Air Safety Through Investigation JULY-SEPTEMBER 2017 Journal of the International Society of Air Safety Investigators Commentary—Air Transport Safety Issues Persist—page 4 Organizing the MH17 Crash Investigation—page 6 Linking State Safety Oversight Agencies—page 15 Aircraft Controllability and Primary Flight Displays—page 18 CONTENTS Air Safety Through Investigation Journal of the International Society of Air Safety Investigators Volume 50, Number 3 Publisher Frank Del Gandio Editorial Advisor Richard B. Stone Editor J. Gary DiNunno Design Editor Jesica Ferry Associate Editor Susan Fager ISASI Forum (ISSN 1088-8128) is published quar- terly by the International Society of Air Safety FEATURES Investigators. Opinions expressed by authors do not necessarily represent official ISASI position 4 Commentary—Air Transport Safety Issues Persist or policy. By Kathy Fox, Chair, Transportation Safety Board of Canada—Despite many successful Editorial Offices: Park Center, 107 East Holly efforts to improve air safety in Canada, the author notes the Canadian TSB has some stub- Avenue, Suite 11, Sterling, VA 20164-5405. Tele- born issues remaining on its WatchList that reoccur in investigation after investigation. phone 703-430-9668. Fax 703-430-4970. E-mail address, [email protected]; for editor, espmart@ 6 Organizing the MH17 Crash Investigation comcast.net. Internet website: www.isasi.org. ISASI Forum is not responsible for unsolicited By Kas E. Beumkes, Senior Investigator/Project Manager, the Dutch Safety Board—The manuscripts, photographs, or other materials. author discusses how and why the MH17 crash investigation was organized and looks Unsolicited materials will be returned only if at how all the different interested parties and exceptional circumstances influenced the submitted with a self-addressed, stamped enve- investigative process. He looks at some of the complex procedures and reports investigators lope. ISASI Forum reserves the right to reject, incorporated into their work to ultimately obtain accurate and independent findings. delete, summarize, or edit for space con- siderations any submitted article. To facilitate 15 Linking State Safety Oversight Agencies editorial production processes, American Eng- By Jeff Guzzetti, Acting Deputy Director, Office of Accident Investigation and Preven- lish spelling of words is used. tion, the FAA—The author examines the importance of cooperation among state air safety Copyright © 2017—International Society of Air agencies that might otherwise rebel against interrelationships under a false premise that Safety Investigators, all rights reserved. Publica- working together is a conflict of interest. He suggests such agencies should find ways to link tion in any form is prohibited without permis- their efforts to accelerate safety improvements in aviation. sion. ISASI Forum registered U.S. Patent and T.M. Office. Opinions expressed by authors do 18 Aircraft Controllability and Primary Flight Displays not necessarily represent official ISASI position or policy. Permission to reprint is available upon By Knut Lande, General Manager/Flight Safety Advisor, LandAvia Ltd.—Although global application to the editorial offices. air accident statistics have improved over the last 50 years, the author suggests loss of control in flight accidents remain a serious issue. He suggests that current accident reports do not Publisher’s Editorial Profile: ISASI Forum is print- address the reasons for pilots losing control, and calling for more pilot training is not the an- ed in the United States and published for profes- swer. The answer, he notes, may be to make primary flight displays more intuitive and easier sional air safety investigators who are members to read. of the International Society of Air Safety Inves- tigators. Editorial content emphasizes accident investigation findings, investigative techniques and experiences, regulatory issues, industry ac- cident prevention developments, and ISASI and DEPARTMENTS member involvement and information. 2 Contents 3 President’s View—ISASI Members Do Make a Difference Subscriptions: A subscription to members is pro- vided as a portion of dues. Rate for nonmem- 28 News Roundup bers (domestic and Canada) is US$28; Rate for 30 ISASI Information nonmember international is US$30. Rate for all 32 Who’s Who—The Air Line Pilots Association libraries and schools is US$24. For subscription information, call 703-430-9668. Additional or replacement ISASI Forum issues: Domestic and Canada US$4; international member US$4; do- mestic and Canada nonmember US$6; interna- ABOUT THE COVER tional nonmember US$8. Ron Smits, left, of the Dutch Safety Board directs recovery of MH17 aircraft parts at one of the crash debris sites in the Ukraine. MH17 aircraft parts, scat- tered over several sites, were later reassembled in a hanger for investigation into probable causes. Photo: The Dutch Safety Board INCORPORATED AUGUST 31, 1964 2 • July-September 2017 ISASI Forum PRESIDENT’S VIEW ISASI MEMBERS DO MAKE A DIFFERENCE few weeks after you receive this A day prior to the official seminar day this group will go to La Jolla, north of issue of the ISASI Forum, several opening, tutorials for civil air safe- San Diego, for lunch and shopping. After hundred delegates and partic- ty investigators taking place in the the seminar concludes, there is an option- Aipants from all over the world morning, will cover differences between al all-day tour for all participants to the will gather in San Diego, California, on flight data and voice recorder practices San Diego Zoo. August 22–24 for ISASI 2017, the Socie- and in the afternoon will take a look When ISASI 2017 comes to a close and ty’s 48th annual international accident at improvements in cabin safety and we travel back to our homes and jobs investigation and prevention conference. aircraft manufacturing that have led to as air safety investigators and safety The theme for this year’s gathering is “Do increased survivability rates for occu- professionals, there will be no question in Accident Investigations Really Make a pants involved in air accidents. Military our minds that we do make a difference— Difference?” accident investigators will participate what we do makes a difference. Our work ISASI members know the answer to in an all-day session to share knowledge is never done. Successful safety efforts that question, but sometimes it seems and to develop relationships among col- are often hard to quantify in dollars that governments and aviation industry leagues from many parts of the world. and cents, but the cost to do otherwise entities and individuals are confused After day-long technical briefings, about how to best use our investigation there will be time for national society is too dreadful to imagine. Our efforts findings and safety recommendations to business meetings and a chance for ISA- have saved countless lives and mitigat- make aviation safer—on a global, region- SI working groups to meet face-to-face ed the seriousness of countless injuries al, and local scale. In the commentary on to discuss project developments. for crews and passengers of civilian and page 4 of this issue, Kathy Fox, chair of Of course, not all seminar partic- military aircraft involved in incidents and the Transportation Safety Board of Can- ipants’ time will entail formal work accidents. That such events have less- ada, says her agency has had several key discussions and technical presenta- ened in recent years and that the severity items on its Watchlist that have remained tions. There is time for networking with of those that have occurred has been for a long period. The U.S. National Trans- investigators and air safety professionals reduced are evidence that we do make a portation Safety Board (NTSB) doesn’t from many countries who can pass on difference. Are we proud of our accom- new ideas plishments? Certainly. But that makes us WHEN ISASI 2017 COMES TO A CLOSE,… and different more resolved to continue, to improve, to THERE WILL BE NO QUESTION IN OUR MINDS approaches push on—to improve air safety through and who have investigation. THAT WE DO MAKE A DIFFERENCE. air safety I hope to see many long-time friends in expertise in San Diego and to meet many new ones, keep an official watch list as such, but areas that demand to be shared. This too. Our Society requires the constant there are also standing recommendations “unofficial” networking opportunity addition of new, younger investigators for safety measures that have been on is almost more important and useful and safety professionals who are thirsty its agenda for a long time. The seminar’s than the technical side of the seminar. for the knowledge and expertise many of theme of making a difference will weave There are planned dinners and informal us have gained over the years. In that in and out of all the technical presenta- lunches during which hangar talk and regard, ISASI tions. The papers will, of course, be stories hold sway. On Tuesday night, we 2017 is a posted on our website in full and pub- go offsite for dinner at the San Diego Air perfect time lished in edited form in the Forum and Space Museum, and on Thursday and place for throughout the next year. evening we have the ISASI reception and each of us ISASI 2017 participants will also hear awards banquet. from keynote speaker Robert Sumwalt, Companions to seminar participants who have air NTSB vice chairman and ISASI member; will be able to enjoy a ride along the safety each of the 2017 Kapustin Scholarship San Diego Bay in an amphibious SEAL experience to winners, who will present their winning vehicle with a guide providing a history prepare a essays; and an ISASI member given the of the U.S. military facilities in the city solid founda- Jerry Lederer Award—the Society’s high- and then a chance to visit Old Town San tion for the Frank Del Gandio est honor for lifetime achievement in air Diego to explore the city’s heritage in Society’s safety investigation.