Air Safety Through Investigation - Journal of the International Society of Air Safety Investigators - ISASI
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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 21CONTENTS 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, isasi@erols.com; 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 INCORPORATED AUGUST 31, 1964
outstanding contributions to technical excellence in accident investigation.
2 • January-March 2018 ISASI ForumPRESIDENT’S VIEW
ICAO AND WHY IT’S IMPORTANT
M
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-
us 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 • 3Society Members Meet in San Diego for ISASI 2017
By J. Gary DiNunno, Editor
M
ore than 360 delegates, guests, ers, discussed the use of data maps, and procedural announcements, Dunn intro-
and companions from 38 coun- examined a typical modern-day installa- duced ISASI President Frank Del Gandio
tries participated in technical tion process. for his traditional opening address.
briefings, listened to pertinent In the afternoon, Martin Maurino, “We are here at ISASI 2017 to share
keynote addresses, and attended tours ICAO, and Jason Fedox, NTSB, covered our views and information on air safety
and social gatherings during the cabin safety technology and improve- investigations, including investigative
Society’s 48th annual International ments in the “Survival Factors” tutorial. techniques, analytical approaches, and
Accident Investigation and Prevention They discussed ICAO’s Survivor Factor emerging issues in the field,” Del Gandio
Conference held Aug. 22–24, 2017, at the Accident and Incident Investigation told delegates and officials seated in the
Sheraton San Diego Hotel and Marina in Manual and outlined some cabin safety filled meeting room. “Our theme this
California. investigations, provided information year is ‘Investigations—Do They Really
about specific cabin safety improve- Make a Difference?’ The short answer is
ments that have increased survivability, yes, they make a big difference.” He ob-
Tutorial workshops, the eclipse,
and discussed several different types of served that investigations in most fields,
and a welcome reception occurrences. “whether they are in aviation or in other
Preceding ISASI 2017, some 122 partic- On the military side, James Roberts, areas, follow a similar intellectual model:
ipants attended Monday’s tutorial ses- Boeing, and David Harper, USAF, led Document what happened and did not
sions targeting civilian and military air an all-day discussion in the “Military happen, complete with technical and
accident investigators that were separate Accident Investigation” session. John scientific testing, interviewing witnesses,
from the seminar. On the civilian side, Karstens, Boeing, discussed adapting survivors, support personnel, and others.
ISASI Flight Recorder Working Group Safety Management Systems (SMSs) That part of the process has been made
Chair Mike Poole, Plane Sciences, and to military operations. José Casido, an a bit more definitive with the use of
ISASI members Frank Hilldrup, NTSB, Airbus accident investigator, discussed onboard data, ATC data, etc. The docu-
and Steve Roberts, AIRINC, conducted a that manufacturer’s safety structure and mentary phase is followed by analysis in
morning session entitled “Flight Re- experience. He provided an overview of an effort to make some coherent sense of
corders: Beyond ICAO Annex 13.” They military accident statistics and Airbus the event and to put it into a larger con-
discussed the design history of flight involvement as a technical advisor. text. Aviation investigations then take
data recorders (FDRs), FDR survivability, Tutorial participants interrupted their a third critical step: when appropriate,
the structure of digital data, and exam- sessions for a few minutes to view (with recommending how to fix an identified
ined development of the third generation proper precautions) a partial eclipse problem.”
of solid-state recorders. The participants of the sun. After the tutorials ended, Del Gandio said, “To some degree we
looked at the design of modern record- everyone gathered in the evening for a are the victims of our own success. Yes,
welcome reception held on the we have witnessed sensational aviation
hotel grounds. events in recent years, including military
shoot-downs or political acts, plus at
ISASI 2017 begins with noted least one suicide (Germanwings) and the
speakers, introductions, and continued saga of MH370. Nonetheless,
major ‘accidents’ have been amazingly
presentations
rare in recent years. The continued rarity
From the podium overlooking
of major accidents may perhaps explain
a packed ballroom, ISASI 2017
why the question about the continued
Committee Chair Barbara
value of investigations could even be
Dunn, president of the Canadi-
posed.”
an Society, on the morning of
He asked, “Do investigations still mat-
Tuesday, August 22, opened the ter and, if so, how?" He answered, “Our
seminar with a warm welcome efforts provide the original documenta-
Tutorial participants, during a break, view a partial
solar eclipse. to San Diego. Following her tion that leads to identifying the risks
4 • January-March 2018 ISASI Forumthat we track in operational data. We [CVRs] to ‘spy’ on pilots. Look how far public deserves SPONSORS
will continue to document and analyze we’ve come. For years now, not only are independent The following
how those or other risks actually play CVRs in every airline cockpit, but now and objective sponsors provided
out when things go badly wrong. Our airlines and several business aviation investigations. support for
findings will continue to be a primary ISASI 2017:
operators routinely monitor hundreds “The second
source of recommendations about how of parameters from flights to look for critical element
to alleviate identified risks. Investiga- exceedances or deviations. And to top it of effective GOLD
tions also will continue to document Airbus
off, these operators actually share their investigations, Boeing
and analyze what happens in high-risk data with government and industry in my opinion, Delta
incidents or accidents that mercifully do to look for potential problems so the is to keep your Embraer
not lead to fatalities.” problems can be addressed before they eye on the GE
Del Gandio closed his opening re- lead to accidents. It’s a system that is goal—preven-
marks “with my usual suggestions to built on trust. Honestly, I believe this is tion. Remember SILVER
attendees. Please participate fully in one of the big reasons our aviation safety that according Lockheed Martin
this seminar. To those who have real record has gotten as good as it is in the to ICAO Annex Southwest
expertise, please be open and share U.S. 13, ‘the sole ob- University of
your knowledge. To any students or new jective of the in- Southern
“I’ve been actively involved in the California
members of our profession, I encourage aviation safety business for more than 30 vestigation of an
you to take advantage of the knowledge years. During that time, I’ve developed accident or an
that is in this room. If you have ques- incident shall be BRONZE
the belief that an effective, credible in- Bombardier
tions about virtually anything related vestigation needs three critical elements. the prevention Executive Jet
to aviation, someone in this room can First, the investigation needs to inde- of accidents and Management
answer your question with authority or incidents. It’s IFSA
will be able to find someone who can. not the purpose JIAAC
Finally, to everyone, enjoy the San Diego of this activity to Parker Aerospace
seminar.” apportion blame WRIGHT
or liability.’ SRCA
“As soon as
NTSB chairman delivers the investigation EXHIBITORS
keynote address starts seeking to The following
Del Gandio then introduced longtime organizations were
apportion blame exhibitors for
ISASI member and NTSB Chairman or liability, the ISASI 2017:
Robert Sumwalt to present the seminar’s ISASI President Frank Del Gandio welcomes focus on true
first keynote address. seminar participants to San Diego and emphasizes safety improve- Aerobytes
“Good morning and thank you for the meeting theme of "Investigations—Do They ments can get Beyond Risk
Really Make a Difference?" Management
inviting me to address this gathering,” derailed. Grant-
Sumwalt began. “It’s great to be here ed, there are Cranfield
pendent and objective. Quite simply, we University
with others who share a passion for air those who are
need to ensure the investigation remains Embry-Riddle
safety investigations. in the business
independent from outside influences. University
“The theme for this year’s ISASI sem- of litigation— JIAAC
Independence is one of the NTSB’s core
inar is ‘Investigations—Do They Make a and that’s not a National
values, and I truly believe it is one of our
Difference?’ Well I certainly hope so, be- bad thing—but Transportation
greatest virtues.”
cause I’ve been going to accident scenes for air safety Safety Board
Sumwalt observed that according to Plane Sciences
since I was 17. On that day, I heard a U.S. Senate Commerce Committee investigators,
about a plane crash on my car radio and remember that Southern
report, “The most single aspect of the California
decided to try to find it. As I approached NTSB must be its total independence we are not in Safety Institute
the crash site, I saw the coroner and de- from those governmental agencies it the business of Transportation
cided to tuck in close to him. As the law oversees in regard to their transporta- pointing fingers, Safety Institute
enforcement officers on scene raised the tion regulatory functions. If the board is laying blame, or TU Delft University
yellow tape and cleared the way for him, under pressure from any administration assigning fault. University of
I ducked in with him. Our goal is the Southern
to pull its punches or to tone down its California
“Don’t ask me how this happened, but reports or to gloss over government prevention of
on the way home, I drove by the airport errors in transportation safety, then future mishaps.
and stopped at a flight school and signed its watchdog function has been fatally “Prevention of future accidents is the
up for flying lessons. So yes, I sort of got compromised.” The U.S. Congress sep- core component of an investigator’s mis-
into aviation by accident.” arated the NTSB from the U.S. Trans- sion; a thorough investigation that deter-
“When I began flying for an airline in portation Department in 1974. “So,” mines the cause of an accident is of little
1981, there was still some distrust of big Sumwalt declared, “my charge to you value to the public if the knowledge does
brother and companies using flight data is to ensure your investigations are free not prevent future accidents. Successful
recorders and cockpit voice recorders from external pressures. The traveling adoption of safety recommendations is
January-March 2018 ISASI Forum • 5we feel our input is ignored; when we
know there is more that can be done;
when we see things that should be
changed, but aren’t; when we feel others
really don’t care. You may occasionally
ask yourself: ‘Is it all worth it? It is really
worth all of the time I have spent on
these safety initiatives?’
“Well, to answer that and keep it all in
perspective, one of my favorite inspi-
rational sayings is ‘And whoever saves
a life, it is considered as if he saved an
entire world.’ You only need to keep one
ISASI Treasurer Bob MacIntosh discusses ISASI Vice President Ron Schleede provides person from getting into trouble in an
ISASI's financial state during a short busi- a business meeting report on the Society's aircraft. If you have done that, it’s as if
ness meeting. ICAO participation
you have saved an entire world. Let me
the forward-looking fulfillment of the I placed this magazine in my office to assure you, the work you are doing—it
work we all do. serve as a reminder of the importance does matter. It does make a difference. It
“The third critical element of effective of going beyond simply stating that is important. And yes, it does keep peo-
investigation is that that we must not be someone committed an error. We need ple from dying. So as one professional air
satisfied at superficial findings. We must to answer why the error was made. safety investigator to another, thank you
look for the underlying issues. If we focus “As I head toward the ending of this for your tireless efforts. I guarantee your
only on the obvious error, we may miss discussion, allow me to put a different work is saving an entire world.”
valuable accident prevention opportuni- twist to the theme of this conference.
ties because systemic flaws may remain Instead of asking if investigations make a
undetected and thus uncorrected. It’s difference, I’d like to put the focus on the More introductions were in order
one thing to say a person committed an dedicated men and women who actually Before the formal presentations began,
error. It’s quite another to try to under- conduct air safety investigations. The Del Gandio introduced the other top
stand all of the factors that may have question now becomes: ‘Investigators— Society officers—Vice President Ron
influenced that error. Where was the rest do they make a difference?’ Schleede, Treasurer Bob MacIntosh,
of the system that should have prevented “Like many of you, I have been doing Secretary Chad Balentine, and Execu-
a simple error from being catastrophic? safety work for a long time. I know there tive Advisor Dick Stone. As chairman of
If we are really interested in improving can be trials and tribulations. I know the ISASI Randolph Kapustin Memorial
safety, then we must look at the entire there can be disappointments, setbacks, Scholarship Committee, Balentine then
system, not just focus solely on the front- frustrations. Perhaps sometimes you feel introduced the four recipients of the
line personnel. your work is all for nothing. And why do Society’s 2017 scholarship awards: Maria
“In my office, I have the framed cover I suspect you may sometimes feel that Gregson, University of Nottingham, UK;
of an ISASI Forum. On the cover, it states: way? Because as one safety professional Dylan Grymonpré, Carleton University,
‘The discovery of the human error should to another, I know from experience that Canada; Mahmood Masood, University
be considered as the starting point of when we care about something as much of Central Missouri, USA; and Ross Ro-
the investigation, not the ending point.’ as we all do, it can be frustrating when zanski, University of Southern California,
USA. During the course of the three-day
seminar, more than $1,500 in donations
for the 2018 scholarship fund were col-
lected from participants and state and
local ISASI organizations.
After the technical presentations for
Tuesday, national societies conducted
business meetings and then seminar
participants and their guests traveled to
the San Diego Air & Space Museum for
a buffet dinner and a chance to wander
through the museum’s exhibits, which
include historic military and commercial
aircraft and vintage automobiles.
Wednesday presentations began
at 9:00
From left, Frank Masoga, South African CAA; NTSB Chairman Robert Sumwalt; Pakistan- Panel presentations on human perfor-
SASI President Naseem Syed Ahmed; and Kapustin Scholar Mahmood Masood. mance investigation techniques and
6 • January-March 2018 ISASI Forumfor a moment. In the decade that preced- tive reports of runway friction based on
ed the formation of CAST, not a single pilot perception could be augmented,
year went by without a fatal accident in- improved, and ultimately replaced by
volving a U.S. air carrier—and in several quantitative calculations of runway fric-
of those years, there was more than one tion derived by onboard measurement
fatal accident. We are now on nearly an and data-processing systems. This builds
eight-year run in which there have been upon the work being done by the Takeoff
no fatal accidents involving a scheduled and Landing Performance Assessment,
U.S. certificated airline. That is why by or TALPA, group.
2008, CAST was able to report that by “Just as a reminder, the TALPA initi-
implementing the most promising safety ative aims to reduce the risk of runway
enhancements [SEs], the fatality rate overruns by providing airport operators
of commercial air travel in the United with a method to accurately and consist-
States was reduced by 83%. As impres- ently determine the runway condition
sive as that achievement was, the entire when a paved runway is contaminated.
industry recognized there was still work “This highlights another virtue of the
James Viola, FAA, delivers Thursday's to be done. CAST methodology, which is to leverage
keynote address about the FAA's CAST, GA “CAST has evolved, and the group is the work of other expert groups and to
aircraft, and helicopter safety efforts. moving beyond the ‘historic’ approach of share data with other groups that seek
examining past accident data to a pro- to achieve common goals. And speaking
helicopter accident trends dominated
active approach that focuses on detect- of common goals, our efforts to improve
the early hours of the seminar. Follow-
ing risk and implementing mitigation general aviation safety are no less ambi-
ing the lunch break, ISASI held a short
strategies before accidents or serious tious than those directed at our airline
membership meeting and then technical
incidents occur. The goal over the next community.
presentations continued throughout the
decade is to transition to prognostic “One of the most effective strategies
day. After the final audience questions at
safety analysis. on which we have embarked is the
the end of the day, ISASI working groups
“CAST aims to reduce the U.S. com- implementation of the General Aviation
held meetings to discuss with interested
mercial fatality risk by another 50% Joint Steering Committee, or GAJSC.
members ongoing projects and efforts.
from 2010 to 2025. CAST has developed The GAJSC was launched in 1997 as part
an integrated, data-driven strategy to of the industry-government Safer Skies
Thursday began at 8:30 with the reduce the commercial aviation fatality Initiative to improve aviation safety.
risk in the United States. The CAST plan Revitalized in 2011, the GAJSC works
second keynote speech currently comprises 96 SEs aimed at to improve GA [general aviation] safety
Moderator James Roberts, chair of the
improving safety across a wide variety through data-driven risk-reduction ef-
ISASI Military Air Safety Investigators
of operations. CAST identifies precur- forts focused on education, training, and
Working Group, introduced James Viola,
sors and contributing factors to ensure enabling new equipment in GA aircraft.
FAA, Office of General Aviation Safety
resources address the most prevalent This public-private partnership works
Assurance, for the final keynote address.
categories of risk that pose the greatest to improve safety by using a consen-
Viola looked toward the seminar par- threat to loss of life. sus-based approach to analyze aviation
ticipants and said, “The quest to improve “To get a better feel for the CAST safety data and develop risk-reduction
aviation safety has taken us down many methodology, let’s take a look at one of efforts.
paths, but few have paid dividends like the SEs aimed at reducing runway excur- “The GAJSC’s goal is to reduce the
good accident investigations and also sions. All of us understand that these ex- GA fatal accident rate per 100,000 flight
public collaboration. By building strong cursions can lead to a loss of life; and like
relationships with operators, manufac- most accidents, they are well within our
turers, trade associations, and academia, power to prevent. Excursions are often
we have collectively made most every the result of unstabilized approaches,
form of aviation safer. incorrect performance planning, and/or
“In this presentation, I will briefly poor runway surface conditions.
highlight the history and successes “SE 222, which began in 2014, tasked
of three of our most important safety the aviation community with performing
teams—the Commercial Aviation Safety research to enable development, imple-
Team, the General Aviation Joint Steer- mentation, and certification of onboard
ing Committee, and the U.S. Helicopter aircraft system technologies to assess
Safety Team. airplane braking action and provide
“The Commercial Aviation Safety the data in real time to the pilot, other
Team was founded in 1998 with a goal to aircraft crews, air traffic controllers, and
reduce the commercial aviation fatality the airport operators.
rate in the United States by 80% by 2008. “In a CAST study of runway excur- Tom Farrier, right, receives ISASI Fellow
sions, the team determined that qualita- Membership recognition from President
“Think about the significance of this Frank Del Gandio.
January-March 2018 ISASI Forum • 7ISASI 2017 TECHNICAL PROGRAM
Monday, August 21, 2017 Systems,” Thomas Farrier, JMA
Tutorials 11:30 “Investigations into ATC Matter,” Curt Fischer, NATCA
8:30–12:30 “Flight Recorders: Beyond ICAO Annex 13,” Mike Poole, 12:00 Lunch
Plane Sciences, and Frank Hilldrup, NTSB Moderator—Ron Schleede, ISASI vice president
12:30 Lunch 1:00 ISASI membership meeting
1:30–5:30 “Survival Factors,” Martin Maurino, ICAO, and Jason Fedox, 1:30 “The Effect of ICAO Type Aerodrome Weather Forecasts on
NTSB Aircraft Operations,” David Wilson, Australian Transport Safety Board
8:30–5:30 “Military Accident Investigation,” James Roberts, Boeing, 2:00 “Why It Makes a Difference to Report and Investigate UAS
and David Harper. USAF Incidents,” Jeff Guzzetti, FAA
6:30 Reception 2:30 Break
3:00 “Managing a Complex Aircraft Systems Investigation,” Barry
Tuesday, August 22, 2017 Holt, TSB, and David Fisher Bombardier
9:00 Barbara Dunn, seminar chair 3:30 “Hazards of Excessive Pilot Flight Control Forces,” Robert Joslin,
9:15 Welcome—Frank Del Gandio, ISASI president FAA, ERAU
9:30 Keynote—Robert Sumwalt, NTSB chairman 4:00 “How Data from Internal Safety Investigations and Processes
Can Be Used to Assess Performance of Safety Management,” Nek-
10:00 Scholarships–Chad Balentine, ISASI secretary tarios Karanikas, Amsterdam University
10:15 Scholarship essay—Maria Gregson, The University of Nottingham 4:30 Working Group Meetings
10:30 Break Dinner on your own
Moderator—Tom Farrier, UAS Working Group
11:00 “Airbus Support to Accident Investigation,” Thursday, August 24, 2017
Nicolas Bardou, Airbus Moderator—James Roberts, MASI Working Group
11:30 “The Role of Investigations in Creating and 9:00 Keynote—James Viola, FAA, Manager, Office of General Aviation
Implementing Safety Nets,” Jim Burin, FSF Safety Assurance
12:00 Lunch 9:30 “Understanding Maintenance Caused Accidents,” Pete Kelley,
Moderator—Alastair Buckingham, NZSASI president FAA
1:00 “Preexisting Fracture in a Helicopter Composite Rotor Blade 10:00 Scholarship Essay—Mahmood Masood, University of Central
System,” Torstens Skujins and Joseph Rakow, Missouri
Exponent 10:15 Scholarship Essay—Ross Rozanski, University of Southern
1:30 “EASA’s Annual Review of Safety Recommendations,” Mario California
Colavita, EASA 10:30 Break
2:00 “Colgan 3407: Eight Years Later—Making a Difference in Aviation 11:00 “Crash Scene Hazard Management: An Updated Approach,”
Safety,” Roger Cox, NTSB (Ret.) Tyler Brooks, CAF; Claire Maxwell, CAF; and Gary Lacoursiere, CAF
2:30 Break 11:30 “Learning from Accidents that Are a Consequence of Complex
3:00 “Video Velocity Analysis,” Adam Cybanski, CAFDFS Systems,” Shem Malmquist and John Thomas, MIT
3:30 “The Passenger Brace Position in Aircraft Accident Investiga- 12:00 Lunch
tions,” J.M. Davis, University of Calgary; M. Maurino, ICAO; and J. Yoo, Moderator—Joann Sheehan. Cabin Safety Working Group
Korea Aviation & Railway Accident Investigation Board
1:00 “Lost Opportunities and Thinking Illusions,” Andrew McGregor,
4:00 “AF447 and Germanwings Investigations—What Difference Do Prosolve Ltd.; Capt. Simon Tapp, Air China; and Barry Hughes, Ringa-
or Did They Make?” Arnaud Desjardin, BEA, and Philippe Plantin de ringa Research Lab
Hugues, ICAO
1:30 “Lessons Learned from Aviation Accidents, Minor Errors, Major
4:30 Scholarship essay—Dylan Grymonpré, Carleton University Effects Accidents that Have Helped Shape Aviation Safety,” Daniel
4:45 National society meetings Cheney, FAA
5:45 Bus pickup—Dinner San Diego Air & Space Museum 2:00 “Integrated Pilots’ Visual Parameters into Flight Data Recorder
for Accident Investigation and Prevention,” Thomas Wang Aviation
Wednesday, August 23, 2017 Safety Council, Taiwan; Wen-Chin Li, Cranfield University; and J.H. Lin,
National Central University, Taiwan
Moderator—Dr. Steve Sparks, General Aviation
Working Group 2:30 Break
9:00 Panel “Analysis Techniques for Investigating Human Perfor- 3:00 “Fiction Versus Reality: The Impact of Hollywood on Accident
mance,” Dr. Randy Mumaw, NASA Ames Research Center; Bill Bram- Investigations,” Katherine Wilson, NTSB
ble, NTSB; Fanny Rome, BEA; and Joel Morley, Canada TSB. 3:30 “Using Scanning and Simulation Technology to Analyze Aviation
10:00 “Helicopter Accident Trends in Eight ISASI Countries & Reducing Mishaps,” Rawson Wood, Biodynamic Research Corp.
Fatal Accidents Even Further,” Robert Matthews and Rex Alexander, 4:00 “Use of Data Science to Make the Difference in Investigation
Air Safety Consultants; and Richard Stone, ISASI Analysis Process,” Marion Choudet, ATR, and S. David, BEA
10:30 Break 4:30 Seminar conclusion—Barbara Dunn
11:00 “Investigations, Recommendations, and Safety Management 6:00 Reception and banquet
8 • January-March 2018 ISASI ForumSeminar participants and guests attend an offsite dinner at the San Diego Air & Space Museum where they view numerous historic
aircraft and exhibits.
hours by 10% from Jan. 1, 2009, to developed an overview of the 2001−2010 ing environment in which they operate
Dec. 31, 2018, with no more than one fatal GA accidents (again, thanks to all pose unique challenges to operators and
fatal accident per 100,000 flight hours those in this room who have contrib- regulators alike.
by 2018. uted data) and determined that 40.2% “The United States Helicopter
To give you an idea of what the GAJSC involved a loss of control. As a result, Safety Team (USHST), formed in 2013
has accomplished to date: the GAJSC’s Loss of Control Working as a regional part of the International
• 38 SEs. Group conducted analysis of 90 fatal GA Helicopter Safety Team (IHST), com-
• 29 loss of control and four system aviation accidents that occurred during pleted a comprehensive analysis of U.S.
component failure power plant, approach or landing. The group then fatal accidents that occurred from 2009
proposed a series of SEs that targeted to 2013. The data are now being used
• 20 SEs compete and another 18 SEs factors such as the need for angle-of-at- to develop specific intervention recom-
are under way. tack systems, improvements in aero- mendations to support further accident
• LOC–approach and landing—first nautical decision-making, reliance on reductions. From 2016 through 2019,
test and demonstration of the CAST automation, the utilization of type clubs the USHST is focusing its attention on
process to the GA community. to improve training, increased emphasis reducing fatal accidents within the U.S.
• LOC–all other phases of flight—the on stabilized approach and landings, civil helicopter industry. The IHST’s goal
first test of the CAST process was and impairment caused by some medi- set in 2016 is to reduce the fatal accident
successful, and a second working cations. rate to 0.61 per 100,000 flight hours by
group was formed that looked at all “Finally, our industry partners are 2019 or 20% by 2020. That organization’s
LOC in all of the remaining phases an invaluable distribution network for fatal accident rate goal for this year is
of flight, information on a variety of safety topics 0.69 accidents per 100,000 flight hours or
such as strategies for the avoidance of lower.
• System component failure power
severe weather or how certain pre- “Thanks in no small part to the
plant—third working group.
scription medications can impact pilot actions of USHST participants, accident
• CFIT was next on the list, but since performance. rates for U.S. helicopters declined in
it had been trending in a downward “So as we continue to make improve- 2016 for the third consecutive year. There
direction and system component ments in fixed-wing aviation, we must were 106 accidents in 2016, with an
failure-power plant had remained not forget another very important sector overall accident rate of 3.19 per 100,000
mostly static, the GAJSC decided to of the aviation community—helicopters. flight hours, compared to 121 accidents
work on system component failure Helicopters perform a number of crit- and an accident rate of 3.67 per 100,000
power plant next. ical missions that among other things accidents in 2015. Seventeen fatal ac-
“You’ll notice the focus on loss of con- save countless lives each year. Still, the cidents were recorded both years, with
trol accidents. That is because the FAA missions they perform and the challeng- a fatal accident rate of 0.51 per 100,000
January-March 2018 ISASI Forum • 9flight hours in 2016, compared to 0.52 “This concludes the substantive with a celebration and recognition
per 100,000 in 2015. portion of my presentation; but be- of exemplary efforts on behalf of
“Looking in terms of percentage, fore I finish, I want to take a moment air safety investigation. The Jerome
the 2016 overall helicopter accident to thank the many organizations and F. Lederer Award, ISASI’s highest
rate represented a decline of 13% from dedicated professionals outside of the honor, is presented to an individual
2015 and a decline of 27% since 2013, FAA who have contributed so greatly to (or individuals or groups) who has
when the USHST was formed. The fatal our collective success. Ours is a difficult shown lifetime efforts to improve or
helicopter accidents also declined 43% business, and we never have the luxury advance air safety investigation and
in the same period. This continues a of resting on our laurels. Our partners in achieving ISASI objectives.
downward trend the industry has seen safety recognize this, and without their The International Society of Air
over the last decade. In fact, during that continued commitment, the success Safety Investigators was proud to
period, the U.S. helicopter accident rate stories I referenced here would be far distinguish Chan, Wing Keong,
has been cut by over half. So that’s the fewer. We all recognize the statistics former chairman of the Air Accident
good news. I presented here represent more than Investigation Board of Singapore
“The bad news is that the accident numbers. They are lives saved and trag- with the 2017 Jerome F. Lederer
rate for the U.S. civil helicopter industry edies averted. So never for one moment Award (see page 14).
rose 6.6 in the first six months of 2017 to doubt that you in this room are making Representatives of new ISASI
3.37 accidents per 100,000 flight hours a difference,” Viola concluded. corporate members were welcomed
from a rate of 3.16 for the full year 2016. The remainder of the day included into the society and received a tra-
The fatal accident rate for the first half technical presentations and Kapustin ditional wall plaque acknowledging
of 2017rose more sharply to 0.58 fatal scholars’ essays. Seminar Chair Barbara their participation. New corporate
accidents per 100,000 flight hours from Dunn finished the day’s session noting members included Discovery Air
a rate of 0.51 for the full year 2016. that ISASI 2018 will be in Dubai, United Defense, Delft University of Technol-
“So how do we drive this trend back Arab Emirates, with the Middle East ogy, Faculty of Aerospace Engi-
downward in order to meet our safe- North Africa Society serving as the host neering, Virgin Galactic, Korea Air,
ty goals? The USHST has a number of organization. Abakan Air, Hawaiian Airlines, and
initiatives under way, many targeting INSITU.
the occurrence categories I previously
Awards banquet recognizes
mentioned. A great deal of effort has
exemplary air safety efforts Optional programs
been focused on providing training and
ISASI’s annual seminar always ends On Tuesday, August 22, companions
educational resources for operators.
and guests of seminar participants
were provided a tour of San Diego’s
military history on an amphibious
SEAL vehicle that traveled along the
San Diego Bay shoreline and then
into the water to view the North
Island Naval Station. The group then
went to Old Town to walk among
the historic buildings and enjoy
lunch.
On Wednesday, August 23, the
companions and guests traveled
to the village of La Jolla, just north
of downtown San Diego, to stroll
through the boutiques, enjoy a lei-
surely lunch, and explore the sights
and sounds of the village.
Participants of a post-seminar
optional tour on Friday, August 25,
traveled to the world-famous
San Diego Zoo, where many took an
initial tour bus ride or an overhead
tram to get an overall introduction
to all of the exhibits before walking
to specific enclosures to find their
From left, ISASI Secretary and Scholarship Committee Chair Chad Balentine introduces
2017 scholarship recipients Mahmood Masood, University of Central Missouri, USA; Ross favorite animals. A buffet lunch was
Rozanski, University of Southern California, USA; Maria Gregson, University of Nottingham, served in a private rotunda dining
UK; and Dylan Grymonpré, Carleton University, Canada. room.
10 • January-March 2018 ISASI ForumISASI Rudolf Ka-
pustin Scholarship Investigations—Do They
Essays
The following article is the
second of four essays from
Really Make a Difference?
the selected Kapustin schol- By Dylan Grymonpré, 2017 Kapustin Scholarship Recipient
arship winners. One essay
appeared in the October–De-
A
cember issue of the Forum ircraft accident investigations are ders, emphasizing the need to implement
and others will appear in fol- critical processes that provide recommendations, quantifying the costs
lowing issues. Details about findings, recommendations, and of an accident, and marketing prevention.
the scholarship, application statistics that can enhance safety
form, and deadline are avail-
in an industry that thrives on the rewards
able on the ISASI website at Enhanced communication of
www.isasi.org.—Editor of assuming ever-greater risk. Although
investigations have been extremely val- existing statistics
uable in reducing the accident rate over Statistics are important; in many cir-
the past century, much of the vigor of the cumstances they are relied upon as the
only objective evidence to enforce an
old days has been lost. The recent inves-
argument for change. Unfortunately, the
tigations of the past few decades have
current method of communicating acci-
not been able to instigate the changes
dent statistics is ineffective in producing
required to significantly improve aviation
change. The statistics do not invoke
safety; the declining occurrence rate has
the urgent requirement to immediately
plateaued. Investigations are no longer
address an issue; instead, the statistics do
making a significant difference. the opposite and encourage passivism.
So what needs to change? Air accident For example, a common method used
investigators work hard, really hard; and to present accident statistics is a graph,
in multiple instances they place their so- similar to Figure 1, accompanied by a
cietal duties ahead of their families. This statement such as “Over the past decade,
effort and dedication deserve showcasing there has been a significant downward
and public exhibition—not for fame or trend in accident rates.” This does not
glory, but in order to stimulate greater portray an issue; this actually sounds
action toward improving aviation safety. good. Why would any action be required?
Episodes of “Air Crash Investigation” [1] The problem seems to be solving itself.
or “Mayday” [1] are simply not enough. Instead, investigators should com-
There is an urgent requirement for acci- municate statistics in a manner that
dent investigators and their overarching highlights an issue. The previous data
safety boards to develop methods that could equally be presented using a more
Dylan Grymonpré better invoke government and industry holistic perspective, such as the graph in
action. This “need to act” can be insti- Figure 2 accompanied by the statement
gated through five key transformations “While history has indicated a significant
recently completed a bachelor’s degree
in the investigation process: enhanced reduction in accident rates, the progress
in engineering–aerospace structures,
systems, and vehicle design at Carleton communication of existing statistics, within the past two decades has pla-
University in Ottawa, Ont. In 2012, he standardization of statistics across bor- teaued despite vast improvements in the
earned a bachelor’s degree in aviation
technology (with honors) from Seneca
College in Toronto, Ont. In addition to his
studies, Dylan worked as an aerospace
engineering cooperative education stu-
dent for the National Research Council
of Canada–Flight Research Laboratory
at the Ottawa International Airport as
a flight instructor at Harv’s Air, Stein-
bach South Airport, Man., and Ottawa
Aviation Services, Ottawa International
Airport, Ont. He served as an aviation
cooperative education student with
Perimeter Aviation, Winnipeg Inter-
national Airport, Man., and as a flight Figure 1.
dispatcher, flight follower, and aircraft Accident
ramp attendant at the Seneca College, rate 2006
Buttonville International Airport, Ont. to 2015.
January-March 2018 ISASI Forum • 11nations can collect and report, rather it States Army (aka “DEFCON”) [7]. These
ISASI Rudolf Kapustin would simply establish a requirement easy-to-understand and media-hyped
Scholarship Essays to report a set of statistics that can be mechanisms are effective in alerting the
commonly understood across all borders. public about important information,
As an additional benefit, developing an such as the probability of an impend-
knowledge and technology available to international standard would expand the ing aviation occurrence. The outcome
defend against such events.” This view- population of data available for statistical of such heightened public awareness is
point highlights an actual problem and examination, presenting opportunities an increased pressure on industry and
even identifies the presence of a solution. to improve accuracy and explore new government to take action (eventually
When presented in a more compelling analytical territory. downgrading or resetting the alarm). As
context, statistics provide much stronger an experienced and objective third-party,
evidence for taking the actions required investigators and their associated safety
Emphasizing the need to implement
to improve aviation safety. boards are in an excellent and informed
recommendations state to regulate and implement such
A key outcome of any accident investiga- alarm mechanisms.
Standardization of statistics tion is the recommendations addressed
across borders to various parties. Nonetheless, these
recommendations are virtually useless Quantifying the costs of an accident
When analyzing and addressing safety,
if not acted upon. To encourage action, One of the main reasons that available
a common question is how does our
investigators must take all steps possible technological- and knowledge-based
performance compare with others? [3]
to emphasize the importance of effective solutions are not implemented by
If one nation has a low occurrence rate,
it is likely that other nations (and their and efficient recommendation imple- industry, or mandated by government,
industry organizations) will be interest- mentation. To address this, one common is due to an inadequate understanding
ed in examining this high performance method is to develop a “Watchlist” [4] or of the financial costs associated with an
so they can emulate best practices and “Most Wanted List” [5] and then lobby accident. It is quite possible that multiple
reduce their own occurrence rate. This both industry and the government ac- solutions would be implemented if there
cannot take place if each nation is un- cordingly. However, “watching” or “want- was greater awareness of these costs.
able to effectively compare occurrence ing” does not create a sense of urgency To assist in this effort, investigators
statistics (admitted as an issue by the to act. Instead, urgency to act can be and their safety boards should take steps
Transportation Safety Board of Canada stimulated through the development of to document and publicize objective in-
[3]). To facilitate the process of compar- a public alarm mechanism. This “alarm” formation regarding the costs associated
ative growth, investigators should strive would sound based on the varying imple- with an accident. Such data can include
to establish an international standard mentation status of recommendations. the costs to the state (including emergen-
for documenting and reporting aviation Examples of such mechanisms include cy medical services, search and rescue,
occurrence statistics. This would not the “Doomsday Clock” [6] and the De- public relations, official visits to the crash
impose restrictions on the statistics that fence Readiness Condition of the United site, accident investigation, and cleanup)
Figure 2. Accident rate 1959 to 2001 [2].
12 • January-March 2018 ISASI Forumas well as the costs to the operator (including capital loss,
increased operating expenses, occurrence expenses, and
lost revenue).
Estimates of these costs can be obtained through
examining historical data, requesting accounting infor-
mation from accident operators, and by using reasonable
approximations. Once analyzed, the financial data can References
be categorized according to aircraft type and presented
alongside accident statistics. If government and industry
understand that there is a multimillion dollar bill asso-
[1] "Mayday," Cineflix Media, [Online]. Available:
ciated with accidents, it will be much more difficult to http://www.cineflixproductions.com/shows/28-May-
argue that safety-based changes are “too costly” to imple- day. [Accessed 13 04 2017].
ment. The cost of an accident is always more than the cost
of its prevention. [2] F. Scholz, "Statistics in Aviation - Celebrating
100 Years of Flight," [Online]. Available: www.stat.
Marketing prevention washington.edu/fritz/Reports/Daytonnew0.pdf.
One of the saddest findings of an accident is the inad- [Accessed 12 04 2017].
equate presence of countermeasures that are currently
available with modern knowledge and technology. This
[3] Government of Canada: Houes of Commons
should not continue to be the case. To arouse action, a
new statistic should be developed that clearly classifies Standing Committee on Transport, Infrastructure
whether or not an occurrence was reasonably preventa- and Communities-Meetings on Aviation Safety,
ble. This should be identified as an objective conclusion, Ottawa, Ontario , 2017.
within each accident report, accompanied by a suitable
evidence-based explanation. This is not an occasion to [4] "Watchlist 2016," Transportation Safety Board
assign blame, but rather a blunt and forceful opportunity
of Canada, 31 10 2016. [Online]. Available: http://
to instigate action and achieve the “sole objective of [an]
investigation” [8]: prevention. www.bst-tsb.gc.ca/eng/surveillance-watchlist/.
[Accessed 13 04 2017].
Conclusion
The docile nature of implementing the changes recom- [5] "2017–2018 Most Wanted List," National Trans-
mended from recent accident investigations has been portation Safety Board, [Online]. Available: https://
rumbled. Five key transformations are suggested to give www.ntsb.gov/safety/mwl/Pages/default.aspx.
the investigation process back its strength (i.e., the ability [Accessed 13 04 2017].
to inspire significant improvements in aviation safety):
• Enhanced communication of existing statistics [6] "Doomsday Clock Timeline," Bulletin of the
advocates to the public that there are problems Atomic Scientists , 2017. [Online]. Available: http://
with aviation safety that compel immediate action.
thebulletin.org/timeline. [Accessed 13 04 2017].
• Standardization of statistics across borders facilitates
the comparison of safety records and the emulation
of best practices while also allowing for increased
[7] "DEFCON," Wikipedia , 13 04 2017. [Online].
statistical accuracy and the potential innovation of Available: https://en.wikipedia.org/wiki/DEFCON.
new analytics. [Accessed 13 04 2017].
• Emphasizing the need to implement recommenda-
tions, accomplished through “alarming” the public of [8] "Annex 13 to the Convention on International
an impending aviation occurrence, pressures industry Civil Aviation: Aircraft Accident and Incident Inves-
and government to effectively and urgently address
safety issues. tigation," International Civil Aviation Organization,
[Online]. Available: www.emsa.europa.eu/retro/
• Quantifying the costs of an accident enables an im-
proved understanding of the cost savings associated Docs/marine_casualties/annex_13.pdf. [Accessed
with proactive occurrence prevention. 13 04 2017].
• Marketing prevention (i.e. objectively reporting
evidenced based conclusions regarding the prevent-
ability of accidents) reinstalls the vigour required to
instigate action and reintroduce a significant decline
in the accident rate.
So investigations, do they really make a difference?
Well, it is up to investigators to decide.
January-March 2018 ISASI Forum • 13You can also read
