OCTOBER–DECEMBER 2005 Cow Town Corrals ISASI 2005
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OCTOBER–DECEMBER 2005 Cow Town Corrals ISASI 2005 (Page 5) Rawson Earns Lederer Award (Page 12) Carly Reil: 2005 ISASI Rudy Kapustin Scholarship Awardee (Page 14) The Problems Facing Air Safety Investigators (Page 15) The ‘Why’ of a Fatal Double Engine Flame-out (Page 16) The Role of Lessons Learned (Page 20) ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ CONTENTS “Air Safety Through Investigation” FEATURES Volume 38, Number 4 Publisher Frank Del Gandio Editorial Advisor Richard B. Stone 5 Cow Town Corrals ISASI 2005 Editor Esperison Martinez By Esperison Martinez, Editor—Aviation safety investigators from 37 countries Design Editor William A. Ford brought an international aviation flavor to Fort Worth, Tex., the place where “the West Associate Editor Susan Fager begins” and now home to many aviation interests—and the area responded by Annual Report Editor Ron Schleede spreading its hospitality upon them. ISASI Forum (ISSN 1088-8128) is pub- lished quarterly by International Society of 12 Rawson Earns Lederer Award Air Safety Investigators. Opinions ex- By Esperison Martinez, Editor—The 2005 Jerome F. Lederer Award recipient is a pressed by authors do not necessarily rep- “don’t tell me, show me” type of investigator. resent official ISASI position or policy. Editorial Offices: Park Center, 107 East Holly Avenue, Suite 11, Sterling, VA 20164- 14 Carly Reil: 2005 ISASI Rudy Kapustin 5405. Telephone (703) 430-9668. Fax (703) 430- Scholarship Awardee ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ 4970. E-mail address [email protected]; for edi- tor, [email protected]. Internet website: By Esperison Martinez, Editor—Insightful and confident best describes the 2005 www.isasi.org. ISASI Forum is not responsible scholarship winner. She is 21-year-old senior at Embry-Riddle Aeronautical Univer- for unsolicited manuscripts, photographs, or sity, Fla., and a member of the ISASI student chapter at the school. other materials. Unsolicited materials will be returned only if submitted with a self-ad- dressed, stamped envelope. ISASI Forum 15 The Problems Facing Air Safety Investigators reserves the right to reject, delete, summa- By Carly Reil—The author’s winning essay entry that gained her the 2005 ISASI rize, or edit for space considerations any sub- mitted article. To facilitate editorial produc- Rudy Kapustin Scholarship, awarded at ISASI 2005. tion processes, American-English spelling of words will be used. 16 The ‘Why’ of a Fatal Double Engine Flame-out Copyright © 2005—International Society By Peter Coombs, Air Accident Investigation Branch, U.K. —Investigation of Air Safety Investigators, all rights re- of a Shorts SD 360 turboprop flame-out produces a new approach to powerplant served. Publication in any form prohibited without permission. ISASI Forum regis- investigation and an unusual cause is determined. tered U.S. Patent and T.M. Office. Opinions expressed by authors do not necessarily rep- 20 The Role of Lessons Learned resent official ISASI position or policy. Per- mission to reprint is available upon applica- By Dr. Paul Werner and Richard Perry, Sandia National Laboratories, U.S.A.— Avail- tion to the editorial offices. able data, facts, and histories make it painfully obvious that most, if not all, accidents Publisher’s Editorial Profile: ISASI Fo- followed one or more precursors or previous accidents that were not acted upon. rum is printed in the United States and pub- lished for professional air safety investiga- tors who are members of the International DEPARTMENTS Society of Air Safety Investigators. Edito- rial content emphasizes accident investiga- 2 Contents tion findings, investigative techniques and 3 President’s View experiences, regulatory issues, industry ac- 4 Advisor’s Corner cident prevention developments, and ISASI and member involvement and information. 26 ISASI RoundUp 30 ISASI Information Subscriptions: Subscription to members is provided as a portion of dues. Rate for non- 32 Who’s Who—A brief corporate member profile members is US$24 and for libraries and of VNV: Dutch Airline Pilots Association schools US$20. For subscription informa- tion, call (703) 430-9668. Additional or re- placement ISASI Forum issues: members US$3, nonmembers US$6. ABOUT THE COVER John D. Rawson, left, accepts the 2005 Jerome F. Lederer Award from ISASI President Frank Del Gandio during ceremonies at the Society’s annual seminar (see page 12). The award is the highest laudation bestowed by ISASI. Photo: Esperison Martinez, Editor. 2 • ISASI Forum October–December 2005 PRESIDENT’S VIEW Welcome to Texas By Frank Del Gandio, President (President Del Gandio’s September 13 opening ○○○○○○○○○○○○○○○○○○○○○○○○ In just 5 short weeks a good story turned into a bad story, remarks to the delegates of ISASI 2005 have with six major accidents and some 500 fatalities. This brought been abbreviated.—Editor) the total to eight major jet accidents, seven major turboprop accidents, and close to 800 fatalities in air carrier passenger Texas has always had a special place in American operations since we last met. Clearly, the past year or so has not folklore. To most Americans and to many people been such a good story. in other lands, Texas symbolizes open space, self- All the major accidents of the past year remind us that when reliance, and, perhaps most of all, size—everything associated major accidents occur, the basic scenarios are all too familiar. For with Texas is BIG. The state is nearly twice the size of Japan, or example, of the major accidents I mentioned, we had five CFITs, 1,000 square miles bigger than France, Belgium, the Nether- four undershoots, one windshear, and one fuel exhaustion. In lands, Luxembourg, and Denmark combined. short, when things go wrong, we continue to see the usual It’s fitting that we should meet in Dallas-Fort Worth, an area suspects. rooted in transportation: first as an early cattle town, then as an Yet, the long-term story remains a good one. Just a few early railroad center; now as an aviation center with two of the short years ago, we would have been thrilled with “only” eight world’s four largest air carrier fleets in American and South- major jet accidents. In fact, we can expect the long-term west, and the world’s largest regional airline in American Eagle. improvement in accident rates to continue and even to acceler- The region also is home to DFW, one of the world’s largest ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ ate. We will continue to see more application of satellite airports and to Love Field. The region also has an important navigation, such as RNP and Local Area Augmentative System history in aircraft manufacturing: General Dynamics and Bell (LAAS) or WAAS. Helicopters and other aerospace firms. Yes, aviation has a strong On the design side, manufacturers continue to make major presence here. advances in their ability to test new designs and materials, Our strong presence is in aviation safety. Once again, the past complete with lifecycle testing, before an actual aircraft is ever year’s accident rate reminds us that we who work in air accident built. The cockpit, too, will continue to advance with synthetic investigation and aviation safety are not at risk of going out of and enhanced vision, vertical situation display, energy-state business. But I must tell you that when I first drafted my displays, electronic flight bags, fault isolation, etc. These are just comments in mid-July, I was touting the wonderfully safe year some of the improvements that are under way or very close at that we had. At that time, the log showed four jet accidents of hand in the airline world. note, worldwide, with 185 fatalities, most of which occurred in a As promising as the future is for air carriers, the real revolu- single event. tion in aviation safety is coming in general aviation. Except Noteworthy jet accidents included the Kam Air CFIT perhaps for large corporate jets at the very top of the market, accident in Afghanistan killing 104; a China Eastern RJ takeoff technology in general aviation had stagnated for years. That crash killing 53; a high-speed overrun by Lion Air of Indonesia state of affairs is finally changing, and fast! killing 25; and an Iranian B-707 that landed long and overran at General aviation has incorporated satellite technology into the high speed into a river, drowning 3 of 176 occupants. Then, I cockpit with precision navigation, much better displays, data planned to add a fairly short list of five significant turboprop link, air-to-air monitoring, on-board diagnostics—the whole accidents, with 99 fatalities. Overall, I was prepared to argue package. Suddenly the term “glass cockpit” is part of the general 2005 was a good year with continued long-term improvements in aviation vocabulary. Every established manufacturer now offers air safety, particularly at the air carrier level. a glass cockpit of one degree or another. New aircraft like the However, as I was working on that draft, an AN-24 crashed on Cirrus SR-20 and SR-22 and the Diamond DA-40 already show climb-out in Equatorial Guinea, killing all 62 occupants. Then 2,000 aircraft on the U.S. registry. These will soon be followed by came August and early September: On August 2, an Air France micro-jets, such as the Adam-700, the Citation Mustang, the A340 overran at high speed in Toronto, with no fatalities but a Diamond D-Jet, and the Eclipse. badly burned-out airplane. Just 4 days later, a Tunisian ATR 72 In short, the air carrier industry, particularly among the ditched off the coast of Sicily, killing 16 of 39 occupants. Then richer countries of the world, already has achieved accident rates came the Helios Airways B-737-300 in Greece (121 fatal), the that we thought were beyond reach just a few years ago, and Colombian MD-80 that crashed in Venezuela (160 fatal), then a those rates will continue to improve.