July–September 2006

JULY–SEPTEMBER 2006 Air Safety Is About Sharing (Page 4) Investigations Use Differing Approaches, Reach Same Objective (Page 6) Litigation and Aviation Safety: Friends or Foes? (Page 10) Smoke, Fire, and Fumes! (Page14) Scaling Up Safety on Smaller Operations (Page 19) ‘Kapustin’ Scholars Selected (Page 22) ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ CONTENTS

“Air Safety Through Investigation” FEATURES Volume 39, Number 3 Publisher Frank Del Gandio Editorial Advisor Richard B. Stone 4 Air Safety Is About Sharing Editor Esperison Martinez Design Editor William A. Ford By Nick Sabatini, FAA— Remarks presented before the ISASI Associate Editor Susan Fager Mid-Atlantic Chapter on May 11, 2006. Annual Report Editor Ron Schleede

6 Investigations Use Differing Approaches, ISASI Forum (ISSN 1088-8128) is pub- Reach Same Objective lished quarterly by International Society of Air Safety Investigators. Opinions ex- By Stéphane Corcos and Pierre Jouniaux, BEA, France—Accident, serious pressed by authors do not necessarily rep- incident, and incident investigations use different approaches, but all strive resent official ISASI position or policy. to reach the same objective throughout what can become, without insight Editorial Offices: Park Center, 107 East into relative safety issues, long and costly processes. Holly Avenue, Suite 11, Sterling, VA 20164- 5405. Telephone (703) 430-9668. Fax (703) 430-

10 Litigation and Aviation Safety: Friends or Foes? ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ 4970. E-mail address [email protected]; for editor, [email protected]. Internet website: By James T. Crouse—In this reprint from the NTSB Bar Association Newsletter, www.isasi.org. ISASI Forum is not responsible this aviation attorney shares with colleagues experiences of attending ISASI 2005 for unsolicited manuscripts, photographs, or and other aviation safety seminars. other materials. Unsolicited materials will be returned only if submitted with a self-addressed, stamped envelope. ISASI Forum 14 Smoke, Fire, and Fumes! reserves the right to reject, delete, summa- By Barbara K. Burian, SJSUF at NASA Ames Research Center—An inflight smoke rize, or edit for space considerations any sub- or fire event is an emergency unlike almost any other. The early cues for nonalerted mitted article. To facilitate editorial produc- tion processes, American-English spelling of smoke, fire, and fumes (SFF) conditions are often ambiguous and elusive. Checklists words will be used. are indispensable tools to guide crews’ decision-making and response when faced with Copyright © 2006—International Society multiple tasks during these high-stress events. of Air Safety Investigators, all rights re- served. Publication in any form prohibited 19 Scaling Up Safety on Smaller Operations without permission. ISASI Forum regis- By Capt. John M. Cox (M03291)—Here is how proactive safety tools used by large tered U.S. Patent and T.M. Office. Opinions expressed by authors do not necessarily rep- operators can be implemented into smaller flight operations to help investigations of resent official ISASI position or policy. Per- incidents and accidents and to improve the safety of daily flight operations. mission to reprint is available upon application to the editorial offices. 22 ‘Kapustin’ Scholars Selected Publisher’s Editorial Profile: ISASI Fo- By Esperison Martinez—Students from Embry-Riddle Aeronautical University, rum is printed in the United States and pub- Florida, U.S.A., and Politecnico di Torino, Italy, have been selected as the 2006 lished for professional air safety investigators who are members of the International recipients of the ISASI Rudy Kapustin Memorial Scholarship Fund. Society of Air Safety Investigators. Edito- rial content emphasizes accident investigation findings, investigative techniques and DEPARTMENTS experiences, regulatory issues, industry accident prevention developments, and ISASI 2 Contents and member involvement and information. 3 President’s View Subscriptions: Subscription to members is 25 ISASI RoundUp provided as a portion of dues. Rate for non- 30 ISASI Information members is US$24 and for libraries and 32 Who’s Who—A brief corporate member profile of schools US$20. For subscription information, call (703) 430-9668. Additional or re- Aircraft Mechanics Fraternal Association placement ISASI Forum issues: members US$3, nonmembers US$6.

ABOUT THE COVER This CRJ that crashed at Brest Guipavas was totally destroyed by impact and post- impact fire. The investigation by BEA France determined that the main causes of the crash were human factors related (see page 6). Photo courtesy BEA France.

2 • ISASI Forum July–September 2006 PRESIDENT’S VIEW

ISASI Stalwart Departs International Council By Frank Del Gandio, President

At the recently conducted International Council ○○○○○○○○○○○○○○○○○○○○○○○○ gation and prevention at IFSA (Institut Français de Sécurité meeting, Max Saint-Germain, our European Aérienne), the French Institute for Flight Safety. He belongs to councillor, announced that he would not run for numerous prestigious international aviation organizations and reelection in the upcoming election of European joined ISASI in 1985. He has attended most of the ISASI officers. His reasons were twofold: medical issues seminars and chaired several ISASI seminar sessions. For relative to glaucoma and his desire to infuse new example, he managed the 1994 seminar in Paris and held commit- vigor into the governing body of the Society. tee positions for the Barcelona, Spain, and Shannon, Ireland, He told the assembled Council: “I have been the European seminars. He is also on the Jerome Lederer Award Committee. councillor for more than 15 years now, and I do think that Although he has given up his Council position, he has applied somebody else, younger, more dynamic, and, very important, for Fellowship status. Max will remain active in the organization, still actively involved in aircraft accident investigation should believing we take the lead. There’s a lot of talent within our membership. I should help, wish to give them the opportunity to express their capabilities through training and use a part of their energy for the benefit of the Society.” and training Max always exhibits the demeanor of a quiet man; those of us guides, develop who have benefited from his counsel know him as a thinking man knowledge about who looks upon ISASI as the premier accident investigation/ ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ the proper accident prevention organization in the world: “I believe ISASI is method of unique relative to accident investigation and its techniques. In conducting an 1985, about 100 people attended the annual seminar; in 2005 investigation. Max almost 400 attended. In 1985 we were only about 500 members; believes such need today we are 125 corporate members and 1,300 individuals, for help applies to representing 58 countries. We are recognized worldwide and well E. MARTINEZ both developed appreciated by everybody associated with accident investigation. Max Saint-Germain, left, accepts an and undeveloped Today it seems that all persons engaged in accident investigation Award of Appreciation for his long-term countries. Sadly, and accident prevention want to attend our seminar because they service to the membership from ISASI he notes, a know that they will meet all of the key people in the world who are President Frank Del Gandio. The presenta- country that can involved in looking after this kind of activity.” tion was made at the May annual meeting use this type of Max’s move to invoke new and younger energy into delibera- of the ISASI Mid-Atlantic Chapter, held training some- tions is commendable, but there is much to say for experience to in conjunction with the May International times doesn’t fend off the ode that says “history repeats itself.” He is an aero- Council meeting. know that it needs dynamic and thermodynamics engineering school graduate whose help—it may be first flight-safety task was military oriented—collecting/drafting caused by funding, by lack of sufficient experienced investigators, accident reports on the twin-jet bombing aircraft Vautour. or something similar. Stating that “where there is a will, there is a His civil career began with Sud Aviation, and his first accident way,” Max intends to stay involved in providing his experience to investigation was a Varig Caravelle crash at Brazilia in 1961. Sud groups that want to become better acquainted with the interna- became Aerospatiale and with that the Concorde venture. For the tional standards of investigation. French side, he was responsible for setting up and defining the As he leaves his councillor’s chair, I asked Max to share with all training, the spares and technical documentation systems, and of us a bit of the thinking about our profession he has developed maintenance programs for the new generation of modern aircraft. over the years. This is what he said: “Accident investigation is a In 1970, he had the responsibility of being in charge of Airbus tremendous job. It is filled with stress, with anxious moments, and Industrie’s Customer Services to investigate in-service problems unforgiving pressures; it is also a very good school for human and incidents concerning the A300, A310, and the A320 in airline behavior. I have come to believe that to be a good investigator one operation. In 1985 he became flight safety director to set up, has to be a good technician, one has to be modest, one has to have organize, and manage the Airbus Flight Safety System for some conviction as to what is right and what should not be done, accident/incident investigations. He retired in 1989, having one has to have a calm demeanor, be able to shake off stress, and investigated and/or managed the investigation of about 35 have an equal temperament. Mostly, a good investigator needs to accidents/incidents affecting the Airbus fleet. accept that one’s views are never fully right and never fully From 1987 and into retirement, he has taught accident investi- wrong—all that is said should be listened to.” ◆

July–September 2006 ISASI Forum • 3 GUEST COMMENTARY Air Safety Is About Sharing By Nick Sabatini, FAA Associate Administrator for Aviation Safety (Remarks were presented before the ISASI Mid-Atlantic started flying above most of the weather and terrain, at least Chapter on May 11, 2006.—Editor) enroute. That change alone significantly reduced CFIT accidents and loss of control in flight. The introduction of VORs and the first It is truly a pleasure to be here tonight. I give ILSs in the 1940s and 1950s also drove down the number of CFIT many speeches to people who do a lot for accidents and approach-and-landing accidents. Radar in the 1950s aviation safety. I have to say that tonight’s changed the environment permanently. VOR/DME receivers in audience is a group that does much and is deeply the 1960s further reduced those types of events. committed to safety. Thank you for what you do. Most agree the jet remains the biggest single long-term The contributions of air safety investigators are improvement in safety. Remember the joke about the four- clear: Air travel in our country is incredibly safe. Tonight, I want to talk briefly about how we reached this remarkable level of safety, about what we in aviation must do to ow do you explain how safe point-zero-zero maintain pressure on the accident rate. And I’ll touch on the role of air safety investigators in the 21st century. Hfour is? We keep trying. Here’s one way: As FAA’s safety official, I am frequently asked, “What are the You must fly every day for 43,000 years to get major causes of fatal airliner accidents?” In the United States to an even chance of being killed in an airline (and the developed world), there are no major causes. Fatal accident. Or how about: An accident with airline accidents are such rare events that there are no longer what qualifies as “common causes.” Air travel is so safe that we fatalities occurs about every 15 to 16 million at the FAA find it a challenge to meaningfully express the level flights. Or try this: you are about 40 times of safety. The official way we express it is in fatal accidents per safer in an airliner than on the safest highway 100,000 departures. That rate is now at .022. system in the country (the interstate). But, what does .022 mean to the man on the street? And, when you drill down, you will find that .022 largely consists of cargo engine DC-7 being the best three-engine aircraft ever designed? accidents or cases where a ground employee is struck by an The introduction of the jet engine dramatically increased engine aircraft on the ramp or an employee drives a tug into an aircraft. reliability for about a twentyfold increase. Within several years If we speak only of events that most people have in mind when of the first jet in the U.S. fleet, reliability increased fiftyfold. they think fatal airline accidents, the rate for passenger airlines Now we are approaching a hundredfold versus the pinnacle of is on the order of 0.007 per 100,000 departures. If we speak only reciprocating engine technology. of passenger jets, the number is about half that level. Before the jet, we averaged 3.5 fatal air carrier accidents per How do you explain how safe point-zero-zero four is? We keep year due to engine failure in a rather small system. In contrast, trying. Here’s one way: You must fly every day for 43,000 years Part 121 jet operators have had just two such fatal accidents in to get to an even chance of being killed in an airline accident. Or the past 20 years (Sioux City and Pensacola). how about: An accident with fatalities occurs about every 15 to If we jump forward to more recent developments, such as 16 million flights. Or try this: you are about 40 times safer in an TCAS and Terrain Awareness Warning Systems (or TAWSs), we airliner than on the safest highway system in the country (the find dramatic examples of technology getting us out of trouble. interstate). With TCAS, no Part 121 U.S. carrier has had a midair collision I think you see the challenge. Add to that challenge the news since 1978. Previously, fatal midairs had been a common accident media’s appeal of airline accidents—they are so rare, therefore, scenario. they are big news. Then, add all the reasons why people are The experience with GPWS and controlled flight into terrain, nervous about flying and you can begin to understand why or CFIT, is more dramatic. Between 1946 and 1955, large people don’t appreciate the magnitude of the achievement that is passenger aircraft averaged 3.5 fatal CFIT accidents a year. modern air travel. Think of it: A fatal CFIT accident about every 15 weeks. Let’s turn to how we reached the point where pilots are safer Through the mid-70s, we were still averaging two fatal passen- on the job than when they are not at work. For the most part, it’s ger airline accidents per year due to CFIT. been continual improvements in technology that reduce the In contrast, no jet operator has suffered such an event in U.S. opportunity for human error or that enable us to recover after a airspace since 1974. serious error. A new rule requiring TAWSs in March 2005 has increased Here are a few examples. Pressurized aircraft in the 1940s both the level of sophistication and, more importantly, the range

4 • ISASI Forum July–September 2006 of aircraft equipped. All turbine-powered airplanes configured While ASAP deals with the human element, FOQA collects for six or more passenger seats now must be equipped with and analyzes digital flight data generated during normal TAWS, whether they are used in air carrier service or in Part 91 operations. FOQA data are unique because they provide operations. objective information not available through other methods. It’s Technology improves our ability to enhance human perfor- this routine data that can give us insight into the total flight mance. Just look at the benefits from simulator training. With the operations environment. Today, 15 U.S. airlines have FAA- six-axis simulator—using real data from real flights—we have approved FOQA programs. We’ve seen a host of benefits from improved crew resource management training with real-world ASAP and FOQA information, including changes in training as scenarios. Pilots gain “real” experience flying through and out of well as enhanced operational and maintenance procedures. windshear. They learn in a risk-free environment how to handle an engine failure or failed flight controls, and so much more. Follow all these improvements with major leaps in automation e need to use every tool, every skill, and and precision flying throughout the 1990s—plus the jet revolu- tion reaching the regional industry—and we come to the level of Wevery resource that we can bring to bear safety we enjoy today. to enhance safety. Those tools, skills, and We often hear that accident rates have reached such a low resources include accident investigators, yes, level that we should no longer expect sudden and sustained to look back, and leveraging information and breakthroughs in future rates. I disagree. analysis to look forward to anticipate to We are on the threshold of reaching the next level in commer- prepare and prevent. That’s how all of us in cial aviation safety. And here is the keystone to the next series of aviation will improve safety and save lives. It breakthroughs—safety information. Achieving a stronger future does not get any more rewarding than that. for aviation safety is all about sharing safety data. Today, we don’t even know how much safety information is How many of you know about the work of the Commercial out there, be it with operators, manufacturers, repair stations, Aviation Safety Team? suppliers, and more across the aviation community. How much CAST, which includes representatives from government, of this safety information do you think the FAA can access? industry, and employee groups, is co-chaired by Hank I’d say about 5 percent. Krakowski, vice-president of Corporate Safety for United If we’re going to continue to put downward pressure on the Airlines, and FAA Deputy Associate Administrator for Aviation accident rate, we need far more information about trends, about Safety Peggy Gilligan. The purpose is to develop an integrated precursors, and about what is going on every day in the manufac- data-driven strategy to reduce the U.S. commercial aviation turing and operating and maintenance environments. We must get fatality risk. better about getting the right information. Our great safety record CAST has been highly successful. How? Because of its disci- has come from a “forensics” and “diagnostics” approach to making plined and focused approach to analyzing accidents and incidents, enhancements. You know this better than anyone. We lose one. You identifying precursors, and developing targeted implementation investigate. We learn what happened. We make corrections. strategies. Furthermore, after the strategies are implemented, Now, with no “common causes,” we need to move more and CAST monitors and measures their effectiveness and identifies more to a “prognostic” or predictive approach. We need more future areas of study. Thanks to CAST, we’re on target to reduce data points. We need analytical expertise to discern trends and the fatality risk in commercial air travel by 73 percent by 2007. identify precursors. That’s the power of using data to drive decisions. And we need to share what we learn. As you know, we’re At the same time, the FAA has been working with NASA to already gathering information to help identify trends and get our arms around the many aviation safety data sources. We precursors. We have a demonstration project with the airlines on want to bring them together and leverage the power of com- gathering and sharing data from Aviation Safety Action Pro- bined databases to help reveal the rare and infrequent emerging grams, or ASAP, and from Flight Operational Quality Assurance, threats and hazards. We want to push the science of advanced or FOQA, programs. ASAP encourages airline employees to data analysis tools that will enable “vulnerability discovery” to voluntarily report critical safety information. Today, 51 carriers reveal precursors to accidents and permit us to proactively take have 106 programs covering pilots, mechanics, flight attendants, steps to mitigate risks before loss of life. and dispatchers. (continued on page 30)

July–September 2006 ISASI Forum • 5 Investigations Use Differing Approac

Accident, serious incident, 15, which carried the theme “Investigating tions, at least a partial loss of situational and incident investigations New Frontiers of Safety.” The full presenta- awareness, lack of crew coordination, de- tion including cited references index is on the viation from SOPs, insufficient or non-exis- use different approaches, but ISASI website at www.isasi.org.—Editor) tent consideration given to safety warnings all strive to reach the same (GPWS in the cockpit, MSAW in the tower). objective throughout what can ncreasingly, BEA accident investiga- Non-stabilized approaches also often high- become, without insight into tions are showing that many accidents light the basics of instrument flight, and Ihave precursors in incidents. Depend- they can be studied in a variety of ways. relative safety issues, long ing on the seriousness of the event, the num- European airlines have long conducted and costly processes. ber of parties involved, and the difficulty of mandatory analysis of flight parameters, carrying out examinations, an investigation known in North America as FOQA (Flight By Stéphane Corcos and Pierre can be a long and costly process. However, Operations Quality Assurance) and have Jouniaux, BEA, France early into the investigation it is often pos- identified many safety deficiencies, includ- (This article was adapted, with permission, sible to identify the major safety issues ing non-stabilized approaches. from the authors’ presentation entitled Acci- raised by an event. The next steps, includ- In addition, while investigative bodies dent, Serious Incident, and Incident Investi- ing the validation process, with its exami- have insights into accidents, investigators gations: Different Approaches, the Same nations, testing, and highly sensitive discus- should not miss an opportunity to study near Objective presented at the ISASI 2005 semi- sions among all the parties, takes much ALARs, near CFITs, or near midair colli- nar held in Fort Worth, Tex., September 12- longer. Noteworthily, 80 percent of causal sions. These studies are complementary. factors are related to human factors. Thus, Here are two examples, one involving a CRJ Stéphane Corcos is the it is important to have an insight into safety and the other an MD-83, of different ways head of the BEA Investi- issues, and to make an early determination to deal with such study of investigations. gations Department. of the potential of an event. This enables A CRJ was flying the Brest-Nantes route Prior to joining the BEA investigators to put the appropriate weight with the captain at the controls. The meteo- in 1996 he worked for the on particular investigations. rological conditions were deteriorating at DGAC (French civil Such an approach has two prerequisites: Brest a short time before the takeoff from aviation authority) for 8 being informed of the majority of events in Nantes. The crew was informed in flight of years. He was graduated from the French time and having an organization that allows the deteriorating visibility to be expected National Civil Aviation School (ENAC) selective choice. To address the first issue, upon arrival. A NOTAM indicated that Cat- with a masters degree in aeronautical the European Union established a regula- egory II and III approaches were not avail- engineering in 1987. He holds a commer- tion that asks all operators (as well as ATC, able at Brest Guipavas from June 2 to cial pilot’s license and a multiengine manufacturers, and repair stations) to re- July 31, 2003. The crew was aware of this. instrument rating. He also has a Beech port significant events to investigative bod- The pilots communicated little with each 200 type rating. ies. These operators should also, in the fu- other during the approach and some callouts ture, participate in event identification. Se- were omitted. The airplane was number two Pierre Jouniaux received lective choice, the second requirement, on arrival. The approach controller asked the a masters degree in poses the problem of being able to identify crew to descend to 4,000, then to 3,000 feet aerospace engineering the relevant type of event. This can be a bit and to enter a holding pattern. He then and aviation operations like panning for gold, so the investigator cleared them to descend to 2,000 feet. from ENAC. He received needs a sharp eye. The best way to do this When the previous airplane [Number 1] a post-graduate degree in is to have a group of dedicated specialists had landed, the controller, seeing the CRJ human factors from working together to draw out the relevant on the localizer track and thinking that they Paris University. He joined the BEA in data from the different events. were established, asked the pilot to continue 1997 and has acted as investigator-in- the approach, before he had joined the hold- charge, accredited representative, or Approaches ing pattern. The crew started the approach group leader on many investigations and Non-stabilized approaches have claimed after this clearance. The APPR mode on the is now a senior investigator. He holds a many lives over the years, and they keep autopilot system was never activated. The commercial pilot’s license and helicopter occurring all around the world. Many have start of the approach was performed in private pilot’s license. these attributes in common: IMC condi- HDG and VS modes.

6 • ISASI Forum July–September 2006 hes, Reach Same Objective

The wind, which was turning progres- sively to the northwest then to the north Photo 2 during the descent, made the airplane drift toward the left. This drift was not detected by the crew. The airplane exited the auto- matic localizer capture beam. The airplane descended below the glidepath and the pilot selected VS to get back onto the path. The crew’s attention was focused on managing the airplane’s vertical track. The airplane intercepted the path from above, and the crew’s attention was then focused on the horizontal track. The airplane then descended through the glidepath and re- mained below it until contact with the ground. (See Photograph 1.) The captain started a turn to the right tween 115 and 120 knots). The first signifi- and post-impact fire. (See Photograph 2.) and disconnected the autopilot. Several cant pitch-up input on the elevators was The causes were identified as GPWS “glideslope” and “sink rate” warn- then recorded 4 seconds after the thrust in- • failure to select APPR mode at the initia- ings were issued without the crew reacting crease. The airplane continued to descend, tion of the approach, which led to a failure to in any significant way. The captain started touched down softly, ran along the ground, capture the localizer, then the glideslope; the go around at decision altitude. The air- and then struck several obstacles that se- • incomplete detection of flightpath devia- plane, offset to the left of the extended verely damaged the cockpit. The aircraft tions due to the crew focusing on vertical centerline, was then at about a hundred feet came to a stop after about 150 meters. The navigation, then on lateral navigation; from the ground and its speed was low (be- airplane was totally destroyed by impact • the continuation of a non-stabilized approach until decision altitude; and • lack of communication and coordination in the cockpit and a strategy change in the controller’s handling of the airplane were contributory factors. Detailed examinations of many airplane components was undertaken: flaps, all the pitch-axis channel components, ELT, electronic components with non-volatile memo- ries, as well as use of the flight simulator, MSAW simulator, flight deck and instrument ergonomics, etc. Due to the condition of the various components after the accident, considerable amount of human and financial resources were used up over an 18- month period. Despite the extensive technical work carried out, the report’s conclusions determined that the main causes were related to human factors. Less than a year later, in the same re- gion of France, at night, a foreign-operated MD-83 was flying a VOR-DME approach into Nantes (LFRS) (see Photograph 3). It Photo 1 was 02 h 20 local time and the weather was

July–September 2006 ISASI Forum • 7 proach procedure TCAS training and ergonomics Photo 3 course) without any The integration of TCAS into the aviation defined or shared ac- system has generated new challenges. To tion plan. mature, the use of TCAS has to be adapted Several factors to the aviation environment. One aviation contributed to the disaster and a number of incidents high- event lighted the need for improved feedback. • Lack of CRM train- Pilots have had to get used to a new device ing by the operator, (procedures, training, knowledge, etc.). • The operator’s in- Controllers have had to find a new way of adequate feedback interacting in order to make the system system, safe. A serious incident that occurred in • Discomfort and March 2003 illustrates this. stress due to adverse An Airbus A319 was climbing to FL260 weather, following the controller’s clearance. The • Deviation from TCAS triggered a Traffic Advisory for a tar- SOPs, and get located above and on an opposing route. • A lack of air-ground Eight seconds later an “Adjust Vertical synergy. Speed” Resolution Advisory was generated, Two investigators asking the crew to reduce the vertical speed. worked on this for 3 The pilot responded with a pitch-up input. months. Safety les- The conflicting traffic was an Airbus A320, sons were learned be- in level flight at FL270. Nine seconds after cause it became clear the initial Resolution Advisory in the A319, marginal with drizzle, poor visibility, and low that the root cause of the incident was re- a “Climb” Resolution Advisory was triggered ceilings. The airplane was deliberately flown lated to human factors. Those persons con- in the A320. The crew acted on this. During with 30° offset from the approach course due cerned were willing to share information the crossing, the crews of both aircraft made to suspected storm cells on the way to the because they understood sharing was in the visual contact. The pilot flying the A319 runway (these were actually no more than interest of safety. The investigators were able turned smoothly to the left. QAR recordings ground clutter on the weather radar). The to establish the facts rapidly, despite the lack enabled us to compute the minimum lateral descent was initiated near the FAP, at a of any flight recorder information, using ra- and vertical separations as 0.8 nautical miles much higher rate than that published. The dar plots and by interviewing all parties in- and 300 feet. (See Figure 2.) airplane overflew the city of Nantes and volved, including those who were abroad. Two investigators were intensely in- broke through the clouds at about 400 feet, then veered sharply to the left as a go- around was initiated. The crew’s situational Figure 1 awareness was affected with reference to the weather information, the position of the city, and a lack of knowledge of the characteristics of non-precision approaches. (See Figure 1.) The causes were determined as • an erroneous interpretation of weather radar display, • a lack of knowledge concerning protection envelopes, and more generally a lack of accuracy concerning VOR-DME approach techniques, and • improvisation of an action (offset from ap-

8 • ISASI Forum July–September 2006 Figure 2 volved in this investigation. Many tests were performed and extensive research was carried out, working with a number of differ- Figure 3 ent organizations: Airbus (system issues, ergonomics), Air France (event analysis, train- pilot logic. The report contained eight safety The TCAS gave an opposite order to the ing), ATC (procedures, testimony), TCAS recommendations. controller’s emergency instruction. In the specialists (systems and events review), While this investigation was under way, end, as the B-737 pilot saw the other air- human factors specialists (ergonomics, fa- TCAS events were becoming more and craft, he decided to follow the controller’s tigue, stress). This was a complex investi- more frequent, all such events being report- instruction and not TCAS. The A330 pilot gation. The report was issued within 2 able. There were a number of events that followed TCAS. The two aircraft crossed years. The major findings concerned the er- had similar origins to the one just men- with a lateral separation of less than one gonomics of the TCAS interface, pilot and tioned. But other events emerged that were nautical mile. (See Figure 3.) controller training, and TCAS versus auto- of a type that had previously been consid- Initially, the seriousness of the event was ered to have been covered by the investiga- underestimated because the local investigation into the Überlingen accident. One of tion, performed by the ATC service, did not Acronym Glossary these events led to a long investigation, bring to light all of the issues, especially those though a full report was not subsequently related to visual separation and to the con- BEA: Bureau D’enquêtes Et D’analyses deemed necessary as most of the issues had flict between a Short Term Conflict Alert and Pour La Sécurité De L’aviation Civile already come to light and been studied. The TCAS. The investigation was reopened 6 ATC: Air Traffic Control BEA issued a simplified form of report on months later by the BEA, and investigators SOP: Standard Operating Procedures this incident to raise awareness and remind worked on it for 4 months. As the aircraft GPWS: Ground Proximity Warning System the aviation community of some important were operated by foreign airlines, two ac- MSAW: Minimum Safe Altitude Warning principles concerning TCAS. credited representatives were associated ALAR: Accident and Landing Accident In the upper airspace of a French con- with the investigation, along with ATC per- Reduction trol area, a B-737 was in climb and an A330 sonnel and radar specialists. The scope of the CFIT: Controlled Flight into Terrain in descent on two converging routes. The investigation was quite extensive and the NOTAM: Notice to Airmen ELT: Emergency Locator Transmitter controller incorrectly gave a level to the report writing process was deliberately sim- CRM: Cockpit Resource Management climbing aircraft above the descending one. plified. One year after the incident, the re- TCAS: Traffic Collision Avoidance System A Short Term Conflict Alert was presented port was issued. This type of simplified re- FAP: Final Approach Point to the controller that was not considered port does not include safety recommenda- QAR: Quick Access Recorder valid by him, and the aircraft continued to- tions but is aimed at contributing to the IMC: Instrument Meteorological ward each other. The controller realized feedback system. Thus, safety issues pre- Conditions HDG: Heading Mode (Autopilot) there was a conflict and issued an emer- sented in this document dealt with ATC VS: Vertical Speed Mode (Autopilot) gency descent order to the climbing aircraft, methods, the coexistence of backup systems APPR: Approach Mode (Autopilot) which the pilot acted upon. A short while based on radar and TCAS, and visual sepa- later the TCAS triggered in both aircraft. ration at high speed and high altitude. ◆

July–September 2006 ISASI Forum • 9 (Reprinted with permission from the NTSB program Investigating New Frontiers of Bar Association Newsletter, Winter 2005 is- Safety and, three weeks later, the Interna- sue, in which it was originally published for tional Helicopter Society’s International its readership of aviation attorneys. The Helicopter Safety Symposium, the stated author is preparing an article for the Janu- purpose of which was to “initiate an inter- Litigation ary/March 2007 issue of ISASI Forum to national collaborative effort to reduce both help accident investigators better under- civil and military accidents in the vertical stand the legal process. He asks readers of flight industry.” My primary goal in attend- And Aviation the reprinted article for feedback that reveals: ing these programs was to learn about new “What’s on the minds of ISASI folks when technical developments in the aviation in- they think of litigation? What do they see as dustry—something that I had not done for Safety: its greatest intrusions? Do they see any ben- years. I also hoped to contribute informally eficial aspects? What would they like to see to the topics of the moment, to renew friend- changed?” He may be contacted at jtc@ ships, and to make new friends. Some of CrouseLaw.com.—Editor) those past friends had been opponents, Friends or some allies, and some neutral government his year, I decided to continue my edu- officials, but all were polite and some were cation by attending some non-legal even enthusiastic. Taviation seminars—the International The technical presentations described Foes? Society of Air Safety Investigators (ISASI) many new and exciting progressions in operations, maintenance, and design, in such By James T. Crouse James T. Crouse has been areas as aircraft system monitoring, terrain a pilot for 32 years and is and obstacle avoidance, and even turbulence a graduate of the U.S. avoidance. Through presentations and con- Army’s Aviation Mainte- versations, I came away with the unmistak- nance Officer’s Course able impression that I had been in the com- and Test Pilot School. He pany of hundreds of dedicated individuals holds commercial and who were deeply concerned about the instrument rotary wing ratings (1973) unimproving safety record of vertical flight, and is rated in the Bell UH-1/205, Bell and who were determined to do something OH-58/206, and Hughes/Schweizer 269/ about it. 300 series aircraft. He graduated from Impressed as I was with the programs Davidson College in 1971 and from Duke and the participants, a gnawing question en- Law School in 1980 and has litigation tered my mind: “What are you and your experience involving major air carriers, profession doing about aviation safety?” general aviation, helicopter, and military Initially, I found refuge in the wisdom of my crashes, as well as non-aviation mass mentor and dear friend, Stuart Speiser, who disaster litigation. He is the founder of taught me that we aviation lawyers play a the Crouse Law Offices Law Firm in role in aviation safety by filling the gaps of Raleigh, N.C., and is a member of the what slips between what the manufactur- American Trial Lawyers Association, the ers, designers, and operators do (and don’t North Carolina Academy of Trial do) and what the government catches. Stu Lawyers, the Lawyer Pilots Bar Associa- persuasively expressed his views on the tion, the National Transportation Safety positive effect of litigation in his book, Law- Board Bar Association, the American suit: “I believe that the deterrent effect of Institute of Astronautics and Aeronau- tort litigation is its most important public tics, the International Society of Air interest feature…. Even though other na- Safety Investigators (ISASI), and the tions have government regulators and First Flight Society. manufacturing experts equally knowledge-

10 • ISASI Forum July–September 2006 able and dedicated to aviation safety, they are not pushed to the limits of their safety performance as American manufacturers Even though other nations have government are by the litigation system. The knowledge that they will have to face intensive ques- regulators and manufacturing experts equally tioning for weeks at a time, covering every piece of paper they signed or handled in knowledgeable and dedicated to aviation connection with the design of an airplane, has a sobering effect on the personnel of safety, they are not pushed to the limits of manufacturers, airlines, and government agencies…. The American tort system also their safety performance as American causes insurers who pay the bills to bring manufacturers are by the litigation system. more pressure on manufacturers and operators to maintain safety. (S. Speiser, Law- suit at 344 and 346 (1980). See also pp. 341- subject matter experts, to test their hypoth- 348.) eses through the litigation process. My ex- Stu’s thoughts are echoed by an experi- perience has shown that we frequently un- NTSB Bar Association enced aviation product liability defense cover facts that were missed or never lawyer: reached by the overworked and hurried Founded in 1984, the NTSB Bar Associa- “I generally attribute to the U.S. tort sys- National Transportation Safety Board in- tion is comprised of attorneys who tem the substantial increases in safety of vestigators and their fellow investigators practice before the United States products for the U.S. consumer— in all prod- from the Federal Aviation Administration. National Transportation Safety Board ucts, not just aviation products. Aviation But there is a downside to this litigation (NTSB), the Federal Aviation Administra- plaintiffs’ lawyers have indeed done their process. As attendees at both conventions tion (FAA), and the Department of part for many reasons, including monetary brought to my attention, the threat of liti- Transportation (DOT). While the main compensation. Unfortunately, the ultimate gation can limit the willingness of individu- focus of the group is the representation of goal desired of an absolutely safe society— als and companies to engage in full disclo- pilots and aviation businesses in regula- especially in aviation—will not be achieved sure. Ever-expanding digital capabilities of tory, certification, and enforcement for the many reasons articulated here. data gathering, recording, and storage actions, many members practice in other Therefore, the threat of tort litigation, mean that more information than ever be- areas of the law as well, such as air crash especially product liability lawsuits, fore will be collected and retained. The po- litigation, aviation insurance defense, and skilled advocacy remain necessary ele- tential of this information getting into the taxation, and business law. Membership in ments of our legal system for our protection. hands of aggressive litigators, or prose- the Association is open to practicing The Ford Explorer cases and recent drug cutorially minded government agents, has attorneys, law students, or other individu- litigation make all this self-evident.” its chilling aspects. We must find a way to als interested in aviation law. Many Maybe Stu and the defense lawyer are balance the fact-finding efforts and the pri- members are active pilots. The NTSB Bar right. Frankly, I cringe at thinking of what vacy concerns so that the information can Association is not affiliated with nor part would happen to families and certificate- be shared in a way that benefits safety with- of any U.S. governmental agency. ◆ actioned pilots if no one was there to repre- out sacrificing the individuals involved. sent them. The same is true of designers, Clearly, lawyers have a role in striking that manufacturers, maintainers, and opera- balance. tors—they are well served by conscientious On a larger scale, what is it that we do, in and competent counsel. I have long be- the performance of our roles, that actually lieved, without any scientific proof except enhances aviation safety? Personally, I for my own empirical observations, that the asked what have I done in my 25-year ca- best way to find out what really happened reer as an aviation accident attorney that in a aviation crash is for opposing parties, has saved a life or prevented an accident? represented by legally and technically as- Other than just being there after the crash tute counsel, aided by honest and diligent in a representative role—a very important

July–September 2006 ISASI Forum • 11 tions under the adversarial rules; as (3) negotiator, we seek an advantageous result for our client consistent with the duty We can do better, not only in streamlining the of honest dealings with others; and as (4) litigation process, but also in providing real evaluator, we examine a client’s legal affairs and advise the client about them. Id. evidence of lessons learned through the litigation [2]. Nothing in these rules helps with the process. We can change this perception, and question of what we do, or what we can do, to augment aviation safety. Even the plati- in so doing, we can become a powerful force for tudes of “A lawyer should render public interest legal service and provide civic lead- what benefits us all—safe skies. ership,” Id.[7] and “lawyers play a vital role in the preservation of society” Id.[16] aren’t job in helping families recover from the fi- much help. Although I cannot think of any- nancial aspects of what has befallen them thing more preserving of a precious part of (and if we are at our best, help provide some society than preventing an aviation mishap renewal)—do we actually help prevent ac- and thereby saving a life, these generali- cidents, and if so, how? ties do not give guidance in the particulars of aviation safety. Attorney roles So, where does that leave us? It leaves Let’s begin the analysis with our roles—our us, in my view, as people whose primary role foundational roles—as attorneys. We rep- is the representation of our clients, but resent people and companies and organi- whose secondary but equally vital role is as zations and government agencies in mul- aviation safety advocates. What good does tiple roles—contracting, tort, tax, legisla- it do if we find real safety issues, life-threat- tion, regulation, employment, investment, ening issues, with operations, flight, main- disability, etc. But whatever word comes tenance, and overhaul manuals; mainte- first, the last word, the defining word, is nance and overhaul procedures; or design “lawyer.” Regardless of our sub-specie, we and manufacturing problems, if the evi- are lawyers first and, secondarily, a particu- dence of these problems goes back into the lar type of lawyer. file and then on to storage? Surely we can So what do our “lawyer rules” say about do better than that. our roles that might impact our potential, if not present, roles as aviation safety en- Promoting aviation safety hancers? According to the North Carolina Here are my thoughts on how we can em- Rules of Professional Conduct, a lawyer is ploy our primary role as advocates to pro- “a representative of clients, an officer of mote, indeed to crusade, for aviation safety the legal system, and a public citizen hav- —to make a difference. ing special responsibility for the quality of 1. Represent your client with all of your justice.” N.C. Rules of Professional Con- legal and technical ability. Without our duct, ¶ 0.1, Preamble, [1]. The North Caro- best efforts, the true causes of aviation lina Rules go on to say that in our repre- crashes might never be fully discovered or sentative capacity we perform various determined. Do your best, whether it is functions: as (1) advisor, we provide the drafting an interrogatory or questioning a client with an informed understanding of witness. Don’t become complacent. Litiga- his/her/its rights and obligations and the tion is nerve-wracking and frustrating at practical implications thereof; as (2) advo- times, but stay the course. Remember that cate, we zealously assert the client’s posi- you took an oath to do your best for your

12 • ISASI Forum July–September 2006 clients. I submit that as an aviation attor- may well be that a government employee perspective. At the risk of offending the ney, you tacitly represent more than the may know someone who would be very in- folks at SMU, Embry-Riddle, TIPS Avia- person or entity on the fee agreement. terested in helping—or at least in hearing tion, and our own NTSB Bar Association, 2. Get the best technical expertise. There what you have to say. try a non-legal symposium for a change. are many subject matter experts who can 5. Actively assist your client in learning There is one almost weekly—AIAA, AHS, help. There are the “usual suspects,” but from mistakes. Eagerly review your HAI, ISASI, AOPA, etc. Join one of the non- resist using the expert whom you know will client’s procedures, processes, manuals, in- legal aviation associations. You’ll be pleased sing your song or with whom you are famil- spection, audit programs, and results for by the camaraderie and impressed by the iar. I am not so naive as to believe that we potential safety problems. Do not simply genuine interest these people have in avia- all want completely neutral experts—that’s defend your client—assist him/her in under- tion safety. not our advocate/adversary system. But standing what went wrong, how to fix it, and When you get back to the office, you will look beyond the usual and find the unique. how to identify other problem areas. In my have a vivid picture of the people who are Find someone who really knows and cares brief life as a defense attorney, I have re- the front line of aviation safety—who daily about the particular matter at issue—not viewed the flight, maintenance, and over- experience the joy of flight but who daily just someone who can come up to speed and haul manuals of a helicopter manufacturer also confront the risk of aviation tragedy. It offer opinions—for a fee. client to identify problems—this after an will make a difference in the way you do If the opportunity presents itself, allow issue had been raised about one of its main- what you do. your experts to work with the government tenance manual procedures. That manufac- 8. Fight for aviation safety. When the case agencies. Encourage them to share their turer got it right. is concluded, that might well be the begin- knowledge with those agencies in a non- 6. Share whatever you learn where it will ning of your aviation safety efforts. With- partisan, technical exchange of information. be most useful. I cannot recall any prod- out violating any rulings or agreements We have done this in the past, and we be- uct liability case in recent years where I was made during the litigation, take what you lieve it has benefited the safety effort. not asked to agree to a confidentiality or- have learned to the Office of Aviation Safety 3. Get help if you need it. Don’t try to der or agreement, which more than not has at the NTSB and the appropriate Director- handle something outside of your expertise. been required before I saw the first piece ate of the FAA. Don’t stop until you get I frequently see e-mails on list-serves that of paper. These agreements often provide someone’s attention; push the bureaucracy. make me wonder what that lawyer is doing not only for non-disclosure of documents See if your client wants to help—clients with that type of lawsuit. Find out who has but also for non-disclosure of certain por- make appealing advocates. handled this type of accident before. I have tions of deposition transcripts. Obviously, found that lawyers are generally willing to one cannot just take what is covered by Conclusion give at least some help for no compensa- these agreements and disseminate it out- I am sure that litigation can and does en- tion other than the reward of helping. Even side of the litigation. hance aviation safety—even if only indi- if a fee-sharing arrangement is necessary, Before you agree to one of these, read it rectly and generally. But it does not assist however, don’t let greed prevent you from carefully. Look at it with the view that it in this goal as much as it could. If one talks doing the right thing. might prevent you from disclosing informa- to the aviation community, there is doubt 4. Talk to the government agencies. Rep- tion that could save a life. Fight for the nar- that we, either plaintiff or defense, serve resentatives from the NTSB and the FAA rowest possible agreement. Take the mat- any vital safety purpose—that we gener- are understandably and legally unwilling to ter before the court if need be. ally only show up after something has gone become embroiled in your litigation. But If you take depositions of government wrong and that we take people away—for that doesn’t mean you cannot ask them officials, look for opportunities to use the meetings, depositions, document searches, questions and discover their releasable files, litigation documents. Share with them, le- etc.—from what they are doing that could and that you cannot impart information to gitimately, what you have learned. And if enhance aviation safety. They have a point. them (see item number 6 regarding restric- no government witness is deposed but you We can do better, not only in streamlining tions on disclosure). With rare exception, I have discovered information that could save the litigation process, but also in providing have found these (and other) government a life, seek court approval to obviate the real evidence of lessons learned through the officials are willing to help if they can. It protective order for that particular purpose. litigation process. We can change this per- may well be that something that arises in This has been successfully done in the past, ception, and in so doing, we can become a your litigation is a special concern of a par- and we’re better for it. powerful force for what benefits us all—safe ticular government employee or office. It 7. Get out of the legal rut: Expand your skies. ◆

July–September 2006 ISASI Forum • 13 Smoke, Fire, and Fumes! An inflight smoke or fire event is an emergency unlike almost any Drivers of nonalerted SFF other. The early cues for nonalerted smoke, fire, and fumes (SFF) checklist design conditions are often ambiguous and elusive. Checklists are Various interrelated factors have tradition- ally influenced how the issues listed in the indispensable tools to guide crews’ decision- making and response Sidebar are dealt with, but not all of these when faced with multiple tasks during these high-stress events. factors have affected the design of every By Barbara K. Burian, Ph.D., SJSUF at NASA Ames Research Center nonalerted SFF checklist currently in use. These factors are (This article was adapted, with permission, ing loss of systems is likely if it spreads, and • Differences in aircraft equipment design. from the author’s presentation entitled Do crews’ ability to respond effectively may be Design of a particular system and aircraft You Smell Smoke? Issues in the Design and impaired. Thus, rapid isolation and elimina- largely determines the steps crews initiate to Content of Checklists for Smoke, Fire, and tion of the ignition source are necessary to isolate and eliminate a source of SFF and re- Fumes presented at the ISASI 2005 seminar prevent the condition from escalating. How- moval of smoke. For example, smoke removal held in Fort Worth, Tex., September 12-15, ever, timely decisions to divert and complete in some aircraft requires depressurization, which carried the theme “Investigating New an emergency landing are also essential if thus necessitating a descent from cruise alti- Frontiers of Safety.” Sources referenced by the ignition source cannot be identified or if tude when passengers are on board. the author have been removed from this text. efforts to extinguish a fire are unsuccessful. • Different types of operations. Extended- The full presentation including cited refer- The stress and workload of responding to range operations (i.e., involving flight over ences and Appendix A and B are on the these events is exceptionally high, and un- an ocean) may use different procedures as ISASI website at www.isasi.org.—Editor) like many other types of emergency or ab- compared to those for short-haul operations normal situations, the flight and cabin crews flown within easy reach of land. Similarly, hen a smoke, fire, or fumes (SFF) absolutely must communicate and coordi- procedures such as depressurization to event occurs in flight, time is the nate their assessment and response. How- minimize fire-feeding oxygen may be appro- Wmost precious resource available ever, even the most rigorous joint training priate for cargo-only operations, but not to crews. Yet, at least some of this resource cannot realistically present crews with the when transporting passengers. must be invested to determine if suspicious full extent of the demands they will face when • History of an air carrier and history cues do in fact indicate smoke or fire, as cues dealing with smoke, fire, and fumes in flight. within the industry. Past SFF events within are often ambiguous, especially for air con- Checklists are indispensable tools to guide an air carrier and across the aviation indus- ditioning, electrical, and other nonalerted crews’ decision-making and response when try as a whole have taught lessons that sources (i.e., SFF for which there are no faced with multiple tasks during these high- clearly influence the design and content of aircraft detection systems). Also, false stress events. Checklist designers must care- SFF checklists and the priority placed on alarms occur frequently enough to make fully consider all essential tasks crews must items within them. crews want to have a definitive picture of perform and prioritize how those tasks are • Knowledge of how different types of fires their situation before committing to a di- to be accomplished, given the wide range of are ignited, fed, and spread. Closely related he version and emergency landing. potential SFF events: those that are easily to an understanding of how differences in When smoke or fire does occur, a cascad- identified, isolated, and extinguished as well aircraft and system design influence proce- as those whose sources are unknown, hid- dures is knowledge of how various types of Barbara Burian was den, and cannot be put out. This article fo- fires are ignited, the availability and flam- the project director of the cuses on some of the many design and con- mable properties of various materials aboard Emergency and Abnor- tent issues for checklists that are used by the aircraft, and how smoke and fire may be mal Situations (EAS) flight crews to respond to nonalerted SFF spread (such as by a ventilation system). Study in the Human events. Current titles of such checklists typi- • Assumptions about efficacy of crew re- Factors Research and cally refer to the ignition source (e.g., air con- sponse. Some current checklists appear to Technology Division at ditioning smoke; electrical smoke, fire, or be written with the implicit assumption that NASA Ames Research Center. She is a fumes; fluorescent light ballast smoke or the actions specified will be successful (or , senior research associate with the San fire), to the location of the event (e.g., galley that guidance about other actions is not nec- Jose State University Foundation, and fire, cabin fire), or to the fact that the igni- essary); in other words, there are no refer- her work on EAS was funded by NASA’s tion source and/or location is unknown (e.g., ences to diverting or instructions regarding Aviation Safety and Security Program. fires of unknown origin). smoke evacuation included in the checklists.

14 • ISASI Forum July–September 2006 Sidebar—Issues in Nonalerted SFF Checklist Content and Design

A variety of difficult issues face designers of all under the high stress and workload typical of SFF • Should checklist actions differ for extended- emergency and abnormal checklists but par- events? range operations as compared to actions for ticularly checklists involving inflight SFF. Sev- • Should any memory items be included, and if so, flights flown over land? eral are listed below in the form of questions. involving what actions? • What kind of guidance, if any, should be given • What is the best way to help crews access • Should the donning of smoke masks and goggles related to expediting a descent/approach, ditch- the correct checklist quickly, especially when be required? ing, conducting an overweight landing, an off- they may not be able to tell what kind of SFF • How long should a SFF checklist be—both in airport landing, a downwind landing, or other they are dealing with? terms of physical length and in terms of amount of types of non-normal landings? • How many checklists for nonalerted SFF are time it takes to complete it? • What is the best way to construct a SFF necessary? • What is the best way to design a checklist that has checklist to accommodate and support the high • What is the best way to guide crews when applicability for serious SFF events as well as for SFF degree of communication and coordination that the SFF is of an unknown origin/hidden? that is relatively minor and easily eliminated? is needed between flight and cabin crews? • What should the relationship be, if any, re- • How much time should crews spend on source Part of what makes responding to some of garding the completion of nonalerted SFF identification/troubleshooting? these issues so difficult is that they involve checklists if an alerted checklist (e.g., engine • Within a checklist, what should the relative pri- tradeoffs that require making choices that may fire, cargo fire) is ineffective? ority of items be for a) source identification, b) conflict with each other. For example, toxic • What size font should be used to increase smoke removal, c) descent initiation, and d) fight- fumes and smoke can quickly enter a cockpit checklist readability in a smoke-filled cockpit? ing/extinguishing a fire? during a SFF event. Therefore, oxygen masks • What colors of text and background are the • Should crews be prompted to divert and, if so, and goggles should be donned by a flight crew most readable if there is smoke? where in the checklist should this guidance be at the first sign of SFF (NTSB, 1998). On the • Do choices of font size and color of text and given? other hand, oxygen masks can make communi- background differ if the checklist is presented • Should guidance regarding different descent cation difficult and goggles can restrict one’s in an electronic format as compared to paper? profiles be included in a SFF checklist? vision; should donning such protective gear be • What is the best way to design a checklist • What kind of special guidance, if any, should be required if the SFF event is unlikely to cause that accommodates the normal cognitive per- given to crews who are transporting dangerous the flight crew difficulty (e.g., a burned muffin formance limitations the crew may experience goods (hazardous materials)? in the back galley)? ◆

Likewise, some checklists may take quite a • Various philosophies, company policies, cies such as the FAA, NASA, the NTSB, and bit of time to complete, seeming to imply that and economic considerations. Philosophies the TSB of Canada. time is not a factor when responding to the (both implicit and explicit) and company Two checklist products have been devel- event. Also, many procedures assume that policies may influence SFF checklist design oped that, it is hoped, will be adopted by the crew is aware of the type/source/serious- and content, as can a variety of economic the international aviation industry as the ness of SFF and thus can readily identify considerations related to the handling of standards that will guide the design and and execute the appropriate checklist or pro- these events (e.g., cost of diversions in terms content of nonalerted SFF checklists. One cedure, leaving crews uncertain about how of fuel, scheduling issues, etc.). Many of product is a template to be used by design- to proceed in more ambiguous situations. these issues implicitly shape procedures and ers when developing a nonalerted SFF These implications and assumptions are in- guidance for crew response and are not a checklist, and the other is a description of herent in the design of the checklists and may part of any stated policy or philosophy. the philosophy upon which the template is not have even been apparent to the develop- founded, as well as a few definitions of vari- ers who constructed them. Developing a new approach ous terms and concepts used in the tem- • Human factors considerations. Text for Because there is so much variability across plate. Both products are currently available some SFF checklists is in a larger-than-nor- air carriers in terms of types of aircraft through the Flight Safety Foundation. mal font size to make reading easier when flown, types of operations, history, philoso- The template is not, in and of itself, a smoke is in the cockpit. Stress-induced hu- phies, and policies, up until very recently checklist but is a framework to guide check- man performance limitations are also some- there has been no industrywide agreed- list design and content. Some of the steps on times accommodated. For example, in one upon approach regarding crew response to the template are actually sections, and sev- of the SFF checklists provided to the crew SFF events and the design and content of eral checklist items might be developed for of Swissair 111, a great deal of information checklists that guide this response. a single template “step.” The accompanying was provided regarding aircraft limitations However, beginning in 2004, a small steer- philosophy and concept definitions must also when configured in a particular manner, ing committee began developing checklist be consulted during checklist development thereby reducing crews’ cognitive process- content and design guidance that could be so that the resulting checklist is truly in keep- ing requirements and memory load. adopted across the industry. Individuals rep- ing with the intent of the template. • Regulations, advisory, and guidance resenting four major aircraft manufacturers Below I discuss a few of the SFF check- material. Often (but not always) as a result (Airbus, Boeing, Bombardier, and Embraer), list issues listed in Chart 1 as they are typi- of accidents or incidents involving SFF, vari- the International Federation of Air Line Pi- cally treated in current checklists and also ous regulations, recommendation letters, lots Associations (IFALPA), and four air car- as they are treated in the newly developed bulletins, advisory circulars, and other guid- riers (Air Canada, British Airways, Delta, template/philosophy. Note that the template/ ance materials are developed that pertain and United) comprised the committee. Con- philosophy represents a significant change to the design and content of checklists. tact was also made with governmental agen- in the approach to these issues and that some,

July–September 2006 ISASI Forum • 15 With an integrated SFF checklist, the time crews would initially spend is actually spent by completing actions that have applicability for all though not all, of the difficult tradeoffs these separate smoke removal checklist when removal, and then only if the SFF is con- issues pose have been addressed. necessary, and to return to uncompleted tinuing. sections of the nonalerted SFF checklist, if In a study of 15 inflight fires that occurred Access—separate checklists vs. any, following smoke removal. (A template between January 1967 and September 1998, an integrated checklist for the separate smoke removal checklist the TSB of Canada determined that the Currently, when crews wish to complete a was not developed by the steering commit- amount of time between the detection of an checklist for a nonalerted SFF situation, they tee; manufacturers and/or air carriers are onboard fire and when the aircraft ditched, must typically access a checklist that has been expected to provide them.) conducted a forced landing, or crashed ranged developed for a specific type of smoke, fire, or The philosophy document states that a between 5 and 35 minutes. These findings in- fumes, e.g., air conditioning smoke, electrical checklist developed using this template dicate that crews may have precious little time smoke, fire, or fumes, etc. Thus, crews are “does not replace alerted checklists (e.g., to complete various checklist actions before presented with a list of several different SFF cargo smoke) or address multiple events.” an emergency landing needs to be completed checklists, and they must first determine what Some air carriers, however, may choose to and, hence, the checklist guidance to initiate type of SFF they have in order to select the have their crews complete the integrated such a diversion should be provided and proper checklist from the list. However, re- nonalerted SFF checklist after having com- should appear early in a checklist. call that the cues for nonalerted events are pleted an alerted checklist if the alerted However, some types of fire or smoke may often quite ambiguous and making a distinc- checklist did not resolve their situation. be relatively simple to identify and extin- tion between air conditioning, electrical, ma- Thus, these crews would need to access two guish, such as a burned muffin in a galley terials, florescent light ballast, dangerous SFF checklists (one each for alerted and oven. Few people would argue that an emer- goods (i.e., hazardous materials), or some nonalerted events) and possibly also a third gency landing is necessary in such a situa- other type of SFF can be quite difficult. Pre- (for smoke removal). The use of the non- tion, and it is undesirable to complete an cious time may be wasted if a crew was to com- alerted checklist following completion of an unscheduled landing unnecessarily because plete a checklist for one type of SFF but, in ineffective alerted checklist is not addressed of the many safety and operational concerns reality, was faced with a different type. by the template or accompanying philoso- involved (e.g., tires bursting and possible In response to these issues, several air phy document. emergency evacuation after an overweight carriers (e.g., Delta, United) have indepen- landing). Thus, developers struggle with the dently developed a single integrated check- Diversion and landing guidance priority to place on guidance to complete a list to be used for multiple types of non- Giving guidance to crews to divert and com- diversion in nonalerted SFF checklists. alerted SFF events. With such an inte- plete an emergency landing and when crews In the newly developed template, the grated checklist, the time crews would should be given this guidance are some of very first item states that “diversion may initially spend trying to figure out which the most hotly debated issues in the design be required.” The intent of this item, and checklist to complete is actually spent by of nonalerted SFF checklists. In many cur- the reason it appears first in the checklist, completing actions that have applicability rent nonalerted SFF checklists, guidance is to “establish the mindset that a diversion for all types of nonalerted events. Similarly, to complete a diversion and/or emergency may be required.” The placement of this the template developed by the steering com- landing is given as one of the last steps, if it item as the very first in an SFF checklist mittee is for an integrated nonalerted SFF is given at all, and the guidance to complete represents a significant change from the checklist in which the first 11 steps/sections such a diversion is only pertinent if efforts current philosophy about how crews are to are to be accomplished irrespective of the to extinguish the SFF were unsuccessful. respond to SFF events described above. It specific type of SFF faced. Actions that are The philosophy implicit in this design is that is not intended that crews read this item as pertinent to specific types of SFF are to be continued flight to a planned destination is direction to immediately initiate a diversion grouped according to SFF type and appear acceptable if inflight smoke or fire is extin- or even begin planning a diversion, however, in Sections 12, 13, and 14 of the template. guished. If crews follow these types of just that they should keep in mind that a Even though the template guides devel- checklists exactly as written, a diversion is diversion may be necessary. It is possible opment of a single checklist to be used for initiated only after the completion of steps that under stress, crews may misread this multiple types of SFF events, crews may related to other actions, such as crew pro- item and begin a diversion right away, so still be required to access more than one tection (i.e., donning of oxygen masks and training and/or a change in wording to em- checklist during their response to such goggles), establishing communication and phasize that they are only to remember that events, however. For example, the template source identification, troubleshooting, a diversion is an option may be needed. and philosophy call for crews to refer to a source isolation, firefighting, and smoke One other concern about this item as it

16 • ISASI Forum July–September 2006 trying to figure out which checklist to complete types of nonalerted events. appears in the template is that it is followed moval checklist, if needed. The nonalerted smoke is continuing or decreasing. by three items that currently are often com- SFF checklist is then “complete” and crews If smoke is continuing, crews are completed from memory during SFF events: are left to focus upon landing the aircraft. In monly instructed to reverse the action(s) crew protection items (donning smoke masks other words, landing has a higher priority at just taken (i.e., turn the switch(es) back on) and goggles—Steps 2 and 3) and establish- this point than the continued completion of and proceed with making the next configu- ing crew communication (Step 4). Neither the additional SFF identification items, such as ration change. The checklist template de- template nor the accompanying philosophy those in Sections 12, 13, and 14. veloped by the steering committee also in- mentions anything about items on the check- The last template step involving guidance cludes a place for such system-specific list being or not being completed from to land is Step 15: “Consider landing imme- source identification items (Sections 12, 13, memory—this decision is left up to the indi- diately.” Crews will reach this step only if and 14), but these actually appear after vidual air carriers and manufacturers using all checklist actions involving source iden- three other steps (or sets of steps) involv- the template. Crews who complete these ac- tification, isolation, and elimination within ing source identification and/or source iso- tions from memory, whether by requirement the checklist were ineffective and the SFF lation/elimination. All source identification/ or out of habit, may miss the first item re- was continuing. It is difficult to imagine a isolation/elimination steps are discussed minding them about a possible diversion situation such as this where the crew would below in the order in which they are pre- unless it, too, is considered a memory item. not choose to land immediately. sented to crews on the template. Step 10 is the first place in the checklist Notably, the template never directs Following the completion of crew self-pro- where crews are specifically directed to “ini- crews to initiate a descent—only a diversion. tection and communication steps, crews tiate a diversion to the nearest suitable air- Some in the industry believe that at the first would complete items related to template port,” and they are to do this “while continu- sign of SFF, crews should initiate a descent Step 5: “Manufacturer’s initial steps… Ac- ing the checklist.” This step follows five steps to the minimum enroute altitude or get complish.” In the accompanying philosophy, (5, 6, 7, 8, 9) pertaining to source identifica- fairly close to the water, if flying over the “manufacturer’s initial steps” are described tion and/or source isolation/elimination. The ocean. This would allow a crew to complete as those “that remove the most probable steering committee believes that crews will the descent and landing/ditching quickly in smoke/fumes sources and reduce risk…. be able to complete all actions in these five the event that a situation becomes uncon- These steps should be determined by model- steps fairly quickly—the philosophy even trollable. Others in the industry point out specific historical data or analysis.” Further- states, “Checklist authors should not design that such a descent may commit a crew to more, the philosophy specifies that these ini- procedures that delay diversion.” Thus, us- completing an unscheduled landing as they tial steps “should be quick, simple, and re- ing a checklist developed according to the may no longer have enough fuel to reach versible; will not make the situation worse template, crews will complete self-protection their planned destination (due to the higher or inhibit further assessment of the situa- and establishing communication items (Steps rate of fuel consumption at lower altitudes). tion; and do not require analysis by the crew.” 2, 3, and 4), complete five sections of “quick” The template is constructed so that crews Thus, when using a checklist designed ac- actions to eliminate probable sources of SFF, will always have the option to continue to cording to the template guidance, crews will and then initiate a diversion in Step 10 if the their planned destination if the source of eliminate the most likely sources of SFF earlier actions to eliminate the SFF source SFF “is confirmed to be extinguished and early on in checklist completion without were unsuccessful. A more-thorough discus- the smoke/fumes are dissipating.” making a determination first as to whether sion of the source identification, isolation, and one of these sources is in fact causing the elimination items in Steps 5 through 9 is pro- Source identification/ smoke, fire, or fumes; this step involves vided below. isolation/elimination source isolation/elimination but not source Following Step 10, wherein crews are di- In many current nonalerted SFF checklists, identification. rected to initiate a diversion, the template in- a number of items are devoted to identify- In Step 6, crews are asked if the source of cludes the following: “Warning: If the smoke/ ing the specific source of SFF and concur- the SFF “is immediately obvious and can be fire/fumes situation becomes unmanageable, rently isolating and eliminating it. Thus, in extinguished quickly” and, if so, are told to consider an immediate landing.” If “landing a checklist for air conditioning smoke, crews extinguish it in Step 7. In Step 8, if the is imminent” (Step 11) crews are directed to are often told to, in a stepwise fashion, turn “source is confirmed visually to be extin- review various operational considerations off various pack switches, bleed air switches, guished” it is suggested that crews consider (e.g., “overweight landing, tailwind landing, and other air conditioning system compo- reversing the manufacturer’s initial steps ditching, forced off-airport landing, etc.”) and nents and, after each configuration change, accomplished in Step 5, presumably if they to accomplish a separate smoke or fumes re- make a determination about whether the know which actions were and were not re-

July–September 2006 ISASI Forum • 17 Crews may complete a template-driven checklist successfully (i.e., fire is extinguished, smoke is dissipating) without ever having positively identified the source of the SFF. lated to causing the SFF, although this is not Therefore, what is meant by “minimal essen- For example, if the actions related to Step addressed in the template. It is then sug- tial” is unclear. However, because the addi- 12 in the template are not successful, they gested that crews complete a smoke removal tional note specifies that these steps still per- should complete items related to Step 13. checklist, if necessary, and this marks the tain to “probable sources,” it can probably If Step 13 actions are successful, they completion of the nonalerted SFF checklist. be safely inferred that crew analysis should should not complete the items in Section 14. These three steps have been developed for still not be required when completing them. Once crews have completed a set of system- those types of smoke or fire that are rela- During the feedback meeting with the specific items that have successfully dealt tively simple to identify and extinguish (re- larger industry group, one manufacturer rep- with the SFF, the template directs them to call the burned muffin in a galley oven). Note resentative to the steering committee ex- review operational considerations for their that if extinguishing is successful and can be pressed the need for crews to be able to com- landing and accomplish a smoke removal visually confirmed, continued flight to the plete quick and simple items that did not en- checklist, if necessary (recall that if crews planned destination is implied. tail crew analysis but might not be able to be are completing any system-specific items in The steering committee believes that reversed or might inhibit further assessment Steps 12, 13, or 14, they should concurrently these steps will be quick and easily accom- of the situation (by cabin crew). Thus, these be diverting and conducting an emergency plished. However, identifying a source of additional steps would meet only some of the landing as directed in Step 10). SFF (even when it appears to be obvious) criteria for the “initial steps” in Section 5. It is Thus, in contrast to some current non- and then extinguishing it can take some likely that Section 9 was added to meet this alerted SFF checklists, checklists devel- time. For example, imagine that a burned need expressed by the manufacturer. oped according to the template include both muffin in a galley oven is the source of As mentioned earlier, according to tem- system-specific source identification items smoke/fire. Cabin crew must let the flight plate specifications, traditional types of as well as smoke elimination items that do crew know there is smoke/fire, confirm that source-specific identification, isolation, and not require source identification. Addition- a muffin is the source (and not something elimination actions are included in Sections ally, crews may complete a template-driven like an electrical short in the oven), turn off 12, 13, and 14, with each section including checklist successfully (i.e., fire is extin- the oven, possibly locate a fire extinguisher, items for a different aircraft system (for ex- guished, smoke is dissipating) without ever put out the fire with the extinguisher or by ample, Section 12 might include items for having positively identified the source of the some other method (e.g., put the smoking systematically identifying and isolating an SFF. muffin in the sink and douse it with water), electrical source of SFF). The actual steps The construction and design of checklists respond to passenger questions/concerns, to be included within these sections are to to be used for nonalerted SFF events is very confirm that the fire/smoke is extinguished, be determined “based on model-specific his- challenging. The types of events for which and get that information back to the flight torical data or analysis.” Although it is not they might be needed vary widely but, at their crew. Thus, even relatively simple events explicitly stated in the philosophy docu- extreme, are highly time critical and life can take some time to resolve. As a result, ment, historical data for a particular aircraft threatening. Additionally, the cues available Steps 6 and 7 in the template represent a model could also be used to determine the to crews may not be very helpful in determin- bottleneck, but the time these actions re- ordering of the various system-related ing their situation and at times may actually quire cannot be helped. Crews should be items across Steps 12, 13, and 14. Thus, if be misleading. The steering committee that aware of this, and in training they may wish aircraft model X has historically had more developed the attached template and support- to address how much time should be de- problems with air conditioning smoke than ing philosophy document should be com- voted to these efforts before moving on to any other type of SFF, source identification mended for addressing a number of difficult subsequent items on the checklist. and isolation items for air conditioning issues and for helping to move the industry The 9th step of the template states: “Re- smoke or fumes would be presented first forward in thinking differently about response maining minimal essential manufacturer’s (i.e., in Section 12). to inflight SFF. There are a number of other action steps…Accomplish” and is followed After each of the system-specific sections issues beyond the scope considered by the by a note to the checklist developer indicat- of items is completed, the crew is to deter- steering committee that checklist designers ing that “These are steps that do not meet mine if their efforts have been successful will also need to consider, however. The treat- the ‘initial steps’ criteria but are probable (i.e., the fire is extinguished, the smoke is ment of these issues within a SFF checklist sources.” This step was one of the last to be dissipating). If so, they are to skip the re- will not necessarily contradict the framework added to the template during its develop- maining system-specific sections. If their for response established within the template, ment, and no other information pertaining actions were not successful, they are to com- but will also need to be addressed as non- to it is included in the philosophy document. plete the next set of system-specific items. alerted SFF checklists are developed. ◆

18 • ISASI Forum July–September 2006 (This article was adapted, with permission, flight, are a primary source of objective dent rates are declining. These data are from the author’s presentation entitled Bring- safety data. However, FOQA (which is by collected from several sources; this article ing Proactive Safety Methods and Tools to nature quantitative) cannot supply subjec- uses the Flight Safety Foundation recita- Smaller Operators presented at the ISASI tive—or qualitative—data. Subjective data, tion of Boeing data where possible (cited at 2005 seminar held in Fort Worth, Tex., Sep- which help explain why a situation occurred, the IASS Conference 2004). tember 12-15, which carried the theme “In- are gleaned by operations personnel A gap remains between the accident rate vestigating New Frontiers of Safety.” Sources through confidential safety reporting sys- for smaller jet and turboprop aircraft and referenced by the author have been removed tems like ASAP. The independent observa- the accident rate for larger jet transports from this text. The full presentation includ- tions from LOSA add a more objective (greater than 60,000 lbs). This gap, well- ing cited references are on the ISASI website “snapshot” to determine the effectiveness known and well-documented, exists even at www.isasi.org.—Editor) of SOPs, checklists, procedures, and other when the data are adjusted for different safety mitigations applied to the operation. exposure levels of different fleets. any large airlines have developed These three data sources provide the safety Are differences in equipment part of the systems and processes that allow Mthe confidential collection of routine flight data. These data can be collected from the airplane and flight crews by pro- Scaling Up Safety on grams such as Flight Operations Quality Assurance (FOQA) programs and/or by confidential reports in the Aviation Safety Smaller Operations Action Program (ASAP) and the Line Op- erational Safety Audit (LOSA). Data collec- Here is how proactive safety tools used by large operators tion programs such as these provide a real- can be implemented into smaller flight operations to time review of current safety issues in the flight operations department. Real-time help investigations of incidents and accidents and to data review facilitates the identification of improve the safety of daily flight operations. areas where modifications to training pro- By Capt. John M. Cox (M03291), FRAeS, President, grams or standard operating procedures Safety Operating Systems (SOPs) or other areas might be appropriate. Such training program modification might prevent the occurrence of future department with a significantly improved reason for the accident rate gap? Terrain safety events (incidents or accidents) and ability to communicate the real needs of a Awareness Warning Systems (TAWSs) reduce costs as well. specific area of flight operations to the ap- have significantly reduced (some would ar- FOQA programs, which evaluate various propriate level of flight operations manage- gue have eliminated) controlled flight into aircraft parameters recorded in normal ment. This is a holistic approach allowing terrain (CFIT) accidents in aircraft the constituent elements of ASAP, FOQA, equipped with TAWS. The TAWS example Capt. John Cox, a and LOSA to become more than the sum of suggests that differences in equipage might veteran major airline, the parts, further benefiting the operator. be a partial explanation for differences in corporate, and general Until recently, smaller operators were un- accident rates between the communities of aviation pilot, has flown able to take advantage of these proactive larger and smaller aircraft. However, other more than 14,000 hours methods and tools due to the substantial in- factors come into play when analyzing the with more than 10,000 frastructure required. The cost of this infra- accident rate gap. For example, another hours in command of jet structure was too high for many operators. factor contributing to the gap in accident airliners. In December 2004, he retired Budget constraints, unfortunately, resulted in rates might be airport facilities. Significant from airline flying after 25 years to missed opportunities for safety enhancement. additional infrastructure is available to a found Safety Operating Systems, a Today, however, there are new market- large, intercontinental jet operator landing Washington, D.C.- based aviation safety place strategies that allow small operators at a big international airport, compared to consulting firm. He holds an ATR to have the same proactive safety programs that available to the small turboprop opera- certificate with type ratings in the Airbus that the large airlines enjoy. The proactive tor landing at a tiny, remote airport. 320 family, the Boeing 737 family, the safety methods and tools, used successfully Economies of scale (size and infrastruc- Fokker F28, and the Cessna Citation. He by large operators, can be implemented by ture) often allow a large operator to enjoy is an experienced accident investigator smaller flight operations. The utilization of significant operational advantages. Dedi- having been involved in six major NTSB proactive safety methodology can facilitate cated in-house safety departments, highly investigations (the best known being the investigations and improve the safety of qualified technical writers, well-developed US Air 427 accident in Pittsburgh in daily flight operations. cultures of SOP usage, and extensive report- 1994) and numerous smaller investiga- ing systems are demonstrably advantageous. tions. He served as the Air Line Pilots Proactive safety Safety reporting systems (such as ASAP, Association Executive Air Safety Accident data (both hull loss and accidents FOQA, and LOSA) allow the large opera- Chairman, ALPA’s top safety job. with fatal injuries) show that aircraft acci- tor to harvest reams of data, upon which a

July–September 2006 ISASI Forum • 19 keener understanding of the realities of the most aircraft operators nowadays. Fuel a significant level of expertise otherwise operation can be based. These data-rich prices have climbed faster than a high-per- unobtainable by the aircraft operator. Any environments, which facilitate a proactive formance jet, and revenue is as hard to find other additional expertise of the consultant approach to problem solving, have paid off as affordable fuel. As a result, outsourcing to potentially enhance the operation should in appreciable improvements to safety and has become the standard. For example, be considered. operational efficiency. For example, adjust- large operators once had their maintenance The proper handling of aviation safety ments and enhancements in training pro- performed “in house.” Today it is often per- reports is critical. How the data and the grams, revisions to SOPs, and modifications formed “off shore” on a “bid-for-contract” reports are to be transmitted to the outside to checklists can be facilitated before an basis. The drive to lower operating costs has safety company must be determined. In accident or incident occurs. Thus the cost become an integral part of today’s flight today’s electronic age (identity theft, hack- of an incident or accident may be avoided operation. ing), the encryption of data is essential to (and the overall risks lowered) by the proper So the question arises: Can a smaller maintain confidentiality and security. It is and timely use of the information extracted operator gain the benefit of data-gathering imperative that the security of this sensi- from these reporting systems. tive information be ensured from the be- These same highly successful data analy- he proper handling of ginning of the project. There must be a non- sis tools have the potential to improve the aviation safety reports is punitive reporting environment so that re- accident rate gap between smaller jets/tur- critical. How the data ports can be filed without fear of disciplinary boprops and large jets. Unfortunately, most T or certificate action. The non-punitive as- small jet/turboprop operators, as well as and the reports are to be pects of an aviation safety reporting pro- some small operators of large jets and some transmitted to the outside gram apply only to sole-source, non-crimi- large operators of large jets, do not gather safety company must be de- nal, and non-deliberate actions. FOQA data. Older aircraft with low-tech Ownership of the information is a diffi- flight data recorders (FDRs) make gather- termined. In today’s electronic cult question. Are the provided data the ing these data very difficult and expensive. age (identity theft, hacking), property of the operator or the outside How can smaller operators gain the same the encryption of data is safety contractor? Clear definitions of data benefits from safety reporting systems that essential to maintain confi- ownership and authority to access informa- large operators enjoy? How can these tion are fundamental. All parties must agree needed data be gathered, evaluated, and dentiality and security. It is upon how the data will be stored, as well as used by a smaller operator at a reasonable imperative that the security of when and how it will be de-identified and cost? this sensitive information be finally destroyed. What reports will the ensured from the beginning safety company provide to the operator? Virtual safety departments How often? What will the reports contain The cost of a large, extensive, and dedicated of the project. exactly? Will the operator indemnify the aviation safety department is high. Those safety company for the content of the re- that shoulder this high cost usually see a programs without having the high costs of ports? These are a few of the many issues quantifiable reduction in risk. Large opera- a dedicated safety department? The answer that require agreement before an outside tors around the world have found this to be is “maybe.” That answer, too, depends on safety contractor can begin to use data gath- a good investment. The payback on the out- the exact requirements of the small opera- ered or reported by an operator’s pilots. The lay has been considerable. With a large fleet tors. Germane questions could include Does outside safety company must keep all data there is direct contribution to the profitabil- the operator fly charters? Does the opera- it receives isolated and confidential. How- ity of the company by FOQA, ASAP, and tor fly internationally? Can the small op- ever, the outside contractor might request, LOSA data-reporting programs. Millions of erator define what aspects of the operation for the purpose of enhanced statistical va- dollars have been saved by information ob- could be improved? Is the operator willing lidity, that an operator’s data be compared tained from FOQA, ASAP, and LOSA. One to seek solutions from outside the company? in the blind to like data from similar opera- U.S. airline saved more than one hundred An operator might hire an outside source tors. million dollars in a single year by using to compile the aviation safety reports. That Data analysis, in this case, requires a FOQA data to explain the causes of engine independent contractor would then evalu- standard of comparison, or it is of very lim- exhaust gas temperature (EGT) excee- ate the safety reports and provide recom- ited value. Pooling sanitized data enhances dances. This allowed the engine to stay on mendations (e.g., training, SOPs, and check- the overall base of information. Comparing wing, in service, for a longer time. This same lists) if appropriate. The small operator like-operators with similar data provides a operator was able to use combined FOQA could benefit from the arrangement. There much better understanding of the real- and ASAP data to show the FAA of the need are, however, important issues that must be world flight operation. A safety company to redesign an instrument approach to re- clearly identified before “outsourcing” is with several similar operator-clients can duce excessive descent rates. LOSA subse- initiated. What are the characteristics of a observe and track trends and report to an quently verified the effectiveness of the im- successful outside consulting firm? The ar- operator without any loss of confidentially. proved approach. For the smaller operator rangement with an outside source should By compiling data into trends over time and to reap similar advantages, the barrier of add value to the operator’s business. To comparison to other similar operators, the high initial cost must be addressed. enhance the operation, the outside consult- maximum benefit for the collective few can Cost of operation is a major concern to ing firm might provide cost savings and/or be achieved.

20 • ISASI Forum July–September 2006 Achieving consensus ERC are referenced only by number, so that The regulator now has a means to moni- There must be agreement among the op- Safety R Us is the only party with the abil- tor safety issues without waiting for an in- erator, the regulator, the pilot representa- ity to identify a flight crew. Should the ERC cident or accident. These data allow the tive organization (if applicable), and the determine that it is imperative that the regulator to work with the airline to resolve safety company. This agreement will result flight crew submitting a report be con- potential safety problems much earlier than in a memorandum of understanding (MOU) tacted, the ERC will submit, in writing, a previously possible. Additionally, the regu- or similar written document. The specifics request that the pilot association represen- lator can compare the airline to other simi- of how the data and reports can be used will tative be given the name(s) of the flight crew. lar airlines with similar programs to better be clearly stated in this document. The The pilot association representative will understand how effectively the safety pro- MOU becomes the backbone of the relation- then call the flightcrew members for clari- grams are working. ship among the operator, the regulator, the fication of their report. The representative The pilot association now has a means to pilot representative body (if applicable), and of the pilot association will then report the submit safety reports with the necessary the outside safety contractor. Successes at results of the call to the ERC. protections from self-incrimination in place. larger operators have proven that achiev- NASA’s highly successful Aviation Safety ing a good, solid MOU is a good predictor he cost of the virtual Reporting System has clearly demon- of notable safety enhancements from the Tsafety department is strated the value of confidential aviation safety reporting program. safety reports. Through its non-incrimina- Guidance material from the FAA pro- usually defrayed for individual tory reporting system, NASA was informed vides standard recommendations on the operators when the of many, many near-miss events that oth- construction of MOUs for large operators. independent safety company erwise might have gone unreported. These templates can be downloaded from contracts with a number of The ERC group members each become the FAA website. Additionally, the outside a part of the solution to the reported prob- safety company should have access to other operator-clients. In numbers, lems or issues. Not only do the ERC mem- approved MOUs. These recommendations it becomes a symbiotic, win- bers accept a report into the program, they and examples from other operators can pro- win relationship. recommend corrective action so that the vide the framework for a virtual safety de- likelihood of recurrence is reduced or elimi- partment. The cost of the virtual safety de- Once the ERC has determined that a nated. The combination of the airline, regu- partment is usually defrayed for individual reports meets the criteria for admission into lator, pilot association (if applicable), and the operators when the independent safety the program (sole source, non-criminal, not outside safety company brings together a company contracts with a number of opera- a deliberate act, etc.), it is logged into the team to recognize, evaluate, and solve safety tor-clients. In numbers, it becomes a sym- system for evaluation. No disciplinary ac- issues facing the airline. biotic, win-win relationship. tion or certificate action will be taken The process is similar for FOQA data. against the flight crew once the report is The data are harvested from Tiny Air’s fleet A theoretical example accepted into the program. of aircraft and sent to Safety R Us where it The following is a purely fictional example Safety R Us evaluates the report and com- is evaluated for “exceedances.” Should an of the benefits gained by a virtual safety de- pares it against other similar reports. If a exceedance be observed, it is plotted, and a partment. Any resemblance to a real event, trend is evident, Safety R Us will advise Tiny monthly trend report is provided to Tiny person, or company is purely coincidental. Air that an undesirable trend is developing. Air. This objective data, when combined Tiny Air, a small jet airline with 10 air- Any trend report generated by the outside with the ASAP reports, provide a compre- craft and 85 pilots, accepts a bid from safety company will include recommenda- hensive evaluation of the performance of the “Safety R Us,” an aviation safety firm, to tions for mitigation of the problem. flight operation. The same process of data provide FOQA and ASAP reports. A meet- Reports are de-identified 2 weeks after protection and reporting used in the ASAP ing is held between Tiny Air and Safety R the ERC meeting so that only a reference program is used with FOQA data. Over Us officials and the exact requirements are number is maintained. The reports can be time, maintenance costs alone can pay for specified. The senior flight management of used to make up month-over-month and this type of program. For example, careful Tiny Air, the regulating authority’s prin- year-over-year trend evaluations so that monitoring of fuel burns can identify spe- ciple operations inspector, the chairman of training effectiveness, SOP changes, and cific aircraft that may need rig adjustment. Tiny Air’s pilot association, and the senior other items of emphasis can be observed, LOSA data are never identified, so the management of Safety R Us meet to detail evaluated, and quantified. confidentiality issues are slightly different. exactly how safety data will be gathered, This fictitious airline now has the ability The flight deck observations and recordings evaluated, held, and reported. to take a realistic look at its flight opera- during normal line operations result in the There is agreement by all parties that de- tion. Tiny Air can now learn of operational tabulation and classification of observed identified reports will be presented to an “near misses” that would have gone unde- problem areas. Specially trained LOSA au- Event Review Committee (ERC), made up tected previously. For the first time, Tiny ditors, like the ERC members, should come of a representative from flight operations Air can make safety improvements before from company flight operations, the regu- management, the regulator, and the pilot an incident or accident occurs. Tiny Air is lator, the pilot association, and the outside association, who will meet once a month to in the proactive league. The little airline has safety company. The uniquely qualified accept or decline reports into the program. made a significant improvement in safety LOSA auditor/pilots mark a form that clas- The reports reviewed by the multiparty at a fraction of the cost of doing it “in house.” (continued on page 29)

July–September 2006 ISASI Forum • 21 The Challenges for Air Safety Investigators: ‘Kapustin’ The Italian Regulatory Framework Scholars Selected By Leonardo Ferrero Students from Embry-Riddle Aeronautical University, Florida, U.S.A., Italy adhered to the Convention on Interna- and Politecnico di Torino, Italy, have been selected as the 2006 tional Civil Aviation as soon as 1947, but it hadn’t a permanent aircraft accident inves- recipients of the ISASI Rudy Kapustin Memorial Scholarship Fund. tigation body until 1999. After a number of By Esperison Martinez, Editor unsuccessful efforts on a national basis, a significant contribution to the rulemaking pro- eonardo Ferrero, Politecnico di System (ECTS) credits each, and it is rec- cess came from the Council of the European Torino, Italy, and Sheena D. ognized by the Partnership of a European Union. On Nov. 21, 1994, the Council adopted L McCune, Embry-Riddle Aeronau- Group of Aeronautics and Space Universi- Directive 94/56/EC establishing the funda- tical University, Florida, U.S.A., have ties (PEGASUS). mental principles governing the investiga- been selected by the ISASI Interna- As the issues of aircraft accident investi- tion of civil aviation accidents and incidents. tional Council as the 2006 recipients of gation (AAI) are not widely known in the Ital- Italy complied with Council Directive 94/56/ the ISASI Rudy Kapustin Memorial ian academic world, his graduation thesis EC, albeit with some delay. In February Scholarship Fund. The Fund was estab- dealt with procedures and techniques in air- 1999, the Italian Parliament adopted decreto lished in memory of all ISASI members craft accident investigation. However, he legislativo n. 66/1999, a law that established who have died and was named in honor notes that “my primary interest was earn- a permanent and independent aircraft acci- of the former ISASI Mid-Atlantic Re- ing some experience in the field with AAI- dent and incident investigation body named gional Chapter president. related activities.” Agenzia Nazionale per la Sicurezza del Volo The scholarship is intended to encour- Originally, he intended to include in his (ANSV,literally translated as National age and assist college-level students in- thesis some critical comments about Ital- Flight Safety Agency). terested in the field of aviation safety and ian regulations on aircraft accident investi- Since its inception, the ANSV has over- aircraft occurrence investigation, ac- gation. He ultimately decided that the is- come many challenges. To name a few, in cording to Richard Stone, ISASI execu- sues were outside the scope of the thesis. 2002, it acquired an office building in Rome, tive advisor and one of the two Fund ad- So, he used the material to form the basis which provides ample space for staff and ministrators. Contributions such as for his scholarship submission. equipment. In 2003, a state-of-the-art labo- those made at the recent MARC meet- Sheena D. McCune graduated this May ratory for readout and analysis of flight re- ing (see page 25) have and will continue from Embry-Riddle Aeronautical Univer- corders became operational. Since 2003, the to provide an annual allocation of funds sity with a B.S. in human factors. She is con- ANSV website provides comprehensive infor the scholarship. tinuing her studies in human factors by ap- formation about the Agency’s activity, includ- The ISASI executive advisor and plying to the graduate program this fall. In ing full text incident and accident reports. ISASI vice-president, offices presently an academic competition for her human- filled by Stone and Ron Schleede, serve centered systems engineering senior design as executors and administrators of the project, her team won first place present- Fund. They review all applications, which ing research for a non-profit organization. include a 1,000 (+/- 10%) word essay in Sheena’s aspiration, as a student of en- English addressing “The Challenges for gineering design, is to optimize usability in Air Safety Investigators.” The scholar- the cockpit. She believes her preliminary ship consists of an annual $1,500 award, research as an undergraduate in glass cock- a one-year ISASI membership, and a pit displays will direct her work as a gradu- fee-free attendance at an accident inves- ate student. She says, “I am interested in tigation course at both the FAA’s Trans- how humans interact with a program that portation Safety Institute and the South- does a large amount of the information pro- ern California Safety Institute. cessing. As a Wilderness First Responder Leonardo Ferrero (ST5135) was en- with heavy concentration on human physi- rolled in a program leading to a master ology, I am also interested in survival as- of science degree in aerospace engineer- pects of accidents, and I am definitely in- ing, which he received in March. It is a terested in aircraft accident investigation.” 5-year curriculum that includes 29 The scholarship essays of both awardees Ferrero courses of 10 European Credit Transfer follow.

22 • ISASI Forum July–September 2006 There are still some open issues, the most vestigation. If requested, the ANSV is vision of the legal system defined in the significant of which is the need to harmo- obliged to cooperate with the judicial author- constitution. At the same time, it should nize the investigative activity of the ANSV ity. The access to the evidence pertaining to be considered that existing regulations with the existing domestic law on criminal an occurrence under criminal investigation allow for the establishment of satisfactory investigations. Italy is a civil law country. by air safety investigators still requires prior practices as long as the pubblico As a consequence, the application of the consent from the pubblico ministero. ministero in charge of the criminal inves- principles of accident prevention and inves- On a positive side, the law has made the tigation understands and accommodates tigation as developed in common law coun- legal status of air safety investigations less the needs of the air safety investigation. tries is not always straightforward. A num- ambiguous, and now there is a better aware- In conclusion, under current law, the ber of crimes listed in the Italian penal code ness of the mandate of the ANSV. Generally key issue is the orientation of the judicial are applicable to aviation occurrences: for speaking, the “deep-seated distrust” of the authority toward the air safety investiga- example, omicidio colposo (manslaughter) judicial authority is slowly changing into a tion. This does not mean that the air if the occurrence involves fatalities, lesioni will to cooperate. For example, in May 2001, safety investigators should assume a pas- personali colpose (negligent personal in- the Italian Ministry of Justice issued a cir- sive attitude and rely on the good will of jury) for non-fatal accidents, and/or disastro cular on possible cooperation between the the pubblico ministero. On the contrary, aviatorio colposo (negligent aviation disas- judicial authority and the ANSV during the they should actively voice their concerns ter). Moreover, in Italy the prosecution of a preliminary phase of aircraft accident inves- with the support of the international com- crime is compulsory. tigations. Recent experience has shown that, munity of air safety investigators, and This means that prosecutors have a duty with the open cooperation of the judicial au- they should assist the judicial authority to immediately start a criminal investiga- thority, the fact-finding phase can proceed in making reasoned decisions on matters tion into many air-safety-related occur- faster and with a better respect of the aims that may compromise the timely conduct rences, even non-fatal ones. and objectives of each investigation. of air safety investigations. Under his/her authority, the pubblico A word of caution. In some cases, coop- ministero (public prosecutor) can impound eration has led to a formal involvement of (The views expressed in the paper are any evidence, and he/she can withhold any the air safety investigator in criminal inves- those of the author and do not necessar- information while the preliminary investi- tigations as an expert witness of the ily reflect the opinion, policy, or official gation is under way. Any person who may pubblico ministero. It should be noted that, position of the Agenzia Nazionale per la have played a role in the occurrence can be according to the law, the air safety investi- Sicurezza del Volo or Politecnico di put under investigation. This does not nec- gator can not refuse to act as an expert wit- Torino.—Editor). ◆ essarily imply a punitive intent, as it allows ness, if so requested by the pubblico mini- those under investigation to enjoy the fun- stero. This form of cooperation allows the damental rights of the accused. For ex- air safety investigator to access the evidence The Challenges for ample, their defense counsels can be rapidly, with a positive effect on the crimi- present during evidence gathering or nal investigation as well. Air Safety Investigators: teardown of components and have access However, in my opinion, this compromise A Human Factors to the documents pertaining to the case. could be a threat to the effective separation Before the establishment of the ANSV, of the air safety and criminal investigations. Perspective there were a number of examples of inter- It is true that the expertise of the air safety By Sheena D. McCune ference between the criminal and the air investigator is of great assistance in the fact- safety investigation. In his book Safety is No finding phase, that there is a need for an The International Society of Air Safety Accident, William H. Tench, former chief immediate release of the evidence to the air Investigators (ISASI) is a unifying en- inspector of the U.K. AIB, cites the case of a safety investigator, and that a closer collabo- tity exchanging ideas to promote safety pubblico ministero who caused a delay in the ration with the pubblico ministero is to be awareness, education, and information readout of a flight recorder during the in- fostered, but there shouldn’t be any formal about preventable accidents and advanc- vestigation of the crash of a U.K.-registered involvement of the air safety investigator ing flight safety. ISASI, along with in- aircraft in Italy in 1969. In a study on air- with any party to a legal proceeding, be it vestigative bodies such as the FAA and craft accident investigation resources in criminal or civil. It is worth mentioning that the NTSB, are all in positions of respon- Europe sponsored by the European Com- the draft of Council Directive 94/56/EC ad- sibility to ensure that the purpose of mission, Geoffrey C. Wilkinson, former chief dressed the issue of the incompatibility be- flight safety is actively moving forward. inspector of the U.K. AIB, stated that in Italy tween the role of the air safety investigator Without “safe skies,” passengers may there was “a deep-seated distrust of the tech- and that of expert witness in legal proceed- feel uncomfortable with flight as a mode nical administration by the judiciary.” ings. This provision, among others, was de- of transportation and flood the already What has changed after the adoption of leted in the final version of the text because overcrowded roads. The challenges arise decreto legislativo n. 66/1999 and the estab- of the conflicts with existing domestic laws. for air safety investigators on multifac- lishment of the ANSV? Formally, not much A radical change in the Italian regulatory eted levels, including age gap, glass cock- because the law still gives a priority to the framework is not foreseeable in the near fu- pit displays in general aviation, un- criminal investigation over the air safety in- ture because it would require a complex re- manned aerial vehicles interfering with

July–September 2006 ISASI Forum • 23 airspace, and very light jets emerging of autonomy for UAVs is to replace the hu- find significant evidence of where to fix with personal-use consumers. All of man pilot, almost like training the UAV to and prevent the most errors. these areas entertain the news media react and perform even better than a hu- Another challenge arises during an and cause headaches for lawyers and in- man would. Although this technology will aircraft crash investigation that lacks the vestigators alike. Leading causes and reduce risk to military airmen, GA pilots cockpit voice recorder (CVR) or flight factors in aircraft accidents hold evi- may be faced with additional problems of data recorder (FDR). In this case, the dence concluding that human factors as shared airspace, causing confusion in the glass displays will leave behind no physi- the human-machine interaction is an on- sky and possible midair collisions. Aircraft cal data for investigators to capture as going concern that needs to be continu- accident investigators would then find it factual evidence. ally addressed. difficult to determine what exactly hit the The challenges described for air As a forward-moving entity, ISASI al- airplane depending on the type of crash. Ad- safety investigators, including age gap, lows relationships between younger nov- ditionally, rulemaking by the FAA will need glass cockpit displays in general aviation, ice investigators to be directly involved to be organized, because with lack of ATC unmanned aerial vehicles, and very light with senior investigators who have the communication due to non-pilots operating jets promise more research and investi- experience and wisdom that a student the UAVs, the skies may become condensed gation to keep promoting safety aware- may not be able to gain by simply read- with confusion. ness. No improvement will take place ing a book. Unfortunately, the gap be- New markets for very light jets (VLJ) unless the aeronautical field accepts and tween novice investigators and senior have allowed complex airplanes with more enforces the recommendations. investigators is rising. Valuable knowl- power to become accessible not only for For example, the FAA issued rules on edge should be passed on, but it takes smaller companies, but also for personal- runway safety area in 1999 that provide effort and organization to do so. Even use consumers. The Eclipse 500 has a buffer space free of obstacles on the pe- workshops that allow time for open con- brought innovative design, proficient per- rimeter of airports. To this day, many U.S. versations or provide starter topics at formance, and is surprisingly affordable. airports do not meet this law, and as a ISASI meetings could solve some of the The Avio Total Aircraft Integration System result, Southwest Airlines had its first age-gap problems. in this VLJ works like a software operat- fatal accident at Chicago’s Midway Air- General aviation (GA) is quickly ad- ing system for the entire airplane to en- port in December 2005. The fatality did vancing in flight technology due to glass hance safety through reducing pilot work- not occur on board the jet, but at a nearby cockpit displays. Advantages of the glass load and increasing aircraft reliability. Avio intersection, in a car that was crushed by cockpit display include the increase of issues cautions and alerts if it senses elec- the oncoming jet. situational awareness through instru- tronic trouble and can stop non-dominant Safety awareness is not always pre- ment scanning techniques. The glass functioning to locate problems. It can even dictable and may be costly or difficult to cockpits have brought concerns with re- help with checklists and emergencies. Any- provide for, as in this example of provid- gard to pilot training. Aging pilots who time a computer can override the pilot’s will, ing a runway safety area in a major city. have decades of experience with the “six a very dangerous situation is created, as Fortunately, with Congress’s help, nor- pack” may have difficulty adapting to the learned from the problems with Airbus au- malization of deviance, which occurs as newer glass cockpit, while younger pilots topilot accidents. Proactively looking at individuals or teams repeatedly accept with little experience may quickly adapt. where accidents could occur will benefit a lower standard of safety until that Most aircraft accidents and near inci- from further research and investigation to lower standard becomes the norm, can dents and accidents are preventable. be avoided by providing funding for the They usually reveal a deeper problem investigative bodies such as the FAA and that involves a series of events. The is- the NTSB. sue here with a fundamental difference Presently, the NTSB lacks minimal re- in the negative transfer of training be- sources and, therefore, lacks the time to tween the glass cockpit and the six pack complete thorough investigations of all fa- is that it could possibly be a first link in a tal accidents. Determining initial errors is chain of events leading to an accident, costly and can take microscopic evaluation especially as glass cockpits are more fre- to avoid missing factual evidence. In ex- quently put in use. Investigators will change for valuable lifesaving information, need more research in this area to de- it is priceless. As a final point, investiga- termine whether the concern for danger tors are faced with enormous responsibil- is apparent or simply cognitive theory. ity; therefore, they must take action to in- The military offers the possibility of a vestigate, make recommendations for fu- cheaper, more capable fighting machine ture design, and never stop trying to avoid that decreases risk to pilots due to ad- complacency and apathy in investigation. vancing technology with unmanned We must not become so impressed by new aerial vehicles (UAV) throughout the technology in our culture that we put civi- ◆ U.S. The ultimate goal in development McCune lization in jeopardy.

24 • ISASI Forum July–September 2006 ISASI ROUNDUP

MARC Meeting Draws Enthused Crowd

More than 75 persons, both MARC ○○○○○○○○○○○○○○○○○○○○○○ ○ ○ ○ ○ ○ ○ the guests milling about during the ○○○○○○○○○○○○○○○○○○○○○○ ○ ○ ○ ○ ○ ○ He noted that the Society now numbers Chapter members and non-members, refreshment period that preceded dinner. some 1,300 active members from 58 attended the annual Chapter gathering As dinner was being consumed, Tom countries and that the Society’s Reachout that coincides with the spring meeting of McCarthy, MARC member and ISASI program has achieved worldwide acclaim the ISASI International Council. The treasurer, began the first of a series of for its 16 investigator training efforts event has come to be a premier evening door prize raffles, and winners came conducted throughout the world. He for folks who are most interested in an forward to select from a table laden with estimated that its programs have taught international aviation safety venue to hats, models, cups, and a variety of other about 1,000 persons. In closing his exchange ideas and promote air safety prizes. The top prize of the evening was a comments, President Del Gandio made a investigators’ primary mission—the donation by AirTran of two sets of surprise presentation to Max Saint- prevention of aircraft accidents. roundtrip tickets to anywhere within its Germain, a long-term member of the MARC President Ron Schleede system. The winners of the two drawings Society’s International Council, which conducted the meeting held at the Days were guest Nancy Wright and Jayme serves as its highest governing body (see Hotel & Conference Center at Dulles in Nichols of the ISASI Florida Chapter. page 3). Herndon, Va. Before introducing the ISASI President Del Gandio spoke Sabatini then addressed the group (his guest speaker, the Federal Aviation briefly on the status of the Society, saying full remarks begin on page 4). He spoke Administration’s Associate Administrator that it was financially sound and lauding of how the industry reached its remark- for Aviation Safety Nick Sabatini, the payback of purchasing an office able level of air safety, about what the Schleede opened the buffet dinner lines to condominium versus continued renting. aviation groups must do to maintain E. MARTINEZ MARC President Ron Schleede, left, and Jim Hall relax just before pledging begins for the “match” fund scholarship fundraising.

July–September 2006 ISASI Forum • 25 ISASI ROUNDUP Continued . . . ○○○○○○○○○○○○○○○○○○○○○○ ○ ○ ○ ○ ○ ○ PHOTOS: E. MARTINEZ

ABOVE: MARC President Ron Schleede. ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ ○ ○ ○ ○ ISASI Voting ABOVE RIGHT: AirTran ticket winners Nancy Wright, left, and Jayme Nichols, Goes On Line right, are congratulated by Floy Ponder, ISASI members are being AirTran director of flying. RIGHT: Winners urged to use the newly of door prizes select their choice from a adopted on-line VoteNet table laden with donated gifts. system to vote in the current election of the pressure on the accident rate, and on the national Executive role of air safety investigators in the 21st Officers and Councillor century. positions for the years Just prior to closing the meeting, the 2007-2008 before the MARC president raised the matter of August 1 deadline. The contributions to the ISASI Rudy positions to be filled are Kapustin Memorial Scholarship Fund. president, vice-president, The Fund is a tribute to all ISASI secretary, treasurer, U.S. members who have died. It was initiated councillor, and interna- upon the death of Rudy Kapustin, who at tional councillor. All the time was president of the Mid-Atlantic incumbents, except Keith Chapter. What began as a call for Hagy, secretary, are on the contributions, which Schleede began with continued awarding of scholarships. ballot. Nominated for the position of a $100 personal pledge, was transformed Scholarship donors were $100—Vicki secretary is Chris Baum, manager of the into a $1,000 “match” rally by MARC Anderson, Jim Danaher, Barbara Dunn, Engineering and Air Safety Department member Jim Hall, former NTSB chair- Keith Hagy, Cynthia Keegan, Mike of the Air Line Pilots Association. man, and now president of Hall & Klasing, Tom McCarthy, Joe Reynolds, The goals for implementing the Associates. In all, $1,500 in pledges were Ron Schleede, and Richard Stone. The electronic ballot are to make it easier, made and that became $2,500 with the Dallas-Ft. Worth Chapter (John Darbo), faster for members to vote, and to $1,000 match by Jim Hall—a good night $300, and John Purvis, $200. Matching significantly reduce postage, labor, and for the Fund, which will enable the the first $1,000 donated, Jim Hall. ◆ materials costs. President Del Gandio

26 • ISASI Forum July–September 2006 ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ ○ ○ ○ ○ case), and click on “sign in.” This action ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ assisted throughout the workshop by the CORRECTION—ISASI 2006 takes you to your ballot (U.S., Regional/ aviation investigators Esko Lahteenmaki National Society, International). The and Hannu Melaranta of the AIB– The Fiesta Americana Grand Coral Following membership categories are not Finland. Beach Hotel in Cancun, Mexico, site eligible to vote: Affiliate, Students, The advanced accident investigation of ISASI 2006, has issued a correc- Corporate, Honorary. If any problems are workshop comprised five working days. It tion to its fax number to which all encountered, please contact Ann Schull at was conducted by Caj Frostell, Alain hotel reservations must be sent. The (703) 430-9668 or at [email protected]. Guilldou, and Ron Schleede. The workshop corrected fax number is 52-998-881- As you vote, please consider how the contained presentations on the require- 3263. The hotel reservation form International Council shapes the pro- ments and international obligations printed in the April/June ISASI grams and direction our association takes. contained in ICAO Annex 13, selection and Forum, page 25, may continue to be This is another action taken by the training of investigators, preparing used, but use the corrected fax Council to ensure that Society resources investigators and their managers for a number. A hotel reservation form is are spent in a productive manner. Your major investigation, planning and organi- also available on the ISASI website, vote counts! Remember—Your vote is zation to conduct an investigation, proce- ISASI.org. ◆ confidential! ◆ dures and checklists, underwater wreckage recovery, field investigation, accident Reachout 16 Held in site management, group organization and noted, “We depend upon the participation group progress meetings, flight recorders, of the eligible membership to make this a Helsinki, Finland technical investigation, flight operations success.” The Accident Investigation Board of investigation, off-scene testing, crashwor- To access VoteNet, go to the ISASI Finland hosted the 16th ISASI Reachout thiness, witness interviewing, human website (ISASI.org), click on VoteNet workshop. The workshop was arranged factors, family assistance, avoidance and (http://www.votingondemand.com/ISASI), for the Nordic countries (Denmark, protection of biohazards exposure, news and a menu will appear. Follow the Finland, Iceland, Norway, and Sweden) as media, factual reports and public records, instructions: Use the same password and an advanced aircraft accident investiga- writing the final report, identification of identification as you do to access the tion workshop. The workshop was opened safety deficiencies, making safety ISASI website, e.g., username (member on Monday, April 24 by the director of the recommendations, and eight interactive number), password (first name, lower AIB–Finland, Tuomo Karppinen. He was case studies. Of the participating organizations, at least four were corporate members of ISASI (AIB–Finland, AIB–Norway, AIB– ○○○○○○○○○○○○○○○○○○○○○○○○○○ Sweden, and Finnair). In addition, some of the participants were individual ISASI members. The participants expressed their appreciation to ISASI for bringing the workshop and the ISASI activities to the Nordic countries. The ISASI membership forms and ISASI corporate membership forms were made available to the participants. ◆ Engleman-Conners Leaves Safety Board Member Ellen Engleman-Conners, who served 2 years as the NTSB’s chairman, More than 30 persons from five countries attended the workshop and all received ISASI left the Safety Board on May 31. In her certificates for participation in the advanced aircraft accident investigation workshop. April 17 letter of resignation to President

July–September 2006 ISASI Forum • 27 ISASI ROUNDUP Continued . . .

2005 Annual Seminar Proceedings Now Available

Active members in good standing and corporate members purchase the Proceedings on a CD-ROM for the nominal fee may acquire, on a no-fee basis, a copy of the Proceedings of of US$15, which covers postage and handling. Non-ISASI the 36th International Seminar, held in Fort Worth, Tex., members may acquire the CD-ROM for a US$75 fee. A Sept. 12-15, 2005, by downloading the information from the limited number of paper copies of Proceedings 2005 are appropriate section of the ISASI web page at http:// available at a cost of US$150. Checks should accompany the www.isasi.org. The seminar papers can be found in the request and be made payable to ISASI. Mail to ISASI, 107 E. “Members” section. Alternatively, active members may Holly Ave., Suite 11, Sterling, VA USA 20164-5405. Speakers and Technical Papers Presented at ISASI 2005 (Listing is in order of presentation, by paper title and author.)

TUESDAY—Topic: Recent Investigations Similarities and Differences in the Characteristics of Fatal General Aviation Kam Air Flight 904—Investigation Challenges in Kabul and on Chaperi Ghar By Accidents in Several Countries By Robert Matthews, Ph.D., U.S. FAA Robert Benzon, Investigator-in-Charge, U.S. NTSB Wet (?) Runway Operations By A. Ranganathan, Capt., SpiceJet, India Accident, Serious Incident, and Incident Investigations: Different Approaches, the Turbulence Forecasting, Detection, and Reporting Technologies: Safety and Same Objective By Stéphane Corcos and Pierre Jouniaux, BEA, France Operational Benefits By Christian Amaral, Delta Air Lines Removing Pilot Errors Beyond Reason! Turning Probable Causes into Plausible *Panel 2—Post-Accident/Incident Stress Management Guidance for the Solutions By Dr. Robert O. Besco, President, PPI; Capt. (Ret.), American Investigator Brenda Tillman, Readiness Group International, and Mary Airlines Cotter, Air Accident Investigation Unit, Ireland Performance and Flight Dynamics Analysis of the Flight in Ice Accretion THURSDAY—Topic: Human Factors and Safety Management/Investigative Presented by Wen-Lin Guan, Aviation Safety Council, Taiwan, R.O.C. Techniques Are the ACAS/TCAS Safety Improvements Sufficient? By Johann Reuss, Federal Total Safety Management for Aircraft Maintenance Using Total Quality Bureau of Aircraft Accidents Investigation, Germany Management Approach By Derrick Tang, Advent Management Consulting, *Panel 1: Industry Flight Safety Information Sharing Activities Jim Ballough, Singapore AFS-1, U.S. FAA; Michelle Harper, University of Texas; Capt. Terry McVenes, Maintenance Error Prediction Modeling By Howard Leach, MRAeS, British Executive Central Air Safety Chairman, ALPA; Dr. Steve Predmore, JetBlue Airways, England Airlines; Tom O’Kane, FRAeS; Jill Sladen-Pilon, IATA System Identification Techniques Applied to Aircraft Accident Investigation WEDNESDAY—Topic: Data Analysis Presented by Donizeti de Andrade, Ph.D., ITA, Brasil Flight Data Analysis—A New Approach By Dieter Reisinger, Quality Manager Runway Awareness and Advisory System (RAAS) By Jody M. Todd, Capt., Flight Operations, Austrian Airlines, Vienna, Austria; Simone Sporer, Honeywell Aerospace Electronic Systems Psychologist, FH Joanneum/University of Applied Sciences, Department of Rotor Seizure Effects By Al Weaver, Senior Fellow Emeritus, Gas Turbine Aviation, Graz, Austria; and Gernot Knoll, Electronic and Communication Investigations Engineer, FH Joanneum/University of Applied Sciences, Department of 3-D Photogrammetric Reconstruction in Aircraft Accident Investigation By Aviation, Graz, Austria Michiel Schuurman, Investigator, Dutch Safety Board, the Netherlands A Case-Based Reasoning (CBR) Approach for Accident Scenario Knowledge Man- Do You Smell Smoke? Issues in the Design and Content of Checklists for Smoke, agement By James T. Luxhøj and Ahmet Oztekin, Department of Industrial Fire, and Fumes By Barbara Burian, Ph.D., SJSUF, NASA Ames and Systems Engineering, Rutgers, the State University of New Jersey Selecting the Next Generation of Investigators By Keith McGuire, U.S. NTSB Airline Flight Data Analysis (FDA)—The Next Generation By Michael R. Poole, Applying Human Performance Lessons to Smaller Operators By Kathy Abbott, P. Eng., Managing Partner, Flightscape, and David Mawdsley, CEng, FRAeS, Ph.D., FRAeS, Chief Scientific and Technical Advisor, U.S. FAA Director-Safety, Safety, Operations and Infrastructure, IATA Bringing Proactive Safety Methods and Tools to Smaller Operators By John Cox, Investigation of Causes of Engine Surge Based on Data in Flight Operations Capt., FRAeS, Safety Operating Systems Quality Assurance Program By C. Edward Lan, University of Kansas, and The Use of Operational Risk Management in the Royal Netherlands Air Force Capt. Samson Y.C. Yeh, Vice-President, Safety, Security, and Compliance Applied to Apache Helicopter Operations in Afghanistan By Rombout Wever, Division, China Airlines NLR, the Netherlands Practical Human Factors in the Investigation of ‘Daily Events’ By Paul The Unified Field Theory By Michael Huhn, ALPA, and Mark Solper, Jansonious, Standards Pilot, West Jet, and Elaine Parker, North Cariboo Air, Chairman, ALPA Accident Investigation Board Canada GAIN Contribution to an Airline Safety Management System By Mohammed Safety Incident Classification Systems—Made Redundant by Text Mining Tools? Aziz, Ph.D., Advisor to Chairman, Middle Eastern Airlines By Tom O’Kane, FRAeS, Aviation Safety Advisor An Analysis of Flight Crew Response to System Failures By A.L.C. Roelen, and Update: Finding Wreckage Under Water By John Fish, American Underwater Rombout Wever, National Aerospace Laboratory NLR, the Netherlands Search and Survey, and John Purvis, Safety Service International Boeing Runway Track Analysis By Mark Smith, Boeing

George W. Bush, member Engleman- ○○○○○ a member of the NTSB. Her term as ○○○○○○○○○○○○○○ ○ Aviation Department of the Ministry of Conners said: “With great humility and member was to expire on Dec. 31, 2007. ◆ Transport, Czech Republic, conducted its thankfulness, I tender my resignation as a second European Cabin Safety Sympo- member of the National Transportation ○○○○○○○○○○ sium in Prague on June 7-9. Almost 100 Safety Board effective May 31, 2006.” SCSI, Czech Republic delegates participated in the event. States She joined the Safety Board on March Conduct 2nd Cabin Safety represented were the Czech Republic, the 24, 2003, when she began a 2-year term as Symposium Netherlands, Germany, Canada, Norway, chairman and chief executive officer of the the United States, Great Britain, Ireland, agency. Since the expiration of her chair- The Southern California Safety Institute Poland, Finland, Sweden, Denmark, manship in March 2005, she has served as (SCSI), in cooperation with the Civil France, Croatia, Portugal, Lebanon, New

28 • ISASI Forum July–September 2006 Some of the 100 attendees from 18 countries show deep involvement in the cabin safety material being presented.

○○○○○○○○○○○○○○○○○○○ ○ ○ ○○○○○○○○○○○○○○○○○○○ ○ ○ trends and best practices in cabin safety training and cabin safety security and health. Information and experiences from the investigation of the year 2005 aircraft accidents were also presented. Ladislav Mika (MO4226) served as the coordinator for the event on behalf of the country’s Civil Aviation Department. He noted that the Czech Republic is “becoming quite active in the field of aviation safety within ICAO.” He gave special Zealand, and Taiwan. Representatives Michel Beland, North Atlantic Office acknowledgement to Czech Airlines, from Airbus Industrie and CAT magazine of ICAO, was the keynote speaker. The which, he said, “significantly supported also participated. content of the Symposium focused on the Cabin Safety Symposium.” ◆

Scaling Up Safety (from page 21) sifies errors made by the flight crew. This ing operational safety are well-understood and sues, followed by proper mitigation of those data is then compiled by the outside safety proven. Since small operators are held to the issues, is a time-honored methodology to company and presented to the other par- same standards as large operators and the achieve continuous improvement of aviation ticipant groups for a consensus-based virtual safety department is a reality, cost is safety. That continuous improvement in solution. no longer a viable excuse for not having a dedi- operational safety will result in cost efficiencies throughout the airline. Limited resources and he methodology to A safer airline has fewer on-the-job inju- increased expectations improve safety at the ries, often has lower insurance costs, has As the news media widely reports the air- small operator exists at fewer passenger injuries (and resulting liti- line industry’s ever-improving safety T gation), and can expect better resale price record, airline customers’ expectations of the large operator. Those for equipment. The safer airline, too, may safer flights rise accordingly. Paradoxically, successful safety solutions enjoy better relationships with the news the flying public expects the airline indus- from the greater part of the media and the regulator. try to continue to improve flight safety while The aviation industry has historically offering low-fare tickets, all in the face of industry must now be applied been a leader in safety. Our industry has record-high fuel prices. at the lesser part. The virtual the most enviable safety record in all of The current economic squeeze is affect- safety department brings public transportation. Our accident rates ing some tangential aspects of the airline proactive safety methods and have declined sharply over the years. This industry, too. Regulatory agencies (the FAA trend must continue. One method to help in the U.S.) face increased pressure on bud- tools to smaller operators keep the safety trend going in the right di- gets. Those agencies must often do more efficiently and at an rection is the utilization of all the means work with fewer personnel. Regulatory affordable price. available for the early detection and miti- oversight, while still mandated to improve gation of safety deficiencies. The method- aviation safety, is under significant fiscal cated safety department using all available ology to improve safety at the small opera- pressure. New tools are needed to facilitate safety tools. The virtual safety department tor exists at the large operator. Those suc- the administration of regulatory agencies offers the best of both worlds: the services cessful safety solutions from the greater and enhance aviation safety—concurrently. and benefits enjoyed by the larger operators part of the industry must now be applied at One way to meet the emerging safety needs at a very affordable price. the lesser part. The virtual safety depart- of the airline industry is to take big-airline All operators can now enjoy the benefit ment brings proactive safety methods and proactive safety methods to the small opera- of reduced risks and improved efficiencies. tools to smaller operators efficiently and at tors. These methods of improving and enhanc- Early detection and reporting of safety is- an affordable price. ◆

July–September 2006 ISASI Forum • 29 Guest Commentary (from page 5) ISASI Information This is how we will achieve the next level globalization, and more—we must keep of breakthrough safety technology that will our eye firmly focused on the horizon. lead the way to orders-of-magnitude We also know that risk will always be reduction in fatality risk—sharing safety higher than zero. U.S. airlines have more information in a more powerful way than than 30,000 daily flights. This will likely ever before—and desperately needed to surpass 40,000 daily flights in the not-too- keep pace with the planned increases in distant future. In a system of this size and transportation system capacity. complexity, fatal accidents will not go away. OFFICERS Earlier this year, we established an I applaud the work ISASI is doing to President, Frank Del Gandio ([email protected]) look ahead. You recognize that the role of Executive Advisor, Richard Stone air safety investigators is changing. You ([email protected]) Vice-President, Ron Schleede applaud the work ISASI is know that we are no longer domestic or ([email protected]) international or even global. We are now in Secretary, Keith Hagy Idoing to look ahead. You ([email protected]) space. Increasingly, machines and technol- Treasurer, Tom McCarthy recognize that the role of air ogy will be different. The medical issues ([email protected]) safety investigators is will be different. The human factors issues changing. You know that we will be more complex. In addition, business COUNCILLORS Australian, Lindsay Naylor are no longer domestic or models are changing, as is the infrastruc- ([email protected]) ture of the entire National Aviation System. Canadian, Barbara Dunn international or even global. ([email protected]) What skills do we need in future air European, Max Saint-Germain We are now in space. safety investigators? ([email protected]) International, Caj Frostell Increasingly, machines and Keith McGuire put it plainly at ISASI ([email protected]) 2005. Top of the list—and this won’t New Zealand, Ron Chippindale technology will be different. ([email protected]) change—is “logical thought process.” United States, Curt Lewis The medical issues will be McGuire also listed strong interpersonal ([email protected]) different. The human factors skills, psychological and physical prepared- issues will be more complex. ness, and a person who is continually NATIONAL AND REGIONAL learning. A person who is continually SOCIETY PRESIDENTS Australian, Kenneth S. Lewis Aviation Safety Analytical Unit headed by learning, that is especially important with ([email protected]) Jay Pardee. Jay headed our Engine and the rate of change we’re experiencing. Canadian, Barbara M. Dunn ([email protected]) Propeller Directorate. In his new role, Jay Would you have imagined just several European, Ken Smart and his team will pick up the analytical years ago the activity we’re seeing today ([email protected]) Latin American, Guillermo J. Palacia work that Jay did for CAST, as well as with very light jets, light sport aircraft, (Mexico) work with NASA on Aviation Safety Infor- unmanned aircraft, and commercial space? New Zealand, Peter Williams ([email protected]) mation Analysis and Sharing Systems A few weeks ago we lost one of Russian, V. Venkov (ASIAS). aviation’s greats—Scott Crossfield. As a ([email protected]) SESA-France Chap.,Vincent Fave In addition, the new unit will support boy, Crossfield watched Boeing’s test pilot ([email protected]) Jay’s work as the FAA aviation safety Eddie Allen fly, and he took the advice he United States, Curt Lewis ([email protected]) lead for the Joint Planning and Develop- got seriously: “Be an engineer. Help build ment Office (JPDO) Safety Integrated the airplanes. Then fly them and find out Product Team, or IPT. The Safety IPT is what you did wrong.” committed to implementing a Safety Fly them and find out what you did Management System within JPDO and its wrong. We will not always have that luxury. member governmental agencies and We need to use every tool, every skill, and customers. A Safety Management System every resource that we can bring to bear to will set the standards for safety culture enhance safety. Those tools, skills, and and safety risk management. Its founda- resources include accident investigators, tion will be based on aviation safety yes, to look back, and leveraging informa- information analysis and sharing. tion and analysis to look forward to Another assignment for the analytical anticipate to prepare and prevent. That’s unit is, quite simply, looking ahead. Often how all of us in aviation will improve safety we get so caught up responding to today’s and save lives. It does not get any more issues that we don’t make the time to look rewarding than that. ahead and see what’s coming, what it is That’s what you as professional air we will need to address. With growing safety investigators do, and you do it demand, introduction of new aircraft, extremely well. ◆

30 • ISASI Forum July–September 2006 UNITED STATES REGIONAL CORPORATE MEMBERS Exponent, Inc. Federal Aviation Administration CHAPTER PRESIDENTS Accident Investigation Board, Finland Finnair Oyj Alaska, Craig Beldsoe Accident Investigation Board/Norway Flight Attendant Training Institute at ([email protected]) Aeronautical & Maritime Research Laboratory Melville College Arizona, Bill Waldock ([email protected]) Accident Investigation & Prevention Bureau Flight Safety Foundation Dallas-Ft. Worth, Curt Lewis AeroVeritas Aviation Safety Consulting, Ltd. Flight Safety Foundation—Taiwan ([email protected]) Air Accident Investigation Bureau of Singapore Flightscape, Inc. Florida, Ben Coleman ([email protected]) Air Accident Investigation Unit—Ireland Galaxy Scientific Corporation Great Lakes, Rodney Schaeffer Air Accidents Investigation Branch—U.K. GE Transportation/Aircraft Engines ([email protected]) Air Canada Pilots Association Global Aerospace, Inc. Los Angeles, Inactive Air Line Pilots Association Mid-Atlantic, Ron Schleede Hall & Associates, LLC Air New Zealand, Ltd. Hellenic Air Accident Investigation ([email protected]) Airbus S.A.S. Northeast, David W. Graham ([email protected]) & Aviation Safety Board Airclaims Limited Honeywell Pacific Northwest, Kevin Darcy Aircraft Accident Investigation Bureau— ([email protected]) Hong Kong Airline Pilots Association Switzerland Hong Kong Civil Aviation Department Rocky Mountain, Gary R. Morphew Aircraft Mechanics Fraternal Association ([email protected]) IFALPA San Francisco, Peter Axelrod Aircraft & Railway Accident Investigation Independent Pilots Association ([email protected]) Commission Int’l. Assoc. of Mach. & Aerospace Workers Southeastern, Inactive Airservices Australia Interstate Aviation Committee AirTran Airways Irish Air Corps COMMITTEE CHAIRMEN Alaska Airlines Japan Airlines Domestic Co., LTD Alitalia Airlines—Flight Safety Dept. Japanese Aviation Insurance Pool Audit, Dr. Michael K. Hynes All Nippon Airways Company Limited ([email protected]) JetBlue Airways Allied Pilots Association KLM Royal Dutch Airlines Award, Gale E. Braden ([email protected]) American Eagle Airlines L-3 Communications Aviation Recorders Ballot Certification, Tom McCarthy American Underwater Search & Survey, Ltd. Learjet, Inc. ([email protected]) ASPA de Mexico Lockheed Martin Corporation Board of Fellows, Ron Chippindale Association of Professional Flight Attendants Lufthansa German Airlines ([email protected]) Atlantic Southeast Airlines—Delta Connection MyTravel Airways Bylaws, Darren T. Gaines ([email protected]) Australian Transport Safety Bureau National Air Traffic Controllers Assn. Code of Ethics, John P. Combs Aviation Safety Council National Business Aviation Association ([email protected]) Avions de Transport Regional (ATR) National Transportation Safety Board Membership, Tom McCarthy ([email protected]) BEA-Bureau D’Enquetes et D’Analyses NAV Canada Nominating, Tom McCarthy ([email protected]) Board of Accident Investigation—Sweden Phoenix International, Inc. Boeing Commercial Airplanes Reachout, James P. Stewart ([email protected]) Pratt & Whitney Bombardier Aerospace Regional Aircraft Seminar, Barbara Dunn ([email protected]) Qantas Airways Limited Bundesstelle fur Flugunfalluntersuchung—BFU Qwila Air (Pty) Ltd. Cathay Pacific Airways Limited Republic of Singapore Air Force WORKING GROUP CHAIRMEN Cavok Group, Inc. Rolls-Royce, PLC Air Traffic Services, John A. Guselli (Chair) Centurion, Inc. Royal Netherlands Air Force ([email protected]) China Airlines Royal New Zealand Air Force Ladislav Mika (Co-Chair) ([email protected]) Cirrus Design RTI Group, LLC Cabin Safety, Joann E. Matley Civil Aviation Safety Authority Australia Sandia National Laboratories ([email protected]) Colegio De Pilotos Aviadores De Mexico, A.C. Saudi Arabian Airlines Corporate Affairs, John W. Purvis Comair, Inc. SICOFAA/SPS ([email protected]) Continental Airlines Sikorsky Aircraft Corporation Continental Express Flight Recorder, Michael R. Poole Skyservice Airlines Ltd. COPAC/Colegio Oficial de Pilotos de la Singapore Airlines, Ltd. ([email protected]) Aviacion Comercial General Aviation, William (Buck) Welch SNECMA Moteurs Cranfield Safety & Accident Investigation Centre South African Airways ([email protected]) DCI/Branch AIRCO Government Air Safety, Willaim L. McNease South African Civil Aviation Authority Delta Air Lines, Inc. Southern California Safety Institute ([email protected]) Directorate of Aircraft Accident Investigations— Human Factors, Dr. Robert C. Matthews Southwest Airlines Company Namibia Star Navigation Systems Group, Ltd. ([email protected]) Directorate of Flight Safety (Canadian Forces) State of Israel Investigators Training & Education, Directorate of Flying Safety—ADF Transport Canada Graham R. Braithwaite Dutch Airline Pilots Association Transportation Safety Board of Canada ([email protected]) Dutch Transport Safety Board U.K. Civil Aviation Authority Positions, Ken Smart EL AL Israel Airlines UND Aerospace ([email protected]) EMBRAER-Empresa Brasileira de University of NSW AVIATION Aeronautica S.A. University of Southern California Embry-Riddle Aeronautical University Volvo Aero Corporation Emirates Airline WestJet ◆ Era Aviation, Inc. European Aviation Safety Agency EVA Airways Corporation

July–September 2006 ISASI Forum • 31 WWHO’SHO’S W WHOHO

Aircraft Mechanics Fraternal Association ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ (Who’s Who is a brief profile of, and ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ counsel before presenting it to the relations advice, insurance/pension prepared by, the represented corporate company. When a contract is submitted to actuaries, and national administration. member organization to enable a more AMFA-represented technicians and National officers oversee these profes- thorough understanding of the organiza- related members for a vote, the entire sionals and report to the membership. tion’s role and function.—Editor) contract is presented, not merely a Candidates for national office need the summary or highlights sheet. endorsement of only one local to have his he Aircraft Mechanics Fraternal Except for negotiations under bank- or her name placed on the ballot. National Association (AMFA) is a craft- ruptcy, AMFA has never accepted officers are subject to the same recall Toriented, independent aviation union. concessions, give-backs, two-tier pay procedures as local officials. It is not an industrial union and represents scales, or “B” rate mechanics. One reason only airline technicians and related for this is that the local airline representa- Safety & Standards employees in the craft or class in accor- tives, who are well- AMFA is involved in ASAP (Aviation dance with the National Mediation Board acquainted with their Safety Action Program) at three of its rules and their dictates. AMFA is commit- airline’s problems, are carriers to date. This is an FAA-approved ted to elevating the professional standing at the bargaining table program designed to obtain safety- of technicians and to achieving progressive with the national sensitive information from an event that is improvements in the wages, benefits, and officers. AMFA also then utilized to prevent reoccurrences of working conditions of the skilled craftsmen believes in having its members attend and mishaps, incidents, etc., and to develop and women it represents. observe contract negotiations. Although prevention strategies with the data that AMFA was created in 1962 but did not this is considered by many to be a novel are obtained. Participants are the FAA, represent any carrier until Ozark Airlines idea, AMFA has been doing this in nego- AMFA, and the airline, all of which sign an in 1964. It later represented Pacific Air- tiations for years, and it has helped both MOU and each has a voting member on lines, Airlift International, Hughes Air- sides to understand the problems and the ERC (Event Review Committee).Addi- west, and Southern Airways. AMFA’s craft issues that must be resolved at the tionally AMFA has Go Teams trained and union now represents aircraft maintenance bargaining table. ready to assist the NTSB in the party technicians and related support personnel process for all of its represented airlines.

at Alaska Airlines, ATA, Horizon Air, ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ Structure Training is provided to team members on Mesaba Airlines, Northwest Airlines, Local officers and representatives are accident investigation, and members Southwest Airlines, and United Airlines. elected by the local membership and can attend classes conducted at the NTSB The goal of AMFA is to have all airline be recalled by the membership. A petition Academy. AMFA works with the Air Line technicians and related employees under signed by 25 percent of the members Pilots Association (ALPA) and has sent

the AMFA “umbrella.” Its mission is to begins the recall procedure. The national ○○○○○○○ many folks to the ALPA advanced accident raise the standards of and increase recog- office assists the locals throughout the investigation training course. Annually it nition of the technician and related class system. The National Executive Council conducts a Safety & Standards Chairman or craft for the protection of the profes- hires professionals to provide CPA training course held in conjunction with sion, and to afford protection for AMFA accounting, legal representation, labor industry forums. ◆ members before government agencies and expand the education of members’ rights and privileges before Congress ISASI NON-PROFIT ORG. whenever it pertains to the craft. 107 E. Holly Ave., Suite 11 U.S. POSTAGE Sterling, VA 20164-5405 PAID USA Permit #273 Negotiations ANNAPOLIS, MD AMFA employs professionals at the bargaining table to present and utilize their particular expertise. For example, in economic areas AMFA hires a financial expert; in the pension and welfare areas it hires a pension actuary. The contract language is reviewed by AMFA’s legal

32 • ISASI Forum July–September 2006