OCTOBER–DECEMBER 2005 Cow Town Corrals ISASI 2005

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 published 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 editor, [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-addressed, 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 submitted 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 published for professional air safety investigators 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 information, 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. Meanwhile, we still have B-737-200 operated by TANS of Peru, killing 40 people. Finally, some work to do, and our annual seminars offer a chance to a B-737-200 crashed on climb-out in Indonesia, killing 111 on improve our skills and understanding of a broad range of issues board and up to 50 people on the ground. in accident investigation and aviation safety in general. ◆

October–December 2005 ISASI Forum • 3 Advisor’S CORNER

ISASI Website Gets New Look By Richard Stone, Executive Advisor

At its May 2005 meeting, ○○○○○○○○○○○○○○○○○○○○○○○○ ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ the International Council determined that the Society’s website required change to meet some new needs. Up to this point, Corey Stephens, with support from corporate member the Air Line Pilots Association (ALPA), had developed and maintained the existing site at minimal cost to ISASI. We all appreciate that vital service Corey and ALPA provided. However, it appeared that the web update and maintenance would require more time and resources than could be provided on a volunteer basis. We turned ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ to a commercial concern, Communications by Design (CBD), a full-service technology company that provides repair, instruction, web hosting, and design. After extensive exploratory sessions with Ann Schull, ISASI office manager, and myself, CBD has redesigned and expanded, forward a donation to ISASI (tax free for • Reachout Workshops—program by category, our website to allow for high U.S. residents). defined and workshop reports (14). efficiency with timely updates. • ISASI Kapustin Scholarship— • Corporate Members—list of corporate The changeover to the new server is provides history, past winners and essays, members. When a listing is “clicked,” the now accomplished. Members and the application instructions, and form. user is taken to the appropriate Internet general public can access the site using • Jerry Lederer Award—provides website. the same web address, http:// history, past winners, nomination instruc- Another significant change is that the www.isasi.org. The changes involve a new tions, and form. membership, corporate directories, and overall page design and website expan- • Members Only—two sections: (1) the bibliography of Forum articles are sion that presents these nine categories: Requires sign in to access individual, now maintained from the ISASI computer • About ISASI—two sections: (1) corporate, or bibliography database. “User system. This means that our office General—history, positions, guidelines; name” and “password” restrict access. manager can make additions, deletions, or (2) Join—member classification defini- Each member in good standing can enter other changes in a more timely fashion. tions, applicable forms to join, upgrade his or her member number in the “user Most of the other information on the classification, and reinstate membership. name” space and the member’s first name web page is housed in the host computer • Contact Us—provides contact infor- will be the “password.” All entries should system of Communications by Design. All mation for all elected officials, all chair- be made in lowercase letters; (2) Publica- matters pertaining to changing, updating, men of working groups and committees, tions & Governance—Forum magazine, or editing any of the material on the Forum magazine, safety-related aviation Proceedings, ISASI By Laws, Code of website should be submitted to Ann resource Internet links, and the Govern- Ethics and Conduct, International Council Schull at [email protected] by the first of ment Air Safety Investigators Group meeting minutes. (When downloading, the month; changes will occur monthly. Directory, which lists all official govern- members should be aware that the Forum Submission and corrections by commit- mental investigation authorities world- material and Proceedings files are lengthy tee/working group chairpersons should wide, whether or not the authorities are and can be time consuming to download.) follow the above procedures. This also members of ISASI. • Promotional Items—regalia wear and applies to placing announcements on the • Donations—directions and form to order form. home page. ◆

4 • ISASI Forum October–December 2005 PHOTOS: E. MARTINEZ

verything about Texas is BIG, ISASI once drove longhorns to market and played the prizes were domestic and international EPresident Frank Del Gandio told the as- in poker and piano saloons. airline tickets, many models of airliners, and sembled attendees when he opened Owing to the tightly woven programming an array of smaller, but useful, prizes. A ISASI 2005 in Fort Worth, Tex., which is of the event, tourist sights had to be seen highly appreciated innovation was the es- more reverently thought of in terms of before the seminar start date or after its tablishment of a “network café” donated by “Cow Town, where the West begins.” So, it end date. Some attendees managed to do RadioShack, which gave attendees com- is fitting that this year’s seminar earned the this, as the majority registered on Sunday puter and printer access, including Internet tag of “one of the biggest” yet held: 431 to- with the seminar opening on Tuesday. The and e-mail capability. tal overall participants. This number rep- registration welcoming kit contained an resents 390 delegates and 41 companions. hour-by-hour agenda of the occurring Tutorials The 1-day tutorial program attracted 145 events; full details of the local areas, includ- While the seminar is a 3-day event, it is a attendees, also a high for that part of the ing easily read maps, dining locations, and weeklong affair because of the full day of event. In all, 37 countries were represented tourist brochures. tutorials that occur on the first day of the in the makeup of the delegates. Other innovations developed by the semi- week and the post-seminar social tour that City Mayor Mike Moncrief invited all to nar planners included a vastly energized occurs on the last day of the week. This year explore the city of “cowboys and culture,” and enlarged exhibitors’ area. In all, 29 com- was no exception and the two tutorials nicely blending in the city’s preserved his- panies opted to display their services at this squared nicely with the overall program toric past with its successful urban renais- ISASI event. The exhibit area was adjacent theme “Investigating New Frontiers in sance. What the delegates quickly discov- to the main hall, so the space was very busy Safety.” The first tutorial dealt with helicop- ered was that their “corral” was the city’s during all coffee breaks and pre- and post- ter accident investigation basics and the sec- Sundance Square, which is filled with res- event times. Many of the exhibitors also ond with emergency response preparedness. taurants, theaters, night clubs, and the ex- gained “sponsor” status by contributing The helicopter session was very apro- pansive two-city-block large Renaissance funds to the success of the seminar. This pos for the area as Fort Worth is the home Worthington Hotel, the conference hotel. year, sponsors were able to select a specific of Bell Helicopter, as well as the center of The culture museum district was a $10 cab event with which they wished their contri- a great deal of helicopter activity to ser- ride away, but well worth the trip to feast bution to be associated. vice offshore oil rigs. The cadre of rotary- eyes on “western” art and sculpture. Simi- In another move to hold attendees’ at- wing experts speaking included Matthew larly, the historic Stockyards area was also tention, drawings of donated prizes were Rigsby, FAA; Chris Lowenstein, Sikorsky; a drive away, but city-provided shuttles car- made at unannounced times throughout the Yasuo Ishihara, Honeywell; Sergio Sales, ried visitors to the place where cowboys technical programs. As expected, some of Safety and Security Ltd, Brazil; and Tom

October–December 2005 ISASI Forum • 5 Rigsby’s morning-long presentation was tion procedures…. We are here to share interrupted by a fire alarm that sounded, experiences, not to point fingers at anyone, emptying the lecture level floor; it proved so we are not going to talk about compa- false. Upon return, Rigsby continued and nies or crew names.” included full statistical data on Gulf of With that he began his presentation on off- Mexico operations (off shore) and restricted shore operations characteristics in the Cam- category (External Load Part 133, Agricul- pos area of Brazil and a look at offshore acci- tural Craft Part 137) operations. He may dents and incidents in the 5 years previous to be contacted at [email protected]. 2005. He described the Campos oil area: Indeed, offshore helicopter operations southeastern Brazil; 100,000 thousand square were a heavy topic of the tutorials. Both Sales kilometers, producing 1,265,000 barrels a day; and Workman addressed the subject. Work- 500,000 passengers per year. His talk centered ISASI 2005 registrants receive their man, addressing helicopter safety in the oil on problems caused by helidecks locations, “welcoming” kit to the annual seminar. and gas business, talked about Shell Oil sizes, obstacles, and turbulence. The talk was In all, 431 delegates and companions Company’s safety experience and presented supported by digital images of accident in- from 37 countries attended. an accident review and a lessons learned re- vestigation scenes. He noted that there are view that led into a risk management analy- many types of helidecks with various ob- Workman, Shell Oil Company. sis. He said he wanted to leave the audience stacles to overcome, such as roll and pitch Providing the proverbial “All you ever with three main points: (1) Passenger risk in on ship pads, and cranes on stationary plat- wanted to know…,” the helicopter speak- a helicopter is on an order of magnitude forms. Types of accidents encountered run ers covered a large number of topics. greater than and airliner; (2) Helicopter the full scale: one engine inoperative, Rigsby, from FAA’s Rotorcraft Directorate, safety can be improved (he delved into how birdstrikes, hard landing, hovering hard over, provided an analysis of U.S. civil helicopter it could be done); (3) Success needs a com- and disbelieving new technology. accidents. He related that rotorcraft opera- bined effort from regulators, manufacturers, Speaker Ishihara concentrated his pre- tions with the highest numbers of accidents operators, and their customers. sentation on CFIT accidents and helicop- were restricted category, air medical, and Sales, too, turned to offshore operations, ter EGPWS. He provided a short flight his- Gulf of Mexico. The top operational causes only in Brazil. At the outset, he gave a clue tory of data recovery in helicopter opera- of accidents included wire/object strikes and to the gravity of his presentation by say- tions and described the workings of flight into terrain/water. The number one ing: “I hope this presentation can help you helicopter enhanced ground proximity cause of fatal accidents was fuel starvation. to develop some kind of accident preven- warning system (EGPWS). He said that He went on to reveal the main mechanical causes of accidents in turbine and recip craft in the 1998-2004 period. He noted that the helicopter medical ISASI 2005 Sponsors emergency service (HEMS) operations have increased 100 percent between 1999 Platinum Sponsor Austin Digital and 2004 with 660 rotary-wing flying an es- Southwest Airlines Continental Airlines timated 300,000 hours annually, accounting Airbus Pratt & Whitney for one takeoff every 90 seconds in the U.S. Gold Sponsor Directorate of Flying Safety The country’s areas of greatest HEMS ac- Boeing Australian Defense tivity are the East, West, and Southern Embraer Blue Sponsor Coasts. In the 1998-2004 period, 85 HEMS Silver Sponsor ALPA accidents occurred, 27 of which recorded 74 AirTran American Airlines fatalities; 21 of the 27 fatal accidents oc- RadioShack Air Transport Association curred at night. The FAA’s Emergency Sagem Avionics AQD Medical Service Task Force remains heavily University of Southern California Cavok Group involved in working with the air medical JetBlue Cranfield University community in developing intervention strat- ATSB Flightscape ◆ egies for reducing the accident numbers.

6 • ISASI Forum October–December 2005 Hinckley did an equally comprehensive presentation on the subject of, NTSB family assistance: history and support requirements issues, opportunities and challenges, with her tutorial review. The timeliness of this daylong presentation is attested to by a recent NTSB action to offer in 2006 extra sessions of its family assistance course at its NTSB Academy to “accommodate the increased interest from airlines and other transportation providers worldwide.” Above: Technical presentations revolved By the end of the tutorial, attendees were around data mining, analysis, and well schooled in the total history of how the research, providing emphasis on aviation current family assistance program came safety management. Left: Q-&-A sessions into being, the laws that govern it, and the proved zestful and probing. regulations and procedures that must be followed. In recounting the history, management and family assistance issues Hinckley was able, through direct quotes, and was presented by Marten Bosman, Ad- to provide an inkling to the sorrow felt by vance Aviation Safety Services, and Christa families of victims, and the shoddy treat- Meyer Hinckley, an aviation attorney in pri- ment they received prior to the existence vate practice. of “family assistance.” She provided a clear Bosman’s presentation stressed his view development path to today governing Avia- of the need to develop an aircraft accident tion Disaster Family Assistance Act management system to enable airlines to be (ADFAA) and the Foreign Air Carrier Fam- two-thirds of all helicopter accidents result better prepared to respond rather than just ily Support Act (FACFSA), which insure from controlled flight into terrain (CFIT). by participating in the accident investigation. families of victims now receive the consid- In describing the various modes of opera- The four main topics of such a system are erations due in such circumstances. tion of the EGPWS, he explained that the technical investigation, internal and ex- Her detailed presentation gave attend- Honeywell developed a version of EGPWS ternal communications, the legal investiga- ees, who could find themselves cast in a specifically designed for helicopters. The tion, and assistance to the families of victims. player’s role during accident crises, knowl- helicopter EGPWS provides terrain aware- He reviewed each of the topics, touching on edge of the respective roles of governmen- ness display and terrain alerting system cus- the requirements of ICAO Annex 13 and how tal, local, and aid agencies as well as that of tomized for helicopter operations. A high- its mandates are fulfilled, and explained comair carriers. She made clear what types of resolution terrain/obstacle database is in- munications methods, means, strategy, and actions are prohibited, the enforcement concluded in the system. By knowledge of the preparation to meet the press and family is- sequences an air carrier would suffer for aircraft’s 3-D location, speed, and track, sues. Legal issues review also included iden- failure to meet lawful requirement, and the EGPWS can “see” conflicting terrain/water/ tifying key players and interacting with the role of family assistance coordinators in in- obstacles along the flightpath that may not investigation process. terfacing with investigators, among others. be seen by the pilots or a radio altimeter, and The main substance of his tutorial, how- provides visual and aural alerts to the pilots ever, was the need to develop a crisis cell to Main program when a threat is detected. He also reminded sustain a proper aircraft accident manage- The main program began on September 13 the audience that GPWS cannot be used for ment system. He defined the cell as a “co- and was opened with a few welcoming re- navigation, but only for situational display. herent organizational unit geared to man- marks by Curt Lewis, president of the ISASI He, too, showed a series of helicopter acci- age an aviation crisis.” He went on to com- Dallas-Ft. Worth Chapter, which hosted the dent scene images to impact his discussion. prehensively describe its six main elements 36th annual international seminar. ISASI There were 50 attendees to the second and how they create the whole: policy, guid- President Frank Del Gandio, who in a for- tutorial, emergency response prepared- ance, organization, infrastructure, people, mal address welcomed the assembled to ness, which encompassed aircraft accident and training. ISASI 2005, followed him. His remarks cen-

October–December 2005 ISASI Forum • 7 Al Weaver, right, responds to a question as panel members, left to right, Joseph Rakow, Michiel Schuurman, and Barbara Burin, look on.

tered on the progress of lessening the aircraft accident rate and improving the overall air safety level, despite several accidents occurring in 2005. In urging the group to become actively involved in the activities and opportunities offered by the seminar, he said, “Look around you. Chances are very good that you are seated close to someone who knows everything there is to know about Keynote speakers ing a full-scale investigation in some of the some topic that interests you.” (See John J. Goglia, retired NTSB Board mem- most challenging environments on Earth.” “President’s View,” page 3.) ber, ISASI member, and presently a faculty However, the recognition factor has to be He next introduced the selectee for the member of Saint Louis bolstered by “acting like an international 2005 Jerome E. Lederer Award and the University, where he group,” he added. He recognized that mere winner of the ISASI Rudy Kapustin Me- serves as a professor of attendance at the seminar in the numbers of morial Scholarship Award for 2005. John aviation science, made the persons that registered is evidence that the D. Rawson, ISASI Fellow, claimed the opening keynote presen- importance of “looking and acting” like an Lederer Award (see page 12). Identifying tation. In addressing the international body is well understood. He ap- the Lederer awardee on the opening day, group he said: “In the re- plauded the proactive stance of investigators rather than on the final banquet night, was cent past weeks we’ve in Europe in their periodic “lessons learned” a recent innovation. It was designed to had six major plane crashes with interna- forums in which they share experiences. permit delegates to offer personal con- tional involvement.… In light of these new Addressing the “little brothers,” he urged gratulations throughout the seminar. Win- tragedies our industry is facing, I think it is that they assert their talents and not rely ner of the $1,500 scholarship award was important to focus on just what are we, as upon “big brother” to “take care of them.” Carly Reil from Embry-Riddle Aeronau- an international body, to do to best prepare ICAO Annex 13, he said is both “ a bless- tical University. The scholarship fund hon- for a drain on our resources, meaning not ing and a curse”—a blessing because it pro- ors the memory of “tinkicker extraor- just financial, but human and technological.” vides guidelines for conducting interna- dinaire” Rudy Kapustin, who served for One of the first recognitions required, he tional accident investigation, a curse be- years as the ISASI Mid-Atlantic Regional noted, is that ISASI is an international cause it does not “deal with the real Chapter president. This is the third award- group, “not just a conglomerate of indepen- obstacles to accident investigation, which ing of the scholarship (see page 14). dents. Of course, we cannot deny the reality are the intangible idiosyncrasies that vary Noting that the three previous winners of that we are a group of big brothers and little from country to country.” Lastly, he ad- the scholarship were in attendance at the brothers.” He defines big brothers as “those dressed the matter of new entities that “do seminar, Ron Schleede, ISASI vice-president who have had the experience, have people not take the proactive approach,” urging and scholarship fund administrator, said, with the expertise, and have massive tech- them not to rely solely on “big brother.” “The scholarship program along with the nological capabilities, while perhaps lacking He closed telling the assembled group: Reachout program signifies the best of the sheer number of human resources.” “ISASI has shown the ability to bring to- ISASI.” He added, with a smile of pride for Little brothers are those organizations just gether the biggest grouping of world-class their accomplishments, that the first year’s developing their program and that lack the investigators with a common goal. If we can two award winners, Michiel Schuurman and resources of the larger organizations. begin to address some of these issues un- Noelle Brunelle, are both now employed in He cautioned that the drain of resources der their umbrella, perhaps we can move aircraft accident prevention positions, also affects the corporate partners of the forward another notch or two using the Schuurman with the Dutch Safety Board and Society, “because when our accident investi- proven training tools we have seen over the Brunelle with Sikorsky Aircraft. Moreover, gators are adrift, it puts increased burdens years….” Delegates engaged in a robust he related, Schuurman made a delegate tech- on our corporate partners to try and com- question-and-answer period following his nical presentation at the seminar and has ac- pensate.… [They] not just have to look out presentation. cepted a seat on the ISASI scholarship se- for their own industry, but be ready to assist FAA Director of Flight Standards Service lection committee. The second year winner, at a moment’s notice to do anything from Jim Ballough opened the second day’s ses- Shannon Harris, is in her last year of school decoding FDRs and CVRs to providing sion with a keynote address titled Voluntary at Embry-Riddle Aeronautical University. qualified investigators to assist in conduct- Safety Programs—Partnerships for Safety.

8 • ISASI Forum October–December 2005 Speakers and Technical Paper Presented at ISASI 2005

TUESDAY—Topic: Recent Investigations Operations Quality Assurance Program • Jody M. Todd, Capt., Honeywell Aero- • Bob Benzon, Investigator-in-Charge, • Paul Jansonious, Standards Pilot, West Jet, space Electronic Systems—EGPWS RAAS— NTSB—Challenges in the Afghan Investiga- and Elaine Parker, North Caribou Air, Runway Awareness and Advisory System tion of the KAM Air Flight 904 Canada—Practical Human Factors in the • Al Weaver, Senior Fellow Emeritus, Gas • Stephane Corcos and Pierre Jouniaux, Investigation of Daily Events Turbine Investigations—Rotor Seizure Effects BEA, France—Accident, Serious Incident, • Tom O’Kane, FRAeS, Aviation Safety • Michiel Schuurman, Student, Aerospace and Incident Investigations: Different Advisor—Incident Classification Systems Made Engineering, Technical University Delft, Approaches, the Same Objective Irrelevant by Text Mining Tools? Netherlands—3-D Photogrammetric • Dr. Robert O. Besco, President, PPI; • John Fish, American Underwater Search and Reconstruction in Aircraft Accident Capt. (Ret.), American Airlines—Find the Survey, and John Purvis, Safety Service Investigation Reasons: Stop Feeding the Causes and Let International—Sonar as a Tool to Retrieve • Barbara Burian, Ph.D., SJSUF, NASA the Reasons Starve Airplanes and Schooners Ames—Do You Smell Smoke? Issues in the • Wen Lin Guan, Aviation Safety Council • Robert Matthews, Ph.D., U.S. FAA— Design and Content of Checklists for Smoke, Taiwan, R.O.C.—Performance and Flight International Similarities and Differences in Fire, and Fumes Dynamics Analysis of the Flight in Ice the Characteristics of Fatal General Aviation • Keith McGuire, NTSB—Selecting the Accretion Accidents in Eight Countries Next Generation of Investigators • Johann Reuss, Federal Bureau of Aircraft *Panel 2—Post Accident/Incident Stress • Kathy Abbott, Ph.D., FRAeS, Chief Accidents Investigation, Germany—Are the Management Guidance for the Investigator Scientific and Technical Advisor, U.S. FAA— TCAS/ACAS Safety Improvements Sufficient? Brenda Tillman, Readiness Group International Applying Human Performance Lessons to *Panel 1: Industry Flight Safety Information Mary Cotter, Air Accident Investigation Unit, Smaller Operators Sharing Activities Ireland • John Cox, Capt., FRAeS, Safety Operat- Jim Ballough, AFS-1, U.S. FAA; Michelle Papers: Special Investigations ing Systems—Bringing Proactive Safety Harper, University of Texas; Capt. Terry • A. Ranganathan, Capt., SpiceJet, India—Wet Methods and Tools to Smaller Operators McVenes, Executive Central Air Safety Runway Operations • Frank Gerards, Col., Royal Netherlands Chairman, ALPA; Dr. Steve Predmore, • Christian Amaral and Bill Watts, Delta Air Air Force, and Rombout Wever, NLR, JetBlue Airlines; Tom O’Kane, FRAeS; Jill Lines—Delta Air Lines Emerging Technologies Netherlands—The Use of Operational Risk Sladen-Pilon, IATA for Turbulence Avoidance: The Delta Perspective Management in the Royal Netherlands Air Force WEDNESDAY—Topic: Data Analysis THURSDAY—Papers: Human Factors and • Mark Solper, Chairman, ALPA Accident • Simone Sporer, Psychologist, University of Safety Management/Investigative Techniques Investigation Board, and Michael Huhn, Applied Science, Austria—Flight Data • Derrick Tang, Advent Management Consult- ALPA—The Unified Field Theory Monitoring—A New Approach ing, Singapore—Total Safety Management for • Mohammed Aziz, Ph.D., Advisor to • Ahmet Oztekin, M.S., Student, University Aircraft Maintenance Using TQM Approach Chairman, Middle Eastern Airlines—The of Rutgers—A Case-Based Reasoning • Howard Leach, MRAeS, British Airways, Role of GAIN in Enhancing Air Carrier Approach for Accident Scenario Knowledge England—Maintenance Error Prediction Safety Management Management Modeling • A.L.C. Roelen, National Aerospace • Jill Sladen-Pilon, IATA, and Mike Poole, • Donizeti de Andrade, Ph.D., ITA, Brasil, and Laboratory, Netherlands, and Rombout Flightscape, U.S.—Airline Flight Data Gustavo Moraes Cazelli, Embraer, Brasil— Wever, NLR, Netherlands—An Analysis of Analysis (FDA)—The Next Generation Aircraft Accident Investigation Applications of Flight Crew Response to System Failures • C. Edward Lan, University of Kansas, and System Identification Techniques • Mark Smith, Boeing—Boeing Runway Samason Y.C. Yeh, Capt., China Airlines, • Joseph Rakow, Ph.D., Exponent Failure Track Analysis. Taiwan, R.O.C.—Investigation of Causes of Analysis Associates—Thermostructural Failure *Panel participants did not submit written Engine Surge Based on Data in Flight in Aviation Accidents text of their discussions. ◆

His talk dovetailed nicely through traditional means. permanent rule, and publication of an up- with the topic for the day • Better identify risks to public safety. dated LOSA and IEP advisory circular. He Papers: Data Analysis. • Implement risk-reduction strategies concluded by expressing that in the future Ballough discussed based on voluntarily provided safety data. the partnership program hoped to achieve FAA’s realization from • Track the effectiveness of these strate- better integration of safety information past experiences that tra- gies over time. from multiple programs, to transition ditional methods of FAA Today there are these six voluntary safety VASIP from a demonstration program to a surveillance and enforce- programs administered by the Flight Stan- permanent systematic venue for safety in- ment would not achieve increased levels of dards Service: (1) voluntary disclosure pro- formation sharing, and to develop FAA safety. He noted that raising the bar would gram (VDRP), (2) aviation safety action pro- guidance and incentives for a voluntary require the augmentation, “not replace- gram (ASAP), (3) flight operational quality safety management system (SMS). ment,” of traditional FAA oversight with assurance (FOQA) program, (4) advanced volunteer safety partnerships bundled into qualification program (AQP), (5) line opera- Technical sessions a volunteer safety program. tions safety audit (LOSA) program, and (6) In an assembly of 400 people, the measure The FAA then set the goals for such a internal evaluation program (IEP). of success isn’t the content of the program, program— Ballough described the partner relation- as much as it is the comfort level afforded • Foster partnerships for safety. ships and working details of each of the pro- those who, hour after hour, listen to the dron- • Decrease accidents, incidents, and viola- grams. He then outlined the programs that ing of speech and watch the flashing of tions. were on the horizon, such as expansion of PowerPoint images. Astute planners know • Obtain safety information not available FOQA and ASAP, codification of AQP as a this and select conference hotels accordingly.

October–December 2005 ISASI Forum • 9 So, while the outside temperatures in Cow Social activities Town hovered near the 100-plus degree Relaxed interactions contribute as much to Fahrenheit mark, those attending the 3-day- the success of an event as does the formal long ISASI 2005 technical program comfort- program. To take full advantage of this fact, ably sat in air so cool that some resorted to ISASI seminar planners set social activities long sleeves and jackets. Tables were angled through a full companions’ program and ac- so all could easily view the side screens and tivities for all attendees. The Welcome Re- water jugs, drinking glasses, and hard candy ception allowed for a shake off of the travel were just an arm’s length away. weariness and an awakening of friendships With that setting, 46 speakers addressed from past seminars. Midway through the the group either in an individual presenta- technical programming was an evening of tion or as a member of a panel. While the gaiety related to the norms of the local area. general theme of the event was Investigat- ISASI 2005 bussed its crowd to Billy’s Bob’s, ing New Frontiers in Safety, each daily a.m. billed as the world’s largest “honky tonk.” It and p.m. segment carried its own topic is housed in the middle of the historical Ft. theme. Recent Investigations was the first Worth Stockyards area. The western-attired day’s subject for six morning speakers. The guests were greeted by comparatively afternoon’s seven-member panel delved dressed dance hall “queens” and “wranglers” into Industry Fight Safety Information as they stepped off the bus to be escorted Sharing. Each panel member presented a into a one-time barn used for prize cattle short paper on the subject before taking during the stock shows. questions. The Data Analysis topic was ad- Companions, although small in number, dressed by the first 12 speakers on the sec- 41, were treated to an array of entertain- ond day; an afternoon two-member panel ing venues. They toured movie studios, dis- were fired on Nov. 22, 1963. The group then discussed Post Accident/Incident Stress covering how images of mystical happen- went on to a visit of the Circle R Ranch, an Management Guidance for the Investiga- ings and physical deformities are created. authentic, theme-oriented ranch on 100 acres tor, and the last two speakers of the day ad- At the Botanic Garden, the high humidity of green rolling hills and open pastures. Dis- dressed Special Investigations. The 16 overshadowed the magnificence of the rain embarking from the busses, the group was speakers who addressed attendees used the forest, and most companions welcomed the welcomed by cowhands who draped them final day’s topic, Human Factors and Safety cool comfort of the tasty lunch that followed with 2-foot square red, white, and blue ban- Management/Investigative Techniques, in the tour. A visit to the National Cowgirl danas bearing the Circle R brand and the both the a.m. and p.m. sessions. Museum displayed the spirit of the women star of Texas. The line queued at the “chuck As can be seen from the daily topics, shar- who made their living on ranches of the wagon” for grilled steak and other morsels. ing of information was the heavy underly- early West. But its captivating Hall of Fame Then it was off to the corrals and horseback ing element of the seminar’s technical pro- display of slowly changing images of cow- riding for some and boarding of hay wagons gram. Accordingly, papers’ content revolved girls was a crowd pleaser. The final com- for others who were entertained by a wire- around data mining, analysis, research, the panion event took them on a riverboat sce- thin songster wearing a large-brimmed practical, and the theoretical. One long-time nic cruise around Lake Granbury, where Texas hat and strumming a well-used gui- attendee summed up the technical session despite the hot sun, the upper deck breeze tar. In all, it was a relaxing time after the this way: “The difference this year versus cooled the group as they viewed the lavish rigor of sitting in auditorium seats for 3 days. other years was the heavy emphasis on avia- homes along the lake’s shores. tion safety management. There was more The post-event day activity has always Awards banquet of this than on investigation.”(See adjacent been proven a great closer to a week of “stu- The evening before the Circle R excursion list of speakers and subjects.) dious” attention. First came a visit to the was the time for the heavily attended and Throughout the technical program days, Sixth Floor Museum, which examines the anticipated awards banquet. The hall’s linen- the various societies, committees, and work- life, times, death, and legacy of President clothed tables seated 10 persons each; 40 ing groups held meetings. President Del John F. Kennedy. The museum is housed in tables filled the floor. Following dinner, Ralph Gandio also conducted the annual member- the Texas School Book Depository building Hood, with his background of being a pilot, ship meeting. and floor from which the assassination shots aircraft salesman, book author, and profes-

10 • ISASI Forum October–December 2005 named chairman of the Fellow selection committee. He also called for audience recognition of the 2005 winner of the Kapustin Memorial Scholarship, Carly Reil (see page 14) and made special plaque presentations to the Cirrus Aircraft Corporation (see “RoundUp”) and to Capt. A. Ranganathan, SpiceJet Limited, India. The nature of the Award for Excellence “ISASI 2005 Best Seminar Paper” is a first Above left: Hay wagon singing cowboy for ISASI, but one that will continue to oc- serenades riders. Above: Seminar cur for the foreseeable future. The award is planners C. Lewis (left) and J. Darbo an outgrowth of an anonymous contribution (right) accept prop-clock award from to the Society to reward the writer(s) of the President Del Gandio. Left: Capt. best paper presented at any respective an- Ranganathan accepts “Best Seminar nual seminar. The President and Executive Paper” Award of Excellence. Advisor, Richard Stone, make up the selec- Below: B. Dunn accepts traditional tion committee. “Based on the criteria estab- “passing of the Bell” from T. Carroll. lished by the anonymous donor,” said Stone, Below left: At this “table of winners,” “the committee’s criteria was a paper that each person won a significant prize provided meaningful technical advancement in the final day’s many prize drawings. in accident investigation, properly addressed the theme of the seminar, and a written text and oral presentation that was understand- able and interesting.” Capt. Ranganathan’s paper was titled “Wet Runway Operations” and dealt with the hazards of operating in such conditions, what causes the hazards, and how the hazards can be reduced, along with a call for sional speaker, entertained the aviation-ori- improved training and certification stan- ented audience with comical barbs and praise dards to overcome the accident potential for their profession. He “loosened” up the involved. (The award-winning paper will be group for the upcoming presentation of published in the January/March 2006 issue awards to deserving ISASI folk. of the Forum.) People and groups honored included The final presentation of the evening was ALPA and Corey Stephens for website sup- the awarding of the 2005 Jerome E. port and webmaster work and new corpo- Lederer Award to John D. Rawson. The rate members AeroVeritas Aviation Safety details of the presentation ceremony and Consulting, Ltd, Aircraft Mechanics Fra- Airworthiness Authority, My Travel Air- the awardee’s comments are published on ternal Association, Centurion Inc., Cirrus ways, Star Navigation Systems Group, Ltd, page 12 of this issue. Design, Colegio Oficial Pilotos Aviation Hellenic Air Accident Investigation and The closing ceremony of ISASI 2005 was Commercial/Spain, Cranfield University Aviation Safety Board-Greece, and Accident the traditional passing of the “Call to Or- Safety and Accident Investigation Centre, Investigation and Prevention Bureau, Fed- der Bell” to ring the opening of ISASI 2006, Directorate of Aircraft Accident Investiga- eral Ministry of Aviation-Nigeria. which will be held in Cancun, Mexico, Sep- tions-Namibia, Dutch Airline Pilots Asso- President Del Gandio also announced the tember 11-14 and is hosted by the ISASI ciation VNV, European Aviation Safety awarding of Fellow status to John D. Seminar Committee in cooperation with the Agency, Flight Attendant Training Institute Rawson, Itzhak Raz, and Ken Smart. Ron ISASI Latin American Society and the at Melville College, Irish Air Corps/Military Chippindale, New Zealand Councillor, was Mexican ALPA group. ◆

October–December 2005 ISASI Forum • 11 Rawson Earns Lederer Award infancy. Jerry Lederer “flew west” on Feb. 6, 2004, at age 101. Awarded annually by The 2005 Jerome F. Lederer ISASI, the Lederer Award also recognizes achievement of the Society’s objectives and Award recipient is a “don’t tell technical excellence of the recipient. me, show me” type of The presentation of the award always takes place on the last evening of the semi- investigator. nar, and it is the highlight of the award banquet. In introducing the winner to the audi- By Esperison Martinez, Editor ence, President Del Gandio commented, “The Jerry Lederer Award is the most pres- ohn D. Rawson, a Fellow member of the tigious award that the Society can confer, and JSociety, was an almost-absent recipient John Rawson’s 45 years of experience in air- of the Jerome F. Lederer Award for 2005 craft accident investigation and aviation at the ISASI annual awards banquet. Un- safety has proven spectacularly worthy of the aware of his selection for the prestigious highest accolades.” He went on to relate award, his original plans to attend the an- highlights of Rawson’s contributions: nual seminar were abruptly altered when “John started his career in accident in- Hurricane Katrina changed some of the vestigation in 1960, when he accepted em- landscape of his property in Meridian, Miss. ployment with the engineering division of

This change of plans caused a dilemma for the Civil Aeronautics Board (CAB), prede- PHOTOS: E. MARTINEZ President Frank Del Gandio, who secrets cessor of the NTSB. President Del Gandio, right, presents the away the name of the selectee until the As a system specialist, he became one of 2005 Lederer Award to John Rawson. opening day of the seminar. Finally reach- only two original flight data recorder read- ing Rawson by phone, Del Gandio inquired, out specialist for the CAB. He also was in- lems in dozens of major accidents. “John, have you decided if you are coming volved with investigating and analyzing “In 1962, he transferred to the CAB’s to Texas?” The reply was quick and posi- electrical/electronics instrument systems Miami field office where he was an investi- tive, “Can’t make it.” With no recourse, Del and hydraulics and communications prob- gator-in charge (IIC) for 8 years and inves- Gandio had to share the secret: “John, you are receiving the Lederer Award!” Stunned silence was the reply, until, again, a quick and positive: “I’ll be there.” Past Lederer Award Winners So while the pleasure of surprise was absent when President Del Gandio intro- 1977—Samuel M. Phillips 1992—Paul R. Powers duced award winner Rawson to the near 400 1978—Allen R. McMahan 1993—Capt. Victor Hewes attendees who filled the cavernous room, 1979—Gerard M. Bruggink 1994—U.K. Aircraft Accidents he appeared humbled at the thundering 1980—John Gilbert Boulding Investigation Branch applause that filled the air. The early an- 1981—Dr. S. Harry Robertson 1995—Dr. John K. Lauber nouncement allowed many delegates to of- 1982—C.H. Prater Houge 1996—Burt Chesterfield fer private congratulations to the 29th re- 1983—C.O. Miller 1997—Gus Economy cipient of the award, who would be more 1984—George B. Parker 1998—A. Frank Taylor fully honored on the last evening of the semi- 1985—Dr. John Kenyon Mason 1999—Capt. James McIntyre nar program. 1986—Geoffrey C. Wilkinson 2000—Nora Marshal The Jerome F. Lederer Award is con- 1987—Dr. Carol A. Roberts 2001—John Purvis and the Transpor- ferred for outstanding lifetime contributions 1988—H. Vincent LaChapelle tation Safety Board of Canada in the field of aircraft accident investigation 1989—Aage A. Roed 2002—Ronald L. Schleede and prevention and was created by the Soci- 1990—Olof Fritsch 2003—Caj Frostell ety to honor its namesake for his leadership 1991—Eddie J. Trimble 2004—Ron Chippindale role in the world of aviation safety since its

12 • ISASI Forum October–December 2005 tigated a great many general aviation and is taught at the Bell Helicopter facility in air carrier accidents. In 1968, John left the Fort Worth, Tex. government and joined HydroAire as a “John’s involvement with ISASI is as flight data recorder technical representa- impressive as his government career. He tive. In 1970, he returned to the NTSB as joined in 1965 and held member number an CVR/FDR specialist in the Washington, CH59, marking him as one of the founders D.C., headquarters, subsequently becom- of our Society. He has served as member- ing chief of the CVR laboratory. ship chairman, secretary, and as treasurer. “John transferred to the FAA in 1974 and In that position, he established an account- served as the FAA IIC on more than 70 ing system that served ISASI for many major catastrophic accidents worldwide. In years. He has presented laudable papers 1976 he became a branch manager and in at numerous ISASI seminars and at ICAO 1982 was promoted to manager of the Acci- meetings worldwide. dent Investigation Division in the Office of “His government career and his involve- Accident Investigation, a position he held ment in ISASI indicate a total dedication until retiring in 1994. and concern for aircraft accident investiga- “During his career in both agencies, John tion and aviation safety. His contribution to authored more than a 100 safety recommen- the aviation industry and this Society are dations, which have had a tremendous posi- monumental and worthy of making him the tive impact on aviation safety. He estab- 2005 Jerome F. Lederer Award recipient. Rawson speaks to the assembled lished and was responsible for the curricu- John, I present to you the Jerry Lederer banquet crowd. lum and training activities of the FAA’s Award for 2005. Congratulations.” Accident Investigation School in Oklahoma As the applause of the full room quieted, whispered. And with a stronger voice con- City and lectured at the basic investigation the unassuming, straight-backed, and soft- tinued, “It is a great honor to receive this class for many years. He was also instru- spoken award winner moved to the micro- award and to be included with those people mental in organizing and implementing the phone. The room was now still, all eyes who have come before me as recipients of helicopter accident investigation course that front, ears primed to hear: “Thank you,” he the same award. As Frank said, I have been doing this a long time. I have worked with a lot of you in this room and certainly with your organizations. I can say with all hon- estly that my experience totally shows that ISASI has made a big difference in safety, worldwide. “One of the reasons is, of course, that we exchange information here, meet each other, go back to our organizations and in- form about what is going on. Fortunately, a lot of the people here work for rule-making agencies and accident investigation groups. That’s a good thing, and I want people to keep up the good work. “A thought I want to pass along is something I’ve always practiced in my investigations and urged all the people I have worked with to practice: When you are investigating an accident, tell the person or the group that ‘I appreciate all you have Recent Lederer Award winners strike a pose. Left to right, Ronald L. Schleede (2002), explained to me, but I would rather have Caj Frostell (2003), Rawson, Ron Chippindale (2004), and John Purvis (2001). you show me.’” ◆

October–December 2005 ISASI Forum • 13 chapter. I read every issue of the Forum; it Carly Reil: has so many great articles. From the articles, I digest what the investigators them- 2005 ISASI Rudy Kapustin selves experience as they search accident scenes for cause factors. I agree very much with the prevailing attitude that the results Scholarship Awardee of investigations need to be more thor- oughly acted upon to prevent future similar caused accidents. And to gain that posi- By Esperison Martinez, Editor tive action, more agencies and persons have “Since the first plane crash on September “I focused on the obvious in the beginning, to better understand the investigative pro- 17, 1908, that seriously injured Orville primarily to show the seldom-expressed dif- cess and the findings it produces.” Carly Wright and killed his passenger, First Lieu- ficulty of diverse groups working together joined the student chapter in her second tenant Thomas E. Selfridge, accidents have in one investigation to arrive at one conclu- year at the school and has served as trea- been the shadow behind aviation. Investi- sion. I wanted to express the nature of an surer and vice-president of the group. Her gating them, however, is providing the light investigator’s field work: the trials of work- summers have been spent in aviation- needed to make changes. Though we have ing relationships with unknown investiga- safety-related internships. come a long way, the near art form of piec- tors, the synergy developed in resolving Upon graduation in May 2006, she in- ing together the puzzle formed when a plane differing opinions, the ideas and methods tends to apply for graduate school in a sub- crashes remains a relentless challenge for used. And finally, the necessity for all to ject that will lead to placement into some investigators. From evaluating a crash come together as one group to come to one aspect of the accident investigation profes- scene to educating the industry on their conclusion.” sion. “I am interested in working on an in- findings and everything in between, acci- Carly recounts how her confidence and ternational level, because other cultures dent investigators face a number of chal- ability to write on the subject came about: have always been a high interest of mine. I lenges at every scene.” “The aviation industry has always fasci- think it would be very exciting to become nated me, and in my high school years I involved with cultures that are developing hese insightful thoughts, descriptively became interested in forensic medicine as their own safety investigative programs. To Tcast, open the essay “Problems Facing it applies to accident investigations. When be involved in helping to build up a program Air Safety Investigators” submitted by I was looking at colleges to attend, I noted from the ground up would be a terrific ex- Carly Reil, a senior at Embry-Riddle Aero- that ERAU offered a safety sciences degree perience both from the learning and teach- nautical University (ERAU), Florida, U.S.A., that was related to crash investigations. It ing standpoint.” in her quest to become the 2005 ISASI Rudy appeared perfect for me. It offered a bit How does she feel about her first ISASI Kapustin Memorial Scholarship awardee. about aviation and a bit about forensics, my annual conference? “It’s been wonderful. She succeeded! She was presented the final favorite areas of interest. I’ve met some great people who have honors at the Society’s annual seminar. “So, my insight for the paper came from helped point me in the right direction In presenting the award, ISASI Presi- my classroom studies and exposure to through the many different topics pre- dent Frank Del Gandio noted that the schol- ISASI accident-investigation-generated sented. They opened me up to many dif- arship was established in memory of all material that I receive as a member of the ferent aspects of investigation that I had ISASI members who have died and was University’s ISASI student membership not thought of before.” ◆ named in honor of Rudy Kapustin, the former ISASI Mid-Atlantic Regional Chap- President Del Gandio ter president and long-term ISASI mem- introduces Carly Reil, ber who developed a reputation as “tin- 2005 ISASI Kapustin kicker extraordinaire” among his peers. The Scholarship awardee, scholarship is intended to encourage and to the audience. assist college-level students interested in the field of aviation safety and aircraft occurrence investigation. The memorial provides an annual allocation of funds for the scholarship. Del Gandio announced that Reil would receive a $1,500 ISASI award to help offset attendance at the seminar. In addition, he said the FAA’s Transportation Safety Institute and the Southern Califor- nia Safety Institute are awarding fee-free attendance to the respective school’s accident investigation course. The 21-year-old student said of her es-

say, which is reprinted on the following page, E. MARTINEZ

14 • ISASI Forum October–December 2005 ince the first plane crash on tinue to look at the whole picture SSeptember 17, 1908, that se- and not jump to conclusions. An riously injured Orville additional piece of evidence may Wright and killed his passenger, The Problems add new insight to the events First Lieutenant Thomas E. leading up to an accident. Inves- Selfridge, accidents have been tigators next-best sources of in- the shadow behind aviation. In- Facing Air Safety formation come from records and vestigating them, however, is witnesses. providing the light needed to Operations, maintenance, make changes. Though we have Investigators ATC, aircraft, and weather come a long way, the near art records are all important pieces form of piecing together the By Carly Reil (ST5133), Safety Sciences of information that investiga- puzzle formed when a plane Embry-Riddle Aeronautical University tors want to take into account. crashes remains a relentless However, crew and aircraft challenge for investigators. records are often lost or de- From evaluating a crash scene to educating the industry on their stroyed. Assembling a history for the flight using these records findings and everything in between, accident investigators face a and the statements of witnesses provides a time line and a base number of challenges at every scene. to put events together. Sights investigators may encounter when they get to a crash Interviewing witnesses is a delicate but beneficial process. They scene can affect them emotionally in a number of ways. Any such are the people who saw the crash, were in contact with the crew, or devastating scene is always hard to overcome, but it is necessary are family members and friends. They provide the insider’s view for to do so in order to accomplish the far greater goal. Memories can investigators. Witnesses should be interviewed as soon after an ac- stay with investigators their entire life, yet they ultimately know cident as practical to avoid bias and loss of information. Survivors they are there to find answers and to help prevent such catastro- may be in shock, unable to clearly reveal anything, and relatives and phes in the future. friends of the crew may be prejudiced in the information they give. Investigators must be able to work with diverse groups. These “Eyewitnesses” may have conflicting accounts or may have heard groups help investigators locate, stories from other witnesses. Interviewing can be frustrating, but preserve, gather, and analyze evi- investigators must be respectful and understanding when listening; dence from crash scenes. For ex- their goal is to gain information. Not only do they have to be careful ample, when Copa Flight 201 dis- in the questions they ask, but they must also take into account nu- appeared over Panama, investi- merous factors concerning the validity of each statement. gators relied heavily on locals to After gathering evidence from the field, a new challenge navigate the dense jungle. When emerges. Now the pieces of the puzzle need to be evaluated and fit investigators work with local law together; the who, why, and how need to be answered. Most im- enforcement and fire depart- portantly, once answers are determined, investigators must present ments, evidence can be disturbed their findings and hope that they do not fall on deaf ears. After all, or destroyed in an effort to put the goal is not just to figure out what happened but how to prevent out fires or rescue survivors. This it from occurring in the future. relationship is important, though; Clarifying the series of events that lead up to an accident can law enforcement helps to protect take months, if not years, to establish. Investigators work diligently a scene and often provides sup- to organize a final report on the determining factors behind an port for investigators. When par- accident. In the process, important and useful information is inte- ties to an investigation are al- E. MARTINEZ grated into these reports. Though, there will always be someone lowed, they can bring investiga- Carly Reil who doubts these findings. And more often than not, these data tors from different areas of the industry together with varying ideas are simply not implemented into areas of the industry where they and goals. Every situation and every person will be different, and could be of great use. Unfortunately, this is one of the biggest chal- accident investigators must be prepared for this diversity. The challenges to investigators. It is counterproductive to put effort into lenge is to maintain organization, cooperation, and an open mind. solving what went wrong only to have the event repeated. Acci- Numerous obstacles always face investigators in the field. Wreck- dent investigators work to prevent similar accidents from occur- age is often in the least likely place, scattered over great distances ring in the future; it is up to them to be sure that their work is and in pieces offering sharp edges and the presence of bloodborne noticed and applied. pathogens. Ephemeral evidence poses a challenge to time, and move- Accident investigation is an incredibly challenging occupation able parts can shift during impact. New technology can mislead an that requires a special person. There is a common thread among investigator, such as composite materials, which fail differently from all investigators: a passion to solve the problem and save lives. traditional materials. Evaluation of the cockpit voice recorder and How else could someone persevere through emotional, physical, flight data recorder may hold key information, but they are not avail- mental, and social challenges? Everything from searching through able in a certain aircraft or are unable to be found. If they are lo- debris to evaluating data to compiling the final report is a long and cated, they can be damaged or unreliable. With pieces of informa- difficult journey for investigators. The greatest reward is to see tion coming from many different sources, investigators must con- their findings put to good use to save lives. ◆

October–December 2005 ISASI Forum • 15 The ‘Why’ of a Fatal Double Engine Flame-out Investigation of a Shorts SD 360 turboprop flame-out produces a new approach to powerplant investigation and an unusual cause is determined.

By Peter Coombs, Air Accident Investigation Branch, U.K.

(This article was adapted, with permission, ABOVE: Figure 1: General view of main from the author’s presentation entitled In- section of wreckage at low tide, on the vestigation of Fatal Double Engine Flame- morning after the accident. out to Shorts SD 360 Turboprop prepared LEFT: Figure 2: View of partly submerged for the ISASI 2004 seminar held in wreckage at subsequent low tide. Australia’s Gold Coast region Aug. 30 to BELOW: Figure 3: View of almost- Sept. 2, 2004, which carried the theme “In- submerged wreckage at high tide. vestigate, Communicate, and Educate.” The entire paper, including cited references index, is on the ISASI website at www.isasi. org.—Editor)

n the early evening of Feb. 27, 2001, a Shorts SD 360 twin turboprop aircraft was received stating that both engines had Itook off from Edinburgh, Scotland. Al- failed. The machine descended rapidly and though normally serving as a passenger ditched in shallow but exposed and ex- airliner, on this occasion it was carrying only tremely choppy waters of a local sea inlet, two flight crew and a cargo of mail. Just the Firth of Fourth. It sustained consider- over a minute after takeoff, a distress call able damage at water impact and soon became partly submerged. Neither crew- Peter Coombs joined the member survived. U.K. AAIB in 1972 and Investigation of the accident required has performed more than salvage of the aircraft from the very ex- 200 field investigations to posed waters, where it was lying between was further hampered by the extent to which civil and military fixed- low-and high-tide positions, followed by the aircraft became buried in the sand with and rotary-wing aircraft detailed examination of its systems and succeeding tides (Figure 3). and a comparable number powerplants, development of a robust Eventually, however, the wreckage was of other technical investigations. While theory as to the cause of the obscure double salvaged (Figure 4) and detailed examina- with the British Aircraft Corporation power loss, and the preparation and imple- tion began. In the meantime, both the from 1966, he gained experience of manu- mentation of experiments to support the DFDR and the CVR were recovered, de- facture, development, and testing of air- theory. contaminated, and replayed successfully. craft including BAC 1-11, VC10, and The wreck site was such that the aircraft My past experience of multiple power Bristol Britannia airliners, before be- could only be accessed on one occasion on loss has led me to expect that one engine coming a design engineer on the Concorde foot (Figure 1) before the changing tidal cycle may lose power for a variety of reasons, SST. He was awarded a master of science dictated that at the lowest tides the aircraft while a second engine generally does so af- degree in aircraft design at the College of still remained partly submerged (Figure 2). ter a time interval, usually following crew Aeronautics, Cranfield, in 1971, and flies This situation was to continue until approxi- actions intended to secure the first engine single- and multi-engine aircraft. mately a week had passed. The recovery task but incorrectly applied. The only other

16 • ISASI Forum October–December 2005 double power losses I can recall investigat- each external intake, passes being have been low the whole length of the rel- • an occasion on which both engines were evant engine, before turning selected to nearly empty main tanks on de- through a right angle and trav- parture, following accidental fuel uplift into eling vertically upward into air- auxiliary tanks, unobserved by the crew. tight plenum chambers. From • an occasion when an Eastern Bloc cer- these, it is drawn into each en- tificated aircraft, equipped with an auto- gine compressor through a cy- matic engine safety/shut down system, suf- lindrical mesh guard (Figure fered an electrical fault that energized fuel 5). An external view of a nacelle shutoff valves on both engines, driving them on the salvaged wreck, show- to the closed position shortly after takeoff. ing the intake and one exhaust Fuel exhaustion, severe engine intake ic- stack, is shown in Figure 6. ing, and volcanic ash contamination are, of In icing conditions, the crew course, also well-known multiple power loss may select so-called anti-icing causes. vanes to the ON position (Fig- The simple two-tank fuel system layout Figure 5: Schematics of nacelle with ure 5). Under these circumstances, a ramp inertia separator vanes in normal (or OFF) (or forward vane) is lowered from the top position, above, and deployed (or ON) surface of each air intake path, reducing the position, below. Plenum chamber volume available cross-section for the airflow and is shaded in upper section. Vane drive causing it to both accelerate and change di- mechanism is shown in middle diagram. rection through a bigger angle than would be the case without the vanes deployed. This I learned from our recorder specialists that centrifuges solids and liquids to the outer both engine torque values dropped from climb radius of the curved airflow path. At the same power to zero precipitately and within milli- time, a bypass door (or aft vane) opens in seconds of one another. This occurred at about each airflow, causing that part of the flow 1,800 feet, within 8 seconds of the captain re- cross-section containing the solids and liq- questing the first officer to select the anti-ice uids to be ejected overboard rather than to Figure 4: Salvage ships in position during systems and almost exactly 5 seconds after enter the plenum chambers to risk forming lifting 6 days after accident. the sound of two switch selections, which were a frozen obstruction on the mesh guard cov- immediately followed by the electrical sound ering the inlet to the relevant engine. of the SD 360 did not favor the possibility of two motors operating. of a system handling error. The possibility Initial tests of a repetition of the second failure scenario Relevant aircraft features Tests carried out on an example of the lin- described above was effectively precluded Two PT 6A series reverse-flow turboprop ear actuator type, which drives the inertia by the purely mechanical operation of both engines power the aircraft type. Each en- separators (Figure 5), confirmed that the HP and LP fuel valves and the ergonomic gine is orientated with its compressor at the frequency of the electrical “noise” produced difficulty of operating both left- and right- rear. There are a number of reversals of air was identical to that of the acoustic noise hand controls of either simultaneously. The and combustion gas flow directions within present on the CVR initiating 5 seconds large fuel uplift apparently carried out at each powerplant (a total of 720 degrees di- before engine torque was recorded as lost Edinburgh, together with fuel remaining on rection change of flow axis between the ex- by the DFDR. It, therefore, became clear arrival, virtually precluded the possibility ternal intake and the aft-facing exhausts). that staggered operation of the selector of complete fuel exhaustion so soon after As shown in Figure 5, air is supplied to the switches of each inertia separator took place departure, and the aircraft was not flying engines via a forward-facing intake behind 5 seconds before a similarly staggered sud- in icing conditions at the time of the power and below each propeller, while exhaust den loss of all power on both engines oc- loss. Finally, there are no volcanoes within gases leave via a pair of curved pipes at the curred. There was thus little doubt that 5,000 miles upwind of Edinburgh. front of each engine, arranged to direct the deployment of each inertia separator had It was, therefore, with great surprise that gases backward. The air, having entered lead to the consequent power loss of the

October–December 2005 ISASI Forum • 17 RIGHT: Figure 6: Left engine nacelle with external intake and one exhaust stack visible after wreckage recovery. BELOW RIGHT: Figure 7: Assembled nacelle mock-up, utilizing panels salvaged from wrecked aircraft, incorporating cylinder forming dummy engine. Extractor fan can be seen. Adjustable valve has yet to be fitted to threaded shaft in front of fan. Transparent corresponding engine. This left the ques- Plexiglas bulkheads are fitted in place of tion of how this entirely normal system op- metal bulkheads at front and rear of eration could have had such a dramatic and plenum chamber (not visible). abnormal effect on both engines. started. During taxiing, the normal checks Relevant weather were carried out. These included a check of Early in the investigation it became clear that the autofeather. When a propeller is feath- the aircraft had arrived at Edinburgh at ered on this type, the corresponding iner- midnight, approximately 17 hours before the tia separator is automatically powered to accident and had been refueled with the in- the anti-ice position to further reduce drag. tention of departing within 2 hours. Snow began to fall as the aircraft arrived, however, The accident flight and became so severe that deicing services With inertia separators now reset to the and runway snow clearance activities became normal position, takeoff and initial climb overwhelmed. No movements took place took place followed by torque and RPM through the remainder of that night, and reduction to climb settings. Only shortly snow continued to fall until 0800 the next after further reselection of the inertia sepa- morning. Services only recovered early in the rators to the anti-ice position, in prepara- afternoon. Through the night, moderate tion for entering a sub-zero cloud layer, did snow (the meteorological term) was accom- the fatal double power loss occur. blades in each engine, the velocity through panied by wind gusting up to 40 knots from the system was found to be a high percent- a NNE direction. The aircraft was also Investigation process age of the local wind speed. parked on a heading of approximately NNE. Since the most unusual event during the An engine intake system and engine The temperature was between zero and +1 period of idleness at Edinburgh was the cowling panels, salvaged from the wrecked degree C. As the day began, the wind mod- weather of the night, I decided to find out aircraft, were then assembled into a mock- erated but continued to gust up to 17 knots what affect the snowfall had on the air in- up of a nacelle incorporating a dummy en- on the same heading while the temperature take systems. A special rig was, therefore, gine, complete with the intake mesh. Sealed slowly rose to 2 degrees C by midday. built, consisting of a controllable extractor plenum chamber bulkheads were manufac- fan mounted on a tapered transition tube tured from Plexiglas and fitted in represen- Sequence of events prior incorporating pressure-tapping points. The tative positions within the cowlings. An elec- to departure tube was bolted in the place of one exhaust tric extractor fan was mounted within the A new crew arrived in the early afternoon stack of an engine in a borrowed SD 360 dummy engine and an adjustable shutoff and observed that the aircraft was now free aircraft. The other exhaust on that engine valve was fitted at the forward end. Figure of visible contamination apart from an area was sealed off. The pressure tapings were 7 shows the front of the arrangement be- of the windscreen. Following a preflight connected to a digital pitot-static test set. fore the adjustable shutoff valve was fitted. check, the aircraft was started but it was A downstream pressure drop was cre- The fan was run and the valve adjusted to found that a generator would not come on ated by the fan, having similar magnitude create airflow velocities in the mock intake line. The aircraft was shut down and assis- to the pressure difference between the in- system of similar values to those measured tance summoned. take face and exit pipe pressures (Figure and calculated earlier in the intake of the A ground engineer carried out trouble- 5) calculated for the known average borrowed aircraft. shooting and a simple rectification. This headwind speed recorded during the night’s Simulated snowflakes, comprised of required both engines to be briefly run by snow storm. The speed of the airflow cre- finely cut fragments of expanded polysty- the crew while electrical loads were applied. ated in the extractor tube was measured by rene, were released near the external in- These included operation of all anti-icing means of the digital test set and the corre- take, and their progress through the systems, i.e., windscreens, propellers, air sponding speed in the intake system calcu- trunking and into the plenum chamber was intakes, and inertia separators, before the lated. Despite the complex flow path observed via the Plexiglas rear bulkhead. engines were again shut down. Once the through the total powerplant and the effect It was found that the flakes readily rose up problem was rectified, normal predeparture of at least seven stages of fixed blades and to and over the top of the dummy engine. actions took place and the engines were re- a similar number of stages of rotating It was, therefore, clear that during the

18 • ISASI Forum October–December 2005 Figure 8 (below): View of interior of plenum chamber with cowlings removed. Enclosed volume is between the forward and rear flexible bulkhead seals. Exhaust stack visible at top left.

sons, enable the interior of the plenum gines at the position of each first vane and a chambers to be seen. similar 50% blocking at the more down downstream position of the bypass door (Figure Effect of subsequent engine 5). Data supplied by the engine manufacturer operation showed that an 87% reduction of cross-sec- Engine starting would rapidly raise the tional area of the intake duct, under the temperature of the engine carcasses, caus- torque, RPM, and ambient air conditions ing the deposited snow to turn to slush and recorded and derived at the time of the power fall from the plenum chambers into the re- loss, would cause engine surge and flame- gion of the inertia separators. Although out. A similar degree of blocking occurring some melt material may have been ingested, at the low power settings and, hence, much the bulk of the tightly packed slushy sub- lower mass-flow rates present during opera- night, the wind, despite the complex flow stance would have arrived at and remained tion of the intake vanes on the ground, how- path involved, created a powerful airflow in the area of the vanes. Since air was being ever, would not have this effect. into the external forward-facing intakes, drawn through a narrowing cross-section Thus a mechanism can be visualized in through the intake trunking, upward via the created by the wet slush deposit, and the which weather conditions introduced large plenum chambers, through the engine in- deployed inertia separators, a condition volumes of snow into the intake systems let mesh filters, and through the engines. analogous with the throat of a carburetor where it remained undetected and in a This airflow had sufficient speed to lift would occur in which a temperature drop largely solid state. Operation of engines and snowflakes up into the area of the plenum would be created. A drop of only approxi- vanes took place in a sequence that resulted chambers, passing around and over the en- mately 2 degrees C would lead to gradual in a large volume of refrozen slush finally gines. Numerous pipes, tubes wiring looms, refreezing and solidification of the surface lodging in the region of the inertia separa- and skin stiffeners within the plenum cham- of the slush. Operation of the inertia sepa- tors where it added to the blocking effect bers would have ensured that snow was rators would cause the bypass doors to created by deployment of the latter. With readily deposited on these obstructions and move the solidifying ice volume forward. the final volume of slush reducing each in- the chamber volumes easily filled with snow. Once the separators were returned to the let duct cross-section by approximately Figure 8 shows a plenum chamber interior normal position, however, the solidified 40%, the effect of its presence and that of volume with the upper cowling removed. masses would be free to slide backward to- the deployment of the vanes would have The condition of many parked aircraft noted ward the bypass doors, under the influence been sufficient to cause both engines to in the morning after the snowfall ceased of the airflow. After engine shutdown, the surge and flame out. The DFDR shows that attested to the large volume of snow that wind would continue to drive air at just the HP spools of both engines decelerated must have passed into the intake and thus above freezing temperature over the refro- almost immediately to below their self-sus- remained in the plenum chambers. zen slush, limiting the effect of the hot en- taining speed. This effect, coupled with the gines on the ice and rapidly cooling the en- absence of continuous or auto ignition, en- Effect of ambient conditions gines by both internal and external flow. sured that flame-out was total and the en- Although the ambient temperature rose The engines were soon restarted, creat- gines did not relight. above freezing during the following morning a renewed cooling effect, presumably Although many other possible causes have ing, the large heat sink of the snow-filled returning the slush to a fully frozen state. been suggested for this power loss, none was plenum chambers, allied with the latent heat Again, inertia separators were operated found to be as likely as the process described of melting ice and the small margin of am- automatically during autofeather checks, above, given the known conditions and se- bient temperature above freezing level, presumably driving refrozen slush forward. quence of events. As with most accidents in- would have severely limited the volume of Once the separators were returned to the volving icing, the direct evidence was lost, trapped snow that melted. In contrast, the off position, the ice was again free to slide and in this case the contamination conditions outside surfaces of the aircraft heated more back toward the bypass doors. within the intake systems could not be physi- rapidly, due to exposure to sunlight and ul- As was stated earlier, there is compelling cally confirmed. Nonetheless, a process of timately required no deicing. Examination, evidence that the anti-ice vanes were selected reasonable deduction, based on all the avail- by a crew, of the high-mounted aircraft in- ON seconds before the fatal power loss. This able evidence and the test results, leads us takes from the ground or indeed from a action normally causes a 50% area reduction to conclude that the sequence described closer position would not, for geometric rea- or blocking of the free flow of air to the en- above was the cause of the power loss. ◆

October–December 2005 ISASI Forum • 19 (This article was adapted, with permission, theless, accidents still occasionally occur. in each and every phase, capturing and us- from the author’s presentation entitled The When they do occur, it is important to iden- ing lessons learned from all phases of a Role of Lessons Learned in the Investigate, tify the root causes, precursors, and lessons product’s lifecycle to continuously improve Communicate, Educate Cycle for Commer- learned of these accidents so that appropri- standards, validate design assumptions, cial Aviation prepared for the ISASI 2004 ate steps may be taken to reduce the risk of identify precursors, mitigate risk in safety- seminar held in Australia’s Gold Coast re- their reoccurrence. When presented with the related decision-making, and correct under- gion Aug. 30 to Sept. 2, 2004, which carried data, facts, and histories available, it becomes lying sources of problems systemwide. Les- the theme “Investigate, Communicate, and painfully obvious that most, if not all, accidents sons learned from accidents are perhaps the Educate.” The presentation was not orally followed one or more precursors or previous most costly. It is vital to capture these les- presented due to unexpected circumstances accidents that were not acted on for several sons through investigation, communicate affecting the authors. The entire paper, in- reasons. The predominant reason is that those them to the appropriate organizations, and cluding cited references index, is on the involved were unaware of the significance of educate people to recognize and use these ISASI website at www.isasi.org.—Editor) what they had observed. This lack of aware- hard-learned lessons to proactively make ness was due to a failure to view the event commercial aviation safer. viation safety begins with safe air- from the airplane level rather than the aircraft. The safety of large transport craft system, subsystem, or component level. Why lessons learned are important Aairplanes operating in commercial Another reoccurring reason is that those in- Lessons learned are defined as knowledge service throughout the world has steadily im- volved were unaware of the existence of criti- or understanding gained by experience. The proved over the last several decades. Never- cal, relevant information. These reasons are experience may be positive, such as a suc- actually common throughout many industries cessful test or mission, or negative, such as Dr. Paul Werner is a program manager in and tolerated or accepted by most. It is unac- a mishap or failure. A lesson must be sig- the Airworthiness Assurance Department ceptable in commercial aviation. nificant in that it has an impact on safety; of the Energy and Transportation Surety The aviation industry cannot afford the valid in that it is factually correct; and ap- Center, Sandia National Laboratories. He time and resources related to the loss or plicable in that it identifies a specific design, holds a B.S. and M.S. in physics and a non-use of important safety information. process, or decision that reduces or elimi- Ph.D. in electrical engineering. Much of Work must go on and airplanes must fly. The nates the potential for failures and mishaps, his work has involved researching and lessons learned system must allow individu- or reinforces a positive result. reviewing accidents across many indus- als to do their jobs more effectively and the Establishing a culture where we capture tries, including aviation, for lessons aviation system to operate safer and more and use day-to-day information and expe- learned. He has more than 2,000 hours in efficiently. Such a system did not exist in rience from certification, maintenance, and the U.S. Navy’s S-3 Viking and serves the FAA. The need and urgency has been operational activities is crucial to improv- with Air Test and Evaluation Squadron recognized and action taken to move in that ing aviation safety. By doing so, we can ex- Three One 0176 in the rank of captain. direction. The first step is awareness and a pect to gain benefits that include transition to a different way of making de- • documented guidance, information, and Richard Perry is manager of the Air- cisions for regulatory and industry person- best practices passed on to less-experienced worthiness Assurance Department of nel at all levels doing their job. people, Sandia National Laboratories. An Air Safety standards and the methods used • more-consistent safety decisions, Force Academy graduate, he holds a M.S. to apply them must continually evolve due in aeronautical engineering. He is an air- to advances in technology and demand for line transport pilot rated with 4,600 hours higher levels of safety. Each phase of the of flight experience in a broad range of air- product lifecycle continuum impacts safety craft. He has served as the director of sys- as information and experience derived from tem safety and engineering at the Air Force one phase is systemically applied to the other The Role Safety Center, reviewing approximately 50 phases. Success of the entire continuum is accident investigations annually. dependent on effective safety management of Lessons Learned By Dr. Paul Werner and Richard Perry, Sandia National Laboratories, U.S.A.

20 • ISASI Forum October–December 2005 • improved safety by reducing accidents Barriers to capturing and using Critical concepts and preventing any repeat accidents, and lessons learned The concepts discussed below are critical • reduction in safety problems caused by Several observations have been noted to the identification of design and certifica- breakdowns in communication between across diverse industries regarding effec- tion lessons learned from accidents. design and maintenance or operation tive capture and use of lessons learned. Aircraft-level awareness—When pre- organizations. First, most organizations strive to reuse all sented with the data, facts, and histories The best way to learn and improve is to kinds of documented experience, but it is available, it becomes painfully obvious that analyze previous experience and draw con- not easy to do so in an effective manner. The most, if not all, accidents followed previous clusions for future direction based on them. reuse is rather ad hoc and unplanned, and events that were not acted upon because One way regulators capture lessons learned it is often hard to know what to search for someone was unaware of the significance is through development of regulations, poli- or how to find useful documents. of what they observed. Often this was be- cies, and procedures. (See page 22.) Another observation is that the “right” cause they failed to view the significance of knowledge for solving a problem often ex- the event at the airplane level rather than Attributes of a successful process ists somewhere within the organization, the system, subsystem, or component level. Development and implementation of an ef- but the challenge is to take the time to In most cases, those involved were unaware fective lessons learned process is critical for search for it, identify it, get access to it, of the existence of critical, relevant infor- improving aviation safety. Ideally, it would and then learn from it. Because that expe- mation, i.e., lessons learned. be an integrated, common infrastructure rience is represented internally by experts, A conclusion from many of the accidents that captures and provides access to lessons the major problem is often finding and reviewed during the Commercial Airplane learned safety information throughout a getting access to the “expert” in order to Certification Process Study (March 2002) product’s lifecycle. As such, a successful les- solve a problem. was that adequate processes do not exist sons learned process would have the follow- In today’s complex and fast-moving avia- within the FAA or in most segments of the ing characteristics: tion system, engineers and inspectors of- commercial aviation industry to ensure that • A structured process for incorporating ten do not have the time to do extensive re- the lessons learned from specific experi- lessons learned into rules, policies, and pro- search and analysis of aircraft accidents and ences in airplane design, manufacturing, cedures for certification, maintenance, and incidents. Instead, they must rely on their maintenance, and flight operations are cap- operations. The process should ensure that experience and training, and possibly the tured permanently and made readily avail- in-service lessons learned are incorporated insight of others. So, why are lessons not able to the aviation industry. Consequently, in design or certification methods of com- learned? the failure to capture and disseminate les- pliance, and results of project-specific deci- • Cultural barriers, such as the lack of time sons learned has allowed airplane accidents sions are easily accessible by other certifi- to capture or submit lessons and a percep- to occur from causes similar to those of past cation projects. tion of intolerance for mistakes, accidents. In response to this concern, • Use of a disciplined, data-driven ap- • Organizational barriers, such as commu- Change Area 1.C, Precursor Awareness, proach to find root causes and determine nication across companies or lines of busi- was tasked to specifically “Develop AVR the best actions to break the chain of events ness is often difficult or nonexistent, airplane-level awareness for improved that lead to accidents. • Lessons are not routinely identified, col- identification and risk assessment of acci- • A process that includes periodic reviews lected, or shared across organizations and dent precursors. Define methods to capture, and feedback. This should be a unique task industry due to a lack of communication or share, and use lessons learned information from daily business for a “look back” and other factors, and throughout industry and the lifecycle.” should ensure reviews are conducted at • Unorganized lessons are hard to use with Precursors—The role and importance of ac- regular intervals. too much material to search; information may cident precursor recognition cannot be over- • A process that ensures corrective actions be formatted differently for different accident emphasized. Precursor data can be a valuable are implemented for all root causes as- reports; the information needed is not avail- source of information for decision-making, sessed, so that underlying sources of probable; it’s not quickly available; or work pres- either directly or as a supplement to risk lems are corrected systemwide. sures don’t allow the time or resources. analysis. Moreover, precursor data inherently

October–December 2005 ISASI Forum • 21 Partial Listing of Major Transport Airplane Accidents that Have Helped Shape U.S. Federal Aviation Regulations (FARs) and Policies

• Ford Trimotor in U.S.—1930 (engine waste bin fire in lavatory) (system isolation, pressure venting) failure on takeoff) • Turk Hava Yollari DC-10 near Paris—1974 • Mexicana B-727 near Maravatio, Mexico— • TWA L1049/UAL DC-7 near Grand (pressure relief, human factors) 1986 (wheelwell fire) Canyon—1956 (enroute ATC) • Lufthansa B-747 near Nairobi—1974 (takeoff • Northwest DC-9 at Detroit—1987 (human • Braniff L-188 near Buffalo, Texas—1959 warning, human factors) factors, takeoff warning) (propeller whirl mode) • TWA B-727 near Berryville, Virginia—1974 • South African Airways B-747 in Indian • U.S. operator/Viscount in Maryland—1962 (human factors, ground proximity) Ocean—1987 (cargo compartment fire) (birdstrike to tail) • Eastern B-727 near New York City—1975 • Aloha Airlines B-737 in Hawaii—1988 • Northwest L-188 near Cannelton, (windshear) (structural corrosion) Indiana—1960 (propeller whirl mode) • KLM B-747/Pan Am B-747 at Tenerife—1977 • American Airlines DC-10 at Dallas/Ft. • Eastern L-188 at Boston—1960 (bird (human factors, ATC) Worth—1988 (break wear) ingestion to engines) • Southern Airways DC-9 near Atlanta, • TACA B-737 near New Orleans, Louisi- • Pan Am B-707 near Elkton, Maryland— Georgia—1977 (rain ingestion to engines) ana—1988 (hail ingestion to engines) 1963 (lightning strike to fuel tanks) • Pacific Southwest Airlines B-727 at San Diego, • United Airlines B-747 in Hawaii—1989 • United B-727 at Salt Lake City—1965 California—1978 (human factors, TCAS) (structural inspection) (stretchable fuel lines) • United Airlines DC-8 near Portland, Oregon— • United Airlines DC-10 near Sioux City, • Pan Am B-707 at San Francisco—1965 1978 (human factors, low fuel warning) Iowa—1989 (system isolation, engine (rotor burst) • American Airlines DC-10 at Chicago, Illinois— inspections) • Mohawk BAC1-11 in United States—1967 1979 (system isolation, human factors) • USAir Jetstream 3100 at Beckley, West (APU inlet fire) • Saudia L-1011 near Riyadh, Saudi Arabia— Virginia—1991 (tail plane icing) • U.S. carrier B-727 at Los Angeles Int. 1980 (interior fire, human factors) • Lauda B-767 near Bangkok, Thailand— Airport—1969 (human factors, cockpit • Air Florida B-737 at Washington, D.C.—1982 1991 (thrust reverser inflight deployment) switches) (human factors, airframe/engine icing) • American Eagle SF340 near New Roads, • Air Canada DC-8 near Malton, Ontario— • British Airtours B-737 at Manchester, Louisiana—1994 (propeller beta in flight) 1970 (human factors, spoilers) England—1985 (fuel tank access covers) • Simmons Airlines ATR 72 near Roselawn, • Eastern L-1011 near Miami—1972 (human • Delta L-1011 at Dallas, Texas—1985 Indiana—1994 (freezing rain) factors, ATC) (windshear) • ValuJet DC-9 near Miami—1996 (hazmat, • VARIG B-707 near Paris—1973 (smoking/ • Japan Air Lines B-747 near Tokyo—1985 cargo fire protection) incorporate the effects of factors such as hu- Accident precursor data can be from any Type 3: All other precursor events—those man errors and intersystem dependencies. discipline (e.g., risk analysis, statistics, en- that have at least one consistent or depend- Accident precursor identification should gineering, ergonomics, psychology, sociol- able protection or mitigation element asso- identify latent and potential design, certifica- ogy, organizational behavior). ciated with the prevention of the event ini- tion, and operational safety issues and correct Daniel Cheney of the Federal Aviation tiation, progression, or consequences. Type them before they become accidents through Administration suggested the following 3 precursors require at least one other con- • comprehensive monitoring, sharing, and definitions of precursor types: dition in addition to the event condition to use of design and operational safety infor- Type 1: Precursors with no protection or occur. These represent the vast majority of mation and a consequent growth in the un- mitigation elements associated with the service information (i.e., data) used in the derstanding of current and emerging acci- prevention of the event initiation, progres- safety-oversight process. dent precursors and direct causes. sion, or consequences. Types 1 are the most An example of a Type 1 precursor for the • immediate certification and operational potentially serious of all precursor events. 1979 American Airlines DC-10 crash would interventions at the regional, national, and Type 2: Precursors with no consistent or de- be the 1978 pylon flange failure on a Conti- international levels. pendable protection or mitigation elements nental Airline DC-10 during maintenance. Precursor events can be any service in- associated with the prevention of the event This incident was essentially masked in formation or experience or test or inspec- initiation, progression, or consequences. trivia in a report circulated to other airlines tion data that could be interpreted as a pre- Nearly as potentially serious as Type 1, but and did not specifically identify that the fail- dictor that the event consequence could oc- may have an opportunity for intervention ure was related to the method used to re- cur if the event conditions were present. by flight crew, ground crew, or others. move the pylon.

22 • ISASI Forum October–December 2005 Precursors are not just technical in na- There is a strong link between root mine whether the results are satisfactory. ture. The DC-10 example also shows how causes, decision-making, and lessons One cannot be practiced without the other precursors can be related to procedural/ learned, especially in to have a positive impact on safety. human factors, political events, and deci- • establishment and communication of a System safety is characterized by the sions. Accident precursor recognition is a regulation or policy, systematic identification and control of haz- vital part of a proactive intervention strat- • application of a regulation or policy, ards throughout the lifecycle of a system. egy and needs to be an important part of • establishment and communication of It calls for the timely identification of sys- any safety management program. monitoring and oversight, and tem hazards before the fact and emphasizes • enforcement of that regulation or policy, the designing an acceptable level of safety Root causes based on monitoring and oversight. into the system. A driving reason for investigating accidents Some basic concepts of system safety are is to prevent future accidents. By identifying System safety that root causes (a cause is a set of sufficient con- In commercial aviation, a single accident is • safety should be built into the system, not ditions—each is necessary but only together often disastrous. One obvious lesson from the added on to a completed design. are they sufficient), we can potentially avoid short history of aviation is that most acci- • safety is a property of the system, not a a whole “class” of accidents. Unfortunately, dents are not the result of unknown scien- component. there is significant variation in people’s per- tific principles but more likely result from • accidents are not always caused by fail- ceptions of accidents. For example, the failure to apply well-known engineering ures and all failures do not cause accidents. • viewing accidents as a single event. This practices. A valuable lesson is that technol- • analysis to prevent the accident is em- often includes regulatory compliance/viola- ogy alone will not provide a solution; another phasized instead of reacting to the accident. tion thinking. lesson from history is that the non-technical • emphasis is on identifying hazards as • linear chain-of-events thinking, like issues cannot be ignored. Safety requires early as possible and then designing to knocking over a row of dominos. control of all aspects of the development and eliminate or control those hazards (more • statistical analysis methods. operation of a system. System safety covers qualitative than quantitative). • viewing an accident as a process involv- the entire spectrum of risk management, • tradeoffs and compromises in system de- ing concurrent actions by various actors to from design of hardware to the culture and sign need to be recognized. produce an unintended outcome. attitudes of the people involved. • system safety is more than just systems At the heart of root-cause analysis is the Safety is a property of a system. For ex- engineering. knowledge that things do not just happen. ample, determining whether an aircraft is Events are caused to happen, and by under- acceptably safe by examining the landing Design safety concepts standing the causes we can decide which ones gear, or any other component, is not pos- Aviation safety begins with safe aircraft. are within our control and manipulate them sible. Talking about the “safety of the land- The safety of large transport airplanes op- to meet our goals and objectives. Root causes ing gear” out of context of the aircraft and erating in commercial service throughout can be defined as the first factor in a chain of how it operates is really meaningless. Safety the world has steadily improved over the events that can be controlled through a regu- can only be determined by the relationship last several decades. Many techniques are lation, policy, or standard. It is a point in the between the landing gear and other aircraft used to achieve a safe design and include chain of events at which internal control can components, that is, in the context of the • design integrity (will not fail or has very be exercised. Simply put, they can be found whole aircraft and its environment. high margins, e.g., propellers, landing by stating the end result and keep asking A systems approach provides a logical gears, turbine rotor discs) and quality, “why?” until you have found a factor that can structure for problem solving. It views the • redundancy, be corrected by the application of a regula- entire system as an integrated whole. To • isolation, tion/policy/standard at the governing/man- make the system safe, we must manage • reliability, agement, implementing, or individual level, safety (risk) and we must assess safety. • failure indication, or you have reached a non-correctable situ- Management is what is done to ensure • flight crew procedures, ation. There may also be insufficient data to safety (limit risk), and assessment (surveil- • checkable/inspectable, proceed further. lance, in this case) is what is done to deter- • damage tolerance,

October–December 2005 ISASI Forum • 23 • failure containment, FAR Parts 25, 33, and 35 are the legal 25, safety is not reliability. As standards, they • designed failure path, codifications of the basic “fail-safe design are related but distinctly different concepts • margins/factors of safety, and concept” that was developed by the U.S. with different objectives. Both are concerned • error tolerance. aircraft transport industry over a period with the causes of failure. The difference is, from the days of the Ford Trimotor of the briefly, reliability is concerned with the fre- Four basic elements of design 1920s until the present day. quency of failure and safety is concerned with safety (U.S. transport-category the impact of failure. An aircraft design can aircraft) ELEMENT NO. 3. The Type Design Check be safe but unreliable, it can be reliable but ELEMENT NO. 1. Basic Design Philoso- The purpose of the “design safety check” is unsafe, and it can be safe and at the same time phy and Methodology to verify or validate that the design does, in reliable. Safety and reliability are essentially The design philosophy governs the overall fact, meet the required minimum safety related, independent design parameters that design approach, establishes design criteria, standards embodied in Elements 1 and 2. tend to complement or oppose each other, but and dictates failure assumption. The fail-safe The “Type Design Safety Check” is formally one cannot be substituted for the other. The philosophy is the chosen basic design philoso- completed with the issuance of an FAA type type certification process finds an aircraft de- phy and from this has emerged the fail-safe certificate. The design safety check also in- sign to be in compliance only with safety stan- design concept, i.e., “no single failure or prob- cludes the manufacturer’s in-house safety dards; it does not and cannot establish the able combination of failures during any one assessments, flight, and laboratory test pro- reliability level of the design. flight shall jeopardize the continued safe grams, qualification test programs, and the flight and landing of the airplane.” FAA Type Design Certification Program. Design integrity Design safety precedence: The probability of failure of an aircraft com- • Design to minimum hazard—Design the ELEMENT NO. 4. The Official Accident ponent is controlled by its design specifica- hazard out. If it cannot be eliminated, mini- Investigation and the Finding of Probable tion, including its qualification testing, and mize the residual risk. Cause is a measure of its design integrity. The con- • Use safety devices—Do this by incorpo- This includes an official public report of the cept of design integrity is concerned with rating a fail-safe mode, safety devices, or accident findings. The knowledge contained the quality of the design and its ability to fault-tolerant features. in the findings, especially the lessons perform its intended functions as required • Use warning devices—Done through learned, is used to improve and strengthen by the design specification and FAR measuring devices, software, or other the design philosophy, code, and checks of 25.1309(a). Design integrity is generally means. The warning should be unambigu- Elements 1, 2, and 3. established through the qualification test- ous and attract the operator’s attention. ing of individual aircraft components to • Use special procedures—Used when the Safety and reliability their design specification requirements. above means are unable to control the hazard. System safety and reliability are often con- Design integrity is an integral part of the fused. Although similar, it is important to first basic aircraft safety concept. The achieved ELEMENT NO. 2. The Official Code of understand the difference between the two. reliability of a component in service is a Airworthiness Design Standards for Trans- Fundamentally, the two disciplines ask and measure of its design integrity. The port-Category Aircraft, Engines, Propel- seek to answer two different questions about operator’s approved maintenance program lers, and APUs two different concepts. Reliability asks, “How and the operator’s/manufacturer’s product This is the legal codification of Element No. often does something fail?” System safety improvement program control the reliabil- 1 and is usually referred to as the type cer- asks, “What happens (to the system) when ity of an approved aircraft design. tification code. The legal design safety code something fails or behaves unexpectedly?” specifies how the design safety methodol- Although it is obviously concerned with sys- ogy is to be applied; what general or spe- tem failure, reliability is usually concerned cific design safety methods are to be incor- with individual parts. Remember, a reliable It is necessary to adopt a porated; what, if any, specific exceptions are system is not necessarily a safe system. more rigorous and syste- to be allowed; and any specific additions. As applied to civil aircraft designed to FAR matic approach to lessons learned safety training and management. A first step is awareness and a transition to a different way of making decisions for regulatory and industry personnel at all levels doing their job.

24 • ISASI Forum October–December 2005 Aircraft-centered system 20-year design life of a passenger aircraft. out quickly what’s going on and how to deal As discussed earlier, accidents, and conse- Significant attention must accordingly be with it. The safety of an aircraft depends on quently the lessons learned, are products given to better understanding and quanti- designing and building it to the highest stan- of system interactions. Therefore, it is criti- fying the mechanisms of aircraft aging. If dards of safety we know, and the same goes cal to have at least a minimal understand- these failure mechanisms are left un- for its computer systems. Careful attention ing of all the subordinate elements and how checked, the significantly longer times in must be paid to how well we design and build they behave as a system in order to iden- service that can be anticipated could lead those computer systems. tify, understand, and apply lessons learned. to a significant increase in the accident rate. Most accidents will have lessons learned The hierarchical breakdown used here is Human factors—Basic automated flight in more than one of the previously men- consistent with and adds to the Air Trans- control systems and electromechanical dis- tioned elements and involve one or more of port Association (ATA) index. This break- plays are giving way to new generations of the concepts and factors discussed. down provides a familiar structure and is jet transport aircraft equipped with highly consistent with normal systems engineer- automated flight management systems and Conclusion ing practice. It is convenient for lessons flat panel or liquid crystal displays. The new Lessons learned are defined as knowledge learned because it groups subsystems to- technology has significantly changed the or understanding gained by experience. gether technologically. The aircraft is bro- work of airline pilots and has implications for Aviation experience and knowledge now ken down as all elements of the aviation system, especially spans several generations of safety manag- • Airframe—This element includes wing, design and safety regulation. Air safety in- ers and engineers. It is no longer possible fuselage, and empennage. vestigators and researchers worldwide have for comprehensive knowledge to be ex- • Mechanical—This element includes land- witnessed the emergence of new human fac- changed from experienced safety individu- ing gear, hydraulics, flight controls, and tors problems related to the interaction of als to the next generation of safety person- cargo loading equipment. pilots and advanced cockpit systems. nel through on-the-job training alone. The • Electrical—This element includes elec- Environment—This is the environment system is so complex that it is unlikely that trical power and lighting. external to the aircraft. Weather is prob- any one individual can possess truly com- • Propulsion—This element includes the ably the most prominent factor. prehensive system safety understanding. engine pod and pylon and their components, Maintenance, operations—Maintenance Advances in technology and demands for fuel components, and thrust management and operational events are the primary higher levels of safety dictate that standards components. source of information for accident precur- and the methods used to apply them must • Avionics—This element includes commu- sors and lessons learned. continually evolve. nication, navigation, and aircraft monitor- Regulations, policies, standards—Past The role of lessons learned in the inves- ing equipment. lessons learned are often captured in regu- tigate, communicate, educate cycle for com- • Environmental—This element includes lations, policies, and standards. Most acci- mercial aviation cannot be overstated. It is cabin pressure, air conditioning, and oxy- dents have factors related to the absence of a necessary part of the organizational safety gen equipment. or misapplication of such guidance and di- strategy involving continuously improving • Interior—This element includes crew rection. Accident precursor information and standards, validating design assumptions, and passenger accommodations. lessons learned are a valuable source to aid identifying precursors, mitigating risk in • Auxiliary, other—This element includes in interpretation, implementation, and cer- safety-related decision-making, and cor- auxiliary electrical and pneumatic power tifications decisions. recting underlying sources of problems supplies. Software—All commercial transport air- systemwide. It is necessary to adopt a more craft designed and built within the last 15 rigorous and systematic approach to lessons Other factors in aircraft years have some computer technology, learned safety training and management. accidents mostly in the cockpit. The computers are in- A first step is awareness and a transition to Aging aircraft—The average age of the tended to make flying easier and safer, and a different way of making decisions for U.S. commercial aircraft fleet today already in general they do. But when things don’t regulatory and industry personnel at all exceeds 75 percent of the typical nominal happen as expected, it can be hard to figure levels doing their job. ◆

October–December 2005 ISASI Forum • 25 ISASI ROUNDUP

Cirrus Training Effort Is Recognized

ISASI President Frank Del Gandio ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ recognized the Cirrus Aircraft Corpora- tion with an award at ISASI 2005 for its development of “First Responder” training seminars. In making the award presentation Del Gandio said, “Cirrus, one of the leading general aviation aircraft manufacturers, has made a remarkable commitment to general aviation safety awareness presenting ‘First Responder’ seminars.” He added, “On its own initiative, the corporation has initiated hundreds of seminars and workshops across the country. These presentations are being given to familiarize and educate First Responders, which include rescue personnel and accident investigators who may respond to an accident involving an aircraft equipped with a Ballistic Recov- ery System (BRS). This training is invaluable,” he concluded. Cirrus is a pioneer in an innovative and E. MARTINEZ revolutionary general aviation safety enhancement known as the Cirrus aviation safety inspectors are also aware ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ Bill King (left) and Mike Busch (center) Airframe Parachute System (known as of the safety precautions involving accept recognition plaque from CAPS.) CAPS is a “ballistic parachute” Ballistic Recovery Systems installed on ISASI President Del Gandio. system created by Ballistic Recovery other types of aircraft, Del Gandio Systems for Cirrus Design to safely lower noted. and assist university and college-level a light airplane from an emergency in the The Ballistic Recovery Systems, Inc. students interested in the field of aviation air to the ground. A solid-fuel rocket, was named a recipient of a prestigious safety and aircraft occurrence investiga- housed in the aft fuselage, is used to pull Laureate Award by Aviation Week & tion. All members of ISASI enrolled as a the parachute out from its housing and ○○○○○○○○○○○○○○○○○○○○○○○○○○ Space Technology magazine as the top full-time student in an ISASI-recognized fully deploy the canopy within seconds. business and general aviation company in education program, which includes The CAPS system is designed into all of 2004. The award was made in April. ◆ courses in aircraft engineering and/or the aircraft Cirrus builds—SRV, SR20, operations, aviation psychology, aviation and SR22. Kapustin Scholarship Is- safety, and/or aircraft occurrence investi- In the recent past, two different Cirrus gation, etc., with major or minor subjects pilots encountered inflight emergencies sues 2006 Application Call that focus on aviation safety/investigation, and brought their planes safely to the The ISASI Rudolf Kapustin Memorial are eligible for the scholarship. A student ground by deploying their onboard Scholarship Committee has issued its call who has once received the annual ISASI parachutes—only the second and third for scholarship applications to universities Rudolf Kapustin Memorial will not be emergency uses of CAPS. This technol- and colleges whose students are eligible eligible to apply for it again. One or more ogy was first used in an emergency in to participate in the program, according students will be selected in this process. October 2002. to the Fund’s administrators, Richard The scholarship consists of a $1,500 Cirrus has been instrumental in Stone, ISASI Executive Advisor, and Ron award to help cover travel, registration, assisting the Federal Aviation Adminis- Schleede, ISASI vice-president. The lodging, and meal expense in attending tration in modifying its aircraft accident deadline for applications is April 1, 2006. ISASI’s annual seminar, which will be school’s curriculum to ensure that The goal of the Fund is to encourage held in Cancun, Mexico, Sept. 11-14, 2006.

26 • ISASI Forum October–December 2005 Winners of the ISASI Kapustin Scholarship Fund to date. All attended the ISASI 2005 seminar and are shown here with the two Fund administrators. Left to right, R. Schleede, C. Reil, Noelle Brunelle, Shannon Harris, M. Schuurman, and R. Stone.

○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ authentic, original work. • The papers will be judged on their content, original thinking, logic, and clarity of expression. • The student must complete the application available at the university or at ISASI headquarters and submit it to ISASI with his/her paper by April 1, 2006. E. MARTINEZ • Completed applications should be Application requirements ○○○○○○○○○○○○ student must be a member of ISASI. forwarded to ISASI, 107 Holly Ave., Suite • A full-time college or university student • The student is to submit a 1,000 (+/- 10 11, Sterling, VA 20164-5405 USA. E-mail in courses in aircraft engineering and/or percent) word paper in English address- address: [email protected], Telephone: 703- operations, aviation psychology, aviation ing “The Challenges for Air Safety 430-9668. safety, and/or aircraft occurrence investi- Investigators.” • Applicants will be notified of ISASI’s gation, etc., with major or minor subjects • The paper is to be the student’s own decision by May 1, 2006. that focus on aviation safety/investigation work and must be countersigned by the • The judges’ decision is final. ◆ of minimum duration of 1 year. The student’s tutor/academic supervisor as Athens Reachout Workshop Teaches 36 Attendees Call for Papers—ISASI 2006 ISASI’s 14th Reachout Workshop conducted in Athens, Greece, July 18-29, covered aircraft accident investigation The International Society of Air Safety Investigators and safety management systems. The Presents its 37th International Seminar Sept. 11-14, 2006, Hellenic Aircraft Accident Investigation at the Fiesta America Grand Coral Beach Hotel, and Aviation Safety Board (AAI & ASB) hosted the workshop. Capt. Akrivos Cancun, Mexico Tsolakis, chairman of the AAI & ASB, Theme: “Incidents to Accidents: Breaking the Chain” opened the popular training session. Held in the facilities of the AAI & ASB If you wish to offer a presentation in gation and translate those lessons to at the Athens International Airport, the

line with the seminar’s theme, please effective prevention will be considered. ○○○○○○○○○○○○○○○○○○○○○○○○○○○ 7-day-long accident investigation module adhere to the below schedule: was conducted by Ron Schleede and Caj Indication of interest: Jan. 31 2006 PowerPoint presentations are not Frostell. This module presented ICAO Abstracts due: March 31, 2006 acceptable for publication in seminar requirements and international obliga- Selected papers due in electronic Proceedings or seminar CDs. Submit- tions, Annex 13, selection and training of format: July 31, 2006 tal of an abstract implies agreement investigators, planning and organization that the author authorizes publication to conduct an investigation, procedures Topics sought of the completed paper in the seminar and checklists, wreckage recovery, field The Technical Committee is looking for Proceedings and the ISASI Forum. investigation, accident site management, about 16 papers on current investiga- group organization, flight recorders, tion experience, techniques, and Send indication of interest and technical investigation, operations lessons learned with particular abstracts to Jim Stewart, Technical investigation, off-scene testing, crashwor- emphasis on international investiga- Program Chair, e-mail to thiness, witness interviewing, pathology, tion challenges. In keeping with the [email protected], or mail to family assistance, avoidance and protec- theme, papers directed toward 307-1500 Riverside Drive, Ottawa tion of biohazards exposure, news media, emphasizing how we can maximize the Ontario, Canada, K1G4j4. factual reports and public records, writing lessons learned from accident investi- Phone: 613-736-1491. the final report, identification of safety deficiencies, making safety recommenda-

October–December 2005 ISASI Forum • 27 ISASI ROUNDUP Continued . . . ISASI Annual Report 2004—Profit & Loss Budget

Jan.-Dec. 04 Budget $ Over Budget % of Budget Ordinary Income/Expense Income tions, and nine interactive case studies. ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ 601 Dues-New Individual Member 11,650.00 10,000.00 1,650.00 116.5% 603 Dues-New Corporate Member 4,183.00 5,000.00 -817.00 83.66% Jim Stewart and Frostell conducted the 611 Dues-Renewal Individual Member 65,700.00 71,000.00 -5,300.00 92.54% 3-day safety management systems (SMS) 613 Dues-Renewal Corporate Member 63,356.00 50,000.00 13,356.00 126.71% 614 Dues-Late Fees 1,460.00 500.00 960.00 292.0% module. It contained presentations on the 615 Dues-Upgrade Fees 185.00 300.00 -115.00 61.67% international and national requirements 616 Dues-Reinstatement Fees 150.00 621 Contrib.-Unres. Membership 1,950.00 2,000.00 -50.00 97.5% for SMS, statistics and the need for data, 631 Publication Subscriptions 792.00 500.00 292.00 158.4% the safety eras, the SHELL model, the 632 Publication Income 1,451.00 500.00 951.00 290.2% 634 Library Services 58.06 150.00 -91.94 38.71% Reason model, the MEDA/PEAT analysis 642 Membership Services 187.37 400.00 -212.63 46.84% tools, safety management evolution, 643 Membership Regalia Sales 268.57 400.00 -131.43 67.14% 650 Seminar-Proceedings 0.00 5,000.00 -5,000.00 0.0% building a non-punitive reporting pro- 651 Seminar-Net Proceeds 32,951.79 10,000.00 22,951.79 329.52% gram, SMS processes, lessons from the 652 Seminar-Reimbursed Advance 3,000.00 3,000.00 0.00 100.0% Total Income 187,342.79 158,750.00 28,592.79 118.01% Challenger accident, risk management, safety culture, dealing with change, Expense 700 Condo Fees 3,968.60 2,800.00 1,168.60 141.74% regulating SMS, assessing an SMS 705 Mortgage Interest 5,719.14 9,500.00 -3,780.86 60.2% program, and three case studies. 711 Repairs and Maintenance 969.76 1,000.00 -30.24 96.98% 712 Storage Rental 1,620.00 1,000.00 620.00 162.0% The instructors prepared the training 801 P/R Exp.-Office Mgr. Salary 41,237.92 37,000.00 4,237.92 111.45% material for their modules consisting of 802 P/R Exp.-Health Insurance 11,182.00 9,000.00 2,182.00 124.24% 803 P/R Exp.-SEPP 1,864.02 1,800.00 64.02 103.56% paper handouts and CD-ROM libraries of 804 P/R Exp.-Trng. Misc. and Benefits 0.00 300.00 -300.00 0.0% published manuals and booklets. Each 808 P/R Expense-Bonus 0.00 500.00 -500.00 0.0% 811 Accounting-Payroll 880.55 850.00 30.55 103.59% participant received copies of documents 812 Accounting-Tax Prep. 405.00 500.00 -95.00 81.0% and CD-ROMs with considerable back- 814 Insurance 3,166.00 1,500.00 1,666.00 211.07% 817 Licenses and Permits 140.00 150.00 -10.00 93.33% ground materials for future reference 821 OPS-Rent 233.38 Thirty-six persons attended the 822 OPS-Telephone & Telex 3,465.87 2,400.00 1,065.87 144.41% 824 OPS-Equip Maint. & Repair 2,148.44 1,800.00 348.44 119.36% workshop. They represented the AAI & 825 OPS-Other Utilities 3,065.79 3,000.00 65.79 102.19% ASB, Athens International Airport, 826 OPS-Postage and Shipping 7,136.00 6,500.00 636.00 109.79% 827 OPS-Printing and Reproduction 3,211.38 1,600.00 1,611.38 200.71%

Hellenic ATA, Hellenic Coast Guard, ○○○○○○○ 828 OPS-Office Supplies 4,293.97 3,000.00 1,293.97 143.13% Hellenic Police, Hellenic Fire Corp., 830 OPS-Computer Tech. Support 2,932.50 250.00 2,682.50 1,173.0% 831 OPS-Equipment Purchase 0.00 4,000.00 -4,000.00 0.0% Hellenic Air Force, Hellenic Army, 832 OPS-Equipment Lease 3,948.04 1,000.00 2,948.04 394.8% Hellenic Navy, Cyprus AAIB, Olympic 833 OPS-Petty Cash 200.00 200.00 0.00 100.0% Airlines, and Aegean Airlines. All

○○○○○○○○○○○○○○○○○○○○○○○○○○○ Biohazards students shown in protection garb during course work. Also shown is Nikos Pouliezos (left), Ron Schleede (center), and John Papadopoulus (right).

participants received ISASI certificates for the accident investigation module, the avoidance and protection of biohazards exposure course, and the safety management systems module. Caj Frostell reports that AAI & ASB and the participants were appreciative of the ISASI initiative to bring the Reachout Workshop program to Greece. ISASI membership forms and corporate membership forms were made available to the participants. Capt. Tsolakis announced that the AAI & ASB was

28 • ISASI Forum October–December 2005 vs. Actual

Jan.-Dec. 04 Budget $ Over Budget % of Budget

840 OPS-Temp. Help 384.00 500.00 -116.00 76.8% ○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ 844 Publications-Forum Expense 36,523.28 38,000.00 -1,476.72 96.11% 845 Publications-Proceedings 6,324.95 5,000.00 1,324.95 126.5% DUES NOTICE 848 Publications-Handbook Expense 1,069.00 1,000.00 69.00 106.9% 856 Membership-Regalia Items 0.00 500.00 -500.00 0.0% Invoices for the 2006 annual dues 861 Membership-Service Expense 4,860.48 1,500.00 3,360.48 324.03% (January 1 through December 31) to 871 Library Expenses 592.69 1,000.00 -407.31 59.27% ISASI have been mailed. All individual 881 Management Council-Travel 12,324.43 16,500.00 -4,175.57 74.69% 882 Management Council-Admin. Exp. 951.83 1,300.00 -348.17 73.22% members are asked to check individual 883 Management Council-Other 3,911.74 3,000.00 911.74 130.39% identification information and update 886 Management Council-Rep. Travel 93.84 500.00 -406.16 18.77% where necessary. Members are reminded 887 Management Council-Rep. Admin. 0.00 200.00 -200.00 0.0% that the deadline for payment is Jan. 31, 891 Rebate-Natl./Reg./Corp. 0.00 2,000.00 -2,000.00 0.0% 2006. A fee of $20 will assessed for late 901 Seminar-Advances 0.00 3,000.00 -3,000.00 0.0% payments. Credit card payment may be 903 Seminar-Lederer Award 173.90 500.00 -326.10 34.78% made. See the mailed invoice for credit 911 Bank Fees 290.48 400.00 -109.52 72.62% card use. Checks should be made payable 912 Credit Card Charges 2,862.97 2,500.00 362.97 114.52% Total Expenses 172,151.95 167,050.00 5,101.95 103.05% to ISASI and forwarded to ISASI, 107 E. Holly Avenue, Suite 11, Sterling, VA Net Ordinary Income 15,190.84 -8,300.00 23,490.84 -183.02% 20164-5405 USA. ◆

Other Income/Expense Other Income 661 Rent-Tenant Rental Income 7,465.00 8,460.00 -995.00 88.24% Forum in China in order to assist our 671 Interest-Checking Acct. 200.62 500.00 -299.38 40.12% Chinese colleagues in the aviation safety 681 Other Income-Miscellaneous 30.00 682 Other Income -Refunds 10.70 investigation field. We wish Ms. Yang success in her endeavors in promoting Total Other Income 7,706.32 8,960.00 -1,253.68 86.01% ISASI, aviation safety, and accident Other Expenses investigation in China.” 926 Penalties 1.58 922 Misc.-Other Reimb. Exp. 976.88 Ms. Yang graduated in 1994 with a BS 924 Misc.-Death/Illness Exp. 154.20 in electronics engineering from Shandong 925 Misc. Refunds 259.40 930 Depreciation 11,039.00 University in China. She joined the flight safety group of the Civil Aviation Safety Total Other Expense 12,431.06 Research Center, which later became the Net Other Income -4,724.74 8,960.00 -13,684.74 -52.73% CAAC’s Accident Investigation Labora- Net Income 10,466.10 660.00 9,806.10 1,585.77% tory (CASTC). Ms. Yang is now a senior engineer. She has also translated several flight crew operations manuals into Chinese for airlines in China, as well as becoming an ISASI corporate member. ○○○○○○○○○○○○○○○○○○○○○○○○○○○ communication from one of our members a flight data monitoring manual. ◆ Also, three workshop participants joined in China. Ms. Lin Yang wrote: ‘I will never ISASI as individual members. forget a day 10 years ago when I read the Transportation Fatalities Olympic Airlines, Aegean Airlines, ISASI Forum for the first time. The Athens International Airport, Hellas Jet, authors with their valuable and diversified Decrease In 2004 Air BP, Karayannis Group of Companies, experiences gave me insights and inspira- Transportation fatalities in the United and the Hellenic Flight Safety Foundation tions. From then on, I have read every States decreased slightly in 2004, accord- provided local sponsorships. All travel and article in every issue of the ISASI Forum ing to preliminary figures released by the daily subsistence costs for the three in- and I have never been disappointed.’ National Transportation Safety Board. structors were covered by AAI & ASB. ◆ “Ms. Yang further suggested: ‘As a Deaths from transportation accidents in member of ISASI in China, I think I could the United States in 2004 totaled 44,870, International Councillor promote the ISASI mission in China and down from the 45,158 fatalities in 2003.

get more Chinese colleagues aware of ○○○○○○○○ “Although it is always gratifying to see Shares Mail ISASI, and to participate in the sharing of transportation fatalities decline,” NTSB ISASI’S International Councillor, Caj air safety investigation findings, investi- Acting Chairman Mark Rosenker said, Frostell, shares mail he received from a gation techniques, and experiences.’ In “the yearly toll, especially on our high- Society member in China. He wrote: this respect, she is planning to translate ways, continues to be unacceptable. We “I recently received a very interesting and distribute each issue of the ISASI need to do more at all levels—federal,

October–December 2005 ISASI Forum • 29 ISASI ROUNDUP ISASI Information Continued . . .

OFFICERS Australian and New Zealand Societies of President, Frank Del Gandio ([email protected]) Air Safety Investigators Executive Advisor, Richard Stone ([email protected]) Vice-President, Ron Schleede PRELIMINARY NOTICE and ([email protected]) Secretary, Keith Hagy ([email protected]) Treasurer, Tom McCarthy CALL FOR PAPERS ([email protected]) 2006 Regional Air Safety Seminar COUNCILLORS Hilton on the Park, Melbourne, Victoria Australian, Lindsay Naylor ([email protected]) Friday, Saturday, and Sunday, June 2–4, 2006 Canadian, Barbara Dunn ([email protected]) European, Max Saint-Germain This seminar will be an educational the Friday afternoon. ([email protected]) event with emphasis on contemporary If you wish to offer a presentation International, Caj Frostell ([email protected]) regional issues in aircraft accident for the seminar, please provide an New Zealand, Ron Chippindale investigation and prevention. abstract (approximately 100 words) ([email protected]) The Asia-Pacific Cabin Safety plus personal details by Feb. 1, 2006, to United States, Curt Lewis ([email protected]) Working Group is expected to meet on Paul Mayes, e-mail: Paul.Mayes@ Friday, June 2, and there will be a visit airnz.co.nz, phone: +64 9 256 3402, fax: NATIONAL AND REGIONAL to the Defence Science and Technology +64 9 256 3911, post: ASASI, P.O. Box SOCIETY PRESIDENTS Organization at Fishermen’s Bend on 588, Civic Square ACT 2608 Australian, Kenneth S. Lewis ([email protected]) Canadian, Barbara M. Dunn

○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○○ ([email protected]) state, and local—to protect our traveling 2003 to 651 in 2004. There were no European, Ken Smart public.” fatalities on commuter carriers in 2004. ([email protected]) The number of persons killed in all The number of general aviation fatalities Latin American (Vacant) New Zealand, Peter Williams aviation accidents dropped from 710 in also decreased from 632 in 2003 to 556 in ([email protected]) 2004. There were 14 airline fatalities, 13 of Russian, V. Venkov which occurred in a crash of a Jetstream ([email protected]) SESA-France Chap.,Vincent Fave Who is Where? aircraft in Kirksville, Mo. Air taxi ([email protected]) fatalities increased from 42 to 65. United States, Curt Lewis Richard F. Healing, National Highway transportation, which ([email protected]) Transportation Safety Board accounts for the largest portion of member, has retired from govern- fatalities, decreased from 42,884 in 2003 ment service. He left his position as to 42,636 in 2004. The number of fatalities member of the National Transpor- increased in the motorcycle, light trucks tation Safety Board on August 1. and van, and medium and heavy trucks Jim LaBelle has been named as categories. However, there was a decrease director of the National Transporta- in the number of deaths occurring in the tion Safety Board’s regional aviation passenger car category, which recorded office in Anchorage, Alaska. He is a 634 fewer fatalities in 2004 than in 2003. senior NTSB air safety investigator Total rail fatalities increased from 760 in who has been working in the Alaska 2003 to 802 in 2004, reflecting a rise in office for the last 10 years. For the every category except passenger fatalities,

past year, he has been acting ○○○○ which remained at 3. Fatalities occurring director of the office. ◆ on light rail, heavy rail, and commuter rail increased from 165 to 186. ◆

30 • ISASI Forum October–December 2005 UNITED STATES REGIONAL CORPORATE MEMBERS EVA Airways Corporation Exponent, Inc. Accident Investigation Board, Finland CHAPTER PRESIDENTS Federal Aviation Administration Accident Investigation Board/Norway Alaska, Craig Beldsoe Finnair Oyj Aeronautical & Maritime Research Laboratory ([email protected]) Flight Attendant Training Institute at Melville AeroVeritas Aviation Safety Consulting, Ltd. Arizona, Bill Waldock ([email protected]) College Air Accident Investigation Bureau of Singapore Dallas-Ft. Worth, Curt Lewis Flight Safety Foundation Air Accident Investigation Unit—Ireland ([email protected]) Flight Safety Foundation—Taiwan Air Accidents Investigation Branch—U.K. Florida, Ben Coleman ([email protected]) Flightscape, Inc. Air Canada Pilots Association Great Lakes, Rodney Schaeffer Galaxy Scientific Corporation Air Line Pilots Association ([email protected]) GE Transportation/Aircraft Engines Air New Zealand, Ltd. Los Angeles, Inactive Global Aerospace, Inc. Airbus S.A.S. Mid-Atlantic, Ron Schleede Hall & Associates, LLC Airclaims Limited ([email protected]) Honeywell Aircraft Accident Investigation Bureau— Northeast, David W. Graham ([email protected]) Hong Kong Airline Pilots Association Switzerland Pacific Northwest, Kevin Darcy Hong Kong Civil Aviation Department Aircraft Mechanics Fraternal Association ([email protected]) IFALPA Aircraft & Railway Accident Investigation Rocky Mountain, Gary R. Morphew Independent Pilots Association Commission ([email protected]) Int’l. Assoc. of Mach. & Aerospace Wkrs Airservices Australia San Francisco, Peter Axelrod Interstate Aviation Committee AirTran Airways ([email protected]) Irish Air Corps Alaska Airlines Southeastern, Inactive Japan Airlines Domestic Co., LTD All Nippon Airways Company Limited Japanese Aviation Insurance Pool Allied Pilots Association JetBlue Airways COMMITTEE CHAIRMEN American Eagle Airlines KLM Royal Dutch Airlines Audit, Dr. Michael K. Hynes American Underwater Search & Survey, Ltd. L-3 Communications Aviation Recorders ([email protected]) ASPA de Mexico Learjet, Inc. Award, Gale E. Braden ([email protected]) Association of Professional Flight Attendants Lockheed Martin Corporation Ballot Certification, Tom McCarthy Atlantic Southeast Airlines—Delta Connection Lufthansa German Airlines ([email protected]) Australian Transport Safety Bureau MyTravel Airways Board of Fellows, Ron Chippindale Aviation Safety Council National Air Traffic Controllers Assn. ([email protected]) Avions de Transport Regional (ATR) National Business Aviation Association Bylaws, Darren T. Gaines ([email protected]) BEA-Bureau D’Enquetes et D’Analyses National Transportation Safety Board Code of Ethics, John P. Combs Board of Accident Investigation—Sweden NAV Canada ([email protected]) Boeing Commercial Airplanes Phoenix International, Inc. Membership, Tom McCarthy ([email protected]) Bombardier Aerospace Regional Aircraft Pratt & Whitney Nominating, Tom McCarthy ([email protected]) Bundesstelle fur Flugunfalluntersuchung—BFU Qantas Airways Limited Reachout, James P. Stewart ([email protected]) Cathay Pacific Airways Limited Republic of Singapore Air Force Seminar, Barbara Dunn ([email protected]) Cavok Group, Inc. Rolls- Royce, PLC Centurion, Inc. Royal Netherlands Air Force WORKING GROUP CHAIRMEN China Airlines Royal New Zealand Air Force Air Traffic Services, John A. Guselli (Chair) Cirrus Design rit, LLC ([email protected]) Civil Aviation Safety Authority Australia Sandia National Laboratories Ladislav Mika (Co-Chair) ([email protected]) Comair, Inc. Saudi Arabian Airlines Cabin Safety, Joann E. Matley Continental Airlines SICOFAA/SPS ([email protected]) Continental Express Sikorsky Aircraft Corporation Corporate Affairs, John W. Purvis COPAC/Colegio Oficial de Pilotos de la Singapore Airlines, Ltd. ([email protected]) Aviacion Comercial SNECMA Moteurs Flight Recorder, Michael R. Poole Cranfield Safety & Accident Investigation South African Airways ([email protected]) Centre South African Civil Aviation Authority General Aviation, William (Buck) Welch DCI/Branch AIRCO Southern California Safety Institute ([email protected]) Delta Air Lines, Inc. Southwest Airlines Company Government Air Safety, Willaim L. McNease Directorate of Aircraft Accident Investigations— Star Navigation Systems Group, Ltd. ([email protected]) Namibia State of Israel Human Factors, Dr. Robert C. Matthews Directorate of Flight Safety (Canadian Forces) Transport Canada ([email protected]) Directorate of Flying Safety—ADF Transportation Safety Board of Canada Investigators Training & Education, Dutch Airline Pilots Association U.K. Civil Aviation Authority Graham R. Braithwaite Dutch Transport Safety Board UND Aerospace ([email protected]) EL AL Israel Airlines University of NSW AVIATION Positions, Ken Smart EMBRAER-Empresa Brasileira de Aeronautica University of Southern California ([email protected]) S.A. Volvo Aero Corporation Embry-Riddle Aeronautical University WestJet ◆ Emirates Airline Era Aviation, Inc. European Aviation Safety Agency

October–December 2005 ISASI Forum • 31 WWHO’SHO’S W WHOHO

VNV: Dutch Airline Pilots Association

(Who’s Who is a brief profile of, and pre- attend courses or by calling in know-how does not avoid a confrontation. Several pared by, an ISASI corporate member to from external sources. times in the history of the VNV, actions have enable a more thorough understanding been necessary to enforce negotiations. of the organization’s role and functions A real labor union —Editor.) The VNV is a real union, which stands for A committed professional above-average employment terms and association he employment terms and labor conditions for pilots. It is successful as well. As a professional association, the VNV has conditions for pilots, taken for Since the first collective labor agreement dedicated itself to a continuous improve- Tgranted at the moment, have not with KLM in 1969, a number of labor ment of flight safety and professionalism of come about automatically. In its 75 years agreements have been concluded for VNV pilots. This is a technical matter as well as of existence, the Dutch Airline Pilots members. The VNV has also managed to a professional one. And the VNV is an up- Association (VNV) has largely contrib- collectively regulate employment terms to-date knowledge center for these uted to the promotion of interests and and conditions with smaller companies. matters. Commissions concerned with professionalization of pilots. And the VNV When collective labor agreements are flight technical matters, work and rest still stands for attention for flight safety, concerned, salary always takes first times, training and assessing, flight employment terms, and labor conditions priority. But in the course of years, the medical matters, and accident/incident on behalf of the professionals it repre- investigations make contributions. The sents. From their daily activities, mem- VNV also provides effective individual and bers contribute valuable knowledge and legal support for its members. experience to the union and the profes- The VNV has contributed to the sional group, which marks the VNV. formation of legislation in the flight The following practical objectives are VNV has managed to lay down several, for technical sphere to finding a solution to characteristic of the VNV: pilots, important rules in labor agree- collisions of airplanes with birds and to • advancing safety in aviation, ments. Examples are the pilot career turbulence caused by buildings surrounding • creating good terms of employment, scheme, pension scheme, work and rest the airport. Through its international • increasing pilots’ professionalism, regulation, legal assistance, and legal contacts, the VNV has made contributions • promoting individual member’s protection in case of disciplinary measures. from a pilot’s perspective to Boeing and interests. In many labor agreements, regulations Airbus to the design and use of new The VNV pursues its objectives with the governing redundancy, function proficiency airplanes. The VNV also maintains contacts support of 3,000 members, almost all investigation, and flight safety investiga- with sister organizations abroad and is co- employed by Dutch airline companies. A tion have been included. founder of the International Federation of high degree of organization is a major If necessary, and if convinced of the Air Line Pilots Associations and the factor in issues such as promoting interests reasonableness of its demands, the VNV European Cockpit Association. ◆ and exercising influence. But power from the number of members is not the means by which VNV achieves its aims. The VNV ISASI NON-PROFIT ORG. prefers the power of the argument because 107 E. Holly Ave., Suite 11 U.S. POSTAGE PAID substantively better results can be Sterling, VA 20164-5405 USA Permit #273 achieved through constructive negotia- ANNAPOLIS, MD tions. Three thousand members form a rich source of knowledge of and experience with aviation. Several active members are highly qualified in other areas as well. Through them, the VNV has a range of disciplines at its disposal, varying from technology and economics to medical aspects and accident analysis. And when expertise is not available internally, the VNV provides it by having its members

32 • ISASI Forum October–December 2005