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Air Safety Through Investigation JULY-SEPTEMBER 2018 Journal of the International Society of Air Safety Investigators Analysis Techniques for Investigating Human Performance page 4 Airbus Support to Accident Investigation page 12 ISASI Kapustin Scholarship Essay— Accident Reports and Aeronautical Decision- Making: Applying Case- Based Reasoning to Improve GA Safety page 16 The Role of Investigations in Creating and Implementing Safety Nets: Minding the Gap page 19 Investigations, Recommendations, and Safety Management Systems page 22 CONTENTS Air Safety Through Investigation Journal of the International Society of Air Safety Investigators FEATURES Volume 51, Number 3 Publisher Frank Del Gandio 4 Analysis Techniques for Investigating Human Performance Editorial Advisor Richard B. Stone By Randy Mumaw, Researcher, NASA Ames Research Center; William Bramble, Senior Editor J. Gary DiNunno Human Performance Investigator, NTSB; Joel Morley, Former Senior Human Factors Design Editor Jesica Ferry Investigator, Transportation Safety Board of Canada; and Fanny Rome, Human Factors Associate Editor Susan Fager Safety Investigator, BEA—The authors examine human performance factors as one of many contributors to air accidents and incidents and that they can be shaped by contextual ISASI Forum (ISSN 1088-8128) is published quar- and system factors. terly by the International Society of Air Safety Investigators. Opinions expressed by authors do 12 Airbus Support to Accident Investigation not necessarily represent official ISASI position By Nicolas Bardou, Director of Flight Safety, Airbus—The author outlines support Airbus or policy. provided during investigation of the crash and lo.ss on Oct. 31, 2015, of an A321 flying from Editorial Offices: Park Center, 107 East Holly Ave- Sham El-Sheikh, Egypt, to St. Petersburg, Russia, that resulted in the deaths of all 224 nue, Suite 11, Sterling, VA 20164-5405. Telephone crewmembers and passengers aboard. 703-430-9668. Fax 703-430-4970. E-mail address, [email protected]; for editor, jgdassociates@ 16 ISASI Kapustin Scholarship Essay—Accident Reports and starpower.net. Internet website: www.isasi.org. ISASI Forum is not responsible for unsolicited Aeronautical Decision-Making: Applying Case-Based Reasoning manuscripts, photographs, or other materials. to Improve GA Safety Unsolicited materials will be returned only if By Ross Rozanski, University of Southern California, 2017 Kapustin Scholarship submitted with a self-addressed, stamped enve- Winner—The author proposes that using case-based reasoning in GA pilot training rather lope. ISASI Forum reserves the right to reject, than rule-based reasoning can produce safer pilots who are more capable of reacting posi- delete, summarize, or edit for space con- siderations any submitted article. To facilitate tively to emergency scenarios. editorial production processes, American Eng- lish spelling of words is used. 19 The Role of Investigations in Creating and Implementing Safety Nets: Minding the Gap Copyright © 2018—International Society of Air Safety Investigators, all rights reserved. Publica- By Jim Burin, ISASI Member and Flight Safety Foundation Fellow—The author observes that tion in any form is prohibited without permis- air travel has superb safety nets that are the result of outstanding investigations over many sion. ISASI Forum registered U.S. Patent and years. He says there is, however, a gap between creating safety nets and using safety nets that T.M. Office. Opinions expressed by authors do must be identified and corrected. not necessarily represent official ISASI position or policy. Permission to reprint is available upon 22 Investigations, Recommendations, and Safety Management Systems application to the editorial offices. By Thomas A. Farrier, Senior Safety Analyst, JMA Solutions, LLC—The author suggests that Publisher’s Editorial Profile: ISASI Forum is print- as safety management systems and “proactive approaches” continue to gain prominence, ed in the United States and published for profes- the need for effective investigations and well-founded recommendations that highlight their sional air safety investigators who are members limitations has never been greater. of the International Society of Air Safety Inves- tigators. Editorial content emphasizes accident investigation findings, investigative techniques and experiences, regulatory issues, industry ac- cident prevention developments, and ISASI and DEPARTMENTS member involvement and information. 2 Contents Subscriptions: A subscription to members is pro- vided as a portion of dues. Rate for nonmem- 3 President’s View bers (domestic and Canada) is US$28; Rate for 28 News Roundup nonmember international is US$30. Rate for all 30 ISASI Information libraries and schools is US$24. For subscription 32 In Memoriam—Charles Foster information, call 703-430-9668. Additional or replacement ISASI Forum issues: Domestic and Canada US$4; international member US$4; do- mestic and Canada nonmember US$6; interna- ABOUT THE COVER tional nonmember US$8. Airbus participated as part of a team (see page 12) to investigate the 2015 crash of an A321. The investigation included assembling a layout of recovered wreck- age on a grid that was completed in only a few days. This process allowed the investigation team to concentrate on particular areas of interest. INCORPORATED AUGUST 31, 1964 2 • July-September 2018 ISASI Forum PRESIDENT’S VIEW ANOTHER ASPECT THAT SOMETIMES OCCURS AS A RESULT OF HUMAN INTERACTION ON INVESTIGATIONS—IT IS EXTREMELY RARE, BUT IT DOES HAPPEN—INVESTIGATORS FALL IN LOVE AND GET MARRIED. THEY MET BY ACCIDENT ircraft accidents to improving air travel safety, Carolina, USA. National Aviation University. create a great deal of investigations bring together There was a second mar- After graduation, she worked trauma and misery for a wide range of people who riage—one that followed at the National Bureau of Air A surviving passengers sometimes develop life-long the American Airlines Flight Accidents Investigation of and flightcrew members, fam- professional relationships 191 accident in May 1979, in Ukraine and was part of the ilies, and people present at the and personal friendships. This Chicago, Illinois, USA. The Ukraine investigating team. impact site. Air accidents and includes governments, indus- accident fatally injured 273 She subsequently enrolled as a incidents can also be difficult tries, unions, first respond- people, including two people Ph.D. student at Delft Univer- for other people in the world ers, operators, and anyone on the ground. Dr. Andy Horn, sity in aerospace engineering. who are not directly affected, involved in the investigation. representing the U.S. Feder- Both Julia and Michiel were but who feel empathy and Another aspect that some- al Aviation Administration on break and met in the hall. compassion for those directly times occurs as a result of hu- (FAA), was on the Survival Sparks flew, and the rest is involved even though they are man interaction on investiga- Factors Group. Kathy Russo history. strangers. tions—it is extremely rare, but was on the team representing Michiel was the first recipi- ISASI members realize that it does happen—investigators the Association of Professional ent of ISASI’s Kapustin schol- fall in love and get married. every accident and incident Flight Attendants. They were arship in 2003, which led to his On April 4, 1977, Southern is an opportunity to improve married shortly after the acci- employment with the Dutch Airways Flight 242, a DC-9-31, aviation safety and survivabil- dent. Horn passed away about Safety Board. In addition, at crashed in New Hope, Georgia, ity. Safety is enhanced if we, as 10 years ago, and we were the Adelaide, Australia, sem- USA, following an encounter unable to locate or obtain inar in 2014, Michiel shared investigators, do a thorough with hail that caused a loss of job and make meaningful safe- information on Russo. the Award of Excellence for thrust in both engines. Sev- best seminar paper with Kas ty recommendations that get On June 8, 2018, Michiel and enty-two people were fatally Beumkes, a fellow employee at acted upon. Last year’s annual Julia Schuurman were married injured, including nine on the the Dutch Safety Board. ISASI seminar theme was at the Delft City Hall, in Delft, ground. There were 27 survi- ISASI extends congratula- “Do Air Safety Investigations the Netherlands. They first vors. tions to Michiel and Julia on Really Matter?” The consensus met in Kiev, Ukraine, following The U.S. National Transpor- their recent wedding. of technical papers presented tation Safety Board (NTSB) the Malaysia Airlines Flight was clearly, yes, they do. investigated the accident, 17 shootdown that occurred That knowledge helps us and Matt McCormick was the on July 17, 2014. At the time, deal with trauma-induced chair of the Survival Factors Michiel’s employer was the stress that we face in our pro- Group. Patricia Hopkins, a Dutch Safety Board, and he fession. But sometimes more flight attendant with South- was a member of the accident human interaction is needed. ern Airlines, was on the team investigation team. Subse- Airlines, aircraft manufactur- representing the Transport quently, he accepted employ- ers, and employee organiza- Workers Union. About two ment with Delft University of tions recognize the adverse years later, Matt and Patricia Technology as an associate consequences of facing such came together while testifying professor teaching aviation- trauma and have developed at a U.S. congressional

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