Air Safety Through Investigation JANUARY-MARCH 2020 Journal of the International Society of Air Safety Investigators Examples from Airmanship 2.0: Flying Over Flying Over The Paradox Kapustin Scholar Airbus: Black Innovating Human Conflict Zones: Conflict Zones: of Intuition: Essay—Air Safety Swan Events Factors Forensics Follow-up The Way Forward Training Pilots for Cybersecurity: page 4 page 8 Recommendations from MH17 Unexpected Events Why Cybersecurity from MH17 page 20 page 22 Is a Threat for Air page 18 Safety page 25 CONTENTS Air Safety Through Investigation Journal of the International Society of Air Safety Investigators FEATURES Volume 53, Number 1 Publisher Frank Del Gandio 4 Examples from Airbus: Black Swan Events Editorial Advisor Richard B. Stone By Stéphane Cote, Director of Flight Safety, Accident Investigator, Airbus—The author Editor J. Gary DiNunno defines and provides examples of black swan events and discusses lessons learned that Design Editor Jesica Ferry could be incorporated into preevent training or might assist crews to mitigate the problem. Associate Editor Susan Fager 8 Airmanship 2.0: Innovating Human Factors Forensics ISASI Forum (ISSN 1088-8128) is published quar- terly by the International Society of Air Safety By Frederik Mohrmann, Aerospace Engineer and Aviation Training Expert, Netherlands Investigators. Opinions expressed by authors do Aerospace Center and 2012 Rudolph Kapustin Scholar; and John Stoop, Aerospace Engi- not necessarily represent official ISASI position neer, Safety Investigator, and Professor of Forensic Engineering and Safety Investigation or policy. at Lund University, Sweden, and Deft University of Technology and Amsterdam Universi- ty of Applied Sciences, the Netherlands—The authors present new methods to investigate Editorial Offices: Park Center, 107 East Holly Ave- human factors forensics in air accidents and events and suggest the need for a new human nue, Suite 11, Sterling, VA 20164-5405. Telephone factors model and possible countermeasures. 703-430-9668. Fax 703-430-4970. E-mail address, [email protected]; for editor, jgdassociates@ 18 Flying Over Conflict Zones: Follow-up Recommendations from MH17 starpower.net. Internet website: www.isasi.org. ISASI Forum is not responsible for unsolicited By Marieke van Hijum, Senior Investigator, Dutch Safety Board—The author describes the manuscripts, photographs, or other materials. Dutch Safety Board’s follow-up investigation of the MH17 disaster and the global effort to Unsolicited materials will be returned only if improve management of the risks associated with flying over conflict zones. submitted with a self-addressed, stamped enve- lope. ISASI Forum reserves the right to reject, 20 Flying Over Conflict Zones: The Way Forward from MH17 delete, summarize, or edit for space con- By Kas Beumkes, Senior Policy Advisor, Aviation Safety and Security Division, Civil Avia- siderations any submitted article. To facilitate tion Directorate, Ministry of Infrastructure and Water Management, the Netherlands—The editorial production processes, American Eng- lish spelling of words is used. author discusses actions of the Dutch Safety Board and the Dutch government since the board issued its final MH17 accident report on Oct. 13, 2015. Copyright © 2020—International Society of Air Safety Investigators, all rights reserved. Publica- 22 The Paradox of Intuition: Training Pilots for Unexpected Events tion in any form is prohibited without permis- By Laurie Earl, Coventry University, the UK, and Jim Sheffield, Victoria University, New sion. ISASI Forum registered U.S. Patent and Zealand—The authors examine how intuition influences decision-making and explore how T.M. Office. Opinions expressed by authors do not necessarily represent official ISASI position pilots make decisions in complex situations when they can’t rely on procedures. or policy. Permission to reprint is available upon application to the editorial offices. 25 Kapustin Scholar Essay—Air Safety Cybersecurity: Why Cybersecurity Is a Threat for Air Safety Publisher’s Editorial Profile: ISASI Forum is print- By Nur Amalina Jumary, 2019 Kapustin Scholarship Recipient, University of New South ed in the United States and published for profes- Wales, Australia—The author discusses the growth of digital data communications in avia- sional air safety investigators who are members tion and the subsequent threat to air safety from vulnerable information security and the lack of the International Society of Air Safety Inves- tigators. Editorial content emphasizes accident of common cybersecurity standards. 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- 2 Contents vided as a portion of dues. Rate for nonmem- 3 President’s View bers (domestic and Canada) is US$28; Rate for 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 MENASASI Holds Seminar in Abu Dhabi 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. 2019 Kapustin Scholarship winners meet Andre Kulpers, a Dutch physician and European Space Agency astronaut, following his ISASI 2019 keynote address. Shown, from left, are Elise Vondra, Alex Hall, Kulpers, Nur Amalina Jumary, and Stacey Jackson. INCORPORATED AUGUST 31, 1964 2 • January-March 2020 ISASI Forum PRESIDENT’S VIEW Participants of ISASI’s 55th Reachout Workshop gather in Athens, Greece, on January 7-10. ATHENS REACHOUT WORKSHOP recently had the opportunity to participate in the 55th ISASI Orange2fly, Sky Express, Superior Air, Swiftair Hellas, Athens In- Reachout Workshop, which was held at the Eleftherios ternational Airport, Goldair Handling, Skyserv Aero, Swissport, Venizelos International Airport in Athens, Greece, from Janu- Egnatia Aviation, Global Aviation Academy, JetStream Aviation I ary 7–10. The workshop was hosted by the Greek Air Accident Academy, TAE Aviation Academy, the Hellenic Civil Aviation Investigation and Aviation Safety Board (AAIASB) and focused Authority, Fraport Greece, the University of Patras, other aca- on accident investigation and aviation safety. Caj Frostell, ISASI demia, and the Hellenic Air Force, Army, Navy, Coast Guard, fire international councilor, and I conducted the training session. service, and police. Antonios Athanasiou, AAIASB chair, opened the workshop. The workshop provided ISASI instructors with a delightful In addition, Capt. Akrivos Tsolakis gave a moving speech about opportunity to connect with AAIASB board members, as well Greece and ISASI. Tsolakis was the recipient of the Jerome F. as former AAIASB investigators Dr. Nikos Pouliezos and John Lederer Award at ISASI 2019 in The Hague, the Netherlands Papadopoulos. There were 64 participants representing the AAIASB, Aegean ISASI is appreciative of the sponsors’ support that made it Airlines, Olympic Air, Air Intersalonica, Air Mediterranean, possible to organize the workshop. The sponsors that funded Bluebird Airways, Ellinair S.A., Gainjet Aviation S.A., Helistar, the seminar included Aegean Airlines, Olympic Air, Athens I-Fly, Life Line Aviation, Lumiwings, Olympus Airways, International Airport, and Sofitel Hotel. ISASI has conducted Reachout Workshops since 2001, which provide subject-orientated training to individuals, government officials, and organizations responsible for aspects of air safety in regions where substantial gains for accident prevention may occur. To date, nearly 2,950 individuals have attended. The program is designed to assist aviation professionals who may not be able to attend formal training due to monetary or travel restrictions. Senior ISASI members who are requested to attend as instructors volunteer their time and expertise and Workshop attendees include, from left, Odysseas Paxinos, doc- do not receive compensation. tor-consultant of the Greek Air Accident Investigation and Aviation The host organization provides Safety Board (AAIASB); Kimon Avgerinos, Jetstream Flight Academy travel, food, and lodging head of training; Caj Frostell, ISASI international councilor; Frank Del Gandio, ISASI president; Antonios Athanasiou, AAIASB chair; expenses for these ISASI Frank Del Gandio and Grigorios Flessas, AAIASB member. participants. ISASI President January-March 2020 ISASI Forum • 3 ExamplEs from Airbus: Black Swan Events By Stéphane Cote, Director of Flight Safety, Accident Investigator, Airbus (Adapted with permission from the author’s technical paper The Paradox of Intuition—Black Swan Events: Examples from Airbus History presented during ISASI 2019, Sept. 3–5, 2019, in The Hague, the Netherlands. The theme for ISASI 2019 was “Future Safety: Has the Past Become Irrelevant?” The full presentation can be found on the ISASI website at www.isasi.org in the Library tab under Technical Presentations.—Editor) hat defines a black swan the captain’s sidestick event? Black swan events being inverted in roll. are characteristically The issue remained Wextremely hard to predict undetected during or rare and beyond the realm of normal maintenance and expectations. In ancient Greece, it was the preflight control assumed a black swan could not exist… check. At takeoff, the until it was unexpectedly discovered in captain