protected], Website: www. isasi.org of an airline’s maintenance and flight operations programs. However, this program could also help air safety investigators

4 • ISASI Forum July–September 2009 determine a cause (s) of an accident or incident. Since ATOS the world airline industry’s flight operations programs and is a multifaceted system, Africa’s airlines could adapt to a maintenance programs, there is a need to enhance human-fac- similar system structure. Safety culture is a key aspect with tors-related programs within the airline industry. The CAST the ability for this system to produce positive and meaningful program, ATOS program, or similar types of programs could results. The airline must understand that effective organiza- be essential to Africa’s air safety enhancement and could aid tional safety culture and the acceptance of this culture from air safety investigators with African-related air safety inves- upper-level management could make the process of investigat- tigations; however, these types of programs will present more ing an incident/accident easier from the air safety investigator challenges to the air safety investigator in Africa but could standpoint by helping the investigator understand the airline’s reduce the amount of times the investigator is “kicking’ tin.” ◆ dynamic culture. Seemingly enough, the utilization of the ATOS system safety attributes within Africa’s airlines could be a good evaluation tool to improve air safety within Africa and possibly reduce the rate of accidents from the commercial Caring for the Mental Health of scheduled domestic air carrier perspective. Air Safety Investigators The six ATOS system safety attributes are responsibility, By Brian Dyer authority, procedures, controls, process measurements, and interfaces. These attributes would capture areas of satisfaction oday’s aviation industry possesses many challenges for and related areas of needed improvement within particular air safety investigators. Some of these challenges include, areas such as manual currency, flight operations, personnel Tbut are not limited to, composite materials, jagged edged and training, and compensatory rest requirements. Moreover, metals, environmental hazards, wildlife, blood-borne patho- airlines would have the opportunity to utilize safety attribute gens, parachute systems, hazmat, and aviation inspections (SAIs) to determine if their entire processes fluids. Among all these challenges, there is one incorporate the six safety attributes, thus meeting the require- that receives very little attention: the mental ments of Africa’s Civil Aviation Agency (ACAA), and then health aspects or mental preparation of air provide an assessment to the airline utilizing elemental per- safety investigators formance inspections (EPIs). These types of analysis and the The International Civil Aviation Organiza- associated results that are documented by the airlines and the tion (ICAO) training guidelines for aircraft ACAA could aid U.S. investigators when they proceed with accident investigators (Circular 298-AN/172, assisting the applicable agency (s) with the accident or incident page 5) recommends that investigators be trained in investi- investigation (s). U.S. investigators would have the opportu- gator safety, including psychological stress. The accident site nity to share information and assist “as needed” with helping safety (Section 4.1.2.5, page 8) of that same document man- determine a cause of the incident or accident if this process dates that the subject of dealing with the psychological stress is followed by utilizing the source data from the inspections. of investigators and other personnel exposure to an accident However, as stated earlier, the safety culture could be a pivotal site must be covered. This training does not imply that the factor in determining any primary or final cause of an incident investigators are trained to be emotionally tough. It merely or accident depending on the organizational safety culture prepares them for what is anticipated at an accident site. make-up of the airline. Aircraft accident investigators (AAI) generally arrive at the The U.S. has implemented the Commercial Aviation Safety scene of an accident after the emergency services personnel. Team (CAST), which focuses on the reduction of aircraft However, there are instances where the investigators are incidents and accidents within the U.S. The CAST team has exposed to the chaotic, traumatic, and emotional situations at been very successful in the reduction of aircraft accidents and the scenes of accidents. While exposure to extreme psychologi- incidents since its inception almost 10 years ago. The develop- cal stressors does not always bring about negative reactions in ment of a similar team in Africa would seem most practical aircraft accident investigators, there is empirical evidence that from the organizational standpoint and could aid with accident the exposure to these critical events does pose a challenge. and incident investigations by providing more information Understanding the cases in which the investigators allow an regarding the aviation-safety-related incident or accident. The event to become a traumatic stressor is both important and es- CAST team could be a similar infrastructure from the U.S., sential for diagnosis and to provide timely mitigation measures. teaming with industry partners and other related government Recently, the awareness of the psychological impacts of officials to reduce the rate of aircraft incidents and accidents traumatic and critical events has increased, and post-trau- in Africa. After implementing this team in Africa, there could matic treatments have received considerable attention. This be more of an awareness of the underlying “common threads” attention has brought greater interests in the events that are causing incidents and accidents within the African continent. likely to lead to post-traumatic stress symptoms. Empirical Team investigators could meet and discuss air-safety-related evidence has found that post-traumatic stress symptoms may incidents and accidents. develop after a single exposure to a critical event. However, The reduction of incidents and accidents could possibly although clinical procedures have been developed primarily decrease the global percentage and could decrease Africa’s for assisting first responders, military personnel, and public current rate if other factors such as safety culture and orga- safety employees (police, EMTs, firefighters) with symptoms nizational safety are considered. Since human-factors-related of acute distress, there is currently no specific program devel- incidents and accidents continue to remain prominent within oped for intervention and prevention of distress experienced

July–September 2009 ISASI Forum • 5 by aircraft accident investigators (Coarsey-Rader, 1993). behavioral, and physical change must be treated immediately The traumatic effects of aircraft accidents on aircraft ac- to prevent additional problems. It has been proven that early cident investigators have received very little attention since intervention can greatly reduce the time and expense of the the primitive aviation days of early aviation enthusiasts and treatment process, as each individual may have a different the Wright Brothers. Aviation accidents are sometimes fatal, reaction to the traumatic distresses (Flannery, 1999). However, and aircraft accident investigators often experience graphic individuals have a tendency to feel that asking for support is a exposure to severe injuries, mutilated bodies, mass destruc- sign of weakness and results in that person ignoring the side tion, the stench of burnt flesh, and aviation fluids at the scenes effects, which may have irreversible effects. of these accidents. It is prudent to develop a training package similar to that of In the search for the probable causes of these accidents, OSHA’s blood-borne pathogens course that may provide inves- the investigators are also required to conduct interviews with tigators with the mental conditioning required to address the surviving participants, along with coworkers and the family traumatic events that are most likely to occur at accident sites. This course may include procedures to evaluate the resources within an organization and training investigating teams to he traumatic effects of aircraft accidents develop effective communication channels for the flow of sensi- on aircraft accident investigators have tive information. In addition, institutions conducting training T for personnel involved in accident investigating should provide received very little attention since the early psychological intervention, training, and/or services as a primitive aviation days of early aviation critical component of their respective programs. enthusiasts and the Wright Brothers. In the interim, communication and educational awareness regarding exposure to critical events must continue in earnest members of the deceased crew. It is also a common practice to throughout the aircraft accident investigating community. While listen to the cockpit voice recorders (CVRs) capture the last we cannot prevent exposure to these emotional and psychologi- transmissions of the pilots’ conversation with air traffic control cal situations during the discourse of our duties, the failure to (ATC). In these final moments prior to impact, it is not uncom- provide awareness and training may result in the investigators mon to hear the vivid screams, outcries, and panic among the themselves becoming the silent victims of the disasters. ◆ crewmembers as they face certain death on these doomed References flights. All of these factors may contribute to the accident Coarsey-Rader, C.V. & Rockwood, T. (1993) “Secondary Trauma and the Air Safety Investigator.” Paper presented at the 14th Annual Seminar of the International Society of Air Safety Investiga- investigator experiencing the effects of traumatic distress tors. Ottawa, Manitoba, Canada; October. International Civil Aviation Organization (ICAO). Training Guidelines for Aircraft Accident Inves- and other psychological symptoms if the coping skills of that tigators. Cir. 298 AN/172 page 5, page 8, Section 4.1.2.5. June 2003. individual are overwhelmed. Raymond B. Flannery, Jr. (1999). Psychological Trauma and Posttraumatic Stress Disorder: A Review of Psychological Trauma and PTSD. It has been recognized that immediate intervention follow- ing a traumatic experience will reduce the long-term impact of acute stress and other psychological-related problems. In an at- tempt to mitigate the psychological effects of the traumatic ex- Impediments to ASI Investigations posure, formal clinical interventions have been adapted. These By Murtaza Telya interventions include critical incident stress debriefing (CISD), critical incident stress management (CISM), crisis counseling viation safety investigators (ASIs) are undervalued and (CC), and resiliency management (RM). However, despite the berated quite often, but the fact of the matter is, ASIs popularity of the many clinical applications to mitigate psycho- Aare crucial and intrinsic to commercial aviation. Being an logical distresses, there has been some controversy about how ASI can also be perilous at times; stepping into a hazardous best to address the onset of exposure to the critical events. area surrounded by debris and toxic fumes Research from the International Critical Incident Stress to investigate an accident can pose a serious Foundation (ICISF) demonstrated that more than 90% of indi- threat, but it must be done to find the root viduals involved in a traumatic event would develop some type cause of an accident and to improve aviation of adverse psychological effect. These psychological effects are safety. ASIs deserve credit for improving air enhanced by a number of risk factors that include, but are not safety within the past decade. The average limited to, previous traumatic exposure, limited intelligence accident rate has dropped to only 1.6 per or awareness, limited social support, genetics, prior mental million departures between 1998 and 2007 illness, and problems associated with personal family life (Boeing, 2008); however, there are still many issues that need (Flannery, 1999). to be addressed to improve global air safety, especially for In 1994, the American Psychiatric Association (APA) pub- ASIs. Some of these issues are cultural factors, detrimental lished a table of common symptoms of psychological trauma news media coverage, and judicial and legal duress. and post-traumatic stress disorder. According to the table, The first issue that needs to be addressed is the role of those who are traumatized will develop symptoms that may cross-cultural factors in accident investigations, particularly include intrusive recollections of the critical event, avoidance national cultural factors. Cultural factors are pivotal and have of the traumatic situation with a numbing of general respon- a significant impact on the methods of accident investigation siveness, and increased physiological arousal. An individual and the interpretation of events leading to an accident. All experiencing substantial and long-lasting cognitive, emotional, accident investigators don’t necessarily concur on the causes

6 • ISASI Forum July–September 2009 of an accident. For example, after the crash of Flash Airlines cases, gathering and analyzing evidence takes a long time, and Flight 604 in Egypt, the NTSB and the BEA concluded that sometimes excessive pressure can compromise the quality of an both pilots on the aircraft were insufficiently trained and investigation. attributed the accident to human error; however, Egyptian The last issue that needs to be mentioned is that of judicial authorities persistently disagreed with the assessment and and legal duress. Legal and judicial authorities tend to com- stated that the plane crashed because of a mechanical failure plicate investigations because of their unnecessary interfer- (Sparaco, 2006). Such biases can impede the investigation if ence and unwarranted criminalization of aviation personnel they are not tackled properly. These differences can be at- involved in an accident. This needless meddling from legal tributed to the fact that Egyptians tend to be more collectivist authorities has become increasingly prevalent, especially since the September 11 attacks. Judges and prosecutors constantly tend to seek criminal sanctions against aviation personnel mproper accident investigation is one of in the wake of accidents involving human error, even though the primary causes of poor safety, and even the facts do not support the findings of sabotage, criminal I negligence, or willful misdemeanors (Quinn, 2007). This has though there have been many advancements been illustrated in many accidents, such as Gol Airlines Flight in the area of accident investigation, cultural 1907 crash, where the surviving pilots of the Embraer jet factors, detrimental news media coverage, and that crashed into the Gol aircraft were charged with involun- unnecessary regulatory and legal duress can tary manslaughter, even though there is no evidence (Quinn, 2007). The maintenance crew of the Concorde aircraft that be cumbersome for the ASI. These issues need crashed on July 25, 2000, experienced similar treatment from to be dealt with promptly and efficiently. the French government, which prosecuted four Continental Airlines maintenance crewmembers for manslaughter (Quinn, than Westerners, which means their society is more integrated 2007). Such legal pressures can have drastic ramifications for and cohesive and they don’t encourage individual reproba- the ASI, since it discourages personnel from providing acci- tion (Staunch, 2002). Methodologies can differ from culture to dent information that would make them susceptible to unnec- culture as well. A recent study conducted on 16 Taiwanese and essary prosecution. At times, prosecutors and judiciaries even 16 British ASIs found that while Taiwanese investigators focus tend to withhold valuable information from investigators; case on accidents in a holistic manner and try to understand how all in point, after the crash of a Cessna citation in Rome on Feb. the casual factors leading to an accident interact with each 7, 2009, Italian authorities confiscated the cockpit and flight other, British investigators basically focus on preferred data records and refused to disseminate them to the ASIs, in patterns of explanations and an object-oriented method of order to conduct their criminal investigation before the ac- accident investigation; in other words, Eastern cultures use cident investigation could be concluded (Flight Safety Founda- a holistic approach to investigate accidents while Western tion, 2009). Authorities must realize that unless there is solid cultures use a more individualistic approach (Li, Young, Wang, evidence of sabotage or criminal negligence, crucial evidence & Harris, 2008). These cultural conflicts become quite preva- cannot be withheld from authorities and personnel cannot be lent when international accidents occur, and one must learn to incriminated either, or else the investigation process will be utilize the differences in culture to one’s advantage instead of hampered and safety will be compromised. trying to eradicate them. Improper accident investigation is one of the primary causes Another prominent challenge that aviation investigators face of poor safety, and even though there have been many advance- is detrimental news media coverage. News media attention can ments in the area of accident investigation, cultural factors, det- be very cumbersome for investigators, since many news media rimental news media coverage, and unnecessary regulatory and outlets tend to propagate conjuncture and incomplete reports; legal duress can be cumbersome for the ASI. These issues need the news media coverage of the Colgan Flight 3407 crash cor- to be dealt with promptly and efficiently. They must be solved roborates the aforementioned statement. News media reports by improving cultural training, improving relations with news propagated that the crash was caused because the plane was media outlets to disseminate accident information in a respon- on autopilot in icing conditions, even though there were other sible and accurate manner, and by urging authorities to change factors involved, thus undermining the official investigation and regulations that can impede an accident investigation. These are misinforming the public (Learmount, 2009). Similarly, news me- not quick-fix solutions, but the only way to improve safety and dia outlets such as The Times of London and The Sun published enhance aviation is to implement them. ◆ many inaccurate articles related to the Air France Flight 4590 References crash before the investigation had concluded; they incorrectly Bills, K. (2007, September). Accident investigations still important. Aero safety world. Boeing. (2008). Statistical Summary of Commercial Jet Airplane Accidents. Seattle, WA: Boeing. speculated that the supposed cracking of the Concorde’s wings Flight Safety Foundation. (2009, February 26). Flight safety foundation criticizes prosecutorial interference with accident investigation. Flight Safety Foundation press release. and metal fatigue in the fan blade caused the accident (Johnson, Johnson, C.W. (2003). A Case Study in the Role of the Media in Reporting the Causes of Major 2003). Such misinformation can be very harmful. The news me- Accidents. Retrieved March 19, 2009, from http://www.dcs.gla.ac.uk/~johnson/papers/ISSC2003/ Media%20Final.htm. dia frenzy after airline accident in certain countries is so great Learmount, D. (2009, February 16). Colgan 3407, Icing, and Turboprops. Retrieved March 17, 2009, from http://www.flightglobal.com/blogs/learmount/2009/02/colgan-3407-icing-and-turbopro. that investigators in Russia are compelled by the news media to html. Li, W. C., Young, H.T., Wang, T., & Harris, D. (2008). The Art and the Science: Approaches of Ac- finish their investigations within a year, or else they are bound cident Investigation in Different Cultural Contexts. Halifax, NS, Canada. to face excessive scrutiny and badgering (Bills, 2007). Finishing Quinn, K.P. (2007, January). Battling accident criminalization. Flight Safety Foundation Aero Safety World. an investigation within a year may sound efficient; but in many Sparaco, P. (2006, April 4). Safety First, Always. Aviation Week & Space Technology.

July–September 2009 ISASI Forum • 7 Why Do Emergency Evacuation Slides Fail? The author presents an analysis of historical emergency evacuations in which slides were used. The factors that have hampered the use of emergency evacuation slides are identified from these data and are analyzed in-depth. By Gerard van Es, Senior Consultant, NLR-Air Transport Safety Insti- tute, Amsterdam, the Netherlands

Figure 1. Evacuation of passengers at Exit L2 without an emergency evacuation slide.

(This article is adapted, with permission, poor braking action, and the Air France evacuation slide did not deploy and the from the author’s paper entitled Problems aircraft’s weather radar was display- passengers had to jump out (see Figure in Operating Emergency Evacuation ing heavy precipitation encroaching on 1). Of the 16 passengers using this exit, Slides: Analysis of Accidents and Incidents the runway from the northwest. The 2 were seriously injured: one when he with Passenger Aircraft presented at the aircraft landed long down the runway, jumped from the exit (10-12 feet above ISASI 2008 seminar held in Nova Scotia, and reverse thrust was selected late the ground), and the other when pushed Canada, Sept. 8-11, 2008, which carried after touchdown. The aircraft was not the theme “Investigation: The Art and the able to stop on the 9,000-foot runway Gerard van Es is a Science.” The full presentation, includ- and departed the far end. The aircraft senior consultant in safe- ing cited references to support the points stopped in a ravine and caught fire. The ty and flight operations at made, is on the ISASI website at www. cabin crew ordered an evacuation within the NLR-Air Transport isasi.org.—Editor) seconds of the aircraft stopping because Safety Institute, the fire was observed out the left side of the Netherlands. For 12 n Aug. 2, 2005, an Air France aircraft, and smoke was entering the years, he has been in- Airbus A340-300 aircraft departed cabin. All passengers and crewmembers volved in accident and incident investiga­ OParis, France, on a scheduled flight were able to evacuate the aircraft before tion and analysis. He has conducted nu- to Toronto, Canada, with 297 passengers the fire reached the escape routes. A to- merous studies into runway incursions, and 12 crewmembers on board. While tal of 2 crewmembers and 10 passengers landing overruns, flight data analysis, approaching Toronto, the flightcrew were seriously injured during the crash pilot-controller communication, occupant members were advised of weather- and the ensuing evacuation. survivability, and more. He holds a bach- related delays. On final approach, they The aircraft was equipped with emer- elor of science degree in aircraft engineer- were advised that the crew of an aircraft gency evacuations slides as required by ing and a master of science degree in landing ahead of them had reported certification rules. At one exit (L2) the aerospace engineering.

8 • ISASI Forum July–September 2009 out of the exit by another passenger. The Aerospace Laboratory NLR, Report evacuation slides. The evacuations with slide at another exit (R3) deployed cor- NLR-CR-2004-371, 2004, was to make this last category of aircraft were excluded rectly. However, shortly afterward this an inventory of common problems when from this study in light of its objectives. slide deflated and Exit R3 was assessed using emergency evacuation slides. The as unusable by the cabin crew. study was limited to Western-built pas- Analysis results The slide at Exit L1 partially deployed/ senger aircraft equipped with evacuation A literature survey of previous investiga- inflated. Given the nose-down, left-wing- slides. tions on problems with evacuation slides high attitude of the aircraft, neither the In order to make an inventory of com- was conducted. Many relevant studies intermediate tie restraint device nor the mon problems when using emergency were found, and the most interesting toe tie restraint device separated from evacuation slides, data of historical evacu- results (in light of the present study) are the slide. As a result, the slide came to ation occurrences were analyzed. For the briefly discussed here. rest folded in half against the fuselage. purpose of this study, an evacuation is In a review of techniques used in crash When passengers jumped from Exit L1, defined as the disembarkation of passen- protection and emergency egress from some became trapped in the folded portion gers because of an existing or perceived transport aircraft, deficiencies with emer- of the slide and were unable to extricate emergency. The term evacuation is used in gency escape equipment were summarized themselves before other passengers a generic sense and includes precaution- by R.G. Snyder in Advanced Techniques jumped on top of them. ary evacuations and emergency egress in Crash Impact Protection and Emer- During the evacuation, the slide at situations. gency Egress from Air Transport Aircraft, L1 deflated completely. Post-occurrence First we analyzed some of the available AGARD AG-221, 1976. The deficiencies examination of the slide revealed that it studies on aircraft emergency evacua- quoted by Snyder are inflation problems, had been punctured in two areas. While tions. Secondly, evacuation occurrences problems due to wind, burnt slides, punc- the slide at emergency Exit R1 deployed involving passenger aircraft were identi- tured slides, and aircraft attitude. These automatically as designed, the angle of fied using several data sources. The first problems are based on NTSB reports the slide was very shallow because it was data source to be used was the NLR Air concerning accidents that occurred during almost perpendicular to the aircraft. As Safety Database, which covers accidents the early 70s. a result, the rate of descent was slowed and (major) incidents with civil aircraft The CAA UK studied the reliability of considerably. At the bottom of the slide, worldwide. The accidents in the NLR slides by analyzing slide occurrences from vegetation on either side of the deploy- Air Safety Database are often related to 1980 to 1994 with UK-registered aircraft. ment path pushed against the slide, occurrences involving (significant) dam- The study looked both at problems that causing it to curl inward, forming a tube. age to the aircraft and/or injuries to the occurred with slides during maintenance/ At one point, the R1 cabin attendant passengers. Since such occurrences are test deployment and the use of slides had to stop the evacuation to wait for rare, it was also necessary for this study during actual evacuations. Some of the passengers already on the slide to pass to analyze evacuations with less serious problems identified during maintenance/ through this tube. consequences. These are often precaution- test deployment are incorrect assembly Other problems with several of the ary evacuations. For this purpose, data of the slides (29%), grit-bar mechanism slides on the Air France A340 hampered from the following mandatory occurrence failure (15%), misrigging (11%), inflation the evacuation and also caused serious reporting systems were used: the Cana- device malfunctions (7%), and failure to injuries to the passengers. In the end, the dian Civil Aviation Occurrence Reporting deploy with no obvious cause (6%). In evacuation was successful due to the train- System (CADORS), the UK’s Mandatory the period studied by the CAA UK, 62 ing and actions of the whole cabin crew. Occurrence Reporting Scheme (MORS), actual emergency evacuations (with slides and the U.S. FAA Accident Incident Data involved) occurred with UK-registered System (AIDS). Additional data for U.S. aircraft. In nine cases (15%), slide problems Study objective and scope operators were obtained from a survey were identified. No fatalities were recorded The above occurrence and the experi- made by Hynes and Associates for the with these evacuations indicating that these ences of emergency evacuation slide use FAA in 1999. were minor events only (incidents). The is but one example of the problems that All the data from the previous-men- study conducted by the CAA UK does not hamper slide use. Thus, the main objective tioned sources include occurrences with report any reasons for the slide problems. of our study, Analysis of Problems Using aircraft that are equipped with evacuation Detailed studies on emergency evacu- Aircraft Evacuations Slides, National slides as well as aircraft that do not have ations were conducted by the accident

July–September 2009 ISASI Forum • 9 Figure 2. Relative Number of Evacuations with Slide Problems during the Period 1970-2003 investigation organizations from the U.S. 70% (NTSB) and Canada (TSB). These orga- nizations reviewed past emergency evacu- ation accidents with U.S.- and Canadian- 60% registered passenger-carrying aircraft 55% 48% covering different periods in time (NTSB, 47% 47% 1974; NTSB, 2000; TSB, 1995; and Fedok, 2001). The TSB study, A Safety Study of Evacuations of Large Passenger-Carrying Aircraft, Transport Safety Board Canada, Report SA9501, 1995, showed that in 47% of the evacuations where slides were used, some problem occurred with the slides. The Evacuations with slide problems Emergency Evacuation of Commercial Air- planes, National Transport Safety Board, 0% Safety Study NTSB/SS-00/01, 2000, found 1970-1974 1975-1980 1981-1985 1986-1990 1991-1995 1996-2003 that in 37% of the evacuations involving slide use, the slides did not operate cor- rectly. In a 1974 NTSB study, an almost in the sample of 81 accidents. or over an embankment. Steep slide angles similar percentage was found (40%). This In 25 (28.1%) cases, the slide did not appear to be the biggest problem for leads to a combined slide problem rate of inflate (not automatically nor manually). evacuees. At a slide angle of approximately 41% (combination of the results of the three The cases in which the slide did not inflate 48 degrees, evacuees have a tendency to studies). The problems with evacuation automatically—but did directly after the hesitate before entering the slide because slides identified in the TSB/NTSB studies manual inflation handle was pulled— of its steep appearance. Such steep angles are listed in Table 1. Failure of the slide to were not considered as slide problems were reported in a number of cases. inflate was identified in 46.9% of the cases in this study. However, when there was a Wind had an adverse effect on the use of and is by far the biggest problem found by significant delay in deploying the slides escape slides in 11 (12.4%) cases. In these the NTSB and the TSB. manually, the case was considered. The cases, the wind blew the slides up against NTSB/TSB results shown in Table 2 show the sides of the aircraft preventing their Accidents involving evacuations a higher amount of problems with the use. Table 3 lists the 11 cases. The mean Searches were conducted in the NLR Air inflation of slides. This is because in those wind during these evacuations varied from Safety Database for survivable, Western- cases where the slide would not automati- built passenger jet aircraft accidents cally deploy, but did manually, the events involving evacuations in which emergency were still counted as a slide problem by Table 1: Problems with slides evacuation slides were used. The query, the NTSB/TSB. There did not appear to identified by NTSB and TSB which identified 151 accidents, was con- be a general explanation why some slides ducted for the period 1970-2003 and cov- did not inflate properly. There are many Identified problem Amount (%)* ered aircraft operations worldwide. Prob- different causes for failure to inflate, such No (automatic) inflation of slide 46.9 lems with using the slides were identified as empty inflation bottles and incorrect Problems due to wind 12.5 in 81 (54%) accidents. As shown in Figure assembly. Problems with slides due to extreme attitude of the aircraft 12.5 2, this share increased starting from the In 14 (15.7%) cases, the aircraft attitude No deployment of slide due to late 70s until the early 80s. The share has at rest was such that some of the slides problems with emergency exit door 9.4 dropped during the late 80s. Since then it were either too steep, did not reach the Slide broke loose of aircraft 9.4 has not changed much. An overview of the ground, or curled up under the aircraft Slide inflated inside aircraft 6.3 identified problems with evacuation slides (due to limited space to deploy it properly). People injured because they loose stabilization on descent 3.1 in 81 analyzed accidents is shown in Table Unusual aircraft attitudes were mainly the 2. The ICAO ADREP taxonomy was used result of the collapse of the nose gear or * One accident can have more than one for the classification of the slide problems. the main aircraft landing gear. However, slide problem assigned. Eighty-nine slide problems were identified in some cases the aircraft ended in a ditch

10 • ISASI Forum July–September 2009 Table 2: Problems Identified with the Use of Slides in 81 Accidents Analyzed

Identified problem Amount (%)* Slide not inflated 28.1% Aircraft attitude 15.7% Other 13.5% Wind 12.4% Slide burnt 11.2% Incorrect rigging 7.9% Slide ripped 6.7% Table 3: Cases with Slide Problems due to Wind as Unknown 4.5% Identified in the Accident Sample * One accident can have more than one slide problem assigned. Date Location Aircraft type Wind speed (kts) 7-30-1971 San Francisco, USA B-747-100 20 1-02-1982 Sault Ste. Marie, Canada B-737-200 22 gusting to 36 5-12-1983 Regina, Sask, Canada DC-9-32 18 gusting to 28 6 to 28 kts. A similar range of wind values 11-05-1983 Johannesburg, South Africa B-747-B 6 (3-25 kts) was found for those evacua- 3-25-1987 Chicago, USA DC-10-10 14 tions in the sample in which wind did not 2-01-1990 Baltimore, USA DC-10-10 12 cause a problem when using the slides. 3-05-1994 Regina, Canada DC-9-32 22 gusting to 27 An explanation for this last observation in 12-24-1997 Schiphol, the Netherlands B-757-200 32 gusting to 42 7-09-1998 San Juan, Puerto Rico A300-600 13 the data could be that the wind direction 7-12-2000 Wien, Austria A310 13 gusting to 17 relative to the aircraft’s position also plays 11-30-2000 Shannon, Ireland B-737-800 28 gusting to 42 an important role. The slides were burned in 10 (11.2%) cases. In all these cases, slides were de- tions higher than 25 kts. Evacuation data by high-heeled shoes). In the last case, the ployed at the side of the aircraft where a from the following mandatory occurrence slide deployed partially into the galley. fire was present. Due to the intensity of reporting systems were used: the Cana- M.K. Hynes, in Frequency and Costs most of the fires, the burning of the slide dian Civil Aviation Occurrence Reporting of Transport Airplane Precautionary was unavoidable. System (CADORS), UK’s Mandatory Emergency Evacuations, FAA Report Incorrect rigging of the slide was iden- Occurrence Reporting Scheme (MORS), DOT/FAAJAM-99/30, 1999, evaluated pre- tified as the cause of the slide problem in and the U.S. FAA Accident Incident cautionary emergency evacuations with seven cases (7.9%). Data System (AIDS). The U.S. data were U.S.-registered aircraft that occurred dur- In six cases (6.7%), the slide was ripped. expanded with additional evacuation oc- ing the period 1988 through 1996. The pri- In four cases, it was determined that currences obtained from other sources mary data sources used for the evaluation this was caused by the shoes some of the including an airport survey. The overall included the FAA, the NTSB, and NASA, evacuees were wearing. time period ranged from 1987-2003. How- as well as the records of airport managers There are a variety of problems with ever, each of the three sources had slightly (through a survey sent to 63 airports). Ad- slides that were listed under the category different time periods. The Canadian data ditional data were obtained from airlines, “other” in Table 2. Some examples are covered the period 1995-2003, the UK insurance adjusting firms, and litigation slides falling off the aircraft after being data 1987-2003, and the U.S. data 1988- records. The final data sample contained a deployed and slides that inflated into the 1996. Narratives were available for all the total of 130 emergency evacuations involv- aircraft itself. reported evacuations with Canadian- and ing the deployment of slides. For 80 of the UK-registered aircraft in the time periods 130 evacuations, narratives were available. Incidents involving evacuations considered. However, this was not the case Analysis of the 80 evacuations revealed The accidents analyzed in the previous for all of the U.S. data. that in seven cases (8.8%) the slides did section were often related to occurrences For the period 1995 through 2003, 12 function as expected. In three cases, the involving (significant) damage to the air- slide-involving evacuations with Canadian- slides would not inflated; in one case the craft and/or injuries to the passengers. To registered aircraft were identified. There slide fell off the aircraft. The reasons for have an understanding of slide problems were no reported slide problems with slide problems in the remaining three that have occurred during less serious these 12 evacuations. cases were not reported. events, incidents involving slide use were For the period of 1987 through 2003, 63 analyzed (including precautionary evacu- slide-involving evacuations with UK-reg- Discussion of results ations). These incidents were also used istered aircraft were identified. In three The problems with evacuation slides as to estimate the slide use frequency of oc- cases (4.7%), problems with the slides identified in this study are similar to those currence. This frequency can be used to were reported. There was a case in which identified in previous studies. The data determine the probability of emergency the slide twisted on inflation, another in analyzed in this study suggest that the evacuation slide use in mean wind condi- which the slide was punctured (possibly basic problems with evacuation slides in

July–September 2009 ISASI Forum • 11 accidents have not been resolved over the problems. Improper packing/installation wind was 28 kts, which is slightly higher last 33 years. Safety organizations such as and improper maintenance cause many than the maximum wind under which the the NTSB of the U.S. have addressed the of these problems. slides should be able to function without problem of proper functioning of evacu- Problems with slides due to wind have problems due to the wind. ation slides in the past. The importance been identified in several cases. The prob- of having proper functioning slides fol- lems occurred under moderate as well Conclusions lows from the examination of the fatality as severe mean wind conditions, which • Examination of historical accidents rate of the analyzed evacuation accidents indicate that the mean wind speed itself involving evacuation slides showed that in this study. The fatality rate in those is not a decisive factor. This is further in 54% of all cases one or more slides did evacuations where problems with the shown by the fact that numerous evacu- not function properly. slides occurred is 1.7 times higher than ations with slides occurred without any • Examination of historical incidents for those evacuations where no problems problems due to wind, despite the fact involving evacuation slides showed that were encountered with the slides. Clearly, that the wind conditions were very similar in 6.5% of all cases one or more slides did properly functioning evacuation slides can to those when problems did occur due to not function properly. reduce the number of fatalities during the wind. Most likely the wind direction • The most important slide problems survivable accidents. plays an important role. With an unfa- identified in evacuation accidents are slide The share of problems (54%) with slides vorable wind direction, even moderate inflation problems, aircraft attitude, wind, found in the analyzed accidents is much wind conditions can cause problems when burnt slide, incorrect rigging of the slide, higher than found in the incidents (6.5%, using slides. Another factor could be the and ripped slide. combined result). There are several rea- gust levels of the wind. When having • Problems with evacuation slides have sons for this difference. Accidents often moderate wind conditions, strong gusts been reported since their first appearance are related to damaged aircraft, fires, and can cause difficulties when operating the on aircraft. Despite many recommenda- collapsed nose and main gears resulting in slide. The influence of strong gusts upon tions made by accident investigation rather unique problems with evacuation the proper functioning of slides has not boards regarding the improvement in slides. By definition, such problems will been examined to the knowledge of the slide reliability, problems with slides keep not be found with incidents. However, author. occurring at a similar rate. it was expected that inflation problems The current EASA CS/FAR 25, Section would have occurred at a similar rate for 25.810 emergency egress assist means Recommendations both accidents and incidents (in the order and escape route, states that “An ap- • Disseminate the findings of this re- of 28%). It is believed that the incident proved means to assist the occupants in port to all interested parties (including reports examined in this study do not descending to the ground must have the civil aviation authorities, transport safety always mention problems with evacuation capability, in 25-kt winds directed from boards, aircraft manufacturers, slide slides when they occurred. The level of the most critical angle, to deploy and, manufacturers, and airlines). detail of the information provided in the with the assistance of only one person, to • Analyze the influence of strong gusts incident reports is normally far less than remain usable after full deployment to upon the proper functioning of slides. the information that is given in accident evacuate occupants safely to the ground.” • Analyze service difficulty reports reports. Detailed information regarding This rule became effective Aug. 20, 1990. related to slides to identify the relation evacuation means is often not provided in The rule originates from a proposal made with problems found during accidents and incident reports; therefore, the number of in the 80s. Except for the B-737-800, all incident evacuations and to monitor any problems with evacuation slides identified aircraft listed in Table 3 were certified influence of regulations regarding slide in incidents in the present study could be before 1990. This means that the involved reliability. ◆ underreported. aircraft were certified for manufacture The most significant problem with prior to the introduction of the require- Acknowledgement slides identified in this study is that the ment JAR/FAR 25, Section 25.810, regard- The author gratefully acknowledges the slides would not inflate. An analysis of ing the maximum wind speed under which cooperation and assistance given by Joji service difficulty reports (SDRs) filled by slides must function and are therefore Waites of the CAA UK SRU; Jennifer U.S. operators also showed that the vast exempted from this requirement. The McCarthy of Transport Canada, System majority of SDRs related to slides (28%) B-737-800 listed in Table 3 was certified Safety; and Günther Raicher of the Flug­ would have resulted from slide inflation in 1998. During this accident, the mean unfalluntersuchungsstelle of Austria.

12 • ISASI Forum July–September 2009 Accident Investigation A Complete Service? Using examples from investiga- A more tions to illustrate the article’s complete content and to confirm or chal- service lenge the notion of complete- ness, the author discusses improvements that could be made to enhance the investiga- tion process, including advances in technology. Figure(s) 1 By Phil Taylor, Senior Inspector of Air Accidents (Operations), UK AAIB

(This article is adapted, with permission, from the author’s paper entitled Accident Investigation--A Complete Service? pre- sented at the ISASI 2008 seminar held in Nova Scotia, Canada, Sept. 8-11, 2008, which carried the theme “Investigation: The Art and the Science.” The full pre- overhaul on an automobile or machine.” sentation, including cited references to But that doesn’t apply here! support the points made, is on the ISASI Insofar as the sole objective of accident website at www.isasi.org.—Editor) investigation is the prevention of accidents and incidents, our work is clearly not fin- ne of my brothers who is a dental ished, but is it perfect in quality? One Irish surgeon once told me that one of the things that attracted him to Phil Taylor joined the the profession was the fact that AAIB as an operations whenO a patient comes to him with a dental investigator in 2002 and problem, he can follow their treatment has investigated ac all the way through to the end. Does this of complete service, I came across many cidents and incidents to also apply to air accident investigation? companies that claim to provide what they most classes of aircraft, Who are our patients or,? more appropri- term a complete service (Figure 1). both fixed and rotary ately, stakeholders? At face value, it might One dictionary definition of “complete” wing, in the UK and overseas. He holds seem obvious; they are the operators, the is “perfect in quality or kind.” For “ser- ATLP licenses for aeroplanes and he- manufacturers, and regulators, the bodies vice” it gives “performance or work for licopters and maintains his fixed-wing to whom we make our recommendations. another.” Combined this gives “work, currency by flying online operations However, those affected by our work also perfect in quality, for another.” with a commercial operator. He has include passengers, bereaved relatives There were other definitions for “com- recently converted to the Boeing 757 and and friends, and, in some instances, the plete,” including “finished,” and for Boeing 767 and continues to fly heli- public at large. Do we provide all of them “service,” “a periodic overhaul made on copters, as he did while with the Royal with a complete service? an automobile or machine”—making a Navy prior to retiring after 17 years. He In searching for a suitable definition “complete service” a “finished periodic is also an aeronautical engineer.

July–September 2009 ISASI Forum • 13 approach to Inverness Airport, it disap- Figure 2 peared from radar at FL78 and contact with the pilot was lost. A day later, the remains of the aircraft and the pilot were found in a remote loca- tion on the Scottish highlands within a few hundred meters of the position of the final radar return (see Figure 7). The aircraft was very badly fragmented, so much so that from the air it was difficult to distinguish from the surrounding rocks and vegetation and was ultimately discov- ered by a mountain rescue team that had joined the search. It was established that the aircraft was structurally intact when it struck the ground in an estimated 70° nose-down attitude with its longitudinal axis at an angle of 68° to the ground at impact, i.e., poet once wrote, “Finality is death, perfec- In that investigation, as in many oth- left wing low (see Figures 8 and 9). The tion is finality; nothing is perfect, there are ers, a lot of data and witness evidence extreme fragmentation of the wreckage lumps in it.” However, an English cleric were available to the investigation team. suggested a high impact speed, probably said, more optimistically, “Perfection is However, that is not always the case— in the region of 350 kts. Evidence sug- the child of time.” particularly where there is no requirement gested that the engines were producing a The procedure for the notification of for the aircraft to be equipped with an significant amount of power and that the accidents and serious incidents is clearly FDR or CVR and few witnesses. elevator trim actuators were near to their laid out in the appropriate manuals and, In October 2004, a Reims Cessna F406, full nose-down position. with rapid means of communication, the G-TWIG, took off from Stornoway, in the What caused the aircraft to carry out an transmission and receipt of this notifica- Outer Hebrides, to the west of Scotland, apparently dramatic maneuver could not tion is often very speedy. This enables to return to Inverness on the mainland be established, and there was nothing to investigation teams to be formed quickly (see Figure 5). indicate that the pilot contributed to the and, with modern-day transport, reach The aircraft had earlier delivered news- aircraft’s departure from its flight path. very remote accident sites, assisted in papers and magazines to the Orkneys and This was an unusual accident. Those with the location process by emergency loca- Shetland Islands and was returning empty a close interest in the final report were the tor transmitters. Thereafter, the analysis with only the pilot on board. airline, other F406 operators, the manu- of evidence, witness statements, and The aircraft climbed to its cruise level of facturer and the pilot’s family, friends, and data often produce reports that are able Flight Level 95 where it flew in or between his fiancée. Ultimately we were unable to to provide comprehensive findings and cloud layers in much the same conditions determine what had happened or why. We causes from which appropriate safety as it had encountered flying in the opposite considered it possible that the pilot may recommendations can be made. direction earlier that morning (see Figure have become incapacitated. Internationally In August 1985, a Boeing 737, registra- 6). The pilot of another aircraft that fol- agreed-upon standards did not require G- tion G-BGJL, suffered an uncontained lowed the same route about 20 minutes TWIG to carry either a flight data recorder failure of the left engine during its takeoff later stated that there was no icing or or a cockpit voice recorder. Had it been, from Runway 24 at Manchester in the UK turbulence at his level, FL75. Shortly we would have stood a better chance of (Figure 2). A wing fuel tank access panel after G-TWIG began its descent for the determining what had? occurred, although was punctured, and leaking fuel ignited as the takeoff was rejected. Figure 3 Tragically, during the subsequent fire and evacuation, 55 of the 137 passengers and crew on board lost their lives, and the aircraft was destroyed (Figures 3 and 4). The investigation team had access to the damaged aircraft, recorded data, medical and pathological information, and witness statements. The investigation included much testing and research, and the com- prehensive final report on the accident made 31 recommendations to the regula- tor, operators, and manufacturers.

14 • ISASI Forum July–September 2009 Figures 4, above, 5, left, and 6, below Figures 7, top, and 8, above

and the two families and friends of the deceased pilot and his passenger. Notably, this was one of a number of investigations in which we have been able to use GPS data to establish some elements of the history of the flight. In July 2003, a Hughes 500C helicopter, the why may still have eluded us. registration G-CSPJ, took off from Biggin In July 2002, a Robinson R22 helicop- Hill Airfield, an aerodrome near London, ter, registration G-VFSI, took off from for a flight in the local area. The weather an airfield in the middle of England for was good and the pilot was accompanied a sightseeing flight around the town of by his wife and their 4-year-old son. Within Warwick. On board were the pilot and his 2 minutes of its departure, the aircraft had girlfriend’s father. The pilot had already descended from a height of about 400 ft, completed three flights earlier that day turned left through approximately 130°, with a friend and, separately, his girl- and crashed into a field in an estimated friend’s mother. The weather was good and also recovered radar data that corrobo- 30° nose-down attitude and at a forward the aircraft followed the same route as it rated the aircraft’s track and showed the speed of approximately 80 kts (see Figure had on the previous flight. We established flight paths of other aircraft in the area, 11, page 17). this from data that were later retrieved which was of assistance in determining Witness statements were compared from GPS equipment recovered from the whether wake turbulence had been a fac- with radar data that recorded some of the ?wrecked aircraft. tor. It was considered not to have been (see flight. Also, radio calls between the pilot Abeam the western edge of Warwick, Figure 10, page 16). and ATC were analyzed. Shortly before with the aircraft flying level at a height Evidence suggested that, as a result of the accident, the pilot was instructed to of about 1,500 feet and cruising at about mast bumping, the tail cone of the aircraft change radio frequency, an instruction 70 kts, it was seen to break up in flight was struck by the main rotor blades. This that had to be repeated by ATC. The pilot and descend into a field. Evidence also can be caused by abrupt control inputs, acknowledged the second call by ATC and included various eyewitness accounts and and in this case it was considered possible gave no indication what had distracted him photographs that had been taken by a that this occurred as the result of an unin- from hearing the first call or that there camera that was recovered from the heli- tentional input on either the cyclic control was any problem. A brief transmission on copter. The data from the GPS equipment or yaw pedals, or both. the new frequency, which was timed just and the photographs gave us information Again, we were unable to establish with before the moment the aircraft crashed, on the aircraft’s altitude and groundspeed certainty what had caused the accident was considered to have been made by shortly before the accident and an indica- and answer the questions that were of the pilot. It was a brief distressed utter- tion of what the passenger had been doing particular interest to owners and opera- ance rather than recognized RTF. This seconds before the aircraft broke up. We tors of R22 helicopters, the manufacturer, established that the pilot had success-

July–September 2009 ISASI Forum • 15 tion. Also, the local population in the area, where there have been other accidents, Figure 9 had a vested interest in the findings. Two recommendations were made urg- ing the promotion of the safety benefits of fitting, as a minimum, cockpit voice recording equipment to all aircraft oper- ating with a certificate of airworthiness in the commercial air-transport category, regardless of weight or age and, secondly, urging the promotion of research into the design and development of inexpensive, fully changed frequency on the combined lightweight, airborne flight data and voice communications and navigation equip- recording equipment. These and another ment, on which it was possible to toggle similar recommendation relating to ap- between communications and navigation propriate recording equipment that can be frequencies while making such a change. practically implemented on small aircraft While it was possible that the time it took were reiterated in the report on the ac- the pilot to change frequency may have cident involving the F406, G-TWIG. been an ingredient, it was unclear why The helicopter accidents I have referred the aircraft, piloted by someone who was, to will be among the accidents that attract by all accounts, very safety conscious, the attention of the International Helicop- should crash in this fashion in such benign ter Safety Team and its European partner, conditions. the European Helicopter Safety Team, The investigation revealed no evidence as they endeavor to reduce helicopter ac- of any pre-impact faults in the aircraft. cidents by 80% in the 10-year period up to Figure 10 Many explanations were explored but 2016. In these and many other accidents each was flawed. As a result of insufficient involving light aircraft, data from suitable subsequently ceased trading. information, the cause or causes of this lightweight recorders for flight data and The investigation revealed a trend of voice would greatly assist investigation shortcomings that were not addressed aintaining the teams. GPS equipment and cameras, by the operator despite assurances to the independence of which survive an accident sufficiently to regulator. The regulator had expended the investigating provide an incomplete record of the flight, much effort in encouraging the operator M give a glimpse of how useful such record- to meet the required standard but this had authority is surely the ers could be. This would not only assist the not been achieved. In the final report, it was basis of ensuring that the investigation teams but would also provide considered that a contributory factor to the greater closure for those with a personal incident was that close monitoring by the perception and reality interest in an accident and present inde- regulator had not revealed the depth of the of a complete investigation pendent evidence for a concerned general lack of knowledge of standard operating is realized. public, whose fears can be fuelled if there procedures within the operator’s Flight Op- is an absence of proven facts. erations Department until after the over- accident, which happened in good weather In March 2006, a Hawker Siddeley run incident. As a result, a recommendation and shortly after departure from Biggin HS748, G-BVOV, overran the runway was made to the regulator regarding its Hill Airport, remain unresolved. This was at Guernsey Airport, in the Channel oversight of AOC holders in order to ensure unsatisfactory from two perspectives. It Islands, while landing in poor weather that AOC holders meet and maintain the was not possible to state what measure or (see Figure 12). required standard. This recommendation measures would prevent such an unusual The aircraft suffered damage to two was made only after very constructive and accident from happening again and, sec- tires but was otherwise unscathed. The positive discussions between the AAIB and ondly, those with a personal interest may operator had been involved in previous the regulator. While underlining the impor- never know why the accident occurred. serious incidents that had been investi- tance of good working relations between all This might not have been? the case if the gated by the AAIB and had a history of those involved in ensuring aviation safety, aircraft had been fitted with a flight data non-conformities being raised during au- it also exemplified the value of an indepen- recorder or cockpit voice recorder or both. dits by the regulator and had been closely dent investigation. No such equipment was required or fitted monitored for at least 2 years. Concerns Examination of the recommendations on this aircraft. included the operator’s management that are made in accident and incident Once more, as well as other operators structure, competencies, and its ability to reports reveals that many are made to and the manufacturer, two families and the maintain standards of safety. Shortly after regulators. I would suggest that this is a friends of the deceased were particularly this incident, the operator’s AOC was sus- thoroughly healthy state of affairs, and interested in the outcome of the investiga- pended by the regulator and the company the independence of an accident investiga-

16 • ISASI Forum July–September 2009 that we are better prepared globally. Figure 11 The independence of an investigation authority seems fundamental to the com- pleteness of the service we provide, while also acknowledging that working closely with our various stakeholders—be they operators, manufacturers, regulators, or members of the public, all of whom can provide us with information that can en- able us to carry out our investigations—is also important. The fact that we do not apportion blame or liability can only as- sist us in that aspect. The independence of an investigation surely enhances the integrity of the process and provides the beneficiaries of the results with confidence in the outcome. In conclusion, do we perform “work, perfect in quality, for another”? It would be arrogant to suggest that we do, and I have indicated where there are some “lumps” in our endeavors to supply a com- tion authority is important in being able place is clearly the objective. plete service, although there are also many to provide a complete service in which all However, the introduction of lightweight investigations that I suspect come very stakeholders can have confidence. recorders would be of great assistance in close to that ideal. Many investigations I would briefly like to mention a third those investigations involving aircraft could be enhanced with the introduction of aspect of our global efforts to improve that are not currently required to carry lightweight flight data and voice recorders aviation safety, and it is a subject that them so that the cause, or causes, can be on aircraft that are currently not required could be a point of discussion on its own. established and suitable recommendations to be fitted with them. Also greater mutual It is the matter of mutual assistance. for prevention can be made. If we want to assistance and support between states States have different strengths, and sharing them seems the best way to Figure 12 tackle aviation safety on a global scale. As technology and skills develop, strengths vary and fluctuate. That seems logical. There is the provision for assistance between states, and outreach programs provide helpful training. However, when assistance is requested, perhaps there is more that could be done. The speed with which a suitable response can be deliv- ered raises the question as to whether more cannot be done before the perceived need is challenged. So, who benefits from our work? It’s operators, manufacturers, regulators, passengers, families and friends of the deceased and injured, and the public at large. Do we provide a complete service? There are many examples of excellent investigations that have brought about significant improvements in aviation safety. Instances in recent years where aircraft have crashed and caught fire reduce the rate of accidents among heli- could help to achieve a more complete or crashed and not caught fire and all copters, I would suggest that this could service globally. Not the least, maintaining the passengers and crew have success- be a significant step in that endeavor. I the independence of the investigating au- fully evacuated are indications of an would also suggest that our global effort thority is surely the basis of ensuring that improvement in survivability, although can be enhanced by increasing the speed the perception and reality of a complete the avoidance of the accident in the first of response to requests for assistance so investigation is realized. ◆

July–September 2009 ISASI Forum • 17 Cockpit ‘Conversations’ Pilot Error or Failure? (This article is adapted, with permis- Mental models (also known as cognitive sion, from the author’s paper entitled models or schema) are developed as we Conversations in the Cockpit: Pilot Error explore the world around us. When we Communications or a Failure to Communicate? presented first encounter an object, symbol, task, at the ISASI 2008 seminar held in Nova or situation, we focus our attention on the Scotia, Canada, Sept. 8-11, 2008, which larger elements of its structure. Over time, carried the theme “Investigation: The Art we discern more details, such as size, use, and the Science.” The full presentation, construction, and context. Tasks become including cited references to support the subconscious, and key elements are ar- points made, is on the ISASI website at ranged in patterns for retrieval at a later www.isasi.org.—Editor) time. As our knowledge matures, details needed to anticipate future behaviors crew hears an aural warning but are added to our overall system models. fails to recognize that it signals Well-developed mental models of the an oxygen system malfunction. flight environment allow expert pilots to A warning light is perceived as detect and place environmental elements Aa false alarm when an engine fire actually and detect both emerging trends and the exists. During a cascading event, dozens absence of anticipated signals. When like of advisories, cautions, and warnings are or similar events are encountered again, displayed to the crewmembers, making these models are activated and guide it difficult for them to correctly diagnose behaviors and expectations. The robust- the emergency. What do these three situ- ness of these models is affected by the ations have in common? Each involves a amount and quality of the information breakdown in communication between communicated during our experiences, aircraft and the crew. with each repetition reinforcing the links Communication serves many func- between cues. tions—to transfer information, to develop The development of mental models used relationships, to predict behavior, and to by pilots begins long before the current coordinate tasks. Communication occurs flight. Knowledge and habits are commu- on many levels, ranging from impulses nicated from instructor to student during sent between molecules or cells to mes- training. These interactions result in a sages transferred between human ac- framework of behavior and expectations tors and objects in their environment. that underlie each subsequent flight. This Communication begins when a message framework influences preparation for a is transmitted and continues through re- flight, including the type of information ceipt, interpretation, and response. Every sought, the methods used to obtain this moment, millions of signals are commu- information, the depth of the information nicated to us through sight, sound, taste, sought, and the expectations and goals touch, and smell. Due to the sheer volume assigned to a flight. of these inputs, we are unable to process Once a flight has begun, pilots main- every message we encounter. To compen- tain their mental models by performing sate for the perceptual, cognitive, and a scan of the outside environment, the memory limitations of the human mind, flight instruments, powerplant/drivetrain each of us uses a system of goal-driven instruments methodical, and the status of internal representations to recognize, any utility systems. Information displayed interpret, and store these messages and by the cockpit indications is cross-checked use them to navigate the world around us. with cues from the external environment, These internal representations are known as well as the sounds, smells, and vibra- as mental models. tions generated by the aircraft, and are

18 • ISASI Forum July–September 2009 Pilot Error or Communications equivalent mental models. This shared awareness includes representations of The author asserts that the automation the goals and expectations of the flight, installed in today’s advanced aircraft has the flight environment, aircraft systems and capabilities, other actors (ATC, en- assumed the role of a crewmember, and explores emy forces), aircrew responsibilities (both the conversations between the aircrew and the individual and team), and the status of required inflight tasks. aircraft and how aircrew mental models Indoctrination training provided by are developed, maintained, and used to support a company or service is used to develop shared mental models of behaviors and situational awareness and decision-making. expectations. Reinforcement of these By Noelle Brunelle, Field and Production Safety, models continues through preflight ac- Sikorsky Aircraft Corporation. tions designed to coordinate goals and individual responsibilities. During flight, these shared mental models are used to integrated into a representation of the According to Dr. Micah Endsley, as plan and coordinate actions and evaluate current status of the flight. The current noted in her 1999 “Situational Aware- the progress of the flight. Crew mental status of flight is then cross-referenced ness in Aviation Systems,” situational models are maintained by communica- with previous indications and compared to awareness is composed of five elements: tion. Crew resource management (CRM) predetermined expectations and goals to geographical, spatial/temporal, system, was developed to enhance the sharing of forecast the future status of the flight. In environmental, and tactical. Geographical information among crewmembers. the early stages of a flight, these mental SA refers to maintaining awareness of models can be closely aligned with actual one’s aircraft and its relation to other fea- Traditional vs. contemporary events, but the models naturally diverge tures such as terrain, airports, waypoints, In traditional cockpits, pilots monitored over time. or other aircraft. Knowledge of a flight’s dials and meters to maintain awareness In aviation, the use of mental models relationship to elements of space such as of system status. Over time, computers is commonly referred to as “situational attitude, altitude, heading, and projected have assumed monitoring and control awareness” or “SA.” flight path and elements of time, such as tasks previously performed by pilots. velocity and estimated arrival times, are Course guidance, once accomplished by Noelle Brunelle is classified as spatial-temporal SA. System pilots flying a manually selected bearing with Sikorsky Aircraft SA consists not only of an awareness of the to a station, is now performed by com- Corporation. She has settings, status, and functions of aircraft puters using satellites to triangulate an 20 years’ experience in systems but also the impact of a subsystem aircraft’s position and execute a prepro- aviation, including crew degradation or malfunction of the overall grammed route. Engine and fuel controls station design and eval- system on a flight. Environmental SA is previously actuated by the pilot have uation, airfield man- concerned with weather and regulatory been replaced with computer-controlled agement, and air traffic control, and environments; tactical SA includes the engines programmed to optimize thrust, she holds commercial and instrument understanding of aircraft capabilities fuel burn, and speed. Terrain, weather, and airplane ratings. She is currently a in reference to a task and mission tim- traffic information can be integrated into masters candidate in the human factors ing and status. Situational awareness is displays, providing increasingly detailed and systems program at Embry-Riddle maintained with communications among representations of the external environ- Aeronautical University with a focus on a pilot, the aircraft, the environment, and ment. Control of today’s computer-based cognitive and social psychology. Noelle other crewmembers. and monitored systems is provided by is a past recipient of the Rudy Kapustin Multicrew aircraft (or multiaircraft avionics management systems or digital Memorial Scholarship. flights) requires crewmembers to maintain cockpits. As automated cockpit systems

July–September 2009 ISASI Forum • 19 assume tasks previously performed by provide an interface for crews to direct the human crewmembers, these digital sys- operation of navigation, communication, tems are increasingly being included in and utility systems. the definition of cockpit crew. To mitigate the potential for mis- In a digital cockpit, communication be- communication, the presentation of tween cockpit crew and aircraft systems information on these displays follows is accomplished via multifunction displays common guidelines. Dynamic data may (MFD) and flight management systems be presented in dial or tape or graphic or (also known as control display units). textual form. Clockwise motion of a dial Multifunction displays are full-color liquid- and upward movement of a tape signify an EXPLORING COMMUNICATION

(1) Available Cues • Was a checklist available to manage observed, several signals were com- • What cues were available to the crew this event? bined into a single alert.) during the event? • Did the cues presented by the displays ac- • Did the crew select the appropriate —Describe the pertinent signals. These curately reflect the status of the aircraft? response? descriptions should include the icon/ • Did the cues presented by the displays —If not, why? text used, whether the cue was visual/ support the correct decision/response aural/other, location of the cue, whether path? (3) Previous Interactions the cue was attenuated, coupled with • Were ambiguous indications displayed • What previous experiences had the another cue, constant or intermittent, during this event? crew had with the displays? and/or displayed in more than one (Include social interactions such as location. (2) Crew Response false alarms.) • When did the cues appear (or extin- • What cues did the crew need to resolve • What experience level/familiarity guish) during the time line of events? (detect/diagnose/respond to) this event? with the interface did crews have? —Lay out signals along a chronologi- —Can include digital display or other • Did crew have experience on more cal scale. system interfaces, aircraft, and environ- than one interface/aircraft? —Include: whether the information mental cues. —How current was crew with this updated during the course of events (if • Were these cues available (generated by interface? so how rapidly), whether the changes aircraft or in environment)? • Did cues used during simulator train- were attenuated, whether the loca- —If not, why? (Can include parameter not ing match those used on the aircraft? tion of the information was static or monitored, system inoperative.) • Did crews trust/distrust or accept/ dynamic, and (if available) what rules • If available, was the cue detected? dismiss the information once it was drove the presentation of the data? —If not, why? (Can include cue was pre­ detected? • Were any distractors present during sented outside visual range, on MFD page • Was scenario something they had the event? not selected by crew, crew unaware in- encountered before be it in an aircraft, —Describe each distractor. formation was available, alert had been in a simulator, or anecdotally? —Was the distractor presented in inadvertently silenced or extinguished or visual, audio, tactile (vibration), scent was otherwise masked.) (4) Concluding Questions form? • If detected, was the cue correctly in- • Were there any other obstacles to —Were threats such as smoke, fire, terpreted? effective communication between the extreme weather conditions present? —If not, why? (Can include presentation crews and the displays? —Were any social influences (provided did not allow for normal reaction times, • Did any elements of the display/ by other crewmembers, agencies, or meaning of icon/phraseology was not interface contribute to effective com- culture) in play? easily recognized, icon was infrequently munication? ◆

crystal displays (LCDs) installed on the increase, while graphic information (such instrument panel that use symbols, text, as attitude indications) is provided with and graphics arranged on formatted pages a recognizable reference to the environ- to communicate the status of selected air- ment or system they reference. Color is craft and environmental parameters to the used to supplement, differentiate, or at- crew. Flight management systems consist tenuate symbols or cues; green identifies of an alphanumeric keypad and dedicated normal operating ranges, amber indicates keys coupled with a color LCD screen to that a limit is being approached or a sys-

20 • ISASI Forum July–September 2009 tem is degraded, and red indicates that when encountering an unusual situation, crew’s ability to detect, assess, and ap- a limit has been exceeded or a system is an individual attempts to match the cur- propriately respond to signals present inoperative. The size of numerical and rent situation to one experienced before. in the environment. The consequences textual symbols is selected to allow them If this is not possible, previous experiences of making incorrect decisions can be to be read in the normal operating envi- are evaluated for their relevance to the dire: miscommunication regarding head- ronment; an increase in font size indicates current situation. If no clear matches can ing, altitude, or location could result an escalation of events. be found, a random search for solutions is in controlled flight into terrain, while Transient alerts, such as warnings, used. Matching is driven by signals (stop misdiagnosis of a system malfunction cautions, and advisories, are normally cues) that trigger a known pattern. Events could result in a delayed or incorrect presented when pilot action is required, indicated by clearly defined alerts or that response, causing damage to the aircraft when a system is approaching a limit, or include cues that have been encountered or injury to personnel. It is important to when the information is not normal for the previously can be quickly matched with recognize that selection of an improper current aircraft configuration. Designers existing mental models, increasing the course of action may not be the result may also elect to advise crews of a change opportunity for crews to use established of poor decision-making by the crew, in system status and when the automation checklists or procedures to resolve the but rather the result of the displays is performing a corrective action to enable situation. inaccurately communicating the current them to predict future system behavior. When ambiguous cues are present, situation. Each accident, incident, and Alerts may be grouped by function, pri- pattern matching becomes more difficult. unusual event provides the opportunity ority, or sequence of occurrence. These Infrequently displayed cues or those to evaluate the transfer of information rules are communicated to users by the operating instructions and are reinforced over time as experience with the system increases. ach accident, incident, and unusual Communication challenges Eevent provides the opportunity to Despite the use of standardized presen- evaluate the transfer of information between tations and symbology, challenges to ef- fective communication between aircrew the aircraft and the crew and the strengths and automation exist. Before a decision can be made, the need for a decision and weaknesses of these interactions. must be recognized; but change is not always easy to detect. When a signal is closely aligned with the observer’s field without a clear message can delay com- between the aircraft and the crew and of vision, it is easy to see. But presenting prehension of a message. Unexpected or the strengths and weaknesses of these a signal as little as 2 degrees from fixa- ill-defined cues generate the search for interactions. My challenge to safety in- tion reduces detection to as little as 20 to patterns and can increase the likelihood vestigators is to use these opportunities 40% of the time. Focusing on a task can that cognitive processes such as satisfact- to gather data that can then be used to affect the detection of unrelated cues. ing (choosing the first option that meets improve cockpit interfaces. Research exploring the failure to detect minimum matching criteria) and confirma- “Exploring Communication” pres- a visible cue (inattentional blindness) tion bias (affirming prior interpretations ents a series of questions for use when showed that only 54% of participants by discounting or dismissing conflicting exploring the effectiveness of commu- were able to detect an unexpected event information) may delay or prevent the nication between an aircraft and the while performing a vigilance task. We correct assessment of a situation. Previous crew. These questions are organized also anticipate trends will continue; “social” interactions may make otherwise into four sections. The first section looks research into the phenomena of change clear indications ambiguous; less emphasis at the cues available to the crew, when blindness (the inability to detect changes is placed on an alert known to have false they were available, and the quality to a display while attention is diverted) indications, while a highly reliable alert of the signals presented. The second demonstrated that changes that occurred reduces monitoring of the indicated pa- investigates what cues the crew needed during eye movements (saccades) were rameter. Choices made early in an event to successfully resolve the event and detected correctly on the first try only impact the choices available as the event whether the crew detected, interpreted, 71% of the time. Attenuation, including unfolds, and the longer it takes a crew to and responded to these cues. The third pairing a visual signal with an audio cue, recognize that an error has been made, is concerned with previous interactions can increase the probability a signal will the more difficult it is to recover once the between the crew and this and other be detected. correct course of action is recognized. display interfaces. The fourth presents Once change is detected, mental models Unusual inflight and on-ground events concluding questions. This list is not are used to guide the response to an event. require operators to respond quickly with intended to be all inclusive; it is offered Research has shown complex problems limited or partial information while in as a guide to increase the understand- are solved utilizing the conscious or a dynamic environment. The quality of ing of communication between display subconscious matching of patterns. Thus these responses is dependent upon the interfaces and the crew. ◆

July–September 2009 ISASI Forum • 21 (Compiled from submitted reports and was favorably impressed with the efforts seminar in order to avoid confusion and Council meeting minutes prepared by to develop the new society and encouraged possibly approaching sponsors twice. Barbara Dunn, as stand in for the ISASI the effort to continue as the organizers Williams announced a bid to host ISASI secretary. The full minutes report is cleared up some infrastructure questions 2012 in New Zealand starting September 9 available on ISASI’s website, www.isasi. that Council members put forth. The of that year. The Council unanimously ac- org.—Editor) Council asked that clarifications be made cepted. This will be the third time that the early enough so that the topic could be ISASI seminar has been held in New Zea- he spring ISASI International Coun- voted on at the September meeting. land. Williams also reported that the New cil meeting, held on May 1, set into Dick Stone reported that the Interna­ Zealand Society has created a Ron Chip- Tmotion plans for the formation of an tional Working Group on Human Fac- pindale Memorial Presentation in memory Asian ISASI society, withdrew its support tors, formed 2 years ago and on which he of the ISASI Fellow who was a founding member of the New Zealand Society and became its first president. Ron was the victim of an automobile incident that took his life on Feb. 12, 2008 (see Forum Council Meets in April/June 2008, page 3). The award will be presented annually at the ANZSASI seminar to either a person specially in- Spring Session vited to address the seminar or one whose submitted paper has been designated as worthy of the presentation. Sugimura, chairman of the ISASI 2010 seminar to be held in Sapporo, Japan, provided a PowerPoint presentation on the plans for the annual event. It will be held September 5-9 at the Royton Sapporo Hotel. The selected theme is “Investiga- tion to Be ASIA in Mind—Accurate, Speedy, Independent, and Authentic; the subtheme is “Overcoming Cultural Differ- ence and Language Barrier.” Dan McCune PHOTOS: E. MARTINEZ provided a full report on the planning for from the International Working Group on Caj Frostell, David King, Barbara Dunn, ISASI 2009 to be held in Orlando, Fla. Human Factors, accepted a New Zealand Ron Schleede, Frank Del Gandio, Dick (see page 25). Society bid to host ISASI 2012, received Stone, and Dan McCune prepare for the The issue of criminal prosecution was an update on ISASI 2010 to be held in Sap- Council meeting. again a topic of lengthy discussion. The poro, Japan, and considered a “position” on the matter of criminalization of aircraft serves as chairman, is “not functioning accidents, among other issues. as we had hoped.” He recommended that President Frank Del Gandio called the ISASI withdraw its support and form its meeting to order. Attendees included Dick own working group using as its model the Stone, executive advisor; Ron Schleede, work done by the TSB of Canada. The vice-president; Peter Williams, New Zea- ISASI goal would be to develop an HF land councillor; Barbara Dunn, Canadian manual designed for use by investigators. councillor; Caj Frostell, international Permission to use TSB documentation councillor; Lindsay Naylor, Australian has been awarded to ISASI. The Council councillor; David King, European Na- unanimously approved a motion to adopt tional Society president; and Dan McCune, the recommendation. Stone will head proxy for Jayme Nichols, chair of ISASI up the new human factors effort. Stone 2009. Mamoru Sugimura, chair of ISASI also announced the recipients of the 2009 2010; Marty Martinez, editor of ISASI ISASI Kapustin Memorial Scholarship Forum; and Ann Schull, ISASI office (see page 3). manager, attended as guests. Ron Schleede discussed securing inter- President Del Gandio put forward a national seminar sponsorship and noted petition in which the Singapore Ministry the need for each society to appoint one of Transport, acting as “Organizing sec- person to act as the local coordinator for retary,” requested the Council’s approval international seminar sponsorship. This to form the “Asian Society of Air Safety person would liaise with Ron prior to Ron Schleede briefs on the sponsorship Investigators” (AsiaSASI). The Council soliciting any sponsorship funds for the program.

22 • ISASI Forum July–September 2009 From left: Lindsay Naylor reports on Australia Society events; David King speaks about criminalization; Tom McCarthy listens.

Council reviewed cases of persons pros- office condominium of $51,542. The office membership was at 155; that a December ecuted or being charged and agreed on was purchased in 2000 for $101,000. His 2008 Reachout workshop was highly suc- the threat such practices by some states report noted a comparison of the “net cessful; and that planning was under way pose to occurrence investigations. It also asset/fund balance” from 1990—$39,451 for the ANZSASI 2010, which will be reviewed the Flight Safety Foundation to year 2007—$220,250. Regarding mem- hosted by the Australian Society. 2006 resolution on the subject, which bership, he reported 1,474 members and Barbara Dunn, CSASI, reported 117 included a significant number of industry 195 delinquencies. Corporate membership members, 17 of which joined in Halifax signatories. Council members were asked totalled 144 with 27 delinquent in dues. at ISASI 2008, the attendance at which to thoroughly review the FSF document Those members in dues arrears have left the local Society in “good financial for possible adoption by ISASI. The mat- all benefits suspended, including voting shape.” She also noted that in elections ter will be voted on at the September rights, and delivery of the Forum until held earlier this year she and Elaine meeting. dues payment is received. Parker, vice-president, were returned Tom McCarthy, in his role as treasurer to office. She also noted that in Octo- and Membership chairman, reported that National societies/councillors ber CSASI will be hosting a Winter the Society is in “excellent condition” In reports from national society council- Operations Conference in partnership financially, enabling an early payoff of the lors, Lindsay Naylor, ASASI, noted that with the Air Canada Pilots Association. More information can be found at www. winterops.ca. Dave King, ESASI, reported that the European regional seminars have been very successful, with more than 100 at- tending the April 20 seminar held in Hamburg (see page 26). Both turnout and sponsorship have been excellent, with many people attending who are not able to participate in the international seminars. He noted that Airbus and the BEA have both expressed a desire to be involved next year, with April 2010 being proposed as the next date. Randall Mainquist, chairman of the General Aviation Working Group, and 12 members met during ISASI 2008 and will meet again at ISASI 2009. At the 2008 meeting, discussions were held on non-volatile memory (NVM) use and applications in general aviation, includ- ing the incorporation of NVM into small, Mamoru Sugimura reports on ISASI 2010. inexpensive cockpit recorders. ◆

July–September 2009 ISASI Forum • 23 ISASI ROUNDUP

Mid-Atlantic Council Conducts Spring Meeting

The ISASI Mid-Atlantic Council Dallas-Fort Worth Chapter, the Euro- Del Gandio noted that the Singapore (MARC) hosted 83 members and guests pean Society of Air Safety Investigators, Ministry of Transport, acting as “Orga- at its annual spring dinner 2009 meeting the Mid-Atlantic Regional Chapter, and nizing secretary,” requested the Coun- in May. William R. Voss, Flight Safety the Northwest Regional Chapter. cil’s approval to form the “Asian Society Foundation president, was the guest President Del Gandio overviewed of Air Safety Investigators” (AsiaSASI). speaker for the event, which is held ISASI’s finances. He said they are in Showing ISASI’s outreach, he reported in conjunction with the spring ISASI “good shape,” attributing the condition that recent ISASI website statistics International Council meeting. ISASI to well attended and sponsored seminars showed 1,490 hits from 88 countries and President Frank Del Gandio also ad- and to the savings of $60,000 in rent that the Reachout Workshop program dressed the group. costs resulting from the purchase of the has delivered 34 sessions in 21 differ- MARC President Ron Schleede called office condominium in 2000. He remind- ent countries with an attendance that the meeting to order following a “get ed the group of the “mortgage burning” exceeds 1,300. reacquainted” refreshment hour. He ceremony conducted before them last A surprise event caught Ron Schleede outlined the evening’s program, thanked year. Membership has reached 1,474 unaware as President Del Gandio called corporate members for the donation of individuals and 144 corporate members. him to the front and presented the cov- the many door prizes that lined the gift This reflects the representation of 59 eted ISASI Fellow member status to him. table, and announced that among the countries in the Society. In this regard, Ron’s pleasure was evident in the large prizes were two sets of roundtrip airline tickets for travel to any destination within the U.S. Tickets were donated by AirTran Airways and Globetrotter Travel Agency. After the buffet dinner and raffle distribution of the prizes, Ron noted the status of the ISASI Kapustin Schol- arship Fund challenge issued by the Dallas-Fort Worth Regional Chapter. He explained that a feature of the annual meeting is a report on the progress of the Fund. It is named for the past presi- dent of MARC, but was established in memory of all ISASI members who have “flown west.” For this year’s event, the DFW Chapter made a sizeable donation PHOTOS: E. MARTINEZ and challenged attendees to meet the $4,000 campaign goal. The response was ABOVE: From left, Robert Sumwalt, “outstanding,” said Ron in announcing NTSB, William Voss, and Frank a tally of $5,600. Contributors included Del Gandio share a conversation. Victoria Anderson, Chris Baum, Coug RIGHT: Ron Schleede, left, enjoys Cassaro, Edward M. Cullinane, Frank accepting the ISASI Fellow pin from Del Gandio, Jerome Frechette, Cynthia President Del Gandio. Keegan, Gina T. Pellegrino, Tom and Ginger McCarthy, Charlie Pereira, John Purvis, Alissa Rojas, Ron and Kathie Schleede, Richard and Ruth Stone, the Alaska Regional Chapter, Curt Lewis and Associates LLC, the Canadian Society of Air Safety Investigators, the

24 • ISASI Forum July–September 2009 systems that will maintain the high level • how do we approach the issue of of safety in difficult economic times. investigators? Chief among these are competent and • how do we deal with a pubic that is independent regulators. They must have just angry no matter what? the ability to do risk-based surveillance, • how do we keep the public from doing strong carrier oversight, maintain a something that we know is wrong: losing close but appropriate relationship with safety data that protect them? the industry, and have non-political in- • How do we get the message across? ◆ terference. The next big problem he sees is a “competent, qualified workforce.” Register Now for Many skills have been lost in the down-

E. MARTINEZ turn, signaling a skill shortage for the ISASI 2009 William Voss speaks to the assembled next 2 to 5 years when continued growth Jayme Nichols, ISASI 2009 chairperson, group. will place heavy demands on air travel. reminds members that all registration This means that regulators won’t have fees to attend the 40th annual seminar to smile he wore as the Fellow symbol was the people needed to do the work. be held in Orlando, Fla., September 14- pinned to his lapel. Del Gandio also pre- He said that the pressure is on to deal 18 increase effective August 11 and that sented a corporate membership plaque with Safety Management Systems with a registration cancellation made before to David Gleave, representing Aviation strong focus on process and not so many July 10 will incur a $10 fee. Cancellations Safety Investigation, West Sussex, UK. rules, meaning more performance-based between July 27 and August 10 will incur Guest speaker Voss opened with the standards as opposed to prescriptive a $75 fee. There will be no refund of fees admission that the group was a difficult checklists. Voss gave examples of what for cancellations after August 10. one to speak before because, “a lot of an industry without Safety Management Seminar planners have established you taught me a lot of what I know.” Systems would be like. a detailed and easy-to-manage website He was referring to his 23-year climb In closing, he challenged the investi- accessible through the ISASI website, up the ranks at the Federal Aviation gators in the audience to “find a way to www.isasi.org. All areas of delegate Administration to become director of help the regulator who is bouncing out interest are easily identified and accessed air traffic systems development. After left and right, battered by political op- on the site. A seminar registration form that he did a stint with ICAO’s air position. Find a way to keep the regu- found on the website can be submitted navigation bureau and moved to FSF in lators moving forward toward a more electronically. The seminar will be held October 2006. systematic-based approach.” at the Coronado Springs Resort, which is He talked about the future of safety FSF has long been concerned with offering a delegate room rate of US$144 management—what does it mean to us the growing trend to criminalize acts for either a single or double and is subject and where is it going and criminaliza- and omissions of parties involved in avia- to taxes. The special rate is available until tion of aviation accidents. In discussing tion accidents and incidents. Criminal- August 24 for reservations from Septem- the worldwide accidents of the past 9 ization of aircraft accidents, he said, is ber 11-21 to allow early arrival or late months, he said the most prominent all about what the public perceives and departure. No provisions exist for special question received was “Is the downturn that tends to drive governmental belief. rates on upgrade rooms. Delegates to the economy doing this to us?” He The decay of trust that encircles the should deal directly with the Coronado doesn’t think so, as there is no com- world is bringing about a real crisis and Springs Resort regarding their accom- mon economic-related thread among is driving some of the highly regulated modations. The hotel registration form the accidents. Rhetorically, he asked environment that exists, he noted. He is available through a link on the ISASI “What will inoculate us from the idea provided examples of accidents that 2009 seminar website. that the downturn means less safety?” ended in criminal charges, à la Brazil, The ISASI 2009 seminar will kick off In response, he pointed to the spate of and in which investigators lost control of with a golf scramble that will benefit bankruptcies air carriers experienced in the accident site or the “black boxes.” the ISASI Rudolf Kapustin Memorial the opening years of 2000 and noted how Voss concluded the topic discussion by Scholarship fund-raising campaign. One high the levels of safety remained. asking the investigators to think about hundred percent of the funds raised by Voss believes it is proactive safety • how the regulator revolution is going. the 1st Annual Kapustin Memorial Golf

July–September 2009 ISASI Forum • 25

ISASI ROUNDUP In Memoriam Continued . . . C.H. Whitburn (LM0787), Sutherland NSW, Australia, March 2009 Arthur E. Pearsall (LC0115), Oceanside, Calif., USA, Oct. 31, 2008 John W. Carlson (MO3537), Boca Ratun, Fla., USA

Scramble benefit the Scholarship Fund. Pacific states. A number of capable and a home hidden by the trees at the ap- The scramble will begin at 8:00 a.m. competent delegates provided initial proach end of the field. That home was on Sunday, September 13. The cost to indications of tangible support for the struck by the aircraft, killing two persons play will be $100 per person. Prizes will program. All expressions of interest are inside. This accident occurred at night, be awarded for the longest drive and being vigorously pursued. ◆ in very hazardous terrain, in a fully the closest ball to the pin (holes to be loaded B-747 with only one operating en- announced). Golf clubs are available for gine. All on board survived. I am proud rent at the Disney Magnolia Golf Course Correction to count Capt. Beebe among my personal for a fee. All food and beverages will be In President’s View, published in the friends and heartily concur with the at the player’s own expense. April-June 2009 issue of ISASI Forum, IBT’s opinion of his airmanship. ◆ The full seminar program, along with the second of the two cited Kalitta Air registration forms, is available on the accidents was incorrectly described, as ESASI Hosts Second seminar website. The information may noted by Capt. Scott Schwarz (MO5275), also be found in the April/June Forum, Kalitta Air Safety Committee chairman, Regional Air Safety Seminar page 25. ◆ who wrote: Following the success of its inaugural The second accident, in Bogota, was seminar last year, the European Soci- not the result of an aircraft stall. I was ety of Air Safety Investigators held its Reachout Report a party to this investigation and am second seminar in Hamburg on April Shows Continued quite familiar with the facts. That crash 20-21. The event was hosted in the was the result of a deliberate off-airport historic Patriotosche Gesellschaft in the Program Interest landing. Our aircraft was fully loaded city center, which provided an excellent John Guselli, chairman of the Reachout with flowers bound for Miami. The venue for the presentations. Approxi- Workshop program, reports that the aircraft lost one engine 7 seconds after mately 74 attendees travelled from all Reachout program continues its consoli- rotation. While executing the engine-out over the world. The emphasis of the dation process. Although impacted by escape maneuver to return to El Dorado technical program was on current Euro- current economic issues, communication International, a second engine failed 36 pean issues and the technical challenge continues between stakeholders at all seconds after rotation, at which point the of accident investigations. levels with the objective of being ready aircraft was no longer capable of climb- There were presentations from the when the situation improves. ing. The captain elected to proceed to a EASA and the European Union on Good support from the UK AAIB en- nearby Columbian Air Force base, which the legal framework, and Ulf Kramer abled European Society delegates to be was now closer than El Dorado Interna- from the German BFU spoke about the canvassed during the Hamburg seminar tional. As the crew was turning toward proposed changes to ICAO Annex 13 in April. Many positive responses to the the base, at approximately 60 seconds following the recent AIG meeting. Paul- call for capable instructors to assist the after rotation, a third engine began a Louis Arslanian from the French Bureau program were received. series of long-period compressor stalls. d’Enquêtes et d’Analyses (BEA) spoke During May, the Reachout program At this point, the captain (Bryant Beebe, about the particular challenges of inter- received significant input and response who has since been recognized by the IBT national accidents and the intense news from geographically diverse ATM man- Airline Division for superior airman- media involvement. There were also a agers in developing states. This activity ship) realized that there was no possibil- number of presentations on the British followed the ATS Safety Management ity of making an on-airport landing. He Airways B-777 accident at Heathrow in and Investigation Course, conducted at was familiar with the local area from January 2008. The contributions from Changi by the Singapore Aviation Acad- years of flying in South America and the UK and the U.S. illustrated the emy. Active participation by the Singa- knew of an open field that, while situ- complex technical challenges presented pore AAIB reinforced this process and ated between two towers, appeared long by this accident and the broad range encouraged an enthusiastic response. enough to attempt a landing. He was of scientific approaches, both in terms In addition, the June NZSASI region- fully under control at touchdown. By the of testing and research that have been al seminar in Rotorua, New Zealand; time the aircraft was landing, the third applied to determine the cause of the provided another forum for discus- engine had ceased producing usable power loss on both engines. sion of the Reachout concept for South thrust. Unfortunately, there was A civic reception was held at the City

26 • ISASI Forum July–September 2009 Some of the 74 attendees are shown preparing for the start of the EASI workshop held in Hamburg, Germany.

royal warrant from the Queen of Eng- land, Elizabeth the Second. The Medal was to be awarded for those special services under regulations that the governor-general of New Zealand, act- ing on the advice of the prime minister Hall in Hamburg, hosted by Carsten The Medal was instituted in Novem- or a minister of the crown acting for the Frigge, a state senator, and the DEKRA ber 2002 to recognize the service of prime minister, may determine. ◆ organization, which provides specialist those New Zealanders, and citizens of inspection service to many areas, includ- the United States and other countries, ing aviation. The reception was followed who were involved with the extremely NZSASI Safety Seminar by a tour of the beautifully ornate rooms difficult and very unpleasant, hazardous, Inaugurates Chippindale within the City Hall, which are not nor- and extreme circumstances associated mally open to the public and included a with the body recovery, crash investiga- Memorial visit to the Parliament Chamber. tion, and victim identification phases of The New Zealand Society (NZSASI) Following the seminar, on April 22, a Operation Overdue. hosted a joint Australian, New Zealand technical visit was made to the Airbus Operation Overdue was mounted by regional air safety seminar in Rotorua, A320 family production line at Finkelw- the New Zealand police following the New Zealand, June 5-7. Approximately erder. The group enjoyed superb Airbus crash of Air New Zealand (a McDonnell- 95 people registered, along with 20 hospitality and an interesting tour of the Douglas DC-10-30 ZK-NZP) Flight TE901 partners, an excellent number given the state-of the-art production line. on the north slope of Mount Erebus, Ross economic situation. A highlight was the The feedback from attendees was Island, Antarctica, on Nov. 28, 1979, with inaugural Ron Chippindale Memorial very positive in terms of the length and the loss of all 257 passengers and crew. Presentation, in honor of the ISASI extent of the technical program. ESASI The Medal was struck pursuant to a Fellow and New Zealand ISASI council- expressed its gratitude for all the superb lor who was killed in a motor vehicle acci- local arrangements, particularly the dent in 2008. Peter Williams, New Zealand assistance of Klaus Ardey in making Society presi­dent, said that the memorial the seminar such a success. ESASI is is in the form of a presentation by an planning to hold next year’s seminar in invited speaker that “touches on the aims Toulouse, France. ◆ and ethics and inspires us to be better investigators.” Councillor Chippindale’s long-time ISASI Member Honored friend and current president of the For ANZ DC-10 Antarctica Australian Society, Lindsay Naylor, was asked to give the first such address. He Crash Work gave a summary of Ron’s illustrious and ISASI member Steven Lund, director safety-devoted career before outlining of air safety investigations for the the known circumstances of a runway McDonnell-Douglas Heritage Boeing excursion accident currently under Commercial Aircraft Group, was pre- Steve Lund, center, receives his medal investigation. sented the New Zealand Special Service from the New Zealand ambassador to The CAA of New Zealand, Air Nelson, Medal (Erebus) on May 12 in a private the U.S., His Excellency Roy Ferguson. Mount Cook Airlines, and Airclaims New ceremony from His Excellency Roy Looking on, right, is the New Zealand Zealand, Ltd., helped sponsor the seminar. Ferguson, New Zealand ambassador police liaison officer at the embassy, The Royal New Zealand Air Force and to the U.S. Other ISASI New Zealand- Superintendent Sandra Manderson. As the Australian Defence Force safety office, ers had received their medals in 2007, former head of the police department in both corporate members of ISASI, sup- including the late Ron Chippendale, who Christchurch, New Zealand, she sup- ported large contingents. Attendees also headed the New Zealand government’s ported Lund’s investigation team while came from Japan, Tahiti, and the U.S. investigation. enroute to Antarctica. Distinguished attendees were the

July–September 2009 ISASI Forum • 27 ISASI ROUNDUP Continued . . .

potential for fuller investigation of bird- DFWRC Co-sponsors strike incidents. Other papers discussed the challenges involved in implementing Human Factors Seminar Safety Management Systems; some les- In March, the Dallas-Ft. Worth Regional sons learned in the deep-water recovery Chapter co-sponsored the “Aviation Hu- of a helicopter; the use of a panoramic man Factors and SMS Conference: Real camera for recording an accident scene; World Flight Operations and Research and the influences of organizational, Progress.” The seminar, held at the situational, and social pressures on pilot Frontiers of Flight Museum in Dallas, decision-making. Tex., was well attended, with more than During the seminar, the New Zealand 200 attendees. The Conference focused and Australian Societies held general on research issues, academic challenges, meetings and received five applications and system advances for human factors for ISASI membership. in the real-world of operations for FAR Lindsay Naylor, right, accepts a memento The joint annual seminar is a long- Part 121, 135, 141, and 91, fixed-wing from New Zealand President Peter Wil- standing event on the accident investiga- and rotorcraft. liams inscribed: “To commemorate the tion and air safety calendar. Next year’s During the seminar, Chapter Presi- Ron Chippindale Memorial Presentation seminar will be hosted by ASASI in dent Tim Logan informed the attendees made by Lindsay Naylor, NZSASI 2009.” Canberra. ◆ about ISASI and the benefits of mem- bership. Following the presentation, chief of the Air Force and the director PNWR Chapter Meets at several interested attendees requested of the CAA. On behalf of the ISASI applications for membership. president, Williams presented Ashley Boeing Facility Following the seminar, the Chapter Smout, the chief executive of Airways The Pacific Northwest Regional held its first meeting for 2009. Time was New Zealand, with a certificate of ISASI (PNWR) Chapter held a technical semi- taken to recognize and thank Curt Lewis corporate membership. Smout then gave nar on June 18 at the Boeing Longacres for 8 years of service as the Chapter’s the opening address. training facility in Renton, Wash. president. Also discussed at the meeting The 18-paper program began with Richard Anderson made a presenta- were plans for a Chapter safety day to presentations that clarified practical and tion to the PNWR Chapter summariz- be held later this year. ◆ legal aspects of major investigations ing the accidents and major incidents conducted in accordance with Annex 13, that have occurred to Boeing aircraft and the CAA’s approach to investigation during the past year. This “Year in and enforcement and explained why the Review” presentation has become a police might treat an air accident scene favorite among the Chapter members as a potential crime scene. in the Northwest because it gives an Papers on current investigations de- overview of the year’s accidents and scribed a serious B-744 depressurization how the overall accident trends are incident and some A330 pitch events. developing. Papers were also given on investigations This year was no exception since into large turbine engine surges and the Richard provided both insights into unexpected result of degraded dampers recent accidents and highlighted some in piston engines. A very interesting safety issues that were applicable to paper was given on how to evaluate the investigators. merits of computer graphics animations All ISASI members are encouraged of accidents. to attend the technical sessions offered An enlightening presentation was by PNWR. A current schedule of events made by an airline on some human can be obtained by e-mailing the Chap- Curt Lewis (left) accepts his Leadership factors issues encountered with RNAV ter president, Kevin Darcy, at KDarcy@ Award for past service from the new operations. A further paper showed the safeserv.com. ◆ Chapter president, Tim Logan.

28 • ISASI Forum July–September 2009 New Members

CORPORATE Little, Stephen, R., Abu Dhabi, United Arab Aviation Safety Investigations, UK Emirates David P. Gleave, chief investigator Lucbernet, Dominique, L., Abu Dhabi, Air Astana (Kazakhstan) United Arab Emirates Gerhard Coetzee, vice-president Maranhao Neto, Pericles de Andrade, Mel- corporate and quality bourne, FL, USA Iger Darilor, acting as manager safety McCarthy, Neil, S., Cow Bay, NS, Canada investigations Mulligan, Brian, M., Coventry, RI, USA Administration des Enquêtes Techniques Osman, Wail, Abu Dhabi, United Arab (Luxembourg) Emirates Jean-Claude Medernach, director Papouis, Constantinos, Athienou, 7600, Cyprus Marc Determ, investigator Plets, John, E., FPO, AP, USA Allianz Aviation Managers, LLC, USA Price, Michael, F., Pompano Beach, FL, USA Brian R. Hogan, vice-president aviation Ramos, Elaine, Y., Abu Dhabi, United Arab Michael L. Carlucci, claims adjuster/ Emirates aviation claims Saindon, Karl, Belleville, ON, Canada Schmid, Carl, P., Mossman, QLD, Australia INDIVIDUAL Sciarra, Daniela, Abu Dhabi, United Arab Abdulkarim, A., N., Kaduna, Nigeria Emirates Black, Joshua, M., Venice, FL, USA Silcock, Aaron, J., Morrinsville, New Cassaro, Douglas, J., Alexandria, VA, USA Zealand Faryniuk, Glaucia, R., Abu Dhabi, United Smith, Everett, W., Albuquerque, NM, USA Arab Emirates Storey, Alicia, G., Enterprise, AL, USA Hatchell, David, B., Irmo, SC, USA Subramaniam, Vijay, P., Abu Dhabi, United Jeyalingam, Gerard, Abu Dhabi, United Arab Emirates Arab Emirates Watkins, Justin, T., Prescott, AZ, USA ◆ President Del Gandio, left, presents a certificate of corporate membership to David Gleave, representing Aviation Unmanned Aircraft System UAS development, deployment, and Safety Investigation, West Sussex, UK. integration are holding their members to WG Issues Year One Report remarkably strict levels of confidential- that either will be publicly debated— In September 2008, ISASI President ity about their activities. This is counter- with solid information gained from Frank Del Gandio approved the forma- productive, but a fact of life. Given the operational experience—for some time tion of an ISASI working group focusing growing number of potential arguments to come, since these are also the most on new investigative challenges aris- that could be raised against different controversial aspects of UAS operations ing from the growth of the unmanned aspects of current and proposed UAS in mixed manned/unmanned airspace. aircraft system (UAS) sector of aviation. operations and regulations, limiting pro- “In short, the path that ISASI’s ex- He named Tom Farrier (MO3763) chair fessional discourse on them may inhibit ploration of the UAS arena will follow in of the Unmanned Aircraft Systems the cause of safety but it’s smart politics. the months and years to come is slowly Working Group. Following is his first “So, where do we fall short today in evolving, and is guaranteed to be twisty contribution to the membership through being able to proceed? The easy—and and bumpy. However, the growth of the the Forum. frustrating—answer is that there’s UAS sector is proceeding, and we’ll need “In accepting the chairmanship of almost no hard data to work from. The to keep moving forward with it. To the this Group, I thought we could hit the reasons for this vary from user to user extent that the emerging constellation ground running. Unfortunately, that has and system to system, but a few general of unmanned aircraft systems will be not turned out to be the case. Still, the themes keep cropping up: any loss of the different from today’s fleet of manned issues that need to be tackled are begin- bigger ones is considered militarily sen- aircraft, we as investigators will need to ning to take shape. sitive, nobody is centrally tracking how be ready to deal with those differences. “Our first and greatest challenge is a many hours the smaller ones are flown, The general course we’ll need to chart to lack of Working Group (WG) members materials and propulsion technologies get from today to tomorrow seems clear with UAS-specific knowledge. There’s are considered proprietary, etc. Further, enough. a gratifying amount of interest within perhaps the two most critical issues • We need to encourage dialogue ISASI in the subject of UAS in general. associated with UAS operations are (1) and consciously address the baseline However, the WG itself is hampered The necessity of reliable control and obligation to investigate UAS accidents by having a wealth of avenues deserv- datalinks between the pilot and the air- to prevent their recurrence, without ing inquiry, but lacking the expertise or craft; and (2) Feasible means of ensur- taking any position on the merits of UAS rolled-up sleeves willingness needed to ing that ‘see and avoid’ remains a viable themselves. do them justice. The WG needs fewer strategy for manned aircraft through • We should not enter into any debates observers and more doers. some functionally equivalent analogue to regarding the wisdom of any particular “A secondary challenge, possibly it for unmanned aircraft systems. regulatory approaches or design solu- related to the first, is that most of the “Although a failure in either of these tions. government and government-industry areas can easily be foreseen as an under- • We need to approach unmanned air- groups taking on various aspects of lying cause of an accident, it’s unlikely craft systems from the highest concep-

July–September 2009 ISASI Forum • 29 ISASI ROUNDUP ISASI Information Continued . . .

tual level possible (aircraft one place, that is incompletely or ineffectively in- pilot another), and then work from that vestigated will lead to another. As such, OFFICERS starting point in developing investiga- recommendations aimed at preventing President, Frank Del Gandio ([email protected]) tive strategies that account for all of the the recurrence of each UAS accident will Executive Advisor, Richard Stone resulting accident possibilities. need to be made, but the only way they ([email protected]) Vice-President, Ron Schleede • We need to move forward on the will be useful will be if they are made ([email protected]) assumption that just about any current knowledgeably. Secretary, Chris Baum ([email protected]) aircraft may someday be capable of be- The bottom line: there’s only spotty Treasurer, Tom McCarthy ing flown remotely (so-called ‘optionally data publicly available on numbers of ([email protected]) piloted aircraft’), and that there also will losses, very little on failure modes or be a growing diversity of purpose-built causes, and nothing reliable that would COUNCILLORS Australian, Lindsay Naylor aircraft optimized for carrying out the allow any of the losses to be normalized ([email protected]) ‘dull, dirty, or dangerous’ activities at for comparison purposes. Several of the Canadian, Barbara Dunn ([email protected]) which unmanned aircraft systems excel. most likely vectors of loss aren’t part of European, Anne Evans “With the above precepts firmly in the public discourse because of their po- ([email protected]) International, Caj Frostell mind, the investigator community also litical sensitivity. And, many of the best ([email protected]) needs to remind both regulators and minds in our business are in one way or New Zealand, Peter Williams ([email protected]) UAS manufacturers that where aircraft another constrained from working coop- United States, Curt Lewis fly, they also crash. Any UAS accident eratively on any outside activity like that ([email protected]) of the ISASI UAS Working Group. “Sound like fun? You bet! If you think NATIONAL AND REGIONAL you can help move the ball forward, SOCIETY PRESIDENTS Australian, Lindsay Naylor please drop me a note at uas@earthlink. ([email protected]) Moving? net. Here’s hoping the upcoming year will Canadian, Barbara M. Dunn ([email protected]) Please Let Us Know bring greater transparency and more will- European, David King Member Number______ingness to openly address the things that ([email protected]) Latin American, Guillermo J. Palacia we all need to know to help make future (Mexico) Fax this form to 1-703-430-4970 or mail to UAS operations as safe as possible.” ◆ New Zealand, Peter Williams ISASI, Park Center ([email protected]) 107 E. Holly Avenue, Suite 11 Russian, Vsvolod E. Overharov Sterling, VA USA 20164-5405 ([email protected]) Revised Membership SESA-France Chapter,Vincent Fave Old Address (or attach label) ([email protected]) Cards Now Available United States, Curt Lewis Name______On Sept. 7, 2008, the International ([email protected]) Address______Council decreed to update the member- UNITED STATES REGIONAL City______ship cards from a laminated paper card to a plastic PVC .30 mil card, similar to CHAPTER PRESIDENTS State/Prov.______Alaska, Craig Bledsoe credit-card size and type. The member- ([email protected]) Zip______Arizona, Bill Waldock ship card is now available. Each card is ([email protected]) Country______designed with a different color strip des- Dallas-Ft. Worth, Tim Logan ([email protected]) New Address* ignating the membership status: Fellow- Great Lakes, Matthew Kenner black, Full-olive, Associate-sea green, ([email protected]) Name______Los Angeles, Inactive Affiliate-maroon, and Student-slate blue. Mid-Atlantic, Ron Schleede Address______Because Life Membership cards are ([email protected]) Northeast, David W. Graham City______already plastic embossed cards, they are ([email protected]) State/Prov.______not included in the revision. Pacific Northwest, Kevin Darcy If you would like a new membership ([email protected]) Zip______Rocky Mountain, David Harper card please send an e-mail or note to ([email protected]) Country______San Francisco, Peter Axelrod Ann Schull, international office manag- ([email protected]) E-mail______er; [email protected] or 107 E. Holly Av- Southeastern, Robert Rendzio *Do not forget to change employment and enue, Sterling, VA 20164. Include your ([email protected]) e-mail address. membership number in the request. ◆

30 • ISASI Forum July–September 2009 Allied Pilots Association Int’l Assoc. of Mach. & Aerospace Workers COMMITTEE CHAIRMEN American Eagle Airlines Interstate Aviation Committee Audit, Dr. Michael K. Hynes Irish Air Corps ([email protected]) American Underwater Search & Survey, Ltd. Award, Gale E. Braden ([email protected]) AmSafe Aviation Irish Aviation Authority Ballot Certification, Tom McCarthy Aramco Associated Company Japan Airlines Domestic Co., LTD ([email protected]) ASPA de Mexico Japanese Aviation Insurance Pool Board of Fellows, Ludi Benner ([email protected]) Association of Professional Flight Attendants Jeppesen Bylaws, Darren T. Gaines ([email protected]) Atlantic Southeast Airlines—Delta Connection JetBlue Airways Code of Ethics, Jeff Edwards Australian Transport Safety Bureau Jones Day ([email protected]) Aviation Safety Council KLM Royal Dutch Airlines Membership, Tom McCarthy Aviation Safety Investigations, UK Korea Air Force Safety Ctr. ([email protected]) Avions de Transport Regional (ATR) Korea Aviation & Railway Accident Investigation Nominating, Jayme E. Nichols BEA-Bureau D’Enquetes et D’Analyses Board ([email protected]) Board of Accident Investigation—Sweden Kreindler & Kreindler, LLP Reachout, John Guselli Boeing Commercial Airplanes L-3 Communications Aviation Recorders ([email protected]) Bombardier Aerospace Regional Aircraft Learjet, Inc. Seminar, Barbara Dunn ([email protected]) Bundesstelle fur Flugunfalluntersuchung—BFU Lockheed Martin Corporation Cathay Pacific Airways Limited Lufthansa German Airlines WORKING GROUP CHAIRMEN Cavok Group, Inc. MyTravel Airways Air Traffic Services, John A. Guselli (Chair) Centurion, Inc. National Aerospace Laboratory, NLR ([email protected]) Charles Taylor Aviation, Singapore National Air Traffic Controllers Assn. Ladislav Mika (Co-Chair) ([email protected]) China Airlines National Business Aviation Association Cabin Safety, Joann E. Matley ([email protected]) Cirrus Design National Transportation Safety Board Corporate Affairs, John W. Purvis Civil Aviation Safety Authority Australia NAV Canada ([email protected]) Colegio De Pilotos Aviadores De Mexico, A.C. Nigerian Ministry of Aviation and Accident Flight Recorder, Michael R. Poole Comair, Inc. Investigation Bureau ([email protected]) Northwest Airlines General Aviation, Randall S. Mainquist Continental Airlines Continental Express Parker Aerospace ([email protected]) Phoenix International, Inc. Government Air Safety, Willaim L. McNease COPAC/Colegio Oficial de Pilotos de la Aviacion Comercial ([email protected]) Cranfield Safety & Accident Investigation Centre Pratt & Whitney Human Factors, Richard Stone Curt Lewis & Associates, LLC Qantas Airways Limited ([email protected]) DCI/Branch AIRCO Qatar Airways Investigators Training & Education, Defence Science and Technology Organization (DSTO) Qwila Air (Pty), Ltd. Graham R. Braithwaite Delta Air Lines, Inc. Raytheon Company ([email protected]) Directorate of Aircraft Accident Investigations— Republic of Singapore Air Force Unmanned Aerial Systems, Tom Farrier Namibia Rolls-Royce, PLC ([email protected]) Directorate of Flight Safety (Canadian Forces) Royal Netherlands Air Force Directorate of Flying Safety—ADF Royal New Zealand Air Force Dombroff Gilmore Jaques & French P.C. RTI Group, LLC Dutch Airline Pilots Association Sandia National Laboratories CORPORATE MEMBERS Dutch Transport Safety Board SAS Braathens AAIU Ministry of Transport Bulgaria EL AL Israel Airlines Saudi Arabian Airlines Accident Investigation Board, Finland Embraer-Empresa Brasileira de Aeronautica S.A. SICOFAA/SPS Accident Investigation Board/Norway Embry-Riddle Aeronautical University Sikorsky Aircraft Corporation Accident Investigation & Prevention Bureau Emirates Airline Skyservice Airlines, Ltd. Administration des Enquêtes Techniques Era Aviation, Inc. Singapore Airlines, Ltd. (Luxembourg) European Aviation Safety Agency SNECMA Moteurs Aeronautical & Maritime Research Laboratory EVA Airways Corporation South African Airways AeroVeritas Aviation Safety Consulting, Ltd. Exponent, Inc. South African Civil Aviation Authority Aerovias De Mexico, S.A.De C.V. Federal Aviation Administration Southern California Safety Institute Air Accident Investigation Bureau of Singapore Finnair Oyj Southwest Airlines Company Air Accident Investigation Unit—Ireland Finnish Military Aviation Authority Southwest Airlines Pilots’ Association Air Accidents Investigation Branch—U.K. Flight Attendant Training Institute at Melville College Star Navigation Systems Group, Ltd. Air Astana (Kazakhstan) Flight Safety Foundation State of Israel Air Canada Pilots Association Flight Safety Foundation—Taiwan Transport Canada Air Line Pilots Association Flightscape, Inc. Transportation Safety Board of Canada Air New Zealand, Ltd. Galaxy Scientific Corporation U.K. Civil Aviation Authority Airbus S.A.S. General Aviation Manufacturers Association UND Aerospace Airclaims Limited GE Transportation/Aircraft Engines University of NSW Aviation Aircraft Accident Investigation Bureau—Switzerland Global Aerospace, Inc. University of Southern California Aircraft Mechanics Fraternal Association Gulf Flight Safety Committee, Azaiba, Oman Volvo Aero Corporation Aircraft & Railway Accident Investigation Commission Hall & Associates, LLC WestJet ◆ Airservices Australia Hellenic Air Accident Investigation AirTran Airways & Aviation Safety Board Airways New Zealand Honeywell Alaska Airlines Hong Kong Airline Pilots Association Alitalia Airlines—Flight Safety Dept. Hong Kong Civil Aviation Department Allianz Aviation Managers, LLC, USA IFALPA All Nippon Airways Company Limited Independent Pilots Association

July–September 2009 ISASI Forum • 31 WHO’S WHO

(Who’s Who is a brief profile of, and pre- nance organizations are unique in the port—Customized human factors and pared by, the represented ISASI corporate industry. The surveys can be rapidly just culture training for managers, in- member organization to enable a more customized to meet the needs of the cli- cluding the findings of the safety culture thorough understanding of the organiza- ent. The surveys help to quickly identify surveys within the clients organization. tion’s role and functions.—Editor) the risks or “hotspots” in an organi- • Organizational investigation pro- zation and allow immediate focus on cesses to support a client’s error/risk aines Simmons Americas is an intervention strategies. The following is reduction efforts including human- avia­tion safety consulting company a “snapshot” of the survey process: centered event investigation training for Bbased in Atlanta, Ga., specializing 1. The surveys consist of between 65 and organizations. in integrated human factors and error/ 92 questions and are conducted in focus risk reduction services for aviation orga- groups ranging in size from 3 to 32 people. Sample of offered training courses nizations of all sizes, including airlines, 2. The surveys are conducted on site and Implementing Effective Safety OEMs, maintenance repair and overhaul during the regular work hours of the Management Systems organizations (MROs), aviation ground population being surveyed. An agreed- 1. Implementing an Effective SMS handling companies, and other high-risk upon percentage of the total population is (3 days)—Intended audience: safety aviation operations surveyed to obtain a valid data sampling. managers, quality managers, internal The Baines Simmons group of com- 3. Data are gathered in a way that allows evaluation program (IEP) managers, panies has worked with more than 250 the participants to remain anonymous accountable managers, training manag- aviation companies worldwide, including and helps ensure candid, honest feedback. ers, human factors managers, regulatory advising national aviation authorities in 4. Executive and summary reports are inspecting staff and managers. 40 countries. The managing directors of produced for the organizations manage- 2. SMS Implementation for Leaders (1 Baines Simmons Americas and Baines ment team detailed down to location, day)—Intended audience: senior lead- Simmons, Ltd., have been recognized workgroup, or shift. The surveys are ers, directors, senior managers. with three international awards for currently available in English, Spanish, 3. SMS Implementation for Front-Line aviation human factors and safety work. and Portuguese. employees (1 day) (maintenance-specific This partnership allows for knowledge • Integrated Error Management focus)—Intended audience: front-line sharing and capability development that Systems (IEMS)—While surveys and managers, supervisors, lead technicians, is industry leading in the areas of safety training are important first steps in the technicians, support shop staff, materiel culture assessment; Safety Management error management and cultural change services, etc. Systems (SMS) assessment, develop- process, they are just the beginning. Effective Event Investigation (3 days)— ment, and change-management imple- BSA also specializes in fully integrated Intended audience: ground and flight safe- mentation support; human factors/error error management system development. ty staff, quality assurance staff, MEDA/ management program development; and • “Just Culture” post-event process REDA coordinators, any other staff tasked human factors training—instructor-led construction and implementation sup- with conducting investigations. ◆ and computer-based training (CBT) available in English and Spanish The Baines Simmons group of companies ISASI Non-Profit Org. U.S. Postage utilizes a Safety Management and Risk 107 E. Holly Ave., Suite 11 Sterling, VA 20164-5405 USA PAID Reduction Toolkit (SMARRT) approach to Permit #273 assessing large organizations safety pro- CHANGE SERVICE REQUESTED ANNAPOLIS, MD cesses. The SMARRT diagnostic approach is designed to address the challenge of improving safety performance from the perspective of individual and organization- al performance to reduce business risk.

Additional capabilities • Safety Culture Surveys—The surveys for both ground-handling and mainte-

32 • ISASI Forum July–September 2009