JULY-SEPTEMBER 2004

Forensic Medicine and Toxicology (Page 4) The Role of Aerospace Medicine (Page 6) Using Injury Pattern Analysis (Page 9) Forensics and Victim Identification (Page 12) Accident Investigation Without the Accident (Page 17) CONTENTS

“Air Safety Through Investigation” FEATURES Volume 37, Number 3 Publisher Frank Del Gandio 4 Forensic Medicine and Toxicology Editorial Advisor Richard B. Stone By Steven Lund—Forensic medicine provides today’s aircraft accident investigators Editor Esperison Martinez with scientific data and other factual evidence to support safety recommendations. Design Editor William A. Ford Associate Editor Susan Fager Annual Report Editor Ron Schleede 6 The Role of Aerospace Medicine By Allen J. Parmet—The role of preventing future accidents and illness in everyone ISASI Forum (ISSN 1088-8128) is pub- lished quarterly by International Society of involved in aviation will continue as long as there are airplanes and people who fly them. Air Safety Investigators. Opinions ex- pressed by authors do not necessarily rep- 9 Using Injury Pattern Analysis resent official ISASI position or policy. Editorial Offices: Park Center, 107 East By William T. Gormley—Correlation of medical with other accident investigation Holly Avenue, Suite 11, Sterling, VA 20164- data can help reconstruct the mishap sequence through injury pattern analysis. 5405. Telephone (703) 430-9668. Fax (703) 430-4970. E-mail address [email protected]; for editor, [email protected] . Internet 12 Forensics and Victim Identification website: www.isasi.org. ISASI Forum is not re- sponsible for unsolicited manuscripts, pho- By M.A. Cimrmancic (FO4172)—Postmortem examination of the occupants can tographs, or other materials. Unsolicited serve the goals of the safety investigation: prevention of death and injury. materials will be returned only if submitted with a self-addressed, stamped envelope. ISASI Forum reserves the right to reject, de- 17 Accident Investigation Without the Accident lete, summarize, or edit for space consider- ations any submitted article. To facilitate edi- By Michael R. Poole (M03278)—The author describes flight animation pitfalls torial production processes, American-En- that can mislead investigators and stresses the importance of the airline and investigation glish spelling of words will be used. communities learning from each other. Copyright © 2004—International Society of Air Safety Investigators, all rights re- served. Publication in any form prohibited DEPARTMENTS without permission. ISASI Forum registered U.S. Patent and T.M. Office. Opinions ex- 2 Contents pressed by authors do not necessarily rep- 3 President’s View resent official ISASI position or policy. Per- mission to reprint is available upon appli- 22 ISASI RoundUp cation to the editorial offices. 31 ISASI Information Publisher’s Editorial Profile: ISASI Forum 32 Who’s Who—A brief is printed in the United States and published corporate member profile for professional air safety investigators who are members of the International Society of of the Association of Air Safety Investigators. Editorial content Professional Flight emphasizes accident investigation findings, investigative techniques and experiences, Attendants regulatory issues, industry accident preven- tion developments, and ISASI and member involvement and information. Subscriptions: Subscription to members is provided as a portion of dues. Rate for non- members is US$24 and for libraries and schools US$20. For subscription informa- tion, call (703) 430-9668. Additional or replacement ISASI Forum issues: members US$3, nonmembers US$6.

ABOUT THE COVER Forensics and victim identification was extensive in the November 2001 disaster of American Airlines Flight 587, which crashed into a residential area just after takeoff from New York’s JFK Airport. (Photo: ISASI Proceedings 2003)

2 • ISASI Forum July-September 2004 PRESIDENT’S VIEW

The State of ISASI By Frank Del Gandio, President On May 7, ISASI held its semi-annual Chapter just hosted a highly successful ISASI 2003 and holds International Council meeting at ALPA scheduled meetings. The Dallas/Ft. Worth Chapter is vibrant headquarters in Herndon, Va. The Society is and has undertaken ISASI 2005. There are other positive sound, and our publications and programs examples, but two of our U.S. chapters, Los Angeles and are proactive and accomplishing stated goals. Southeastern, are inactive and other societies and chapters The Council voted two significant ad- are relatively quiet. Local activities are vital to the health of vances into action (both are fully reported in ISASI. One of the strongest attraction points of our Society is the “RoundUp” section of this magazine). The first deals the opportunity to interact with our fellow members. We with feedback I have received from some of our members in need to take a good look at our local activities and make a the general aviation sector. These members believe there is concerted effort to keep the ISASI voice out front in accident value in establishing a General Aviation Committee within the structure of ISASI, to address more specifically the issues that affect that sector’s role in accident prevention The Society is sound, and our pub- and its investigation. The Council members looked closely at the issue, discussing if the Society would be able to lications and programs are proactive adequately support such an effort and if it could be of and accomplishing stated goals. benefit. The final consensus was that the establishment of such a group would benefit the overall Society by a potential increase in membership of investigators trained in the investigation and aviation safety. We also need several specialties of general aviation investigation, and that volunteers for the Positions Working Group. support for such a committee was feasible, especially if the Now a few words about recent activities. ISASI 2003, task was managed by existing general aviation members. celebrating the 100th anniversary of the Wright brothers’ Accordingly, the Council approved creation of the Commit- first flight, was a huge success, setting new standards in tee with the proviso that existing ISASI general aviation attendance and sponsorship contributions. A record members develop it. I urge any such member with an number of papers was presented, and delegate feedback was interest in this endeavor to contact me, or Curt Lewis, who that the seminar theme of “100 Years of Identifying Safety is working on the development of the Committee. Deficiencies and Solutions” was met. Barbara Dunn has The second Council action deals with a special member- done a great job in revising and clarifying our seminar ship category for persons who attend a Reachout seminar. guidelines and receives a “well done” from the Council. We have now completed 11 Reachout workshops through- We welcomed our first two student recipients of the ISASI out the world and have achieved great success in influenc- Rudy Kapustin Memorial Scholarship to ISASI 2003, and a ing the international community’s accident investigation winner has been selected for ISASI 2004. Incidentally, the process by making low-cost investigator training available to Mid-Atlantic Chapter contributed $6,000 to the scholarship budget-constrained geographic locations. Unfortunately, fund, ensuring that it will be viable for the near future. ISASI’s high cost of membership has discouraged member- Member contributions are tax-deductible and may be ship application from Reachout attendees. To overcome the forwarded to the home office. financial impediment, the Council established a “Reachout Our Forum continues to be a first-class publication, and Associate” membership for those who attend the work- the recent tribute issue to Jerry Lederer was a journalistic shops. The standard membership rate will apply, but the gem. Membership is growing slightly in spite of a downturn initiation fee will be waived. The Council will review the in the aviation industry, and the value of the international progress of the new-member category in December 2006. office space has increased significantly and provides the Aside from actions taken by the International Council, Society with a permanent home base. there is one area that needs to be addressed—the level of ISASI 2004 on the Gold Coast of Australia is well orga- activities of our national/regional societies and local chapters. nized and has every indication of being another hallmark Some are doing a bang-up job. The Canadian Society has seminar. All in all, ISASI continues to be a vital organization been the backbone of, and major contributor to, the dedicated to promoting aviation safety education at mini- Reachout seminar program. The Australian and New mal costs. We are able to do this thanks to our generous Zealand Societies continue to conduct local seminars and corporate members and sponsors, our indispensable office provide valuable services to their members. The Mid-Atlantic manager, and our irreplaceable volunteer membership. ◆

July-September 2004 ISASI Forum • 3 Forensic Medicine and Toxicology orensic medicine is the broad field ally accomplished using personal effects Forensic medicine provides of medical science where medical found on the remains, by comparing fin- Fmatters come into relation with gerprints with government files, match- today’s aircraft accident the law—certification of deaths; the study ing dental records, and, most signifi- investigators with scientific of violent and unnatural deaths, as in ac- cantly, using DNA protocols. To identify data and other factual cident investigations; scientific criminal individuals, forensic scientists examine investigations involving the coroner; 13 DNA regions that vary from person evidence on topics ranging court procedures, etc. The primary in- to person and use the data to create a from positive identification terests of forensic medicine for aircraft DNA profile of that individual (some- and cause of death; the accident investigations are usually medi- times called a DNA fingerprint). There cal and scientific. is an extremely small chance that another possibility of a pre-impact Toxicology relates to poisons of all person has the same DNA profile for a fire, explosion, and bomb kinds and their effects on the human particular set of regions. Only 0.1 per- or incendiary device on body, aiding the airliner accident inves- cent of DNA differs from one person to tigators with factual evidence in such the next. Scientists can use these vari- board; which pilot was areas as to test pilots for substance use able regions to generate a DNA profile controlling the aircraft at or abuse, which might have affected their of an individual, using samples from impact; and the aircraft’s actions before a crash, and to test pas- blood, saliva, bone, hair, and other body sengers’ remains for inflight explosion, tissues and products. Then a compari- attitude at impact to factu- fire, smoke, or fumes for factual evidence son is made with samples from the al evidence supporting of possible pre-impact fire or explosion victim’s close relatives, or, in some cases, safety recommendations. contribution to the cause of an accident. from the actual victim, such as hair from Some important examples of forensic a hairbrush, or blood samples from the By Steven R. Lund medicine in airliner accidents are posi- family doctor. The identification process tive identification of persons killed in a also includes a lay description of sex, age, crash for the statutory responsibility to height and weight, coloring of hair and issue the death certificate. This is usu- eyes, and any special characteristics, such as birthmarks, scars, tattoos, or even any About the author: Steven signs of some plain natural diseases. R. Lund retired after a Another victim identification tool is 32-year career at Douglas forensic radiography, which relies on X- Aircraft Company (now ray images of accident victims’ remains Boeing), which was devoted to obtain information. In the case of the to flight test, flight safety, Transportation Safety Board of Canada and commercial jet trans- (TSB) investigation of Swissair Flight port incident and accident investigation. He 111, which crashed off the coast of Nova has been involved in the investigation/analy- Scotia in September 1998, the identifi- sis of more than 130 jet transport airline cation of passengers and crew was car- accidents worldwide and more than 5,000 ried out by a team consisting of the chief incidents. He participated in the RAND medical examiners of the provinces of Institute for Civil Justice Study on the U.S. Nova Scotia and Ontario, the Royal Ca- national transportation aircraft accident nadian Mounted Police (RCMP), Depart- investigation process—“Safety in the Skies— ment of National Defense (DND) per- Personnel and Parties in NTSB Aviation sonnel, and others from the local medi- Accident Investigations.” Among other affili- cal community. One passenger was ations, he was a member of the U.S. Nation- identified by visual means. The remain- al Research Council Committee on Aircraft ing 214 passengers and 14 crew mem- Certification Safety Management, a strategy bers were identified through a combina- for the FAA’s Aircraft Certification Service. tion of dental record comparison, fin-

4 • ISASI Forum July-September 2004 Forensic Medicine and Toxicology gerprint matching, forensic radiography, ing the crash/aircraft break-up sequence. ages), but are instead added to the com- and deoxyribonucleic acid (DNA) pro- • Product liability litigation evidence—When pensatory damages in order to discour- tocols. All 229 occupants of the aircraft the inevitable writs begin flying after a age other would-be wrongdoers from act- were identified within 4 months after the major airliner accident, forensic medicine ing in a similar way. Punitive damages are accident. analysis invariably finds its way into court- just what they sound like—they “punish” Other examples of the role forensic rooms. In most states, to prove a product’s the defendant. medicine has played in accident investi- liability, a plaintiff has to show that the • Promote safety changes—In a more posi- gation include product was defective and was the main tive area, forensic medicine and toxicol- • A determination of which pilot was at the cause of the injury. In addition, the sur- ogy evidence has provided aircraft controls at impact—through a forensic viving relatives or heirs of an individual manufacturers and flight safety officials medicine analysis of the fractured bones who died in a fatal accident oftentimes in the pilots hands as a result of tightly file a wrongful-death lawsuit. The suit is gripping the control wheel upon impact. against the person or company whose ome important ex- • Cause of death—The laws in most coun- conduct led to the wrongful death. Plain- tries require a determination of whether tiffs can be awarded compensatory and Samples of forensic an airliner catastrophe was an accident punitive damages. Compensatory dam- medicine in airliner acci- or was due to a criminal act. In at least ages are comprised of those financial one case this determination was made losses that the victim has suffered as a di- dents are positive identifi- by a combination of a loud bang re- rect result of the defendant’s action. Com- cation of persons killed in corded on the CVR and the forensic pensatory damages are the most common a crash for the statutory medicine finding of a bullet hole through type of damages awarded to plaintiffs. the scull of one of the pilots. Criminal Compensatory damages can include pay- responsibility to issue act or not, forensic medicine usually de- ment from the defendant to compensate the death certificate. termines the cause of death of all fatali- for, among other things, lost wages, lost ties in an airliner crash for inclusion into profits, hospital bills (current and future), the necessary means to implement a “medical certificate of cause of death.” cost of home medical care, property dam- changes to aircraft design to mitigate Forensic medicine results are also used age, mental anguish, loss of friends, loss threats to passengers and crew, such as to determine the possibility of an explosive of respect in the community, loss of repu- requiring aircraft interiors to be con- or incendiary device on board by analyzing tation, loss of consortium, and pain and structed using materials that don’t eas- full-body forensic radiographic images suffering (p and s). Forensic medicine ily burn and generate pernicious prod- for small plastic or metallic fragments evidence, obviously, can play a significant ucts of combustion. Past examples of being deeply imbedded in intact victims, role in proving wrongful death; and even some of these changes were substituting which could only result from an in the amount of pain and suffering (p stainless steel for plastic counter tops in explosion’s high-velocity fragmentation and s) that might be shown to occur be- galleys and lavatories and the addition of aircraft parts in the vicinity of passen- fore death, this is normally gauged by the of “fire blocking” material around all gers. Also, the intense heat from an ex- amount of time a victim experiences the “polyurethane” foam passenger seat plosion or inflight fire might be detected p and s as derived from the forensic evi- cushions because of the pernicious tox- by forensic medicine when synthetic gar- dence. For instance, 10 seconds of p and icity of some of the combustion prod- ments—e.g., nylon—are melted into the s is often awarded twice as much as 5 sec- ucts (such as hydrogen-cyanide gas)! flesh of victims. This determination, onds of p and s. Punitive damages are Forensic medicine and toxicology and coupled with the victim’s known location, not awarded as often as compensatory the many facets thereof will continue to has provided investigators with factual damages. The judge will award punitive supply the airliner accident investigator evidence of the physical location of an damages only if the defendant’s act was with the extra added bit of scientific in- onboard incendiary device. so horrible and offensive that the court formation and factual data that might • Impact dynamics—In some cases foren- believes it is important to make an ex- be beneficial in the substantiation of the sic medicine results led investigators to ample out of the defendant. Punitive facts, conditions, and circumstances in- a better understanding of the aircraft damages are not awarded to compensate volved in the findings and conclusions attitude at impact in addition to the a person for his or her direct injuries or in the complicated investigation of air- forces involved as a function of time dur- property damage (compensatory dam- liner accidents. ◆

July-September 2004 ISASI Forum • 5 cal examiner (AME). While the AME is designated by the Fed- eral Aviation Administration to perform flight examinations, the training requirements are basic, and consist of a weeklong course taught in Oklahoma City. This physician is responsible The Role for the most important part of the aircraft: the pilot. Malfunc- tion of the pilot has from the very beginning of flight been the cause of most aviation accidents. Of Aerospace The AMP is a medical specialist who functions within in the areas of preventive medicine and its subspecialty, aerospace medicine. One of the 24 medical specialties recognized in the United States, aerospace medicine is the smallest of all spe- Medicine cialties, with about 1,000 physicians completing the 3 years of residency training and becoming certified in the United States The aerospace medicine physician has over the past 50 years. They differ from most of their medical the role of preventing future accidents colleagues in that prevention of illness and injury is the goal and illness in everyone involved in aviation rather than therapy after one is already sick. Their job, then, is to prevent accidents of aircraft and other forms of vehicles, including pilots, passengers, rescuers, for prevention is much more effective than treatment after and investigators. This role will continue the accident. as long as there are airplanes and people While not all accidents can be prevented, the AMP can use the information derived from accident investigations to de- who fly them. rive the causes of injury and help modify those factors. This leads to addition of engineering changes for both active and By Allen J. Parmet, MD, MPH, FACPM passive protection of occupants, reduction of crash-related (This article was adapted, with permission, from the author’s presen- environmental factors, and providing for survival and rescue tation entitled The Role of Aerospace and Preventive Medicine in the post-crash phase. presented at the ISASI 2003 seminar in Washington, D.C., USA, The lessons learned from accidents are also translated into August 2003. The full presentation is available on the ISASI website training to help prevent future accidents, design safer aircraft, at www.isasi.org.—Editor) and improve crash/rescue operations. The information may also find its way into the courtroom, as the AMP may become an revention of future mishaps has long been the primary expert witness in helping derive forensic and legal conclusions. goal of aircraft accident investigation. The secondary Customarily, there is no separate Medical Factors Working Ppurpose for conducting an inquiry is to derive causes Group in U.S. civil aviation mishap investigations, aside from of death and injury, with the objective of modifying those fac- the participation of the local medical examiner or coroner, who tors and improving mishap survivability. Thirdly, the facts of may provide trauma data to the Survival Factors/Crashworthi- the mishap are essential for purposes of establishing cause ness Working Groups. However, U.S. military aviation mishap and subsequent action in the litigation and regulatory arenas. investigations have a flight surgeon as a member of every board. Since the earliest days of flight, physicians have played an In civil accidents, when the AMP is called to participate, it is integral role in the progress of aviation safety. usually through invitation of the safety investigators or after Experts in a diverse array of disciplines, ISASI members the investigation closes and when litigation starts. Although a are united in their pursuit of the advancement of aviation considerable proportion of aviation mishap causation is hu- safety. Amid the multidisciplinary working groups focused man-related, the specialist of the human aspect is not a propor- upon structures, systems, and operational data, an effective tionately routine participant in aircraft accident investigations. member of an accident investigation team is the human sys- tems maintenance engineer, also known as the aerospace Human factors and accidents medicine physician (AMP), flight surgeon, or aviation medi- The primary causes of accidents have always been human fac- tors. Even before the Wright brothers flew in 1903, there had About the author: Dr. Allen Parmet received his been numerous aviation accidents and deaths. Probably the B.S. in chemical engineering from the United first true accident occurred in 1785 when Pilâtre de Rozier, a States Air Force Academy and served on active duty French physician who had been on board the very first flight with tours in Vietnam and NORAD before going to of a Montgolfier brothers balloon in 1783, sought to be the medical school. He received his MD from the first to fly a balloon from France to England, westbound across University of Kansas and Masters in public health the English Channel. The American physician, John Jeffries, from the University of Texas and completed a preceded him on January 7 of that year, but Jeffries had the residency in aerospace medicine at the USAF School of Aerospace advantage of much stronger prevailing winds and needed to Medicine in San Antonio, Tex. After numerous assignments, he spend less time aloft in a hot air balloon. De Rozier decided retired from the Air Force in 1992. He was the medical director of to combine Charles’ invention of a hydrogen balloon with the TWA and currently is in private practice at Midwest Occupational Montgolfiers’ hot air balloon. Hot hydrogen, however, proved Medicine in Kansas City, Mo. to be a very dangerous combination, and de Rozier died in

6 • ISASI Forum July-September 2004 the fiery crash. One might say then that physicians invented accidents, spatial disorientation another 30 percent. Mechani- the aviation accident. cal problems accounted for 8 percent and combat a mere 2 Over the next hundred years, ascents to higher and higher percent. Pilots were entering training and often dying there. altitudes were made with safer methods of handling hydro- Medical conditions such as asthma (German Oswald Boelcke), gen, and high-altitude ballooning came into being. Soon, the skull fracture, and epilepsy (Manfred von Richthofen), tuber- problems of cold and hypoxia became apparent. In 1862 the culosis (Georges Guynemer), blindness (William Thaw, Ed- English aeronauts Glaisher and Coxwell ascended to 9,480 m ward Mannock), bleeding ulcers (Roy Brown), and psychosis (29,388 ft), but they were unconscious above 8,833 m (27,382 (Frank Luke) were considered unsuitable for such military arms ft) due to hypoxia. as the infantry or cavalry. Aviation was deemed to be much Following this, the French physician, Paul Bert, began ex- like an office job; after all, the pilot just sat there. periments that determined that humans could not live at oxy- Medical regulations were soon in place and a military doctor, gen pressures below 45 mmHg (equivalent to air at 33,000 ft/ known as a surgeon, was assigned to flight units. In the United 10,000 m, which would ultimately be proved a century later States, Major Theodore Lyster became the head flight surgeon when Austrian Reinhold Messner climbed Mt. Everest with- for the flying Army and established standards that would screen out oxygen in 1980. Just behind him was an American physi- out nearly 30 percent of all U.S. flying applicants. In 1926 Dr. cian with a team of Sherpas carrying a bicycle ergometer to Louis Bauer would be reassigned from the Army to become the the base of the Hillary Step in order to replicate Bert’s work. first federal air surgeon. Dr. Bauer would begin the training Bert was also the medical advisor to a team of French aero- program of AMEs that is the standard today. The medical stan- nauts, Crocé-Spinelli, Sivel, and Tissandier. In the summer of dards for civil pilots were also established at this time. 1874, they attempted to set a new altitude record of 10,000 The presence of AMEs would not do much to affect the first meters) using a primitive oxygen supply system, which con- high-profile aircraft accident, the 1931 crash of a Fokker Trimo- sisted of three bags of 72 percent oxygen and simple tubes that tor in Chase County, Kans., that killed Notre Dame coach Knute were held in the mouth. Bert warned them that this was inad- Rockne. There was no national system for investigating acci- equate, but on April 15, 1875, the trio ascended. While they dents. Spectators drove around the site, taking souvenirs and probably did exceed their goal, all were unconscious and only destroying evidence. Bodies were barely identified by their cloth- Tissandier survived. The accident was a national tragedy that ing. In contrast, the investigation of the 1950s crashes of the shook France as much as the Challenger disaster would rock Comet IA were directed by an AMP, who noted that the deaths America. As a result, high-altitude attempts would come to a were due to explosive decompression, not terrorist bombs. halt until the 1930s. As the AMP during the loss of TWA 800, the author’s role Physiologic issues had become established as one factor in fell to providing identification data to the local medical ex- the cause of aviation accidents. Hypoxia would remain a chal- aminer, crew medical information to the NTSB, support for lenge until oxygen supply systems were perfected and pres- disaster response and family assistance, as well as counseling surized cabins came into use in the 1940s. Other physiologic and helping company employees affected by such a catastro- issues remain with low barometric pressure at altitudes over phe. The loss of space shuttle Columbia was complicated by 50,000 feet and toxic gases both in the systems and in the the hazards to people on the ground from toxic chemicals event of crashes and fires. Finally the problem of acceleration used for propulsion and power. The author had trained the forces would not become evident until the U.S. Navy invented military flight surgeons who deployed and cared for the mili- dive-bombing and a plane capable of 5 g pullouts in the 1930s. tary personnel involved in wreckage search and recovery. Soon fighter aircraft were beginning to dogfight in the realm The imposition of medical standards on pilots effectively above 5 g’s and acceleration-induced loss of consciousness minimized medical conditions as the primary cause of acci- (G-LOC) became an additional cause of accidents. dents. However, human factors still comprise 80 to 90 per- The first fatal accident of an airplane occurred on Sept. 17, cent of all aircraft accidents. Today medical accounts for 2 1908, at Ft. Myer, Va. The starboard propeller failed on a dem- percent of accidents, spatial disorientation 36 percent, con- onstration flight, seriously injuring Orville Wright and killing trolled flight into terrain 38 percent, drugs and alcohol are 6 his passenger, Army Lieutenant Thomas Selfridge. An Army to 9 percent, midair or ground collisions 6 percent, and me- surgeon conducted the autopsy and found that Selfridge was chanical problems only 2 percent. Hostile actions such as ter- thrown out of the aircraft on impact and died of a skull frac- rorism are still 2 percent. ture. His Army colleagues, such as Lieutenant Henry (Hap) Arnold, were later encouraged to wear their West Point football Spatial disorientation helmets while flying. It would not be until the 1940s that Dr. Spatial disorientation accidents began to occur as soon as pi- John Paul Stapp would lead design changes in helmet safety. lots began to fly into clouds, bad weather, and at night. The Within a few years, aviation was an important part of world first real solution to this problem was the Sperry turn-and- military activities and most militaries developed medical stan- bank indicator (TBI), but it met with resistance from pilots dards—particularly after early studies of Britain’s Royal Fly- who distrusted it. Dr. Ocker developed a combination of a ing Service in 1915 found that the life expectancy of a pilot rotating chair equipped with a TBI to train pilots in the ef- was a mere 2 weeks. Of the deaths, 90 percent were due to fects of vertigo while on the ground and to instill in them the what we would today call human factors. What has changed, confidence they needed to use their instruments. The “Ocker however, is the mixture. Box” was the forerunner of instrument simulators, later In 1915, medical conditions were the cause of 60 percent of brought into its common form by Link.

July-September 2004 ISASI Forum • 7 AMP physicians continued their work improving vision, life gist/medical examiner. Medical examiners may not necessar- support, and escape, as well as crashworthiness. High-altitude ily be attuned to the specific needs of the accident investiga- bailouts were researched by Dr. Randall Lovelace, who discov- tor, such as determining who was at the controls of a multi- ered the high opening shock forces, cold, and hypoxia and pilot aircraft. Nor should it be assumed that the medical ex- recommended free-fall to lower altitudes. After World War II, aminer would automatically turn that information back to Dr. John Paul Stapp began his impact acceleration work on prevent the next accident. It is important to determine if the the Corum ranch in California, using the Muroc dry lake bed pilot and passengers were incapacitated prior to, during, or for sled testing (now known as Edwards Air Force Base). His after the crash. Pre-crash incapacitation may be due to medi- research team developed the limits of human tolerance to cal causes such as cardiac disease, carbon monoxide poison- impact accelerations and all modern energy-absorption lim- ing, or hypoxia. Crash-related injury is analyzed using CREEP: its are derived from his work. Stapp’s team would develop the container, restraints, environment, escape and post-crash fac- standards for ejection seats, shock absorbers, passive restraints, tors. As a result of this accident analysis, the AMP will help in crash helmets, air bags, and seating arrangements. Stapp’s recommending remedial actions to prevent the next accident chief engineer, Ed Murphy, also discovered that whatever can from occurring and reducing injury. go wrong eventually will. The discoveries in aviation safety were to eventually be ap- Role of the AMP plied to many other areas of safety, including automobiles The aerospace medicine physician can be a resource to assist and highways and motorcycle and football helmets. the medical triage teams and should be involved in mass ca- sualty issues. Leaving out the preventive medicine physician Psychological factors means that the disaster responders may themselves become Accidents still occur due to psychological factors. Judgment and ill or injured during the response phase and recovery. Their drugs are the main issues. It is difficult to evaluate a pilot’s care and feeding is a basic public health function. Finally, there judgment, but many factors come into play, including learning are preventive measures needed for both rescuers and acci- ability, rate, experience, and transfer. Attention, boredom, com- dent investigators. The environment of the accident site may placently, task saturation, fatigue, and complacency all have represent a human health hazard. roles to play. Personality states of self-discipline, motivation, Environmental issues include clean water and food, sleeping supervisory pressures, and cumulative workload interact with arrangements, and thermal protection. Sometimes a hazard- outside psychosocial factors of job satisfaction, career expecta- ous chemical, high altitude, or underwater environment exists tions, family, and community conflicts. Within the operating and additional protective measures must be taken to prevent environment there are supervisory and management issues as the investigating team from becoming additional casualties. well as crew coordination and cockpit resource management. Finally, there is the problem of infectious diseases. Disease can Organizational issues of aircraft systems, transitions, mainte- spread to the investigators through four methods: nance, weather, and air traffic control all interact. • First is blood and body fluids. Any area where there has Analysis of these factors is known as the “Swiss Cheese been spillage of blood and human body products represents a Model” after Drs. Shappell and Weigman, in their article “The biological hazard. Personal protective equipment must be worn Human Factors Analysis and Classification Systems” in 2000. by investigators to avoid contamination by such diseases as An accident is inevitably the end result of a chain of errors. hepatitis B and C or HIV, the AIDS virus. Of these, a vaccine These are classified into latent and active issues. Latent issues exists only for hepatitis B. consist of organizational and supervisory preconditions. These • Food and water supplies must be secured to avoid the spread may include pressure to perform to schedules and ignore crew of contamination. Such diseases as hepatitis A, typhoid fever, rest, fuel reserves, or mechanical problems. Active issues in- and polio can be prevented by vaccination. Airborne spread clude preconditions such as medical problems, weather or traf- of disease from person to person is unlikely at the accident fic, and finally unsafe acts. The unsafe act is a decision made site, but may be an issue due to the surrounding social condi- by the pilot to arrive first at the scene of an accident. tions. Illnesses such as tuberculosis and SARS are real risks in Drugs and alcohol are common in society and contribute some areas. significantly to aviation accidents. Their use is rare in com- • Last is the problem of vector-borne diseases. Mosquitoes, mercial and military aviation. However in general aviation, ticks, and fleas carry illnesses such as malaria, West Nile virus, the use of prescription and non-prescription drugs as well as yellow fever, dengue, Lyme disease, and plague. The best pro- illicit drugs is a growing problem. The detection and deter- tection is to know what areas are at risk and use insect repel- rence of their use is a societal problem as well as an aviation lants. Medications and vaccinations are also of use. Always safety issue. Drug testing does serve to deter use by casual consult the Centers for Disease Control and Prevention website illicit drug users, but not those who are addicted. Treatment at www.cdc.gov and check Travelers’ Health for the latest area works. The HIMS program, originated by the Air Line Pilots assessment. Association and the FAA in the late 1960s, successfully returns The aerospace medicine physician has the role of prevent- to duty 90 percent of pilots with alcohol problems and 50 ing future accidents and illness in everyone involved in avia- percent of those with illicit drug problems. tion, including pilots, passengers, rescuers, and investigators. The AMP should participate in the aircraft accident inves- This role will continue as long as there are airplanes and people tigation and help determine the cause of the accident, as well who fly them. Most AMPs are members of the Aerospace Medi- as the causes of death/injury along with the forensic patholo- cal Association and can be contacted, along with other aero- medical professionals, at www.asma.org. ◆ 8 • ISASI Forum July-September 2004 Using Injury Pattern Analysis (This article was adapt - The legal pur- ed, with permission, Correlation of medical with other accident investigation pose of postmortem from the author’s pre- data can help reconstruct the mishap sequence examination by sentation entitled En- through injury pattern analysis. Such techniques often medical examiners hanced Occupant or coroners is to sci- Protection Through help identify and validate, or eliminate, proposed entifically identify Injury Pattern Analy- mishap sequences. the remains and cer- sis presented at the tify the cause and ISASI 2003 seminar By William T. Gormley, MD, Ph.D., Office of the Chief Medical manner of death. In in Washington, D.C., Examiner, Commonwealth of Virginia, USA aircraft mishaps, the USA, August 2003. cause of death is The full presentation is usually blunt force available on the ISASI website at www.isasi. org.—Editor) injury, fire injury, or both. For this purpose, the examination need only document lethal injuries and the absence of suspi- he victims of a fatal aviation mishap experience the cious features such as bullets, stab wounds, or explosives. The same damaging events as the aircraft. Analogous to manner of death is certified as an accident unless circumstances Tengineering analysis of the wreckage, medical exami- and findings suggest another manner of death such as sui- nation of occupant injuries can provide important scientific cide, homicide, or natural. Postmortem toxicology is also col- data for mishap investigators. In fact, the human body is struc- lected for analysis by the FAA laboratory, at least for pilots. turally more robust than any aircraft: aircraft structure will In the Commonwealth of Virginia, we perform complete fragment under forces an order of magnitude less than it would autopsies on all fatalities in aircraft mishaps. As part of our take to produce the same result in an occupant. death investigation, we routinely request information about When aircraft mishap investigations are conducted in the the circumstances of death verbally and in writing. Unfortu- United States of America, federal regulations mandate post- nately, we usually get little or no response from investigators. mortem examination of some, or all, occupants fatally injured With limited information about the circumstances of death, in an aircraft mishap. Postmortem examination of aircraft the postmortem examination will produce little more than a mishap fatalities: 1) U.S. civilian—pilots by federal law, crew document that certifies the cause and manner of death. and passengers by local jurisdiction; 2) U.S. military—pilots, The postmortem examination should be more than an ad- crew, and passengers. ministrative exercise to produce documents proving that the For more than two decades, specially trained military pa- occupants are truly dead. For maximum investigational im- thologists who directly support the mishap investigation board pact, postmortem medical examinations should function as have performed postmortem examinations of military aircraft an interdisciplinary effort, with the pathologist and mishap mishap fatalities. In civilian mishaps, postmortem examina- investigation team sharing of data on 1) flight history, 2) crash tions are performed by civilian medical examiners, or patholo- site data, 3) wreckage analysis, 4) occupant medical data, 5) gists employed by elected coroners. While federal investiga- postmortem examination results, and 6) other pertinent data. tors can order postmortem examinations for civilian pilots, This type of effort would promote accurate, effective, and com- state or local regulations and policies determine the extent of plete medical input for many concerns of accident preven- postmortem examination for each occupant. tion and occupant safety.

About the Author: Dr. Gormley received his Natural diseases Ph.D. in chemical and biomedical engineering A complete postmortem examination, in addition to docu- from the University of California, Davis and his menting traumatic injuries, will identify pre-existing natural MD from the Medical College of Ohio at Toledo. disease. Natural diseases of the heart, brain, and lung are the He is certified in anatomic, clinical, and forensic most likely to be possible mishap factors because they can pathology. During almost 20 years at the Armed cause rapid incapacitation. Atherosclerotic cardiovascular dis- Forces Institute of Pathology, he participated as an ease is by far the most commonly identified natural disease in aviation pathology consultant in many hundreds of aircraft accident middle-aged or older pilots. This disease may or may not have investigations and served as a consultant in aviation pathology a significant role in the aircraft mishap. The flight history and forensic pathology to the USAF Surgeon General. must be correlated with the specific anatomic disease to de-

July-September 2004 ISASI Forum • 9 Correlation of medical with other accident investigation data can help reconstruct the termine the role in a mishap. mishap sequence extensive burns and multiple lethal In one mishap, a middle-aged pi- blunt force injuries, including skull lot flew a single-engine private aircraft through injury pattern and rib fractures and lacerations of into a commercial airliner approach- lungs, liver, heart, aorta, and brain. ing an airport. Both aircraft crashed, analysis. There was no soot in the airways of and there were no survivors. Autopsy any victim, and carboxyhemoglobin of the private pilot demonstrated se- was not elevated in any victim. The vere atherosclerosis in the coronary patient had a fracture of his neck, with arteries, and local authorities an- hemorrhage in the deep cervical nounced that the mishap, and almost muscles. All deaths were certified as 100 deaths, was caused by the private due to blunt force injuries and the pilot having a heart attack. While ath- manner of death was certified as erosclerosis can cause a heart attack, accidental. there are many people living quite well with similar disease. What more could be done? The medical data can be corre- Investigative interviews, wreckage analysis, autopsy data from lated with some information about the mishap. The crash scene all occupants of the private aircraft, crash scene documenta- shows that the helicopter hit a tree with a main rotor blade, tion, and radar data indicated that the pilot was mildly lost, then crashed and burned about 50 yards beyond the tree strike. navigating visually using a road map, unaware that he had The post-crash fire incinerated most of the wreckage. wandered into an approach path to the commercial airport Since there were no thermal injuries, the pilot must have and inadvertently flew into the airliner. There was no evidence separated from the helicopter prior to impact. The amputa- of pilot incapacitation prior to the collision, and the heart tion of the right arm was caused by a sharp, chop-like injury disease was not a factor in this mishap. most consistent with a rotor strike. This injury suggests that In another case, a small aircraft with two occupants crashed the blade may have passed through the cockpit, damaging into trees near an airport on a dark and foggy night. Both the tie-down-chain for the pilot’s restraint system, and sepa- occupants died instantly and their bodies were fragmented rating the pilot from the crashing helicopter. Engineering with evisceration of most internal organs. A heart was recov- analysis of wreckage verified this correlation. ered from the crash site, and there was severe atherosclerosis The patient was being transported to a hospital following in the coronary arteries. Since the pilot was 65 years old and an accident that may have involved neck injury. The docu- the passenger was 45 years old, it was assumed that the heart mentation of bleeding in the neck muscles around the frac- was that of the pilot. While heart attacks are not uncommon ture provided scientific data that the neck fracture occurred in 65-year-old people with atherosclerosis, crashing while before the helicopter crash. Why? With multiple blunt force making an approach instead of finding an alternate airport is injuries there is very rapid loss of blood pressure and circula- also not uncommon. While it is possible that both events oc- tion. To form a bruise (contusion, intra-muscular hemorrhage, curred at the same time, such a coincidence would be un- etc.) requires both damage to blood vessels and pressure to usual. There was no way to determine the true mishap factors propel blood through the torn vessels into the soft tissues. with scientific certainty. DNA analysis demonstrated that the Thus, the patient was alive at the time of the neck injury and diseased heart was from the passenger, not the pilot. was not dying in the helicopter crash. Another question that may be answered with data from ex- Mishap sequence reconstruction. amination of pilots and copilots involves who was controlling Correlation of medical with other accident investigation data the aircraft at the time of the crash. When the hands and feet can help reconstruct the mishap sequence through injury pat- of a pilot or copilot are in firm contact with aircraft controls tern analysis. Such techniques often help identify and vali- (yokes, sticks, throttles, rudder pedals, anti-torque pedals), date, or eliminate, proposed mishap sequences as shown in crash forces may be mechanically transmitted to the hands the following illustrative examples. and feet, causing characteristic injuries. Classic injuries of the A medical evacuation helicopter crashed and burned with hands may include palmar lacerations, fracture-dislocation of five occupants, including pilot, copilot, two medics, and a pa- the thumb base, serial fractures of the metacarpals, and frac- tient. All died and the remains were sent for autopsy. The tures of the wrists and lower arms. On the feet, plantar lacera- pilot was not burned, but had multiple lethal injuries to the tions and fractures of the feet, ankles, and lower legs may be trunk and amputation of the right arm. The other bodies had characteristic.

10 • ISASI Forum July-September 2004 If a human body must compete with environmental structures during a crash sequence

Survivability analysis for a place to be, body may document the impact of re- Incorporation of data from postmor- straint systems. Pattern injuries have tem examination into survivability tremendous equal and also documented submarining failure analysis can help provide improved of systems with less than 5 points of design criteria to decrease deaths and opposite forces may be restraint and subsequent lethal dam- injuries in those aircraft mishaps that exchanged with age to internal organs. They have also occur. Throughout the mishap, se- demonstrated lethal neck injuries as- quence survival depends upon toler- lethal results. sociated with rotation of helmets able crash forces, maintenance of oc- around neck straps during crash se- cupiable space, and a survivable post- quences. Such observations are ex- crash environment. tremely important to avoid lethal pro- Overall crash forces as experienced tective equipment injuries. by the occupants in general must be less than 50 g to avoid lethal injuries (laceration of aorta). Optimal medical consultation Crash forces can be estimated by engineering physics based The following steps will optimize collection, documentation, on scene data, aircraft post-crash structural integrity, and oc- and incorporation of significant medical data into any air- cupant injuries. These three independent estimates should craft mishap investigation: be of the same general magnitude if the crash sequence and • Contact the pathologist before autopsy to explain mishap dynamics are understood. General medical crash force indi- history, crash site, and specific concerns. cators are as follows: • Attend the postmortem exam to share information, con- cerns, and questions. (Contact pathologist after the autopsy Injury Forces Survivability with questions—sub-optimal but better than nothing.) Compression of Spine 20-25 Gz Yes • Arrange a brief visit to the crash site (wreckage) by patholo- Laceration of Aorta 50 Gxyz Borderline gist and medical consultants. Transection of Aorta 100 Gxyz No • Arrange a meeting to review medical findings and correla- Body Fragmentation 350+Gxyz No tion with other mishap investigation data. Participants should include pathologist and representatives of Human Factors, If the overall crash forces are within survivable limits, then Investigator-in-Charge, Structures, Engineering, and others survivability depends on maintenance of occupiable space. If depending on mishap specifics. a human body must compete with environmental structures Sometimes, such active and interactive consultation cannot during a crash sequence for a place to be, tremendous equal be arranged. Local medical examiners or coroner’s patholo- and opposite forces may be exchanged with lethal results. gists may not have the time or interest to fully participate in When such interactions occur, the occupant may sustain pat- the investigation. terned injuries, which can be correlated with structures and When this occurs, the following elements from the autopsy mechanisms. Such correlations naturally require significant examination can provide a basis for later consultation with consultation between physicians, engineers, and other mis- aviation pathologists, if necessary. hap investigators. These correlations are also the most valu- • Diagnosis list including all significant injuries and disease. able for future survivability design. • Complete autopsy report. If crash forces are tolerable and occupiable space in main- • Toxicology report. tained, then mishap survival depends on the post-crash envi- • Photographs of all external body surfaces, clothed and un- ronment. Usually, post-crash fire and post-crash drowning are clothed. the hazards to prevent or remediate through engineering • Total body X-rays with special attention to hands and feet design. The success of crashworthy fuel system design in pre- of pilots. venting fire deaths in otherwise survivable helicopter crashes Such documentation, especially the photographs and X- is an obvious example. rays, may severely tax the budget and resources of many civil- Postmortem injury pattern correlation is an important ele- ian death investigation systems. Mutual respect, friendly per- ment in evaluating the safeguards provided by occupant pro- suasion, and financial reimbursement for additional expenses tection systems. Examples include pattern injuries to deter- are key to effective incorporation of injury pattern analysis in mine restraint use and function. Bruises on the surface of the the aircraft accident investigation process. ◆

July-September 2004 ISASI Forum • 11 Forensics and Victim Identification The postmortem examination process aviation mishaps have evolved into multi-agency, even multinational, efforts encompassing a wide range of may at first seem unrelated to the disciplines. mishap investigation itself; however, Although conducted independently, the parallel investi- gations carried out by air safety investigators and local examination of the occupants can serve authorities can provide mutual support. The medicolegal the goals of the safety investigation: death investigation conducted under the aegis of the local prevention of death and injury. medical examiner or coroner (ME/C) serves to account for the fatalities and to certify their deaths, but the findings can By M.A. Cimrmancic, DDS (FO4172), supplement the safety investigation as well. Correspond- Associate Staff, Transportation Safety Institute, ingly, on-scene investigators may, on occasion, come across Oklahoma City, Okla. previously undiscovered fragments of remains. At the outset, these materials may seem insignificant but may very (This article was adapted, with permission, from the author’s well be important to the victim identification task of the presentation entitled Forensic Aspects of Occupant Protection: death investigation. Victum Identification presented at the ISASI 2003 seminar in To fulfill the legal requirements of establishing cause and Washington, D.C., USA, August 2003. The full presentation is manner of death, and determining victim identity, the local available on the ISASI website at www.isasi.org.—Editor) ME/C leads what can be a diverse team of forensic special- ists in the field recovery and postmortem examination n Sept. 17, 1908, the first fatal mishap of a powered procedures. The considerable efforts put forth in this aircraft in the U.S. occurred at Ft. Myer, Va. Orville process ultimately serve the families who anxiously await the OWright was at the controls of the “Wright Flyer” news of the fate of those persons presumed to have been being tested for the U.S. Army Evaluation Board, with victims of the mishap. With the certification of death and Board member Lieutenant Thomas Selfridge as his passen- return of the remains identified as their loved ones, the ger. The propeller struck a guy wire, breaking the blade and family can settle estate matters and commence grieving. causing subsequent loss of control. The machine pitched As each mishap presents its own unique set of circum- and fell 75 feet to the ground. Held in their seats at impact stances and evidence, so goes the disaster response and by wire braces crossing in front of them, the occupants’ investigative procedures, including field recovery and positions were noted before they were transported for mortuary operations. A very general description is offered: medical treatment. Mr. Wright survived, with fractures to At the site, field recovery personnel may be assigned to the ribs and femur and injuries to the eye area and lip. methodically locate, document, mark, and recover the Lieutenant Selfridge died that evening, having sustained a fatalities for transport to the mortuary facility, where a set fatal skull fracture as he struck a wooden support or one of flow of procedures is carried out. Remains are assigned case the wires. He was buried with full military honors at Arling- numbers and documented via X-ray images and photo- ton Cemetery on September 25. graphs, while personal effects and other items are docu- The mishap investigation conducted by the U.S. Army mented and removed for security. Each case is directed to Signal Corps contained elements not unfamiliar to modern- the appropriate forensic postmortem examinations, triaged day air safety investigators: collection of witness accounts, according to the condition of the remains, and nature of the examination of aircraft damage and occupant injuries, and evidence present. Often a series of stations is set up, each correlation of these data to reconstruct the sequence of designed for specialized examination and collection of events. In the century that followed, investigations of fatal evidence by forensic experts in such areas as anthropology, odontology (forensic dentistry), fingerprints, radiology, and About the author: Dr. Mary Cimrmancic has a pathology (autopsy). When indicated, DNA and toxicology background in forensics and aviation, serves as specimens are collected for laboratory analysis. When associate staff at the Transportation Safety Institute examinations are completed and remains are identified, in Oklahoma City, Okla., and is an adjunct funeral directors may be present to embalm the remains assistant professor at Marquette University, in before they are released. Milwaukee, Wisc. She is in private practice with In the United States, when a major aviation mishap Greenbrook Dentistry, S.C., in Brookfield, Wisc. overwhelms local and state response capabilities, federal level

12 • ISASI Forum July-September 2004 Forensics and Victim Identification response teams can be deployed to function under local determine whom the remains represent. Scientific ID jurisdictional authorities. Access to these resources is facili- methods involve comparison of the unique physical features tated by legislation that assigns the NTSB Office of Transpor- recorded during an individual’s life, with those features tation Disaster Assistance with the responsibility for coordi- recorded in the postmortem examination process. When nating federal resources with local and state authorities. sufficient evidence is gathered, the provisional ID may be confirmed or refuted. Safety investigation The flight manifest and witness accounts can provide While victim identification (ID) is a key element in the legal initial data indicating who may have been present. As and humanitarian outcome of the death investigation, it can families of the presumed victims come forward seeking also contribute to the safety investigation by facilitating information, they may be asked to provide information placement of individuals in the sequence of events relating describing the individual and for healthcare provider to the crash. Identification of the flight crew can direct information. efforts in postmortem examination and toxicologic analysis Provisional identification methods—An initial step in the to ascertain potential factors relating to mishap causation, identification process involves establishing whom the evidence of control injuries, and other injuries related to the remains might represent—a provisional or tentative ID. impact and post-crash environment. If detected, these data General physical descriptors such as facial features, height, can be correlated with the events of the mishap and struc- weight, hair color, gender, and age can provide a good start, tural damage. Also of interest is physical evidence of as do photo ID cards, clothing, eyewear, jewelry, and other criminal activity and passenger interference with the personal effects. Visual features and personal effects can be operation of the aircraft. useful when there is strong corroborating evidence indicat- The methods by which fatalities are identified depend ing the presence of the individual at the mishap. However, upon, in part, the nature of the mishap and its effects upon these methods need to be used cautiously, as they can be the occupants. Initially surviving the impact of the 1908 misleading. For example, items worn by or found with an Wright Flyer crash, the identity of Lieutenant Selfridge was individual at the site may belong to someone else. Nonethe- not in question. Strong circumstantial evidence corroborated less, personal effects are recovered and transported along his presence at the scene: he was personally known, witness with the remains with which they are found. At the mortuary accounts confirmed his participation in the flight, his physical facility, the items are carefully documented, also noting features and clothing were in sufficiently good condition to where at the scene, and with which body, they were found. permit visual recognition. On the opposite end of the Photographs and physical descriptors shown on driver’s spectrum, crash sites have presented notable challenges to licenses may not necessarily reflect the actual height, weight, mishap investigation, evidence recovery, and victim identifi- hair color, and usual facial appearance of the license holder, cation. The effects of high-velocity impact, fire, immersion in and used alone may mislead the ID effort. Furthermore, water, and difficult-access locales have resulted in the reduc- identifications based solely on facial features can also lead to tion of the volume of evidence recovered . an erroneous identification by a distraught family member Both wreckage and remains can exhibit extensive frag- or friend viewing remains fitting the general description of mentation, commingling, and thermal and chemical their loved one. In spite of these drawbacks, personal effects damage. At the scene, human materials may be difficult to and visual features can form the basis for a provisional or recognize when fragmented and burned, and may not tentative identification, establishing whom the remains appear to be identifiable. Yet, observant field investigators might represent. With sufficient corroborating evidence to can facilitate the recovery and identification process by establish the presence of the individual in the mishap, the recognizing and protecting these materials at the scene, ME/C may identify the individual based on this data. documenting them if possible, and by notifying the ME/C. Scientific identification methods—Scientific methods can The identification process is a multidisciplinary effort. confirm or refute a provisional ID. The unique physical Methods employed will vary with the condition of the features of a subject, and a known antemortem reference, remains and available evidence. In short, determining who are compared for consistencies. The subject is identified might have been present may be a provisional conclusion, when there is sufficient consistency of features with those of based upon initial available data. This information can a known reference. An individual may be identified by more guide the search for antemortem medical and dental than one method, depending upon the quality and avail- records, and other reference exemplars used to scientifically ability of antemortem and postmortem data, and particu-

July-September 2004 ISASI Forum • 13 Teeth have been used for identification since ancient Roman times. larly when remains are fragmented. Dental identification The American Board of Forensic Odontology describes Teeth have been used for identification since ancient the strength of conclusions for identification. “Positive Roman times. Variations in shape, position, color, alter- identification” indicates that there is sufficient evidence to ations, and patterns of loss are distinguishing characteristics conclude that the subject and the reference are the same that are readily seen. Teeth are durable, which allows them individual. A “possible identification” reflects consistencies, to retain their fundamental characteristics through the but lesser quality or quantity of antemortem and/or post- effects of fire, decomposition, immersion, and impact. mortem evidence. Inconsistencies between antemortem and Their internal and external contours can be sufficiently postmortem data can result in “exclusion.” “Insufficient unique to allow a jaw fragment with a couple of teeth, or a evidence” reflects the lack of data to form a conclusion. displaced single tooth, to support an ID. Dental X-ray Antemortem reference exemplars document identifying images reveal the external and internal outlines of teeth, features during life in the form of diagnostic medical/dental their restorations, and other alterations acquired through images, written records, biopsy specimens, recorded and disease, trauma, or treatment. Antemortem X-ray images latent fingerprints, and personal items to name a few. To document these landmarks, and are compared with analo- aid in comparison, postmortem photographic and X-ray gous postmortem X-rays to reveal consistencies or differ- images, fingerprints, and DNA profiles are recorded in a ences that would reveal whom remains represent. manner similar to their antemortem counterparts. Postmortem dental examinations, photographs, and A photograph or portrait may serve as a reference radiographs are conducted in a standard manner to gather exemplar when distinctive features are shown. To some the same data that would be compiled in a clinical setting. extent, tattoos, piercings, and other body modifications can The presence and absence of teeth, their restorations and provide supporting information, depending upon their replacements, orthodontic appliances, and other features uniqueness. The individual anatomical features of the teeth, are documented. fingerprints, and skeleton, as well as DNA and artifacts of The same types of data are compiled from antemortem surgery and disease, provide more substantial evidence. dental records, X-rays, and other materials, and a composite Identification procedures are carried out in three chart is constructed, depicting the existing dental condi- phases: postmortem data collection, antemortem data tions of an individual at the most recent visit to the dentist. collection, and comparison of postmortem and antemor- These postmortem and antemortem data are entered tem data. Computer databases store the data as they are into a computer database. When a dentist queries the amassed, and speed the tedious process of searching database regarding a specific postmortem case file, for through antemortem and post-mortem case files for those example, the computer quickly sorts the available data and most likely to match. This permits experts to examine the directs the dentist to the most likely antemortem files that antemortem and postmortem files most likely to result in fit the case description. Dentists then compare the X-rays an ID. Finally, with evidence assembled from the various and data from those files to determine whether the remains examinations and analyses, it is the ME/C who assigns in question represent one of those individuals. Among identity to the individual remains. The time frame for this dealing with many other issues in dental identification, process can be significantly extended by difficulties with additional analyses may be conducted, dealing with specific recovery, extreme fragmentation, sheer numbers of restorative materials and thermal damage, for example. fatalities, and delays with obtaining antemortem records. While untreated teeth and jaw structures are already distinc- Classic, scientific means of establishing identity are useful tive, alterations can further differentiate one individual from in mass-fatality incidents. Used alone, together, or com- another. With 32 possible permanent teeth, the potential bined with other data, dental features and fingerprints have combinations of missing and present teeth are considerable. been important identifiers, particularly where there has Add five surfaces per tooth that can be restored, and catego- been tissue destruction. Radiographic examinations and rize restorations as either metallic or tooth-colored, the anthropologic analyses also provide useful data for identifi- potential combinations for present/missing/filled teeth are vast. cation, as well as for evaluation of injury patterns. With the Individual teeth can be restored with a variety of materi- arduous disaster scenarios of recent years, DNA has als: metal alloys comprised of silver, tin, copper, and emerged as a significant means of identification. Instead of mercury; gold alloys; cast semi-precious or base metal replacing classic methods, DNA has supplemented them, alloys; tooth-colored composite resins; porcelain-fused-to- extending to those remains not identifiable by other means. metal restorations; and all-porcelain restorations. Each of

14 • ISASI Forum July-September 2004 Teeth have been used for identification since ancient Roman times. these materials exhibit specific physical properties that out, develop cracks, and enamel can separate from the influence their clinical application as well as their response underlying tooth. The outer layer of bone that surrounds the to high temperatures sustained in a fire. teeth can become charred or fractured, with loss of teeth as Single displaced teeth that are not restored may exhibit supporting bone is destroyed. Eventually, the remaining teeth abrasions that can sometimes provide information about and bone become ashed, exhibiting a grey color. metallic restorations that may be present on adjacent teeth. Burned teeth and bone can be very fragile, and can crumble The enamel surface that contacts an adjoining metallic if handled. These materials require careful handling by restoration can be evaluated by elemental microanalysis for forensic personnel, who may document them at the site with trace metal to reveal the presence of alloys comprising that photographs and portable X-rays before stabilizing them for restoration. Traces of elemental gold can indicate that the transport. When remains are highly fragmented as well as adjacent tooth was restored with a gold alloy, while the burned, their volume can be significantly reduced, including detection of silver, mercury, or tin can indicate an adjacent teeth and bone. Recovery is difficult, and there are fewer ma- silver amalgam restoration. The data can be queried in the terials with which to make identifications. Despite the challeng- antemortem database to reveal which records contain the ing situation, the humanitarian mission served by personnel at same information for those specific teeth. the scene and mortuary encourages their best effort. Replacements for missing teeth are quite varied. They can be removable, supported by natural teeth, or implants. Other scientific methods Others can be fixed to natural teeth or implants. Many Fingerprints—The fingers, palms, and soles exhibit distinc- permanently cemented fixed bridges are cast in a strong tive patterns of friction ridge details forming the basis for metal alloy, with porcelain fused to the surface for esthetics, what can be a fair proportion of identifications in aviation while others are constructed entirely of porcelain. As with disasters. These patterns can be recorded from remains that natural dentition, these structures possess unique contours have been exposed to fire or undergone fragmentation and useful for identification, even when displaced from the oral decomposition. In fire, contraction of major muscle groups cavity. Fabricated under high temperatures, they can begin causes the decedents arms, hands, and fingers to curl to distort as a fire nears their specific fusing temperatures, inward, forming fists. To an extent, this protects the finger giving some indication as to the temperature of the fire they pads from the effects of the fire. Fingerprint experts can were exposed to in the mishap. print postmortem friction ridge details, and compare them Like Cinderella’s glass slipper, removable appliances best fit with recorded antemortem prints on file with the the person for whom they are made. Required by state laws, individual’s employer, fingerprint databases, or other removable dentures and partials discretely bear the name, or sources. In the absence of recorded prints, latent prints can other identifying mark, of the patient for whom they are be lifted from items frequently handled by the individual. made. Constructed of various combinations of acrylics, resins, Identifications are a product of comparison between the and metal alloys, removable prostheses can, to various extents, postmortem and antemortem patterns. show resistance to the effects of fire and impact. Radiographic identification—Medical X-ray images are Implants function as artificial tooth roots, supporting a useful for comparison with postmortem full-body radio- single replacement tooth, or a larger, multiple-tooth prosthe- graphs. Useful medical radiographs include views of the sis. Many are manufactured of pure titanium of specific skull, chest, abdomen, spinal column, and extremities. design and dimensions. Their appearance on X-ray, and the Normal anatomical variations of the skeleton, abnormal bone restorations they support, can be useful in identification. formation, evidence of disease, and surgical artifacts can As with aircraft components, fire can produce characteristic serve as identifying features. When viewed on radiographs, thermal damage to teeth, bone, and dental restorations. the configuration of surgical plates, wires, implants, pacemak- Thermal changes can indicate approximate fire temperatures ers, and defibrillators can provide identifying data. Conve- and the presence of accelerants. The effects produced are the niently, the latter three items typically have serial numbers result of multiple factors, such as the duration, intensity, that can be traced to the manufacturer, and to the recipient. direct or indirect application of heat, rates of onset and X-ray scanning of body bags can reveal not only remains and cooling, and thermal protection surrounding the affected their injury patterns, but also personal effects, aircraft parts, structures. Posterior teeth are afforded some protection from and items potentially hazardous to morgue personnel. fire by surrounding jaw muscles, cheeks, and tongue. With Fractured bones, displaced teeth, and jewelry can be located increasing duration and temperature, teeth can darken, dry and documented for subsequent identification procedures.

July-September 2004 ISASI Forum • 15 DNA can be copied to amplify its volume. Anthropology—The expertise of forensic anthropologists is question, or there is another individual with the same key to search-and-recovery efforts as well as the identifica- genetic profile. Population statistics provide the analyst with tion process, particularly in scenarios involving extensive probabilities indicating the likelihood of the remains fragmentation, commingling, and burning. Anthropologists representing the subject in question. can direct excavation of difficult recovery sites and distin- This technology offers a means of identifying remains guish human skeletal materials from those of animal origin. that could not be identified by classic means. DNA profiles Their familiarity with the distinctive anatomical features of generated from those already identified by classic means the human skeleton allows them to locate, sort, and reasso- can help to reassociate other fragments from the same ciate fragmented remains, fundamental to establishing how individual. Environmental insults can damage the DNA many individuals are represented. Some patterns of damage molecule and hamper identification. to bone can be amenable to anthropologic interpretation as Molecular biologists have developed methods to extract to mechanisms of injury, be it traumatic fractures or thermal DNA from diverse biologic samples: bone, teeth, whole changes produced in a fire. blood, saliva, muscle tissue, and various cell-containing Depending upon materials available, anthropologists can tissues and fluids. A small yield of DNA can be copied to reconstruct and analyze the individual bones and skull to amplify its volume. Suitable quantities of DNA are pro- make gender determination and estimates of stature, age, cessed to generate a profile that reflects the sequence or the and muscularity. The compiled data form a biological length of the components of the molecular reference points profile—an approximate physical description of an indi- being examined. vidual. The profile can be compared with physical descrip- Interestingly, human X and Y chromosomes, present in tions of persons listed on the flight manifest, forming the cell nuclei throughout the body, contain a gene that codes basis for a provisional ID. for amelogenin, a protein involved in the production of Approximate age at time of death can also be estimated, tooth enamel. The length of the gene that codes for this based upon the stages of development of the skeleton and protein serves as a marker for gender determination. dentition during infancy, childhood, and adolescence. DNA is present within the teeth and contained within Estimates of age at death are generally based upon areas cells of the pulp and porous dentin comprising the greater where multiple structures are forming: hands and wrists, part of the crown and root structure. As vessels for DNA, knees, feet and ankles, as well as jaws with developing teeth offer protection from damaging environmental permanent teeth. Age estimates can be calculated from conditions. DNA can be retrieved from teeth using methods statistics derived from normal reference populations. developed to preserve their unique contours. Narrower age ranges can be derived from younger individu- als who still exhibit numerous areas of growth. With growth Conclusion processes completed, degenerative changes are used for The fundamental goals of air safety investigators are the making more broad age range estimates in adults. prevention of mishaps and mitigation of injuries. Forensic DNA—DNA analysis is based upon examination of specific science can directly support their mission by contributing segments of human genetic material that can distinguish victim injury and identification data that can place mishap one individual from another. These molecular variations are victims within the aircraft or on the ground, and demon- processed and viewed as a distinctive graphic pattern, or strate their interaction in the development and conse- DNA profile. As with classic forms of identification, the quences of the event. Victim identification can enhance the pattern of DNA profile from a postmortem sample is value of medical evidence to the overall investigation. compared with profiles derived from reference samples In difficult field situations, on-scene personnel may from known sources. A direct reference sample is taken from encounter remains yet to be recovered. As materials in these the decedent in life: a blood sample, biopsy specimen, hair scenarios can be greatly reduced, seemingly insignificant sample, biological residues from a toothbrush, clothing, or fragments become increasingly necessary for identification. other personal items. An indirect reference may be a blood Field investigators can facilitate the recovery and identifica- sample or cheek swab obtained from a close relative. The tion process by recognizing and protecting these materials patterns of the subject and reference profiles are examined at the scene, documenting them if possible, and notifying for consistencies. When the profile derived from the subject the ME of their presence and position. In assisting this matches that of a known reference, two conclusions can be effort, air safety investigators can ultimately serve the drawn: Either the remains represent the individual in families of the victims. ◆

16 • ISASI Forum July-September 2004 Accident Investigation

(This article was adapted, with per- Without the recorder that recorded analog mission, from the author’s presen- traces of five basic parameters tation entitled Accident Investi- (airspeed, magnetic heading, gation Without the Accident Accident pressure altitude, vertical ac- presented at the ISASI 2003 semi- The author puts forth the argument that the celeration, and VHF keying on nar in Washington, D.C., USA, a time base). Then came the August 2003. The full presentation airlines, in many ways, are performing digital era (early 1970s) where is available on the ISASI website “accident investigation without the accident,” flight data were digitally re- at www.isasi.org.—Editor) and that there are some significant benefits corded on magnetic tape and from discovering some of the lessons learned the FDR name was changed light data volume and from to DFDR to denote digi- availability have come from the relatively small accident tal FDR (there are no analog Fa long way since the be- investigation community. FDRs today so the D is not ginning days of aviation. Tra- By Michael R. Poole (M03278), P. Eng. used anymore). ditionally, accident investiga- Although the military intro- tors were the only people who examined flight data in great duced solid state (digital data stored on memory chips) in the detail, in aid of detailed investigation. Today, with airlines em- 1980s, it wasn’t until the early 1990s before solid-state memory bracing routine flight data monitoring (FDM) programs and was acceptable for use in civilian aircraft. The military was the most recent trend for the airlines to use flight animation to able to use solid state before civil aviation because the military replay the data, the domain of flight data analysis is rapidly recorded typically much less data than did the civilian sector being driven by the larger airline industry. (Note: Flight data and did not have the same crash survivability requirements as analysis [FDA] is ICAO nomenclature. Flight operations qual- civilian standards, thereby being able to take advantage of ity assurance [FOQA] is U.S. nomenclature, and FDM is Cana- early chip designs that did not meet international FDR/CVR dian and sometimes European nomenclature.) This article will standards at the time (Eurocae ED55 and ED56). The digital argue that the airlines, in many ways, are performing “accident flight data acquisition unit (DFDAU) provided the data source investigation without the accident,” and that there are some for the FDR, accepting inputs from various sensors and data significant benefits from discovering some of the lessons learned busses on the aircraft and “packaging” them into a serial bit from the relatively small accident investigation community. stream that was sent to the FDR. A common statement I have heard lately is that FDM pro- Airlines quickly discovered that extracting data from the grams and accident investigation are not the same and there- mandatory FDR was by no means an easy process. For many, fore require different tools, and there is perhaps a misperception this meant only pursuing the data in reaction to a significant that “accident investigation” tools are not needed for FDM. event. The recorder had to be removed from the aircraft and Before exploring this issue, a brief recap of the evolution of in some cases opened and recertified. Copy processes took flight data is worthwhile. In the 1960s there was the metal foil hours and were fraught with “dropouts” or bit errors due to the mechanical nature of the recording system. About the Author: Michael Poole is a managing This erratic process inspired the first generation of quick partner at Flightscape, which he joined in Febru- access recorders (QARs) in the early 1970s. QARs were built ary 2002, following retirement from the Transpor- with a removable media (initially tape as well) so that the airline tation Safety Board of Canada (TSB). Flightscape could simply pull out the media and substitute another at any is a flight safety company specializing in flight time. In the majority of these early systems, the FDAU sent the sciences and flight data analysis systems. A identical data stream to both the FDR and the QAR simply to professional engineer, Poole has with a current facilitate easy access to the data. Effectively, airlines had two pilot’s license and is a recognized expert in the field of flight recorder recorders on board the aircraft, one that conformed to rigor- analysis. He started in the field of aircraft accident investigation in ous standards (FDR) and one that conformed to no standards 1977 and worked 20 years with the TSB, where he served as the (voluntary), and both recorded the same information. head of the flight recorder and performance laboratory, which he The data stream in those early days was, for some airlines, developed for the Board. He represented Canada as the national not enough, so they asked if they could have more. A very expert panel member to the International Civil Aviation common misconception is that the issue of capacity is rarely Organization’s Flight Recorder Panel. an FDR problem, rather it is an acquisition problem. The rea-

July-September 2004 ISASI Forum • 17 The advent of solid state was a great advancement in data quality and FDR reliability since there were no moving parts.

a thing of the past. If you added a parameter to the FDR and First Generation QARs the parameter became problematic during routine FDM, regu- latory bodies invoked the minimum equipment list (MEL) and grounded the airplane. In the late 1980s, Air Canada actually removed non-mandatory parameters from the FDR because of MEL problems. Operators, still today, do not want to add parameters to the FDR because of the regulatory interpreta- tion of the MEL. The reality is that 99 percent of the param- eters today are from a digital data bus and the parameters exist for the operation of the aircraft, not the FDR. The FDR is simply taking advantage of their ready availability. If the airspeed does not work on the FDR for an Airbus A320, for example, it is not an FDR problem—it is an aircraft problem. Yet, some still interpret this as a reason to ground the FDR system. The rules were developed from the days when sensors son that larger mandatory parameter lists did not exist is be- were dedicated to the aircraft, and the rules have not really cause of lack of data availability, not lack of FDR capacity. If been updated even though parameters from digital data bus- the data were to be added to the FDR, they did not help the ses are incredibly reliable. airline because the data were not accessible and any changes It makes much more sense to have an integrated system to the FDR meant rigorous recertification issues. The data whereby airlines can routinely access the data and the same were naturally added to the QAR instead and in some cases a data set is available to the accident investigator. In some ways complete additional voluntary FDAU was added to the air- it is simply a “packaging” issue. There was no technical rea- craft, which the airline could reconfigure at will to determine son why all of the Swissair data going to the QAR could not which parameters were recorded. have also been going to an FDR. There tends to be two differ- Solid-state memory media recorders were the next to be ent groups in the industry, those who deal with the manda- introduced. The advent of solid state was a great advance- tory FDR and those who deal with the QAR. And it is long ment in data quality and FDR reliability since there were no overdue that they talk to each other. moving parts. They were also readily downloadable making Eurocae ED112 and the recent U.S. Future Flight Data them truly “quick access.” Many investigators thought the QAR Collection Committee are trying to change history in this re- would simply die a natural death with the advent of solid- gard. state flight data recorders (SSFDRs). Why did investigators ED112—“With today’s solid-state technology, significantly increased come to dislike the QAR? The Swissair Flight 111 MD-11 ac- capacities, readily available data on the aircraft, and affordable ground- cident off Peggy’s Cove in 1998 is a good example. The Swissair based wireless download capabilities, an integrated crash-protected 111 FDR was a solid-state recorder with 64 words/sec. The recording system that satisfies both accident investigators’ and opera- QAR was a 384 word/sec tape-based unit, arguably less quick tors’ routine playback needs is highly desirable.” access than the FDR. The FDR survived but the QAR did not. “… it is recommended that industry provide operators with solu- The data were available, but they were in the wrong box! The tions that protect the core mandatory list while allowing the operator QAR was developed because the FDR was not accessible and to change the recorded data (e.g., additional data, sample rates, or has now surpassed the FDR in terms of data quantity. Param- resolutions) in the crash-protected medium without requiring recertifi- eter rules must consider many aircraft types and, therefore, cation of the flight recording system.” tend to cater to the lowest common denominator. Addition- The bottom line is that it is really unacceptable to record ally, early standards encouraged a separate box for fear that the more data for routine monitoring of flight data than for a mandatory box would be adversely affected. Any change to major accident investigation. the mandatory box meant costly certification issues. Airlines on the one hand complained about the costs of additional Flight animation parameters and on the other hand went to the trouble and Accident investigators have been using flight animation since expense of recording extra data for their own purposes. the early 1980s. Airlines did not use it because there were no There were some other factors that affected the continued commercial systems available, and it was relatively expensive use of the QAR, despite logic dictating that it should become to do. Today, that is not the case and flight animation is readily

18 • ISASI Forum July-September 2004 Different Stimuli…Same Process!

FDM is part of a safety management system. It is a system- atic collection of flight data for improvement in the areas of available, and numerous systems are commercially available. operations, maintenance, training, and risk management. Investigators have long known about the benefits and pit- It is effectively an information technology (IT) system to falls of animation and throughout the late 1980s and 1990s distribute objective information to reduce operations and sup- have presented papers at ISASI annual seminars, as anima- port costs and improve dispatch reliability. Above all, it is a tion systems became increasingly popular and controversial. system that identifies precursors to accidents. For clarification purposes, let’s look at FDM as two distinct components. Benefits of flight animation • Assimilate complex information FDM 1 event detection • Facilitate analysis • Routine monitoring of flight data • Stimulating and effective means of communication • Automatic detection of events • Powerful and compelling • Until recently, plagued with poor quality data • Effective training tool • Outputs statistical database • Easy to disseminate • Flight animation not useful • Lend credibility to findings • Examining daily flights in small detail Pitfalls of flight animation FDM 2—occurrence investigation • Pretty-picture syndrome (seeing is believing) • Examination of a single event(s) in great detail • Fabrication • Similar to accident/incident investigation • Subjective information • Flight animation is very useful for routine events • Drawing conclusions without understanding and complex events underlying principles Regardless as to whether the stimuli to study a flight se- • Misplaced credibility quence is an accident, incident, FDM 1 event, or a PIREP, it can be argued that once you perform the study, there should Investigation vs. analysis be no difference in the techniques, expertise, and tools re- We all know and understand the elements and reasons why quired. Whether the aircraft hits the ground has no bearing we investigate accidents. FDM programs are very valuable as on the analysis of the data leading up to the event that initi- it makes a lot of sense to study the data before things become ated the analysis. FDM 2 is arguably accident investigation catastrophic. FDM is a proven concept and is being embraced without the accident. worldwide. So what is the problem? First let’s define an FDM Unfortunately, in the quest to provide user friendly auto- program. matic tools to eliminate the need for expertise, there is a com-

July-September 2004 ISASI Forum • 19 As airlines make more and more decisions based on routine flight data, it will become increasingly important that similar standards of data recording, extraction, and processing that have evolved from years of accident ponent of the industry that believes and/or advertises that “in- investigation are applied to the rest vestigation” skills/tools are not necessary for FDM programs. Some persons believe that you have to be an expert to use an of the industry. “investigation” system, but you do not need to be an expert to use an “airline” system. The fact is that the expertise required cess in itself. Flight recorder manufactures like to sell boxes is not a function of the “tools” one uses, but rather it is a and sell hundreds of FDRs for every replay station they sell. function of the flight data itself. If you did not need to have Consequently, their replay systems, while they will recover the expertise to analyze flight data, we would not need expert data, have fairly poor analysis tools. Other companies capital- accident investigators. ized on this and developed analysis tools but relied on some- Many airlines want to routinely animate events for training one else to perform the actual data recovery. purposes—just hit a button and up pops the animation. While When EU files have to be passed from one process or sys- virtually all software on the market can do this, it should be tem to another as a CSV or spreadsheet file, it becomes prob- noted that flight animations are actually quite useful for ana- lematic to pass all of the recorded parameters. A modern air- lyzing complex events and understanding and disseminating craft may have well over a thousand parameters. Imagine an those events. The current limitations of sample rate, resolu- Excel spreadsheet 1,000 columns wide! In fact, that cannot be tion, accuracy, and number of parameters is such that often done in Excel due to limitations. What typically occurs is the significant judgment is required. Accident investigators grew sending of only the parameters needed. Although the person up with lousy tools in the 60s, 70s, and 80s, and their experi- at the other end may normally want only to look at a core set, ence in flight data analysis and the tools used to perform the that person’s ability to “investigate” the data is compromised job grew up together. Today the airline can jump in with very because not all the data are sent and the person must then attractive tools that have internally automated many of the prejudge what is important. As a former Transportation Safety steps investigators performed manually. With this automation Board of Canada (TSB) investigator, I do not like to have to and marketing of products as being automatic and requiring prejudge what I think I might be interested in. Since investi- little expertise to use comes a significant danger that the judg- gation systems access the ARINC binary data file, which is a ment is simply lost in the process. relatively small and nicely packaged file already, investigators Airline playback systems were originally designed for main- have access to all of the data all of the time. tenance. Only in recent years have such systems been used for Another more serious problem with passing EU files around detailed operational analysis of events, partly inspired by for analysis is the time element. Two parameters that are both readily available animation capability. Airlines are going to recorded at one sample per second are actually not sampled increasingly make operational decisions based on their flight at the same time within the second. There is a relative offset data analysis well beyond this traditional role. based on the word location. For example, aileron position and control wheel, while both sampled once per second, will be Examples of concerns offset from each other by as much as just under a second. In There are many technical examples that illustrate some of the order to maintain the timing resolution of the original data, concerns. One example is the problematic trend in the air- the EU file must be incremented at intervals coincident with lines to use engineering units (EU) or comma separated vari- the data frame rate. For example, a 64 word/sec rate would ables (CSV) or spreadsheets to pass the data to their analysis/ require the data printed out in 1/64 time intervals to maintain animation systems. The problem with passing EU files is that the same time resolution for each parameter. This means that your analysis/animation tool may be showing you an artifact if you want to look at 25 hours of data using EU files, you of the recorded data instead of the real data due to processing would need 64 lines of data for each second. that you may be totally unaware of. To pass 25 hours of all of the flight data to someone in an Investigators use systems that interactively handle the EU file format maintaining the recorded accuracy would re- ARINC bit stream data directly. That is, all applications inter- quire a spread sheet 5,760,000 lines long and 1,000+ col- act with the source binary data and convert to EU “on the fly” umns wide! If you move to a 256 or 512 word/sec recording, as required. Many systems in use by the airlines, however, can- the numbers get even more impractical. Instead, shortcuts not accept ARINC data and must first have the data pre-pro- are taken by prejudging what parameters the analysis or ani- cessed by another application so that it is “readable” by their mation system needs and by truncating the data all to the analysis/animation system. This is largely because handling nearest second. The NTSB and other investigation agencies the ARINC data from the aircraft directly is a significant pro- have delivered technical papers on how important it is that

20 • ISASI Forum July-September 2004 do not have the ability to check the EU conversion process if Typical Airline vs. Investigation Data Flow they suspect a problem. The EU conversion process has many opportunities for error, especially with parameters infrequently analyzed, and one should never accept the EU data as factual. Since the ARINC data file is magnitudes smaller to send and has no compromises, it does not make much sense to be pass- ing EU files. Manufacturers are starting to ask that the air- lines please send the raw data, not some artifact of the data in which they have no way of assessing its validity.

ICAO Annex 13, Appendix D ICAO Annex 13 Appendix D recognizes the difference be- tween an “airline” facility and an “investigation” facility and recommends States use investigation facilities. This was writ- ten by the ICAO FLIREC Panel because some States started taking the recorders to airline facilities after a major accident and other States with significant recorder labs felt that this could compromise an investigation. This was written before FDM programs were popular. With the FDM evolution, ICAO will need to revisit this as the stakes have gone up as airlines we be able to trace data latency. They are talking about laten- can now have a flight animation done very quickly. If it is not cies within the second for the most part. For all of these sys- accurate, or misleading, it is very hard to backtrack once people tems out there that truncate the data to the nearest second, have seen it. The golden rule of accident investigation is to there is no point in worrying about latency—you have already get it right before disseminating the results. With the accessi- reduced the accuracy well beyond the latency concerns. This bility of “automatic” flight animation systems and the man- is simply unacceptable for accident investigators who have ner in which some systems process the data, combined with expertise in flight data analysis. Systems that can process the philosophies that purport that you do not need any expertise ARINC data on the fly do not suffer from this problem, and to generate animations, we are setting ourselves up to com- they will display the data at precisely the times it was recorded. promise this golden rule. In many flight animations, it will not matter that the data As airlines make more and more decisions based on rou- are inaccurate in the time domain as there are lots of smooth- tine flight data, it will become increasingly important that simi- ing processes going on internally and the animation is being lar standards of data recording, extraction, and processing used to look at a relatively simple, routine event. However, that have evolved from years of accident investigation are ap- should the team come across a more complex event, it is hu- plied to the rest of the industry. man nature that they will try to use the tools they have to do With flight animation becoming more and more a popu- the work. This has already happened where an airline has run lar part of FDM programs, airlines will almost certainly go incidents through its “automatic” tools before the investiga- down the same path the investigation labs have already gone tion authority even has the data. If we believe that FDM is down and eventually demand the same tools and require accident investigation without an accident and accident in- the same expertise. If you are using animations for training, vestigators are not willing to compromise data quality and you still need to make sure that it is right—you can’t always have stringent standards, why is it acceptable at the airlines? jump from the data to training with the investigation part in The answer is, it shouldn’t be and, like the QAR dilemma, it is the middle! The investigation part may be trivial for routine another example of how history has taken us to a place that events but will not be trivial for complex events. When is the we do not really want to be and it is very hard to undo. transition whereby the investigation expert is required, and Aircraft manufactures are also becoming aware of this grow- will you know when you have crossed it? Like most things in ing problem as airlines will frequently wish to send data to life, nothing is free. The proper solution is to make sure the them for assistance in troubleshooting something. Airlines data are treated with the respect they deserve and to de- send a CSV file and the analysts at the other end do not get all velop an expertise and thorough understanding of the pro- the parameters, do not get the proper time resolution, and cess being operated. ◆

July-September 2004 ISASI Forum • 21 ISASI ROUNDUP

Council Sets New Membership Category

(Adapted from minutes and notes of the member who signs up as a result of International Council meeting recorded by attending a Reachout seminar. This Keith Hagy, Secretary.—Editor) program will remain in place until the end of 2006, at which time the Council The ISASI International Council on will review the results of the program. May 7 in a general meeting in Other actions included reaffirmation Herndon, Va., set, on a trial basis, a that the ISASI Executive meetings, new membership category to be known conducted by the elected officers 1 day as Reachout Associate Member. prior to the full Council meeting, is Council action came after lengthy open to all members of the Council discussion, which included a review of and issued a standing invitation for the attendance at the nine Reachout such attendance by Council members. workshops already conducted in The Council debated a change of conjunction with ICAO. The Council policy to permit “limited” business- noted that each workshop was placed class travel to Council meetings. The in geographic location that have few, if term “limited” means that for flights any, ISASI members and that approxi- originating outside North America, mately 100 people have attended each Council representatives may be able to session. In areas where the workshops travel business class over long, oceanic are conducted, issues of lack of avail- sectors to the first port of entry into able funds, distance of travel, and North America. From that point on, minimum staffing limit the pursuit of travel would be economy class. air safety objectives. ISASI is attempt- Experience gained in arranging travel ing to assist in this objective by furnish- to past meetings indicates that a ing low-cost training in the region. reasonable deal can usually be ob- While the workshops have received tained. The Council decided to great support and high praise, ISASI maintain its current policy of coach has not been able to receive these travel because of the potential for attendees as new members due in part significant cost increase to ISASI for Joanne Matley and Barbara Dunn to the high cost of membership. ISASI Council meetings. work on a proposed resolution. has been reluctant to reduce the cost of In another Council action, discus- membership for international mem- sion centered on the formation of a He also reported that refinancing the bers due to the cost of international General Aviation Committee within office condo with a lower interest rate mailing. The Internet now seems to ISASI to support that arm of the is an action that is under way. He offer an alternative to international industry. The Council decided to move further reported that at his recent mailing. With the provision that all forward as long as an ISASI member attendance of a Southern California mailings will be available through the from the general aviation area was Safety Institute (SCSI) seminar he ISASI website, the ISASI Council willing to take the lead in forming the recruited 8 to 10 new members. Also created a new membership category group. Also being considered is the reported was the resignation of Chuck entitled Reachout Associate Member. formation of a Corporate Committee Mercer as chairman of the Bylaws The Council will offer attendees at for the corporate aviation community Committee. Lastly, he reported on the Reachout workshops this special from within ISASI. special activities and articles associated classification. Each Reachout Associate Reporting activities of the Council with the passing of Jerry Lederer and will be given a membership number meeting follow. C.O. Miller, some of which are still that will permit access to the ISASI President—Frank Del Gandio reported being initiated to highlight the signifi- website and its members only sections. on the status of the ISASI office condo cant contributions both had made to Membership dues for this classification to include costs of a special assessment ISASI, aviation, and aviation safety. will be at the standard rate with the levied by the condo association and Treasurer—Tom McCarthy reported initiation fee waived for any new minor renovation of the office interior. that financially ISASI was in sound

22 • ISASI Forum July-September 2004 shape, noting that ISASI had received Zealand for providing complimentary an additional $11,000 from the upgrade to/from the U.S. to attend the Victoria seminar. He further reported Council meeting. that because the profit from that USSASI—Curt Lewis reported that seminar was turned over to the Taiwan ISASI 2005 had opened a website, government, the Taipei seminar did Ron Chippindale and Ron Schleede www.ISASI2005.com, for communicat- not split the proceeds generated from engage in an ISASI 2004 discussion. ing details regarding the Dallas/Ft. the seminar with ISASI. This action Worth seminar planned for the week represented an approximate $13,000 Reports of National of Sept. 12, 2005. He also is planning loss to ISASI, which includes the Societies/Councilors a U.S. Society newsletter. publication of seminar Proceedings. All ASASI—Lindsay Naylor reported that International Councillor—Caj Frostell avenues have been exercised in an most of his activities since the last reported on his activities in support of attempt to recover ISASI’s portion of Council meeting have been in prepara- Reachout (see “RoundUp” Section). the profit from this seminar, he said. tion for ISASI 2004. ISASI Forum Editor—Esperison He also reported key bank account CSASI—Barbara Dunn reported that (Marty) Martinez reported no changes balances. the Canadian Society was in sound have occurred in the editorial gather- Executive Administrator—Richard financial condition with 100 members ing, production, or printing aspects of Stone reported on the selection of and that her involvement with SCSI was the magazine. He also reported on the Shannon Harris as the awardee of the producing new members for CSASI publication process of the ISASI Rudy Kapustin Scholarship fund (see and ISASI. She also reported that Proceedings, the compilation of the page 26). He noted that it was the goal CSASI continues to get requests for and technical papers presented at the of the selection committee to select two is providing bloodborne pathogen annual seminar. During his report the award recipients but of the four papers training, most recently for Transport Council discussed the printing of submitted, the Committee felt that Canada and that plans are being made seminar Proceedings and of additional only one qualified for the award. He to train representatives from the Royal copies of ISASI Forum. The Council then opened discussion with the Canadian Mounted Police. She also reiterated its position that the seminar Council on whether the award winner reported that she had received requests Proceedings should continue to be should be provided transportation to to conduct cabin safety Reachout distributed electronically via the ISASI the seminar in addition to the financial seminars in India and Pakistan. website and on CD-ROM. In addition award. After some discussion, the ESASI—Max Saint-Germain/Ken a very limited quantity (25) of hard Council decided that transportation Smart reported that the European copies would be produced for sale would not be provided as a standard in Society continues to attract new purposes and for Council use. The the award but Council members were members from all areas of the aviation Council further directed the printing encouraged to solicit, through their safety community and that currently of 100 additional copies of the ISASI individual contacts, complimentary or ESASI is active with 118 individual and Forum for the use of members involved reduced-cost transportation for award 19 corporate members. Within the last in Reachout and other ISASI activities winners. year, 10 individual and one corporate that may result in new members. The members were recruited. issue was raised of the $5,000 that is NZSASI—Ron Chippindale reported presently required for the Seminar Upcoming Events current membership at 50 and that the Committee to provide to ISASI to • ISASI 2004 Gold Coast Australia— New Zealand Society was in sound cover the cost of publishing seminar Aug. 30-Sept. 2, 2004 financial position. A membership Proceedings. The question was asked if • ISASI 2005 Ft. Worth, Tex., USA meeting and dinner is being planned the cost was still necessary. It was • 57th Annual International Air Safety Seminar, Nov. 15-18, 2004. Location: for NZSASI members and their explained that the bulk of the $5,000 Pudong Shangri-La Hotel, Shanghai, partners. Election of a new Executive was actually used for completion of China. Further information: Ahlam will occur at the membership meeting. editorial processes and prepress Wahdan [email protected] or Ann Hill, [email protected] or As in the past, NZSASI will be subsidiz- production procedures that would +1-703-739-6700 ing NZSASI members who attend continue to be required even for ISASI 2004. He thanked Air New electronic distribution. In addition, it

July-September 2004 ISASI Forum • 23 ISASI ROUNDUP Continued . . .

was reported that the ISASI Executive membership database at renewed the editor’s contract for ISASI headquarters so that another 3 years; the Council agreed when changes are made with the action. there the changes would also be seen in the roster ISASI Committees available through the Membership—Tom McCarthy provided website. He also reported a written report and verbally reported that a search engine had that the current ISASI membership been added and that a status stood at 1,385 individual corporate membership members, of which 135 were delin- database would also be quent in dues. There are 109 corpo- added to the site. Also to be rate members, of which 10 were available on the site will be delinquent in dues. He and the the CSASI membership President reminded all Council application and the Cana- members to review the list of delin- Curt Lewis (left) and Ken Smart listen dian Society web address. quent members and to contact the to ongoing discussion. Cabin Safety—Joanne members personally for renewal. Matley reported that she Seminar—Barbara Dunn reported that had recently completed the NTSB the seminar manual had been final- course and had distributed the materi- ized. She noted that no formal bids for als obtained from the course to the the 2006 seminar had been received cabin safety group. MOVING? yet, but individuals and societies had Positions—Ken Smart reported that Please Let Us Know expressed interest in hosting in 2006 the biannual Positions review would be Member Number______from the following locations: Prague, submitted in May 2005. Ken also Hong Kong, Israel, Mexico, and reported that the Committee was down Fax this form to 1-703-430-4970 or mail to ISASI, Park Center Korea. In addition, Singapore ex- to three members. 107 E. Holly Avenue, Suite 11 pressed an interest in hosting a Corporate Affairs—John Purvis Sterling, VA 20164-5405 seminar in 2007. She also reported reported that attendance at the Old Address (or attach label): that Jim Stewart had offered to help corporate meeting held during ISASI with the Seminar Committee. 2004 was small due to the scheduling Name______Reachout—Jim Stewart was unable to of overlapping meetings. The Council Address ______attend the meeting but submitted a asked that the Seminar Committee City ______written report in which he noted the minimize scheduling overlapping State/Prov. ______Mexico City workshop in January. He meetings during future seminars. also noted a Beijing workshop sched- 2004 Gold Coast Australia Seminar— Zip ______uled for late May. Interest in a work- Lindsay Naylor provided a status Country ______shop has been shown by Bulgaria and update on ISASI 2004. The technical New Address* South Africa. Barbara Dunn men- program has been finalized. Registra- Name______tioned cabin safety Reachout in India tion has begun and the hotel indicates and Pakistan. Caj Frostell mentioned that accommodation bookings have Address ______that discussions have been held with also commenced. Naylor expects great City ______the FAA international office about technical and social programs. State/Prov. ______coordinating Reachout with the ICAO 2005 Dallas/Ft. Worth Seminar—Curt Zip ______COSCAP activity. Lewis reported that the Seminar Technical Library—Corey Stephens Committee is planning a get together Country ______provided an update on developments sometime this summer to begin E-mail ______with the ISASI website. He said that preparations for the 2005 seminar. He *Do not forget to change employment and the ISASI membership roster was now also reported that he was preparing an e-mail address. “real time,” meaning it is tied to the info package regarding ISASI 2005 for

24 • ISASI Forum July-September 2004 NEW MEMBERS

Corporate Heck, John, W., MO5033, Washington, D.C., USA BEA—Bureau D’Enquetes et D’Analyses, CP0220 Hughes, Kerri, L., FO5060, Higgins, ACT, Martine Del Bono Australia Aircraft Accident Investigation Bureau— Hunter, Skye, A., FO5039, Terrigal, NSW, Australia Switzerland, CP0223 Iqbal, Javed, MO5067, Karachi, Pakistan Jean Overney Khan, Tanzeem, A., MO5044, MacDill, FL, USA Olivier De Sybourg King, Brian, T., MO4962, Summerville, SC, USA State of Israel, Ministry of Transport, Aviation Langhof, Dietrich, MO5009, Kelsterbach, Incidents & Accidents Investigation, CP0224 Germany Itzhak Raz (Razchik) Larrain, Monique, C., ST5040, Daytona Beach, FL, USA On Tuesday, the companion group Individual Lohmar, John, S., AO5054, St. Charles, MO, USA Abruzzese, Charlie, FO5059, Sydney, NSW, Mahmood, Suheli, AO5065, Dhaka, Bangladesh will enjoy lunch while cruising the Australia Menniti, Maximo, AO5038, Rome, Italy Southport Broadwater to Sanctuary Ahsan, Imran, MO5045, MacDill, FL, USA Puggaard, Martin, F., MO5056, Roskilde, Alberto, Jr., Conrad, ST5035, Los Angeles, Denmark Cove, Australia’s first fully integrated CA, USA Roberts, Cameron, J., MO5057, Ocean Reef, tourism resort. (Readers can get a Alghamdi, Ali, G., AO5048, Jeddah, Saudi Arabia Australia Almotairy, Ayedh, N.D., MO5051, Jeddah, Sefton, Adam, R., AO5042, Thornton, CO, USA photo look at these two areas by Saudi Arabia Sheehan, James, E., MO5034, Greenwich, visiting the ISASI 2004 website— Bagsair, Sameer, S., MO5043, Jeddah, CT, USA Saudi Arabia Shehab, Ahmad, T., AO5047, Jeddah, Saudi Arabia companion programs—and clicking Barden, David, W., MO5052, Jeddah, Saudi Arabia Siska, Frankie, J., MO5062, Nowra, NSW, Australia the names of the two interest points.). Binyousef, Hussein, I., MO5055, Jeddah, Wadud, Muhammad, A., MO5066, Dhaka, Saudi Arabia Bangladesh Companions will have the choice of Cha, Kisu, MO5037, Geyonggido, South Korea Watson, James, R., MO5053, Friendswood, staying to shop or returning to the De Silva, Anoma, AO5064, Mirihana Nugegoda, TX, USA Sri Lanka Wood, Mark, A., AO5041, Boulder, CO, USA hotel. Activity planners said of the Doxey, Justin, M., MO5063, Clitheroe, England Younes, Mohamed Hany, A., AO5049, Jeddah, evening, “Get ready to hear the tunes Erini, Mark, P., AO5036, Canberra, ACT, Australia Saudi Arabia Fearon, Rod, G., MO5058, Mt. Warren Park, Young, Steven, D., FO5061, Macgregor, ACT, of a Bush band, participate in some OLD, Australia Australia fair ‘dinkum’ Outback activities, pet Haider, Abdulaziz , A., AO5050, Jeddah, Zahid, Rana Farooq Ali, MO5046, MacDill, Saudi Arabia FL, USA the kangaroos and koalas, and watch an Aboriginal Corraboree—be sure to bring your camera!” distribution at ISASI 2004 and that a and some specific principles useful for On Wednesday, companions will visit website had been established for the different types of interviews and the Hinterland where they will experi- seminar, www.ISASI2005.com. ◆ situations. The tutorial will also include ence “beautiful views, flora, and a practical exercise and an opportunity wildlife and have an opportunity to ISASI 2004 Plans for participants to discuss any issues of purchase gifts and produce hand- interest or concern. Tutorial facilitators crafted by the locals,” said program Complete are Mike Walker and Brent Hayward. planners. The Hinterland, also known The Australian Society of Air Safety Communicating and Educating—Al as the “green behind the gold,” is the Investigators reports program plans Bridges, tutorial facilitator, says Gold Coast’s best-kept secret. It is for ISASI 2004 have been completed. communicating and educating ex- a 30-minute drive from the coastal The 35th annual seminar, which the plores the sometimes-neglected side of strip, and is considered the Gold Society is sponsoring, will take place the investigation process. It concen- Coast’s natural “theme park”—along Aug. 30-Sept. 2, 2004, and carry the trates on the messages that are impor- with its famous beaches. Popular theme “Investigate, Communicate, tant for you, as a safety specialist, as a Hinterland attractions include Curtis Educate.” It will be held in the ANA company pilot, as an engineer, or as a Falls and Gallery Walk at Mt. Hotel Gold Coast, Queensland, passenger; indeed, anyone with a Tamborine, Springbrook and Australia. Registrations continue to be vested interest in aviation. What are Purlingbrook Falls, Aussie Country at received and present count indicates the messages applicable to each of Canungra, Binna Burra Lodge, and an excellent turnout for the Society’s these groups and how should they be O’Reilly’s Guest House. annual seminar, according to Chair- communicated? “We will look at Those staying the extra day for the man Lindsay Naylor. some examples, find the essential wind-down tour will visit Tamborine There will be two tutorial workshops messages for each group and the best Mountain, a volcanic plateau 560 on Monday, August 30. Each costs methods to communicate those meters above sea level . The area has an A$85. The tutorials will run at the messages,” he says. extensive variety of waterfalls, rain- same time. The two subjects to be The social program including the forests, bird life, and many breathtaking delivered are companion program calls for a cocktail walking trails. Next comes a spot of Interviewing—Interviewing is a reception on Monday evening, August wine tasting followed by a leisurely critically important skill for all types of 30, for all delegates and companions. three-course lunch at the historic home- safety investigations. This tutorial will An off-site dinner is planned for stead and award-winning Albert Winery. provide an overview of witness/ Tuesday evening, and the seminar Main program plans are, for the interviewee limitations, general Awards Banquet will be held in the most part, said Naylor, “complete.” He principles of investigative interviewing, hotel on Thursday evening. noted that the keynote address will be

July-September 2004 ISASI Forum • 25 2004 Annual Seminar Proceedings Now Available

Active members in good standing and Investigation Enhancement Through Information corporate members may acquire, on a no-fee Technology by Jay Graser, Galaxy Scientific Corporation Historical Review of Flight Attendant Participation in basis, a copy of the Proceedings of the 34th Accident Investigations by Candace K. Kolander, Association International Seminar, held in Washington, of Flight Attendants D.C., Aug. 26-28, 2003, by downloading the Accident Investigation Without the Accident by Michael R. Poole, Flightscape information from the appropriate section of SESSION IV the ISASI web page at http://www.isasi.org. Keynote Address Growth of ATC System and Controllers The seminar papers can be found in the Union by John Carr, President, National Air Traffic Controllers “Members” section. Further, active members Association, USA made by Bruce Byron, chief executive Crashworthiness Investigation: Enhanced Occupant may purchase the Proceedings on a CD-ROM Protection Through Crashworthiness Evaluation and officer of the Civil Aviation Safety for the nominal fee of $15, which covers Advances in Design—A View form the Wreckage by Authority of Australia, and that the postage and handling. Non-ISASI members William D. Waldock, Embry-Riddle Aeronautical University Enhanced Occupant Protection Through Injury Pattern address will be followed by a video may acquire the CD-ROM for a US$75 fee. A Analysis by William T. Gormley, Office of the Chief Medical limited number of paper copies of Proceed- Examiner, Commonwealth of Virginia tribute to Jerry Lederer. The 3 days of ings 2003 are available at a cost of US$150. Forensic Aspects of Occupant Protection: Victim the seminar will be packed with Checks should accompany the request and Identification by Mary Cimrmancic, Transportation Safety Institute, Oklahoma City, Okla. presentations illuminating the theme be made payable to ISASI. Mail to ISASI, Aircraft Accident Investigation—The Role of Aerospace 107 E. Holly Ave., Suite 11, Sterling, VA USA and Preventive Medicine by Allen J. Parmet, Midwest “Investigate, Communicate, Educate.” 20164-5405. Occupational Medicine, Kansas City, Mo. Expansion of the ICAO Universal Safety Oversight Audit The ISASI 2004 website has a “to date” Program to Include Annex 13—Aircraft Accident and The following papers were presented in Washington, D.C.: full listing of all speakers and subjects. SESSION I Incident Investigation by Caj Frostell, Chief, Accident Keynote Address Human Spirit and Accomplishment Investigation and Prevention, ICAO SESSION V Individual wise, speakers number 45, Are Unlimited by Ellen G. Engleman, Chairman, NTSB, USA which may sound daunting until one The Practical Use of the Root Cause Analysis The CFIT and ALAR Challenge: Attacking the Killers in System(RCA) Using Reason ®: A Building Block for Aviation by Jim Burin, Flight Safety Foundation Flightdeck Image Recording on Commercial Aircraftby sees that many presentations have Accident/Incident Investigations by Jean-Pierre Dagon, Director of Corporate Safety, AirTran Airways Pippa Moore, CAA, UK multiple speakers/authors and all From the Wright Flyer to the Space Shuttle: A Historical Flightdeck Image Recording on Commercial Aircraft by Mike Horne, AD Aerospace, Ltd., Manchester, UK names are listed on the program Perspective of Aircraft Accident Investigation by Jeff Guzzetti, NTSB, USA, and Brian Nicklas, National Air An Analysis of the Relationship of Finding-Cause- ◆ and Space Museum, USA Recommendation from Selected Recent NTSB Aircraft delivered on the website. Accident Reports by Michael Huhn, Air Line Pilots The Emergency and Abnormal Situations Project by Barbara K. Burian, R. Key Dismukes, and Immanuel Barshi, Association. Presented by Chris Baum. NASA Ames Research Center Ramp Accidents and Incidents Involving U.S. Carriers, SESSION II 1987-2002 by Robert Matthews, FAA, USA Kapustin Scholarship SESSION VI Accident Reconstruction—The Decision Process by John W. Purvis, Safety Services International Keynote Address Accident Investigation in Brazil by Col. Winner Named CI611 and GE791 Wreckage Recovery Operations— Marcus A. Araújo da Costa, Chief Aeronautical Accident Prevention and Investigation Center (CENIPA), Brazil Comparisons and Lessons Learned by David Lee, Steven The ISASI Rudy Kapustin Memorial Su, and Kay Yong, Aviation Safety Council, Taiwan, ROC Airline Safety Data: Where Are We and Where Are We Application of the 3-D Software Wreckage Reconstruc- Going? by Timothy J. Logan, Southwest Airlines Scholarship Fund has selected as Use of Computed Tomography Imaging in Accident tion Technology at the Aircraft Accident Investigation by winner of the 2004 award—Shannon Wen-Lin, Guan, Victor Liang, Phil Tai, and Kay Yong, Aviation Investigation by Scott A. Warren, NTSB, USA Safety Council Taiwan. Presented by Victor Liang. Investigating Survival Factors in Aircraft Accidents: Harris (ST4983), a senior at Embry- CVR Recordings of Explosions and Structural Failure Revisiting the Past to Look to the Future by Thomas A. Farrier, Air Transport Association of America, Inc. Decompressions by Stuart Dyne, ISVR Consulting, Institute of Riddle Aeronautical Sound and Vibration Research, University of Southampton, UK The Accident Database of the Cabin Safety Research SESSION III Technical Group by Ray Cherry, R.G.W. Cherry & Associates University, Florida, Limited, UK Keynote Address Learning from ‘Kicking Tin’ by USA, according to Marion C. Blakey, Administrator, FAA, USA Search & Recovery: The Art and Science by Steven Saint Amour, Phoenix International, Inc. Investigating Techniques Used from DHC-6 Twin Otter National Transportation Safety Board Recommendations Richard Stone and Ron Accident, March 2001 by Stéphane Corcos and Gérald Gaubert, BEA, France Relating to Inflight Fire Emergencies by Mark George, Schleede, ISASI co- NTSB, USA administrators of the scholarship fund. Shannon The administrators gation process and the resulting safety encourage and assist college-level Harris received four applica- implications of the findings. students interested in the field of tions for consideration. • submission of a paper that is brief aviation safety and aircraft occurrence In notifying the applicants of their and clear and avoids overusing investigation, according to Richard selection, the Committee said: “The technical language that may not be Stone, ISASI Executive Advisor and one ISASI scholarship was awarded to the understood by non-technical readers. of the two fund administrators. Contri- student we felt wrote the best essay. Shannon Harris’s award provides for butions have and will continue to Some of our criteria were explained attendance at the upcoming ISASI supplement the Kapustin’s family initial in the application, but some were annual seminar. endowment. The memorial will provide based on our view of what knowledge The Fund was established in memory an annual allocation of funds for the a prospective accident investigator of all ISASI members who have died, scholarship. All members of ISASI should have gleaned from his/her and was named the ISASI Rudy enrolled as a full-time student in a education. That criteria included Kapustin Memorial Scholarship Fund recognized and accredited education • submission of a 1,000 (+/- 10 in honor of the former ISASI Mid- program with a concentration on avia- percent) word paper in English Atlantic Regional Chapter president tion safety and/or aircraft occurrence addressing “The Challenges for Air and long-term ISASI member who investigation are eligible for the scholar- Safety Investigators.” developed a reputation as “tinkicker ship. A student who has once received • submission of a paper that indicates extraordinaire” among his peers. the annual scholarship will not be understanding of the accident investi- The scholarship is intended to eligible to apply for it in another year.

26 • ISASI Forum July-September 2004 need for caution on this subject. So, it was with some sense of accomplish- ment that Matthews announced the International Civil Aviation Organization’s (ICAO) agreement to address the subject through an assem- bly resolution at ICAO’s September 2004 ordinary session of the assembly. Similarly, flight operations quality assurance (FOQA) programs have Lucky winners: Top prize been long discussed and studied. winners at the MARC meeting Matthews ratcheted up the discussion were Bob MacIntosh and Don by calling for the FAA to mandate the Arendt. MacIntosh won a establishment of such a program on all roundtrip flight to any place U.S. airlines. He noted that although on AirTran Airways schedule, the present voluntary program has compliments of the airline, and shown its worth through its ability to Arendt won a free registration correctly predict unsafe operational to the FSF Shanghai seminar trends, not all air carriers use it. later this year. Shown in top Already ICAO has issued its recom- photo, left to right, D. Borden, mendation that a non-punitive flight- J.P. Dagon (Air Tran); data-analysis program be established MacIntosh; and R. Schleede, by all operators of airplanes with a MARC President. Photo to left, maximum takeoff weights greater than left to right, Arendt, S. 27,000 kilograms/60,000 pounds, by Matthews, and Schleede. Jan. 1, 2005, and Europe’s Joint Aviation Authority is following ICAO’s The Fund administrators ensure that Guest speaker was Stuart Matthews, lead, said Matthews. the education program is being Flight Safety Foundation president and He believes that if the FAA does not completed at a recognized school and CEO. The FSF is also a corporate mandate FOQA, the many countries applicable to the aims of the Society member of ISASI. outside of Europe that normally follow and assess the applications and Matthews’ address titled “Aviation FAA’s lead will continue their style and determine the most suitable candidate. Safety: Things That Can Be Done not bother to mandate the program’s The scholarship consists of an annual Better” included three prime topics: use. He told the MARC audience, “the $1,500 award. criminalization of accident situations FAA must provide leadership. The FAA Contributions to the Fund may be and its effect on accident investiga- must mandate FOQA.” mailed to the ISASI home office. tions; need for greater use of airline Matthews next raised the audience’s Checks should be made payable to the flight data collection and analysis; and interest level considerably when he ISASI Rudy Kapustin Memorial will aviation safety be affected by opened the topic of security vs. safety. Scholarship Fund. ◆ aviation security costs. The thrust of his talk was that notwith- He said the criminalization issue standing the industry’s disastrous MARC Members Host now threatens the protection of data economic fallout following the terrorist and accident evidence by making use of passenger aircraft as weapons FSF President information difficult to obtain and on Sept. 11, 2001, and the correct The ISASI Mid-Atlantic Regional impeding investigations. The topic has response of heightened security, air Chapter annual meeting kept to its been one of concern to the FSF and safety concerns have not changed since established schedule and was held in many safety officials. At ISASI 2002, that date. Washington, D.C., on May 6, to the chairman of Indonesia’s National Air safety and good security are both coincide with the spring ISASI Council Transportation Safety Committee expensive. Considering the severe meeting, conducted the next day. made a stirring presentation on the cutbacks in air carrier operations and

July-September 2004 ISASI Forum • 27 ISASI ROUNDUP Continued . . .

staff since 9/11, owing to the economic fallout, is air safety in danger of being placed in the shadow of security? Matthews cautioned that “It might be tempting to think that with such a low accident rate, for the time being, the industry was safe enough so that, by relaxing some of the safety safeguards, costs might be saved or be made available to be spent elsewhere. However, this would only increase the overall risk level and I would contend that a major aircraft accident would not only cost the carrier concerned infinitely more than any hoped for Part of the 156 participants who attended the first European edition of the savings, it could well have the same International Aircraft Cabin Safety, Security, and Health Symposium. detrimental effect on the aviation industry as another terrorist attack.” The PNRC will be continuing its Transport of the Czech Republic, in In closing the topic, he noted that technical meetings throughout 2004. discussions with Dr. Peter C. Gardiner, assets and interests need to be wisely Guests from other regions or individu- president and CEO of SCSI (CP0098). directed because, “…day in and day als interested in aviation safety are The Prague organizing committee out, the public’s primary risk in always invited to attend any of the established panels of outstanding commercial air travel will come from Chapter meetings. Details on the exact speakers that focused on trends and accidents, not from criminal acts or times and locations for these presenta- best practices in cabin safety training; terrorism.” ◆ tions can be obtained directly from cabin safety, security, and health; and Chapter President Kevin Darcy at lessons learned from accidents and PNRC Briefed on Year [email protected] or from Leo hijackings. Workshops were also Rydzewski at leo.j.rydzewski@ conducted on arctic, jungle, water, and 2003 Accidents boeing.com. ◆ desert survival training. The Pacific Northwest Regional Planners of the Symposium set the Chapter, well attended by both mem- Cabin Safety Symposium goal of gathering aviation, medical, bers and guests, received a presenta- and security experts from Europe and tion on hull-loss aircraft accidents that Held in Prague States that might not be able to attend occurred during 2003 from Richard The first European edition of the a North American event, and provid- Anderson of the Boeing Air Safety annual International Aircraft Cabin ing them a chance to participate either Investigation at the Chapter’s June Safety, Security, and Health Symposium as panelists making presentations or to meeting held at the Boeing Longacres was held in Prague, Czech Republic, on listen to presentations, attend work- facility in Renton. March 23-25. The Symposium, now in shops, and participate in a realistic Anderson, who has worked exten- its 22nd year, has been traditionally hijack exercise conducted at the Czech sively with the statistical aspects of held annually in North America and Airlines training center. accidents, gave an excellent overview hosted by the Southern California More than 156 delegates from 28 of the year 2003 air carrier accidents Safety Institute (SCSI ), an ISASI countries in central, eastern, and and how that compared with previous corporate member. The special Prague western Europe, the United States, years. He also discussed the shuttle edition marks the first time that the South America, the Middle East, Hong accident and how Dennis Rodriguez, Symposium has held a general session Kong, and Africa traveled to Prague to recently retired from the Boeing outside North America. hear presentations, participate, net- Company, had received the prestigious The concept of conducting a special work, and discuss cabin safety, health, Snoopy Award for his contributions to European edition was introduced by and security issues of mutual concern. that investigation. Ladislav Mika (MO4226), Ministry of Robert Kruger, deputy director of the

28 • ISASI Forum July-September 2004 European and North Atlantic office of was in conjunction with a visit to the May. Most of the participants were ICAO, was a keynote speaker. Delegates Air Force museum and dinner with from China; however, 11 were from the also decided to form two special interest partners. Business discussion involved Republic of Korea and 3 from the groups (SIGs) for continued networking plans for the spring Council meeting, democratic People’s Republic of Korea, and dialoging between symposia by e- the venue for the Australia/New reported Jim Stewart, Reachout mail: SIG Cabin Safety and Security Zealand seminar in June 2005, the Committee chairman. and SIG Training. recent review of the transport sector in The program included a 5-day Plans were made to meet again in New Zealand with reference to the ISASI Reachout workshop consisting Prague in 2006 for a second European comments on accident investigation, of accident investigation and preven- edition. ◆ membership recruiting, subsidizing tion and safety management topics. attendance at ISASI and ANZSASI Instructors came from France and NZSASI Elects seminars, the various scholarship and Canada. Minister Yang Yuan Yuan other prizes offered by ISASI and officially opened the workshop. New Executive associated societies, financial reports, Laurence Barron, president of Airbus, At its biennial meeting the New and comments from the members of China, welcomed the participants to Zealand Society of Air Safety Investiga- the Executive. ◆ the Airbus training facility and empha- tors elected new members as the sized the importance of the ISASI group’s Executive body. Peter Williams 65 Attend Reachout program. was elected to the office of President; The ICAO Cooperative Develop- Wing Commander Russell Kennedy, Reachout Beijing ment of Operational Safety and Vice-President; and Ron Chippindale, Sixty-five participants representing the Continuing Airworthiness Program Secretary/Treasurer and New Zealand full spectrum of civil aviation safety, (COS-CAP) North Asia (COS-CAP- Councillor. All appointments became including airline pilots, government NA), the Civil Aviation Authority of effective on May 30. investigative authorities, and airport China, and Airbus Industrie hosted the The biennial meeting was held on managers, attended the Beijing, workshop, which consisted of 3 days of May 29 at RNZAF base Ohakea and China, Reachout workshop held in accident investigation and 2 days of safety management systems. Jim Stewart taught safety management systems while Caj Frostell (ISASI and ICAO), Nicholas Rallo (BAE, France), and Dr. Kwok Chan (Airbus) taught accident investigation. Instructors prepared their own training material consisting of paper handouts, CD-ROM libraries, and published manuals and booklets. ICAO provided numerous documents that were shipped from its headquar- ters in Montreal. These included Chinese-language copies of the latest accident prevention and investigation documents. Each participant received copies of documents and CD-ROMs with considerable background materi- Part of the group attending the Reachout workshop. Dignitaries in the front row als for future reference. are, from 2nd from the left, Huang Sui Fa, director general CAAC; Jim Stewart; The COSCAP-SA covered all travel Laurence Barron, president Airbus, China; Minister Yang Yuan Yuan; Len and daily subsistence costs for the Cormier, COSCAP; Caj Frostell, ISASI; and Hugues Depigny, vice-president of three instructors. There was no need Customer Services, Airbus, China. for ISASI to obtain any additional

July-September 2004 ISASI Forum • 29 ISASI ROUNDUP Continued . . .

TRAINING COURSE CALENDAR 2004

UNIVERSITY OF SOUTHERN TRANSPORTATION SAFETY • Gas Turbine Accident Investigation (A) CALIFORNIA INSTITUTE & FAA Nov. 8-12 • Aviation Safety Program Management • Aircraft Accident Investigation • Aircraft Performance and Structures Sept. 20, Oct. 1, Dec. 6-17 Jul. 27-Aug. 4, Aug. 18-26 Investigation (A) • Human Factors in Aviation Safety • Accident Investigation Recurrent Tng. Nov. 17-21 (03) Sept. 13-17, Nov. 8-12 Aug. 10-12, Sept. 14-16 • Ramp and Maintenance Safety (T) • Safety Management for A viation • Human Factors in Accident Investigation TBD Maintenance Aug. 31-Sept. 2 • Fire and Explosives Investigation (A) Nov. 1-5 • Aircraft Cabin Safety Investigation TBD • Software Safety Aug. 19-20 • Safety Management Systems (T) Nov. 15-18 Sept. 13-24 • Gas Turbine Accident Investigation For further information contact: • Human Factors in Safety Management Nov. 15-19 Pat Brown, Transport Safety Institute Systems (T) • Accident/Incident R esponse Preparedness Tele: 405-954-7206 Sept. 27-Oct. 1 Oct. 18-20 Website: www.tsi.dot.gov • Photography in Accident Investigations For further information contact: Oct. 21-22 SOUTHERN CALIFORNIA Eduardo Treto, Registrar • Helicopter Accident Investigation SAFETY INSTITUTE SCSI, 3521 Lomita Blvd, Ste 103 Oct. 25-29 A=Albuquerque, NM Torrance, CA 90505-5016, USA • Aircraft Accident Investigation T=Torrance, CA Tele: 1-800-545-3766 or 310-517-8844, Oct. 4-15 O=Ottawa, Canada Fax: 310-540-0532 • Incident Investigation/Analysis V=Vancouver, British Columbia E-mail: registrar@scsi-inccom Aug. 30-Sept. 2 PR=Prague, the Czech Republic Website: wwwscsi-inccom

For further information contact: • Aircraft Accident Investigation (A) University of Southern California/Aviation Oct. 11-22 Safety Programs • Human Factors for Accident Investigators (A) Tele: 310-342-1345 Oct. 25-29 Website: www.usc.edu/dept/engineering/ • Investigation Management (A) AV.html Nov. 1-5 sponsorship from ISASI sources for the NTSB Gains Hersman, following the attacks of September 11. workshop. Local sponsorship was Her term expires Dec. 31, 2008. provided and managed by Len Loses Goglia John Goglia departs the NTSB after Cormier, the chief technical advisor to Deborah Hersman was sworn in on June a tenure of 9 years. He was appointed COSCAP NA, including air travel for 21 as a Member of the National Trans- to the Safety Board in 1995 by Presi- instructors, local ground transporta- portation Safety Board. Before joining dent Bill Clinton. During his time on tion, and instructor lodging. The the Board, Member Hersman was a the Board, he often warned about the Airbus training facility was provided, senior professional staff member of the risks of ill maintenance and of bird- and Airbus sponsored lunches and U.S. Senate’s Committee on Commerce, plane collisions and persuaded refreshments. Sponsorship for ISASI Science, and Transportation for the last airports to do a better job of keeping Reachout was also obtained from the 5 years. Prior to that, she served as staff birds from nesting and feeding near Air Line Pilots Association, Interna- director and senior legis-lative aide to runways. He was the first airline tional, which provided staff time and Congressman Bob Wise of West Virginia mechanic on the NTSB and often administrative support, as did ICAO. from 1992 to 1999. focused on mistakes by his brethren. Airbus representatives were very In her Senate position, Member He was instrumental in persuading positive about the Reachout program Hersman was responsible for the airlines and labor unions to adopt new and made a strong commitment to legislative agenda, oversight, and policy ways to prevent those mistakes. continue their association with future initiatives for surface transportation When he accepted the government ISASI Reachout workshops. issues, including railroad regulation, job, he was required to cut all ties with The support of ICAO was critical in safety and passenger issues, truck and USAir, which meant he had to sacrifice establishing the credibility of the bus safety, pipeline safety, and hazard- about $3,500 per month in retirement workshop, said Stewart. The office of ous materials transportation safety. She pay, plus his health benefits. He COSCAP-NA distributed the invitation was also extensively involved with sacrificed the money because the and the registration form for the work- aviation and maritime issues. She also NTSB gave him “an opportunity to shop to its member States, he added. ◆ worked on transportation security issues make a difference.” ◆

30 • ISASI Forum July-September 2004 ISASI INFORMATION

OFFICERS CORPORATE MEMBERS President, Frank Del Gandio Accident Investigation Board, Finland Flightscape, Inc. Accident Investigation Board/Norway Flight Safety Foundation—Taiwan Executive Advisor, Richard Stone ACE USA Aerospace FTI Consulting, Inc. Vice-President, Ron Schleede Aeronautical & Maritime Research GE Aircraft Engines Secretary, Keith Hagy Laboratory Global Aerospace, Inc. Treasurer, Tom McCarthy Air Accident Investigation Bureau Hall & Associates LLC of Singapore Honeywell Air Accident Investigation Unit—Ireland Hong Kong Airline Pilots Association COUNCILLORS Air Accidents Investigation Branch—U.K. Hong Kong Civil Aviation Department Air Canada IFALPA United States, Curt Lewis Air Canada Pilots Association Independent Pilots Association International, Caj Frostell Air Line Pilots Association Int’l. Assoc. of Mach. & Aerospace Workers Air New Zealand, Ltd. Interstate Aviation Committee Australian, Lindsay Naylor Airbus S.A.S. Japan Air System Co., Ltd. Canadian, Barbara Dunn Airclaims Limited Japanese Aviation Insurance Pool European, Max Saint-Germain Aircraft Accident Investigation Bureau— JetBlue Airways New Zealand, Ron Chippindale Switzerland KLM Royal Dutch Airlines Airservices Australia L-3 Communications Aviation Recorders AirTran Airways Learjet, Inc. UNITED STATES REGIONAL Alaska Airlines Lufthansa German Airlines HAPTER RESIDENTS All Nippon Airways Company Limited Middle East Airlines C P Allied Pilots Association National Aeronautics and Space Arizona, Bill Waldock American Airlines Administration American Eagle Airlines National Air Traffic Controllers Assn. Mid-Atlantic, Ron Schleede American Underwater Search & Survey, Ltd. National Business Aviation Association Alaska, Craig Beldsoe ASPA Mexico National Transportation Safety Board Northeast, David W. Graham Association of Professional Flight Attendants NAV Canada Dallas/Ft. Worth, Curt Lewis Atlantic Southeast Airlines—Delta Northwest Airlines Connection Phoenix International, Inc. Pacific Northwest, Kevin Darcy Austin Digital, Inc. Pratt & Whitney Florida, Ben Coleman Australian Transport Safety Bureau Qantas Airways Limited Rocky Mountain, Richard L. Perry Avianca & SAM Airlines Republic of Singapore Air Force Great Lakes, Rodney Schaeffer Aviation Safety Council Rolls- Royce Corporation Avions de Transport Regional (ATR) Royal New Zealand Air Force San Francisco, Peter Axelrod BEA—Bureau D’Enquetes et D’Analyses Sandia National Laboratories Los Angeles, Inactive Belgian Air Force, Air Staff Brussels, VSF Saudi Arabian Airlines Southeastern, Inactive Bell Helicopter Textron, Inc. Scandinavian Airlines Board of Accident Investigation—Sweden School of Aviation Safety and Management, Boeing Commercial Airplanes ROC Air Force Academy NATIONAL AND REGIONAL Bombardier Aerospace SICOFAA/SPS SOCIETY PRESIDENTS Bombardier Aerospace Regional Aircraft/ Sikorsky Aircraft Corporation de Havilland, Inc. Singapore Airlines, Ltd. Australian, Kenneth S. Lewis Cathay Pacific Airways Limited Smith, Anderson, Blount, Dorsett, SESA-France Chap., Vincent Fave Cavok, International, Inc. Mitchell & Jernigan, L.L.P. Canadian, Barbara M. Dunn Civil Aviation Safety Authority, Australia SNECMA Moteurs New Zealand, Peter Williams COMAIR, Inc. South African Airways Continental Airlines South African Civil Aviation Authority European, Ken Smart Continental Express Southern California Safety Institute United States, Curt Lewis DCI/Branch AIRCO Southwest Airlines Company Russian, V. Venkov Delta Air Lines, Inc. State of Israel, Ministry of Transport, Aviation Directorate of Flight Safety (Canadian Forces) Incidents & Accidents Investigation Latin American, Marco A. de M. Rocha Directorate of Flying Safety—ADF SystemWare, Inc. Dutch Transport Safety Board TAM Brazilian Airlines EMBRAER—Empresa Brasileira de The Ministry of Land, Infrastructure, Aeronautica S.A. & Transport, AAIC, Japan Embry-Riddle Aeronautical University Transport Canada Aviation Emirates Airline Transportation Safety Board of Canada Era Aviation, Inc. U.K.—Civil Aviation Authority EVA Airways Corporation UND Aerospace Exponent, Inc. University of NSW AVIATION Federal Aviation Administration University of Southern California FedEx Pilots Association Volvo Aero Corporation Finnair Oyj WestJet ◆

July-September 2004 ISASI Forum • 31 WHO’SWHO’S WHOWHO

The Association of Professional Flight Attendants (Who’s Who is a brief profile on an ISASI takes an active role with relevant organization, defined by a constitution, corporate member to create a more thorough legislative, government, and other operated by and for its members. The understanding of the organization’s role factions of industry to facilitate cabin APFA is the largest independent flight and function.—Editor) and passenger safety initiatives. attendant union in the United States, As the flight attendant’s bargaining with a membership of approximately eadquartered in Euless, Tex., agent, APFA’s primary function is to 26,000. USA, the Association of negotiate contracts and working Within the organization, there are HProfessional Flight Attendants conditions for all structured departments, each with a (APFA) was certified as the recognized flight attendants at charter. These departments include labor bargaining agent for the Ameri- American Airlines Contract Administration, Communica- can Airlines flight attendants in 1977. and TWA LLC. In tions, Health, Hotel, Safety, and And from the beginning, the organiza- addition, the Scheduling. Daily, there are approxi- tion has worked diligently to keep APFA monitors mately 50 volunteers, staff, and officers safety in the forefront. The APFA has work rule compli- available to assist the flight attendants. been an ISASI member since 1989. ance to ensure that Each of the 18 flight-attendant Aware of the importance of team- American Airlines domiciles is represented within the work, the APFA works with American and the flight organization, and each is committed to Airlines to continually review, monitor, attendants comply the safety of its customers and co- and track safety and security concerns with the terms and workers as a core value. The APFA for its members. The APFA maintains conditions of the officers and union representatives are files and a database for the purpose of current bargaining flight attendants on leave to work for tracking potential safety hazards and agreement, the APFA. All union representatives exchanges this information with its participates in multiple efforts toward maintain their emergency qualifica- counterparts at American Airlines, enhancing aircraft safety, and provides tions, and periodically they work trips. working together to mitigate unsafe up-to-date information to the APFA This keeps the union leadership in conditions and to prevent accidents. membership via award-winning newslet- close touch with the membership. The An important element of APFA’s ters, telephone hotlines, and a dedi- APFA is dedicated solely to the issues safety structure is its GO Team, which cated website. and concerns of the women and men is an organized response team in the The Association is a democratic of the Association’s membership. ◆ event of a serious aircraft accident or incident. Union representatives are trained to assist company and/or ISASI NON-PROFIT ORG. government agents in post-incident/ 107 E. Holly Ave., Suite 11 U.S. POSTAGE Sterling, VA 20164-5405 PAID accident debriefs and investigations. Permit #273 The GO Team is trained to fulfill its USA ANNAPOLIS, MD responsibilities under the provisions of Annex 13 of the International Civil Aviation Organization (ICAO). The APFA, along with other flight attendant groups, has worked on a myriad of issues over the years with industry and regulatory agencies to promote cabin safety. This is done under the direction and guidance of the Association’s president. Similarly, the APFA also responds to proposed government regulations that have both direct and indirect impact on cabin safety. The APFA Safety Department

32 • ISASI Forum July-September 2004