Lessons Learned from Commercial Airplane Accidents

Air Safety Through Investigation JULY-SEPTEMBER 2016 Journal of the International Society of Air Safety Investigators

Page 4 Challenges of Sea Search-and-Recovery Operations

Page 12 The Rogue Pilot Phenomenon

Page 17 Lessons Learned From Commercial Airplane Accidents

Page 18 Modern Technologies and Methodologies Improve Helicopter Accident Investigation

Page 24 ‘Independence Does Not Mean Isolation’: A Practical Approach CONTENTS

Air Safety Through Investigation Journal of the International Society of Air Safety Investigators FEATURES Volume 49, Number 3 4 Challenges of Sea Search-and-Recovery Operations Publisher Frank Del Gandio Editorial Advisor Richard B. Stone By Tatang Kurniadi, Chairman, Indonesia National Transportation Safety Esperison Martinez Committee, and Ng Junsheng, Accident Investigator, Air Accident Investigation Editor Bureau of Singapore—The authors detail the challenges faced by the search team Design Editor Jesica Ferry and the excellent cooperation among the international specialists in the successful Associate Editor Susan Fager sea search-and-recovery operation of the AirAsia Indonesia A320 aircraft operating ISASI Forum (ISSN 1088-8128) is published quar- as Flight QZ8501. terly by the International Society of Air Safety 12 The Rogue Pilot Phenomenon Investigators. Opinions expressed by authors do not necessarily represent official ISASI position By Thomas Anthony, Director, Aviation Safety and Security Program, Viterbi or policy. School of Engineering, University of Southern California—The Germanwings crash has brought the rogue pilot phenomenon to the front and center of aviation Editorial Offices: Park Center, 107 East Holly safety attention. The author adds two additional perspectives to the inquiry into a Avenue, Suite 11, Sterling, VA 20164-5405. Tele- potential rogue pilot investigation: the perspective of a profiler of criminal behav- phone 703-430-9668. Fax 703-430-4970. E-mail ior and the psychological elements of acts of murder-suicide. address, [email protected]; for editor, espmart@ comcast.net. Internet website: www.isasi.org. 17 Lessons Learned From Commercial Airplane Accidents ISASI Forum is not responsible for unsolicited manuscripts, photographs, or other materials. By Daniel I. Cheney, U.S. Federal Aviation Administration—Through creation of a Unsolicited materials will be returned only if web-based safety knowledge system, the FAA has created a tool to help guard against submitted with a self-addressed, stamped enve- complacency and loss of costly safety knowledge. lope. ISASI Forum reserves the right to reject, 18 Modern Technologies and Methodologies Improve Helicopter delete, summarize, or edit for space con- Accident Investigation siderations any submitted article. To facilitate editorial production processes, American Eng- By Dr. Thomas Gogel and Seth Buttner, Airbus Helicopters; and Dr. Marcus lish spelling of words is used. Bauer, MSimulation—The Vision 1000 cockpit image and data recorder was developed as standard equipment in Airbus Helicopters helicopters but outside the Copyright © 2016—International Society of Air regulatory requirements, resulting in simplified certification and much lower costs. Safety Investigators, all rights reserved. Publica- 24 ‘Independence Does Not Mean Isolation’: A Practical Approach tion in any form is prohibited without permission. ISASI Forum registered U.S. Patent and By Johann Reuss, German Federal Bureau of Aircraft Accident Investigation— T.M. Office. Opinions expressed by authors do Due to the complexity of modern aviation, a safety investigation requires a maxi- not necessarily represent official ISASI position mum involvement of manufacturers, airlines, and pilots. or policy. Permission to reprint is available upon application to the editorial offices.

Publisher’s Editorial Profile: ISASI Forum is print- DEPARTMENTS ed in the United States and published for professional air safety investigators who are members 2 Contents of the International Society of Air Safety Inves- 3 President’s View—Taking the Next Step in Cyberspace—The Webinar tigators. Editorial content emphasizes accident 30 ISASI Information investigation findings, investigative techniques 32 Who’s Who—ATR: A Regional Turboprop Aircraft Manufacturer Leader and experiences, regulatory issues, industry accident prevention developments, and ISASI and member involvement and information. ABOUT THE COVER Subscriptions: A subscription to members is provided as a portion of dues. Rate for nonmem- The first fatal accident investigation benefiting from the data captured with bers (domestic and Canada) is US$28; Rate for the Vision 1000 cockpit imaging and flight data recording device involved the nonmember international is US$30. Rate for all Alaska state troopers’ AS350 B3 helicopter (N911AA), which crashed in the libraries and schools is US$24. For subscription Talkeetna Mountains of the Alaska Matanuska–Susitna region. The Vision information, call 703-430-9668. Additional or 1000 system is a flight data, audio, and cockpit image data recorder. It captures replacement ISASI Forum issues: Domestic and pilot/crew actions and behaviors during flight, manipulation of flight controls Canada US$4; international member US$4; do- and systems, noise, and even a view of weather/visibility conditions. The system mestic and Canada nonmember US$6; interna- features a forward-facing image acquisition of the cockpit, audio recording tional nonmember US$8. (ambient noise and intercom system), GPS position data, and an inertial measurement unit to record attitude. The unit weighs 300 grams. A removable memory can store four hours of image and audio and 200 hours of inertial data (position and attitude). The hardened internal memory is capable of storing two hours of image and audio and 200 hours of inertial data (see page 18). INCORPORATED AUGUST 31, 1964 2 • July-September 2016 ISASI Forum PRESIDENT’S VIEW

TAKING THE NEXT STEP IN CYBERSPACE THE WEBINAR By Frank Del Gandio, ISASI President

n March, I was very fortunate and opted for Skype instead of Cisco Webex™ the group was listening so ardently. pleased to participate in the first for our talk on the TWA Flight 800 crash But it was even more jaw-dropping webinar sponsored by the Pakistan Air investigation. It was determined after a to hear Frank revisiting memories from IForce’s College of Aviation Safety Man- few attempts that both sides were getting 20 years ago with such fastidiousness. agement (CASM). The event was so well “conversant” with using Skype. The date It looked as if he was reading it out of a orchestrated, presented, and received decided for the webinar was March 1, book! As soon as the “official” version of using Skype that I’m convinced webinars 2016. Time was always a concern, as we the investigation ended, there was a flurry could well find their way into ISASI’s were halfway across the world and sought of questions. Some were regarding the future planning. The following narrative a comfortable instance for both parties: proceedings and difficulties faced in the by Squadron Leader Fahad Masood (MO 0900 hours “Frank” time and 1900 hours investigation, but most of them revolved 6756), CASM instructor and producer of “CASM–Pakistan” time was selected. around the conspiracy theories that the webinar, describes its development surrounded the “organizational event.” and presentation. “D-Day” But as a seasoned investigator, Frank was Finally, the day arrived. Tuesday, March 1. able to grapple with every question very Background We were online, ready and waiting at 1800 heartily and satisfied each participant before moving on to the next one. Every It all started with Frank Del Gandio, ISASI hours CASM–time. With the exactitude of single “theory” was discussed, including president, and Caj Frostell, international an atomic clock, Frank was bang on the an F-18 shoot-down via air-to-air missile, dot. Fifteen minutes prior to start time, councillor, visiting CASM (previously cosmic catastrophe, electromagnetic we had a trial run of the main event. That called the Institute of Air Safety–IAS) at interference, etc. The session culminated PAF Base Masroor in Karachi, Pakistan, successfully behind us, we had the class with a standing ovation and a round of in 2015. We had a fruitful discussion with of the 70th flight safety officers course applause for Frank—with Frank thanking the participants of the 69th flight safety seated and anxiously awaiting to inter- the audience for patiently listening. officers course. Both visitors shared their mingle electronically with Frank. The 28 experience on and off the “playing field” participants included the Pakistan Air Parting words regarding aviation safety and investiga- Force, Army, Navy, and the allied nations It was heartening to see the vision of the tions. While sitting in the officer com- of Myanmar, Sri Lanka, Bangladesh, and officer commanding and faculty to have manding office—Air Commodore Noor Saudi Arabia. “healthy discussion and interaction on After the initial ritual salutations, Frank Elahi Bajwa, SI(M)—over a “cup o’ tea,” it the international scale” become reality. shared his rich experience regarding his was undertaken with mutual consent that Candidly speaking, this was the first step time with the FAA and the NTSB. Then Frank and Caj would become a part of an toward achieving a global audience/ came the crux of the matter, the TWA ambitious webinar program of CASM. interaction for our college. The journey of Flight 800 crash investigation. During the CASM in this vast arena of cyberspace The buildup morning classes, we showed the National Geographic crash investigation of the known as webinars had just begun! With With the acquisition of an upgraded CPU event to participants for better compre- the efforts of the facilitators of learning and Internet connection, we stepped up hension of the planned evening webinar. and vision of the leader, we intend to gain our preparation to go “international.” Af- The group earnestly listened to what and share the light of enlightened ter tedious efforts and painstaking paper- Frank had to say about his experience learning throughout the world! We thank work, we were finally ready. The contact for about 40 minutes to an hour and had and look forward to more interaction with Frank was reestablished via e-mail multiple questions already jotted down with experienced ISASI members be- at first and through Skype second. Having for the end Q&A session. It was over- cause…“There is no substitute of hours no requirement of a presentation, we awing for us, the facilitators, to see that (experience)!”

July-September 2016 ISASI Forum • 3 tigators, France (BEA): one investigator, and the United Kingdom (UK) (AAIB): one investigator. CHALLENGES OF SEA Management of sea search The NTSC carried out the sea search effort to recover SEARCH-AND-RECOVERY the flight recorders while the search-and-rescue (SAR) operation, led by the OPERATIONS Indonesia National Search By Tatang Kurniadi, Chairman, Indonesia National Transportation and Rescue Agency (BA- Safety Committee, and Ng Junsheng, Accident Investigator, Air SARNAS), was ongoing. The NTSC handled all coordi- Accident Investigation Bureau of Singapore nation between the underwater search team, BASAR- NAS, and other supporting agencies. The NTSC and the BEA investigators who Air Vice Marshal (Ret.) H. Ng Junsheng is an air accident were stationed on shore Tatang Kurniadi was the investigator with the Air Accident chairman of the Indonesian Investigation Bureau of Singapore. provided technical advice National Transportation Safety He was part of the team that and logistic support to the Committee from March 2007 performed the sea search for Flight underwater search team. to August 2015. He coordinated QZ8501’s flight recorders. He holds The Directorate General of the search for the flight recorders an aircraft maintenance engineer of Flight QZ8501. Previously, license and has performed heavy Sea Transportation (DGST) Kurniadi served in the maintenance and modifications of of Indonesia provided the Indonesian Air Force and held avionics systems on various aircraft crew and two vessels from numerous staff command positions. types. which the underwater search team operated. (Adapted with permission from the authors’ technical paper entitled Challenges of Sea Search-and-Recovery Forty-five divers from the Operations—Sharing of Experience From a Recent Joint Operation presented at ISASI 2015 held in Augsburg, Indonesian Navy performed Germany, Aug. 24–27, 2015, which carried the theme “Independence Does Not Mean Isolation.” The full presentation, dive operations to retrieve including cited references to support the points made, can be found on the ISASI website at www.isasi.org under the the flight recorders. tag “ISASI 2015 Technical Papers.”—Editor) The underwater search team’s equipment included directional underwater locator beacon (ULB) detec- THE AUTHORS DETAIL THE CHALLENGES FACED tors—five sets (two from the BY THE SEARCH TEAM AND THE EXCELLENT AAIB Singapore, two from the NTSC, and one from the COOPERATION AMONG THE INTERNATIONAL CAAC); an omnidirection- SPECIALISTS IN THE SUCCESSFUL SEA SEARCH- al ULB detector—one set (the UK AAIB); side-scan AND-RECOVERY OPERATION OF THE AIRASIA sonars—two sets (the MPA); INDONESIA A320 OPERATING AS FLIGHT QZ8501. remotely operated vehicles (ROV)—one set (the MPA); and omnistar differential GPS units—three sets (the MPA). n Dec. 28, 2014, radar contact with an the Air Accident Investigation Bureau (AAIB) of AirAsia Indonesia A320 operating as Singapore to locate the flight recorders of the Predeployment events Flight QZ8501 was lost. The Indonesia aircraft. The Maritime and Port Authority of The AAIB-MPA team and ONational Transportation Safety Commit- Singapore (MPA) supported the AAIB team with the UK AAIB investigator tee (NTSC), Indonesia’s accident investigation marine underwater survey capabilities. traveled on a Republic of authority, coordinated the sea search effort to The AAIB-MPA team was composed of four Singapore Air Force C-130 locate and recover the flight recorders of the AAIB investigators and six MPA hydrograph flight to Tanjung Pandan aircraft. The next day NTSC Chairman Tatang specialists. The remaining overall underwater in Pulau Belitung, Indone- Kurniadi accepted the offer of assistance from search team included China (CAAC): three inves- sia. Clearing Customs and

4 • July-September 2016 ISASI Forum Immigration smoothly, localize the presence of the ULB ping sig- be performed. they met up with the NTSC nal. This would be followed by the deploy- A BEA investigator who was attached to the and BEA investigators ment of the side-scan sonar to pinpoint the NTSC headquarters in Jakarta and who had re- and received a prelimi- source of the ULB ping signal. viewed the Jakarta radar information recommend- nary briefing from NTSC’s The weather conditions in the targeted ed to the underwater search team to concentrate representative in charge search area were forecasted to be stormy with the search in a six kilometer x six kilometer area of the search for the flight a sea state of two to four until January 5. The centered on the last-known radar position (this recorders. investigators from the UK AAIB and the BEA area is hereinafter referred to as Location 1). This The underwater search advised that for a sea state above two, the un- recommendation was based on an analysis of team met and discussed derwater current would produce noise, which ADS-B data derived from a surveillance technology the following: would prevent effective use of the ULB detec- in which an aircraft determines its position using • The coordinates of tion systems. satellite technology and periodically broadcasts the start point for In view of the forecasted bad weather, the it, without pilot or external input, thus enabling it the search would be underwater search team determined that for to be tracked. The main wreckage was expected to 3.60861°S, 109.69611°E, the following days, they would not be able to be in the vicinity of the last-known radar position the last-known radar deploy. In view of the poor sea state condition, where the water depth was about 30 meters with position. The coor- the UK AAIB investigator departed for Jakarta visibility of less than one meter. dinates were derived to speak to the NTSC chairman to discuss if from Jakarta radar the NTSC would need the UK AAIB’s towed Deployment attempts information but with pinger array, which is effective in a sea state of secondary radar First attempt—On January 2, Jadayat and Androm- three to four with a towing speed of about five information taken into eda set sail at 0645 LT for Location 1. The journey account. According to knots He left the UK AAIB’s omnidirectional was expected to take 18 hours (see Figure 2, page the BEA investigator, ULB detector behind for the underwater search 6). However, at 0815 LT, Jadayat ran aground on a Russian study had team to use. a shoal while traveling along Kumai River toward concluded that in the On the evening of December 31, BASARNAS the Java Sea. It was decided not to wait for the next majority of accidents requested through the NTSC that the underwa- high tide (which would be around 1500 LT) for the involving loss of ter search team travel to Pangkalan Bun (PKN) vessel to be freed, so a tow boat was requested to control in flight, the in Kalimantan to evaluate capabilities of ships assist Jadayat. Andromeda continued heading to wreckage was usu- berthed at PKN’s Kumai Port (on the Kumai Location 1. At around 1145 LT, Andromeda in- ally found within a River) available for deployment. formed Jadayat that the sea state at her location, radius of 10 kilometers beyond the mouth of the river, was bad, with waves around the last-known Vessel allocation of three and a half to four meters high. The forecast radar position. Through the help of the Indonesia Transport for Location 1 was expected to be worse. Androme- • Based on this informa- minister, the DGST of Indonesia was asked to da turned back to Kumai Port for safety reasons. In tion, the team decided provide suitable vessels to support the under- view of this, Jadayat also returned to port after she that the initial search water search team. On the evening of January 1, was towed from the shoal at around 1330 LT. pattern would be a 12 the director of navigation of the DGST contact- kilometer x 12 kilo- ed his MPA counterpart, the director of port Second attempt—During the morning of January meter square around services/chief the last-known radar hydrographer, position provided by Jakarta radar. Omnidi- and offered rectional and direc- two buoy tional ULB detectors tender ves- would be used. sels, the KN Jadayat and • The distance between KN Androme- the intermediate points within the da (see Figure search grid would be 1), which were determined after the berthed at underwater search Kumai Port. team conducted a trial The man- to determine the op- power and timal detection range equipment of the ULB detectors on the two in the waters near the vessels were search area. distributed to • The team would allow two par- first deploy the ULB allel search Figure 1. KN Jadayat and KN Andromeda. detector to detect and operations to

July-September 2016 ISASI Forum • 5 3, the team received information that BASARNAS had identified an area with a high probability of finding the main wreckage (the area is hereinafter referred to as Location 2). It was defined by the following coordinates: 3.666667°S, 110.166667°E; 3.666667°S, 110.916667°E; 4.25000°S, 110.916667°E; and 4.25000°S, 110.166667°E. At this time, sonar scans performed by SAR assets in the area had identified a large object at 3.925556°S, 110.563056°E. An oil slick of unknown nature had been spotted within the area. An emergency slide, several other debris pieces, and a Figure 2. Journey from Kumai Port to Location 1. body had also been retrieved from the area. As the journey to Location 1 would pass not far from Location 2 (see Figure 2), the team decided to make a short de- tour to Location 2 in the next deployment attempt. Both vessels set sail at 1520 LT to catch the high tide to avoid running aground again. The team was joined by the director of navigation of the DGST for the mission. On January 4, at around 0415 LT, the team arrived at Location 2. However, the waves were more than four meters high, and the captain of Jadayat advised the team that it was not safe to deploy the omnidirectional ULB detector or side-scan sonar. At 0430 LT, both vessels turned back and headed toward the es- tuary of Kumai River. At around 1130 LT, both vessels were anchored near the estu- ary. On January 5, after some discussions around 0430 LT, both vessels returned to Kumai Port for resupply of logistics and refueling to ensure maximum endurance Figure 3. Search team using the directional ULB detector for ping signal out at sea for the next deployment at- detection. tempt as soon as the weather improved.

Third attempt—On January 6, the BEA investigator left Jadayat to go to Jakarta to assist the NTSC headquarters to coordinate the search efforts. Meanwhile, prior to setting sail from Kumai Port on Janu- ary 6, the underwater search team was advised that BASARNAS had confirmed that the objects found in Location 2 were not aircraft parts. Thus, the team decided to proceed to Location 1 directly. The next day they were joined by three investigators from the CAAC of China who were transported to Andromeda by the coast guard vessel Alugara. In addition, the Figure 4: Results from hydrophone listening on January 7. search team was informed that a team of Russian divers had arrived and deployed on another vessel to assist in the underwater recovery of the flight recorders.

6 • July-September 2016 ISASI Forum While enroute to Location 1, the team that sounded similar to a ULB’s ping sig- identified by the MPA team. The coordi- received information that the tail section nal at their first four locations. They did nates of this northern point were then of the aircraft had been located about not hear the ping signal when listening passed on to the naval divers. (Dive opera- three kilometers southeast of the last- from another four listening locations tions are detailed in another section.). known radar position. This tail wreckage thereafter. was within Location 1, giving added Locating flight recorders using autonomous confidence that the recorders could be Sonar scanning of seabed—At about underwater vessel—On January 9, at 1030 found within that location. The team 1755 LT, the MPA specialists on Jadayat LT, two AAIB investigators and three MPA members decided that they would first detected significant sonar contacts on the specialists boarded the vessel KN Trisula perform hydrophone listening in the seabed (see Figure 5). The contacts were to join a team of Java offshore oceanic central three kilometer x three kilometer scattered over an area of 100 meters x surveyors who were on board with a area of Location 1, i.e., the three kilometer 40 meters, and the largest object detect- Teledyne Gavia autonomous underwater x three kilometer area centered on the ed was about 15 meters x 3 meters x 3 vehicle (AUV). The AUV could perform last-known radar position. On January 7, meters. The spread and reflectivity of the side-scan sonar, multibeam sonar, and at around 0715 LT, after sailing for more sonar contacts suggested the presence take photos simultaneously. An AUV scan than 16 hours, Jadayat and Andromeda of an aircraft debris field. This suspected was performed in a 250 meter x 200 meter arrived at Location 1 where the sea state debris field was about 460 meters north of search area covering the main debris field was relatively calm. the estimated source position of the ping and the two possible ULB locations of the signals provided by the search team. recorders mentioned above. The data gathered by the AUV proved Locating the flight recorders Second round of ULB ping signal detec- unsatisfactory. The mission was in- Initial round of ULB signal detection—At tion—In view of the conflicting results complete, and photos were not useable around 0800 LT, an NTSC investigator reached by the investigators on board because the AUV had carried out the and the AAIB team boarded a motorized Jadayat and Andromeda, three investiga- scanning about three meters above the wooden boat launched from Jadayat, tors on board Jadayat performed another seabed where the visibility was poor (vis- bringing along the omnidirectional ULB round of hydrophone listening on January ibility range was about one half meter to detector and the directional ULB detec- 8, focusing on the debris field identified one meter, and the AUV was not equipped tor. The omnidirectional ULB detector by the MPA team. When the three inves- with lights). malfunctioned so the directional ULB tigators completed the second round of However, the underwater search team detector was used (see Figure 3). hydrophone listening, they confirmed the was told that Java Imperia, an oceano- At around 0830 LT, the team detect- presence of the two ping signals that they graphic survey vessel, was on its way to ed the first two ping signals. Two ping heard the previous day and further local- the search area and that it was equipped signals were heard at six other locations. ized the estimated position of the source with the Sonardyne ultra-short base line In all, the team spent about four hours of the ping signals. The flight recorder (USBL) system, which has ping signal performing hydrophone listening at 13 triangulation software suggested two detection capability. The ship also had locations to triangulate the ping signals. possible ULB locations, about 180 meters differential global positioning system The search team used the AAIB’s flight apart, the more northern of the two being capability and was equipped with an recorder triangulation software to derive, about 40 meters south of the debris field inertial navigational system. This would from the hydrophone listening results, an estimated position of the source of the ping signals (see Figure 4). This estimated source position was passed to the MPA specialists to plan their sonar scan. The MPA specialists scanned a three kilometer x three kilometer area centered on the estimated source position. Meanwhile, at around 1030 LT, Androm- eda recovered a body and debris found floating during the side-scan survey south of Location 1. At around 1200 LT, the CAAC investigators on Andromeda deployed in another motorized wooden boat to perform ULB ping signal detection using the directional ULB detector at a location about three kilometers southeast of Jadayat’s location. This was near the location of the tail section of the aircraft found earlier. Between 1245 LT to 1530 LT, the CAAC investigators detected a signal Figure 5. Side-scan sonar fish being lowered into the water.

July-September 2016 ISASI Forum • 7 recovered from the seabed about three kilometers southeast of Jadayat. The wreckage recovered included • the empennage section, less both horizontal stabilizers (placards indi- cating frames C70, C71, and C72 were seen). • aft galley furnishing. • part of the main deck extending up to six windows from the rear. • part of the aft cargo door. The underwater search team was informed that a team of 17 divers had previously searched the wreckage while it was still under water but could not find any flight recorders. On January 11, dive operations commenced at 0550 LT and continued until around 1030 LT. Additional divers from the Indonesian naval vessel Banda Aceh arrived, bringing the total number of Figure 6. Results from the AAIB and Java Imperia’s ping detection. divers to 45. The first detail of divers reported detecting strong ping signals and aid its USBL system in providing more the flight recorders were installed on the believed the recorders were covered in accurate coordinates of the source of the aircraft and how they looked. The divers sand and being pinned below one of the ping signals. were also advised to use their flashlights engines. to search and to look for the reflection of The MPA team deployed the ROV Locating ping signal using ultra-short base the reflective tapes on the flight recorders. during the second dive operation of the line (USBL) system—On January 10, at After two dives, the divers returned day but let the divers direct the ROV to Jadayat around midday, Java Imperia arrived on to . They reported hearing very the debris field for underwater photos to site. After completing the scan in about loud ping signals using the ULB detector be taken by the ROV’s camera, as there four hours, Java Imperia’s USBL system and seeing a large piece of wreckage that was no underwater camera available for identified a possible ULB location about looked like a wing section. the divers to use. The ROV photos showed The MPA team deployed the ROV at 50 meters north of the more northern of that the divers were in the vicinity of around 0815 LT and obtained the first the two ULB positions initially identified fuselage frame C77, at the tail of the images of some debris near the debris by the search team (see Figure 6). aircraft. As the recorders were installed field identified by the MPA team (see between frames C73 and C74, and as Figure 7). The debris appeared to be from Dive operations strong ping signals were being heard by an aircraft’s cargo compartment. Dive operations commenced on January divers in this area, the search team was As there were only five divers on board 9 at around 0600 LT. The five naval divers confident that the recorders were in the Jadayat, the effective diving time was only vicinity. It was extremely difficult for the on Jadayat went down in turn in teams of about one hour each day. On January 9, two with each team diving for 15 minutes. the NTSC representative, after discussing divers to maneuver the ROV due to strong The directional ULB detectors were con- with the other search team members, currents. Thus, they did not use the ROV figured into diving mode for use by the requested more divers. Nine more divers again. naval divers. Prior to their deployment, from the Indonesian naval vessel Banda The diver-in-charge on board Jadayat the naval divers familiarized themselves Aceh (the on-scene command vessel) outlined two options for raising the with the operation of the directional ULB were made available to the search team, engine and wing section, which were detectors to detect the ping signals. The bringing the total number of divers to 14. believed to be resting on the recorders. search team had also requested AirAsia The dive time on January 10 was signif- Option 1: To attach a sling to a point on Indonesia to provide information on the icantly extended, with 14 divers taking the wing and use the crane (rated at 15 model of the ULBs installed on both flight turns to dive. However, the divers were tons) on Jadayat to lift the wreckage. recorders. The same model of the ULB hampered by strong underwater current Option 2: To attach a sling to two points was then used to replicate the ping sig- as they were unable to hold the ULB of the wing and use a balloon to lift the nals during the training provided to the detector in the direction of the strongest wreckage. divers to give them experience regarding signal. Dive operations ceased at 0930 LT. The diver-in-charge preferred Option how the detected signals felt through the At 1400 LT, an NTSC and AAIB inves- 1 as it posed less risk to the divers and bone conduction transducer. tigator went to the vessel Crest Onyx to was less time-consuming (based on the The divers were also briefed on where survey the tail section that had been experience he had lifting the tail section

8 • July-September 2016 ISASI Forum of the aircraft previously). However, the and believed the CVR was in the vicinity tional Society of Air Safety Investigator search team cautioned him that, instead of an engine. Their dive line, which was (ISASI) seminars (and those of the of lifting the engine and wing section, the tied to the engine, was not long enough regional chapter of AsiaSASI) or Interna- crane would drag the wreckage, and thus to allow them to swim to and explore the tional Civil Aviation Organization (ICAO) the flight recorders, along the seabed. suspected CVR location. Dive operations accident investigation meetings. This option might also not be preferable stopped at 1100 LT as the underwater As for the Asia and Pacific regions, because of a tear along the wing root area current was getting stronger. there exists an Asia Pacific Code of and because the wing and engine were On January 13, at around 0710 LT, the Conduct to foster a cooperative spirit partially submerged in sand. same diver who retrieved the FDR the day on accident investigation-related mat- On checking with the diver-in-charge, before surfaced with the CVR. According ters. Within the Southeast Asia region, the search team realized that the divers to him, the CVR was also on the seabed a memorandum of understanding was were searching at a location about 50 covered in sand, about 10 meters away developed and agreed upon in 2008 by meters away from the coordinates given from where he retrieved the FDR. Like the governments to pledge their com- by the search team. Apparently, they had the FDR, the CVR was attached to its mitment to mutual assistance during an not taken drift into consideration. rack. However, the team was able to investigation into an accident. Clearly, it remove the rack, and the CVR was placed is important for such close relations to be Recovery of recorders in a cooler box for transport. The diving developed before a crisis happens, as was Dive operations resumed at 0545 LT on continued until 1130 LT to retrieve more shown in this sea search-and-recovery January 12. No decision was made on the wreckage from the seabed, as instructed operation. previous day’s deliberation on how to lift by BASARNAS. BASARNAS, which spearheaded the

Figure 7. Photo of cargo sidewall lining captured on the MPA ROV’s first dive (left). SeaBotix ROV used by the MPA team (right).

the wreckage, although a balloon rated to A special-purpose navigational buoy SAR effort, received valuable support lift five tons was brought over to Jadayat was subsequently laid by the Jadayat crew from China, Japan, Malaysia, Russia, and ready to be used. at around 1230 LT to mark the location Singapore, South Korea, and the United On the second dive of the day, a diver of the debris field to facilitate BASARNAS States. BASARNAS managed its own successfully retrieved the flight data re- and NTSC’s subsequent retrieval of bodies resources together with those from these corder (FDR), which was still attached to and wreckage. After having completed foreign countries, the Indonesian mili- its rack. According to him, it was buried the flight recorder recovery operation, tary, and the provincial government to under sand about 30 meters away from both Jadayat and Andromeda returned to conduct the SAR. frame C77. The team attempted but was Kumai Port. On the investigation front, the NTSC unable to separate the FDR from the rack received support from Australia, China, without the appropriate tool—probably International cooperation France, Russia, Singapore, and the UK due to the damaged connector. The NTSC The successful multinational effort in during the sea search phase and readout had prepared a Pelican case that was the retrieval and readout of the flight of the flight recorders. From France, BEA large enough to accommodate the FDR, recorders underlined the importance investigators participated and assisted even with the rack attached, to transport of the close relationship that the NTSC as the state of design and manufacture in the FDR (see Figure 8, page 10). enjoys with its foreign counterparts. One line with ICAO Annex 13. Subsequent groups of divers continued of the avenues to develop such relations The NTSC coordinated with the Min- to search for the cockpit voice recorder is through attending accident investiga- istry of Foreign Affairs of Indonesia for (CVR). They continued to hear loud pings tion-related events such as the Interna- the necessary diplomatic clearance to be

July-September 2016 ISASI Forum • 9 granted to the foreign participants even the coordination. reduced the window of opportunity though the offers for assistance came for the underwater search team to from various channels. In the case of the Challenges faced detect and localize the source of the ping signals. AAIB-MPA team, the NTSC also facilitat- Weather conditions—The key challenge ed in the smooth clearance of the large faced by the underwater search team was • The dive operations were limited amount of equipment through Customs the weather conditions, as the Java Sea to a maximum four-hour window as the team arrived in Belitung. was experiencing the yearly monsoon between 7 a.m. and 11 a.m. due to Knowing that the foreign participants season during the sea search period. The strong underwater currents (beyond may not be conversant in the local lan- weather had the following impact on the three knots) building up after 11 a.m. daily. Hence, even when the Indone- guage, the NTSC ensured that there was initial phase of the sea search: sian Navy provided significantly more always one NTSC person assigned to each • The underwater search team was un- divers, the efforts to retrieve the flight group of foreign participants to facilitate able to perform hydrophone listening recorders were limited by the daily as a translator and the coordinator with as the motorized boats could only be dive time. its headquarters. safely deployed up to sea state two. • The divers had to swim against the While out at sea, the underwater search • Above sea state two, the underwater strong underwater current, which team was able to focus fully on the task noise generated by the waves makes resulted in a reduced amount of of detecting and localizing the ULB ping detection of ULB ping signals using time they had to search around the signal. For all other matters, in particular handheld hydrophones very difficult. the request for more divers, the NTSC wreckage and attempt to locate the • As the ULB battery life is officially personnel on board the ships assisted in recorders. rated for 30 days, the poor weather • Poor visibility of the water limited divers’ view and the use of AUV/ROV.

Logistics—Jadayat and Andromeda both had seven days of endurance to stay out at sea. The only means of resupply was for the ships to return to Kumai Port, which required an 18-hour journey. On two occasions, the underwater search team planned to anchor at the mouth of the Kumai River (which would save about four hours of sailing time) to wait for the weather to pass before heading for the search location. However, that meant a reduction in the maximum endurance the team could have in the search area. As such, the underwater search team decided that it was more prudent to return to Kumai Port and wait for the weather to clear before traveling to the search location. Although this meant a longer traveling time, it would give the team maximum endurance at the search location.

Accommodations—Accommodations can often be an issue if the command center or remote base for an operation is located in a town or city that does not have a large tourism industry. When the underwater search team arrived at Belitung on Dec. 14, 2014, there were only four rooms available, which were booked by BEA and NTSC colleagues, in a local hotel. In view of the accommodations problem, they chose to stay at an Air Force dormitory to allow the 11 personnel from Singapore and the UK to share the four hotel rooms. Figure 8. The FDR in the NTSC’s Pelican box. When the underwater search team ar-

10 • July-September 2016 ISASI Forum rived in PKN on January 1, there were no time. Where possible, umbilical diving, search team operated in a remote area accommodations available due to an in- which allows longer dive time, should be with no terrestrial-based telecommuni- creased number of people coming to PKN considered. The availability of communications, a satellite phone was the only to support SAR efforts and news media cations and image recording capabilities means of communication. Other than activity. An NTSC investigator managed in some umbilical diving systems will having voice communication, it would to arrange with a local hotel to convert a allow a more efficient process of survey- have been beneficial if satellite data function room into a sleeping area. The ing the wreckage and recovering the flight communications were available to hotel provided 10 mattresses, which 16 recorders. Also, divers may not be able to allow the underwater search team to persons shared. The shower facility at understand all that the investigators are send documents, photos, and other the swimming pool was made available trying to explain to them about aircraft data back to headquarters and vice for the team to use. For the rest of the details and the use of equipment. This versa. nights from January 2 to 6, the underwa- may affect the effectiveness of the search. Visual aids and documentation—There ter search team stayed on board Jadayat One possibility is that investigators be were many participants, including the and Andromeda, which were berthed at trained as divers, at least in shallow sea. MPA team and divers, in the under- Kumai Port. The investigators can then be paired with more professional divers. water search team who did not have aviation-specific knowledge. It was Transport—When traveling from Singa- Equipment—It is desirable to have dif- found that the aircraft diagrams, with pore to Belitung, the airlift service pro- ferent sizes of waterproof bags to keep/ dimensions and other details, were vided by the Singapore Air Force allowed protect electronic equipment. Also, as useful during discussions. Hence, before rapid deployment of the Singapore and divers may not be familiar with aircraft deployment, copies of aircraft diagrams the UK personnel and their equipment. parts, they may have difficulty describing showing the color scheme, dimensions, Had the travel been via commercial flight, what they see under water. With under- weight, etc., should be printed. a transit in Jakarta would be necessary. In water cameras, divers can record images While under water, divers may need addition, the equipment that the Singa- of what they see so that they can explain to know how to unlock recorders from pore and the UK team brought for the more easily to the investigators. This is the rack where they are installed. They sea search weighed about 400 kilograms even more critical if the divers and inves- should practice unlocking with a lock and included odd-sized boxes. This tigators do not speak the same language. mechanism mock-up. It would be useful would have resulted in significant excess The AAIB’s ULB detectors do not have for a flight recorder lock mechanism baggage charges and likely required the an underwater compass, so it was mock-up to be fabricated and brought equipment to be transported on more difficult for the divers to know the along during deployment. than one flight. It would also have been direction under water while operating During the search of ULB signal, it challenging for the underwater search the detectors. would be desirable to record the de- team to arrange for land transport for It is essential for personnel on small tected ping signals. The audio recording both personnel and equipment. The boats, when deployed, to maintain could be replayed to those who did not Indonesian Air Force provided the flight communication with the mother ship. have a chance to go out on a boat to as- to help reposition the underwater search Walkie-talkies with longer range (about sure them of what the team has found. team and their equipment from Belitung five nautical miles) would be desirable to PKN. For land transport, the Indone- for maintaining communication with the sian Army, Air Force, and BASARNAS pro- Conclusion mother ship. vided the vehicles and manpower needed The successful recovery of both flight Recorders recovered from under water when the underwater search team was recorders from Flight QZ8501 was made should be kept in water during transport. moving from one point to another. possible through close cooperation To avoid having to check the water level among the various local and foreign in the container and having to open up agencies. The cooperation extended Learning points the container to verify the contents (e.g., beyond the sea search when the Search vessels—As SAR operations and when going through Customs), transpar- NTSC also received assistance from the underwater search for flight record- ent containers should be used. Australia during the readout of the flight ers are different, a vessel used for SAR During the ULB ping signal detection, it recorders. operations may not be suitable for an was noticed that the signal was available Even if an individual agency has the underwater search operation. Ideally, a from a sector of about 30° when closing in capability to perform an underwater dedicated vessel should be used for the on the target. This made pinpointing the search for flight recorders, it is still underwater search of flight recorders and ULB signal source extremely difficult. It beneficial to accept the offer of assis- for the deployment of ULB detectors and has been suggested to use a signal damp- tance from other foreign agencies for side-scan sonar. There should be more er (such as a rubber/foam tube attached greater efficiency while searching for small boats available for the deployment to the hydrophone) to limit the detection the flight recorders. The key challenge of ULB detectors to effectively extend the sector. Hopefully, this can reduce the in this would be to coordinate all the area of the underwater search. signal sensing sector and improve the available resources and assistance accuracy in locating the ULB signal. Dive operations—For dive operations, rendered by the foreign counterparts oxygen tank diving would limit the dive Communications—As the underwater to conduct a successful sea search.

July-September 2016 ISASI Forum • 11

Thomas Anthony has been director of the USC Aviation Safety and Security Program since January 2007. He is an instructor in aviation safety management systems, aircraft accident investigations, SMS for managers, and aviation security courses. He served as a consultant for the International Civil Aviation Organization in aviation security. Anthony also served as the federal security By Thomas Anthony, Director, Aviation Safety and Security Program, director of the Palm Springs International, Yuma International, Viterbi School of Engineering, University of Southern California and Imperial County Airports. He retired from federal service in 2005. While working for the FAA, Anthony was FAA regional division manager for civil aviation security in the Western Pacific region; directed the emergency security response to 9/11 attacks and provided investigative efforts of aviation activities of the hijackers; was the FAA point of contact and provided THE ROGUE PILOTinvestigative assistance in the al-Qaeda, Ahmed Ressam border bomb case; was FAA division manager for civil aviation security; was assistant regional division manager of the FAA Civil Aviation Security Division in the Western Pacific region; and was manager of PHENOMENONthe FAA Investigations Branch in Washington, D.C. (Adapted with permission from the author’s technical paper entitled Human Factors in Extremis: The Germanwings crash has brought the rogue pilot phenomenon to the front The Rogue Pilot Phenomenon presented at ISASI 2015 held in Augsburg, Germany, Aug. 24–27, 2015, and center of aviation safety attention. Here the author adds two additional which carried the theme “Independence Does Not Mean Isolation.” The full presentation, including perspectives to the inquiry into a potential rogue pilot investigation: the cited references to support the points made, can be found on the ISASI website at www.isasi.org under the tag perspective of a profiler of criminal behavior and the psychological elements “ISASI 2015 Technical Papers.”—Editor) of acts of murder-suicide.

he Germanwings crash has brought the rogue pilot pilot phenomenon. I led the Los Angeles phenomenon to the front and center of aviation safety portion of the EgyptAir Flight 990 inves- attention. Unlike other aircraft accidents that may be tigation in cooperation with the FBI and T resolved by evidence recovered from the accident site, have directed and participated in dozens the rogue pilot investigation takes the investigator into nontraditional of intentional acts of unlawful interfer- areas of inquiry. Specifically, it will necessarily take the investigator into the ence against civil aviation, most notably personal and often private life of the flight crew. hijackings and bombings of aircraft. While accident investigators have adeptly addressed the issue of human factors As resource material, I drew primarily via the lens of crew resource management, threat and error management, and human upon the works of two authors: John E. factors analysis and classification for decades, the issue of the intentional crashing of Douglas, a special agent with the FBI an aircraft by the pilot remains largely a dark corner of ignorance. The purpose of this Behavioral Analysis Unit (BAU) who is article is to add two additional perspectives to the inquiry into a potential rogue pilot considered the father of criminal profil- investigation: the perspective of a profiler of criminal behavior and the psychological ing, and Dr. Thomas Joiner, a preeminent elements of acts of murder-suicide. authority on the phenomenon of mur- This is not a review of the Germanwings case. The investigation is not complete, der-suicide. and the facts are not fully established. First, we will look at the definitions and Douglas’s career as an investigative concepts that allow us to proceed with a degree of knowledge into the rogue pilot profiler in the FBI’s BAU served as the phenomenon overall. Second, we will review several of the cases that fall into the inspiration for the character of Jack Craw- rogue pilot/intentional crashing category. Finally, we will look at specific lessons that ford in the motion picture The Silence of have been collected from the perspectives of the rogue pilot as a crime and as the the Lambs. Douglas’s work is contained in manifestation of an extreme human factors mishap and the relevant psychological The Crime Classification Manual (3rd Edi- lessons therein. tion) by Douglas, Burgess, Burgess, and I am not a psychologist. It is important to bring trained psychologists into this kind Ressler and also in Douglas’s biography of investigation as early as possible. I did, however, dedicate 18 years of my FAA ca- Mind Hunter. reer to the investigation and mitigation of unlawful acts against civil aviation. Unlaw- Joiner, who has a Ph.D., is a preeminent ful implies intentional. Unlawful and intentional are two of the elements of the rogue authority on suicide, and murder-suicide

12 • July-September 2016 ISASI Forum in particular. Joiner’s ideas are reflected in The Perversion of Virtue, which is solely focused on murder-suicide and his book Myths About Suicide. Joiner is a The following definitions will prove distinguished professor of psychology at Florida State University. This writing useful in reading this material. also draws from the book Night Falls Fast by Dr. Kay Redfield Jamison. Jamison Homicide: The action, by a human is a professor of psychiatry at Johns Hopkins University and an honorary profes- being, of killing a human being (ety- sor of English at the University of St. Andrews in Scotland. mology: a man-slayer)—Oxford English In addition to the above-cited cases, the crash of Pacific Southwest Airlines Dictionary. (PSA) Flight 1771 should be included. A Los Angeles-based employee of the Murder: The unlawful taking of human airline, after having been terminated from his position, used his airline ID to life. (Douglas, Burgess & Ressler, 2013, board a flight with a handgun, killed his supervisor who was a passenger, the DEFINITIONS p. 111) It is first among the command- other pilots, and caused the aircraft to crash with the loss of all souls on board. ments—“Thou Shalt Not Kill.” It is the The case of FedEx Flight 705, a DC-10 cargo flight from Memphis, Tennessee, to most basic crime. The rogue pilot has San Jose, California, in which a dead-heading pilot attempted a murder-suicide no right to take the lives of the pas- but was prevented by aggressive action by the crew, is very similar and offers sengers; therefore, this action is, at its the same insight into motivations behind in air killings. most basic level, the crime of murder. And while the death of the pilot himself has the effect of muddying the clarity Insights from the perspective of profiling of this realization, we must first and In his time with the FBI’s BAU, Douglas offered the following metaphor to new foremost recognize that it is the unlaw- investigators striving to learn the art and skill of criminal profiling: “If you want ful taking of human lives. It is a crime. to understand the artist, you have to look at the painting.” The painting, for It is murder. What is the good of this him, stands for all the details of the crime itself. These specifics are significant realization? It allows us to see parallels because of the planned and premeditated nature of most of these incidents. with other similar crimes and gives us The specifics are planned and chosen and reflect intention. insights into the minds of those who have committed similar acts. Douglas stresses the concept of victimology, in that a complete understanding of the relationship between the killer and the victim can often yield insights Mass Murder: The unlawful killing into the motive or the reason for the action to have taken place. (Douglas, of four or more victims by the same Burgess & Ressler, 2013, p. 11) Douglas goes on to point out that “most violent offender(s) acting in concert at one crime careers have a quiet, isolated beginning within the offender’s location in a single continuous event imagination.” that may last minutes, hours, or days. (Douglas, Burgess & Ressler, 2013, p. It has been said that the mass murderer will likely have a very active fantasy 16) life. The role of the Internet has fed this. For the purpose of investigation, the recognition of this fact could not be more important as “the Internet has meant Murder-suicide: The term that Joiner that old concepts of boundaries and borders and limitations are gone.... The uses in The Perversion of Virtue to de- Internet seems to have freed something that had previously been repressed in scribe “a murder followed by a suicide.” the human mind or the unconscious or the body itself. Self-imposed restriction (Joiner, The Perversion of Virtue: Under- standing Murder-Suicide, 2014, p. 14) or controls were fading, and people did things in cyberspace they might have He explains that “given the contingent never done anywhere else.” (Douglas, Burgess & Ressler, 2013, p. 39) nature of suicide and murder in these There is also a feeling of privacy on the Internet. One works and searches incidents, and given that both are tied the Internet as an individual, not as a team or social activity. It can be done in together in perpetrators’ minds by a private with no one in attendance. One can log in with an assumed name or perversion of virtue, it is not a surprise identity. Working on the Internet can create the feeling of absolute privacy, but, that the time interval between mur- of course, this is false. Every keystroke is recorded somewhere. The feeling of der(s) and suicide is almost always on absolute privacy is ultimately false. the order of minutes or hours.” (Joiner, Some investigative organizations use a mental model that can be called “the The Perversion of Virtue: Understand- Three Selves” as a way of looking at the range of an individual’s behavior. This ing Murder-Suicide, 2014, p. 16) Joiner model applies to everyone, not just those coming under the scrutiny of behav- asserts that “far from being impulsive” murder-suicide is premeditated. This ioral profilers. This model posits that each of us can be seen as having three gives us a fundamental conceptual selves. building block upon which to build • The first is the social self, the person who is known to friends, workmates, our understanding of the rogue pilot and other individuals we routinely come into contact with. incident. It gives us the insight to look • The second is the personal self, who is only shared with our spouse or clos- for an evolutionary pattern of devel- est friends. opment and planning in cases where murder-suicide is a potential cause. • The third self is the private self, who is shared with no one. Psychosis: Psychosis occurs when a It is often within this private self where the fantasy life exists and the seeds person loses contact with reality. The to violent crime grow. The collision between this private fantasy life and the person may have false beliefs about other two external lives can be devastating. In 1998, the U.S. Customs Service what is taking place or who one is (de- broke up the Wonderland Internet child pornography ring. Four individuals lusions)—National Institute of Health. connected with Wonderland committed suicide shortly after being identified

July-September 2016 ISASI Forum • 13 Sept. 26, 1976 July 13, 1994 Oct, 11, 1999

fatalities. A Russian fatality. A Russian Air fatality. An Air Botswana 12pilot stole an Antonov 1Force engineer stole an 1captain who had been 2 and directed the aircraft aircraft at Kubinka Air Force grounded for medical into the block of flats in Base to commit suicide. The reasons took off in an Novosibirsk where his aircraft crashed when there ATR 42. He made several divorced wife lived. was no more fuel left. demands over the radio and finally stated he was Aug. 26, 1979 Aug. 21, 1994 going to crash the airplane. He caused it to crash into fatalities. A 23-year-old fatalities. A Royal two parked ATR 42s on 4male mechanic who had 44Air Maroc ATR the platform at Gaborone just been fired entered a 42 crashed in the Atlas Airport in Botswana. hangar at Bogotá Airport Mountains shortly after in Colombia and stole a takeoff from Agadir, Oct. 31, 1999 military HS 748. He took off Morocco. The accident was and crashed the airplane in suggested to have been fatalities. EgyptAir a residential area. caused by the captain 217Flight 990, a disconnecting the autopilot Boeing 767, entered a Feb. 9, 1982 and directing the aircraft rapid descent some 30 to the ground deliberately. minutes after departure fatalities, 150 The Moroccan pilots’ union from New York’s John 24survivors. A DC-8 challenged these findings. F. Kennedy Airport. This captain pushed the controls happened moments after of Japan Airlines Flight 350 Dec. 19, 1997 the captain had left the forward against the efforts flight deck and the relief first officer had convinced of other flightcrew members, fatalities. SilkAir causing the aircraft to crash the command first officer 104Flight 185, to relinquish the controls. into Tokyo Bay on approach. a Boeing 737 enroute The captain was tried and The NTSB concluded that from Jakarta, Indonesia, the accident was a “result found not guilty by reason to Singapore, crashed in of insanity. The captain of the relief first officer’s Indonesia following a rapid flight control inputs.” The was found to experience descent from cruising psychotic episodes. NTSB conclusions were altitude. Indonesian heavily disputed by Egyptian authorities were not able authorities. to determine the cause of the accident. It has been suggested by others, Nov. 29, 2013 including the U.S. NTSB, that the captain may have fatalities. LAM committed suicide by 33Flight 470 entered switching off both flight a rapid descent while recorders and intentionally enroute between Maputo, putting the B-737 into a Mozambique, and Luanda, dive, possibly when the first Angola, and crashed in officer had left the flight Namibia. Preliminary deck. In 1997, the captain investigation results experienced multiple indicated that the accident work-related difficulties. was intentional. The captain NTSB findings were made control inputs that disputed by the Indonesian directed the airplane to the investigators. ground shortly after the first officer had left the flight deck. TABLE 1: PILOT-INITIATED CRASHES

14 • July-September 2016 ISASI Forum with the ring. justice thinking. Cho viewed his peers The degree to which individuals can Investigative as “deceitful charlatans” and “rich kids” keep this fantasy life and their associated who engaged in “debauchery.” (Joiner, The crime secret is notable. In Olathe, Kansas, Touchstones Perversion of Virtue: Understanding Mur- in 2000 a middle-aged man by the name der-Suicide, 2014, p. 162) Joiner points out of John Robinson contacted six women • Suicidal intention that in the eyes of the individual enacting via the Internet and after developing a murder-suicide, his or her actions are cyber relationship killed each of them, precedes murder- not “cowardly, vengeful, or selfish.” They concealing their bodies at farm prop- suicide are instead following a compelling path erty that he owned. After his arrest, his resulting from a perversion of justice. neighbors “told the media that he was a • Role of fantasy and Copycat behavior can be seen in two quiet fellow who kept a statue of the Vir- imagination of the most famous murder-suicides. In gin Mary in his backyard and always put the Columbine High School murder-su- up wonderful holiday decorations.” His • Internet and high icides, Eric Harris and Dylan Klebold wife and children also stated that he was tech killed 13 people before losing their lives innocent of the killings. (Douglas, Burgess to the police. In this incident, they sought & Ressler, 2013, p. 43) • Three selves to achieve greater infamy than Timothy The case of Edmund Emil Kemper, “the • Neighbors, family, McVeigh, who killed 168 in the Oklaho- Co-ed Killer,” who was responsible for 10 ma City, Oklahoma, bombing of the U.S. killings in the Santa Cruz, California, area, and professionals Federal Building. (Joiner, The Perversion is another example of the hidden self. unaware of Virtue: Understanding Murder-Suicide, After being released from custody for two 2014, p. 172) murders that he committed as a juvenile, • Different person in Similarly, Charles Whitman, on the he was required to make regular visits different places same day that he heard the news that to state psychiatrists. One appointment Richard Speck had just killed eight nurses took place the day following one of the 10 in their Chicago, Illinois, dormitory, murders. Kemper, on this occasion, was visited the Bell Tower of the University of pronounced no longer a threat to himself Texas. Later that month, he killed 13 peo- or others. He was only halfway through ple and wounded 31, shooting from that suicide. He states that suicide “is not only his murderous career. same tower. (Douglas, Burgess & Ressler, primary, but it is also the source of all that In The Mind Hunter, Douglas recounts 2013, p. 475) Joiner argues convincing- follows, especially including the appalling the perspective of retired Special Agent ly that because of extreme difficulty in murders; murder occurs because of sui- Jim Clement of the FBI’s BAU. It was killing one’s self, suicides and murder-su- cide, as a consequence of suicide having Clement’s view that an individual’s be- icides are not impulsive or spur of the been settled on.” (Joiner, The Perversion havior can be viewed as occurring within moment. of Virtue: Understanding Murder-Suicide, a spectrum or continuum of behavior How common is murder-suicide? In 24 2014, p. 9) and not always within the same narrow samples conducted in the U.S., the range Joiner states that the thinking of the band of behavior. (Douglas, Burgess & individual reflects the feeling that “if I varied from 0.17 to 0.55 murder-suicide Ressler, 2013, p. 9) The point is that while am to die, it is only virtuous that they incidents per 100,000 population, or a individuals may seek to keep their secret do, too.” (Joiner, The Perversion of Virtue: mean value of 0.32 per 100,000. According self apart from the other parts of their life, Understanding Murder-Suicide, 2014, p. to Boeing’s 2013 statistical summary, the there are elements of one that blend with 9) This is the perversion of the virtue of 10-year combined commercial accident the next and threads that extend through justice. It is Joiner’s belief that an individ- rate was 0.33 per 1,000,000. So while being the entire fabric of an individual’s life. ual fixes upon suicide as the answer to a rare phenomenon, a murder-suicide two predominant conclusions: “I am just incident is 10 times more frequent than Murder-suicide as a perspective on a burden upon those that I care about,” a commercial aircraft accident. To put the rogue pilot and “I really don’t belong.” As this line of an even finer point on it, Joiner estimates The Perversion of Virtue is Joiner’s work thinking repeats over time and comes to that there are 1,574 deaths per year that is exclusively devoted to murder-su- suicide as the only answer, it may seek due to murder-suicide in the U.S. The icide. As we have seen earlier, the rogue to justify the suicide by the murder of 10-year average of commercial aviation pilot phenomenon fits the definition others. It may seek to justify the murders fatalities in the U.S. from 2003 to 2012 of murder-suicide just as it does the by seeing them as a virtuous act and was 15.3 per year, one one-hundredth of definition of mass murder. Not all mass necessary act. murder-suicide fatalities. And in recent murders are murder-suicides, and not all Joiner cites four virtues that he believes years in the U.S. (2009–2011), there were murder-suicides are mass murders—in- are operative in cases of murder-suicide: no commercial aviation fatalities. Clearly deed most are not. justice, glory, mercy, and duty. In the case incidents of murder-suicide are hundreds The central idea of Joiner’s work is that of the Virgina Tech University shootings, to thousands of times more frequent than in cases of murder-suicides the primary Korean student Seung-Hui Cho’s actions commercial aircraft accident fatalities idea and intention of the individual is can be seen as a result of perversion of Side note: There are approximately 38,500

July-September 2016 ISASI Forum • 15 SUICIDE RISK SOURCE: CLARE HARRIS AND BRIAN BARRACLONGH, UK

40 35 30 25 20 15 10 5 AIDS Cancer Alcohol Opiates Depression Schizophrenia Anxiety Disorders Multiple Sclerosis Manic-Depression Personality Disorders Huntington’s Disease Previous Suicide Attempt Suicide risk (number of times Psychiatric Substance Mental Health the expected rate in population). Condition Abuse Disorders Conditions

deaths by suicide annually in the U.S. cide do not leave a note.” Studies conduct- tion that precedes many, if not most, Murder-suicides account for 2 percent of ed on the subject range from 0 percent murder-suicide acts. (Japan Airlines the total. Side note 2: It should be pointed to 40 percent of suicides that leave notes, Flight 350 is noted as an exception— out that more than 90 percent of those who the average being about 25 percent. (Join- psychosis/delusions on the part of the commit murder-suicide are men. (Joiner, er, Myths About Suicide, 2010, p. 119) A captain.) The Perversion of Virtue: Understanding suicide note was found, however, among • Second is the role of fantasy and Murder-Suicide, 2014, pp. 41–43) the wreckage of PSA Flight 1771: “Hi Ray. imagination in the evolution of the Also important is that the individual I think it’s sort of ironical that we end up murder-suicide intention. committing murder-suicide, according to like this. I asked for some leniency for my • Third is the Internet and all high- Joiner, is generally not a psychopath. “One family. Remember? Well, I got none and tech opportunities for the individual of the main features of the psychopathic you’ll get none.” to indulge and develop the fantasy/ personality is a callous, unempathetic, Joiner also points out something that secret self. The subject’s computer, and uncaring emotional style. Extreme can strike us as contradictory. People can phone, and chat room activities are selfishness is also involved.” (Joiner, conduct activities that indicate that they the digital flight data recorders of The Perversion of Virtue: Understanding are planning for the future and also be this kind of investigation. Methods of Murder-Suicide, 2014, p. 68) This is not the planning on dying. (Joiner, Myths About payment: credit cards and debit cards murder-suicide profile; such an action is Suicide, 2010, p. 65) Joiner says this later provide an individual’s movements seen by the individual as within the con- when he states, “Attention and emo- and a reflection of the individual’s text of performing a virtuous act. tion do not always operate in lockstep.” value system. Social media provide links to individuals who may prove to The element of life insurance fraud is (Joiner, Myths About Suicide, 2010, p. 128) be productive witnesses. encountered in several murder-suicides, What does this mean to us as investiga- including some in aviation. In the FedEx tors? Simply, it means that just because • Fourth is the understanding that indi- Flight 705 accident, the dead-heading an individual has paid for a vacation viduals who develop a secret/fantasy life are adept at keeping them hidden. pilot took out a $2.5 million dollar life holiday next month, it is not assured that Neighbors, families, and even psychi- insurance policy prior to the attack. Sim- he will not make a fatal decision today. atrists (in the case of Edmund Emil ilarly, the pilot of SilkAir Flight 185 had Kemper) can be fooled. been experiencing financial difficulties Investigative touchstones • Fifth is that pilots, by virtue of their and took out a life insurance policy before While almost all of the forgoing can be work, can live in several places at the the ill-fated flight. useful in investigating potential cases of same time. Their home may be in one Finally, the absence of a suicide note murder-suicide by the pilot, there are sev- city, but they may visit another city means virtually nothing in the course eral points that can serve as fundamental with regular frequency. They may be of a murder-suicide investigation. touchstones. essentially another person in another “Three-quarters of those who die by sui- • First is the primacy of suicidal inten- city.

16 • July-September 2016 ISASI Forum nternational commercial aviation tigation and resolution processes can has achieved unprecedented levels of be very lengthy and involve many steps. safety. According to International Civil During the investigative process, infor- IAviation Organization (ICAO) records, mation is generally on a “need-to-know” 2013 was the safest year in history, with basis and is not made available. However, nine fatal accidents resulting in 173 once information becomes available, the total fatalities. The year 2014 saw fatal FAA recognizes that this higher level of accidents and total number of fatalities accident knowledge can aid in identifying slightly increase, including two fatalities existing safety gaps within today’s safety in the U.S. Even with these increases, systems and can enhance day-to-day accident rates remain at historically low safety work. levels. These advances can be attributed Recognizing the value of a workforce to the combined effects of major world- with an enhanced level of accident wide initiatives targeting specific safety knowledge, the FAA in 2008 issued the areas. However, in light of current trends, first release of the “Lessons Learned from Daniel I. Cheney, U.S. Federal it is important to remain vigilant and be Transport Airplane Accidents” library, Aviation Administration on guard against complacency. Analyses which includes 10 accident modules. of recent accidents have revealed that rel- Subsequent releases have expanded the publications, regulatory materials, and atively minor changes in safety programs library to include 76 modules spanning technical studies. The library also makes have the potential to create gaps in safety. some of the most historically significant, extensive use of animations, graphics, It is also important to recognize that safety-shaping accidents from 1953 to photographs, and videos. the aviation workforce is changing and 2008. The FAA has created a tool to help Lessons Learned From Commercial Airplane Accidents Through creation of a web-based safety knowledge system, the FAA has created a tool to help guard against complacency and loss of costly safety knowledge. By Daniel I. Cheney, U.S. Federal Aviation Administration (Adapted from the author’s technical paper entitled Lessons Learned From Commercial Airplane Accidents presented at ISASI 2015 held in Augsburg, Germany, Aug.24–27, 2015, which carried the theme “Independence Does Not Mean Isolation.” The full presentation, including cited references to support the points made, can be found on the ISASI website at www.isasi.org under the tag “ISASI 2015 Technical Papers.”—Editor)

that the pace of this change is faster than In considering an accident for inclusion guard against complacency and loss in previous periods. Experienced person- in the library, four criteria are applied to of costly safety knowledge. In an hour nel are leaving and being replaced by per- determine its “readiness,” including or less, a reader can acquire sufficient sonnel with limited and, in some cases, 1. The official accident investigation information to be able to teach others key more narrowly focused aviation knowl- is complete, and the final report is information and lessons related to each edge. Information technology advances issued. accident. In many cases, this material has have required the creation of highly spe- required 10 years or more to complete, cialized positions, resulting in challenges 2. Corrective actions are complete or encompassing the investigative and reso- in achieving and maintaining a broad substantially complete. lution processes. The library currently has safety understanding. This, in turn, re- 3. No additional accident/incident that more than 12,000 subscribers, including quires organizations to provide this new would call items 1 or 2 above into manufactures, airlines, international workforce with learning tools that are question. authorities, academia, and others, and safety-relevant, efficient, and focused. As can be found at http://lessonslearned.faa. 4. Litigation is complete. the industry has moved toward expanded gov/. globalization, increased international A candidate accident is also judged to The library is arranged by three per- partnerships, and new airline formations, be lesson-rich and able to provide a sub- spectives: Airplane Life Cycles (3), Threat the call for more comprehensive safety stantial knowledge value to the accident Categories (18), and Common Themes (5). learning tools, including knowledge of library content. Accident modules are These three perspectives allow the library accident causes, exists. created by a team of specialists, with sup- user to learn details of each accident from The U.S. Federal Aviation Administra- port from contractors and industry. Team various dimensions, allowing a more tion (FAA) has recognized that detailed makeup involves both FAA and non-FAA complete understanding of the underlying accident knowledge is widely lacking. aviation experts with wide-ranging back- causes, resolutions, and key lessons. The The complexity of most current acci- grounds, including engineers, pilots, and accident library is now publically availa- dents has made it very difficult to collect researchers. Resources used in the crea- ble as a tool to help advance the safety of and distribute key accident information tion of the accident modules include the an already very safe international com- within the aviation community. Inves- official accident reports, manufacturers’ mercial aviation system.

July-September 2016 ISASI Forum • 17 Dr. Thomas Gogelis the ertification specifications for small Vision 1000 head of aviation safety rotorcraft (CS-27) do not mandate To provide a solution for helicopter flight at Airbus Helicopters Deutschland. He leads that helicopters be equipped with data monitoring for light helicopters, the all aviation safety issues Cdata recorders, nor do operational Vision 1000 system was jointly developed in the Airbus Helicopters’ requirements for a big part of the world- by Appareo Systems and Airbus Helicop- customer center network wide helicopter fleet. The resulting lack ters long before the relevant rulemaking and at Airbus Helicopters Deutschland. He received of flight data severely impacts the effort process for helicopters was initiated. The a diplom-ingenieur and a needed for accident investigation and system is compliant with the Helicopter Ph.D. in aerospace engineering from Stuttgart often prevents the identification of root Emergency Medical Services (HEMS) FAA University in Germany. He holds an honorary causes or the chain of events leading to an professorship for aerospace engineering. Part 135.607 and the European Avia- accident, which in turn prevents the es- tion Safety Agency (EASA) rulemaking tablishment of suitable barriers for future task 0271/0272, mandating a light data avoidance of similar accidents. recorder for light helicopters and aircraft Dr. Marcus Bauer is Airbus Helicopters follows a twofold starting at the end of 2019. On top of the director and founder approach to improve this situation. obvious benefit of creating increased safe- of MSimulation, which Firstly, the Vision 1000 cockpit image and ty through operations quality assurance provides iwi® reports. Since data recorder was developed as standard and training assistance, the device offers 2015 he has been the head of technology at the Center equipment in Airbus Helicopters helicop- great value for incident and accident of Competence Additive ters but outside the regulatory require- investigation. Manufacturing/3-D ments, resulting in simplified certification Accident causations that remained Printing at the Digital and much lower costs. The features of this unknown due to lack of data can now Factory at Siemens. Prior to that, he was the head of simulation and tools device and first applications are present- be established by means of this low-cost at Airbus Helicopters. He received his Ph.D. and ed here, as well as the deployment policy flight data recording device. This is a a master of science degree in mechanical engi- in the fleet. basic enabler to develop preventive bar- neering from Darmstadt University and a bach- Secondly, the method “Immersive elor degree in aeronautics from the University of riers for accidents in the operator’s SMS Applied Sciences of Munich. Witness Interview” (iwi®) is discussed. It or measures being launched by aviation provides a qualitative and simple analysis authorities. The device is also one fore- of accident flight path using eyewitness runner considered in the FAA NORSEE statements. The methodology uses infor- (nonrequired safety-enhancing equip- mation gained from interviewing multiple Seth Buttner is the manag- ment) initiative with the objective to eyewitnesses or recorded videos from er of accident investigation promote the installation of nonrequired for Airbus Helicopters, Inc., smartphones or observation cameras to following his 15 years at the reconstruct and define a vehicle’s flight safety-enhancing equipment. Cessna Aircraft Company path and aircraft attitudes in a 3-D envi- The Vision 1000 system is a flight data, working as both an aero- ronment. All information is compiled and audio, and cockpit image data recorder. space design engineer and The imaging recording capability offers accident investigator. He then processed with the Immersive Wit- has an undergraduate de- ness Analyzer (IWA) software to identify advantages over much more expensive, gree in aviation technology the level of witness error or accuracy. The heavier, and maintenance-burdened from LeTourneau University in Longview, Texas, results can be exported into Google Earth cockpit voice and flight data recorder U.S.A., and a masters degree in aviation safety from Embry-Riddle Aeronautical University in or videos showing the approximated (CVFDR) equipment as required for large Daytona Beach, Florida, U.S.A. flight path from different perspectives. rotorcraft. It captures pilot/crew actions

Figure 1. Vision 1000 system and mounting on cockpit ceiling on an AS350.

18 • July-September 2016 ISASI Forum MODERN TECHNOLOGIES AND METHODOLOGIES IMPROVE HELICOPTER ACCIDENT INVESTIGATION The Vision 1000 cockpit image and data recorder was developed as standard equipment in Airbus Helicopters helicopters but outside the regulatory requirements, resulting in simplified certification and much lower costs. By Dr. Thomas Gogel and Seth Buttner, Airbus Helicopters; and Dr. Marcus Bauer, MSimulation and behaviors during flight, manipula- and reporting with a web-based access again standard equipment; on the H175 tion of flight controls and systems, noise, is provided as well. Vision 1000 is not it is optional equipment. Also, the H160 and even a view of weather/visibility crash-hardened per a certification re- prototype is equipped with the device. conditions. The available CVFDR solu- quirement. But a review of past accidents As for retrofit options, FAA STCs and tions for heavy helicopters do not offer indicates a crash survivability of more EASA certifications are done for the light a solution option for the light helicopter than 90 percent. helicopters, and retrofits are offered to range for the above-mentioned reasons. the fleet worldwide operators. To stim- A much simpler, low-weight, low-cost, Airbus Helicopters’ deployment ulate the use of the equipment, specific and low-implementation effort solution strategy customer trainings are performed during is needed and now provided by the Vision the delivery of the helicopters. Standalone The Vision 1000 system offers a good 1000 system. training courses are available as well. The opportunity for light helicopter opera- next generation of flight data recording tors to enhance their training and move devices for light helicopters is presently Description of system into operations quality control by means under development at Airbus Helicopters. The system features a forward-facing of the helicopter flight data monitoring It will feature a recording capability with image acquisition of the cockpit using (HFDM) features of the device and data more parameters and a higher degree four frames per second, with 2.2 megapix- reduction software. For accident investi- of integration and crash protection by el resolution, audio recording (ambient gation boards and the helicopter manu- means of the Airbus Helicopters’ new noise and intercom system), GPS position facturer, it is a valuable device to establish Avionics Suite HELIONIX. data, and an inertial measurement unit root causes for accident and incidents Overall, Airbus Helicopters is strongly (IMU) to record attitude. The unit weighs that would stay open without this data promoting the installation of the device 300 grams. A removable memory can recording device. Thus, the Vision 1000 into the fleet. It is an important part of store four hours of image and audio and deployment is a key element in Airbus the safety policy. 200 hours of inertial data (position and Helicopters’ “Safety First” initiative, which attitude). The hardened internal memory is the company’s prime objective. is capable of storing two hours of image The strategy is to fit each delivered Role overview of Vision 1000 and audio and 200 hours of inertial data. helicopter with the device and provide On March 30, 2013, the Safety Department The unit is installed in the helicopter affordable retrofit solutions for the in-ser- of Airbus Helicopters realized the critical to provide a view of the instrument panel vice fleet, especially the light range. The value of Vision 1000 at the ultimate cost. and a partial outside view (see Figure 1). actual deployment started in 2011 on the Air safety investigators (ASI) responded A visualization software enables a AS350 fleet under an FAA supplementary to the fatal accident of the Alaska state synchronized replay of images, audio, and type certificate (STC) by Airbus Helicop- troopers’ AS350 B3 helicopter (N911AA), 3-D depictions, including a display of the ters, Inc. in the United States. Vision 1000 which crashed in the Talkeetna Moun- flight instruments. has been fitted as basic equipment in tains of the Alaska Matanuska–Susitna A further review capability offering the AS350 final assembly line since 2013. region approximately 80 nautical miles features such as automated event analysis Fleet deployment for the EC130 T2 and north of Anchorage. The helicopter EC135 started in January 2014, and the impacted wooded and mountainous (Adapted with permission from the certification for the H145 was achieved terrain while maneuvering during a night authors’ technical paper entitled Use of in 2015. Since January 2015, it is standard search-and-rescue operation at 2320 Modern Technologies and Methodologies equipment on the H225 and H225e. Note Alaska daylight time (ADT). The pilot, the to Improve Helicopter Accident that the equipment is installed on heavy tactical flight observer (TFO), and the Investigation presented at ISASI 2015 held in Augsburg, Germany, Aug. 24–27, 2015, helicopters on top of the CVFDR. The im- rescued snowmobiler were killed. The which carried the theme “Independence age recording feature offers information helicopter was destroyed by impact forces Does Not Mean Isolation.” The full presenta- recording on top of the CVFDR require- and postcrash fire. Instrument meteoro- tion, including cited references to support ments, which is extremely valuable. The logical conditions (IMC) prevailed in the the points made, can be found on the ISASI certification for the AS365 N3+ and EC155 area at the time of the accident. This was website at www.isasi.org under the tag B1 is in progress and expected in 2015. the first fatal accident investigation ben- “ISASI 2015 Technical Papers.”—Editor) On the new helicopter type H145 it is efiting from the data captured with the

July-September 2016 ISASI Forum • 19 However, the helicopter’s Vision 1000 unit was recovered from the rubble at the accident scene (see Figure 2). The unit had been mounted on the cockpit ceiling centered between the two forward seats, but became separated from the aircraft structure during the impact event and found lying among the wreckage debris. Although the unit exhibited impact damage on the exterior case and power connector, the crash-hardened memory module and removable card were still intact and undamaged. The unit was shipped to the NTSB’s recorders laboratory in Washington, D.C., where the data were downloaded, Figure 2. Accident site and location of wreckage and Vision 1000. reviewed, and analyzed. The extracted data were plotted by the NTSB’s recorders Vision 1000 cockpit imaging and flight north of Anchorage. The helicopter and lab in the same manner that the para- data recording device. the pilot were restricted to a VFR oper- metric data reports of traditional flight With no survivors, no witnesses, and no ation, and current weather information data recorders (FDR) are processed. reported or recorded radio communica- available to the pilot presented a high risk Several plots were created to cover the tion—and without air traffic radar cover- due to night/low-lighting conditions with entire flight. The recovered data included age in this remote region of Alaska—the possible snow showers in the area. approximately two hours of image and information recovered from the aircraft’s According to the data collected from ambient audio data and 100 hours of Vision 1000 proved to be critical to Vision 1000 after the accident, the fol- parametric data. The images captured investigators. This is best illustrated with lowing information was witnessed and a forward-looking view of the cockpit the following statement from the NTSB’s later assembled with the other informa- from behind the pilot that included the executive summary of the accident: tion collected by the investigative team navigation and system instruments and “It is important to note that the investi- from witness and police dispatchers. displays, the master caution warning gation was significantly aided by infor- At 2111, the flight departed Anchorage panel, and a partial view out the cockpit mation recovered from the helicopter’s International Airport (ANC) in night VFR windscreen. Additionally, it captured onboard image and data recorder, which conditions and flew to pick up a TFO 15 some of the pilot’s left arm and head provided valuable insight about the acci- nautical miles south of Talkeetna. With motions and the TFO’s right shoulder (the dent flight that helped investigators iden- just the two state troopers on board, pilot was seated in the right seat, and the tify safety issues that would not have been the helicopter departed to the reported TFO was seated in the left seat). otherwise detectable. Images captured by rescue location coordinates under VFR The Vision 1000 images allowed inves- the recorder provided information about conditions with the pilot utilizing night tigators to see the activities of the crew, where the pilot’s attention was direct- vision goggles (NVGs). both before and after they picked up the ed, his interaction with the helicopter The recorded data show the aircraft injured snowmobiler—even in the dark controls and systems, and the status of landed at 2156 on a frozen pond just 200 night conditions. The image data revealed cockpit instruments and system indicator meters west of the given coordinates and that after the aircraft was started up in lights, including those that provided in- shut down. Almost an hour later at 2313, Anchorage, the pilot configured both of formation about the helicopter’s position, with the injured snowmobiler now on his available map-displaying navigation engine operation, and systems. Informa- board, the flight departed the rescue loca- systems, the Garmin 296 and the Avalex tion provided by the onboard recorder tion. This leg of the flight was reportedly system. To the Garmin 296, he entered provided critical information early in the destined for the staging area/landing site a “track up” map with a course line to investigation that enabled investigators just south of Talkeetna where the TFO his northerly destination. Consequent- to make conclusive determinations about was previously picked up. At 2320, seven ly, the pilot then made adjustments to what happened during the accident flight minutes after departure, the recorded the Avalex system by changing the map and to more precisely focus the safety Vision 1000 data ended. The accident display (which powered up in a “north up” investigation on the issues that need to be site was located the following day just 2.5 orientation) to a track-up display. He fur- addressed to prevent future accidents.” nautical miles south of the rescue loca- ther reduced the brightness and switched tion during the search after the aircraft from a street-map display to a topograph- was recorded missing. The accident ic-map display. At 2019, the pilot received notification Similarly, after starting the helicopter of a rescue mission involving a stranded, Information obtained from Vision 1000 for the departure from the rescue location hypothermic snowmobiler in a remote The aircraft was totally destroyed from at the frozen lake (the mishap flight), the location approximately 80 nautical miles the impact forces and postcrash fire. pilot made inputs to his Garmin 296 unit

20 • July-September 2016 ISASI Forum to display a track-up map with a magenta ISASI Joins IHST course line that extended to the south- Thanks to an initiative by Capt. Richard those in attendance at IHSS 2005. west (able to show terrain features like Stone, ISASI executive advisor, and Dr. The IHST was created to lead a gov- rivers and lakes), representing a direct Robert Matthews, ISASI has been invit- ernment and industry cooperative effort route to his destination. ed to join the International Helicopter to address the unacceptably high long- However, this time the pilot did not Safety Team (IHST). term helicopter accident rates. The IHST make adjustments to the Avalex system, Stone said the initiative results from chose to pursue the goal of reducing the which then remained in the north-up numerous discussions about the role worldwide civil and military helicopter map orientation and a street-map display ISASI should take in the current chal- accident rates by 80 percent in 10 years that showed the outlines of rivers and lenge of lowering the accident rate by adopting the methods that have been in helicopter operations of all types, used by the Commercial Aviation Safety lakes. Unlike his initial flight to the rescue including medical, law enforcement, Team (CAST) to substantially reduce location, the two displays were presented business, commercial, etc. Many tech- the worldwide fatal accident rate in the with different orientations. nical papers concerning the subject commercial air carrier community. The Garmin 296 was physically located have been presented at ISASI’s annual The process used by CAST was directly closest to the pilot’s ease of view under international accident investigation and linked to real accident data, used a broad his NVGs on the right side of the instru- prevention conference. spectrum of industry experts to analyze ment panel whereas the Avalex was on “Our thoughts were presented to the it, and included objective success meas- the far left side of the panel. With the FAA’s Dr. Steven Sparks, who is leading urements to ensure that the actions taken images showing the TFO and the pilot the effort of the International Helicop- were having the desired effect. pointing to the map display on the Avalex ter Safety Team. Dr. Stevens asked me The all-volunteer IHST effort is coordinated by an executive committee that is and constant head movement across the and Robert Matthews to join their large committee of helicopter representa- co-chaired by a senior representative of panel, different from a regular instrument tives,” said Stone. the FAA’s Rotorcraft Directorate and by scan, it became apparent that the pilot “Our ISASI contribution will be to the president of the Helicopter Asso- was handling all the navigational tasks put together a comprehensive look at ciation International. Other members himself during the accident flight—and helicopter accidents in the recent past. represent the America Helicopter Society that he did not optimally configure the We plan to present the complete report International, the Helicopter Association helicopter’s navigational equipment and of our findings at ISASI 2017, which of Canada, the European Helicopter As- flight instruments before departure. will be held in San Diego, California. sociation, the European Helicopter Safety Furthermore, it was evident that only the Our database will cover more than 676 Team, the National Aeronautics and pilot was using NVGs on both legs of the helicopter accidents from 2001 to 2015 Space Administration, helicopter manu- flight. The pilot’s hands were seen raising, in many of parts of the world.” facturers, and the International Associa- tion of Oil and Gas Producers. lowering, and adjusting his NVGs several The IHST was established following the International Helicopter Safety The initial effort focused on the U.S. times during the entire flight. Symposium (IHSS) held in September helicopter fleet and has grown to en- 2005 in Montreal, Canada, where the compass international partners in Brazil, The mishap leg central theme was the recognition that Canada, India, Australia, the Gulf Cooper- The Vision 1000-recorded flight track data long-term helicopter accident rates ative Council, and Japan. In addition, the were overlaid with weather depiction have remained unacceptably high, and European Helicopter Safety Team joined charts. Thus, the investigators were able trends have not shown significant im- in 2007 to cover the European helicopter to see the flight’s encounter with IMC that provement over the last 20 years. A call fleet. Outreach efforts are under way in had accumulated in the area during the to action was unanimously accepted by Russia, Mexico, South Africa, and Korea. time of the rescue. With just the track information from Vision 1000 overlaid with a mapping software, like Appareo’s AS-Flight Analysis or even Google Earth, the investigation team was able to retrace the flight (see Figure 3). The first leg was a straight and level flight path at a fixed altitude (~1,200 feet MSL) from Anchorage to the staging area for the TFO pickup and again a direct leg to the frozen lake near the rescue location. However, when the mishap flight departed the frozen lake in a southwest direction, it was noted that its flight path track was at a much lower altitude (~700 feet MSL), apparently tracking a nap-of- the-earth profile. Approximately one mile out from the departure point, the pilot made an abrupt Figure 3. End of the flight path; pilot cages gyro and accident site.

July-September 2016 ISASI Forum • 21 90-degree turn to the east. This was the Vision 1000 data results components or systems failed or first indication that the pilot may have • Human factors—Typically investi- began to weaken or disprove spec- been disorientated. Shortly after the gators have only been able to gath- ulation on technical failures if the turn, it appears that the track had been er personality, health, and ability systems were recorded healthy during realigning with cross-country high-ten- information from family, friends, or the flight. sion power lines that run generally north doctors. In addition, to understand • Environmental factors—Generally to south. Then the flight continued at a how pilots and crews would normally investigators have only had meteoro- low level with a southerly heading. After utilize or interact with the aircraft logical information that was reported and its systems, they would glean approximately two miles, the flight came and/or collected by weather service from statements of other employ- to a clearing in the trees where the final outlets at varying times and distanc- ees, friends, or colleagues who have stages of the track were shown making es away from the accident site. With worked with the crew in the past. Vision 1000, recorded images show noncoordinated maneuvers in both Now with Vision 1000, investigators direction and altitude. In close proximity segments of the weather around the are able to see the actual human con- aircraft at the time of the event. to this area, the flight track ended at the dition and engagement at the time accident site on a heading of 030 degrees. of event. With flight data monitoring The inclement weather may have (FDM) history, investigators can see Vision 1000 data value for this accident explained the 90-degree left turn to the flight operational/behavior trends as investigation east and then realignment back to the well. Trends that are an important aspect of the investigators’ collection • Investigators were able to capture the south when the pilot saw a power line entire flight on both image and digital pole directly out in front of him. Deter- process include the pilots’ recent experience or their 72-hour history. parametric data and were able to mining the cause of the sporadic nonco- replay the flight for detailed analysis. ordinated maneuvers at the end of the Typically, investigators only know flight was a focus of the investigation. what is reported by friends, family, • The image recording was instrumen- or employers. However, with FDM tal in determining the accident cir- The parametric data from the digital history, the trends are logged with cumstances by enabling investigators gyro information of the Appareo unit time-stamped records that show to identify “why” the event happened was correlated with the aircraft’s analog the workload expressed in the flight and not just “what” happened. Also, it instrument readings that were obtained from the captured image information to further understand the mishap sequence (see Figure 3, page 21). The actions of the pilot as seen in the image information revealed the “why” and “what” that contributed to the ultimate peril of the flight. At approximately 2318, just after the helicopter flight path was seen to slow down and almost began to hover in the clearing of trees, the helicopter began to drift up and turn back and to the left, as the pilot reached out and caged the attitude indicator gyro during the flight. Caging an attitude indicator sets its display to a level flight attitude (0 degrees pitch and 0 degrees Figure 4. Overview of available information for accident reconstruction. roll). This action is intended to be performed only when an aircraft is in a level activity levels, and further review can confirmed the absence of mechanical flight attitude, such as on the ground show fatigue or actual pilot handling. malfunctions as determined during or in straight-and-level, unaccelerated the traditional wreckage examination. flight. After this event, the helicopter • Mechanical factors—Typically investigators have only had aircraft • The images showed that the pilot entered a series of erratic turns, climbs, engineering records or logbook infor- caged the attitude indicator in flight. and descents. mation, culminated with tedious fo- This discovery resulted in developing The parametric data confirmed the rensic analysis on postaccident parts important safety recommendations pilot’s action of caging the attitude indi- and pieces for operational integrity related to pilot recurrent training and cator gyro that was seen in the recorded or failure modes analysis. However, attitude indicator limitations. It also images. Without the imagery and para- now with the onboard Vision 1000, highlighted the dangers of instru- metric data obtained from the Appareo investigators are able to see many of ment panel information overload unit, we would never have known this the aircraft’s mechanical, electrical, in using multiple mapping tools by pilot action and would have lost critical or pneumatic systems function from identifying the difference in navigat- information on the contributing factors the pilot’s point of view. As well, with ing with one unit displaying track up leading to the accident FDM history we can see at what time versus north up. The discovery is also

22 • July-September 2016 ISASI Forum dent. However, more and more accidents are recorded by witnesses with their smartphones or by surveillance cameras. The Immersive Witness Interview (iwi®) is designed to compensate for inaccuracies in witness information and to quickly approximate the available information. The method iwi® was developed in 2009 to make use of available witness information for accident reconstruction with reduced time and costs, especially for accidents with limited information available (missing radar data due to low flight altitude and/or FDR data not available) as shown in Figure. 4

Quality and accuracy of witness statements The quality and accuracy of a witness statement depends on the stimulation of Figure 5. Witness awareness, memory, and the influence of stress on memory accuracy. a witness memory, the complexity of the useful in preventing future accidents of a detailed and expensive postcrash observation, and the level of stress that from practices like caging the gyro in investigation analysis. occurred to the person during the situa- flight. • Although the intercommunication tion. Figure 5 shows the overview of the • It provided strong information about system audio recording was not in- main senses of a human and information where the crew’s attention was stalled, the ambient audio recording of an aircraft observation. An eyewit- directed. allowed the resonation of the main ness uses surrounding objects/reference rotor blade RPM and transmissions to • It showed the pilot’s interaction with objects to recall the observed aircraft the helicopter’s input flight controls be heard. positions and movements. and systems. The accuracy of a testimony has been Immersive Witness Interview (iwi®) differentiated between a simple (linear • It showed the cockpit configuration, flight, for example an aircraft flying by) e.g., GPS/mapping units; the status methodology and a complex observation (dynamic of cockpit instruments, switches, and The analysis of aircraft accidents can be indicator lights, including those that complicated and time-consuming, espe- flight, for example an acrobatic air show provided information of the aircraft’s cially when limited information about the flight with many maneuvers). According systems; navigation and position; flight path and the accident situation are to psychology studies, Figure 5 shows in engine operation; and tools in use available. Eyewitnesses can be taken into the lower left that the memory accura- by the pilot, such as his lip light and account, but it is often difficult to find out cy of simple and complex observations NVGs. which witness is giving accurate informa- differs with the amount of stress the • It excluded any technical issues on tion and which one can provide a good eyewitness is experiencing. the helicopter without the necessity statement regarding the observed acci- A minimum amount of stress is required to give a minimum amount of attention to the observation to gather a necessary amount of information. Stress during an observation can also reduce the amount and quality of the information that is stored in the human memory—for example, emotions or a situation that puts the witness in danger.

Witness information processing Witness reports are transformed into 3-D coordinates, and the flight path of an observed aircraft can be approximated considering all potential errors. Iwi® was evaluated in the beginning of 2009 with a Figure 6. Reconstructed flight path (black line), lines of sight (grey lines), test in real circumstances in cooperation and radar data (grey path). (Continued on page 29)

July-September 2016 ISASI Forum • 23 cal system. The international regulation ICAO Annex 13 has developed accordingly and is providing a good foundation for the conduct of complex investigations. One important element is the organization of teams, according to ICAO Annex 13. It not only stipulates rights and duties of the states of design, manufacture, registry, and oper- ‘Independence Does ator involved in the investigation, but also establishes the basis for the organization of teams. The advantage: the synergistic effect Not Mean Isolation’: of the concentrated know-how. The state conducting the investigation and therefore A Practical Approach the SIA responsible for the investigation gain important advantages by establishing Due to the complexity of modern aviation, a safety investigation teams. The responsible SIA has to ensure requires a maximum involvement of manufacturers, airlines, and pilots. the most important requirement—protect- ing the independence of the investigation. By Johann Reuss, German Federal Bureau of In past years, major transport aircraft Aircraft Accident Investigation accidents worldwide have shown that the implementation and use of accredited representatives (AccReps) and advisers in accordance with ICAO Annex 13 are factors in an effective safety investigation. Other factors—and also challenges—are the contact and interaction with the news media and relatives and the cooperation with police, prosecution, other non-ICAO Annex 13 authorities, politicians, and legal representatives. In Germany, the standards of ICAO Annex 13 are applied in the Regulation (EU) No. 996/2010 and the he work of safety investigation authorities (SIA) national Law Relating to the Investigation into Acci- has changed in the course of the last few years. dents and Incidents Associated With the Operation of Currently, and in the future, not just the causes Civil Aircraft (FIUUG). Tin accordance with the definitions in the Inter- national Civil Aviation Organization’s (ICAO) Annex SIA independence 13 will be the focal point of an investigation. More and The BFU is the responsible SIA for the investigation more investigations are influenced by the news media, into accidents and serious incidents in civil aviation family members of accident victims, the exchange of and has to adhere to European and national require- important information with other authorities, and na- ments. The BFU is subordinated to the federal Min- tional and international politics. Due to the complex- istry of Transport and Digital Infrastructure (BMVI). ity of modern aviation, a safety investigation requires The national flight accident investigation law stipu- a maximum involvement of manufacturers, airlines, lates the professional independence of the BFU. Based and pilots. on this law, the director of the BFU decides to initiate This article uses some examples to show how the an investigation and appoints the responsible investi- German Federal Bureau of Aircraft Accident Investiga- gator-in-charge (IIC), who then determines the extent tion (Bundesstelle für Flugunfalluntersuch- and depth of the investigation. The director of the BFU ung—BFU) incorporates this involve- also decides whether safety recommendations are (Adapted ment in its work today. Experiences issued. The IIC identifies and describes the safety defi- with permission and indications of earlier investi- cits that are determined by the investigation. The BFU from the author’s technical gations are presented. is of the opinion that this mode of operation practiced paper entitled “Independence In the 1970s and 1980s, the since 1998 provides maximum independence. The Does Not Mean Isolation”: A Practical determination of “technical” BFU has the legal right to ignore any kind of profes- Approach presented at ISASI 2015 held in causes was widely practiced. sional instructions or interference. Augsburg, Germany, Aug. 24-27, 2015, which Nowadays, an investiga- However, the BFU has never interpreted this legal carried the theme “Independence Does Not tion goes beyond that and Mean Isolation.” The full presentation, independence as isolation. Many investigations of the including cited references to support the includes complex connec- past years—especially the investigation of the acci- points made, can be found on the ISASI tions between machine and dent near Überlingen in 2002—have shown that the website at www.isasi.org under the human beings and organiza- improvement of flight safety is more than just deter- tag “ISASI 2015 Technical tions. From the vantage point mining the causes of an accident. It has also become Papers.”—Editor) of the present, humans are one clear that duties and requirements of other parties are element in a complex sociotechni- justified and have to be supported.

24 • July-September 2016 ISASI Forum Criteria of an effective safety investigation involved is indispensable. To achieve this, me it is possible to put independence in The requirements for effective safety relatives, the news media, and politicians the center of attention and not isolate investigations have changed over time. must be provided with information. A the SIA in the process. It is my opinion During the 1970s, an investigation was major investigation is effective if that this concept can be implemented in considered “good” if the technical cause, • rights of SIAs of states involved are Germany, Europe, and many other places e.g., the fractured pin, was found. During adhered to in accordance with ICAO in the world. the 1980s, operational aspects were added Annex 13 and proper exchange of As the IIC at the BFU, I can say that the to the technical ones; during the 1990s, information occurs. BFU has consequently implemented the human factors received more attention. • the investigation process is viewed as theme of the ISASI 2015 meeting “Inde- Then other combinations became the transparent. pendence Does Not Mean Isolation” since focus: The interface between humans and the Überlingen accident. The establish- machines or the breakdown into indirect • the final investigation report lists ment of the European and national regu- and direct causes were forms of describ- the causes, and the subsequent lations (Regulation No. 996/2010 and the ing the causes that had the quality criteria safety recommendations are FlUUG) created the necessary framework. “state of the art.” comprehensible. Some tools and methods are neces- The Swiss cheese model by James Rea- • the news media receives sound facts sary or at least helpful to ensure that “we son illustrates the connection between about the ongoing investigation. are not isolating.” One example is the latent and active human failure contrib- communications model that we basical- • relatives receive sound facts about uting to the collapse of a complex system. ly use during major investigations. This the ongoing investigation before the The chain of causes becomes evident. The communications model defines three news media does. model described by Reason is accepted by responsibilities: SIAs the world over and defines the struc- • the ministry responsible for the SIA 1. The director of the BFU has the ture of the analysis in the investigation and other politicians receive sound overall responsibility. He decides if report, sometimes in modified forms. facts about the ongoing investigation. the investigation is a major investi- The BFU successfully applied this gation and appoints an IIC. model during the investigation of the • police and the public prosecution mid-air collision near Überlingen (South- department not only receive sound ern Germany) on July 1, 2002, involving a facts about the ongoing investigation, Boeing 757-200 and a Tupolev TU154M. but also exchange information in The differentiation between direct and accordance with valid regulations (in indirect causes illustrated the back- Europe: Regulation No. 996/2010; in grounds for the accident very well, and Germany: the FlUUG). the subsequently identified safety deficits were a good foundation for the safety rec- • licensing and regulating authorities ommendations the BFU later issued. But are involved in accordance with reg- times do change here also. Nowadays, the ulations (in Europe: EASA; in Germa- examination of human factors includes ny: Luftfahrt–Bundesamt (LBA); and resilience engineering, i.e., determination authorities responsible for air traffic and description of causes are continuous- management). ly improved. • appropriate and objective attention There is no doubt that the current mod- (in accordance with the regulations) els and presentations allow a very precise to enquiries and demands of legal ad- and detailed description of causes. Today, visers (solicitors) of parties involved the formal investigation report of an in- is given. dependent SIA in accordance with ICAO Annex 13 or Regulation No. 996/2010 is If these aspects are viewed as a task Johann no longer the sole quality characteristic breakdown of the SIA, it becomes clear Reuss holds a of a major investigation. Above and be- that a major investigation can be a chal- degree in engineering and has yond the quality of the investigation lenge. The SIA must focus on its inde- been working since 1987 as an acci- report and the safety recommendations, pendence, which must not be compro- dent investigator for the German Federal Bureau of Aircraft Accident Investigation the perception of the investigation mised. However, the task breakdown (Bundesstelle für Flugunfalluntersuchung— process by the public, the relatives of acci- also shows very clearly that independ- BFU). He has participated in several national and dent victims, and politicians should not ence should not be confused with international aircraft accident investigations as an be underestimated. isolation of the SIA. The organization of the SIA and the individual IICs have investigator-in-charge, an accredited representative, We, as safety investigators, know that adviser, or an expert for investigation of avionic to take care of the independence of the an investigation can only be effective if equipment. Reuss is deputy director of the BFU investigation and the communication the investigation process is clear and in- and is a lecturer for the aircraft accident investigation results and subsequent safety with parties involved. vestigation course at Cranfield University recommendations are comprehensible. I have almost 30 years’ experience as an in the UK. The acceptance and perception of an investigator in different capacities during independent and successful investigation varied investigations. My experience and by the parties either directly or indirectly the development of the regulations show

July-September 2016 ISASI Forum • 25 2. The IIC is responsible for the extent Case Study: during the night all open worksta- and depth of the investigation. tions were continuously staffed by 3. The spokesperson is responsible Überlingen accident controllers. for public relations. On July 1, 2002, a mid-air collision • Management and quality assurance The communications model describes in cruise flight involving a Tupolev of the air navigation service company the process for the exchange of infor- TU154M and a Boeing 757-200 tolerated for years that during times mation during an ongoing investigation. occurred in Southern Germany. of low traffic flow at night only one The IIC reports to the director and the The TU154M was on a flight from controller worked and the other one spokesperson the determined facts of the Moscow, Russia, to Barcelona, Spain. retired to rest. ongoing investigation. Initially the inter- The B-757-200 cargo airplane was The description of the causes illustrates vals of such reports are rather frequent on a flight from Bergamo, Italy, to the complexity of the investigation. The and become longer over time. The validity Brussels, Belgium. Both aircraft flew international importance of the accident of the information is discussed, and it is according to IFR (instrument flight posed an additional challenge for the established which pieces of information rules) and were under control of BFU. Both aircraft had foreign registra- will be passed on to which party at what ACC Zurich. After the collision, both tions, and the passengers of the Tupolev time. The communications model also aircraft crashed into an area north of were mainly children and young adults defines who provides outside parties with Überlingen. There were a total of 71 from Bashkortostan in the Russian Fed- relevant information and presents results people on board the two airplanes, of the ongoing investigation. The tasks are eration. In addition to the investigation and none survived. aspects in accordance with ICAO Annex distributed as follows: The BFU investigated the accident • The director of the BFU informs 13, the political significance and the news (file No. AX001-2/02) in accordance the BMVI and answers politicians’ media attention played an important role. with ICAO Annex 13 involving other questions. The BFU gained substantial insights states. The final report stated the from this particular safety investigation. • The IIC pays attention to the inter- causes as follows: The following insights relate to this year’s face between prosecution authorities, theme “Independence Does Not Mean such as police and public prosecu- Immediate causes Isolation.” tion. He or she also informs persons • The imminent separation in- The accident near Überlingen explains involved and relatives of accident fringement was not noticed by victims. The IIC is also responsible for very well the importance of an inde- ATC in time. The instruction for pendent safety investigation, because everyone involved in the accident and the TU154M to descend was giv- safety deficits were identified in several their legal advisers. en at a time when the prescribed places of the “system aviation.” Five • The spokesperson is responsible for separation from the B-757-200 could no longer be ensured. addresses received a total of 19 safety all news media enquiries and also recommendations. coordinates interview requests with • The TU154M crewmembers With the benefit of hindsight, valuable the director and the IIC. followed ATC instruction to experience can be derived from the descend and continued to do so Everyone involved in this communica- public relations work, the assistance tions process is aware that only coordi- even after TCAS advised them to climb. This maneuver was per- of family members of victims, and the nated and secured factual information formed contrary to the generated cooperation with the police and is given to outside parties. In addition, TCAS RA. prosecution department. information is given in general terms Public relations—The police at the ac- regarding the investigation and reporting cident site conducted most of the work process. Systemic causes with the news media. BFU staff members A similar communication model is • The integration of ACAS/TCAS II in Braunschweig answered news media appropriate for the team work with into the system aviation was in- enquiries addressed directly to the BFU. sufficient and did not correspond AccReps and advisers. At a very early Active public relations work on site by the stage of an investigation process, the in all points with the system BFU was almost nonexistent. IIC and the AccRep, respectively, should philosophy. The regulations con- These experiences and others derived define responsibilities and rules for com- cerning ACAS/TCAS II published from investigations conducted in the munication. We have to keep in mind that by ICAO, and as a result the last years have made clear that active AccReps and advisers are not completely regulations of national aeronau- independent. AccReps have to keep their tical authorities, and operational public relations work after an accident national SIAs informed, and advisers are and procedural instructions of and during the ongoing investigation in constant contact with their respective the TCAS manufacturer and is indispensable. It is also true that the companies. the operators were incomplete, changing news media scene plays an partially contradictory, and not important part. The modern media scene, standardized. including the social media scene where • Management and quality assur- users exchange information among ance of the air navigation service themselves, makes a structured and tar- company did not ensure that geted approach necessary. The BFU now

26 • July-September 2016 ISASI Forum has a press office to meet these require- the FlUUG. Of the accidents, serious incidents, and ments. In regards to internal exchange of In Germany, two independent inves- incidents reported to the BFU between information, the communications model tigations take place after an accident: 2006 and 2013, a total of 845 cases were described above is proven and tested. one conducted by the BFU and one by taken into consideration. A connection Informing the relatives of accident vic- the prosecution department. The FlUUG with cabin air could be determined in 663 tims—The day after the accident, relatives describes the cooperation “…in consulta- reports. In 460 of these reported fume arrived at the site from Bashkortostan, tion with the local prosecuting authori- events, smell development was reported, and local organizations and authorities ty....” This means that the BFU and police and in 188 cases smoke development was took care of them in a very professional have access to the wreckage and other reported. In 15 cases, there was neither fashion. evidence and have to make arrangements smell nor smoke but health impairments. In the first days after the accident, concerning the use of evidence. The For this study, the BFU divided the the BFU did not have any direct contact prosecution department can decide to reported occurrences into the following with the victims’ family members. In the appoint its own experts. The investigation categories: course of the ongoing investigation, rel- into the accident near Überlingen applied • Fume events affecting flight safety. atives of victims or their representatives these principles. On site, facts were de- • Fume events possibly affecting the made direct enquiries. The IIC answered termined and exchanged. After the field occupational safety of crewmembers. these enquiries in regard to the investi- investigation was finished, the BFU and • Fume events affecting the comfort of gation process and the results by giving police, having different aims, conducted aircraft occupants. factual information. After the first interim their investigation processes separately. report had been published, an alleged The police had access to the flight data • Fume events and possible long-term spokesperson of the relatives asked the recorder (FDR) and the cockpit voice effects on aircraft occupants. BFU for information concerning the recorder (CVR). The BFU is of the opinion investigation and said he would then that the cooperation during the investiga- Relevance for flight safety, flight personnel, inform the other relatives accordingly. tion was very constructive and that deci- and passengers At a later date, it turned out that he was sions were made in mutual agreement. The data analysis for this study showed a legal representative working only for a After Regulation No. 996/2010, Para- that the criteria for a serious incident small group of relatives. graph 14, was implemented, information were met by some of the fume events, Before the final report was published, had to be assessed in regard to its sensi- because the cockpit crewmembers de- the BFU in Braunschweig set up a meet- tivity and protected accordingly. In gen- cided to don their oxygen masks or one ing so that relatives could receive infor- eral, data protection becomes important. pilot was partially incapacitated. In a few mation ahead of the public. Only a few Paragraph 14, Subparagraph 3, allows of these events, the safety margin was relatives took advantage of the meeting. for consideration whether other authori- reduced such that the safe conduct of the It was especially tragic that one relative ties, e.g., prosecution authorities, should flight was affected. There were clear indi- decided to kill the controller involved in receive sensitive information. Germany cations of health impairments in terms of the accident before the final report was implements this requirement together occupational health for the pilots and the published. He believed the controller was with the stipulations from the FlUUG. cabin crew. to be blamed for the accident. After commensurate consideration, other The BFU came to the conclusion that Today Regulation No. 996/2010, Para- authorities may receive information. compared to all reports, a significant graph 21, stipulates that all EU member number affected the comfort of passen- states have to ensure the support of gers only. These are reports that describe, victims of accidents and their families Case study: fume events for example, unpleasant but harmless and relatives. In Germany, the BFU sup- Last year, the BFU published a study, file smells. In 10 of all fume events reported ports the relatives of victims through the No. 803.1-14, on the issue of fume events. to the BFU, the reporting person report- IIC giving information to them during I am going to use this study as an example ed long-term health impairments at a each phase of the investigation. The BFU of the significance of communication in later date. All these incidents were fume also supports the responsible authorities respect to this year’s theme “Independ- events in which either oil smell or “old caring for the relatives. ence Does Not Mean Isolation.” socks” were reported. In eight cases, the Similar to public relations work, this The background and content of the BFU learned that the reporting person experience has shown how important it is study were as follows: For the last few received medical treatment. to organize active and targeted informa- years, the BFU has been receiving an tion distribution to the relatives of acci- increased number of reports of so-called Analysis dent victims. It is most important that the fume events. These kinds of events The fume events taken into account in relatives receive firsthand information. include smell, smoke, or vapor inside the this study showed that no significant Cooperation with police and prosecution airplane and/or health impairments of reduction of flight safety occurred. The department—During the investigation aircraft occupants. In addition, this topic study did show that fume events occur into the accident near Überlingen, the was increasingly discussed among flight and can result in health impairments. cooperation with the prosecution crews, occupational unions, the news With the methods of air accident investi- authorities occurred in accordance with media, and in political committees. gation, the BFU cannot assess the possi-

July-September 2016 ISASI Forum • 27 ble long-term effects of fume events. problem exists. of the fuselage and the cargo. The BFU issued four safety recommen- 2. Objectifying the issue and clearly The proper landing technique and the dations along with the study. Addressees illustrating the duties and activities bounce recovery technique were not were the German Aerospace Indus- the BFU has in this regard. applied. The aircraft was destroyed. The tries Association (Bundesverband der 3. Communicating the BFU point of first officer sustained serious injuries. Deutschen Luft–und Raumfahrtindustrie view and the results of the study to From the BFU point of view, the investiga- e.V.—BDLI), the German Aviation Asso- the federal government and politi- tion was effective and was conducted in ciation (Bundesverband der Deutschen cal committees. close cooperation with the safety inves- Luftverkehrswirtschaft—BDL), and the The study showed that concrete tigation authorities and the advisers of European Aviation Safety Agency (EASA). questions still needed clarification. The the aircraft operator and aircraft manu- The safety recommendations aim at BFU determined no relevant flight safety facturer involved. The Safety Department 1. Improvement of identification issues but issued safety recommendations of the General Authority of Civil Aviation and avoidance actions of cabin air recommending scientific investigations to of the Kingdom of Saudi Arabia issued contamination possibly hazardous clarify open questions. the following safety recommendation to health. It became clear that the independence along with the publication of the final 2. Improvement of the reporting of the BFU was an important and vital report: Lufthansa cargo should consider procedure. factor. In addition, it was important installing head-up displays (HUDs) on its 3. Improvement of the demonstration to maintain communications with the MD-11F aircraft. of compliance of cabin air quality responsible ministry and political com- Despite the significant expense, the during the certification process of mittees. By keeping the communications aircraft operator accepted and supported transport aircraft. channels open, political committees the safety recommendation to equip the 4. Assessment of a possible connec- responded with great acceptance of the Lufthansa Cargo MD11 fleet with tion between long-term health study and, at the same time, speculations head-up displays. The SIA involved the impairments and fume events by a prior to publication were prevented. aircraft operator early on in the qualified institution. The BFU exchanged information with decision-making process regarding all addressees of safety recommendations the safety recommendation. Reasons for the study and intensive prior to publication of the study. Due to The safety recommendation could not communication these meetings, the formulation of the be realized because it was not possible to In Germany, cabin air quality, and espe- safety recommendations was more pre- find a design organization and a manu- cially possible oil fumes contamination, cise, and the addressees were prepared. facturer for the head-up display. Several has been on the radar of the news media meetings with the aircraft operator, the and public for several years. The BFU BFU, and EASA took place as well as received a number of reports from flight- Case Study: MD-11 consultations with the Safety Department crew members concerning smoke and On July 27, 2010, at King Khalid Interna- of the General Authority of Civil Aviation smell developments in aircraft cabins that tional Airport in Riyadh, Saudi Arabia, a of the Kingdom of Saudi Arabia. These re- were associated with health impairments. Boeing MD-11 registered in Germany and sulted in a mutual agreement that instead Political committees and different news operated by a German operator suffered of a head-up display a simple indicator media communicated and discussed an accident during the landing. The Safety would be installed in the cockpit, which these types of occurrences and possibly Department of the General Authority of would indicate an additional liftoff after associated health impairments. The BFU Civil Aviation of the Kingdom of Saudi touchdown. had only individual cases that were classi- Arabia conducted the investigation in ac- Subsequently, a discussion lasting fied as serious incidents. cordance with ICAO Annex 13. The BFU, several months ensued among the aircraft Over time, public and political pressure representing the state of operator and operator, the aircraft manufacturer, increased considerably. The BFU repeat- registry, and the U.S. National Transpor- EASA, the U.S. Federal Aviation Admin- edly had to appear before committees tation Safety Board (NTSB), representing istration (FAA), the NTSB, and the BFU of the Deutscher Bundestag (German the state of design and the manufacturer, whether a safety deficit even existed that Parliament) for hearings regarding this participated in the investigation. could be fixed with the intended action. issue. Respective news coverage and the The MD-11F was on a flight from Frank- After the aircraft operator had conducted discussion in political committees criti- furt, Germany, to Riyadh, Saudi Arabia. several demonstrations of compliance cized the reporting culture of airlines and During the landing phase on Runway regarding the necessity and feasibility of the limited investigations by the BFU. 33 Left in Riyadh, the MD-11F bounced the intended action, and discussed them Due to this, the BFU decided to assess during the initial firm landing, which was with EASA, the safety recommendation all reports of possible cabin air contami- followed by two hard landings. The aft could finally be implemented. nations from 2006 until 2013 and publish fuselage ruptured, and the aircraft even- This case, BFU file No. 2X003-10, a study in accordance with Regulation No. tually stopped to the left of the runway showed quite clearly that without an 996/2010. In May 2014, the BFU published following the collapse of the nose gear. A independent safety investigation in the study. The study aimed at fire occurred in the area of the ruptured accordance with ICAO Annex 13 this 1. Clarifying if a relevant flight safety fuselage, which consumed a great portion safety recommendation to install head-up

28 • July-September 2016 ISASI Forum displays would never have been made. MODERN TECHNOLOGIES AND METHODOLOGIES And there we once more come full circle IMPROVES HELICOPTER ACCIDENT to this year’s theme “Independence Does Not Mean Isolation.” It also shows that (Continued from page 23) the safety recommendation would not with the Federal Armed Forces Flight gathered experiences: http://www. have been implemented if the different Safety Division and support by the Ger- iwi.eu parties—aircraft operator, registration man Air Force. A real flight was observed authority, and SIAs—had not worked • Free app to perform interview on and reconstructed based on testimony together. iPad: http://app.iwi.eu information. The amount of time between The BFU has learned in this process witness observation and interview had Iwi® has been presented to several inter- that intended safety recommendations been evaluated as well. national authorities, including the Bun- should be discussed early on with the The witness interview using iwi® can desstelle für Flugunfalluntersuchung, the addressees and that there are cases where be performed in an office environment Bureau d’Enquêtes et d’Analyses pour la support in the implementation phase is at any time without limits due to weath- Sécurité de l’Aviation Civile, the European absolutely necessary. er and day conditions. Only the witness Aviation Safety Agency, the NTSB, and position and the possible area where the the FAA. It has been successfully applied Conclusions witness was standing during observation since 2009 to support different investiga- Effective flight safety work through the have to be identified on site. Witness tions in Africa, Argentina, Australia, Chile, investigation of accidents and serious statements can be recorded with the free Germany, and the United States. Some incidents requires independent SIAs. The iwi® app. published reports can be found at http:// requirements of international, European, The information (witness statements or www.iwi.eu/references.html. and national regulations constitute a videos) is loaded into the Immersive Wit- good basis for a comprehensive, verifia- ness Analyzer (IWA), which approximates Iwi® experiences and lessons learned ble, and clear investigation. the flight path with the assigned errors. This new method can especially help to We should come to the important The performed iwi® studies have shown investigate accidents of small helicopters conclusion that a significant aspect of our that the error of a described aircraft and aircraft that are not equipped with an work is the independence of the SIA, but position increases in elevation with the FDR to reconstruct the flight path. Airbus this should not lead to isolation of the distance of the original aircraft position Helicopters has supported this develop- safety investigation and respective activ- to a referenced object (for example, a ment to provide as much information as ities. On the contrary, as important as it tree, house, mountain). The iwi® method possible to clarify the cause of an acci- is for the SIAs to involve the AccReps and takes all relevant errors into account, for dent to maximize the lessons learned. their advisers in the investigation process, example the distance of the witness to Even if the aircraft was equipped with as ICAO Annex 13 requires, it is equally the reference objects, which drives the an FDR or radar data are available, this vital to keep open the communications errors in elevation and azimuth. Thus, a method allows merging witness informa- channels with the respective ministry, the reference object close to a witness causes tion with the available information, prosecution authorities, accident victims, a bigger error for the reconstructed flight thus taking into account all available and their relatives. Finally, for implemen- path. information. tation in practice, here are “some “golden Based on at least two different witness The iwi® method provides a way for rules.” As anywhere in life, applying these reports or videos taken from different po- witnesses to give a more visual, objec- “rules” might serve you well: sitions, a flight path can be reconstructed tive recollection of their observations in • Tell the truth. by IWA. The result contains the aircraft comparison to conventional techniques. • Keep it simple. positions showing the approximated Investigators can leverage this informa- • Focus on factual information or (fi- flight path with the estimated error but tion to better understand the flight path, nal) content of the report. without time information. The attitude of attitude, and maneuvers of the aircraft the aircraft can be individually given due prior to impact, which is crucial to under- • Explain the aim and process of the to witness description or video infor- standing the causes and contributing fac- safety investigation. mation. The results can be shown to the tors of accidents. Experience has shown The BFU is convinced and speaks from witness for final verification. the following: 1. There is a strong corre- its own experience that it is possible to A final reconstruction (see Figure 6, lation between the number of witnesses implement these requirements in page 23), is calculated based on Newton’s and the accuracy of the reconstructed Germany, Europe, and large parts of the iterative method, and the total residuum flight path. 2. There is also a strong cor- world. declares the maximum error of the recon- relation between the number of different structed flight path. vantage points and the accuracy of the All the necessary information is gath- reconstructed flight path. 3. Witnesses ered during an interview with the witness. who observe the flight path without any For more information, visit the following significant reference objects seem to have links: difficulty judging altitude. • Overview about the method and To illustrate the usefulness of the July-September 2016 ISASI Forum • 29 ISASI Information OFFICERS President, Frank Del Gandio ([email protected]) Executive Advisor, Richard Stone ([email protected]) Vice President, Ron Schleede ([email protected]) Secretary, Chad Balentine ([email protected]) Treasurer, Robert MacIntosh, Jr. ([email protected]) COUNCILLORS Australian, Richard Sellers ([email protected]) Canadian, Barbara Dunn ([email protected]) European, Olivier Ferrante ([email protected]) International, Caj Frostell Figure 7. Car camera view with imported lines of sight (lower right), reconstructed ([email protected]) helicopter path, and pilot’s perspective (upper right). New Zealand, Alister Buckingham ([email protected]) method, a flight path of an event has this information based on camera lens Pakistan, Wg. Cdr. (Ret.) Naseem Syed Ahmed ([email protected]) been reconstructed using information information and the locations of visible United States, Toby Carroll obtained from two witnesses (“red” and reference objects as shown in Figure 7, ([email protected]) “blue” witness). The witnesses described an example showing the capabilities an observed flight path that depicted of iwi® to reconstruct a moving object NATIONAL AND REGIONAL a relatively horizontal track, seemingly based on moving witnesses. SOCIETY PRESIDENTS from east to west, only slightly descend- AsiaSASI, Chan Wing Keong ing as it moved across the horizon from Conclusion ([email protected]) Australian, Richard Sellers their vanish point In the absence of data-recording equip- ([email protected]) It is obvious that both witnesses’ ob- ment on many helicopter operations, Canadian, Barbara Dunn ([email protected]) servation are matching, increasing their it is often extremely difficult to obtain European, Keith Conradi credibility. Yet in reality, the observed a proper and detailed causation for ([email protected]) flight path, once mapped into the 3-D Korean, Dr. Tachwan Cho (contact: Dr. Jenny helicopter accidents. Thus, a strong Yoo—[email protected]) mountainous terrain, was not from east initiative was taken by Airbus Helicop- Latin American, Guillermo J. Palacia (Mexico) to west, but in fact from north to south, ters to equip the fleet with the light data Middle East North Africa, Ismaeil Mohammed as seen in the top-down view. Detailed recording device—enabling the opera- Abdul (contact: Mohammed Aziz— information can be found in the report tors to perform flight operations quality [email protected]) at http://www.iwi.eu/downloads/ha- New Zealand, Alister Buckingham improvement by using the equipment, ([email protected]) waii.pdf. Without the use of this method, and also vastly improving the investiga- Pakistan, Wg. Cdr. (Ret.) Naseem Syed the written statements alone would have tion after an accident. The significant Ahmed ([email protected]) told a wrong story. added value has been clearly illustrated Russian, Vsvolod E. Overharov by the application on the Alaska state ([email protected]) Increased quality and accuracy due to United States, Toby Carroll trooper accident. ([email protected]) video recordings Even in the absence of any recorded Today, more and more accident obser- flight data, but with witnesses or camer- UNITED STATES REGIONAL vations are recorded by witnesses with as observing or recording an accident, a CHAPTER PRESIDENTS their smartphones, car cameras, or by meaningful reconstruction of the flight Alaska, Craig Bledsoe surveillance cameras, providing a new path can be done using the Immersive ([email protected]) Arizona, Bill Waldock ([email protected]) source of good information. In these Witness Interview (iwi®) method, taking Dallas-Ft. Worth, Erin Carroll cases, the accuracy of the observation into account errors in recollection or ([email protected]) depends mainly on the resolution of the memory accuracy and reducing the data Great Lakes, Matthew Kenner camera, the pixel size of the observed accordingly with optimizing numerical ([email protected]) aircraft, and the information regard- methods. Mid-Atlantic, Ron Schleede ([email protected]) ing the location of the camera. Many Both methods described offer a Northeast, Luke Schiada ([email protected]) cameras are already equipped with GPS significant improvement in accident Northern California, Kevin Darcy and attitude sensors and are recording investigation for helicopter accidents ([email protected]) these data. It is possible to estimate or accidents in general aviation. Pacific Northwest, Kevin Darcy

30 • July-September 2016 ISASI Forum ISASI Information

([email protected]) Air Astana JSC Global Aerospace, Inc. Rocky Mountain, David Harper Air Canada Grup Air Med S.A. ([email protected]) Air Canada Pilots Association Gulfstream Aerospace Corporation Southeastern, Robert Rendzio Air Line Pilots Association Hall & Associates LLC ([email protected]) Airbus HNZ New Zealand Limited Airclaims Limited Honeywell Aerospace Southern California, Thomas Anthony Airways New Zealand Hong Kong Airline Pilots Association ([email protected]) Alitalia SpA Human Factors Training Solutions Pty. Ltd All Nippon Airways Co., Ltd. (ANA) Independent Pilots Association COMMITTEE CHAIRMEN Allianz Insitu, Inc. Audit, Dr. Michael K. Hynes Allied Pilots Association Interstate Aviation Committee ([email protected]) Aloft Aviation Consulting Irish Air Corps Award, Gale E. Braden ([email protected]) Aramco Associated Company Irish Aviation Authority Ballot Certification, Tom McCarthy Asiana Airlines Japan Transport Safety Board ([email protected]) ASPA de Mexico Jones Day Board of Fellows, Curt Lewis ([email protected]) ASSET Aviation International Pty. Ltd. KLM Royal Dutch Airlines Bylaws, Darren T. Gaines Association of Professional Flight Attendants Korea Aviation & Railway Accident ([email protected]) Australian and International Pilots’ Association Investigation Board Code of Ethics, Jeff Edwards ([email protected]) (AIPA) L-3 Aviation Recorders Australian Transport Safety Bureau Learjet/Bombardier Aerospace Membership, Tom McCarthy ([email protected]) Aviation Investigation Bureau, Jeddah, Lion Mentari Airlines, PT Mentoring Program, Anthony Brickhouse Kingdom of Saudi Arabia Lockheed Martin Aeronautics Company ([email protected]) Aviation Safety Council Middle East Airlines Nominating, Troy Jackson Avisure Military Air Accident Investigation Branch ([email protected]) Becker Helicopters Pty. Ltd. National Aerospace Laboratory, NLR Reachout, Glenn Jones ([email protected]) Bundesstelle fur Flugunfalluntersuchung (BFU) National Institute of Aviation Safety and Scholarship Committee, Chad Balentine Bureau d’Enquêtes et d’Analyses (BEA) Services ([email protected]) CAE Flightscape National Transportation Safety Board Seminar, Barbara Dunn ([email protected]) Cathay Pacific Airways Limited National Transportation Safety Committee- Charles Taylor Aviation Indonesia (KNKT) WORKING GROUP CHAIRMEN China Airlines NAV CANADA Air Traffic Services, Scott Dunham (Chair) Civil Aviation Authority, Macao, China Pakistan Air Force-Institute of Air Safety ([email protected]) Civil Aviation Department Headquarters Pakistan Airline Pilots’ Association (PALPA) Ladislav Mika (Co-Chair) ([email protected]) Civil Aviation Safety Authority Australia Pakistan International Airlines Corporation Airports, David Gleave ([email protected]) Civil Aviation Safety Investigation and Analysis (PIA) Cabin Safety, Joann E. Matley Center Papua New Guinea Accident Investigation ([email protected]) Colegio Oficial de Pilotos de la Aviación Commission (PNG AIC) Corporate Affairs, Erin Carroll Comercial (COPAC) Parker Aerospace ([email protected]) Cranfield Safety & Accident Investigation Phoenix International Inc. Critical Incident Stress Management (CISM), Centre Plane Sciences, Inc., Ottawa, Canada David Rye--([email protected]) Curt Lewis & Associates, LLC Pratt & Whitney Flight Recorder, Michael R. Poole Dassault Aviation PT Merpati Nusantara Airlines ([email protected]) DDAAFS Qatar Airways Defence Science and Technology Organisation Republic of Singapore Air Force (RSAF) General Aviation, Steve Sparks (DSTO) Rolls-Royce PLC ([email protected]) Defense Conseil International (DCI/IFSA) Royal Danish Air Force, Tactical Air Command Co-Chair, Doug Cavannah Delta Air Lines, Inc. Royal Netherlands Air Force ([email protected]) Directorate of Flight Safety (Canadian Forces) Royal New Zealand Air Force Government Air Safety Facilitator, Dombroff Gilmore Jaques & French P.C. RTI Group, LLC Marcus Costa ([email protected]) DRS C3 & Aviation Company, Avionics Line of Saudia Airlines-Safety Human Factors, Richard Stone Business Scandinavian Airlines System ([email protected]) Dubai Air Wing Sikorsky Aircraft Corporation Investigators Training & Education, Dutch Airline Pilots Association Singapore Airlines Limited Graham R. Braithwaite Dutch Safety Board SkyTrac Systems Ltd ([email protected]) Eclipse Group, Inc. Southwest Airlines Company Military Air Safety Investigator, Bret Tesson Education and Training Center for Aviation Southwest Airlines Pilots’ Association ([email protected]) Safety Spanish Airline Pilots’ Association (SEPLA) Unmanned Aerial Systems, Tom Farrier EL AL Israel Airlines State of Israel ([email protected]) Embraer-Empresa Brasileira de Aeronautica Statens haverikommission S.A. Swiss Accident Investigation Board (SAIB) CORPORATE MEMBERS Embry-Riddle Aeronautical University The Air Group AAIU, Ministry of Transport Etihad Airways The Boeing Company Accident Investigation Board Norway European Aviation Safety Agency (EASA) The Japanese Aviation Insurance Pool (JAIP) Accident Investigation Bureau Nigeria EVA Airways Corporation Transportation Safety Board of Canada Administration des Enquêtes Techniques Executive Development & Management Advisor Turbomeca Aero Republica Finnair Plc UND Aerospace Aerovias De Mexico, S.A. De C.V. Finnish Military Aviation Authority United Airlines Air Accident Investigation Bureau of Mongolia Flight Data Services Ltd. United States Aircraft Insurance Group Air Accident Investigation Bureau of Singapore Flight Data Systems Pty. Ltd. University of Balamand/Balamand Institute of Air Accident Investigation Unit-Ireland Flight Safety Foundation Aeronautics Air Accident Investigation Sector, GCAA, UAE Gangseo-gu, Republic of Korea University of Southern California Air Accidents Investigation Branch-UK GE Aviation Virgin America Air Asia Group General Aviation Manufacturers Association WestJet

July-September 2016 ISASI Forum • 31 ISASI 107 E. Holly Ave., Suite 11 Sterling, VA 20164-5405 USA CHANGE SERVICE REQUESTED

INCORPORATED AUGUST 31, 1964

WHO’S WHO ATR: A Regional Turboprop Aircraft Manufacturer Leader (Who’s Who is a brief profile prepared by the represented ISASI corporate member organization to provide a more thorough understanding of the organization’s role and function.—Editor) egional turboprop aircraft man- efficiency and operational flexibility. Both aircraft feature the latest technolog- ufacturer ATR is the world leader The ATR aircraft benefit from the widest ical enhancements available in regional in the market for regional aircraft cabin in the regional market (seat width aviation, remaining at the leading-edge in Rup to 90 seats. The 50-seat ATR 42 is equivalent to the seats of the Boeing the fields of efficiency, passenger com- and the 68–78-seat ATR 72 are the perfect 737), thus providing maximum passen- fort, proven dispatch reliability, and low solution on short-haul routes around the ger space and setting new standards of fuel burn and operating costs. The main world. ATR is based in Toulouse, France, comfort. developments of the -600 series ATRs and benefits from the experience and ATR aircraft are labeled the most include a new avionics suite integrating know-how of two of the major leading fuel-efficient in their category, thanks to the most accurate computing systems European aerospace industries, Airbus high-tech engines and propeller efficien- for navigation, recording, autopilot, and Group and Finmeccanica—which each cy. On a 200-nautical-mile sector, the communications. The ATR -600 series also have a 50 percent share in the ATR ATR 72 fuel consumption and CO2 emis- features a new stylish cabin (Armonia), program. sions are up to 50 percent lower than equipped with new thinner seats and LED ATR aircraft represent nearly 40 percent those of a 70-seater jet and up to 30 per- lightening. of all below-90-seat regional aircraft sales cent lower when compared to those of an An important feature of the ATR since 2010, and almost 80 percent when equivalent-sized turboprop. In addition, family is the high degree of commonality compared to other regional turboprops. all ATR models have a large margin with between the ATR 42 and the ATR 72. They ATR aircraft currently are operated by regard to International Civil Aviation have the same fuselage cross-section, use more than 200 airlines in nearly 100 coun- Organization noise regulations. the same basic systems, share the same tries. Since the beginning of the program ATR’s success among operators is also engines and propellers, and have the same in the early 1980s, ATR has sold more than due to its ability to operate in severe cockpit. Common spare parts further 1,500 aircraft and has delivered more than or restricted environments, including represent a significant cost reduction in 1,200. In 2015, for the first time the aircraft on narrow and short runways, at high terms of maintenance, particularly when manufacturer reached a US$2 billion airports, on semi-prepared airfields, operating a mixed fleet of ATR 42s and turnover. and in cold and hot temperatures, thus ATR 72s. There is some 85 percent com- The ATR 42 and ATR 72 are built around bringing air services to remote locations monality in value for a mixed fleet of ATR the design of with limited facilities. 42s and ATR 72s. a high-wing, According to this principle of contin- To be as close as possible to its opera- twin-turbo- uous improvement, ATR launched the tors, ATR has also developed a strong prop aircraft newest ATR -600 series aircraft. The customer support network over the years, conceived new ATR 72-600 and ATR 42-600 have including representative offices, ware- from the become the preferred regional aircraft houses, training facilities, and partner- start for for airlines operating short-haul sectors. ships worldwide. 32 • July-September 2016 ISASI Forum