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JANUARY-MARCH 2016 Journal of the International Society of Air Safety Investigators

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JANUARY-MARCH 2016 Journal of the International Society of Air Safety Investigators Air Safety Through Investigation JANUARY-MARCH 2016 Journal of the International Society of Air Safety Investigators Independence Does Not Mean Isolation Page 4 A New Tool for Analyzing the Potential Influence of Vestibular Illusions Page 6 Investigating the Voyager Pitch-Down Incident Page 13 Investigating Human Fatigue Factors: A Tale of Two Accidents Page 18 Unstable Approaches: A Global Problem Page 22 January-March 2016 ISASI Forum • 1 CONTENTS Air Safety Through Investigation Journal of the International Society of Air Safety Investigators FEATURES Volume 49, Number 1 4 Independence Does Not Mean Isolation Publisher Frank Del Gandio Richard B. Stone By Rémi Jouty, Director, Bureau d’Enquêtes et d’Analyses pour la sécurité de Editorial Advisor Editor Esperison Martinez l’aviation civile (BEA), France—Remarks presented by Director Jouty in his keynote Design Editor Jesica Ferry address to the delegates of the ISASI 46th annual international conference on air safety Associate Editor Susan Fager accident investigation. ISASI Forum (ISSN 1088-8128) is published quar- terly by the International Society of Air Safety 6 A New Tool for Analyzing the Potential Influence of Investigators. Opinions expressed by authors do Vestibular Illusions not necessarily represent official ISASI position or policy. By Randall J. Mumaw, Associate Technical Fellow, Human Factors, Boeing; Eric Groen, Senior Scientist, TNO; Lars Fucke, Lead Engineer, Boeing; Richard Editorial Offices:Park Center, 107 East Holly Anderson, Senior Accident Investigator, Boeing; Jelte Bos, Senior Scientist, TNO Avenue, Suite 11, Sterling, VA 20164-5405. Tele- phone 703-430-9668. Fax 703-430-4970. E-mail and Professor, VU University; and Mark Houben, Research Scientist, TNO— address, [email protected]; for editor, espmart@ Boeing saw the need for a valid, accessible tool that allows investigators to look at comcast.net. Internet website: www.isasi.org. flight data and determine if spatial disorientation may have contributed to pilot ISASI Forum is not responsible for unsolicited control inputs. manuscripts, photographs, or other materials. Unsolicited materials will be returned only if submitted with a self-addressed, stamped enve- 13 Investigating the Voyager Pitch-Down Incident lope. ISASI Forum reserves the right to reject, By Col. Crispin Orr, Head of the UK Military Air Accident Investigation Branch— delete, summarize, or edit for space con- siderations any submitted article. To facilitate The Voyager investigation is a case study of civil/military cooperation demonstrating editorial production processes, American Eng- that independence most certainly does not mean isolation. lish spelling of words is used. 18 Investigating Human Fatigue Factors: A Tale of Two Copyright © 2016—International Society of Air Safety Investigators, all rights reserved. Publica- Accidents tion in any form is prohibited without permis- By Katherine Wilson, Ph.D., Human Performance and Survival Factors Division, sion. ISASI Forum registered U.S. Patent and T.M. Office. Opinions expressed by authors do U.S. National Transportaton Safety Board—The key to any robust investigation is not necessarily represent official ISASI position to ask the right questions and gather as much data as possible to ensure important or policy. Permission to reprint is available upon fatigue-related factors are not being missed. application to the editorial offices. 22 Unstable Approaches: A Global Problem Publisher’s Editorial Profile: ISASI Forum is print- ed in the United States and published for profes- By David Ross (MO5600), Senior Regional Operations Investigator, Transporta- sional air safety investigators who are members tion Safety Board of Canada—Teamwork is essential in every investigation, and of the International Society of Air Safety Inves- investigators should be encouraged to surround themselves with experts and to tigators. Editorial content emphasizes accident investigation findings, investigative techniques collaborate with them. and experiences, regulatory issues, industry ac- cident prevention developments, and ISASI and member involvement and information. DEPARTMENTS Subscriptions: A subscription to members is pro- 2 Contents vided as a portion of dues. Rate for nonmem- 3 President’s View—ISASI Welcomes New Year bers (domestic and Canada) is US$28; Rate for nonmember international is US$30. Rate for all 30 ISASI Information libraries and schools is US$24. For subscription 32 Who’s Who—Embry-Riddle Aeronautical University information, call 703-430-9668. Additional or replacement ISASI Forum issues: Domestic and Canada US$4; international member US$4; do- mestic and Canada nonmember US$6; interna- ABOUT THE COVER tional nonmember US$8. The shown engineering flight animation was one of the components of the Transportation Safety Board (TSB) of Canada investigation process in the de- velopment of the sequence of events leading to the unstable approach accident of the Boeing 737-210C operating as First Air Flight 6560 from Yellowknife, Northwest Territories, to Resolute Bay, Nunavut, on Aug. 20, 2011 (see page 22). TSB photo. INCORPORATED AUGUST 31, 1964 2 • January-March 2016 ISASI Forum PRESIDENT’S VIEW ISASI Welcomes New Year By Frank Del Gandio, President n behalf of all your elected ISASI by the UAS Working Group, achieved who spoke about officers and appointed chair- continuing growth of students selected to developing inves- men of committees and working receive ISASI’S Kapustin memorial schol- tigative capabil- Ogroups, I wish all Society mem- arships, celebrated the award of the first ities. Another 13 bers and supporters a healthy, prosper- ISASI–Robertson Family Aviation Safety presentations ous, and happy new year. Fellowship endowed by ISASI’s Lederer covered biohaz- I am sure that 2016 will bring collec- Award recipient Dr. Harry Robertson, and ards, investigator tive and individual challenges as we go saw continuing growth in safety confer- safety, analysis, about our tasks of making the skies safer ences conducted by our ISASI societies. manufacturer through analytic, thorough, and con- In this regard, I attended the Middle support, chal- clusive accident investigations aimed at East and North Africa Society (MENA- lenges of sea determining cause and not blame. I am SASI) third annual seminar in November search and recovery operations, and equally sure that we are up to the task of 2015. The seminar was held at the Inter- family assistance. meeting such challenges. continental Hotel Festival City in Dubai, “Young Investigators Presentations” In 2015, the Society enlarged its scope United Arab Emirates (UAE). The event, were given by Fatima Al Mansoori of Abu of activities to service the broader land- hosted by the general civil aviation au- Dhabi University and Crystal Ioannou scape of air safety. For example, we have thority, with sponsorship from Airbus, Eti- of the Emirates Aviation University. Al achieved unprecedented involvement in had Airways, Emirates Airline, flydubai, Mansoori gave a presentation titled “As- International Civil Aviation Organiza- and the Gulf Aviation Academy, attracted similating Western-Based Crew Resource tion (ICAO) deliberations, seen greater 120 attendees. Management into a Middle Eastern attention to issues in both our working Speakers included Marcus Costa, chief Culture—A Personal Perspective,” and groups and committees, established two of air accident investigation for ICAO, Ioannou gave her presentation on “The new working groups: Airports and Critical who updated the delegates on control Good, the Bad, and the Ugly: The True Incident Stress Management (CISM), of information initiatives at ICAO; Keith Story Between SMS and Reality.” published the ISASI Unmanned Aircraft Conradi, chief inspector of the UK Air Workshops on aviation insurance and System (UAS) Handbook and Accident/ Accidents Investigation Branch, who human factors were held prior to the Incident Investigation Guidelines prepared discussed a series of North Sea helicopter seminar. These were very informative and accidents; Dr. were attended by more than 80 delegates. Edna Naddaf, MENASASI is growing very rapidly a corporate in both individual and corporate mem- and aviation bership. The next MENASASI seminar is psychology scheduled to take place in November 2016 consultancy, in Rabat, Morocco. The 2017 MENASASI who gave an seminar will be held in Saudi Arabia. The interesting MENASASI group has committed and is presentation currently planning to host the interna- on the role tional ISASI conference to be held in fall of aviation 2018 in Dubai, UAE. psychology Since its founding in August 2013, in building MENASASI has exhibited phenomenal a culture of growth. This is recognition of ISASI’s safety; and international value and a tribute to Capt. Ibrahim MENASASI President Ismaeil Al Hosani Koshy, direc- and his colleagues at the Air Accident tor general of Investigation Sector of the UAE General the Aviation Civil Aviation Authority. Investigation I close this message with the knowledge Shown are some of the 120 participants who attended the Middle East Bureau of the that with your help our Society will move and North Africa Society’s third annual conference held in Dubai, United Kingdom of forward into 2016 in a positive and Arab Emirates. Saudi Arabia, productive way. January-March 2016 ISASI Forum • 3 opportunity to improve safety.” This is obviously our domain, we safety INDEPENDENCE investigators. It is also a domain in which reg- DOES NOT MEAN ISOLATION ulators, manufacturers,
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