Air Safety Through Investigation JANUARY-MARCH 2018 Journal of the International Society of Air Safety Investigators Society Members Meet in San Diego for ISASI 2017—page 4 ISASI Rudolf Kapustin Scholarship Essays: Investigations—Do They Really Make a Difference?—page 11 ISASI Recognizes Chan, Wing Keong with the 2017 Jerome Lederer Award—page 14 Managing a Complex Aircraft Systems Investigation—page 17 Making a Difference in Aviation Safety: Colgan Flight 3407 Nine Years Later—page 21 CONTENTS Air Safety Through Investigation Journal of the International Society of Air Safety Investigators FEATURES Volume 51, Number 1 Publisher Frank Del Gandio 4 Society Members Meet in San Diego for ISASI 2017 Editorial Advisor Richard B. Stone By J. Gary DiNunno, Editor—Some 360 ISASI delegates, companions, and Society guests Editor J. Gary DiNunno gather in San Diego, California, for the annual seminar to hear technical presentations, Design Editor Jesica Ferry recognize outstanding air safety achievements, and to network with colleagues from all over Associate Editor Susan Fager the world. ISASI Forum (ISSN 1088-8128) is published quar- 11 ISASI Rudolf Kapustin Scholarship Essays: terly by the International Society of Air Safety Investigations—Do They Really Make a Difference? Investigators. Opinions expressed by authors do By Dylan Grymonpré, 2017 Kapustin Scholarship Recipient—The author suggests that the not necessarily represent official ISASI position manner in which air safety statistics are presented may not accurately show the importance or policy. of continued air safety improvements. He argues that investigators may need to ensure that Editorial Offices:Park Center, 107 East Holly their findings and recommendations result in actual changes. Avenue, Suite 11, Sterling, VA 20164-5405. Tele- 14 ISASI Recognizes Chan, Wing Keong with the phone 703-430-9668. Fax 703-430-4970. E-mail address, [email protected]; for editor, espmart@ 2017 Jerome Lederer Award comcast.net. Internet website: www.isasi.org. By J. Gary DiNunno, Editor—ISASI’s highest honor for air safety achievement recognizes ISASI Forum is not responsible for unsolicited Chan, Wing Keong, former director of the Air Accident Investigation Board of Singapore, for manuscripts, photographs, or other materials. his long-standing air safety efforts and for building the AAIB Singapore into a world-class Unsolicited materials will be returned only if investigative organization. submitted with a self-addressed, stamped enve- lope. ISASI Forum reserves the right to reject, 17 Managing a Complex Aircraft Systems Investigation delete, summarize, or edit for space con- By Barry Holt, Western Region Senior Technical Investigator, Transportation Safety Board siderations any submitted article. To facilitate of Canada, and David Fisher, Manager, Air Safety Investigations, Commercial Aircraft, editorial production processes, American Eng- Bombardier Air Safety Investigation—The authors discuss a complex investigation of two lish spelling of words is used. Bombardier Q400 main landing gear failures that required extensive testing of the aircraft gear mechanics and resulted in software updates for existing proximity switch electronic units Copyright © 2018—International Society of Air Safety Investigators, all rights reserved. Publica- and new PSEUs for newly manufactured aircraft worldwide. This paper won the award for the tion in any form is prohibited without permis- best presentation of the 2017 seminar. sion. ISASI Forum registered U.S. Patent and 21 Making a Difference in Aviation Safety: T.M. Office. Opinions expressed by authors do not necessarily represent official ISASI position Colgan Flight 3407 Nine Years Later or policy. Permission to reprint is available upon By Roger Cox, U.S. National Transportation Safety Board (NTSB) Operational Factors application to the editorial offices. Group Chairman During the Colgan Flight 3407 Investigation—The author examines an investigation of Colgan Flight 3407, a Bombardier DHC-8-400 (Q400) that crashed near Publisher’s Editorial Profile: ISASI Forum is print- Buffalo, New York, on Feb.12, 2009. He notes that as a result of the accident, the U. S. Congress ed in the United States and published for profes- sional air safety investigators who are members enacted a new aviation safety law in 2010, building on and adding to the NTSB’s recommen- of the International Society of Air Safety Inves- dations from its investigation. Nine years after the accident, over half the NTSB’s recommen- tigators. Editorial content emphasizes accident dations are still open, and some of the actions mandated by the law remain incomplete. investigation findings, investigative techniques and experiences, regulatory issues, industry ac- cident prevention developments, and ISASI and member involvement and information. DEPARTMENTS Subscriptions: A subscription to members is pro- vided as a portion of dues. Rate for nonmem- 2 Contents bers (domestic and Canada) is US$28; Rate for 3 President’s View nonmember international is US$30. Rate for all 28 News Roundup libraries and schools is US$24. For subscription 30 ISASI Information information, call 703-430-9668. Additional or 32 Who’s Who—Cranfield University replacement ISASI Forum issues: Domestic and Canada US$4; international member US$4; do- mestic and Canada nonmember US$6; interna- tional nonmember US$8. ABOUT THE COVER During the final event of ISASI’s 2017 seminar, Society President Frank Del Gan- dio presents Dr. Chan, Wing Keong with the 2017 Jerome F. Lederer Award for outstanding contributions to technical excellence in accident investigation. INCORPORATED AUGUST 31, 1964 2 • January-March 2018 ISASI Forum PRESIDENT’S VIEW ICAO AND WHY IT’S IMPORTANT ost ISASI members know the air and on the ground and glob- ISASI has continued to expand its that International Civil al standardization for air navigation global reach and networking through Aviation Organization facilities. regional, national, and local meetings; (ICAO) Annex 13 provides New aviation technology and pro- training seminars and workshops; stu- Mus with international standards and cedural innovations demand that dent chapters; and our flagship journal, recommended practices (SARPs) for ICAO continually updates many of ISASI Forum. We remain financially the conduct of aviation accident and the Chicago Convention’s 19 annexes sound, and our active membership incident investigations and the develop- and five PANS. The development and numbers are stable because we’re able ment of aviation safety improvements. updating of SARPs and PANS follow a to recruit new members to replace In addition, ISASI’s official ICAO inter- complex amendment process, involving those who are no longer active. I urge national observer organization status, a number of technical and nontechnical each of you to encourage your col- granted in 2013, has provided a means bodies within ICAO and official ob- leagues who aren’t part of our organiza- to give our input to strengthen, update, server organizations, such as ISASI. An tion to consider becoming members. and improve ICAO’s official policies initial proposal for a new or improved Please remember that details about and declarations. I do, however, still get standard, recommended practice, or the Kapustin scholarship fund are occasional questions about what ICAO procedure to be formally adopted or posted on our website and that student is and how it was created. approved for inclusion in an annex or a applications and essays are due in mid- ICAO is a United Nations’ special- PANS typically takes about two years. April. The number of scholarships that ized agency. ICAO administers and Ron Schleede, ISASI vice president, ISASI can provide each year is based governs the Convention on Interna- serves as the Society’s ICAO Working on your donations, which in the United tional Civil Aviation. Recognizing the Group chairman and leads the States are tax deductible. I look forward ISASI AND ICAO BOTH BENEFIT FROM OUR DIRECT PARTICIPATION—ICAO OBTAINS OUR EXPERIENCE AND EXPERTISE, AND WE STRENGTHEN OUR GLOBAL REACH AS A TRULY INTERNATIONAL AIR SAFETY SOCIETY. growth potential and importance of ISASI delegation to ICAO meetings. The to a productive and successful year for civil aviation, representatives from 52 Society’s delegation has also includ- ISASI and hope to see many of you at states met in Chicago, Ill., in 1944 to ed Bob MacIntosh, ISASI treasurer, our annual seminar held in Dubai, develop that cooperative international and Nick Stoss. ISASI representatives United Arab Emirates, this fall. A call agreement, which is also known as the participated in ICAO’s biannual 2015 for technical papers to be presented Chicago Convention. In 1947, a majority High Level Safety Conference and the at this year’s annual gathering and of member states ratified the agreement organization’s subsequent Accident guidelines for authors is now posted on and ICAO became official. Through Investigation Panel (AIGP) meetings. the website and ICAO, 192 current state members, plus ISASI’s team participates in several of in this Forum. industry groups such as ISASI, work for the 11 AIGP working groups that use Abstracts for consensus on international civil avia- correspondence, conference calls, and papers to be tion SARPs and guidance materials to occasionally face-to-face meetings to considered are promote safety and security on a global develop materials for discussion and also due in scale. resolution during the next full panel mid-April. Creating, maintaining, and updating gathering. As Ron noted in an AIGP trip On a final SARPs and procedures for air naviga- report posted in our website library, note, I wish tion (PANS) are the basic function of ISASI and ICAO both benefit from our ISASI members ICAO’s mission. SARPs and PANS are direct participation—ICAO obtains and their vital for ICAO member states and other our experience and expertise, and we families a happy stakeholders to ensure harmonized strengthen our global reach as a truly and safe new Frank Del Gandio global aviation safety and efficiency in international air safety society. year. ISASI President January-March 2018 ISASI Forum • 3 Society Members Meet in San Diego for ISASI 2017 By J.