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Lessons Learned from Commercial Airplane Accidents

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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 permis- sion. 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 profes- sional 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 ac- cident prevention developments, and ISASI and member involvement and information. ABOUT THE COVER Subscriptions: A subscription to members is pro- vided 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
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