APRIL-JUNE 2004

In Memoriam Singular dedication, wisdom, and courage Jerome F. Lederer (1902-2004) CONTENTS

“Air Safety Through Investigation” FEATURES Volume 37, Number 2 Publisher Frank Del Gandio Editorial Advisor Richard B. Stone Special Section—Jerome F. Lederer 1902-2004 Editor Esperison Martinez Design Editor William A. Ford 3 In Tribute Associate Editor Susan Fager Annual Report Editor Ron Schleede By Frank Del Gandio—ISASI publishes this 17-page special section in celebration of the life of “Jerry” Lederer, who leaves behind a legacy of dedication to aviation safety and a body ISASI Forum (ISSN 1088-8128) is pub- of knowledge to keep improving it. lished quarterly by International Society of Air Safety Investigators. Opinions ex- pressed by authors do not necessarily rep- 4 Jerome F. Lederer: “Father of Aviation” resent official ISASI position or policy. By Esperison Martinez, Editor—Known as the “Father of Aviation Safety” throughout Editorial Offices: Park Center, 107 East the industry even before the U.S. Congress recognized him as such in 1997, Jerry himself Holly Avenue, Suite 11, Sterling, VA 20164- never believed that to be true. 5405. Telephone (703) 430-9668. Fax (703) 430-4970. E-mail address [email protected]; for editor, [email protected]. Internet 10 Jerry and ISASI Moments website: www.isasi.org. ISASI Forum is not re- sponsible for unsolicited manuscripts, pho- A photo feature displays Jerry’s attendance and interactions with fellow investiga- tographs, or other materials. Unsolicited tors at various ISASI functions. materials will be returned only if submitted with a self-addressed, stamped envelope. ISASI Forum reserves the right to reject, de- 12 Safety Innovations, Solutions Show lete, summarize, or edit for space consider- ations any submitted article. To facilitate edi- Contemporary Relevance torial production processes, American-En- By Flight Safety Foundation Editorial Staff—This reprint of FSF’s Flight Safety glish spelling of words will be used. Digest delivers excerpts from some of Jerry’s best-known writings, which provide insight Copyright © 2004—International Society into his concerns and perspectives. of Air Safety Investigators, all rights re- served. Publication in any form prohibited without permission. ISASI Forum registered ® U.S. Patent and T.M. Office. Opinions ex- 20 Root Cause Analysis with REASON pressed by authors do not necessarily rep- By Jean-Pierre Dagon (CP0204)—Root Cause Analysis (RCA) is commonly used in resent official ISASI position or policy. Per- engineering and reliability programs, but is not always emphasized in accident/incident mission to reprint is available upon appli- cation to the editorial offices. investigations. Publisher’s Editorial Profile: ISASI Forum is printed in the United States and published for professional air safety investigators who DEPARTMENTS are members of the International Society of 2 Contents Air Safety Investigators. Editorial content emphasizes accident investigation findings, 25 V.P’s Corner investigative techniques and experiences, 26 ISASI RoundUp regulatory issues, industry accident preven- tion developments, and ISASI and member 31 Benefits of ISASI Membership involvement and information. 32 Who’s Who—A brief corporate Subscriptions: Subscription to members is member profile of the provided as a portion of dues. Rate for non- Flight Safety Foundation members is US$24 and for libraries and schools US$20. For subscription informa- tion, call (703) 430-9668. Additional or replacement ISASI Forum issues: members US$3, nonmembers US$6. ABOUT THE COVER Jerome F. Lederer in a photo by Bruce Stotesbury, Victoria Times Colonist (Victoria, British Columbia, Canada) taken during ISASI 2001 and used in a feature article titled From the Wright Brothers to the First Man on the Moon. (The photo is reprinted with one-time-use-only permission.—Editor)

2 • ISASI Forum April-June 2004 BRUCE STOTESBURY IN TRIBUTE

hile the few pages that for outstanding lifetime contribu- We recently celebrated the follow reflect only a small tions in the field of aircraft accident invention of the airplane by the Wbit of Jerry Lederer’s investigation and prevention. Wright Brothers, a tremendous tremendous contributions to the I first heard Jerry’s name being accomplishment. However, it was world’s level of aviation safety and mentioned in 1980 when I joined Jerry and a few others who initiated accident investigative techniques, the FAA Office of Accident Investi- the changes and improvements we publish them in a celebration of gation. A few years later, I became that have advanced aviation his life that came to its final end, at the Secretary of ISASI and discov- to what it is today. age 101, due to congestive heart ered that Jerry’s writings were in My thoughts are that we should failure at 2:30 a.m. PST February 6 constant demand and his reputa- not dwell on Jerry leaving us, but at Saddleback Memorial Medical tion was widespread. As others rather on being thankful that Center in Laguna Hills, Calif. talked about Jerry and his accom- our industry had his presence for Jerry’s aviation lore stretches plishments, my deep-seated, but all these years and for his many back to the time of wooden wings unspoken, wish was to meet him contributions that have made flight and iron men when he joined the one day and shake his hand. In safer for persons worldwide. We U.S. Air Mail Service in 1926 at 1986, at an ISASI seminar where he should consider ourselves very Maywood, Ill., as an aeronautical was to present the award named fortunate that we had Jerry’s engineer. His aviation safety prow- after him, I got my wish. Shaking genius. And if you had and took ess would become renowned. Along his hand and speaking with him the opportunity to talk and work his route to becoming a legend, he was a thrill I shall never forget. As with him, be doubly grateful. I became, in 1965, a member of the the years went by, Jerry and I spent believe Jerry Lederer’s spirit lives Society of Air Safety Investigators, more time together and we had on in each of us as we continue our forerunner to ISASI, and in 1969 fantastic conversations about pursuit of accident investigations he became the second president of aviation safety. He shared his and that his teachings shall our organization. In time, we would insights with me, and the more I forever be found in future air establish the Jerome F. Lederer heard, the more I realized that safety advancements. Award. In his honor, it is awarded owing to his background, training —Frank Del Gandio skills, and experiences he stood ISASI President head and shoulders above all in recognizing and explaining what creates safety in aviation.

April-June 2004 ISASI Forum • 3 versity’s College of Engineering in 1924 with a bachelor’s degree of science in me- chanical engineering, securing his Jerome F. Lederer: master’s degree the next year. During his school year, he also was appointed assis- tant director of aeronautical engineering. ‘Father of Aviation “I erected and operated the first wind tun- nel at New York University. It was a 4- foot, 40-mile-per-hour wind tunnel that we got from Curtiss Co. and I was paid Safety’ $12.00 a week,” Jerry recalled during a recorded living history interview with Aviation and manned space flight have seldom, if ever, had Flight Safety Foundation (FSF) staff mem- one person contribute so much for so long to the advance- bers. ment and the consequent well-being of humanity. Saving U.S. Air Mail Service lives and conserving other resources is what accident In 1926, Jerry joined the U.S. Air Mail prevention is all about. Jerry Lederer, upon making his Service (1918-1927), at Maywood, Ill., final flight west at age 101, has created a textbook without and became aeronautical engineer of the world’s first system of scheduled air an end in this area. Succeeding chapters will be written ad transportation, in which one of every six infinitum based upon his legacy.—Author Unknown. airline pilots died in crashes each year. It was here that his predilection for flight Prepared from news and magazine sources by Esperison Martinez, Editor safety took hold. Bad-weather flying,

nown as the “Father of Aviation belied his towering public stature. Safety” throughout the industry Born Sept. 26, 1902, the year before Keven before the U.S. Congress the Wright Brothers launched the world recognized him as such in 1997, Jerry him- into powered flight, Jerry’s flight safety self never believed that to be true: “It’s nice career spans the entire aerospace safety to be known as that, but I don’t really think spectrum and other areas of public in- I am,” he told Jeff Rud, reporter for the terest as well. During his remarkable avia- Vancouver Times Colonist newspaper in Sep- tion career of more than seven decades, tember 2001, while attending the ISASI he has become, as one author wrote in annual seminar. “I think the Wright Broth- 1970, “a veritable walking encyclopedia ers really deserve that honor,” Jerry added of aviation lore and safety facts and fig- to his comment. He pointed out that it ures and a man of vision to challenge was they “…who originated simple design the seers of all times.” concepts that included positioning the He lived with the growth of aviation engine beside the pilot to lessen danger safety from the time the U.S. Post Office …and who invented the first flight data operated the nation’s accident-plagued recorder…,” wrote Rud. transcontinental air mail service and with That exchange personified Jerome F. the nation’s early ill experiences of space Lederer’s quiet, unassuming nature. Yet, flight safety to the present, when avia- those who knew him, worked with him, tion is considered the safest form of pub- PHOTO COURTESY FSF talked with him recognized the depth of lic transportation. Born in New York City, N.Y., on Sept. knowledge and selflessness that lay “Jerry,” as this most congenial of 26, 1902, Jerry is shown here at age 5 within the man whose small frame, che- gentlemen liked to be called, was gradu- in his neighborhood, Washington rubic features, and twinkling blue eyes ated with honors from New York Uni- Heights.

4 • ISASI Forum April-June 2004 Jerome F. Lederer coupled with field and I looked the airplane over. I bile manufacturing plant into an air- 1902–2004 technical prob- did not have too much hope that he plane plant manufacturing the Mono- lems, predomi- would make it. He did not ask me to look coupe. He would later design the four- nated as the cause of aircraft accidents at the airplane. I just went out because I place Monocoach for Velie. that were taking the lives of so many was a friend of his and I wanted to see it, His involvement in aircraft accident pilots. to look the situation over.” After the flight prevention began in earnest when he “We used the British de Havilland 4 Lindbergh was called “Lucky Lindy.” joined Aero Insurance Underwriters of biplanes-powered airplane. When we lost New York in 1929. He became chief en- all those Air Mail Service pilots in the Designer, fabricator, gineer in charge of loss prevention for one early 1920s, the usual cause of death was communicator of the world’s largest insurance compa- a fire following a crash. We built a con- In June 1927, Jerry left the Air Mail Ser- nies. “I was in charge of accident risk crete ramp with a concrete wall at the vice and began a consulting career by analysis. I would go over the losses, and I end of it, put these ships under full power, and let them go down the ramp “I put out my first bulletin into the wall. Slow-motion pictures showed that when the airplane crashed, when I was with the Air the fuel spilling out of the tanks—which Mail Service. We had a lot were carried up front in the fuselage— would go onto the hot exhaust manifold of crack ups, of course. We and start the fire. I drew specifications had a lot of spare wings for new parts and developed test meth- but no spare fuselages. So ods for new ways of operating the plane. I put out my first bulletin when I was my first safety bulletin with the Air Mail Service. We had a lot addressed to the pilots said, of crack ups, of course. We had a lot of spare wings but no spare fuselages. So ‘If you do crash, please my first safety bulletin addressed to the crash the wings first. Go pilots said, ‘If you do crash, please crash between two trees and take the wings first. Go between two trees and take the wings off. We have plenty of the wings off. We have wings, but no fuselages,’” he told FSF. plenty of wings, but no While with the Air Mail Service of “hel- met-and-goggled pilots,” Jerry met PHOTO COURTESY FSF fuselages.’” Charles Lindbergh. The two men were Jerry at age 25, just about the time he working at Maywood, Ill., where Lind- formed Aerotech in Davenport, Iowa. learned a lot about what was happening bergh flew for an airline carrying U.S. in aviation that should not happen. I mail. Their first meeting involved a dis- forming his own company, Aerotech, in started writing a newsletter to keep our cussion about a silk parachute Lindbergh Davenport, Iowa, later that year. He did insured operators out of trouble. We re- had used during a bailout, which ended structural work on the world’s first cabin duced accidents. The newsletters made in a field covered with grasshoppers. The monoplane that had, in his words, “very such a big hit that we used to send them parachute was full of great big, brown odd wheels that looked like baby-carriage by the thousands to airlines [worldwide],” holes. Unbeknown at the time was the wheels.” His work involved some 48 he told FSF interviewers. In his lifetime fact that grasshoppers exude a juice that changes in the structure of the airplane he would write one book (Safety in the burns through silk. The interests the two before getting it certified by the Aero- Operation of Air Transportation, Norwich men shared in aviation developed into a nautic Branch of the Department of University, 1938) and hundreds of papers life-long friendship. On the day before Commerce. He began work that led to and articles that are now archived in the Lindbergh began his historic solo flight having the design of the two-place FSF Jerry Lederer Aviation Safety Library. across the Atlantic, May 20, 1927, Jerry Monocoupe accepted for certification, Jerry believed that risk management had this experience: “I went out to the then helped convert the Velie automo- was a more useful term than safety. He

April-June 2004 ISASI Forum • 5 often stated, “Risk management is a his tenure, Jerry laid the foundation and Jerry said, “When a senator gets killed, more-realistic term than safety; it implies led the development of accident investi- all hell breaks loose. I was investigated that hazards are ever present, must be gation procedures and regulatory stan- by both houses of Congress…. I got my identified, analyzed, evaluated, and con- dards. The principles and procedures he gray hair at that time. The Senate Com- trolled or rationally accepted. Accepting developed are essentially followed to this mittee on Aviation was pretty mean…. I the premise that no system is ever abso- day by the United States National Trans- indicated that perhaps he [Sen. Lun- lutely risk free or conversely that there portation Safety Board (NTSB) and deen] might have been sabotaged…so countless other government and military they ended the investigation. We devel- safety investigation groups. Indeed, the oped the wheel-landing system tail high provisions eventually became a part of the so that the airplane would not be flying U.S. contribution to standards, recom- near the stall, and the DC-3 came to be mended practices, and guidance mate- a pretty safe airplane. So I did not have rial in Annexes 1,6,8, and 13 of the ICAO to ground it….” Accident Investigation and Prevention During his years at the CAB, Jerry was Manuals as well as other documentation. involved with many safety advances. Two The rapid growth in aviation and the in particular involve the evolution of anti- increasing emphasis on national regula- collision lights and flight data recorders. tions placed a heavy burden of responsi- Jerry received a report from the Air Line bility on the Bureau. For example, the Pilots Association (ALPA) of a developing crash of a Douglas DC-3 over Lovettsville, nighttime hazard involving DC-3s and the Va., in August 1940 in which U.S. Sen. faster military aircraft being developed. Ernest Lundeen of Minnesota died, along The report said that military pilots could with 25 other persons, spotlighted the Air not distinguish the stationary lights of the Safety Bureau and its handling of the in- DC-3 from city lights when the DC-3 was vestigation. After only 1 month on the being overtaken in flight.

PHOTO COURTESY FSF job, Jerry came under great pressure to Jerry recorded this recollection, “Be- Jerry Lederer, right, and C.R. Smith, ground the DC-3, owing to alleged stall cause ALPA believed we should do some- president and CEO of American Air- characteristics of the aircraft. At that time thing about it, I started a project to test lines, at a celebration of Flight Safety the DC-3 represented about 90 percent flashing lights. Some people in the Civil Foundation’s (FSF) 10th anniversary. of the air traffic in the country. Jerry ar- Aeronautics Administration did not ranged to borrow two DC-3s from local are certain risks inherent in every sys- air carriers, and the airplanes were sent tem, it becomes an absolute necessity that to Langley Field, Va. Aerodynamics of the management should know and under- DC-3 were reevaluated as the CAB con- stand the risks that it is assuming.” For sidered, and then rejected, the stall theory more than a decade, he helped reduce in the Lovettsville accident. losses through safety audits and other In recalling the incident for FSF, he programs. noted that there was severe turbulence and lightening during the storm. Jimmy Aviation’s first safety chief Doolittle, flying in the same storm in a By 1940 Jerry had attained a full-fledged light plane, reported the storm as the reputation in the flight safety arena and worst he had ever encountered. The was selected to become the first director CAB, in its final report, said that the of the Safety Bureau of the Civil Aviation probable cause of the accident was “the

Board, serving until 1942. As director, he disabling of the pilots by a severe light- PHOTO COURTESY FSF was responsible for the promulgation and ning discharge in the immediate neigh- Jerry is sworn in as director of safety violation investigation of all civil aviation borhood of the airplane, with resulting (1970) for NASA by Dr. George Mueller, safety regulations and for directing all civil loss of control.” Changes in DC-3 pilot associate administrator for manned aviation accident investigations. During training later were implemented. space flight.

6 • ISASI Forum April-June 2004 Jerome F. Lederer think much of book immediately because an aircraft formation; he established the Aircraft 1902–2004 the idea and carrier could not embark on its mission Engineering for Safety (AES). It dissemi- were fighting until the book was published. nated safety information across commer- me…. We went ahead anyway. American He was later appointed to the United cial and national boundaries. The event Airlines loaned us a DC-3. We had sev- States Strategic Bombing Survey in Eu- leading to the formation of AES in 1947 eral different kinds of flashing lights rope to evaluate the effectiveness of this was the crash of a TWA Lockheed Con- made and put on the airplane, on the strategy. Of this experience he said, “We stellation resulting from an inflight fire tail, and also on the navigation lights. that killed all occupants except one pilot. The way we judged the best intervals of As a result of the investigation and public the light/no light was to stand on the hearings into the crash, several flight roofs of our houses at night and make safety experts recognized the usefulness notes while the airplane circled… that’s of the Aero Insurance Underwriters safety was how anti-collision lights evolved.” bulletins, which Jerry had published. It Today’s FDRs began with very primi- was suggested that similar efforts would tive FDRs being installed on DC-3s also be valuable to the entire aviation in- owned by TWA and United. Jerry and dustry. “When word got around that I was his staff found the instruments very use- starting up, some people said that I ful in their investigations and deter- should not get into this stuff, that I would mined that FDRs should be in all trans- be sitting on a keg of dynamite, that it port airplanes by regulation. The deci- would ruin my career and that safety was sion was unpopular with ALPA and air not a saleable object—shows you how carriers. “ALPA said that this was just safety was a hard sell in those days. You nothing but a mechanical spy that would mentioned safety and you scared people tell lies about the pilot. I put through PHOTO COURTESY FSF away. That is the big thing that I had to the regulation anyway. A few weeks later During Jerry’s tenure at NASA, Charles overcome—by diplomacy, mostly, and by a pilot was accused of flying too low….We M. Schulz’s Snoopy was the astronauts’ not putting out things that would scare proved by the FDR that he was flying at mascot, and they presented this banner people,” said Jerry. the correct altitude. He was a member to Jerry. Here he displays it just before AES merged with a group that was of ALPA and that persuaded them to go presenting it to the FSF Jerry Lederer studying cockpit layouts from a human along with the FDR. The airlines were a Aviation Safety Library in 1989. factors point of view. The merged group little harder. After I put the regulation took the name Flight Safety Foundation through, World War II began and the air- learned that bombing of a factory was (FSF). The first seminar drew only eight lines said the war effort…stood in the not always very productive because people, but the number grew to 50 at the way of buying FDRs. The CAB rescinded bombs could not damage the steel ma- second seminar and kept growing. The the regulation,” Jerry recorded. chinery very much, but would damage present-day FSF is rooted in the recogni- The war years were an especially busy the brick walls and make the Germans tion that sharing safety information is vi- time for Jerry, as they were for so many in the area very angry. So they would all tal to the health of the industry. Jerry’s others. In 1942, he was tapped by the pitch in and build a factory again very work has made the FSF a leader in influ- U.S. Air Transport Command to serve quickly. The bombing of the oil industry encing the formation of airline safety cul- as director of training within the Airline in Germany was effective, because that tures and in implementing worldwide War Training Institute. In this position reduced the amount of fuel going to the accident prevention programs. he had oversight responsibility for the air force. We bombed the German trans- While at the Foundation in 1948, he training of more than 10,000 pilots and portation centers, their canals, railroads, organized the first U.S. aircraft accident navigators and 35,000 aircraft techni- and bridges and kept them from putting investigation course by a private organi- cians. Under his guidance, the command their war materiel together.” zation, using former CAB colleagues as produced 15 textbooks in 15 weeks, in- instructors. More recently, the FSF cluding one on survival in the event of a Breaking new ground formed the industry task force for the crash in a jungle, in the ocean, or else- Following the war, Jerry found a way to prevention of controlled flight into ter- where. It was urgent to produce this text- achieve his passion for sharing safety in- rain (CFIT) and approach and landing

April-June 2004 ISASI Forum • 7 accidents. The FSF has been instrumen- Panel formed to evaluate the acceptance to mental resources than safety, because tal in assisting, and continues to assist, of the introduction of jet transport air- it stresses the uncertainties.” His close ICAO with the promulgation of stan- craft in international civil aviation. friend, Charles Lindbergh, supported dards and recommended practices and Two years later, in 1967, following the this view in a note written in 1969. other prevention materials to combat tragic space capsule fire at Cape Jerry dedicated much of his free time CFIT. Jerry directed the FSF for 20 years Kennedy in which three astronauts lost to investigations of unique and challeng- and developed most of the programs for their lives, Jerry was invited to organize ing safety problems, such as drug abuse, which it is noted, such as the worldwide and become director of the new Office subtle cognitive incapacitation of pilots, exchange of prevention information, of Manned Space Flight Safety for cockpit boredom, and interpersonal research projects, and safety seminars. NASA. At that time, he was 65 and had communications. He also served as chair- just retired from the FSF, having already earned the unofficial title “Mr. Aviation Safety” among his peers. He told his interviewers, “I did not know what I was getting into, and prob- ably would not have taken the position if I had known this would be the most complicated thing I could ever imagine. For example, the idea of getting to the moon by stages and then taking off from the moon, and meeting another stage in flight to come back to Earth was very foreign to me. If I had had anything to say, I would have said this was impos- sible, but it was done.” Neil Armstrong

E. MARTINEZ, EDITOR and Jerry became good friends during Jerry addresses the audience of ISASI the Apollo program. In recalling his time 2001, held in Victoria, B.C., Canada. with Jerry, the astronaut said, “Jerry was a realist. He recognized that flight with- These activities continue today. The FSF out risk was flight without progress. But has established an extensive library in he spent a lifetime working on minimiz- E. MARTINEZ, EDITOR his name. ing that risk.” J. Lederer receives FAA award from In 1970, having been awarded the FAA Adminstrator Marion Blakey. National roles NASA Exceptional Service Medal for his From 1950 to 1967, concurrent with his work in the Apollo program, he became man of the Crew Fitness Panel, SAE FSF leadership, Lederer was director of director of safety for all NASA activities, Committee on the Technology of Hu- the Cornell University-Guggenheim responsible for the concept and execu- man Behavior. He is listed in Who’s Who Aviation Safety Center, whose mission tion of safety programs throughout the in America, Who’s Who in Engineering, paralleled that of the Foundation. The entire organization. He knew the daunt- Who’s Who in Aviation, American Men of Center frequently highlighted significant ing task of managing the risk associated Science, and the Architects of the Age of areas for further research. In 1956, he with the complex NASA technology. His Flight. He was elected into the OX-5 Avia- was appointed to U.S. President Dwight background of analyzing risk in the air- tion Hall of Fame, the Safety and Health D. Eisenhower’s seven-person Aviation craft insurance field influenced his think- Hall of Fame, and the International Facilities Investigation Group, which ing and the terms he used to communi- Space Hall of Fame. paved the way for the organization of the cate his ideas about safety. He further Following his retirement from NASA, FAA and modernized the air traffic con- believed that defining the task as risk Jerry turned to academia to spread his trol system. And in 1965, Jerry repre- management would help attract the cali- safety beliefs. He served as adjunct pro- sented the United States in supporting ber of personnel he wanted at NASA, fessor and lecturer at the Institute of the ICAO Jet Transport Implementation because “it served as more of a challenge Safety and Systems Management at the

8 • ISASI Forum April-June 2004 Jerome F. Lederer University of Air Traffic Controllers Association, and Lederer received the K.E. Tsiolkovsky 1902–2004 Southern Cali- the Air Line Pilots Association. Medal from the Soviet Federation of fornia. He ac- Jerry received more than 100 honors Cosmonauts. In 1965, he was awarded tively lectured at various civil aviation including the 1999 Edward Warner the prestigious Wright Brothers Memo- safety seminars as well as at the United Award, one of civil aviation’s highest hon- rial Award. The citation read, in part: States Air Force Safety Center at Norton ors, from the Council of ICAO. In No- “Aviation’s extraordinary safety record to Air Force Base. He organized and con- vember 2003, he received the 2003 Cliff a significant degree is a result of the tire- ducted numerous meetings on aviation Henderson Award for Achievement from less and devoted efforts of Mr. Lederer. safety for the FSF, the International So- the National Aeronautic Association. In For 35 years, he has worked unceasingly ciety of Air Safety Investigators (ISASI), February 2003, he was selected as one of to improve all elements of the flight the System Safety Society, the National safety spectrum and concentrated on Fire Protection Association, the Institute making compatible the primary ele- of Navigation, the Society of Automo- Jerry is survived by his wife, Sarah; ments of flight—the man, the machine, tive Engineers (SAE), and the American two daughters, Susan Lederer of and the ground environment—to ensure Institute of Astronautics and Aeronau- Santa Rosa, Calif., and Nancy Cain maximum safety. In accomplishing this tics; and he served as president emeri- of Oklahoma City, Okla.; and two objective, he has taken the leadership in tus of the International Society of Air granddaughters, Melissa Cain and correlating, coordinating, and improv- Safety Investigators. Bryn Cain, both of Oklahoma City. ing the flight safety activities of the many Following the Three Mile Island The family has asked that in lieu varied organizations and agencies com- Nuclear Power accident, Jerry became a of flowers, contributions may be prising world aviation.” member of the Institute of Nuclear made to the ISASI Rudy Kapustin In May 1997, the U.S. Congress rec- Power Operations (INPO) Advisory Memorial (Scholarship) Fund. At ognized the then 95-year old aviation Council, a group mandated to enhance press time, contributions from the safety innovator by bestowing upon Jerry the safety of nuclear generations. He following have been received: John the title “Father of Aviation Safety” and served two 3-year terms with the Coun- X. Stefanki, Theodore J. Banick, presenting him special congressional rec- cil where he was instrumental in trans- Association of Professional Flight ognition for his numerous achievements ferring aerospace risk-management con- Attendants, John W. Purvis, Re- and outstanding service toward the im- cepts to the nuclear power industry. becca Finnerty, Stephanie A. Mo- provement of aviation safety for all Jerry’s fundamental accident prevention ray (CPA), and the ISASI Mid- Americans. advice about incident reporting, team Atlantic Regional Chapter. N But if the Father of Aviation Safety, training, involvement of top manage- with all he accomplished, didn’t believe ment in safety issues, etc., became ac- that title described him, what did he cepted as major parts of INPO’s modus the Laurel Legends for 2002 by Aviation think did? He once said that the follow- operandi. Week & Space Technology; the award hon- ing words from an FSF Distinguished ors individuals who have made signifi- Service Award, which he received in Honors cant contributions to the global aero- 1967, best defined his career: “For pio- As one might expect, many organizations space field. In 2002, he received an hon- neering the flight safety discipline at a bestowed membership upon Jerry, for orary doctorate in safety science from time when it was all but unknown, and example, Honorary Fellow of the Insti- Embry-Riddle Aeronautical University. for pursuing the objective of safer flight tute of Astronautics and Aeronautics So- Among his other awards are the NASA with a singular dedication, wisdom, and ciety; Fellow of the Aerospace Medical Exceptional Services Medal, the FAA Dis- courage. His belief in, and application Association; Fellow of the Human Fac- tinguished Service Medal, the Daniel of, the sharing of flight safety informa- tors Society; Honorary Fellow of the Sys- Guggenheim Medal, the Amelia Earhart tion and experience formed the corner- tem Safety Society; Honorary member Medal, the Von Baumhauer Medal of the stone of the effort.” N of the National Academy of Engineer- Royal Dutch Aeronautical Society, the ing; Tau Beta Pi, Pi Tau Epsilon; Fellow Airline Medical Directors Award, and the Singular dedication, wisdom, of the Royal Aeronautical Society and Aerospace Life Achievement Award of and courage—Jerome F. Lederer Royal Society of Arts; Honorary mem- the American Institute of Aeronautics (1902-2004). ber of the Institute of Navigation, the and Astronautics (AIAA). In 1988,

April-June 2004 ISASI Forum • 9 PHOTOS: E. MARTINEZ, EDITOR Jerry and ISASI Moments ntermixed in this montage are scenes of Jerry participating in Isome recent ISASI annual semi- nars. He always took a front-row seat, peppered questions at speakers and panel members at appropriate times and addressed the delegates when the need arose. He delighted in meeting and posing with members who spoke with him. When in attendance he always participated in the presentation of the Jerome F. Lederer Award, speaking knowing words of the recipient’s deeds and retelling in a light manner some of his experiences related to the subject of the award.

10 • ISASI Forum April-June 2004 Jerome F. Lederer 1902–2004

April-June 2004 ISASI Forum • 11 (This article in tribute to ISASI’s President takes advantage of the design to actually ing Conditions, USAir Flight 405, N485US, Emeritus is adapted and reprinted with per- operate regularly from such airports. La Guardia Airport, Flushing, New York mission from the Flight Safety Foundation’s This is a foible of human nature and is [U.S.], March 22, 1992.) Flight Safety Digest, Special Issue: Jerry very much to be commended for its ef- **** Lederer—Mr. Aviation Safety, August- fect on design but its effect on accidents Lederer’s 1939 book Safety in the Opera- September 2002.—Editor) is not favorable, except indirectly. Im- tion of Air Transportation—published by provements in design usually make fly- Norwich University, Northfield, Vt.—was erome F. “Jerry” Lederer, president ing easier or make it more useful, thus written to show the relationship between emeritus of Flight Safety Foundation inducing more people to fly. The mile- technological developments and safety J(FSF), envisioned solutions to avia- age flown per accident seems to increase at a time when other books in the field focused on advances in aircraft speed, payload, range, and efficiency. The fol- lowing examples in the book reflect time- Safety Innovations, less safety principles or show how far aviation safety has evolved: • “To discuss safety in air transportation Solutions Show is difficult because it is so intimately con- nected with human nature and weak- nesses.… It is unfortunate for the sake Contemporary of safety that human nature is so consti- tuted that instead of using a device as a safety measure we like to use it to increase Relevance our efficiency.” • “Undoubtedly, our airlines are not yet Excerpts from some of his best-known writing as free from danger as are our railroads, provide insight into the concerns and perspectives and it may be some time before they are. of Jerome F. “Jerry” Lederer. But, on the basis of passenger miles flown, it is safe to say that traveling in an air- By the FSF Editorial Staff plane operated by one of the airlines ap- proved by the Civil Aeronautics Author- tion safety problems throughout his ca- with greater use; hence the indirect in- ity is no more hazardous than traveling reer and retirement years. In speeches fluence of improvements on safety in the ordinary passenger automobile.” and articles, he suggested methods for records. However, on the basis of num- • “There is, therefore, an economic limit worldwide exchange of aviation safety in- ber of airplanes per accident, the future to safety in terms of equipment. But we formation, for counteracting compla- seems pessimistic. It must be admitted are willing to risk riding in these [twin- cency among pilots of highly automated that the human element creates a greater engined transport] airplanes because we aircraft, for real-time remote monitor- hazard than the airplane itself.” believe that the airplane personnel is so ing of pilot/aircraft performance via te- **** organized as to take every reasonable pre- lemetry, and for alerting flight crews to “Strange as it may seem, a very light coat- caution to see that the engines will not signs of fatigue—to name a few ex- ing of snow or ice, light enough to be fail on the takeoff, that the airplane is amples. Following are excerpts from hardly visible, will have a tremendous ef- taken off in such a way as to reduce that some of Lederer’s papers, articles, sto- fect on reducing the performance of a critical period [of risk of failure of one ries, and solutions, and a few comments modern airplane. Although this was engine] to a minimum, and, if any doubt by others about him. known in Canada for many years, only in exists regarding the safety of the flight, **** the last three years has this danger been the airplane will not be permitted to take In “Loss Prevention in Non-scheduled recognized here. It occurs only when the off at all.… Whatever the equipment lacks Civil Aviation”—presented to the Na- ship is on the ground, and makes takeoff in safety is assumed to be restored by ad- tional Aircraft Production Meeting of the dangerous. To avoid this danger, the air- equate organization and managerial Society of Automotive Engineers in Los lines cover the wings with tarpaulins, or policy to achieve safety.… The ability to Angeles, Calif., Oct. 13-15, 1938— they make certain that all ice is off before maintain altitude with a full load on one Lederer said, “Human nature is so con- the airplane is allowed to depart.” (From engine was probably the greatest factor stituted that improvements in design are “Safety in the Operation of Air Transpor- in advancing the safety and reliability of employed not to achieve safety but to tation,” a lecture under the James Jack- the modern airplane.… Since there were take advantage of the greater utility son Cabot Professorship of Air Traffic 1,246 powerplant failures of minor and which such improvements usually afford. Regulation and Air Transportation at major degree in 1936 and 1937, the need A pilot may obtain an airplane with Norwich University, April 20, 1939. for multi-engined equipment for safety which it is possible to get in and out of a Quoted in U.S. National Transportation is obvious.” very small airport. Instead of consider- Safety Board [NTSB] Aircraft Accident Re- • “With the introduction of high-speed ing this an emergency operation, he port NTSB/AAR–93/02, Takeoff Stall in Ic- ships [aircraft] came the necessity of

12 • ISASI Forum April-June 2004 more thorough • “Safety is defined as freedom from dan- The establishment of semi-annual main- training of pilots ger or risk, but wherever people come in tenance meetings to which all the airlines because less time close contact with an object which under sent representatives to discuss mainte- was left to think human control moves fast, or is associ- nance problems was one of the greatest or to react in ated in any way with kinetic or potential cooperative ventures for safety in the re- emergencies.” energy of high value, such as an automo- cent history of transportation.” • “In the early bile, a train, or an airplane, the public • “Another airline is studying methods days of sched- must realize that it is practically impos- of reducing danger from birds striking uled transporta- sible to achieve absolute freedom from the windshields in flight. Following sev- tion from 1922 risk. Conversely, whatever freedom from eral cases of considerable damage from Jerome F. Lederer to 1925, one pi- danger does exist is obtained through striking birds, reinforcements in the 1902–2004 lot was killed for careful maintenance to preclude failure windshield posts were made to reduce every 10,000 of material and through a high degree of the seriousness of these collisions. An- hours of flying. Most of the fatalities were control while the vehicle is in motion. No other airline is using bullet-proof glass.” caused by bad weather. The pilot would matter how many safety devices are in- • “The gradual adoption [by airlines] take off ignorant of the weather ahead stalled in a machine, adequate mainte- of conservative practices by mutual because of lack of adequate weather sta- nance and proper control achieved by agreement, coupled with more certain tions. If the weather at his point of de- organization remain the essence of safety.” methods of forecasting weather, has parture and at a few points along the route • “It is unfortunate that much of the enormously stimulated safety, especially happened to be good, he would risk the necessary, careful maintenance proce- in winter.” flight. In fact, in the early days the air- dure and flying control has been ob- • “Serious accidents, especially if they mail operations were based on the slo- tained only through sad and costly ex- cannot be adequately explained, awaken gan, ‘The mail must fly.’ This slogan prob- perience. The lessons from these had to the fear against flying which is inherent ably caused more deaths than any other be, and continue to be, intelligently and in most of us. This means loss of passen- policy in aviation.” immediately applied to avoid recur- ger revenue, idle airplanes, and curtail- • “Although pilots are able to fly suc- rences [of accidents].” ment of business growth. Furthermore, cessfully by instruments in bad weather, • “Another instance, also in the early days the investigation to determine the cause the airlines have mutually agreed that of the airmail, is worth noting. A steady of a serious accident may often cost more no such flying should be undertaken, ei- series of accidents had occurred, in every money than the value of the equipment ther over the top or through clouds, if case the pilot being killed and the ship lost.” the distance between available landing destroyed without leaving clues as to the • “Accidents are costly because they in- areas is greater than 100 miles. This cause. Finally, one crash occurred in which volve loss of personnel, loss of equip- means a maximum of about 40 minutes the investigators found that the pilot had ment, discouragement of passengers, of flight on instruments. If there is any inserted a metal pencil of the common expensive investigations, the threat of indication that the pilot will have to fly automatic variety through a bolt hole in idle equipment, and higher insurance on instruments greater than this distance a fitting which connected the control stick costs. Conversely, an airline that builds with unlandable weather below him, the to the control assembly. The investigators a reputation for safety and dependabil- flight is not undertaken. This is a safety concluded that the bolt which had been ity will find its costs lowering due to policy of the first magnitude, which there had sheared in flight and the pen- greater use of equipment and person- should be credited to conservative and cil was the only object that the pilot had nel, and in every way stands to gain eco- cooperative airline executive policy.” to replace it. The pencil, too, broke off nomically through safety.” • “The flight analyzer, a recording and fell out while the pilot was too low to • “To overcome this dangerous ten- barograph which automatically records adjust [for] the trouble again, and he dency [paying pilots for each hour altitude, the operation of the automatic crashed. Evidently, the cause of this acci- flown], the airlines, in the bad winter pilot, the time and frequency of radio dent and of the previous similar acci- months, pay the pilots according to a transmission, and vertical acceleration, dents was the weakness of that bolt at- fixed scale regardless of the amount of is another aid which standardizes and taching the control stick to the control flying they do. They have thus, through controls flight operations, supplies proof assembly. When this was discovered, the economic means, eliminated the psycho- that the trip was flown as planned, and bolts in every plane were increased in logical pressure to go through bad indicates proof of the rate of climb and size, eliminating [that] bolt failure as the weather. The psychological aspects of descent in case passengers complain. It cause of [other] accidents. It is unfortu- safety are as important as maintenance can be made to record many other flight nate that many pilots had to lose their and operations.” factors.” lives before this weakness in equipment • “Besides experience, the pilot should • “Initial developments inside labora- was discovered.” have a clean record, with no accident of tories with a few months in the field on • “Standardization of equipment reduced a serious nature within the previous five experimental airplanes cannot possibly the maintenance problems and created years, unless the accident could not be compare with practical tests made on greater opportunities for the airlines to attributed to him. But even if he should rigorous airline schedules day in and day exchange mutually useful information re- be the victim of a series of accidents out through all four seasons.” garding the safe operation of their ships. through no fault of his own, he would

April-June 2004 ISASI Forum • 13 probably not be hired. There is no rea- erature has been prepared. There are the punitive action that might follow. But son for denying him a position except pamphlets, posters, motion pictures, such statistics on near-accidents should that he is running in bad luck, and why safety codes, and books. They are almost be known if accidents are to be reduced. take a chance?” always directed at the pilot. He is sub- A way should be found to confess with- • “Forms fix responsibility. The fixing jected to a continuous bombardment of out jeopardizing one’s career. Informa- of responsibility is as important for safety safety signs and slogans. By and large, tion on potential accidents is often ob- in airline operation as are good equip- they reflect the weaknesses and deficien- tained by casual gossip.… For example, ment and trained personnel. In a well- cies in design or especially training which a captain checking his [instrument land- operated airline, no move is made with- he is asked to overcome.… Perhaps some ing system flight] path under [ceiling and out having it recorded on a form. … Ver- of the money and energy being spent visibility unlimited] conditions found bal orders can be forgotten, there is no on improving the pilot might give that [the flight path] was considerably verification of their issuance, and they greater value if directed toward the de- in error; the cause was determined to be reach only a limited number of people.” sign engineers, the instructors, and even some disturbance in the ignition system. • “The meteorologist assumes that the management. They certainly are no less At that time, few if any pilots realized worst conditions will prevail and so in- human than pilots and therefore should that such disturbance could throw off the forms the pilot and dispatcher. This phi- eventually succumb to a safety program ILS [cause erroneous indications] even losophy of preparing for the most unfa- directed at them.” though the instruments would indicate vorable conditions in doubtful weather, **** normal functioning. In a casual way, he being humble in the face of uncertainty, Around 1950, Lederer wrote the Pilot’s mentioned his trouble to a fellow pilot a is highly important in achieving safety.” Code and the Mechanic’s Creed to em- few weeks later. Eventually, it got around • “The recently established [Air] Safety body values and responsibilities of the two to management. Such important infor- Board should also have a marked influ- professions. He later wrote in an Air Mail mation should not be allowed to migrate, ence in spreading the gospel of safety Pioneers publication, “The creed was it should be propelled. by reason of its independent studies of adopted by the U.S. Air Force Military Air “…The industry often prefers to move accidents and the recommendations Transport Service and was posted on slowly in safety matters and for good rea- which follow.” cockpit doors and pilot ready rooms.” son. The government does not have to • “The future should bring an accelerated **** live with the safety measure as the air- record for safety because of refinements In “Observations on Flight Safety”—pre- line does. The airline may not have the in powerplant construction, such as direct- sented to the Society of Automotive En- personnel required to service properly a injection carburetion; improvements in gineers Annual Meeting in Detroit, safety device; it may have had unfortu- cowling and in fuel and oil installations to Michigan, Jan. 8-12, 1951—Lederer nate experience with previous hasty reduce fire hazards; stall warning indica- said, “Our answer to the problem of se- adoption of a safety measure; it may lack tors; use of anti-stalling devices; improve- curing information on near-accidents is the manpower to study the numerous ments in wing sections; improved perfor- to have a place where personnel can con- safety ideas that are always being ad- mance with partial powerplant failure; fess without being ridiculed or punished vanced; it may have huge sums invested better undercarriage structures; more ac- or [required to] publicly cast [a negative] in the old way of doing things with a curate altimeters or terrain clearance in- reflection on fellow workers. A flight en- good record [so that] it may not be con- dicators; radio static elimination; larger gineer not so long ago related how the vinced on a safety measure; and there is airports with clearer approaches; advances pilot and copilot, in using the checklist always the point that if only limited funds in our knowledge of vibration prevention; preparing for an approach, had ne- are available for safety, who has the wis- continuous research in structures, aerody- glected to read the gauge to get the hy- dom to decide with certainty where it namics, meteorology, and metallurgy; im- draulic pressure. It was not the flight should be spent most profitably to ob- proved methods of orientation and navi- engineer’s function to read the hydrau- tain the greatest safety.” gation; and especially study of pilot psy- lic pressure but as a matter of curiosity **** chology and fatigue.” he did, because the gauge was of a new In handwritten notes after an address **** type; much to his surprise, it read zero titled “Infusion of Safety into Aeronauti- In “Loss Prevention Programs in Civil pressure. He immediately informed the cal Engineering Curricula” before the Aviation”—presented to the Air Trans- captain, who declared an emergency. A Third International Conference of the port Design Session of the 16th annual safe landing was made but the results Royal Aeronautical Society of Great Brit- meeting of the Institute of the Aeronau- could have been disastrous. He discov- ain and the Institute of Aeronautical Sci- tical Sciences, New York, Jan. 26-29, ered that the captain was responding to ences of the United States, Brighton, 1948—Lederer said, “The airline safety the challenges on the checklist by habit England, Sept. 3-14, 1951, Lederer wrote, record by any yardstick appears well rather than by actually checking the in- “I had to show that mistakes in design within magnitudes of safety acceptable struments and controls. He could not tell were being made. I used topics from to the public. Nevertheless, the airlines this to management without crossing the [Cornell-Guggenheim Aviation Safety have a moral obligation and, as long as captain. The captain did not consider Center] design notes. Nowhere did I use there are newspapers, a financial incen- that it warranted further attention. the word ‘American,’ but the London Times tive to continue to make it safer.… An “… Pilots are hesitant to report near next morning published on page two immense amount of aviation safety lit- collisions with other aircraft for fear of ‘American Engineers Make Mistakes,’ in

14 • ISASI Forum April-June 2004 bold type. Chris- procedures. This leads to the grave dan- for placing costs above safety. I am more topher Clarkson, ger of complacency.… Safety is an out- inclined to feel that complacency or lack the British air at- growth of good management. It requires of information at the top management taché at the active encouragement of the top echelon level is the cause of most deficiencies that Washington of management. Complacency is over- may exist. I cannot bring myself to be- [D.C., U.S.] em- come by constant supervision, constant lieve that responsible management is less bassy, offered to pressure. Therefore, it is better to stress morally conscientious than myself or this meet with the the proper way to accomplish a job rather audience. I prefer to believe that where editor to make than to show mistakes; the positive ap- backwardness exists, it is due to either amends but I felt proach, rather than the negative. The lack of recognition of the importance of Jerome F. Lederer it would prolong exception is where emphasis is needed to adapting a safety development or hon- 1902–2004 the agony. It took combat the special safety problems cre- est differences of opinion of the kind that two years for me ated by complacency. Because air safety persist between pilots themselves as to to live this down! Very embarrassing!” In is so complex and its problems are so standard color for lights to warn of pro- the address, he said, “Anyone venturing changeable, this requires shifting empha- peller malfunctioning.” into this complex field should do so with sis by an alert management. The tools at **** great humility and restraint, but a begin- hand may be humor, grim incidents, ran- In “Une Initiative Americaine,” dated ning should be made if for no other rea- dom checks by high authority, but most April 3, 1959, Lederer said, “As a mem- son than that others can either build upon importantly, close, constructive personal ber of the ICAO Jet Implementation it, or tear it down, and in doing so estab- contacts between well-qualified specialists Panel, the director of the Flight Safety lish a science of accident prevention in (who may be supervisors) thoroughly sold Foundation was surprised at the progress aviation.” on safety and the people with whom they that had been made to plan for and imple- **** are dealing.” ment the elements necessary for safety in In “Reduction of Aircraft Accidents”— **** aircraft operation. Unfortunately, this was presented to the Air Research and De- In “The Progress and Challenge of Air true mainly of the technically progressive velopment Command Flying Safety Safety”—presented Dec. 9, 1954, to the nations that have always been so oriented. Conference, U.S. Air Force, Baltimore, Nederlandse Vereniging voor Luchtvaart- The governments of many technically Md., Sept. 15, 1954—Lederer said, techniek, Netherlands—Lederer said, “It undeveloped nations are properly con- “When an engineer comes across a de- is an honor for an American to be asked cerned with providing minimum social sign problem that might, with further to speak on air safety in Europe, espe- services for their people —schools, high- attention, be made functionally simple cially in view of your longer tradition of ways, hospitals—but apparently fail to to maintain or operate without the need carrying passengers by air than ours in recognize that funds provided to facili- for literature or extraordinary precau- America. But safety should have no in- tate air operations will enable them to tions, he is often prone instead to put ternational boundaries.… I should like to accelerate their economy and thereby another page in the operations or flight say that I do not consider myself an ex- expedite the provision of improved so- manual, hoping that it will be read. … If pert in air safety and I believe there are cial services to their people.… [The he drops a pencil [in the college labora- no experts in this phase of aviation. Safety Foundation’s] main objectives are to com- tory], there is no danger of jamming a covers too broad a field, and the art of bat complacency (which often is the out- control. So that on top of being literate, aviation changes too rapidly for any per- growth of a good safety record), to refresh the engineer is poorly oriented by his son to consider himself to be an expert. the memories of pilots and mechanics to college training for an adequate appre- The best one can hope to be is a good safety lessons they may have forgotten, ciation for good human engineering. … student of the subject.” call their attention to new techniques, and The rapid growth of the aviation indus- **** plead with them always to remember their try has required experienced talent to In an undated paper (circa 1957) “Prob- tremendous responsibility to their fellow be spread very thinly [among] young lems in Promoting Air Safety,” Lederer men.… The fact that the Flight Safety engineers who have been brought in. It said, “While in one way the threat of liti- Foundation has requests for one million is hardly considered intelligent to repeat gation tends to subdue the circulation bulletins per year from airlines indicates errors made in the past, but with pres- of safety proclamations, in another way, it fills an important gap. The Flight Safety sure on the engineer to produce, [errors] litigation impels management to keep Foundation enjoys a freedom of expres- may be excusable so far as the individual abreast with the state of the art. Back- sion and a liberty of action which is often is concerned, but not from the stand- wardness and omissions in adapting denied a government organization or an point of the organization. When the thor- safety measures furnish ammunition to industry association.” oughly competent designers who have the opposing lawyer for accusations of **** learned their safety lessons by sad expe- negligence. Judgments based on negli- In “Observations on Safety”—presented rience are moved up to higher adminis- gence can run into millions of dollars. to the Radio Technical Commission for trative posts, they often leave a void in However, some managements are more Aeronautics Meeting, Atlantic City, N.J., which the upcoming generation must alert and progressive than others in seek- Oct. 15, 1959—Lederer said, “A proxim- learn again the sad way.” ing and accepting safety developments. ity-warning device or collision-avoidance “Most flying operations involve routine The less progressive are often blamed system would be a partial antidote for the

April-June 2004 ISASI Forum • 15 uncertainties of air traffic control, at least strumentation. Both the sophisticated [pi- superiors to whom they submit their for enroute operation. Furthermore, in lot] and the ordinary pilot will continue to plans. The pressures which militate many parts of the world there will be no depend on proven aids and flight-oriented against safety, the urgency to meet a de- air traffic control complex for a long time; [air] traffic controllers to reduce the possi- sign deadline, fear of competition, pro- therefore, a proximity-warning system or bility of pilot misjudgment.” duction problems, and financial commit- a collision-avoidance device seems enor- **** ments tend to distract the engineer from mously desirable. The problems inherent In 1962, Lederer presented the Daniel his responsibility for the safety of the in developing an anti-collision device are Guggenheim Award Medal Lecture dur- public. The engineer with a conscience tremendous, especially if the perfect de- ing the American Society of Mechanical and a sense of public responsibility will vice is demanded. Perfectionists find no Engineers (ASME) Aviation and Space meet many occasions and situations solution for any difficulties and find a dif- Conference in Washington, D.C, “Per- where his convictions and principles will ficulty in every solution. The search for spectives in Air Safety,” which included be put to the test. A thorough study of perfection may lead to unnecessary de- the following excerpts: the total cost of risk in terms of insur- velopment delay and to collisions. Only • “Civil aviation cannot exist without ance, lost revenue, legal expenses, pub- 8 percent of collisions are head on. Why being safe. … The worldwide air trans- lic acceptance, and other losses has never wait to solve the head-on problem if 92 port system is a technical triumph of the been made. It might help alter the em- percent can be avoided? On the other first magnitude.” phasis on performance and assist the hand, the device should not create more • “Even in the case of a public carrier, engineer in resolving his dilemma.” hazards than it eliminates.” however, the law cannot attempt to pro- • “The infrastructure of aviation never **** tect the passenger against every risk with- seems to catch up with the needs of the In “Airports and Safety”—presented to out closing the frontiers of progress. To aircraft. It has been common in the past a symposium called The Issues and Chal- encourage engineers and designers to for each new generation of aircraft to be lenges of Air Transportation, sponsored exercise their imagination and ingenu- operated under conditions not even en- by Connecticut General Life Insurance ity in the design of aircraft, the civil air tirely satisfactory for the aircraft they re- Co. Nov. 1-3, 1961—Lederer said, “The regulations are phrased in broad objec- placed.… The personnel and financial number of landings per fatal accident tive terms. This provides considerable requirements of the aviation infrastruc- has improved in the past 10 years about latitude for the designer and results in ture compete with roads, schools, hospi- tenfold. The absolute number of fatal ac- variations in safety. By and large, the in- tals, housing, and industry. Operational cidents, as distinct from the rate, con- dustry continues to offer improved air- efficiency and safety suffer as a result. … tinues to be serious because the number craft and equipment. Many manufactur- The civil airspace is not a fitting place for of landings in 10 years has more than ers and airlines are not content to com- political antagonism, rather it is a place doubled. In respect to the airport and ply with the letter of the law; they go far for harmony, cooperation, and coalition.” the operators of aircraft, about 30 per- beyond it voluntarily, to follow the ‘in- • “The Flight Safety Foundation expects cent of all accidents in transport opera- tent’ of the law in adopting safety de- to revive its dissemination of specific in- tions occur in the approach-and-land- vices and procedures. Others hew strictly formation on lessons learned. It started this ing phase. A very high percentage of to the letter of the law or regulation. in 1948 but had to abandon it because these can be attributed to inadequate “Because of this, one may find that some felt its reports might fall into hands facilities at the airport. designers have improved safety in one that would use them against the organiza- “…The problem of the landing aircraft respect and not in others. An example is tions which supplied the information.” can be attacked by giving the pilot the aids the regulation that requires that passen- • “It is not unusual for many years to he needs during the critical time of land- ger emergency-exit markings shall be il- pass before a proven safety device is ing so that even if he is an expert, he will luminated with an emergency power adopted.… These lags perhaps result be less prone to undershoot or overshoot. supply independent of the main electri- from the need for technological states- As a body, the professional pilots indeed cal system. This is done to [en]sure that manship, for the ability to recognize the are experts, else they could not have es- if a crash occurs in darkness, the occu- total value to the industry, and society of tablished a safety record which provides pants have an independent source of accelerating the adoption of a seemingly life insurance at the same rate as a chess light. In most air transports, each light costly device or standard procedure. This player. However, they represent a cross- has a separate battery to power it, but is a more charitable view than ascribing section of the population, with all the hu- the regulation does not specifically de- lag to the egocentric attitudes of deci- man frailties this implies: Their compe- mand this discrete protection, so one sion-makers.” tence will vary; they have good days and may find only one battery supplying all **** bad days. It is not sound to assume that all the emergency lights—and this one bat- In “Reflections on Human Factors”—pre- pilots are continuously at their peak per- tery located in the nosewheel well of the sented to the Aviation Contractors Safety formance. Automatic all-weather landing airplane, the place most likely to suffer Conference Jan. 28-30, 1964, in Virginia systems should improve the situation disintegration in a crash! The letter of Beach, Va.—Lederer said, “My reactions where airports and aircraft are equipped the regulation but not the intent of the to the material I scanned [in preparation with these devices after their reliability is regulation has been satisfied in this case.” for this presentation] was first a feeling of proven. Airports are also used by less-ex- • “People will live or die on the basis of inadequacy to deal with the subject of hu- pert pilots flying without sophisticated in- decisions made by engineers or by the man factors in view of the massive tomes

16 • ISASI Forum April-June 2004 of knowledge remained unexplained. In some cases, the istration (NASA)], I must attract scores which have been reasons may be known to the bureaucracy of technical specialists to help with the produced espe- of the nation where the accident occurred. complex problems of space. Specialists cially in the last The information has been withheld, per- in structures, chemical engineers, civil few years, and haps, for political purposes, for pride, or engineers, reliability experts, test pilots, secondly, a feel- for some other reason of policy.… The and many others. The word ‘safety’ car- ing of satisfac- huge investment, the many innovations ries no romance; it is the absence of dan- tion that so many in SST, the unexplained subsonic acci- ger or risk, and as I said before, it de- fresh, capable dents support the need to improve meth- notes only a small segment of the total thinkers were de- ods to determine accident causation.… problem—protective equipment. Jerome F. Lederer votedly engaged Essential information should be obtain- “Furthermore, the word ‘safety’ implies 1902–2004 in this field, pro- able, not only by flight [data] recorders protection of lives. Many activities involve ducing much alone but, as in missile flight, by great risks of prestige and resources with more information than I had time to telemetering the data to the ground. The minimum or no risk to life. Unmanned read.… Then I reflected on my slowness vast amount of telemetered data need not space operations fall into this category. in helping to spur the development of be retained more than a brief period un- The phrase ‘loss prevention’ covers both human factors as such and this line of less an accident occurred. The data then life and property. But to attract the kind thought led to other opportunities I have would be available for accident analysis. of required talent, and for logical reasons, missed in the development of air safety.… Satellites might be used to transmit the word ‘safety’ is being supplemented In regard to other fields of human fac- telemetered data.” by the phrase ‘risk control.’ This rings with tors which I missed, I reconcile my con- **** challenge, with measurement, with analy- science and my pride by rationalizing that In accepting the Wright Brothers Award sis, with action, with status. In discussing a large part of my efforts from the late from the U.S. National Aeronautic Asso- this concept with Dr. Wernher von Braun 1920s up to the war [World War II] were ciation on Dec. 17, 1965, in Washington, and his staff, the phrase ‘risk manage- devoted to trying to influence men’s atti- D.C.—Lederer said, “The outstanding ment’ was proposed as a better alterna- tude towards safety in design, operations lesson to be learned from the open- tive. Either one is a more satisfying defi- and maintenance; to show them that skill mindedness of the Wrights is that civil nition of the true responsibilities of a alone will not save them from trouble; that aviation should not arbitrarily reject a safety engineer than ‘safety,’ I feel.” judgment, alertness, apprehension, or proven device or technique. Aviation his- **** foresight are also necessary, and especially tory is studded with ideas that were not At the same conference, Lederer said, a sense of responsibility to one’s fellow accepted, later to be regarded as indis- “[Systems safety engineers] must learn men. This is dealing in human factors in pensable. The flight data recorder is a from the experience of others because they a broader sense than what we have in good example.… In brief, expeditious will not live long enough to make all the mind today when human factors is men- recognition of proven techniques or de- mistakes themselves. Preconceived opin- tioned.” vices and a means for monitoring disci- ions and intuitive judgments are often **** pline will accelerate a rise in the level of proven to be wrong when weighed against In “Safety Briefs on SST [Supersonic safety. A corollary to this is to expedite the cold hard facts of service experience.” Transport]”—presented to the Society of the exchange of accident prevention in- **** Automotive Engineers National Aeronau- formation, especially the information In “Ideal Safety System for Accident Pre- tic Meeting, New York, N.Y., April 27-30, learned from incidents.… But there are vention”—presented to the Symposium on 1964—Lederer said, “To this day it has several developments on the horizon Air Safety, sponsored by the Journal of Air been estimated that fewer than 15 per- which promise to improve transport safety Law and Commerce at Southern Meth- cent of the world’s airways are geared to by several orders of magnitude: the in- odist University, Dallas, Tex., April 22-24, jet requirements. The funds to install, stallation of modern navigation and ap- 1968—Lederer said, “Negligence results maintain, and operate ground support proach aids in underdeveloped areas; and from attitudes, the most important single equipment have not been made available. automatic approach devices, if successful, factor in reducing losses. Complacency, Jet aircraft are flying in some areas of the should reduce the fatal accident rate by carelessness, incapacity, arbitrary rejection world where ground support is barely perhaps 30 percent. The prospects of of suggestions because of pride, apprehen- good enough for DC-3s. Jet pilots are preventing fires following a survivable sion, or suspicion, deliberate departure required to orientate themselves on ap- type of crash are good, and they should from accepted good practices (which oc- proaches to airports by nondirectional cut fatalities at least another 50 percent.” curs even in the face of excellent training), beacons. Folios of reports are available **** the nature of pressures exerted on man- which list the deficiencies of ground sup- In an untitled paper presented during agement, and by management in design port in all areas of the world. The prob- the Canadian Industrial Safety Associa- and operation hinge on attitudes—atti- lem is mainly one of economics for the tion Conference in Toronto, Ontario, tudes of individuals, attitudes of society, less wealthy nations of the world. Hospi- Canada, Sept. 18-19, 1967—Lederer attitudes of the government, of sharehold- tals, roads, schools, and other social ser- said, “In my position [as director of ers or industry associations, of unions, and vices have priority over aviation.… A con- manned space flight safety for the U.S. even of the man who sweeps the hangar siderable number of jet accidents have National Aeronautics and Space Admin- floor.… Over the years which I have been

April-June 2004 ISASI Forum • 17 engaged in aviation, nothing has given me In “Human Error Will Persist—Can Its ists because the Foundation enjoys its more gratification than acceptance by me- Effects Be Minimized?” (Flight Opera- freedom of action and of communica- chanics and many pilots of codes prepared tions, 1976)—Lederer said, “Manage- tion in a completely independent and for them.” ment is monitored. Congressional over- objective environment. Some of the past- **** sight committees monitor the [U.S. Fed- funded research activities of the Flight In his keynote address to the Government- eral Aviation Administration (FAA)], the Safety Foundation are Industry System Safety Conference at FAA monitors the airlines, the media also • “Crew complement evaluation (CAB); Goddard Space Flight Center, Greenbelt, monitor the aviation industry by public- • “Cost of general aviation accidents (FAA); Md., May 1-3, 1968—Lederer said, “Sev- ity given to accidents. But day-to-day • “Weather as a contributing factor in air eral problems remain to be solved before cockpit performance has not been moni- transport accidents (U.S. Weather Bureau); a lunar landing can be made with reason- tored until fairly recently. Several airlines • “Synthesis of aircraft crash/fire/rescue able chances of safe return to Earth. Lon- now use flight [data] recorders for this and evacuation technology (FAA); gitudinal vibration, powerplant reliability, purpose. It is done with the consent of • “The communication of weather in- space suit modification, and lunar land- the flight crews under carefully con- telligence to general aviation (U.S. ing techniques are among the prominent trolled conditions which accentuate les- Weather Bureau); subjects receiving concentrated attention. sons learned while punitive measures are • “Survey of occurrences involving loss Time is a major factor. Once basic research eliminated. The results have benefited of control of swept-wing aircraft (FAA); is done, however, time schedules are not safety.… It is a tribute to the cooperative • “Economics of safety in civil aviation undesirable restraints if they are within attitude of managers of aircraft (pilots) (FAA); manpower capabilities. Establishing a tar- that a form of acceptable flight moni- • “Cost effectiveness of using arresting get date induces tight organization, drive, toring has been evolved on several air- gear for air transports (FAA); and spirit; it creates momentum and com- lines. It would appear to be the way of • “Revision of medical standards for air- pels identification and attention to signifi- the future to intercept unaware, uninten- men (FAA); cant factors, establishes motivation. It acts tional, or deliberate departures from • “Psychological requirements for air as a goad to a goal. The target was set by good practice before they become fatal. traffic controllers (FAA); the White House seven years ago and was Incidentally, this was proposed at an air • “Near-collision study—Project SCAN recently reemphasized in a presidential safety conference way back in 1937.” (FAA); address at Houston [,Tex.]. However, the **** • “Project GAPE—General Aviation Pi- loss of time as a result of the [fatal Project In a January 1978 paper, “The Flight lot Education (FAA); Apollo space-capsule] fire of Jan. 27, 1967, Safety Foundation: Early History,” • “Technology for detecting clear air has left its mark. The lessons of the fire Lederer said, “At its peak, the Flight Safety turbulence (FAA); have, of course, been learned. Corrective Foundation had 65 employees.” He said • “CAPTACS—terminal area traffic action has added some 2,000 pounds to that the Foundation’s accomplishments control (FAA); the weight of the spacecraft and this, too, to date included the following: • “Effect of runway grooving on general creates problems. Apollo will be operated • “The Foundation initiated collection aviation aircraft (NASA); with reasonable assurance of success even and dissemination of mechanical-mal- • “Study on cabin evacuation (FAA); [and] if a new target date has to be set.” function reports in 1947, now accom- • “Safety aspects of operating passen- **** plished by the U.S. Federal Aviation ger helicopters from the roof of the Pan On March 16, 1969, Charles A. Lind- Administration; American building (New York Airways).” bergh, known worldwide for his 1927 solo • “Spurred the acceptance of flight data “Flight Safety Foundation publications flight from New York to Paris, France, recorders, anti-collision lights, crash/fire/ [11 scheduled periodicals at the time] are wrote the following letter to Lederer, who rescue training, use of simulators in ac- designed to enhance the effectiveness of was then director of manned space flight cident investigation, and standardization the safety efforts of its members,” he said. safety for NASA: “You have written that I of pilot training; “Information contained in these publica- should not bother to acknowledge the • “Initiated an anonymous pilot report- tions supports management safety pro- items you send from time to time, and ing system in 1964; [and] grams. Publications offer both original probably I will usually take you up on this • “[The FSF] staff has received more and reprint material, and are themselves (with many unstated thanks) because my than 50 individual awards for contribu- reprinted in magazines and flight opera- mail piles up in amounts that I simply tions to aviation safety. FSF has been tions publications throughout the world.” can’t cope with in the hours I devote to it. called the ‘conscience of the industry’ for The Foundation’s two annual meet- But I am so impressed by, and interested quietly disseminating aviation safety im- ings—the International Air Safety Semi- in, your paper on ‘Risk Speculations of perfections and uncertainties with reme- nar and the Corporate Aviation Safety the Apollo Project’ that I can’t resist writ- dial suggestions.” Seminar—“bring together world leaders ing and telling you so. Anne and I have Lederer said, “The Flight Safety Foun- in aviation to share and exchange the best both read it with fascination. I have al- dation has a long history of safety re- and latest operational and technical in- ways felt that risk should be related to search and investigation, both under formation relating to aviation safety,” objective, and you have handled this re- government grants or contracts and con- Lederer said. “In addition to the annual lationship beautifully.” fidential projects for its members. A seminars, the Flight Safety Foundation **** unique research and study capability ex- also holds a number of workshops for

18 • ISASI Forum April-June 2004 pilots, flight • “Incidentally, two members of the dard. Your determination and dedication crews, and flight Wings Club were involved in the very first reflect your allegiance to the highest attendants. No- formal course in aircraft accident inves- standards of public service.” table among tigation. This was conducted by the **** these recently Flight Safety Foundation at Mitchel Air Dr. Assad Kotaite, president of the Coun- was a four-course Force Base [Hempstead, N.Y.] in 1948. cil of ICAO, said while presenting the workshop deal- R. Dixon Speas was one of the lecturers; 1999 Edward Warner Award to Lederer, ing with ap- Gloria Heath was the project manager.” “Safety has been the primary goal of proach-and- **** ICAO since 1944 and it has also been landing accident In “Safety Science in Aviation”—pre- the fundamental goal of Jerome Lederer, Jerome F. Lederer prevention, avia- sented during the First World Confer- who has often been referred to as ‘Mr. 1902–2004 tion safety pro- ence on Safety Science in Cologne, Ger- Aviation Safety.’ From the very beginning gram manage- many, Sept. 24-26, 1990—Lederer said, of his career with the U.S. Air Mail Ser- ment, aircraft accident investigation, and “Safety could be strengthened, in my vice in 1926 until now, Mr. Lederer has human factors in accident prevention.” opinion, if the presidents of the airlines spared neither his time nor his efforts to Advocating “positive safety manage- involved in an accident would be re- make aviation safer.” ment,” the Foundation offered aviation quired to describe in person their safety **** safety assistance programs (ASAP), which policies and their implementation [of In 2002, Lederer said that 14 million comprised “operations and safety sur- policies] at the hearings of the accident Americans have Alzheimer’s disease, and veys to provide management with a con- investigation.” he wondered about their safety when fly- fidential appraisal of the performance **** ing. “How do you remove them quickly levels of safety and efficiency in its air- In 1995, NTSB Chairman Jim Hall closed from an airplane involved in an acci- craft operations,” he said. “By sending his speech during a seminar of the Inter- dent?” he said. “They quickly forget in- highly qualified review teams to those national Society of Air Safety Investiga- structions.” companies requesting such a survey, the tors by paraphrasing the following ideas, **** Foundation helps to uncover major and which he attributed to Lederer: “It is im- The Skygod.com Internet site, on its minor deterrents to safe operations and possible to say that safety in air transpor- page of great aviation quotes, in 2002 offers suggestions as to how to rectify tation is, has been, or will be achieved by quoted Lederer as saying the following: them and prevent recurrence.” any one specific piece of equipment, by • “Every accident, no matter how mi- **** experience alone, solely by conservative nor, is a failure of the organization.” On April 21, 1982, Lederer presented a [investigative] policy, by [solid] research, • “The alleviation of human error, Wings Club Sight Lecture in New York, by virtue of good organization, or because whether design or intrinsically human, N.Y., “Aviation Safety Perspectives: Hind- of government regulations. All these ele- continues to be the most important prob- sight, Insight, Foresight.” The following ments, cemented together by [investiga- lem facing aerospace safety.” examples from the lecture were often tors] imbued with a spirit of apprehen- • “Of the major incentives to improve cited in his articles and lectures: sion combined with a deep sense of re- safety, by far the most compelling is that • “[Aviation pioneers Orville Wright and sponsibility for the safety of the flying of economics. The moral incentive, which Wilbur Wright] installed the first flight public, have brought about our present is most evident following an accident, is data recorder, automatically operated, on laudable air safety record and will con- more intense but relatively short-lived.” the first [powered aircraft] flight [on Dec. tinue to improve on it.” **** 17, 1903]. It recorded engine revolu- **** In 2003 at the conclusion of her presen- tions, distance through the air, and du- Congratulating Lederer in 1997 for re- tation to the International Society of Air- ration of flight.… Several airlines have ceiving the Aerospace Life Achievement craft Accident Investigators annual semi- used [flight data recorders] to detect Award of the American Institute of Aero- nar, FAA Administrator Marion Blakely departures from good practices before nautics and Astronautics, U.S. Rep. made a surprise and special presenta- they result in an accident, a very impor- Randy “Duke” Cunningham of Califor- tion. She told the assembled 350 acci- tant safety measure.” nia said, “You have made outstanding dent investigators: “As you think about • “One in every six airmail pilots was contributions to your industry and to the how you can become more prepared, killed in the nine-year history of the U.S. welfare of the people of the United States here is a role model for you…Jerry Air Mail Service.… From the standpoint of America, and have truly earned the Lederer… a man who has spent three- of safety, the Air Mail Service showed title, ‘Father of Aviation Safety.’” quarters of a century finding the right among other lessons the danger of ex- **** solutions to make aviation safer. In 1948 erting injudicious management pressure In another congratulatory letter for the he organized the Flight Safety Foun- on pilots, a lesson that needs reiteration. award, U.S. Rep. Brian P. Bilbray of Cali- dation’s first accident investigation It also emphasized the differences in fornia said, “As an aerospace pioneer, you course. And I think it is fair to say that if ability of pilots to manage risks.… Good have demonstrated the American spirit there is one person who can be credited airmanship was conceived as a combi- to create a world that is safer for every- for creating an outstanding safety record nation of skill and judgment. Now it one. As an engineer, you have trans- in the first century of flight, it is Jerry embraces resource management.” formed the unimaginable into the stan- Lederer.” N

April-June 2004 ISASI Forum • 19 (This article was adapted, with permission, from the author’s presen- (RCA) is commonly used in engineering and reliability pro- tation entitled The Practical Use of Root Cause Analysis System grams but is not always emphasized in accident/incident in- (RCA) Using REASON®: A Building Block for Accident/Inci- vestigations. RCA can lead to changes in procedures, processes, dent Investigations presented at the ISASI 2003 seminar in Wash- manuals, oversight, and training. ington, D.C., USA, August 2003. The full presentation is available on the ISASI website at www.isasi.org. REASON®, is a trademark RCA using Reason® of DECISION Systems, Inc., which is located in Longview, Tex., not In Root Cause Analysis, one recognizes three basic elements to be confused with Dr. James Reason.—Editor) that built causal patterns: • A change or changes: An action that triggered another step he defense in-depth strategy is common to all safety in a problem. The initial change comes from the problem prevention doctrine. The Swiss Cheese Theory com- statement. For example: Aircraft ship number 123, Flt. 456’s Tmonly illustrates successive layers of protection, one left wing collided with a parked fuel truck. This is a change— behind the other, each guarding against the possible break- something happened that caused the end result, a collision. • A condition: A state of being that existed within the environ- ment over some period Root Cause Analysis with of time, i.e., it was dark. The ramp was wet. The ® fuel truck was parked on the safety zone. The pilot’s scan was poor. • An inaction: Is there anything that could REASON have or should have oc- curred to prevent the Root Cause Analysis (RCA) is commonly used in engineering next step in the prob- lem but did not. The and reliability programs, but is not always emphasized in inaction is akin to al- accident/incident investigations. RCA can lead to changes in lowing the chain of events to continue un- procedures, processes, manuals, oversight, and training. challenged. For ex- By Jean-Pierre Dagon (CP0204), Director of Corporate Safety, AirTran Airways ample, the pilot did not stop when confusing marshalling signals down of the one in front. According to the originator of the were present. The airplane was allowed to continue with a theory, Dr. James Reason, each layer has weaknesses and gaps high rate of descent. The flight crew did not react to a GPWS akin to a Swiss cheese. The Swiss cheese metaphor is best rep- pull-up command, and so forth. resented by a moving picture, with each defensive layer com- A set of facts identifies all of the factors that are essential for ing in and out of the frame according to local conditions. one step to occur within one chain within the REASON® The theory holds that these holes are created by a combi- model. As a person lists the component factors that explain nation of active and latent failures. The active failure consists why a particular step in the event occurred, a set of factors is of errors or violations committed at the sharp end of the sys- built. Each set must contain only factors that are necessary to tem. A latent failure stems from poor design, a shortfall in explain the consequence of that set and nothing more. training, inadequacy of tools, and equipment, which are Certain rules have to be met in order for the system to work: present for sometimes years before these conditions combine with local circumstances and active failures to penetrate the Jean-Pierre Dagon is a native of Switzerland system’s many defensive layers. (Geneva) and is the director of corporate safety for As such, the rare conjunction of a set of holes in successive AirTran Airways. He has been employed with defenses allows hazards to come into damaging contact with Northwest Airlines as manager of flight opera- people and assets, according to Dr. Reason as he defines the tional quality assurance and with FlightSafety accident trajectory. To date, however, accident/incident inves- Texas, San Antonio Learning Center: director of tigations point many times to causal factors (i.e., bringing forth pilot standards. Prior to 1995 he was with Crossair the facts), but leave it up to the recipient of the report to de- LTD, Basel, Switzerland, as head of pilot training. He is a B-717- termine root causes. 200 captain and rated on DC-9 (B-717), SF-340, and SA-2000. This approach offers an opportunity to examine root causes He holds a B.B.A., aviation management option from Boise State and bring forth some measurable indicators of the likelihood University (cum laude) and has attended the College of Geneva of reoccurrences. It may offer an avenue to the question: “What (Switzerland). He is a member of AIAA and a corporate member latent conditions led to the accident?” Root Cause Analysis of ISASI and the Flight Safety Foundation.

20 • ISASI Forum April-June 2004 A set is a group of factors that causally account for the next an alternative to eventual costly engineering changes, which higher step (their consequent) in the model. may not be necessary given the propensity for the event to 1. There can be only one change in a set (a group of answers reoccur. Engineering safety brings forth a comprehensive and that explains one cause, or one change for any level). permanent fix; however, engineering safety can have alterna- 2. Change is produced by change. tive drawbacks: 3. Inactions are always brought about by inactions; therefore, • It can be impractical or hard to market for the industry at you cannot have a change answer in an inaction set. (Some- large. Example: Considering an initiative to equip passenger thing didn’t get done, or didn’t happen, either due to a lack aircraft with aft-facing seats. Although used extensively in the of plan, or the plan did not work.) military, a proposition for aft-facing passenger seats could be 4. Conditions can occur in any set, but it is not necessary to interesting if one considers the flying public’s likely distaste have a condition in every set. for flying “backwards.” There are two types of conditions: those that are brought • It can introduce new threats because of the fix itself. An about by change and those that are brought about by a lack of example is the automation introduced in modern jets, which change. The Reason® software will ask you to designate which is intended to alleviate the workload and monitor parameters. type of condition you are dealing with before its “Advice Area” If the automation fails, it relies on intuitive knowledge by the activates the questions for the set. (Note: The software strin- pilot who is not cognizant at first of a failure in automation, or gently enforces these four rules.) a failure in programmation that could lead to a catastrophe. Example: the Air Inter A320 crash in Strasbourg, where a Building steps for RCA vertical speed of 3.3 (as in 3,300 fpm down) [VS/HDG com- The building steps start with a change (which may be a sum- bined mode] may have been left, or erroneously selected by mary of the incident broken down in simple building blocks). the pilot in command (PIC) in lieu of the track/flight plan That change is developed with a sets of factors, which contrib- angle mode or 3.3° [TRK/FPA mode] desired, leading to a uted to the initial event. This allows the investigator to retrace controlled flight into terrain against Mt. St. Odile. steps that came into effect to bring about the changes. In this • It brings forth a bulldozer approach to level an ant hill—a process, one will find repeating patterns that can be looped disproportional fix to a single and remote possibility of a failure. and thus connected to one factor that accounts for several of Root Cause Analysis is a process designed to discover both these event sets leading to the accident. The process is basi- an engineering solution and organizational alternatives. In cally structured around a pyramid: the REASON® system, these controls can be compared for effectiveness for prevention of a certain event. This effective- ness comparison, coupled with an understanding of the pro- pensity for the specific event to recur, provides decision-mak- ers with important information to aid them in deciding whether engineered controls are preferred.

Root causes division A root cause can be categorized in the following hierarchy: A. Management-Level Action Required—Management principles must be first considered to ensure a policy is in place, is en- forced, and controls are established. Management-level state- ments included are that management did not • communicate this requirement. • designate that this policy apply to this specific situation. Upstream risk analysis—Upstream (top of pyramid) accounts • establish a means to monitor compliance with this policy. for critical steps prior to the event (the last chain of the event • communicate how it was monitoring for compliance. chain). As you move down, the values are becoming smaller; • enforce the policy when an infraction was found. it lends a predominance of weight at the top of the model. • establish a policy to control this. Downstream analysis—A longer chain of events, as analyzed The point at which the statement can be affirmed as true is downstream (or at the bottom of the pyramid), would indi- the point of breakdown in the organizational principles of cate a bigger problem, for there were many opportunities to control. If the statements are not applicable, the next step is break the chain of events from unfolding, yet these opportu- analyzed. nities were either ignored or unknown. It is likely that latent B. Supervision-Level Action Required—At this point, the Rea- effects would be best described by downstream analysis, son® software offers supervision principles to consider in each whereas active failures would more be consequential at the of the following statements: top of the pyramid. • Supervision did not communicate what was wanted. If one assumes a single level of events caused the accident, than • Supervision did not provide the things necessary in order to one has a typical active failure model (a virtual impossibility). comply with policy. • Supervision did not follow the policy in the past. Differing fixes • Supervision did not enforce the policy in the past. The engineering fix versus organizational fix approach offers The point at which a statement can be affirmed as true is

April-June 2004 ISASI Forum • 21 the point of breakdown in the organizational principles of control. After looking at a failure at the management level, filtering down to the supervisory level, the individual perfor- mance may be examined: C. Individual-Level Action Required • The individual’s incorrect action is now acceptable and the policy can be changed. • The individual’s incorrect behavior can be modified. • The individual’s incorrect behavior cannot be changed, and the person must be removed from that particular environment. The software is diligent in giving this as a last-resort option stating: “Selecting an individual root cause (RC ) is a serious and rare decision. Using the RC wizard will help to avoid miss- ing the systemic portion of a RC where the individual(s) shares responsibility.” Often, an organization will resort to disciplin- ary action, at the expense of finding a systemic problem to an incident/accident, thus going against the accepted proposi- tion that individuals for the most part have an innate desire for self-preservation and, in high-consequence environments, seldom create intentional accidents.

Application of RCA Here is a practical application of Root Cause Analysis using REASON® in an actual case of simple ground damage. Problem statement—Aircraft # 123 arrived at destination as Flight 456 from Philadelphia on June 14 with 59 customers and a crew of five, and was assigned to Gate C-3. The ramp crew was at another gate and not in position for an arrival at C-3, but ran to their positions when notified of the waiting aircraft. As the aircraft moved forward into the gate, it struck Figure 1 (top): Leading edge slats 4 and 5 damaged. an unattended fuel hydrant truck left inside the containment Figure 2 (above): Detailed view of the damage with fuel truck. zone, damaging the leading edge and underside of the left wing. line was not visible from the marshaller’s position. As the ramp was wet, and since the safety zone line was not visible from the Narration obtained by the Reason®-software—Because the fuel marshaller’s position, and because the fueler did not park vendor’s supervision did not enforce the policy of parking outside of the safety zone line, the fuel truck’s position rela- fuel trucks in designated areas only and the individual(s) did tive to the safety zone line was unclear to the marshaller. not comply on their own with the established business pro- In addition, because the C-3 gate required a high-angle cess, the fueler did not park the vehicle in a designated park- turn, the pilot had to turn more than a 135-degree angle to ing area. Additionally, because the customer service organiza- park. So, the pilot’s scan was poor. Furthermore, because the tion did not establish a policy to advise fuel company person- marshaller did not have adequate on-the-job experience, she nel about the importance of safety zone lines, the fuel company did not follow her training. did not stress to its truck drivers the importance of not park- Then, because the customer service organization did not ing in safety zones. So, the fueler was not attentive when he monitor the marshalling policy and the individual(s) did not parked the vehicle. comply on their own with the established business process, Also, because the fuel vendor did not establish a policy to the marshaller did not follow established signal procedures park vehicles only in designated parking spots, the fuel com- but instead used her wands to signal to her wing walkers. pany did not have a prohibition against parking in the safety Meantime, the marshaller was under stress, and the mar- zones for office business. Since the fueler was not attentive shalling agent was not following her training, and ramp su- when he parked the vehicle and because the fuel company pervision did not enforce the illustration of hand signals did not have a prohibition against parking in the safety zones (SP6720.3). The individual(s) did not comply on their own for office business, the fueler did not park outside of the safety with the established business process, and the marshaller did zone line. So, when the fueler parked the truck to deliver a not follow procedure in communicating with wing walkers. bill to the fuel vendor’s office, and because the fueler did not Then, because the marshaller needed the wing walkers in park the vehicle in a designated parking area, and because position to guide the aircraft in, the marshaller was trying to the fueler did not park outside of the safety zone line, a fuel communicate the need for the wing walkers to get into posi- truck was parked in the safety zone. tion by using her wands. Moreover, because management did not establish a policy Additionally, as several ramp workers were sick that day, to repaint the lines periodically due to wear, the safety zone and the customer service organization did not monitor the

22 • ISASI Forum April-June 2004 staffing level to ensure adequacy and the individual(s) did not their own with the established business process. comply on their own with the established business process, • This prevention opportunity is the 4th best, eliminating 14 the ramp did not have adequate staffing that day. Conse- percent of the process that produced this problem. quently, as the wing walkers were busy loading a cargo bin at The customer service organization has the opportunity to monitor an adjacent gate, the wing walkers could not take their posi- the staffing level to ensure adequacy, and the individual(s) did not tion in a timely fashion. Since the marshaller was trying to comply on their own with the established business process. communicate the need for the wing walkers to get into posi- • In terms of preventing this problem, this is the 3rd best tion by using her wands, and because the wing walkers could option, removing 15 percent of this model. not take their position in a timely fashion, the marshalling The PIC has the opportunity to comply with the policy requiring agent did not stay in position with her wands crossed. Since safe practices when unclear signals are received. the marshalling agent was using her wands to signal to her wing walkers, and because the marshalling agent did not stay in position with her wands crossed, the marshaller’s crossing signal was not constant. Root Cause Analysis can give an Also, because the pilot in command (PIC) would not com- approach to risk analysis, offering an ply with the policy requiring safe practices when unclear sig- nals are received, the PIC did not follow safe practices. Since insight in the likelihood of reoccurrence the marshaller’s crossing signal was not constant, and because of an event, and encourage sharing of the PIC did not follow safe practices, the PIC did not stop the “best practices” in the industry in terms aircraft when confusing signals were received. As the fuel truck’s height was above the wing’s leading edge, and since a fuel of procedures, processes, and gained truck was parked in the safety zone, and since the fuel truck’s knowledge. position to the safety zone line was unclear to the marshaller, and since the pilot’s scan was poor, and because Flt. 456 tax- • This is the 6th best prevention option. It eliminates 12 per- ied into gate C-3, and because the PIC did not stop the air- cent of this problem. craft when confusing signals were received, aircraft 123, Flt. 456’s left wing collided with a parked fuel truck. Tree model explained The following tree model illustrates a complete Root Cause Case interpretation Analysis on the aforementioned example. Changes are dark Analysis of this investigation shows that it is valid to compare squares. Conditions are grey circles. Inactions are grey rounded the identified root causes to each other, given a calculated squares. Root causes often happen as a result of inaction. reliability of 100 percent. This event contains a typical mix of A level is best described as a collection of events occurring both conditions and actions. horizontally—henceforth, a set. Note that there is only one The fuel vendor’s supervision has the opportunity to enforce the change per level. As the tree model builds up, consider the policy of parking fuel trucks in designated areas only, and the bottom as the flat portion of the pyramid. To understand how individual(s) did not comply on their own with the established busi- REASON® prioritizes actions (most effective action) to affect ness process. the outcome, one can look at the right identical branches of • In terms of preventing this problem, this is the 7th best the 2nd and 3rd conditions (1st level of the model) following option, removing 9 percent of this model. the initial change. The customer service organization has the opportunity to establish “As we eliminate one root cause, they are duplicated, i.e., a policy to advise fuel company personnel on the importance of safety the same root cause eliminates 22 percent of the model, hence- zone lines forth the interpretation: “The customer service organization • This is the best prevention option. It eliminates 22 percent has the opportunity to establish a policy to advise fuel com- of this problem. pany personnel on the importance of safety zone lines.” This The fuel vendor has the opportunity to establish a policy to park is the best prevention option. It eliminates 22 percent of this problem. vehicles in designated parking spots only. However, also note that an active failure at the first level • Preventing this root cause is the 2nd best option, and will was an immediate contributor to the accident by looking at deal with 22 percent of the causes that produced this problem. the far right-hand corner, 1st level: The pilot in command Management has the opportunity to establish a policy to repaint the did not stop when signals where confusing (last line of de- lines periodically due to wear. fense). Hence this interpretation: “The PIC has the opportu- • This action, the 8th best option, will remove 7 percent of nity to comply with the policy requiring safe practices when this problem. unclear signals are received.” This is the 6th best prevention op- The customer service organization has the opportunity to monitor tion. It eliminates 12 percent of this problem. the marshalling policy, and the individual(s) did not comply on their By removing the PIC from the picture, we do not remove own with the established business process. the conditions that exist, or could exist, for this accident to • This option is the 5th best available option. It will remove reoccur. Conditions are still present for another opportunity 13 percent of this problem. to damage an airplane. In the above two examples, we see a Ramp supervision has the opportunity to enforce the illustration of brief overview of a latent failure (systemic issue) and an active hand signals (SP6720.3), and the individual(s) did not comply on failure (individual failing to stop) as contributors to this event.

April-June 2004 ISASI Forum • 23 faults to putting in engineered con- trols, even if solutions dealing with the organizational system seem to be equally effective. Engineered solutions are indeed often effective, yet they often are the most costly options available for dealing with an event. Engi- neered solutions are sometimes quick—they are put in place and if Tree diagram of the event. Each branch represents an designed correctly, they provide in- opportunity to eliminate a root cause. The process of elimina- stant protection. Yet, if the TTP is tion produces the interpretation of the case. low for an incident, the need for an expedient correction is not as REASON® Summary Sheet Chart great. Very often a discovered fix in the organizational system can be both more effective and more cost effective than the engineered solution. Some unwanted events tend to happen over and over due to the repetitive nature of the specific business process associ- ated with them. An example of this is the business process of boarding passengers on a plane, which is an extremely repeti- tive process. Due to its repetitive nature, if any problems exist Summary sheet interpreted in the “boarding passenger business process” one can expect Since the model contains no insufficient data, it is 100 per- those problems to happen again and again. cent reliable (according to our inputs). The raw numbers in- Such problem events tend to have high TTP scores in REA- clude proper causal stress: the value of each changes inac- SON®. Repetitious events, such as those noted, match well with tions and conditions. Proper generating causality: The value the inherent advantages of engineered solutions because such of all changes and inactions (we subtract the existing condi- solutions “dummy proof” the affected business processes, elimi- tions). Relative means the importance assigned depending nating the need to rely on people-induced corrections. Relying on which level of the model these factors occur (the closer the on organizational systems and people to deal with voluminously event to the outcome, the heavier the weight). Proper means repetitive problem issues is not going to be as consistent a con- an equal number per level. Relative gives more importance trol for these problems as will be an engineered solution. and weight to factors occurring early in the model (i.e., top of But often the events encountered (serious or otherwise) are the pyramid). The Causal stress TTP (tendency toward pro- the exceptional, infrequent events associated with business pro- cess) is interpreted to mean the relative number of all factors cesses that are not as repetitive. These types of events tend to (including conditions) divided by the proper numbers of fac- have low TTP numbers. Thus, the TTP metric itself can serve tors (discounting the level at which it occurs). Generating cau- as an indicator that assists a decision-maker in deciding be- sality TTP is interpreted to mean the same, but we discount tween engineered solutions and/or fixes in the organizational the existing conditions. system that often are as preventative and more cost effective. In the “aircraft truck” case study, the TTP is 3.7, which is TTP interpretation just slightly above normal. This score would tend to indicate The tendency toward process (TTP) number is a metric calcu- that organizational fixes would be just as prudently chosen as lated within the REASON® software that indicates the amount any discovered engineered solutions. of “causal stress” present within a specific event model. Given that the discovered corrective actions are not put in place, REASON’s® benefits TTP indicates how quickly and/or frequently the organiza- The root cause approach to incident /accident investigation tion could anticipate a recurrence of the same event. In many using REASON’s® software offers an additional facet to the ways, it is a measure of the potentiality of recurrence. accident investigation. It may assist at looking at a systemic TTP is charted in a numeric range of 0-10. TTP scores of failure (organizationally) leading to an accident; it also may help around 3.0 are normal. This particular case had a 3.7 TTP, to answer the systemic “why” of an accident, complementing which is slightly elevated yet indicates that the event is not the “how” and “when.” Hopefully this approach will provide prone to recur quickly or frequently. In the REASON® soft- additional weight in recommendations following investigations. ware, TTP indicates the degree of quickness and frequency In particular, RCA can give an approach to risk analysis, offer- related to an event’s recurrence, and there are several reasons ing an insight in the likelihood of reoccurrence of an event, why it should be contemplated when prioritizing events for and encourage sharing of “best practices” in the industry in corrective action. terms of procedures, processes, and gained knowledge. This Often, after an organization experiences an incident with seri- tool also affords a framework for Root Cause Analysis investi- ous consequences, decision-makers proceed into the decision- gations. Finally it preempts the old-fashioned approach of “re- making phase of corrective action with a mindset that often de- move the cause and the problem ceases to exist.” N

24 • ISASI Forum April-June 2004 V.P.’S CORNER Disseminating Safety Information By Ron Schleede, Vice-President I wish to add my thoughts developed this program that is directly organizations with the most need for such and recollections to the addressing one of his concerns. information. This also prevents the “spin- extensive coverage of the On a similar note, I believe one of the ning” of the information and incomplete passing of Jerry Lederer, other solutions to the safety information or erroneous reporting by third parties who the Flight Safety dissemination problem is the developing whose interests may not be solely for the Foundation referred to as use of Internet websites by independent prevention of future accidents. I believe “Mr. Aviation Safety,” in its accident investigation authorities. The more investigation authorities should August-September 2002 Flight Safety Di- timely posting of objective, factual infor- adopt the use of the Internet to fulfill the gest. His unparalleled contributions to mation in proper context on such websites goal of timely and accurate dissemination aviation safety included excellence in air- during the course of investigations pro- of safety information. I am sure that “Mr. craft accident investigation and preven- vides direct access to those persons and Aviation Safety” would agree. N tion. I am proud and honored to have received the ISASI Jerome Lederer Award in 2002. During my tenure as chief of 2003 Annual Seminar Proceedings Now Available major aviation investigations for the NTSB for more than 10 years, Jerry would Active members in good standing and • Investigation Enhancement Through Information corporate members may acquire, on a no-fee Technology by Jay Graser, Galaxy Scientific Corporation always call me to discuss recent accidents • Historical Review of Flight Attendant Participation in basis, a copy of the Proceedings of the 34th Accident Investigations by Candace K. Kolander, Association and to offer advice. He often sent me International Seminar, held in Washington, of Flight Attendants background material from his library that D.C., Aug. 26-28, 2003, by downloading the • Accident Investigation Without the Accident by Michael information from the appropriate section of R. Poole, Flightscape was relevant to the safety issues of the cur- SESSION IV Keynote Address Growth of ATC System the ISASI web page at http://www.isasi.org. and Controllers Union by John Carr, President, National Air rent accidents. I treasure the memory of The seminar papers can be found in the Traffic Controllers Association, USA “Members” section. Further, active members • Crashworthiness Investigation: Enhanced Occupant those telephone conversations. Protection Through Crashworthiness Evaluation and may purchase the Proceedings on a CD-ROM Advances in Design—A View form the Wreckage by One of Jerry’s many concerns over the for the nominal fee of $15, which covers William D. Waldock, Embry-Riddle Aeronautical University years pertained to dissemination of safety postage and handling. Non-ISASI members • Enhanced Occupant Protection Through Injury Pattern Analysis by William T. Gormley, Office of the Chief information to prevent accidents. I raised may acquire the CD-ROM for a US$75 fee. Medical Examiner, Commonwealth of Virginia A limited number of paper copies of • Forensic Aspects of Occupant Protection: Victim this issue in my comments in the Janu- Proceedings 2003 are available at a cost of Identification by Mary Cimrmancic, Transportation Safety ary-March 2003 Forum, primarily because Institute, Oklahoma City, Okla. US$150. Checks should accompany the • Aircraft Accident Investigation—The Role of of prompting by Jerry. I received some request and be made payable to ISASI. Mail Aerospace and Preventive Medicine by Allen J. Parmet, to ISASI, 107 E. Holly Ave., Suite 11, Midwest Occupational Medicine, Kansas City, Mo. excellent feedback from ISASI members, Sterling, VA USA 20164-5405. • Expansion of the ICAO Universal Safety Oversight Audit Program to Include Annex 13—Aircraft Accident which I summarized in the April-June The following papers were presented in Washington, D.C.: and Incident Investigation by Caj Frostell, Chief, Accident 2003 Forum. Unfortunately, the feedback • SESSION I Keynote Address Human Spirit and Investigation and Prevention, ICAO Accomplishment Are Unlimited by Ellen G. Engleman, SESSION V primarily addressed the problems and Chairman, NTSB, USA • The CFIT and ALAR Challenge: Attacking the Killers • The Practical Use of the Root Cause Analysis in Aviation by Jim Burin, Flight Safety Foundation reasons for the problems, not solutions. System(RCA) Using Reason ®: A Building Block for • Flightdeck Image Recording on Commercial Aircraft However, I believe that ISASI has de- Accident/Incident Investigations by Jean-Pierre Dagon, by Pippa Moore, CAA, UK Director of Corporate Safety, AirTran Airways • Flightdeck Image Recording on Commercial Aircraft veloped an excellent solution that is de- • From the Wright Flyer to the Space Shuttle: A by Mike Horne, AD Aerospace, Ltd., Manchester, UK Historical Perspective of Aircraft Accident Investigation • An Analysis of the Relationship of Finding-Cause- finitively making a difference. Specifi- by Jeff Guzzetti, NTSB, USA, and Brian Nicklas, National Air Recommendation from Selected Recent NTSB Aircraft and Space Museum, USA Accident Reports by Michael Huhn, Air Line Pilots cally, the ISASI Reachout seminars, nine • The Emergency and Abnormal Situations Project by Association. Presented by Chris Baum. of which have been held around the Barbara K. Burian, R. Key Dismukes, and Immanuel Barshi, • Ramp Accidents and Incidents Involving U.S. NASA Ames Research Center Carriers, 1987-2002 by Robert Matthews, FAA, USA world and many more are in the plan- SESSION II SESSION VI Keynote Address Accident Investigation in • Accident Reconstruction—The Decision Process by Brazil by Col. Marcus A. Araújo da Costa, Chief Aeronautical ning stages. I participated in my third John W. Purvis, Safety Services International Accident Prevention and Investigation Center (CENIPA), Brazil Reachout seminar last January in Mexico • CI611 and GE791 Wreckage Recovery Operations— • Airline Safety Data: Where Are We and Where Are We Comparisons and Lessons Learned by David Lee, Steven Going? by Timothy J. Logan, Southwest Airlines City, and it is obvious to me that ISASI is Su, and Kay Yong, Aviation Safety Council, Taiwan, ROC • Use of Computed Tomography Imaging in Accident • Application of the 3-D Software Wreckage Reconstruc- Investigation by Scott A. Warren, NTSB, USA playing a major role in the dissemina- tion Technology at the Aircraft Accident Investigation by • Investigating Survival Factors in Aircraft Accidents: Wen-Lin, Guan, Victor Liang, Phil Tai, and Kay Yong, Aviation Revisiting the Past to Look to the Future by Thomas A. tion of safety information and lessons Safety Council Taiwan. Presented by Victor Liang. Farrier, Air Transport Association of America, Inc. learned. With the support of the Inter- • CVR Recordings of Explosions and Structural Failure • The Accident Database of the Cabin Safety Research Decompressions by Stuart Dyne, ISVR Consulting, Institute of Technical Group by Ray Cherry, R.G.W. Cherry & Associates national Civil Aviation Organization and Sound and Vibration Research, University of Southampton, UK Limited, UK SESSION III Keynote Address Learning from ‘Kicking • Search & Recovery: The Art and Science by Steven Saint ISASI corporate members, we have Tin’ by Marion C. Blakey, Administrator, FAA, USA Amour, Phoenix International, Inc. reached well over 1,000 delegates from • Investigating Techniques Used from DHC-6 Twin • National Transportation Safety Board Recommenda- Otter Accident, March 2001 by Stéphane Corcos and Gérald tions Relating to Inflight Fire Emergencies by Mark dozens of countries. I believe Jerry Gaubert, BEA, France George, NTSB, USA Lederer would be proud that ISASI has

April-June 2004 ISASI Forum • 25 ISASI ROUNDUP

Australia Awaits ISASI 2004 The Australian Society of Air Safety range of distinguished and knowledge- 360 double-engine flameout and fatal Investigators reports registration for able speakers. Investigation agencies ditching in the Firth of Forth, Scot- ISASI 2004 is progressing exceedingly represented within the program land, and the Ansett Class A mainte- well and that Australia’s Gold Coast include the ATSB, BEA France, BFU nance safety deficiency investigation. awaits delegates and companions. The Germany, the NTSB, TSB Canada, the Other papers will cover a range of 35th annual seminar, which the Society UK AAIB, and the Directorate of informative topics on investigation is sponsoring, will take place Aug. 30- Flying Safety, Australian Defence techniques, technologies, strategies, Sept. 2, 2004, and carry the theme Force. Other well-known organizations analysis tools, investigator training, “Investigate, Communicate, Educate.” represented include ALPA, CAMI, the and valuable lessons learned. Paper It will be held in the ANA Hotel Gold FAA, and the Flight Safety Foundation, authors originate from a range of Coast, Queensland, Australia. while industry manufacturers repre- countries from across the globe. Hotel registration forms are avail- sented include Airbus Industrie, The draft technical program for the able on the ISASI 2004 website. Embraer, Pratt & Whitney, and Rolls- ISASI 2004 seminar is now complete According to the hotel, “A block Royce. and further details are available from booking of hotel rooms for seminar The range of interesting investiga- the seminar website: http:// delegates is being held only until June tions covered within the program www.asasi.org/isasi2004.htm. 30, 2004. After that date, availability of include the Flash Airlines B-737 Social activities include a cocktail rooms is not guaranteed.” The hotel accident at Sharm El Sheikh in the reception on Monday evening, an off- may be contacted at P.O. Box 93, Red Sea, the Ilyushin IL-76 accident in site dinner on Tuesday evening, and Surfers Paradise, Qld 4217 Australia; East Timor, the A300 B4 loss of all the Awards Banquet on Thursday telephone reservations: +61 (0)7 5579 hydraulics following a missile strike at evening. The companion program will 1060; Fax +61 (0)7 5592 2908. Baghdad, ACAS/TCAS aspects of the include a full-day tour and a half-day Registration for the seminar, TU154/B757 mid-air collision over tour. A Friday activity is also being tutorial, and hotel may be completed Überlingen, Germany, the Shorts SD planned as a seminar “wind down.” through the ISASI 2004 seminar website at www.asasi.org/isasi2004.htm. Registration can be done on line or by NEW MEMBERS fax or mail. Alternatively, the registra- Corporate Kyle-Issenman, Lois, I., MO5021, Gatineau, tion from printed adjacent to this UND Aerospace CP0221 PQ, Canada article may be completed and mailed Mr. Dana Siewert Langhof, Dietrich, AO5009, Henstedt-Ulxburg, to the indicated address. Registration Ms. Karen J. Ryba Germany South African Civil Aviation Authority CP0222 Lin, Yang, AO5012, Beijing, Chaoyang Dist., costs will include breakfasts and social Mr. Gilbert Thwala P.R. China functions and (for companions) the Dr. André L. de Kock McNease, William, L., MO5025, Fort Worth, TX, USA day tours. Tutorial registrations and a Individual Middlemass, Duncan, R., AO5024, Wellington, Friday “wind down” tour will be Boerboom, Ryan, C., ST5016, Prescott, AZ, USA New Zealand Bridges, Karl, ST5014, Cranfield, Mitchell, Simon, ST5015, Wavendon, optional extras. United Kingdom United Kingdom Tutorial planning is done and calls Carlson, Brent, R., ST4999, Prescott, AZ, USA Noel, Ivan, MO5023, Calgary, AB, Canada for two sessions to be conducted: (1) Cheong, Kah, S., MO5019, Singapore Olsen Deigaard, Lise-Lotte, AO5028, Vedbaek, Culver, Frank, A., FO5004, Gilbert, AZ, USA Denmark interviewing and (2) communicating de Haas, Francisco, F., MO5013, Mexico City, Pfarr, Robert, P., ST5007, Prescott, AZ, USA and educating. More information will Mexico Power, John, R., AO4996, Dublin, Ireland DeGuire, Jr., Arthur, H., ST5000, Chesterfield, Radford, Karrie, M., FO5010, Whitehorse, Canada be posted on the seminar website as it MO, USA Rallo, Nicolas, MO5030, Montreal, PQ, Canada becomes available. Falsina, Alessandro, AO5027, Crema, CR, Italy Rynerson, Eric, A., ST4997, Prescott, AZ, USA The ISASI 2004 Organizing Com- Fogg, Larry, L., MO5022, Los Angeles, CA, USA Sin, Hyon, S., MO5018, Chun Chon, Korea Franklin, Bryan, S., ST5032, Glendene, Auckland, Smith, Aaron, G., ST5001, Prescott, AZ, USA mittee has been inundated with offers New Zealand Stahly, Joshua, R., ST5031, Grand Forks, ND, USA of quality papers for this year’s semi- Graves, Nathan, B., ST5020, Daytona Beach, Steel, James, F., ST4998, Prescott, AZ, USA FL, USA Tsachiridis, Paul, MO5026, Brossard, PQ, Canada nar, with submissions outnumbering Hedlund, Lars, AO5029, Ljungbyhed, Sweden Vickers, Denise, A., AO5017, Prescott, AZ, USA the available speaker slots by more Ingram, G. Michaelle, ST5002, Daytona Beach, Westbrook, Matthew, B., ST5005, Hammondsport, than two to one. As a result, the ISASI FL, USA NY, USA Johnson, Clinton, O., MO5006, Anchorage, AK, USA Wischmeyer, Ed, AO5003, Prescott, AZ, USA 2004 program offers an enticing array Kaltenegger, Jorg, A., AO5008, Coraopolis, PA, USA Yeroolt, Sedjay, AO5011, Ulaanbaatar, Mongolia of stimulating papers from a diverse

26 • ISASI Forum April-June 2004 INVESTIGATE, COMMUNICATE, EDUCATE—2004 August 30–September 2 • A professional training seminar presented by ISASI

Name: ______ISASI No. ______Organization: ______Address: ______Tel. (Hm): ______Tel. (Bus): ______Tel. (Cell): ______E-mail Address: ______Name & title on badge: ______Companion’s name on badge: ______

Please check appropriate box (Please note, all fees are shown in Australian dollars):

Registration by July 10 Registration after July 10 Full Seminar & Function Member K $625 K $700 ISASI Student Member K $500 K $550 Non-member K $750 K $800

Single Day Tuesday K $250 K Student $100 K $250 K Student $100 Wednesday K $250 K Student $100 K $250 K Student $100 Thursday K $250 K Student $100 K $250 K Student $100

Tutorials Interviewing K $85 K $100 Communicating and Educating K $85 K $100

Companion Program K $350 K $400 Post-Seminar Function K $100 K $125 Subtotal: ______Total Amount Due: ______Special Meal Requests (Vegetarian, Halal, Vegan, Kosher, etc.): ______Credit Card Type (Visa, MasterCard, Bankcard): ______Credit Card Number: ______Expiration Date: ______

If paying by credit card, fax to: Lindsay Naylor +61 2 6255 4413 or Paul Mayes +64 9 256 3911 If paying by money order or check, please send to: ASASI, P.O. BOX 588, Civic Square, ACT 2608 Australia For assistance, contact: Lindsay Naylor +61 2 6241 2514 E-mail: [email protected] Cancellations made before July 10, 2004, will incur a $10 processing fee Cancellations made between July 11–August 10, 2004, will incur a $75 administration fee There will be no refunds for cancellations after August 10, 2004

April-June 2004 ISASI Forum • 27 ISASI ROUNDUP Continued . . .

Reachout Reaches Mexico

Mexico City was the venue for the the Reachout workshop and instruc- Continental Airlines, which provided January ISASI Reachout program, tors. Instructors were Caj Frostell and instructor travel, and by MAS Air, which was hosted by ASPA, the Ron Schleede for the two-and-a-half- which provided financial support for Mexican Air Line Pilots Association. day accident investigation session and the program. In addition, the Air One hundred and thirty partici- Jim Stewart and Dick Stone for the Line Pilots Association, International pants representing the full spectrum two-and-a-half-day safety management provided staff time and administra- of civil aviation safety, including system session. tive support as did ICAO. Because of airline pilots, pilot association Instructors prepared their own the work of local hosts in obtaining officials, air traffic controllers, training materials consisting of paper sponsorship, no funds were ex- airport managers, maintenance handouts, CD-ROM libraries, and pended from the Reachout account. personnel, and flight attendant published manuals and booklets. Once again, the support of ICAO safety officials attended the work- ICAO provided numerous documents was critical in establishing the shop. The director of investigations that were shipped from its headquar- credibility of the workshop. The for the Mexican DGCA and an ters in Montreal. These included ICAO Regional Office had distrib- ICAO Regional Office operations Spanish-language copies of the latest uted the notification and registra- specialist also attended. Most of the accident prevention and investigation tion forms for the workshop to its representatives were from Mexico; documents. Each participant received mailing list in the region. N however, there were several repre- copies of documents and CD-ROMs sentatives from other countries, with considerable background materi- including Argentina, Belize, Costa als for future reference. Rica, and Trinidad, among others. The hosts produced delegate The program included a 5-day products, such as nametags. The ISASI Reachout workshop consist- workshop certificate for each delegate ing of accident investigation and was developed by ISASI Reachout and prevention, and safety management the hosts and was produced locally on topics. Instructors came from the high-quality manuscript paper. United States and Canada. The Local sponsorship was provided and deputy regional director of ICAO managed by ASPA, including most air José Diaz de la Serna, ICAO NACC (Mexico City) made opening and travel for instructors, local ground Regional Office, addresses the group welcoming remarks. Ron Schleede, transportation, instructor lodging, as Reachout team looks on. Shown, ISASI vice-president, welcomed the workshop administrative support, and left to right, are Ron Schleede; Jim participants on behalf of the refreshments. Sponsorship for ISASI Stewart; Richard Stone; Capt. Carlos president, ISASI, and introduced Reachout was also obtained from Arroyo, ASPA; and Caj Frostell.

Avis has opted for a sponsorship role Lederer Award Nomina- in accident investigation. and will offer ISASI 2004 participants The nomination process allows any discounted auto rental fees. More tion Deadline Nears member of ISASI to submit a nomi- information about this can be found The ISASI Awards Committee Chair- nation. The nominee may be an on the ISASI 2004 website. man Gale Braden reminds all mem- individual, a group of individuals, or The ISASI 2004 program will set the bers that the nominations for the 2004 an organization. The nominee is not stage for a stimulating and rewarding Jerome F. Lederer Award must be required to be an ISASI member. The professional seminar, and the Organiz- received by the end of May. The nomination may be for a single ing Committee looks forward to purpose of the Jerome F. Lederer event, a series of events, or a lifetime welcoming you to Australia’s Gold Award is to recognize outstanding of achievement. The nomination Coast this August. N contributions to technical excellence letter for the Lederer Award should

28 • ISASI Forum April-June 2004 IN MEMORIUM

Charlie Pocock (MO0257) reports in Afghanistan and Iraq, show the involved in the United States certifica- the death of Gus Economy helicopters not burning on impact, tion efforts when the Concorde was (LM2484) on Jan. 14, 2004. He was as in previous wars. This dramatic first introduced into the United States, the 1997 Jerome F. Lederer Award difference is due in very large provided an excellent overview of that recipient and is survived by his wife, measure to the use of less-flam- process. Jane. Memorial services will be held mable fuel and hydraulic fluid The PNRC will be continuing its Sunday, July 18, 2004, at the pushed so hard by Gus and also to technical meetings on alternate Cortner Chapel on Brookside the Army’s adoption of the crash- months throughout 2004, except for Avenue in Redlands, Calif. Gus was worthy fuel systems pioneered by August and December. Guests from an acknowledged expert in fire and Dr. S. Harry Robertson (MO0262), other regions or individuals interested explosion investigations. He was Lederer Award winner in 1981. in aviation safety are always invited to untiring in his efforts to convince Other ISASI members who have attend any of the Chapter meetings. the Air Force (and the Army) to made the final flight west include: Details on the exact times and loca- abandon JP-4 in favor of the much- Dr. Lothar v.B. Schmidt (LM0189), tions for these presentations can be less-hazardous JP-8 jet fuel (very March 6, 2003, Los Angeles, obtained directly from Chapter similar to Jet A). He also spear- Calif., USA President Kevin Darcy at kdarcy@ headed the development, testing, Richard Ross (AO3318), June 25, safeserv.com or from Leo Rydzewski at and eventual adoption by the U.S. 2003, aircraft crash, Sedgwick, [email protected]. N military of Mil H-83282 (less Kans., USA flammable) hydraulic fluid instead George I. Whitehead, Jr. (LM0603), MARC Donates to of Mil H-5606. The value of his Sept. 14, 2003, Conroe, Tex., USA work is evident as scenes of Army Najeeb E. Halaby (HO0002), July 2, Scholarship Fund helicopters, shot down or crashing 2003, McLean, Va., USA N As the result of the exceptional sup- port of ISASI corporate members and the excellent turnout of delegates for be limited to a single page. except Secretary Keith Hagy have the ISASI 2003 international seminar, Nominations should be mailed or e- expressed a willingness to serve MARC was able to donate $6,000 to mailed to the ISASI office, 107 Holly another term and have been nomi- the ISASI Rudolf Kapustin Memorial Ave., Suite 11, Sterling, VA 20164-5405 nated. Other nominations include for Fund, reported Ron Schleede, Chapter USA; e-mail address: isasi@erols. com; vice-president, Capt. John M. Cox president. He said, “Rudy kept MARC or send directly to the Awards Commit- (MO3291) US Airways (ALPA). N viable for many years and he would be tee Chairman, Gale Braden, 2413 proud that our Chapter was able to Brixton Road, Edmond, OK 73034 PNRC, NAIA Hold provide support for the promotion of USA; e-mail [email protected]. N accident investigation education for Joint Meeting students, who receive the scholarship The Pacific Northwest Regional Chap- support to attend annual seminars. Election Nominations ter had ISASI member Chuck Foster, a Hopefully, other organizations and Closed; Most Incumbents former FAA associate administrator, ISASI members will consider contribu- Nominated speak at a February joint meeting with tions to this very worthwhile program.” the Northwest Aviation Insurance Continued funding for the Memorial The ISASI Nomination Committee Association. The meeting was held at Fund is through donations, which in announced that Call for Nominations Seattle’s Museum of Flight, which re- the United States are tax-deductible. for the ISASI Executive Officer and cently received a Concorde as a dona- Contributions may be sent to ISASI, Councillor positions for the years tion from British Airways. This aircraft 107 Holly Ave., Suite 11, Sterling, VA 2005-2006 closed on April 1, 2004. is one of only 20 ever built and is the 20164-5405 USA. The positions to be filled are presi- only one on display on the West Coast. Schleede also reported that MARC dent, vice-president, secretary, trea- The meeting was well attended by will be hosting its annual dinner/ surer, U.S. councillor, and interna- both members and guests of both meeting on May 6, 2004, to coincide tional councillor. All incumbents organizations. Chuck, who was heavily with the International Council meeting

April-June 2004 ISASI Forum • 29 ISASI ROUNDUP Continued . . .

being held on May 5, 6, and 7. MARC officers and others are planning to UPCOMING EVENTS convene additional Chapter meetings in the future; however, volunteers are • ISASI 2004 Gold Coast, Austra- • Embry-Riddle Safety Sympo- needed to assist with the planning and lia, Aug. 30-Sept. 2, 2004 sium, July 14-15, 2004. Theme— organization, he noted. N • ISASI 2005 Ft. Worth, Tex., USA “Lessons Learned from Safer Skies: • The University of North Dakota Enhancing Safety Above and Below ATSWG Sets Agenda for (UND) and ALPA present a 3-day the Wing.” Location: American aircraft accident investigation course Airlines Training and Conference Australia Meeting to be held June 14, 15, 16, 2004. Center, Dallas, Tex. Further infor- The Air Traffic Service Working Group Location: Grand Forks International mation: www.avsaf.org. continues to quietly develop coopera- Airport, 5 miles west of Grand Forks, • 57th Annual International Air tive networks around the world. For N.D. Further information: www.aero. Safety Seminar, Nov. 15-18, 2004. the first time in many years it will hold und.edu/AccidentCourse/Index.htm. Location: Pudong Shangri-La a group meeting in Australia during • Annual Flightscape Users Hotel, Shanghai, China. ISASI 2004. “This 2004 conference Conference June 23-24, 2004. Further information: Ann Hill represents an opportunity for reassess- Location: Ottawa, Canada. Further [email protected] or ment of the ATSWG objectives and the information: www.flightscape.com. 1-703-739-6700. N chance to realign the group’s targets for the coming year,” said Group Chairman John Guselli. the efficiency and value of investigative Flight 261 off the coast of southern He added, “The fundamental tasks, such as the development of California. He was also instrumental in component of any progressive safety process hazard analyses; accident and the painstaking reconstruction of the program is one of ongoing profes- incident investigation; investigation wreckage of TWA 800, which exploded sional development. For this reason, quality assurance; change manage- in July 1996 off Long Island, N.Y. The we are fortunate that Vice-Chairman ment; and recommendation develop- reconstruction will be used to teach Ladislav Mika has commenced the ment, evaluation, documentation, and accident investigation techniques to planning of a review of the peculiar communication. Outputs have mul- students at the NTSB Academy in skills required by an ATS investigator. tiple uses in organizations. Starline Ashburn, Va. Goglia’s NTSB safety The review of these skills will form the Software, Ltd., has released the new legacy also includes leading a drive for basis of our collective presence at product. A preview of the main more-compassionate treatment of the ISASI 2004. It will also enable the features and trial version of the families of victims of air accidents. whole group to become familiar with software for Macs is available online at NTSB Chair Ellen G. Engleman was contemporary developments in the http://www.starlinesw.com. N honored for implementing a SWAT field of ATS investigation with inputs (“Safety with a Team”) effort aimed at from the broad membership.” Aviation Week Awards quickly closing a long list of safety ATSWG seeks any constructive recommendations. In December 2003, advice from any ISASI members prior NTSB 2003 Laurels the Board reported that the number of to the meeting at ISASI 2004. N John J. Goglia, a long-term ISASI open recommendations had dropped member, was honored by Aviation Week to below 1,000 for the first time since New Investigation Tool and Space Technology magazine for his 1975. contributions to aviation safety as an Shortly after Engleman was ap- Becomes Available NTSB member from 1995-2004. His pointed in March 2003, she led a Ludwig Benner (WO2202) has been association with the NTSB will halt critical agency self-analysis focused on instrumental in the software develop- with the end of his term next month. finding improved efficiencies, includ- ment of new investigation-support Goglia was indefatigable in raising ing “cleaning up our recommenda- software that is based on his more than industry awareness to the importance tions.” To that end, the SWAT strategy 25 years of investigation process of maintenance in air safety, as evi- was applied. The Board and the FAA research. His work incorporated into denced in the Board’s investigations of joined forces, and now periodically the Investigation Catalyst is a set of self- the January 2003 crash of Air Midwest Transportation Department and directing software tools and procedures Flight 5841 in Charlotte, N.C., and the industry representatives address open that enable investigators to improve January 2000 crash of Alaska Airlines recommendations. N

30 • ISASI Forum April-June 2004 Benefits of Individual ISASI Membership

About You provide our corporate members an opportunity to directly You are an air safety professional. You may work for an airline, affect safety in those areas where it will have the greatest return. a manufacturer, a government, the military, an operator, or on your own. But you are a person who is dedicated to im- • The ISASI publication, FORUM, is a first-class magazine, provement of aviation safety and you joined ISASI with the published in color four times a year. Its editorial content expectation of enhancing the achievement of that goal. emphasizes accident investigations findings, investigative techniques and experiences, regulatory issues, industry About ISASI accident prevention developments, and member involvement ISASI is the only organization specifically for the air safety and information. Each issue also features one of our corporate investigator. Our motto is “Air Safety Through Investigation.” members in a full back-page “Who’s Who” article. We are a growing, dynamic organization with a full range of membership. • The annual seminar-published Proceedings are provided to individual members at no cost on line. Why Join? Lots of reasons—activities, education, services, and networking • Individual members have access to past ISASI publications, our library, and accident database. • The yearly ISASI seminar has become a focal point for aviation safety professionals throughout the world. Attendance • ISASI now has an easily accessible website, www.isasi.org, has steadily grown and the presentations are state of the art with an extensive “Members Only” information section and a and meaningful. The 2002 seminar was held in Taipei, Taiwan, limited general public area. and the 2003 seminar was held in Washington, D.C., celebrat- ing the 100th anniversary of flight. • Our corporate and individual members are a large and diverse group working in all facets of the industry worldwide. • The new Reachout seminar program was instituted to provide This presents a unique opportunity for personal and on-line low-cost, subject-oriented seminars in regions of the world with networking. higher accident rates. Since the first Reachout held in Prague, Czech Republic, in May 2001, there have been nine Reachout ISASI is the place for those dedicated seminars, some of which were held in Lebanon, Chile, India, to improving aircraft accident investigation Sri Lanka, Tanzania, and Costa Rica. All have been an unquali- fied success in attendance and content. These mini-seminars and aviation safety.

PREAPPLICATION FOR INDIVIDUAL MEMBERSHIP (Cut and mail to the address below or otherwise contact ISASI to receive a full membership application.)

PLEASE PRINT investigators who do not yet fulfill the requirements for member. K Affiliate Member—A public, non-professional membership class for Name (last, first) ______persons who support ISASI’s goals and objectives. J Student Member—A membership class for students who support Date of birth ______ISASI’s goals and objectives. (If student, list name of institution where enrolled______.) Home address ______

City ______Present employer ______

State, district, or province______Employer’s name ______

Country ______Address and telephone ______

Postal zip/zone ______Did your position involve aircraft accident investigation? J Yes J No

Home telephone ______Your title or position: ______

Citizen of (country) ______Dates: from:______to ______

E-mail address (optional) ______INTERNATIONAL SOCIETY OF AIR SAFETY I AM INTERESTED IN APPLYING FOR SOCIETY INVESTIGATORS MEMBERSHIP IN THE MARKED MEMBERSHIP Park Center CLASSIFICATION. PLEASE FORWARD TO ME A FULL 107 East Holly Avenue, Suite 11 MEMBERSHIP APPLICATION. Sterling, VA 20164

K Member—A professional membership class requiring at least 5 Telephone: 703-430-9668 years’ active experience as an air safety investigator. Fax:703-430-4970 K Associate Member—A professional membership class for air safety E-mail: [email protected]

April-June 2004 ISASI Forum • 31 WHO’SWHO’S WHOWHO

Flight Safety Foundation’s Role in Aviation Safety (Who’s Who is a brief profile on an ISASI cite FSF reports as background for operations. In the informal and neutral corporate member to enable a more thor- official accident investigation reports. environment of the seminars, the best ough understanding of the organization’s The seven regularly published FSF minds in aviation can exchange infor- role and function.—Editor) periodicals contain no paid advertising, mation and provide clear direction for and the material they present is prized the further reduction of risks in avia- ince its official founding in 1947, because readers rely on the publica- tion. The Foundation publishes pro- the Flight Safety Foundation tions’ accuracy and objectivity. Original ceedings of its seminars so that aviation S(FSF) has been a catalyst for the articles in these periodicals provide in- professionals worldwide can share the continuous improvement of aviation depth examinations of important valuable information and ideas ex- safety. The Foundation is an indepen- changed at these meetings. dent, nonprofit international organiza- The International Air Safety Semi- tion that provides a neutral forum in nar (IASS), begun in 1947, is held in which the aviation industry can meet selected cities worldwide to ensure in a noncompetitive environment to contact with the international aviation identify safety concerns, determine community. The IASS typically draws solutions, and implement ideas and as many as 600 representatives of actions to improve safety. aviation safety issues and are based on organizations from 50 or more coun- Often referred to as the “conscience the most current information from a tries. Since 1992, the IASS has been of the industry,” the Foundation has variety of resources, including aviation conducted as a joint meeting with the contributed significantly to the evolu- specialists, government reports, inde- International Federation of Airworthi- tion of aviation safety and the saving of pendent research, and academia. To ness (IFA). Since 1995, the meeting lives. The Foundation occupies a ensure wide dissemination of this infor- also has included the International Air unique position among the many mation, FSF publications, since 1988, Transport Association (IATA). organizations that strive to improve are available to everyone at the Founda- The European Aviation Safety aviation safety standards and practices tion’s Internet site, www.flightsafety.org. Seminar (EASS) was established in throughout the world. Effectiveness in Perhaps the best known among the 1989. Similar in format to the IASS, it bridging cultural and political differ- Foundation’s activities are its three addresses the safety challenges of ences in the common cause of safety annual safety seminars. These seminars aviation growth in Europe. Since 2000, has earned the Foundation worldwide constitute major gatherings of aviation the EASS has been co-presented by the respect. Engaged in research, auditing, professionals and are designed for European Regions Airline Association education, advocacy, and publishing to decision-makers in government, indus- (ERA) in different cities throughout improve aviation safety, the Founda- try, and academia—people charged the continent. tion currently has about 900 members with the responsibility to influence The Corporate Aviation Safety Semin- from more than 145 countries. The safety in design, manufacture, develop- ar (CASS) is held annually in North FSF membership roster represents a ment, training, maintenance, and America. N “who’s who” of industry leaders from airlines, airframe and engine manufac- turers, corporate operators, suppliers, ISASI NON-PROFIT ORG. insurance companies, regulators, and 107 E. Holly Ave., Suite 11 U.S. POSTAGE PAID many other organizations. Sterling, VA 20164-5405 USA Permit #273 Aviation professionals, the aviation ANNAPOLIS, MD press, and respected mainstream newspapers and magazines rely on FSF publications for clear and accurate information on aviation safety. Member airlines often reprint FSF articles for distribution to their management, flight crews, cabin crews, and maintenance personnel; and government authorities

32 • ISASI Forum April-June 2004