Aviation Accident Investigation

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    Presented by : Sianturi, MBA Avi Mgt

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    NAME : B. R. PARDOMUAN SIANTURI, MBA AVI MGT

    RANK : MAYOR TEK / 520232

    DOB : BANDUNG / 21 JUNI 1973

    POSITION : KASIBINPALLAMBANGJA

    UNIT : DISLAMBANGJAAU

    ADDRESS : GEDUNG B-1 LT. 3 MABESAU

    PHONE : 8709254 / FAX 8714523

    MOBILE : 081319132662/083850900538

    E-MAIL : [email protected]

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    MILITARY COURSES

    A A U 1995

    Sesarcabpa Teknik XI 1996

    Susfam F27 dan C-130 1997

    Remotely Piloted Vehicle Operator Course, France 2000

    Dikkualsus JMU F27 2001

    37th Qualified Aero Engineering Instructor Course, India 2001

    SF260 Marchetti Mechanic Course, Singapore 2002

    Sekkau 76 2004

    Targadik 2005

    49th Flight Safety and Accident Investigation Course, India 2008

    Peace Support Operations Instructor Course 2009

    Indonesian Military Landworthiness Inspector Course 2009

    FORMAL EDUCATIONS

    SD 012 Tarakan 1985

    SMPN I Tarakan 1988

    SMAN 4 Medan 1991

    Post Graduate (S2) RMIT Australia 2007

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    Employment History

    Skadron Teknik 021 Lanud Halim PK 1996 - 2000

    Skadron Udara 2 2000 - 2002

    Skadron Udara 17 2002 - 2003

    Skadron Udara 2 2004 - 2005

    Skadron Pendidikan 303 Wingdiktekkal 2005 - 2007

    Dislambangjaau 2008 - NOW

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    SCOPE1. INTRODUCTION

    2. PURPOSE OF INVESTIGATION AND INVESTIGATION

    3. INITIAL FIELD INVESTIGATION

    4. GATHERING EVIDENCE

    5. PRESERVATION OF EVIDENCE

    6. DETERMINATION OF ACCIDENT SITE AND

    RECONSTRUCTION OF FLIGHT PATH

    7. SAFETY PRECAUTIONS

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    INTRODUCTION

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    CRASH SITE INVESTIGATIONThe remains of a crashed aircraft

    are not necessarily mute, and may

    have a story to tell, if properly

    investigated.

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    INVESTIGATION

    A PROCESS CONDUCTED FOR THE

    PURPOSE OF ACCIDENT PREVENTIONWHICH INCLUDES THE GATHERINGAND

    ANALYSIS OF INFORMATION, THE

    DRAWING OF CONCLUSIONS, INCLUDING

    THE DETERMINATION OF CAUSES AND,

    WHEN APPROPRIATE, THE MAKING OF

    SAFETYRECOMMENDATIONS.

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    DEFINITIONS AIRCRAFT ACCIDENT

    An occurrence associated with the operation of

    an aircraft which takes place between the timeany person boards the aircraft with the intentionof flight until such time as all such personshave disembarked, in which: A person is fatally or seriously injured as a result

    of direct contact with the aircraft or its jet blast.

    The aircraft sustains substantial damage, theaircraft is missing or completely inaccessible.

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    DEFINITIONS AIRCRAFT INCIDENT

    An occurrence other than an accident,associated with the operation of an aircraft,

    which affects or could affect the safety of

    operations.

    FATAL INJURYAny injury that results in death within 30 days

    of the accident.

    Contd...

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    DEFINITIONS SERIOUS INJURY

    An injury which is sustained by a person in an accidentand which: Hospitalization for more that 48 hrs, commencing within

    seven days from the date the injury was received.

    Fracture of any bone (except simple fractures).

    Lacerations which cause severe hemorrhage, nerve,muscle, or tendon damage.

    Injury to any internal organ.

    Second or third degree burns, or an burns affecting morethan 5% of the body surface.

    Verified exposure to infectious substances or injuriousradiation.

    Contd...

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    DEFINITIONS

    SUBSTANTIAL DAMAGE

    Damage or failure which adverselyaffects the structural strength,

    performance, or flight characteristics of

    the aircraft, and which would normallyrequire major repair or replacement of the

    affected component.

    Contd...

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    TYPE OF INVESTIGATION

    STATE / DOMESTIC INVESTIGATION

    Done by country (NTSC, ATSB, etc)

    IN-HOUSE INVESTIGATION

    Done by special agency (PPKPU)

    INTERNATIONAL INVESTIGATION

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    SCOPE OF INVESTIGATION The extent of the investigation depends on the

    actual or potential consequences of the

    occurrence or hazard. The depth of investigation should be that which

    is required to clearly identify and validate the

    underlying hazards.

    Line between relevance and irrelevance is often

    blurred, so it needs better understanding.

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    INVESTIGATION METHOD Used to identify and validate perceived

    safety hazards.

    Competent analysis.

    Effective communication.

    All above: INTEGRATED APPROACH.

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    Hazard or occurrence

    notification and assessment

    Data collection process

    Sequence of events

    Integrated investigation

    Risk assessment process

    Defense analysis

    Risk control analysis

    Safety communication process

    Assess notification and decide to

    investigate or not

    Identify events and underlying factors

    Reconstruct logical progression of

    occurrence events

    Analyze facts and determine

    findings regarding underlying

    factors and hazards

    Estimate risk and determine

    acceptability for each hazard

    Identify defenses that are missing

    or inadequate

    Identify and evaluate risk control

    options

    Communicate safety message to

    stakeholders

    INTEGRATED SAFETY INVESTIGATION

    METHODOLOGY

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    GOOD Investigators:

    They are not afraid to be wrong. They will

    accept facts that are contrary to their presenttheory.

    They readily admit that they dont knoweverything. When they need help, they seek

    help.They listen to the other investigators. Theydont necessarily believe them, but they listento them.

    INVESTIGATION TECHNIQUE

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    QUALIFIED PEOPLE

    PROMPTNESS

    RESPONSIBILITYORGANISATION

    THOROUGH

    ACCURATE

    OBJECTIVE

    COMPREHENSIVEREPORTING

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    The National Transportation Safety Board (NTSB).

    The Federal Aviation Administration (FAA).

    International Civil Aviation Organization (ICAO). The National Transport Safety Committee (NTSC).

    Panitia Penyelidik Kecelakaan Pesawat Udara

    (PPKPU).

    INVESTIGATIVE ORGANISATIONS

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    PURPOSE OFINVESTIGATION

    ANDINVESTIGATOR

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    INITIAL TEAM TO ARRIVE AT THE CRASH SITE

    INITIAL COORDINATION AND ACTION

    PRESERVE PERISHABLE EVIDENCES

    SECURING THE CRASH SITE

    MAPPING & PHOTOGRAPHS THE CRASH SITE

    DETERMINE FACTS, CONDITIONS AND

    CIRCUMSTANCES OF THE ACCIDENT SITE

    LIAISON OF DISLAMBANGJAAU

    PURPOSES

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    PREPARATION BEFOREHAND

    INITIAL FIELD INVESTIGATION

    REPORTING

    INITIAL INVESTIGATIONPROCESS

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    INITIAL COORDINATION

    INVESTIGATION EQUIPMENTS

    PERSONAL SURVIVAL ITEMSDIAGRAM & PLOTTING EQUIPMENTS

    WITNESS INTERVIEWING EQUIPMENTS

    EVIDENCE COLLECTION EQUIPMENTS

    PHOTOGRAPHIC EQUIPMENTSREPORT WRITING EQUIPMENTS

    TECHNICAL DATAS

    PERSONAL ITEMS

    PREPARATION

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    ESTABLISH A BASE OF OPERATIONS

    ESTABLISH LIAISON WITH AUTHORITIES

    SECURE AND PROTECT CRASH SITEDETERMINE WHAT HAS HAPPEN SO FAR

    CONDUCT AN ORGANISATIONAL MEETING

    ESTABLISH SAFETY RULES

    INITIAL WALKTHROUGH

    TAKE INITIAL PHOTOGRAPHSCOLLECT PERISHABLE EVIDENCE

    INVENTORY WRECKAGE

    DIAGRAMING AND PLOTTING

    INITIAL ON-SITE ACTIONS

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    INITIAL FIELDINVESTIGATION

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    ESTABLISH SAFETY RULES

    CHEMICAL HAZARDS

    PRESSURE VESSELS

    MECHANICAL HAZARDS

    PYROTECHNIC HAZARDS

    HYGIENE HAZARDS

    MISCELLANEOUS HAZARDS

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    GATHERING

    EVIDENCE

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    INITIAL SITE SURVEYINITIAL WALKTHROUGHPHOTOGRAPHIC & DIAGRAMMINGRECORD ALL OBSERVATIONSCOLLECT EVIDENCE

    GATHERING EVIDENCE

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    GATHERING EVIDENCE

    Initial Site Survey

    Use helicopter to orbit site at various altitudes.

    Aerial photography.Make a pass down the flight path vector to

    impact point.

    Conduct walk through inspection starting fromimpact point.

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    GATHERING EVIDENCE

    Initial Walkthrough

    Locate all major components (TESTED)

    Tag and identify all possible parts.DO NOT move wreckage unless necessary.

    Advice supplementary personnel.

    Make thorough attempt to locate FDR.Record objects that are not a part of aircraft.

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    Record all observations in a Tape Recorder &

    Video Camera.

    Questioning witnesses.

    GATHERING EVIDENCE

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    Fluid samples (Fuel, Oil, Hydraulic, etc).

    Loose papers, maps and charts.

    Evidence of icing.Runway condition.

    Switch positions and instrument readings.

    Control surface and trim tab positions.FDRs and CVRs.

    Ground scars.

    GATHERING EVIDENCE

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    CRITICAL TIME EVIDENCE:

    SAMPLES.

    FIRE PATTERN.

    LIGHT BULBS.

    WITNESSES.

    RETRIEVABLE DATA:

    CSFDR.

    AC LOADING RECORDERS.

    HEAD-UP DISPLAY VIDEOS.

    AC VIDEO TAPE RECORDER.

    PERSONAL RECORDERS.

    TYPES OF EVIDENCE

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    Use appropriate containersFluid container compatibility

    AircraftFuel

    Oil (Each engine)

    Hydraulic fluid (Each system)

    Servicing EquipmentImpound until samples taken

    Take atleast two samples One for investigation team

    One for immediate analysis

    FLUID SAMPLING

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    VARIES WITH THE ACCIDENTS.

    VITAL IN SOME CASES.

    DEFERENTIATE BETWEEN WHAT THE WITNESSSAY AND THE FACT.

    INTERVIEW NOT INTEROGATION.

    WITNESSES

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    COMMON ERRORS

    LACK GOOD INTERVIEWING SKILLS.

    TEND TO INTERROGATE THAN INTERVIEW.INTERRUPT.

    DONT LISTEN TO THE ANSWERS.

    HUMILIATION.

    INHIBITIVE.

    NOT EASILY ESTABLISH RAPPORT WITH

    PEOPLE WE DONT KNOW WELL.

    WITNESSES

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    PLANNING THE INTERVIEWSet priorities

    Obtain contacts

    Select locationPrepare for the interview

    CONDUCTING THE INTERVIEWMake the witness feel at ease (tell the right and

    purpose)Qualify the witness

    Encourage to tell a story

    Repeat the story to ensure the facts

    Thank the witness / reward

    IDEAL INTERVIEW

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    WITNESS BACKGROUND IN AVIATION / IQ

    PERCEPTION OF WITNESSEMOTION / EXCITEMENTS

    INTERPRETATION OF THE AMBIGUOUS

    AGREEMENT WITH OTHER WITNESS

    ENVIRONMENTALPHYSIOLOGICAL

    PSYCOLOGICAL

    FACTORS AFFECTING

    WITNESS REPORTING

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    Crash survivable Flt data recorder

    AC loading recorder

    HUD video

    AC video tape recorder

    Personal recorder

    RETRIEVABLE DATA

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    COCKPIT.

    AIRFRAME.

    POWER PLANTS.SYSTEMS:

    FUEL SYS

    HYDRAUL IC SYS

    ELECT SYSINSTRUMENTATION

    EJECTION SYS

    FIRE.

    WRECKAGE PATTERN.

    DETAILED ON-SITE EXAMINATION

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    Traces disappear by evaporation

    Precipitation

    Carelessness

    Nature

    Souvenir hunters

    Site Clearance

    DANGERS TO EVIDENCE

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    All efforts to preserve evidence should be

    understood.

    Evidence gathering exercise must becontrolled.

    Deliberate plan to be made to examine

    site.

    Formulate story with out drawing

    conclusions.

    GATHERING EVIDENCE

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    Cordon off.

    Photograph.

    Identification/questioning of witnesses.

    Samples.

    Preservation of ground traces.

    Completeness of wreckage.

    MEASURES TO SAVE

    EVIDENCE

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    PRESERVATION

    OF

    EVIDENCE

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    Bodies to be photographed and examined

    by doctor before moving.

    Physical evidence must be protected from

    further damage:

    Edges of broken surfaces contamination.

    Do not wash, clean, brush off parts.

    Do not mate together broken pieces.

    PRESERVING EVIDENCE

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    Gather all evidence from cockpit:

    Check all controls, selectors, switches &handles.

    Note readings of all instruments.

    Photograph all items.

    PRESERVING EVIDENCE

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    Wreckage documentation:

    Accurate wreckage distribution diagram.

    Full photographic record.Record damage during wreckage movement .

    Record and protect evidence likely to disappear

    or change (Critical time evidence):Samples of all POL and gases.

    Fire pattern.

    Fragile items like bulbs.

    PRESERVING EVIDENCE

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    All recording devices like FDR, AFTR, CVR, DVR etc.

    Impounding of documents (All records pertaining to

    Man, Machine & Flight)

    Pilot Blue Books & Log Books

    Training records of pilot

    FDR data of previous ten sorties

    Engine Log books

    ATC records

    PRESERVING EVIDENCE

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    DETERMINATION OFACCIDENT SITE

    &

    RECONSTRUCTION OF

    FLIGHT PATH

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    Accident Photograph.

    Impact sketch.

    RECORDING OF SITE

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    Forethought brief SAR crew & photographer.

    Request.Overlay giving:

    Approach direction.

    Point of first contact.Direction and elevation.

    AERIAL PHOTOGRAPH

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    SUGGESTIONS

    Fly in something that has an open window ordoor.

    Dont touch the camera to any part of the aircraftor helicopter.

    Arrange for something of known dimension to bevisible in the wreckage scene

    Get at least one picture as close to vertical aspossible.

    Always take two shots in rapid succession foreach picture.

    Note the altitude for each picture taken.

    AERIAL PHOTOGRAPH

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    PHOTOGRAPHIC PRIORITIES

    PERISHABLE EVIDENCE

    AERIAL OVERVIEWS

    OVERVIEWS OF THE SCENESIGNIFICANT SCENE ELEMENTS

    WRECKAGE INVENTORY

    CLOSE-UPS

    DOCUMENTS

    WITNESS VIEWS

    EXEMPLARS

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    In addition to accident photograph.

    Starts with point of first impact.Types:

    Grid System

    Polar SystemSingle Point System

    Straight Line System

    IMPACT SKETCH

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    Have details of:

    Crater depth.

    Ground markings.Traces of skidding and sliding.

    All essential parts.

    Compass direction.

    Obstacles.

    Wind direction and velocity.

    Inspite of this, should not be cluttered.

    IMPACT SKETCH

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    Tenerife 747s Collision

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    GR

    ID

    TYPE

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    POLA

    R

    TYPE

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    RECONSTRUCTION OF FINAL FLIGHT PATH

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    SAFETYPRECAUTIONS

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    Visiting site in a hurry without preparation.

    Ignoring safe investigating practices andcommon safety precautions.

    Arriving at conclusions before startinginvestigation.

    Disturbing the wreckage before collecting

    evidences/ documentation.

    AVOID COMMON ERRORS

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    Cordon area

    Security arrangements

    Make cartridges safeIdentify Crash site hazards

    Bioenvironmental hazards

    Toxic substances

    Mechanical hazards

    Pressure vessels

    Radioactive hazards

    Fire/Explosive hazards

    SITE SECURITY & SAFETY

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    Hazard control

    Scene control

    Neutralisation of known hazardsSafety awareness brief all personnel

    Personnel Protective Equipment

    Surgical glovesLeather gloves

    Exposure suits, etc.

    PERSONNEL SAFETY

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    Theaccuracyand thoroughnesso f

    invest igat ion determ ines the adequa-cy of u l t imate act ion taken

    to remove or el iminate

    factors that cause or

    contr ibu te tomishaps

    CONCLUSION

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    BIDANG MISI

    PROGRAM OPERASI/LATIHAN.

    SYLABUS LATIHAN.

    PROGRAM SIMULATOR.

    BIDANG MANUSIA

    KESEHATAN (MEDICAL/ILA).

    PSIKOLOGI.

    BIDANG MATERIIL

    TINGKAT/MACAM KERUSAKAN YANG DIAKIBATKAN DARIBENTURAN/IMPACT.

    PENGUJIAN MATERIIL/FUEL/OLI MESIN/HIDROLIK.

    KERUSAKAN BENDA LAIN (DILUAR PESAWAT/ALUTSISTA).

    KONDISI DARI SYSTEM PESAWAT/ALUTSISTA PASCAACCIDENT.

    PENYELIDIKAN PPKPU

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    BIDANG MEDIA

    LINGKUNGAN KERJA/KANTOR.

    LINGKUNGAN KELUARGA.

    BIDANG MANAJEMEN

    ORGANISASI SATUAN/LANUD/KOTAMA/MABESAU/MEBES TNI.

    PENGADAAN SUKU CADANG.

    PEMELIHARAAN SUKU CADANG.

    PENYELIDIKAN PPKPU