OCTOBER–DECEMBER 2005 Cow Town Corrals ISASI … · By Carly Reil—The author’s winning essay entry that gained her the 2005 ISASI Rudy Kapustin Scholarship, ... B-737-300 in

OCTOBER–DECEMBER 2005Cow Town Corrals ISASI 2005 (Page 5)Rawson Earns Lederer Award (Page 12)

Carly Reil: 2005 ISASI Rudy Kapustin ScholarshipAwardee (Page 14)

The Problems Facing Air Safety Investigators (Page 15)The ‘Why’ of a Fatal Double Engine Flame-out (Page 16)

The Role of Lessons Learned (Page 20)

2 • ISASI Forum October–December 2005

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Volume 38, Number 4Publisher Frank Del Gandio

Editorial Advisor Richard B. StoneEditor Esperison Martinez

Design Editor William A. FordAssociate Editor Susan Fager

Annual Report Editor Ron Schleede

ISASI Forum (ISSN 1088-8128) is pub-lished quarterly by International Society ofAir Safety Investigators. Opinions ex-pressed by authors do not necessarily rep-resent official ISASI position or policy.

Editorial Offices: Park Center, 107 EastHolly Avenue, Suite 11, Sterling, VA 20164-5405. Telephone (703) 430-9668. Fax (703) 430-4970. E-mail address [email protected]; for edi-tor, [email protected]. Internet website:www.isasi.org. ISASI Forum is not responsiblefor unsolicited manuscripts, photographs, orother materials. Unsolicited materials will bereturned only if submitted with a self-ad-dressed, stamped envelope. ISASI Forumreserves the right to reject, delete, summa-rize, or edit for space considerations any sub-mitted article. To facilitate editorial produc-tion processes, American-English spelling ofwords will be used.

Copyright © 2005—International Societyof Air Safety Investigators, all rights re-served. Publication in any form prohibitedwithout permission. ISASI Forum regis-tered U.S. Patent and T.M. Office. Opinionsexpressed by authors do not necessarily rep-resent official ISASI position or policy. Per-mission to reprint is available upon applica-tion to the editorial offices.

Publisher’s Editorial Profile: ISASI Fo-rum is printed in the United States and pub-lished for professional air safety investiga-tors who are members of the InternationalSociety of Air Safety Investigators. Edito-rial content emphasizes accident investiga-tion findings, investigative techniques andexperiences, regulatory issues, industry ac-cident prevention developments, and ISASIand member involvement and information.

Subscriptions: Subscription to members isprovided as a portion of dues. Rate for non-members is US$24 and for libraries andschools US$20. For subscription informa-tion, call (703) 430-9668. Additional or re-placement ISASI Forum issues: membersUS$3, nonmembers US$6.

FEATURES5 Cow Town Corrals ISASI 2005By Esperison Martinez, Editor—Aviation safety investigators from 37 countriesbrought an international aviation flavor to Fort Worth, Tex., the place where “the Westbegins” and now home to many aviation interests—and the area responded byspreading its hospitality upon them.

12 Rawson Earns Lederer AwardBy Esperison Martinez, Editor—The 2005 Jerome F. Lederer Award recipient is a“don’t tell me, show me” type of investigator.

14 Carly Reil: 2005 ISASI Rudy KapustinScholarship AwardeeBy Esperison Martinez, Editor—Insightful and confident best describes the 2005scholarship winner. She is 21-year-old senior at Embry-Riddle Aeronautical Univer-sity, Fla., and a member of the ISASI student chapter at the school.

15 The Problems Facing Air Safety InvestigatorsBy Carly Reil—The author’s winning essay entry that gained her the 2005 ISASIRudy Kapustin Scholarship, awarded at ISASI 2005.

16 The ‘Why’ of a Fatal Double Engine Flame-outBy Peter Coombs, Air Accident Investigation Branch, U.K. —Investigationof a Shorts SD 360 turboprop flame-out produces a new approach to powerplantinvestigation and an unusual cause is determined.

20 The Role of Lessons LearnedBy Dr. Paul Werner and Richard Perry, Sandia National Laboratories, U.S.A.— Avail-able data, facts, and histories make it painfully obvious that most, if not all, accidentsfollowed one or more precursors or previous accidents that were not acted upon.

DEPARTMENTS2 Contents3 President’s View4 Advisor’s Corner

26 ISASI RoundUp30 ISASI Information32 Who’s Who—A brief corporate member profileof VNV: Dutch Airline Pilots Association

ABOUT THE COVERJohn D. Rawson, left, accepts the 2005 Jerome F. Lederer Award from ISASIPresident Frank Del Gandio during ceremonies at the Society’s annual seminar (seepage 12). The award is the highest laudation bestowed by ISASI. Photo: EsperisonMartinez, Editor.

CONTENTS

“Air Safety Through Investigation”“Air Safety Through Investigation”

October–December 2005 ISASI Forum • 3

Welcome to TexasBy Frank Del Gandio, President

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PRESIDENT’S VIEW

(President Del Gandio’s September 13 openingremarks to the delegates of ISASI 2005 havebeen abbreviated.—Editor)

Texas has always had a special place in Americanfolklore. To most Americans and to many peoplein other lands, Texas symbolizes open space, self-

reliance, and, perhaps most of all, size—everything associatedwith Texas is BIG. The state is nearly twice the size of Japan, or1,000 square miles bigger than France, Belgium, the Nether-lands, Luxembourg, and Denmark combined.

It’s fitting that we should meet in Dallas-Fort Worth, an arearooted in transportation: first as an early cattle town, then as anearly railroad center; now as an aviation center with two of theworld’s four largest air carrier fleets in American and South-west, and the world’s largest regional airline in American Eagle.The region also is home to DFW, one of the world’s largestairports and to Love Field. The region also has an importanthistory in aircraft manufacturing: General Dynamics and BellHelicopters and other aerospace firms. Yes, aviation has a strongpresence here.

Our strong presence is in aviation safety. Once again, the pastyear’s accident rate reminds us that we who work in air accidentinvestigation and aviation safety are not at risk of going out ofbusiness. But I must tell you that when I first drafted mycomments in mid-July, I was touting the wonderfully safe yearthat we had. At that time, the log showed four jet accidents ofnote, worldwide, with 185 fatalities, most of which occurred in asingle event.

Noteworthy jet accidents included the Kam Air CFITaccident in Afghanistan killing 104; a China Eastern RJ takeoffcrash killing 53; a high-speed overrun by Lion Air of Indonesiakilling 25; and an Iranian B-707 that landed long and overran athigh speed into a river, drowning 3 of 176 occupants. Then, Iplanned to add a fairly short list of five significant turbopropaccidents, with 99 fatalities. Overall, I was prepared to argue2005 was a good year with continued long-term improvements inair safety, particularly at the air carrier level.

However, as I was working on that draft, an AN-24 crashed onclimb-out in Equatorial Guinea, killing all 62 occupants. Thencame August and early September: On August 2, an Air FranceA340 overran at high speed in Toronto, with no fatalities but abadly burned-out airplane. Just 4 days later, a Tunisian ATR 72ditched off the coast of Sicily, killing 16 of 39 occupants. Thencame the Helios Airways B-737-300 in Greece (121 fatal), theColombian MD-80 that crashed in Venezuela (160 fatal), then aB-737-200 operated by TANS of Peru, killing 40 people. Finally,a B-737-200 crashed on climb-out in Indonesia, killing 111 onboard and up to 50 people on the ground.

In just 5 short weeks a good story turned into a bad story,with six major accidents and some 500 fatalities. This broughtthe total to eight major jet accidents, seven major turbopropaccidents, and close to 800 fatalities in air carrier passengeroperations since we last met. Clearly, the past year or so has notbeen such a good story.

All the major accidents of the past year remind us that whenmajor accidents occur, the basic scenarios are all too familiar. Forexample, of the major accidents I mentioned, we had five CFITs,four undershoots, one windshear, and one fuel exhaustion. Inshort, when things go wrong, we continue to see the usualsuspects.

Yet, the long-term story remains a good one. Just a fewshort years ago, we would have been thrilled with “only” eightmajor jet accidents. In fact, we can expect the long-termimprovement in accident rates to continue and even to acceler-ate. We will continue to see more application of satellitenavigation, such as RNP and Local Area Augmentative System(LAAS) or WAAS.

On the design side, manufacturers continue to make majoradvances in their ability to test new designs and materials,complete with lifecycle testing, before an actual aircraft is everbuilt. The cockpit, too, will continue to advance with syntheticand enhanced vision, vertical situation display, energy-statedisplays, electronic flight bags, fault isolation, etc. These are justsome of the improvements that are under way or very close athand in the airline world.

As promising as the future is for air carriers, the real revolu-tion in aviation safety is coming in general aviation. Exceptperhaps for large corporate jets at the very top of the market,technology in general aviation had stagnated for years. Thatstate of affairs is finally changing, and fast!

General aviation has incorporated satellite technology into thecockpit with precision navigation, much better displays, datalink, air-to-air monitoring, on-board diagnostics—the wholepackage. Suddenly the term “glass cockpit” is part of the generalaviation vocabulary. Every established manufacturer now offersa glass cockpit of one degree or another. New aircraft like theCirrus SR-20 and SR-22 and the Diamond DA-40 already show2,000 aircraft on the U.S. registry. These will soon be followed bymicro-jets, such as the Adam-700, the Citation Mustang, theDiamond D-Jet, and the Eclipse.

In short, the air carrier industry, particularly among thericher countries of the world, already has achieved accident ratesthat we thought were beyond reach just a few years ago, andthose rates will continue to improve. Meanwhile, we still havesome work to do, and our annual seminars offer a chance toimprove our skills and understanding of a broad range of issuesin accident investigation and aviation safety in general. ◆


ISASI Website Gets New LookBy Richard Stone, Executive Advisor

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Advisor’S CORNER

At its May 2005 meeting,the International Councildetermined that theSociety’s website requiredchange to meet some newneeds. Up to this point,Corey Stephens, with

support from corporate member the AirLine Pilots Association (ALPA), haddeveloped and maintained the existingsite at minimal cost to ISASI. We allappreciate that vital service Corey andALPA provided.

However, it appeared that the webupdate and maintenance would requiremore time and resources than could beprovided on a volunteer basis. We turnedto a commercial concern, Communicationsby Design (CBD), a full-service technol-ogy company that provides repair,instruction, web hosting, and design.

After extensive exploratory sessions withAnn Schull, ISASI office manager, andmyself, CBD has redesigned and expanded,by category, our website to allow for highefficiency with timely updates.

The changeover to the new server isnow accomplished. Members and thegeneral public can access the site usingthe same web address, http://www.isasi.org. The changes involve a newoverall page design and website expan-sion that presents these nine categories:• About ISASI—two sections: (1)General—history, positions, guidelines;(2) Join—member classification defini-tions, applicable forms to join, upgradeclassification, and reinstate membership.• Contact Us—provides contact infor-mation for all elected officials, all chair-men of working groups and committees,Forum magazine, safety-related aviationresource Internet links, and the Govern-ment Air Safety Investigators GroupDirectory, which lists all official govern-mental investigation authorities world-wide, whether or not the authorities aremembers of ISASI.• Donations—directions and form to

forward a donation to ISASI (tax free forU.S. residents).• ISASI Kapustin Scholarship—provides history, past winners and essays,application instructions, and form.• Jerry Lederer Award—provideshistory, past winners, nomination instruc-tions, and form.• Members Only—two sections: (1)Requires sign in to access individual,corporate, or bibliography database. “Username” and “password” restrict access.Each member in good standing can enterhis or her member number in the “username” space and the member’s first namewill be the “password.” All entries shouldbe made in lowercase letters; (2) Publica-tions & Governance—Forum magazine,Proceedings, ISASI By Laws, Code ofEthics and Conduct, International Councilmeeting minutes. (When downloading,members should be aware that the Forummaterial and Proceedings files are lengthyand can be time consuming to download.)• Promotional Items—regalia wear andorder form.

• Reachout Workshops—programdefined and workshop reports (14).• Corporate Members—list of corporatemembers. When a listing is “clicked,” theuser is taken to the appropriate Internetwebsite.

Another significant change is that themembership, corporate directories, andthe bibliography of Forum articles arenow maintained from the ISASI computersystem. This means that our officemanager can make additions, deletions, orother changes in a more timely fashion.

Most of the other information on theweb page is housed in the host computersystem of Communications by Design. Allmatters pertaining to changing, updating,or editing any of the material on thewebsite should be submitted to AnnSchull at [email protected] by the first ofthe month; changes will occur monthly.

Submission and corrections by commit-tee/working group chairpersons shouldfollow the above procedures. This alsoapplies to placing announcements on thehome page. ◆


Everything about Texas is BIG, ISASIPresident Frank Del Gandio told the as-sembled attendees when he opened

ISASI 2005 in Fort Worth, Tex., which ismore reverently thought of in terms of“Cow Town, where the West begins.” So, itis fitting that this year’s seminar earned thetag of “one of the biggest” yet held: 431 to-tal overall participants. This number rep-resents 390 delegates and 41 companions.The 1-day tutorial program attracted 145attendees, also a high for that part of theevent. In all, 37 countries were representedin the makeup of the delegates.

City Mayor Mike Moncrief invited all toexplore the city of “cowboys and culture,”nicely blending in the city’s preserved his-toric past with its successful urban renais-sance. What the delegates quickly discov-ered was that their “corral” was the city’sSundance Square, which is filled with res-taurants, theaters, night clubs, and the ex-pansive two-city-block large RenaissanceWorthington Hotel, the conference hotel.The culture museum district was a $10 cabride away, but well worth the trip to feasteyes on “western” art and sculpture. Simi-larly, the historic Stockyards area was alsoa drive away, but city-provided shuttles car-ried visitors to the place where cowboys

once drove longhorns to market and playedin poker and piano saloons.

Owing to the tightly woven programmingof the event, tourist sights had to be seenbefore the seminar start date or after itsend date. Some attendees managed to dothis, as the majority registered on Sundaywith the seminar opening on Tuesday. Theregistration welcoming kit contained anhour-by-hour agenda of the occurringevents; full details of the local areas, includ-ing easily read maps, dining locations, andtourist brochures.

Other innovations developed by the semi-nar planners included a vastly energizedand enlarged exhibitors’ area. In all, 29 com-panies opted to display their services at thisISASI event. The exhibit area was adjacentto the main hall, so the space was very busyduring all coffee breaks and pre- and post-event times. Many of the exhibitors alsogained “sponsor” status by contributingfunds to the success of the seminar. Thisyear, sponsors were able to select a specificevent with which they wished their contri-bution to be associated.

In another move to hold attendees’ at-tention, drawings of donated prizes weremade at unannounced times throughout thetechnical programs. As expected, some of

the prizes were domestic and internationalairline tickets, many models of airliners, andan array of smaller, but useful, prizes. Ahighly appreciated innovation was the es-tablishment of a “network café” donated byRadioShack, which gave attendees com-puter and printer access, including Internetand e-mail capability.

TutorialsWhile the seminar is a 3-day event, it is aweeklong affair because of the full day oftutorials that occur on the first day of theweek and the post-seminar social tour thatoccurs on the last day of the week. This yearwas no exception and the two tutorialssquared nicely with the overall programtheme “Investigating New Frontiers inSafety.” The first tutorial dealt with helicop-ter accident investigation basics and the sec-ond with emergency response preparedness.

The helicopter session was very apro-pos for the area as Fort Worth is the homeof Bell Helicopter, as well as the center ofa great deal of helicopter activity to ser-vice offshore oil rigs. The cadre of rotary-wing experts speaking included MatthewRigsby, FAA; Chris Lowenstein, Sikorsky;Yasuo Ishihara, Honeywell; Sergio Sales,Safety and Security Ltd, Brazil; and Tom

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Workman, Shell Oil Company.Providing the proverbial “All you ever

wanted to know…,” the helicopter speak-ers covered a large number of topics.Rigsby, from FAA’s Rotorcraft Directorate,provided an analysis of U.S. civil helicopteraccidents. He related that rotorcraft opera-tions with the highest numbers of accidentswere restricted category, air medical, andGulf of Mexico. The top operational causesof accidents included wire/object strikes andflight into terrain/water. The number onecause of fatal accidents was fuel starvation.He went on to reveal the main mechanicalcauses of accidents in turbine and recip craftin the 1998-2004 period.

He noted that the helicopter medicalemergency service (HEMS) operationshave increased 100 percent between 1999and 2004 with 660 rotary-wing flying an es-timated 300,000 hours annually, accountingfor one takeoff every 90 seconds in the U.S.The country’s areas of greatest HEMS ac-tivity are the East, West, and SouthernCoasts. In the 1998-2004 period, 85 HEMSaccidents occurred, 27 of which recorded 74fatalities; 21 of the 27 fatal accidents oc-curred at night. The FAA’s EmergencyMedical Service Task Force remains heavilyinvolved in working with the air medicalcommunity in developing intervention strat-egies for reducing the accident numbers.

Rigsby’s morning-long presentation wasinterrupted by a fire alarm that sounded,emptying the lecture level floor; it provedfalse. Upon return, Rigsby continued andincluded full statistical data on Gulf ofMexico operations (off shore) and restrictedcategory (External Load Part 133, Agricul-tural Craft Part 137) operations. He maybe contacted at [email protected].

Indeed, offshore helicopter operationswere a heavy topic of the tutorials. Both Salesand Workman addressed the subject. Work-man, addressing helicopter safety in the oiland gas business, talked about Shell OilCompany’s safety experience and presentedan accident review and a lessons learned re-view that led into a risk management analy-sis. He said he wanted to leave the audiencewith three main points: (1) Passenger risk ina helicopter is on an order of magnitudegreater than and airliner; (2) Helicoptersafety can be improved (he delved into howit could be done); (3) Success needs a com-bined effort from regulators, manufacturers,operators, and their customers.

Sales, too, turned to offshore operations,only in Brazil. At the outset, he gave a clueto the gravity of his presentation by say-ing: “I hope this presentation can help youto develop some kind of accident preven-

tion procedures…. We are here to shareexperiences, not to point fingers at anyone,so we are not going to talk about compa-nies or crew names.”

With that he began his presentation on off-shore operations characteristics in the Cam-pos area of Brazil and a look at offshore acci-dents and incidents in the 5 years previous to2005. He described the Campos oil area:southeastern Brazil; 100,000 thousand squarekilometers, producing 1,265,000 barrels a day;500,000 passengers per year. His talk centeredon problems caused by helidecks locations,sizes, obstacles, and turbulence. The talk wassupported by digital images of accident in-vestigation scenes. He noted that there aremany types of helidecks with various ob-stacles to overcome, such as roll and pitchon ship pads, and cranes on stationary plat-forms. Types of accidents encountered runthe full scale: one engine inoperative,birdstrikes, hard landing, hovering hard over,and disbelieving new technology.

Speaker Ishihara concentrated his pre-sentation on CFIT accidents and helicop-ter EGPWS. He provided a short flight his-tory of data recovery in helicopter opera-tions and described the workings ofhelicopter enhanced ground proximitywarning system (EGPWS). He said that

Platinum SponsorSouthwest AirlinesAirbusGold SponsorBoeingEmbraerSilver SponsorAirTranRadioShackSagem AvionicsUniversity of Southern CaliforniaJetBlueATSB

ISASI 2005 SponsorsAustin DigitalContinental AirlinesPratt & WhitneyDirectorate of Flying Safety

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ISASI 2005 registrants receive their“welcoming” kit to the annual seminar.In all, 431 delegates and companionsfrom 37 countries attended.


two-thirds of all helicopter accidents resultfrom controlled flight into terrain (CFIT).

In describing the various modes of opera-tion of the EGPWS, he explained thatHoneywell developed a version of EGPWSspecifically designed for helicopters. Thehelicopter EGPWS provides terrain aware-ness display and terrain alerting system cus-tomized for helicopter operations. A high-resolution terrain/obstacle database is in-cluded in the system. By knowledge of theaircraft’s 3-D location, speed, and track,EGPWS can “see” conflicting terrain/water/obstacles along the flightpath that may notbe seen by the pilots or a radio altimeter, andprovides visual and aural alerts to the pilotswhen a threat is detected. He also remindedthe audience that GPWS cannot be used fornavigation, but only for situational display.He, too, showed a series of helicopter acci-dent scene images to impact his discussion.

There were 50 attendees to the secondtutorial, emergency response prepared-ness, which encompassed aircraft accident

management and family assistance issuesand was presented by Marten Bosman, Ad-vance Aviation Safety Services, and ChristaMeyer Hinckley, an aviation attorney in pri-vate practice.

Bosman’s presentation stressed his viewof the need to develop an aircraft accidentmanagement system to enable airlines to bebetter prepared to respond rather than justby participating in the accident investigation.The four main topics of such a system arethe technical investigation, internal and ex-ternal communications, the legal investiga-tion, and assistance to the families of victims.He reviewed each of the topics, touching onthe requirements of ICAO Annex 13 and howits mandates are fulfilled, and explained com-munications methods, means, strategy, andpreparation to meet the press and family is-sues. Legal issues review also included iden-tifying key players and interacting with theinvestigation process.

The main substance of his tutorial, how-ever, was the need to develop a crisis cell tosustain a proper aircraft accident manage-ment system. He defined the cell as a “co-herent organizational unit geared to man-age an aviation crisis.” He went on to com-prehensively describe its six main elementsand how they create the whole: policy, guid-ance, organization, infrastructure, people,and training.

Hinckley did an equally comprehensivepresentation on the subject of, NTSB fam-ily assistance: history and support require-ments issues, opportunities and challenges,with her tutorial review. The timeliness ofthis daylong presentation is attested to bya recent NTSB action to offer in 2006 extrasessions of its family assistance course atits NTSB Academy to “accommodate theincreased interest from airlines and othertransportation providers worldwide.”

By the end of the tutorial, attendees werewell schooled in the total history of how thecurrent family assistance program cameinto being, the laws that govern it, and theregulations and procedures that must befollowed. In recounting the history,Hinckley was able, through direct quotes,to provide an inkling to the sorrow felt byfamilies of victims, and the shoddy treat-ment they received prior to the existenceof “family assistance.” She provided a cleardevelopment path to today governing Avia-tion Disaster Family Assistance Act(ADFAA) and the Foreign Air Carrier Fam-ily Support Act (FACFSA), which insurefamilies of victims now receive the consid-erations due in such circumstances.

Her detailed presentation gave attend-ees, who could find themselves cast in aplayer’s role during accident crises, knowl-edge of the respective roles of governmen-tal, local, and aid agencies as well as that ofair carriers. She made clear what types ofactions are prohibited, the enforcement con-sequences an air carrier would suffer forfailure to meet lawful requirement, and therole of family assistance coordinators in in-terfacing with investigators, among others.

Main programThe main program began on September 13and was opened with a few welcoming re-marks by Curt Lewis, president of the ISASIDallas-Ft. Worth Chapter, which hosted the36th annual international seminar. ISASIPresident Frank Del Gandio, who in a for-mal address welcomed the assembled toISASI 2005, followed him. His remarks cen-

Above: Technical presentations revolvedaround data mining, analysis, andresearch, providing emphasis on aviationsafety management. Left: Q-&-A sessionsproved zestful and probing.


tered on the progress of lessening the air-craft accident rate and improving the over-all air safety level, despite several accidentsoccurring in 2005. In urging the group tobecome actively involved in the activities andopportunities offered by the seminar, he said,“Look around you. Chances are very goodthat you are seated close to someone whoknows everything there is to know aboutsome topic that interests you.” (See“President’s View,” page 3.)

He next introduced the selectee for the2005 Jerome E. Lederer Award and thewinner of the ISASI Rudy Kapustin Me-morial Scholarship Award for 2005. JohnD. Rawson, ISASI Fellow, claimed theLederer Award (see page 12). Identifyingthe Lederer awardee on the opening day,rather than on the final banquet night, wasa recent innovation. It was designed topermit delegates to offer personal con-gratulations throughout the seminar. Win-ner of the $1,500 scholarship award wasCarly Reil from Embry-Riddle Aeronau-tical University. The scholarship fund hon-ors the memory of “tinkicker extraor-dinaire” Rudy Kapustin, who served foryears as the ISASI Mid-Atlantic RegionalChapter president. This is the third award-ing of the scholarship (see page 14).

Noting that the three previous winners ofthe scholarship were in attendance at theseminar, Ron Schleede, ISASI vice-presidentand scholarship fund administrator, said,“The scholarship program along with theReachout program signifies the best ofISASI.” He added, with a smile of pride fortheir accomplishments, that the first year’stwo award winners, Michiel Schuurman andNoelle Brunelle, are both now employed inaircraft accident prevention positions,Schuurman with the Dutch Safety Board andBrunelle with Sikorsky Aircraft. Moreover,he related, Schuurman made a delegate tech-nical presentation at the seminar and has ac-cepted a seat on the ISASI scholarship se-lection committee. The second year winner,Shannon Harris, is in her last year of schoolat Embry-Riddle Aeronautical University.

Keynote speakersJohn J. Goglia, retired NTSB Board mem-ber, ISASI member, and presently a faculty

member of Saint LouisUniversity, where heserves as a professor ofaviation science, made theopening keynote presen-tation. In addressing thegroup he said: “In the re-cent past weeks we’ve

had six major plane crashes with interna-tional involvement.… In light of these newtragedies our industry is facing, I think it isimportant to focus on just what are we, asan international body, to do to best preparefor a drain on our resources, meaning notjust financial, but human and technological.”

One of the first recognitions required, henoted, is that ISASI is an internationalgroup, “not just a conglomerate of indepen-dents. Of course, we cannot deny the realitythat we are a group of big brothers and littlebrothers.” He defines big brothers as “thosewho have had the experience, have peoplewith the expertise, and have massive tech-nological capabilities, while perhaps lackingthe sheer number of human resources.”Little brothers are those organizations justdeveloping their program and that lack theresources of the larger organizations.

He cautioned that the drain of resourcesalso affects the corporate partners of theSociety, “because when our accident investi-gators are adrift, it puts increased burdenson our corporate partners to try and com-pensate.… [They] not just have to look outfor their own industry, but be ready to assistat a moment’s notice to do anything fromdecoding FDRs and CVRs to providingqualified investigators to assist in conduct-

ing a full-scale investigation in some of themost challenging environments on Earth.”

However, the recognition factor has to bebolstered by “acting like an internationalgroup,” he added. He recognized that mereattendance at the seminar in the numbers ofpersons that registered is evidence that theimportance of “looking and acting” like aninternational body is well understood. He ap-plauded the proactive stance of investigatorsin Europe in their periodic “lessons learned”forums in which they share experiences.Addressing the “little brothers,” he urgedthat they assert their talents and not relyupon “big brother” to “take care of them.”

ICAO Annex 13, he said is both “ a bless-ing and a curse”—a blessing because it pro-vides guidelines for conducting interna-tional accident investigation, a curse be-cause it does not “deal with the realobstacles to accident investigation, whichare the intangible idiosyncrasies that varyfrom country to country.” Lastly, he ad-dressed the matter of new entities that “donot take the proactive approach,” urgingthem not to rely solely on “big brother.”

He closed telling the assembled group:“ISASI has shown the ability to bring to-gether the biggest grouping of world-classinvestigators with a common goal. If we canbegin to address some of these issues un-der their umbrella, perhaps we can moveforward another notch or two using theproven training tools we have seen over theyears….” Delegates engaged in a robustquestion-and-answer period following hispresentation.

FAA Director of Flight Standards ServiceJim Ballough opened the second day’s ses-sion with a keynote address titled VoluntarySafety Programs—Partnerships for Safety.

Al Weaver, right, responds toa question as panel members,

left to right, Joseph Rakow,Michiel Schuurman, andBarbara Burin, look on.


His talk dovetailed nicelywith the topic for the dayPapers: Data Analysis.

Ballough discussedFAA’s realization frompast experiences that tra-ditional methods of FAAsurveillance and enforce-

ment would not achieve increased levels ofsafety. He noted that raising the bar wouldrequire the augmentation, “not replace-ment,” of traditional FAA oversight withvolunteer safety partnerships bundled intoa volunteer safety program.

The FAA then set the goals for such aprogram—• Foster partnerships for safety.• Decrease accidents, incidents, and viola-tions.• Obtain safety information not available

through traditional means.• Better identify risks to public safety.• Implement risk-reduction strategiesbased on voluntarily provided safety data.• Track the effectiveness of these strate-gies over time.

Today there are these six voluntary safetyprograms administered by the Flight Stan-dards Service: (1) voluntary disclosure pro-gram (VDRP), (2) aviation safety action pro-gram (ASAP), (3) flight operational qualityassurance (FOQA) program, (4) advancedqualification program (AQP), (5) line opera-tions safety audit (LOSA) program, and (6)internal evaluation program (IEP).

Ballough described the partner relation-ships and working details of each of the pro-grams. He then outlined the programs thatwere on the horizon, such as expansion ofFOQA and ASAP, codification of AQP as a

permanent rule, and publication of an up-dated LOSA and IEP advisory circular. Heconcluded by expressing that in the futurethe partnership program hoped to achievebetter integration of safety informationfrom multiple programs, to transitionVASIP from a demonstration program to apermanent systematic venue for safety in-formation sharing, and to develop FAAguidance and incentives for a voluntarysafety management system (SMS).

Technical sessionsIn an assembly of 400 people, the measureof success isn’t the content of the program,as much as it is the comfort level affordedthose who, hour after hour, listen to the dron-ing of speech and watch the flashing ofPowerPoint images. Astute planners knowthis and select conference hotels accordingly.

TUESDAY—Topic: Recent Investigations• Bob Benzon, Investigator-in-Charge,NTSB—Challenges in the Afghan Investiga-tion of the KAM Air Flight 904• Stephane Corcos and Pierre Jouniaux,BEA, France—Accident, Serious Incident,and Incident Investigations: DifferentApproaches, the Same Objective• Dr. Robert O. Besco, President, PPI;Capt. (Ret.), American Airlines—Find theReasons: Stop Feeding the Causes and Letthe Reasons Starve• Wen Lin Guan, Aviation Safety CouncilTaiwan, R.O.C.—Performance and FlightDynamics Analysis of the Flight in IceAccretion• Johann Reuss, Federal Bureau of AircraftAccidents Investigation, Germany—Are theTCAS/ACAS Safety Improvements Sufficient?*Panel 1: Industry Flight Safety InformationSharing ActivitiesJim Ballough, AFS-1, U.S. FAA; MichelleHarper, University of Texas; Capt. TerryMcVenes, Executive Central Air SafetyChairman, ALPA; Dr. Steve Predmore,JetBlue Airlines; Tom O’Kane, FRAeS; JillSladen-Pilon, IATA

WEDNESDAY—Topic: Data Analysis• Simone Sporer, Psychologist, University ofApplied Science, Austria—Flight DataMonitoring—A New Approach• Ahmet Oztekin, M.S., Student, Universityof Rutgers—A Case-Based ReasoningApproach for Accident Scenario KnowledgeManagement• Jill Sladen-Pilon, IATA, and Mike Poole,Flightscape, U.S.—Airline Flight DataAnalysis (FDA)—The Next Generation• C. Edward Lan, University of Kansas, andSamason Y.C. Yeh, Capt., China Airlines,Taiwan, R.O.C.—Investigation of Causes ofEngine Surge Based on Data in Flight

Operations Quality Assurance Program• Paul Jansonious, Standards Pilot, West Jet,and Elaine Parker, North Caribou Air,Canada—Practical Human Factors in theInvestigation of Daily Events• Tom O’Kane, FRAeS, Aviation SafetyAdvisor—Incident Classification Systems MadeIrrelevant by Text Mining Tools?• John Fish, American Underwater Search andSurvey, and John Purvis, Safety ServiceInternational—Sonar as a Tool to RetrieveAirplanes and Schooners• Robert Matthews, Ph.D., U.S. FAA—International Similarities and Differences inthe Characteristics of Fatal General AviationAccidents in Eight Countries*Panel 2—Post Accident/Incident StressManagement Guidance for the InvestigatorBrenda Tillman, Readiness Group InternationalMary Cotter, Air Accident Investigation Unit,IrelandPapers: Special Investigations• A. Ranganathan, Capt., SpiceJet, India—WetRunway Operations• Christian Amaral and Bill Watts, Delta AirLines—Delta Air Lines Emerging Technologiesfor Turbulence Avoidance: The Delta Perspective

THURSDAY—Papers: Human Factors andSafety Management/Investigative Techniques• Derrick Tang, Advent Management Consult-ing, Singapore—Total Safety Management forAircraft Maintenance Using TQM Approach• Howard Leach, MRAeS, British Airways,England—Maintenance Error PredictionModeling• Donizeti de Andrade, Ph.D., ITA, Brasil, andGustavo Moraes Cazelli, Embraer, Brasil—Aircraft Accident Investigation Applications ofSystem Identification Techniques• Joseph Rakow, Ph.D., Exponent FailureAnalysis Associates—Thermostructural Failurein Aviation Accidents

Speakers and Technical Paper Presented at ISASI 2005• Jody M. Todd, Capt., Honeywell Aero-space Electronic Systems—EGPWS RAAS—Runway Awareness and Advisory System• Al Weaver, Senior Fellow Emeritus, GasTurbine Investigations—Rotor Seizure Effects• Michiel Schuurman, Student, AerospaceEngineering, Technical University Delft,Netherlands—3-D PhotogrammetricReconstruction in Aircraft AccidentInvestigation• Barbara Burian, Ph.D., SJSUF, NASAAmes—Do You Smell Smoke? Issues in theDesign and Content of Checklists for Smoke,Fire, and Fumes• Keith McGuire, NTSB—Selecting theNext Generation of Investigators• Kathy Abbott, Ph.D., FRAeS, ChiefScientific and Technical Advisor, U.S. FAA—Applying Human Performance Lessons toSmaller Operators• John Cox, Capt., FRAeS, Safety Operat-ing Systems—Bringing Proactive SafetyMethods and Tools to Smaller Operators• Frank Gerards, Col., Royal NetherlandsAir Force, and Rombout Wever, NLR,Netherlands—The Use of Operational RiskManagement in the Royal Netherlands AirForce• Mark Solper, Chairman, ALPA AccidentInvestigation Board, and Michael Huhn,ALPA—The Unified Field Theory• Mohammed Aziz, Ph.D., Advisor toChairman, Middle Eastern Airlines—TheRole of GAIN in Enhancing Air CarrierSafety Management• A.L.C. Roelen, National AerospaceLaboratory, Netherlands, and RomboutWever, NLR, Netherlands—An Analysis ofFlight Crew Response to System Failures• Mark Smith, Boeing—Boeing RunwayTrack Analysis.*Panel participants did not submit writtentext of their discussions. ◆


So, while the outside temperatures in CowTown hovered near the 100-plus degreeFahrenheit mark, those attending the 3-day-long ISASI 2005 technical program comfort-ably sat in air so cool that some resorted tolong sleeves and jackets. Tables were angledso all could easily view the side screens andwater jugs, drinking glasses, and hard candywere just an arm’s length away.

With that setting, 46 speakers addressedthe group either in an individual presenta-tion or as a member of a panel. While thegeneral theme of the event was Investigat-ing New Frontiers in Safety, each daily a.m.and p.m. segment carried its own topictheme. Recent Investigations was the firstday’s subject for six morning speakers. Theafternoon’s seven-member panel delvedinto Industry Fight Safety InformationSharing. Each panel member presented ashort paper on the subject before takingquestions. The Data Analysis topic was ad-dressed by the first 12 speakers on the sec-ond day; an afternoon two-member paneldiscussed Post Accident/Incident StressManagement Guidance for the Investiga-tor, and the last two speakers of the day ad-dressed Special Investigations. The 16speakers who addressed attendees used thefinal day’s topic, Human Factors and SafetyManagement/Investigative Techniques, inboth the a.m. and p.m. sessions.

As can be seen from the daily topics, shar-ing of information was the heavy underly-ing element of the seminar’s technical pro-gram. Accordingly, papers’ content revolvedaround data mining, analysis, research, thepractical, and the theoretical. One long-timeattendee summed up the technical sessionthis way: “The difference this year versusother years was the heavy emphasis on avia-tion safety management. There was moreof this than on investigation.”(See adjacentlist of speakers and subjects.)

Throughout the technical program days,the various societies, committees, and work-ing groups held meetings. President DelGandio also conducted the annual member-ship meeting.

Social activitiesRelaxed interactions contribute as much tothe success of an event as does the formalprogram. To take full advantage of this fact,ISASI seminar planners set social activitiesthrough a full companions’ program and ac-tivities for all attendees. The Welcome Re-ception allowed for a shake off of the travelweariness and an awakening of friendshipsfrom past seminars. Midway through thetechnical programming was an evening ofgaiety related to the norms of the local area.ISASI 2005 bussed its crowd to Billy’s Bob’s,billed as the world’s largest “honky tonk.” Itis housed in the middle of the historical Ft.Worth Stockyards area. The western-attiredguests were greeted by comparativelydressed dance hall “queens” and “wranglers”as they stepped off the bus to be escortedinto a one-time barn used for prize cattleduring the stock shows.

Companions, although small in number,41, were treated to an array of entertain-ing venues. They toured movie studios, dis-covering how images of mystical happen-ings and physical deformities are created.At the Botanic Garden, the high humidityovershadowed the magnificence of the rainforest, and most companions welcomed thecool comfort of the tasty lunch that followedthe tour. A visit to the National CowgirlMuseum displayed the spirit of the womenwho made their living on ranches of theearly West. But its captivating Hall of Famedisplay of slowly changing images of cow-girls was a crowd pleaser. The final com-panion event took them on a riverboat sce-nic cruise around Lake Granbury, wheredespite the hot sun, the upper deck breezecooled the group as they viewed the lavishhomes along the lake’s shores.

The post-event day activity has alwaysbeen proven a great closer to a week of “stu-dious” attention. First came a visit to theSixth Floor Museum, which examines thelife, times, death, and legacy of PresidentJohn F. Kennedy. The museum is housed inthe Texas School Book Depository buildingand floor from which the assassination shots

were fired on Nov. 22, 1963. The group thenwent on to a visit of the Circle R Ranch, anauthentic, theme-oriented ranch on 100 acresof green rolling hills and open pastures. Dis-embarking from the busses, the group waswelcomed by cowhands who draped themwith 2-foot square red, white, and blue ban-danas bearing the Circle R brand and thestar of Texas. The line queued at the “chuckwagon” for grilled steak and other morsels.Then it was off to the corrals and horsebackriding for some and boarding of hay wagonsfor others who were entertained by a wire-thin songster wearing a large-brimmedTexas hat and strumming a well-used gui-tar. In all, it was a relaxing time after therigor of sitting in auditorium seats for 3 days.

Awards banquetThe evening before the Circle R excursionwas the time for the heavily attended andanticipated awards banquet. The hall’s linen-clothed tables seated 10 persons each; 40tables filled the floor. Following dinner, RalphHood, with his background of being a pilot,aircraft salesman, book author, and profes-


sional speaker, entertained the aviation-ori-ented audience with comical barbs and praisefor their profession. He “loosened” up thegroup for the upcoming presentation ofawards to deserving ISASI folk.

People and groups honored includedALPA and Corey Stephens for website sup-port and webmaster work and new corpo-rate members AeroVeritas Aviation SafetyConsulting, Ltd, Aircraft Mechanics Fra-ternal Association, Centurion Inc., CirrusDesign, Colegio Oficial Pilotos AviationCommercial/Spain, Cranfield UniversitySafety and Accident Investigation Centre,Directorate of Aircraft Accident Investiga-tions-Namibia, Dutch Airline Pilots Asso-ciation VNV, European Aviation SafetyAgency, Flight Attendant Training Instituteat Melville College, Irish Air Corps/Military

Airworthiness Authority, My Travel Air-ways, Star Navigation Systems Group, Ltd,Hellenic Air Accident Investigation andAviation Safety Board-Greece, and AccidentInvestigation and Prevention Bureau, Fed-eral Ministry of Aviation-Nigeria.

President Del Gandio also announced theawarding of Fellow status to John D.Rawson, Itzhak Raz, and Ken Smart. RonChippindale, New Zealand Councillor, was

Above left: Hay wagon singing cowboyserenades riders. Above: Seminarplanners C. Lewis (left) and J. Darbo(right) accept prop-clock award fromPresident Del Gandio. Left: Capt.Ranganathan accepts “Best SeminarPaper” Award of Excellence.Below: B. Dunn accepts traditional“passing of the Bell” from T. Carroll.Below left: At this “table of winners,”each person won a significant prizein the final day’s many prize drawings.

named chairman of the Fellow selectioncommittee. He also called for audience rec-ognition of the 2005 winner of the KapustinMemorial Scholarship, Carly Reil (see page14) and made special plaque presentationsto the Cirrus Aircraft Corporation (see“RoundUp”) and to Capt. A. Ranganathan,SpiceJet Limited, India.

The nature of the Award for Excellence“ISASI 2005 Best Seminar Paper” is a firstfor ISASI, but one that will continue to oc-cur for the foreseeable future. The award isan outgrowth of an anonymous contributionto the Society to reward the writer(s) of thebest paper presented at any respective an-nual seminar. The President and ExecutiveAdvisor, Richard Stone, make up the selec-tion committee. “Based on the criteria estab-lished by the anonymous donor,” said Stone,“the committee’s criteria was a paper thatprovided meaningful technical advancementin accident investigation, properly addressedthe theme of the seminar, and a written textand oral presentation that was understand-able and interesting.”

Capt. Ranganathan’s paper was titled“Wet Runway Operations” and dealt withthe hazards of operating in such conditions,what causes the hazards, and how the haz-ards can be reduced, along with a call forimproved training and certification stan-dards to overcome the accident potentialinvolved. (The award-winning paper will bepublished in the January/March 2006 issueof the Forum.)

The final presentation of the evening wasthe awarding of the 2005 Jerome E.Lederer Award to John D. Rawson. Thedetails of the presentation ceremony andthe awardee’s comments are published onpage 12 of this issue.

The closing ceremony of ISASI 2005 wasthe traditional passing of the “Call to Or-der Bell” to ring the opening of ISASI 2006,which will be held in Cancun, Mexico, Sep-tember 11-14 and is hosted by the ISASISeminar Committee in cooperation with theISASI Latin American Society and theMexican ALPA group. ◆


Past Lederer Award Winners

John D. Rawson, a Fellow member of theSociety, was an almost-absent recipientof the Jerome F. Lederer Award for 2005

at the ISASI annual awards banquet. Un-aware of his selection for the prestigiousaward, his original plans to attend the an-nual seminar were abruptly altered whenHurricane Katrina changed some of thelandscape of his property in Meridian, Miss.This change of plans caused a dilemma forPresident Frank Del Gandio, who secretsaway the name of the selectee until theopening day of the seminar. Finally reach-ing Rawson by phone, Del Gandio inquired,“John, have you decided if you are comingto Texas?” The reply was quick and posi-tive, “Can’t make it.” With no recourse, DelGandio had to share the secret: “John, youare receiving the Lederer Award!” Stunnedsilence was the reply, until, again, a quickand positive: “I’ll be there.”

So while the pleasure of surprise wasabsent when President Del Gandio intro-duced award winner Rawson to the near 400attendees who filled the cavernous room,he appeared humbled at the thunderingapplause that filled the air. The early an-nouncement allowed many delegates to of-fer private congratulations to the 29th re-cipient of the award, who would be morefully honored on the last evening of the semi-nar program.

The Jerome F. Lederer Award is con-ferred for outstanding lifetime contributionsin the field of aircraft accident investigationand prevention and was created by the Soci-ety to honor its namesake for his leadershiprole in the world of aviation safety since its

infancy. Jerry Lederer “flew west” on Feb.6, 2004, at age 101. Awarded annually byISASI, the Lederer Award also recognizesachievement of the Society’s objectives andtechnical excellence of the recipient.

The presentation of the award alwaystakes place on the last evening of the semi-nar, and it is the highlight of the award ban-quet. In introducing the winner to the audi-ence, President Del Gandio commented,“The Jerry Lederer Award is the most pres-tigious award that the Society can confer, andJohn Rawson’s 45 years of experience in air-craft accident investigation and aviationsafety has proven spectacularly worthy of thehighest accolades.” He went on to relatehighlights of Rawson’s contributions:

“John started his career in accident in-vestigation in 1960, when he accepted em-ployment with the engineering division ofthe Civil Aeronautics Board (CAB), prede-cessor of the NTSB.

As a system specialist, he became one ofonly two original flight data recorder read-out specialist for the CAB. He also was in-volved with investigating and analyzingelectrical/electronics instrument systemsand hydraulics and communications prob-

lems in dozens of major accidents.“In 1962, he transferred to the CAB’s

Miami field office where he was an investi-gator-in charge (IIC) for 8 years and inves-

President Del Gandio, right, presents the2005 Lederer Award to John Rawson.

1977—Samuel M. Phillips1978—Allen R. McMahan1979—Gerard M. Bruggink1980—John Gilbert Boulding1981—Dr. S. Harry Robertson1982—C.H. Prater Houge1983—C.O. Miller1984—George B. Parker1985—Dr. John Kenyon Mason1986—Geoffrey C. Wilkinson1987—Dr. Carol A. Roberts1988—H. Vincent LaChapelle1989—Aage A. Roed1990—Olof Fritsch1991—Eddie J. Trimble

1992—Paul R. Powers1993—Capt. Victor Hewes1994—U.K. Aircraft AccidentsInvestigation Branch1995—Dr. John K. Lauber1996—Burt Chesterfield1997—Gus Economy1998—A. Frank Taylor1999—Capt. James McIntyre2000—Nora Marshal2001—John Purvis and the Transpor-tation Safety Board of Canada2002—Ronald L. Schleede2003—Caj Frostell2004—Ron Chippindale

The 2005 Jerome F. Lederer

Award recipient is a “don’t tell

me, show me” type of

investigator.

By Esperison Martinez, Editor

Rawson Earns Lederer Award

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tigated a great many general aviation andair carrier accidents. In 1968, John left thegovernment and joined HydroAire as aflight data recorder technical representa-tive. In 1970, he returned to the NTSB asan CVR/FDR specialist in the Washington,D.C., headquarters, subsequently becom-ing chief of the CVR laboratory.

“John transferred to the FAA in 1974 andserved as the FAA IIC on more than 70major catastrophic accidents worldwide. In1976 he became a branch manager and in1982 was promoted to manager of the Acci-dent Investigation Division in the Office ofAccident Investigation, a position he helduntil retiring in 1994.

“During his career in both agencies, Johnauthored more than a 100 safety recommen-dations, which have had a tremendous posi-tive impact on aviation safety. He estab-lished and was responsible for the curricu-lum and training activities of the FAA’sAccident Investigation School in OklahomaCity and lectured at the basic investigationclass for many years. He was also instru-mental in organizing and implementing thehelicopter accident investigation course that

is taught at the Bell Helicopter facility inFort Worth, Tex.

“John’s involvement with ISASI is asimpressive as his government career. Hejoined in 1965 and held member numberCH59, marking him as one of the foundersof our Society. He has served as member-ship chairman, secretary, and as treasurer.In that position, he established an account-ing system that served ISASI for manyyears. He has presented laudable papersat numerous ISASI seminars and at ICAOmeetings worldwide.

“His government career and his involve-ment in ISASI indicate a total dedicationand concern for aircraft accident investiga-tion and aviation safety. His contribution tothe aviation industry and this Society aremonumental and worthy of making him the2005 Jerome F. Lederer Award recipient.John, I present to you the Jerry LedererAward for 2005. Congratulations.”

As the applause of the full room quieted,the unassuming, straight-backed, and soft-spoken award winner moved to the micro-phone. The room was now still, all eyesfront, ears primed to hear: “Thank you,” he

Rawson speaks to the assembledbanquet crowd.

Recent Lederer Award winners strike a pose. Left to right, Ronald L. Schleede (2002),Caj Frostell (2003), Rawson, Ron Chippindale (2004), and John Purvis (2001).

whispered. And with a stronger voice con-tinued, “It is a great honor to receive thisaward and to be included with those peoplewho have come before me as recipients ofthe same award. As Frank said, I have beendoing this a long time. I have worked with alot of you in this room and certainly withyour organizations. I can say with all hon-estly that my experience totally shows thatISASI has made a big difference in safety,worldwide.

“One of the reasons is, of course, that weexchange information here, meet eachother, go back to our organizations and in-form about what is going on. Fortunately, alot of the people here work for rule-makingagencies and accident investigation groups.That’s a good thing, and I want people tokeep up the good work.

“A thought I want to pass along is some-thing I’ve always practiced in my investi-gations and urged all the people I haveworked with to practice: When you are in-vestigating an accident, tell the person orthe group that ‘I appreciate all you haveexplained to me, but I would rather haveyou show me.’” ◆


“Since the first plane crash on September17, 1908, that seriously injured OrvilleWright and killed his passenger, First Lieu-tenant Thomas E. Selfridge, accidents havebeen the shadow behind aviation. Investi-gating them, however, is providing the lightneeded to make changes. Though we havecome a long way, the near art form of piec-ing together the puzzle formed when a planecrashes remains a relentless challenge forinvestigators. From evaluating a crashscene to educating the industry on theirfindings and everything in between, acci-dent investigators face a number of chal-lenges at every scene.”

These insightful thoughts, descriptivelycast, open the essay “Problems FacingAir Safety Investigators” submitted by

Carly Reil, a senior at Embry-Riddle Aero-nautical University (ERAU), Florida, U.S.A.,in her quest to become the 2005 ISASI RudyKapustin Memorial Scholarship awardee.She succeeded! She was presented the finalhonors at the Society’s annual seminar.

In presenting the award, ISASI Presi-dent Frank Del Gandio noted that the schol-arship was established in memory of allISASI members who have died and wasnamed in honor of Rudy Kapustin, theformer ISASI Mid-Atlantic Regional Chap-ter president and long-term ISASI mem-ber who developed a reputation as “tin-kicker extraordinaire” among his peers. Thescholarship is intended to encourage andassist college-level students interested inthe field of aviation safety and aircraft oc-currence investigation. The memorial pro-vides an annual allocation of funds for thescholarship. Del Gandio announced thatReil would receive a $1,500 ISASI award tohelp offset attendance at the seminar. Inaddition, he said the FAA’s TransportationSafety Institute and the Southern Califor-nia Safety Institute are awarding fee-freeattendance to the respective school’s acci-dent investigation course.

The 21-year-old student said of her es-say, which is reprinted on the following page,

“I focused on the obvious in the beginning,primarily to show the seldom-expressed dif-ficulty of diverse groups working togetherin one investigation to arrive at one conclu-sion. I wanted to express the nature of aninvestigator’s field work: the trials of work-ing relationships with unknown investiga-tors, the synergy developed in resolvingdiffering opinions, the ideas and methodsused. And finally, the necessity for all tocome together as one group to come to oneconclusion.”

Carly recounts how her confidence andability to write on the subject came about:“The aviation industry has always fasci-nated me, and in my high school years Ibecame interested in forensic medicine asit applies to accident investigations. WhenI was looking at colleges to attend, I notedthat ERAU offered a safety sciences degreethat was related to crash investigations. Itappeared perfect for me. It offered a bitabout aviation and a bit about forensics, myfavorite areas of interest.

“So, my insight for the paper came frommy classroom studies and exposure toISASI accident-investigation-generatedmaterial that I receive as a member of theUniversity’s ISASI student membership

chapter. I read every issue of the Forum; ithas so many great articles. From the ar-ticles, I digest what the investigators them-selves experience as they search accidentscenes for cause factors. I agree very muchwith the prevailing attitude that the resultsof investigations need to be more thor-oughly acted upon to prevent future simi-lar caused accidents. And to gain that posi-tive action, more agencies and persons haveto better understand the investigative pro-cess and the findings it produces.” Carlyjoined the student chapter in her secondyear at the school and has served as trea-surer and vice-president of the group. Hersummers have been spent in aviation-safety-related internships.

Upon graduation in May 2006, she in-tends to apply for graduate school in a sub-ject that will lead to placement into someaspect of the accident investigation profes-sion. “I am interested in working on an in-ternational level, because other cultureshave always been a high interest of mine. Ithink it would be very exciting to becomeinvolved with cultures that are developingtheir own safety investigative programs. Tobe involved in helping to build up a programfrom the ground up would be a terrific ex-perience both from the learning and teach-ing standpoint.”

How does she feel about her first ISASIannual conference? “It’s been wonderful.I’ve met some great people who havehelped point me in the right directionthrough the many different topics pre-sented. They opened me up to many dif-ferent aspects of investigation that I hadnot thought of before.” ◆

Carly Reil:

2005 ISASI Rudy KapustinScholarship Awardee

President Del Gandiointroduces Carly Reil,2005 ISASI KapustinScholarship awardee,to the audience.

By Esperison Martinez, Editor

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The ProblemsFacing Air Safety

InvestigatorsBy Carly Reil (ST5133), Safety SciencesEmbry-Riddle Aeronautical University

Carly Reil

Since the first plane crash onSeptember 17, 1908, that se-riously injured Orville

Wright and killed his passenger,First Lieutenant Thomas E.Selfridge, accidents have beenthe shadow behind aviation. In-vestigating them, however, isproviding the light needed tomake changes. Though we havecome a long way, the near artform of piecing together thepuzzle formed when a planecrashes remains a relentlesschallenge for investigators.From evaluating a crash scene to educating the industry on theirfindings and everything in between, accident investigators face anumber of challenges at every scene.

Sights investigators may encounter when they get to a crashscene can affect them emotionally in a number of ways. Any suchdevastating scene is always hard to overcome, but it is necessaryto do so in order to accomplish the far greater goal. Memories canstay with investigators their entire life, yet they ultimately knowthey are there to find answers and to help prevent such catastro-phes in the future.

Investigators must be able to work with diverse groups. Thesegroups help investigators locate,preserve, gather, and analyze evi-dence from crash scenes. For ex-ample, when Copa Flight 201 dis-appeared over Panama, investi-gators relied heavily on locals tonavigate the dense jungle. Wheninvestigators work with local lawenforcement and fire depart-ments, evidence can be disturbedor destroyed in an effort to putout fires or rescue survivors. Thisrelationship is important, though;law enforcement helps to protecta scene and often provides sup-port for investigators. When par-ties to an investigation are al-lowed, they can bring investiga-tors from different areas of the industry together with varying ideasand goals. Every situation and every person will be different, andaccident investigators must be prepared for this diversity. The chal-lenge is to maintain organization, cooperation, and an open mind.

Numerous obstacles always face investigators in the field. Wreck-age is often in the least likely place, scattered over great distancesand in pieces offering sharp edges and the presence of bloodbornepathogens. Ephemeral evidence poses a challenge to time, and move-able parts can shift during impact. New technology can mislead aninvestigator, such as composite materials, which fail differently fromtraditional materials. Evaluation of the cockpit voice recorder andflight data recorder may hold key information, but they are not avail-able in a certain aircraft or are unable to be found. If they are lo-cated, they can be damaged or unreliable. With pieces of informa-tion coming from many different sources, investigators must con-

tinue to look at the whole pictureand not jump to conclusions. Anadditional piece of evidence mayadd new insight to the eventsleading up to an accident. Inves-tigators next-best sources of in-formation come from records andwitnesses.

Operations, maintenance,ATC, aircraft, and weatherrecords are all important piecesof information that investiga-tors want to take into account.However, crew and aircraftrecords are often lost or de-

stroyed. Assembling a history for the flight using these recordsand the statements of witnesses provides a time line and a baseto put events together.

Interviewing witnesses is a delicate but beneficial process. Theyare the people who saw the crash, were in contact with the crew, orare family members and friends. They provide the insider’s view forinvestigators. Witnesses should be interviewed as soon after an ac-cident as practical to avoid bias and loss of information. Survivorsmay be in shock, unable to clearly reveal anything, and relatives andfriends of the crew may be prejudiced in the information they give.“Eyewitnesses” may have conflicting accounts or may have heardstories from other witnesses. Interviewing can be frustrating, butinvestigators must be respectful and understanding when listening;their goal is to gain information. Not only do they have to be carefulin the questions they ask, but they must also take into account nu-merous factors concerning the validity of each statement.

After gathering evidence from the field, a new challengeemerges. Now the pieces of the puzzle need to be evaluated and fittogether; the who, why, and how need to be answered. Most im-portantly, once answers are determined, investigators must presenttheir findings and hope that they do not fall on deaf ears. After all,the goal is not just to figure out what happened but how to preventit from occurring in the future.

Clarifying the series of events that lead up to an accident cantake months, if not years, to establish. Investigators work diligentlyto organize a final report on the determining factors behind anaccident. In the process, important and useful information is inte-grated into these reports. Though, there will always be someonewho doubts these findings. And more often than not, these dataare simply not implemented into areas of the industry where theycould be of great use. Unfortunately, this is one of the biggest chal-lenges to investigators. It is counterproductive to put effort intosolving what went wrong only to have the event repeated. Acci-dent investigators work to prevent similar accidents from occur-ring in the future; it is up to them to be sure that their work isnoticed and applied.

Accident investigation is an incredibly challenging occupationthat requires a special person. There is a common thread amongall investigators: a passion to solve the problem and save lives.How else could someone persevere through emotional, physical,mental, and social challenges? Everything from searching throughdebris to evaluating data to compiling the final report is a long anddifficult journey for investigators. The greatest reward is to seetheir findings put to good use to save lives. ◆

E. M

AR

TIN

EZ


Peter Coombs joined theU.K. AAIB in 1972 andhas performed more than200 field investigations tocivil and military fixed-and rotary-wing aircraftand a comparable number

of other technical investigations. Whilewith the British Aircraft Corporationfrom 1966, he gained experience of manu-facture, development, and testing of air-craft including BAC 1-11, VC10, andBristol Britannia airliners, before be-coming a design engineer on the ConcordeSST. He was awarded a master of sciencedegree in aircraft design at the College ofAeronautics, Cranfield, in 1971, and fliessingle- and multi-engine aircraft.

ABOVE: Figure 1: General view of mainsection of wreckage at low tide, on themorning after the accident.LEFT: Figure 2: View of partly submergedwreckage at subsequent low tide.BELOW: Figure 3: View of almost-submerged wreckage at high tide.

The ‘Why’ of a FatalDouble Engine Flame-out

Investigation of a Shorts SD 360 turboprop flame-outproduces a new approach to powerplant investigation

and an unusual cause is determined.

By Peter Coombs, Air Accident Investigation Branch, U.K.

(This article was adapted, with permission,from the author’s presentation entitled In-vestigation of Fatal Double Engine Flame-out to Shorts SD 360 Turboprop preparedfor the ISASI 2004 seminar held inAustralia’s Gold Coast region Aug. 30 toSept. 2, 2004, which carried the theme “In-vestigate, Communicate, and Educate.” Theentire paper, including cited references in-dex, is on the ISASI website at www.isasi.org.—Editor)

In the early evening of Feb. 27, 2001, aShorts SD 360 twin turboprop aircrafttook off from Edinburgh, Scotland. Al-

though normally serving as a passengerairliner, on this occasion it was carrying onlytwo flight crew and a cargo of mail. Justover a minute after takeoff, a distress call

was received stating that both engines hadfailed. The machine descended rapidly andditched in shallow but exposed and ex-tremely choppy waters of a local sea inlet,the Firth of Fourth. It sustained consider-able damage at water impact and soon be-came partly submerged. Neither crew-member survived.

Investigation of the accident requiredsalvage of the aircraft from the very ex-posed waters, where it was lying betweenlow-and high-tide positions, followed bydetailed examination of its systems andpowerplants, development of a robusttheory as to the cause of the obscure doublepower loss, and the preparation and imple-mentation of experiments to support thetheory.

The wreck site was such that the aircraftcould only be accessed on one occasion onfoot (Figure 1) before the changing tidal cycledictated that at the lowest tides the aircraftstill remained partly submerged (Figure 2).This situation was to continue until approxi-mately a week had passed. The recovery task

was further hampered by the extent to whichthe aircraft became buried in the sand withsucceeding tides (Figure 3).

Eventually, however, the wreckage wassalvaged (Figure 4) and detailed examina-tion began. In the meantime, both theDFDR and the CVR were recovered, de-contaminated, and replayed successfully.

My past experience of multiple powerloss has led me to expect that one enginemay lose power for a variety of reasons,while a second engine generally does so af-ter a time interval, usually following crewactions intended to secure the first enginebut incorrectly applied. The only other


Figure 4: Salvage ships in position duringlifting 6 days after accident.

Figure 5: Schematics of nacelle withinertia separator vanes in normal (or OFF)position, above, and deployed (or ON)position, below. Plenum chamber volumeis shaded in upper section. Vane drivemechanism is shown in middle diagram.

double power losses I can recall investigat-ing have been• an occasion on which both engines wereselected to nearly empty main tanks on de-parture, following accidental fuel uplift intoauxiliary tanks, unobserved by the crew.• an occasion when an Eastern Bloc cer-tificated aircraft, equipped with an auto-matic engine safety/shut down system, suf-fered an electrical fault that energized fuelshutoff valves on both engines, driving themto the closed position shortly after takeoff.

Fuel exhaustion, severe engine intake ic-ing, and volcanic ash contamination are, ofcourse, also well-known multiple power losscauses.

The simple two-tank fuel system layout

of the SD 360 did not favor the possibilityof a system handling error. The possibilityof a repetition of the second failure scenariodescribed above was effectively precludedby the purely mechanical operation of bothHP and LP fuel valves and the ergonomicdifficulty of operating both left- and right-hand controls of either simultaneously. Thelarge fuel uplift apparently carried out atEdinburgh, together with fuel remaining onarrival, virtually precluded the possibilityof complete fuel exhaustion so soon afterdeparture, and the aircraft was not flyingin icing conditions at the time of the powerloss. Finally, there are no volcanoes within5,000 miles upwind of Edinburgh.

It was, therefore, with great surprise that

I learned from our recorder specialists thatboth engine torque values dropped from climbpower to zero precipitately and within milli-seconds of one another. This occurred at about1,800 feet, within 8 seconds of the captain re-questing the first officer to select the anti-icesystems and almost exactly 5 seconds afterthe sound of two switch selections, which wereimmediately followed by the electrical soundof two motors operating.

Relevant aircraft featuresTwo PT 6A series reverse-flow turbopropengines power the aircraft type. Each en-gine is orientated with its compressor at therear. There are a number of reversals of airand combustion gas flow directions withineach powerplant (a total of 720 degrees di-rection change of flow axis between the ex-ternal intake and the aft-facing exhausts).As shown in Figure 5, air is supplied to theengines via a forward-facing intake behindand below each propeller, while exhaustgases leave via a pair of curved pipes at thefront of each engine, arranged to direct thegases backward. The air, having entered

each external intake, passes be-low the whole length of the rel-evant engine, before turningthrough a right angle and trav-eling vertically upward into air-tight plenum chambers. Fromthese, it is drawn into each en-gine compressor through a cy-lindrical mesh guard (Figure5). An external view of a nacelleon the salvaged wreck, show-ing the intake and one exhauststack, is shown in Figure 6.

In icing conditions, the crewmay select so-called anti-icingvanes to the ON position (Fig-

ure 5). Under these circumstances, a ramp(or forward vane) is lowered from the topsurface of each air intake path, reducing theavailable cross-section for the airflow andcausing it to both accelerate and change di-rection through a bigger angle than wouldbe the case without the vanes deployed. Thiscentrifuges solids and liquids to the outerradius of the curved airflow path. At the sametime, a bypass door (or aft vane) opens ineach airflow, causing that part of the flowcross-section containing the solids and liq-uids to be ejected overboard rather than toenter the plenum chambers to risk forminga frozen obstruction on the mesh guard cov-ering the inlet to the relevant engine.

Initial testsTests carried out on an example of the lin-ear actuator type, which drives the inertiaseparators (Figure 5), confirmed that thefrequency of the electrical “noise” producedwas identical to that of the acoustic noisepresent on the CVR initiating 5 secondsbefore engine torque was recorded as lostby the DFDR. It, therefore, became clearthat staggered operation of the selectorswitches of each inertia separator took place5 seconds before a similarly staggered sud-den loss of all power on both engines oc-curred. There was thus little doubt thatdeployment of each inertia separator hadlead to the consequent power loss of the


RIGHT: Figure 6: Left engine nacelle withexternal intake and one exhaust stack

visible after wreckage recovery.BELOW RIGHT: Figure 7: Assembled

nacelle mock-up, utilizing panelssalvaged from wrecked aircraft, incorpo-

rating cylinder forming dummy engine.Extractor fan can be seen. Adjustablevalve has yet to be fitted to threaded

shaft in front of fan. TransparentPlexiglas bulkheads are fitted in place of

metal bulkheads at front and rear ofplenum chamber (not visible).

corresponding engine. This left the ques-tion of how this entirely normal system op-eration could have had such a dramatic andabnormal effect on both engines.

Relevant weatherEarly in the investigation it became clear thatthe aircraft had arrived at Edinburgh atmidnight, approximately 17 hours before theaccident and had been refueled with the in-tention of departing within 2 hours. Snowbegan to fall as the aircraft arrived, however,and became so severe that deicing servicesand runway snow clearance activities becameoverwhelmed. No movements took placethrough the remainder of that night, andsnow continued to fall until 0800 the nextmorning. Services only recovered early in theafternoon. Through the night, moderatesnow (the meteorological term) was accom-panied by wind gusting up to 40 knots froma NNE direction. The aircraft was alsoparked on a heading of approximately NNE.The temperature was between zero and +1degree C. As the day began, the wind mod-erated but continued to gust up to 17 knotson the same heading while the temperatureslowly rose to 2 degrees C by midday.

Sequence of events priorto departureA new crew arrived in the early afternoonand observed that the aircraft was now freeof visible contamination apart from an areaof the windscreen. Following a preflightcheck, the aircraft was started but it wasfound that a generator would not come online. The aircraft was shut down and assis-tance summoned.

A ground engineer carried out trouble-shooting and a simple rectification. Thisrequired both engines to be briefly run bythe crew while electrical loads were applied.These included operation of all anti-icingsystems, i.e., windscreens, propellers, airintakes, and inertia separators, before theengines were again shut down. Once theproblem was rectified, normal predepartureactions took place and the engines were re-

started. During taxiing, the normal checkswere carried out. These included a check ofthe autofeather. When a propeller is feath-ered on this type, the corresponding iner-tia separator is automatically powered tothe anti-ice position to further reduce drag.

The accident flightWith inertia separators now reset to thenormal position, takeoff and initial climbtook place followed by torque and RPMreduction to climb settings. Only shortlyafter further reselection of the inertia sepa-rators to the anti-ice position, in prepara-tion for entering a sub-zero cloud layer, didthe fatal double power loss occur.

Investigation processSince the most unusual event during theperiod of idleness at Edinburgh was theweather of the night, I decided to find outwhat affect the snowfall had on the air in-take systems. A special rig was, therefore,built, consisting of a controllable extractorfan mounted on a tapered transition tubeincorporating pressure-tapping points. Thetube was bolted in the place of one exhauststack of an engine in a borrowed SD 360aircraft. The other exhaust on that enginewas sealed off. The pressure tapings wereconnected to a digital pitot-static test set.

A downstream pressure drop was cre-ated by the fan, having similar magnitudeto the pressure difference between the in-take face and exit pipe pressures (Figure5) calculated for the known averageheadwind speed recorded during the night’ssnow storm. The speed of the airflow cre-ated in the extractor tube was measured bymeans of the digital test set and the corre-sponding speed in the intake system calcu-lated. Despite the complex flow paththrough the total powerplant and the effectof at least seven stages of fixed blades anda similar number of stages of rotating

blades in each engine, the velocity throughthe system was found to be a high percent-age of the local wind speed.

An engine intake system and enginecowling panels, salvaged from the wreckedaircraft, were then assembled into a mock-up of a nacelle incorporating a dummy en-gine, complete with the intake mesh. Sealedplenum chamber bulkheads were manufac-tured from Plexiglas and fitted in represen-tative positions within the cowlings. An elec-tric extractor fan was mounted within thedummy engine and an adjustable shutoffvalve was fitted at the forward end. Figure7 shows the front of the arrangement be-fore the adjustable shutoff valve was fitted.The fan was run and the valve adjusted tocreate airflow velocities in the mock intakesystem of similar values to those measuredand calculated earlier in the intake of theborrowed aircraft.

Simulated snowflakes, comprised offinely cut fragments of expanded polysty-rene, were released near the external in-take, and their progress through thetrunking and into the plenum chamber wasobserved via the Plexiglas rear bulkhead.It was found that the flakes readily rose upto and over the top of the dummy engine.

It was, therefore, clear that during the


Figure 8 (below): View of interior ofplenum chamber with cowlings removed.Enclosed volume is between the forwardand rear flexible bulkhead seals. Exhauststack visible at top left.

night, the wind, despite the complex flowpath involved, created a powerful airflowinto the external forward-facing intakes,through the intake trunking, upward via theplenum chambers, through the engine in-let mesh filters, and through the engines.This airflow had sufficient speed to liftsnowflakes up into the area of the plenumchambers, passing around and over the en-gines. Numerous pipes, tubes wiring looms,and skin stiffeners within the plenum cham-bers would have ensured that snow wasreadily deposited on these obstructions andthe chamber volumes easily filled with snow.Figure 8 shows a plenum chamber interiorvolume with the upper cowling removed.The condition of many parked aircraft notedin the morning after the snowfall ceasedattested to the large volume of snow thatmust have passed into the intake and thusremained in the plenum chambers.

Effect of ambient conditionsAlthough the ambient temperature roseabove freezing during the following morn-ing, the large heat sink of the snow-filledplenum chambers, allied with the latent heatof melting ice and the small margin of am-bient temperature above freezing level,would have severely limited the volume oftrapped snow that melted. In contrast, theoutside surfaces of the aircraft heated morerapidly, due to exposure to sunlight and ul-timately required no deicing. Examination,by a crew, of the high-mounted aircraft in-takes from the ground or indeed from acloser position would not, for geometric rea-

sons, enable the interior of the plenumchambers to be seen.

Effect of subsequent engineoperationEngine starting would rapidly raise thetemperature of the engine carcasses, caus-ing the deposited snow to turn to slush andfall from the plenum chambers into the re-gion of the inertia separators. Althoughsome melt material may have been ingested,the bulk of the tightly packed slushy sub-stance would have arrived at and remainedin the area of the vanes. Since air was beingdrawn through a narrowing cross-sectioncreated by the wet slush deposit, and thedeployed inertia separators, a conditionanalogous with the throat of a carburetorwould occur in which a temperature dropwould be created. A drop of only approxi-mately 2 degrees C would lead to gradualrefreezing and solidification of the surfaceof the slush. Operation of the inertia sepa-rators would cause the bypass doors tomove the solidifying ice volume forward.Once the separators were returned to thenormal position, however, the solidifiedmasses would be free to slide backward to-ward the bypass doors, under the influenceof the airflow. After engine shutdown, thewind would continue to drive air at justabove freezing temperature over the refro-zen slush, limiting the effect of the hot en-gines on the ice and rapidly cooling the en-gines by both internal and external flow.

The engines were soon restarted, creat-ing a renewed cooling effect, presumablyreturning the slush to a fully frozen state.Again, inertia separators were operatedautomatically during autofeather checks,presumably driving refrozen slush forward.Once the separators were returned to theoff position, the ice was again free to slideback toward the bypass doors.

As was stated earlier, there is compellingevidence that the anti-ice vanes were selectedON seconds before the fatal power loss. Thisaction normally causes a 50% area reductionor blocking of the free flow of air to the en-

gines at the position of each first vane and asimilar 50% blocking at the more down down-stream position of the bypass door (Figure5). Data supplied by the engine manufacturershowed that an 87% reduction of cross-sec-tional area of the intake duct, under thetorque, RPM, and ambient air conditionsrecorded and derived at the time of the powerloss, would cause engine surge and flame-out. A similar degree of blocking occurringat the low power settings and, hence, muchlower mass-flow rates present during opera-tion of the intake vanes on the ground, how-ever, would not have this effect.

Thus a mechanism can be visualized inwhich weather conditions introduced largevolumes of snow into the intake systemswhere it remained undetected and in alargely solid state. Operation of engines andvanes took place in a sequence that resultedin a large volume of refrozen slush finallylodging in the region of the inertia separa-tors where it added to the blocking effectcreated by deployment of the latter. Withthe final volume of slush reducing each in-let duct cross-section by approximately40%, the effect of its presence and that ofthe deployment of the vanes would havebeen sufficient to cause both engines tosurge and flame out. The DFDR shows thatthe HP spools of both engines deceleratedalmost immediately to below their self-sus-taining speed. This effect, coupled with theabsence of continuous or auto ignition, en-sured that flame-out was total and the en-gines did not relight.

Although many other possible causes havebeen suggested for this power loss, none wasfound to be as likely as the process describedabove, given the known conditions and se-quence of events. As with most accidents in-volving icing, the direct evidence was lost,and in this case the contamination conditionswithin the intake systems could not be physi-cally confirmed. Nonetheless, a process ofreasonable deduction, based on all the avail-able evidence and the test results, leads usto conclude that the sequence describedabove was the cause of the power loss. ◆


(This article was adapted, with permission,from the author’s presentation entitled TheRole of Lessons Learned in the Investigate,Communicate, Educate Cycle for Commer-cial Aviation prepared for the ISASI 2004seminar held in Australia’s Gold Coast re-gion Aug. 30 to Sept. 2, 2004, which carriedthe theme “Investigate, Communicate, andEducate.” The presentation was not orallypresented due to unexpected circumstancesaffecting the authors. The entire paper, in-cluding cited references index, is on theISASI website at www.isasi.org.—Editor)

Aviation safety begins with safe air-craft. The safety of large transportairplanes operating in commercial

service throughout the world has steadily im-proved over the last several decades. Never-

theless, accidents still occasionally occur.When they do occur, it is important to iden-tify the root causes, precursors, and lessonslearned of these accidents so that appropri-ate steps may be taken to reduce the risk oftheir reoccurrence. When presented with thedata, facts, and histories available, it becomespainfully obvious that most, if not all, accidentsfollowed one or more precursors or previousaccidents that were not acted on for severalreasons. The predominant reason is that thoseinvolved were unaware of the significance ofwhat they had observed. This lack of aware-ness was due to a failure to view the eventfrom the airplane level rather than the air-craft system, subsystem, or component level.Another reoccurring reason is that those in-volved were unaware of the existence of criti-cal, relevant information. These reasons areactually common throughout many industriesand tolerated or accepted by most. It is unac-ceptable in commercial aviation.

The aviation industry cannot afford thetime and resources related to the loss ornon-use of important safety information.Work must go on and airplanes must fly. Thelessons learned system must allow individu-als to do their jobs more effectively and theaviation system to operate safer and moreefficiently. Such a system did not exist inthe FAA. The need and urgency has beenrecognized and action taken to move in thatdirection. The first step is awareness and atransition to a different way of making de-cisions for regulatory and industry person-nel at all levels doing their job.

Safety standards and the methods usedto apply them must continually evolve dueto advances in technology and demand forhigher levels of safety. Each phase of theproduct lifecycle continuum impacts safetyas information and experience derived fromone phase is systemically applied to the otherphases. Success of the entire continuum isdependent on effective safety management

in each and every phase, capturing and us-ing lessons learned from all phases of aproduct’s lifecycle to continuously improvestandards, validate design assumptions,identify precursors, mitigate risk in safety-related decision-making, and correct under-lying sources of problems systemwide. Les-sons learned from accidents are perhaps themost costly. It is vital to capture these les-sons through investigation, communicatethem to the appropriate organizations, andeducate people to recognize and use thesehard-learned lessons to proactively makecommercial aviation safer.

Why lessons learned are importantLessons learned are defined as knowledgeor understanding gained by experience. Theexperience may be positive, such as a suc-cessful test or mission, or negative, such asa mishap or failure. A lesson must be sig-nificant in that it has an impact on safety;valid in that it is factually correct; and ap-plicable in that it identifies a specific design,process, or decision that reduces or elimi-nates the potential for failures and mishaps,or reinforces a positive result.

Establishing a culture where we captureand use day-to-day information and expe-rience from certification, maintenance, andoperational activities is crucial to improv-ing aviation safety. By doing so, we can ex-pect to gain benefits that include• documented guidance, information, andbest practices passed on to less-experiencedpeople,• more-consistent safety decisions,

Dr. Paul Werner is a program manager inthe Airworthiness Assurance Departmentof the Energy and Transportation SuretyCenter, Sandia National Laboratories. Heholds a B.S. and M.S. in physics and aPh.D. in electrical engineering. Much ofhis work has involved researching andreviewing accidents across many indus-tries, including aviation, for lessonslearned. He has more than 2,000 hours inthe U.S. Navy’s S-3 Viking and serveswith Air Test and Evaluation SquadronThree One 0176 in the rank of captain.

Richard Perry is manager of the Air-worthiness Assurance Department ofSandia National Laboratories. An AirForce Academy graduate, he holds a M.S.in aeronautical engineering. He is an air-line transport pilot rated with 4,600 hoursof flight experience in a broad range of air-craft. He has served as the director of sys-tem safety and engineering at the Air ForceSafety Center, reviewing approximately 50accident investigations annually.

The Roleof LessonsLearnedBy Dr. Paul Werner andRichard Perry, Sandia NationalLaboratories, U.S.A.


• improved safety by reducing accidentsand preventing any repeat accidents, and• reduction in safety problems caused bybreakdowns in communication betweendesign and maintenance or operationorganizations.

The best way to learn and improve is toanalyze previous experience and draw con-clusions for future direction based on them.One way regulators capture lessons learnedis through development of regulations, poli-cies, and procedures. (See page 22.)

Attributes of a successful processDevelopment and implementation of an ef-fective lessons learned process is critical forimproving aviation safety. Ideally, it wouldbe an integrated, common infrastructurethat captures and provides access to lessonslearned safety information throughout aproduct’s lifecycle. As such, a successful les-sons learned process would have the follow-ing characteristics:• A structured process for incorporatinglessons learned into rules, policies, and pro-cedures for certification, maintenance, andoperations. The process should ensure thatin-service lessons learned are incorporatedin design or certification methods of com-pliance, and results of project-specific deci-sions are easily accessible by other certifi-cation projects.• Use of a disciplined, data-driven ap-proach to find root causes and determinethe best actions to break the chain of eventsthat lead to accidents.• A process that includes periodic reviewsand feedback. This should be a unique taskfrom daily business for a “look back” andshould ensure reviews are conducted atregular intervals.• A process that ensures corrective actionsare implemented for all root causes as-sessed, so that underlying sources of prob-lems are corrected systemwide.

Barriers to capturing and usinglessons learnedSeveral observations have been notedacross diverse industries regarding effec-tive capture and use of lessons learned.First, most organizations strive to reuse allkinds of documented experience, but it isnot easy to do so in an effective manner. Thereuse is rather ad hoc and unplanned, andit is often hard to know what to search foror how to find useful documents.

Another observation is that the “right”knowledge for solving a problem often ex-ists somewhere within the organization,but the challenge is to take the time tosearch for it, identify it, get access to it,and then learn from it. Because that expe-rience is represented internally by experts,the major problem is often finding andgetting access to the “expert” in order tosolve a problem.

In today’s complex and fast-moving avia-tion system, engineers and inspectors of-ten do not have the time to do extensive re-search and analysis of aircraft accidents andincidents. Instead, they must rely on theirexperience and training, and possibly theinsight of others. So, why are lessons notlearned?• Cultural barriers, such as the lack of timeto capture or submit lessons and a percep-tion of intolerance for mistakes,• Organizational barriers, such as commu-nication across companies or lines of busi-ness is often difficult or nonexistent,• Lessons are not routinely identified, col-lected, or shared across organizations andindustry due to a lack of communication orother factors, and• Unorganized lessons are hard to use withtoo much material to search; information maybe formatted differently for different accidentreports; the information needed is not avail-able; it’s not quickly available; or work pres-sures don’t allow the time or resources.

Critical conceptsThe concepts discussed below are criticalto the identification of design and certifica-tion lessons learned from accidents.Aircraft-level awareness—When pre-sented with the data, facts, and historiesavailable, it becomes painfully obvious thatmost, if not all, accidents followed previousevents that were not acted upon becausesomeone was unaware of the significanceof what they observed. Often this was be-cause they failed to view the significance ofthe event at the airplane level rather thanthe system, subsystem, or component level.In most cases, those involved were unawareof the existence of critical, relevant infor-mation, i.e., lessons learned.

A conclusion from many of the accidentsreviewed during the Commercial AirplaneCertification Process Study (March 2002)was that adequate processes do not existwithin the FAA or in most segments of thecommercial aviation industry to ensure thatthe lessons learned from specific experi-ences in airplane design, manufacturing,maintenance, and flight operations are cap-tured permanently and made readily avail-able to the aviation industry. Consequently,the failure to capture and disseminate les-sons learned has allowed airplane accidentsto occur from causes similar to those of pastaccidents. In response to this concern,Change Area 1.C, Precursor Awareness,was tasked to specifically “Develop AVRairplane-level awareness for improvedidentification and risk assessment of acci-dent precursors. Define methods to capture,share, and use lessons learned informationthroughout industry and the lifecycle.”Precursors—The role and importance of ac-cident precursor recognition cannot be over-emphasized. Precursor data can be a valuablesource of information for decision-making,either directly or as a supplement to riskanalysis. Moreover, precursor data inherently


incorporate the effects of factors such as hu-man errors and intersystem dependencies.

Accident precursor identification shouldidentify latent and potential design, certifica-tion, and operational safety issues and correctthem before they become accidents through• comprehensive monitoring, sharing, anduse of design and operational safety infor-mation and a consequent growth in the un-derstanding of current and emerging acci-dent precursors and direct causes.• immediate certification and operationalinterventions at the regional, national, andinternational levels.

Precursor events can be any service in-formation or experience or test or inspec-tion data that could be interpreted as a pre-dictor that the event consequence could oc-cur if the event conditions were present.

Accident precursor data can be from anydiscipline (e.g., risk analysis, statistics, en-gineering, ergonomics, psychology, sociol-ogy, organizational behavior).

Daniel Cheney of the Federal AviationAdministration suggested the followingdefinitions of precursor types:Type 1: Precursors with no protection ormitigation elements associated with theprevention of the event initiation, progres-sion, or consequences. Types 1 are the mostpotentially serious of all precursor events.Type 2: Precursors with no consistent or de-pendable protection or mitigation elementsassociated with the prevention of the eventinitiation, progression, or consequences.Nearly as potentially serious as Type 1, butmay have an opportunity for interventionby flight crew, ground crew, or others.

Type 3: All other precursor events—thosethat have at least one consistent or depend-able protection or mitigation element asso-ciated with the prevention of the event ini-tiation, progression, or consequences. Type3 precursors require at least one other con-dition in addition to the event condition tooccur. These represent the vast majority ofservice information (i.e., data) used in thesafety-oversight process.

An example of a Type 1 precursor for the1979 American Airlines DC-10 crash wouldbe the 1978 pylon flange failure on a Conti-nental Airline DC-10 during maintenance.This incident was essentially masked intrivia in a report circulated to other airlinesand did not specifically identify that the fail-ure was related to the method used to re-move the pylon.

• Ford Trimotor in U.S.—1930 (enginefailure on takeoff)• TWA L1049/UAL DC-7 near GrandCanyon—1956 (enroute ATC)• Braniff L-188 near Buffalo, Texas—1959(propeller whirl mode)• U.S. operator/Viscount in Maryland—1962(birdstrike to tail)• Northwest L-188 near Cannelton,Indiana—1960 (propeller whirl mode)• Eastern L-188 at Boston—1960 (birdingestion to engines)• Pan Am B-707 near Elkton, Maryland—1963 (lightning strike to fuel tanks)• United B-727 at Salt Lake City—1965(stretchable fuel lines)• Pan Am B-707 at San Francisco—1965(rotor burst)• Mohawk BAC1-11 in United States—1967(APU inlet fire)• U.S. carrier B-727 at Los Angeles Int.Airport—1969 (human factors, cockpitswitches)• Air Canada DC-8 near Malton, Ontario—1970 (human factors, spoilers)• Eastern L-1011 near Miami—1972 (humanfactors, ATC)• VARIG B-707 near Paris—1973 (smoking/

(system isolation, pressure venting)• Mexicana B-727 near Maravatio, Mexico—1986 (wheelwell fire)• Northwest DC-9 at Detroit—1987 (humanfactors, takeoff warning)• South African Airways B-747 in IndianOcean—1987 (cargo compartment fire)• Aloha Airlines B-737 in Hawaii—1988(structural corrosion)• American Airlines DC-10 at Dallas/Ft.Worth—1988 (break wear)• TACA B-737 near New Orleans, Louisi-ana—1988 (hail ingestion to engines)• United Airlines B-747 in Hawaii—1989(structural inspection)• United Airlines DC-10 near Sioux City,Iowa—1989 (system isolation, engineinspections)• USAir Jetstream 3100 at Beckley, WestVirginia—1991 (tail plane icing)• Lauda B-767 near Bangkok, Thailand—1991 (thrust reverser inflight deployment)• American Eagle SF340 near New Roads,Louisiana—1994 (propeller beta in flight)• Simmons Airlines ATR 72 near Roselawn,Indiana—1994 (freezing rain)• ValuJet DC-9 near Miami—1996 (hazmat,cargo fire protection)

waste bin fire in lavatory)• Turk Hava Yollari DC-10 near Paris—1974(pressure relief, human factors)• Lufthansa B-747 near Nairobi—1974 (takeoffwarning, human factors)• TWA B-727 near Berryville, Virginia—1974(human factors, ground proximity)• Eastern B-727 near New York City—1975(windshear)• KLM B-747/Pan Am B-747 at Tenerife—1977(human factors, ATC)• Southern Airways DC-9 near Atlanta,Georgia—1977 (rain ingestion to engines)• Pacific Southwest Airlines B-727 at San Diego,California—1978 (human factors, TCAS)• United Airlines DC-8 near Portland, Oregon—1978 (human factors, low fuel warning)• American Airlines DC-10 at Chicago, Illinois—1979 (system isolation, human factors)• Saudia L-1011 near Riyadh, Saudi Arabia—1980 (interior fire, human factors)• Air Florida B-737 at Washington, D.C.—1982(human factors, airframe/engine icing)• British Airtours B-737 at Manchester,England—1985 (fuel tank access covers)• Delta L-1011 at Dallas, Texas—1985(windshear)• Japan Air Lines B-747 near Tokyo—1985

Partial Listing of Major Transport Airplane Accidents that Have Helped ShapeU.S. Federal Aviation Regulations (FARs) and Policies


Precursors are not just technical in na-ture. The DC-10 example also shows howprecursors can be related to procedural/human factors, political events, and deci-sions. Accident precursor recognition is avital part of a proactive intervention strat-egy and needs to be an important part ofany safety management program.

Root causesA driving reason for investigating accidentsis to prevent future accidents. By identifyingroot causes (a cause is a set of sufficient con-ditions—each is necessary but only togetherare they sufficient), we can potentially avoida whole “class” of accidents. Unfortunately,there is significant variation in people’s per-ceptions of accidents. For example,• viewing accidents as a single event. Thisoften includes regulatory compliance/viola-tion thinking.• linear chain-of-events thinking, likeknocking over a row of dominos.• statistical analysis methods.• viewing an accident as a process involv-ing concurrent actions by various actors toproduce an unintended outcome.

At the heart of root-cause analysis is theknowledge that things do not just happen.Events are caused to happen, and by under-standing the causes we can decide which onesare within our control and manipulate themto meet our goals and objectives. Root causescan be defined as the first factor in a chain ofevents that can be controlled through a regu-lation, policy, or standard. It is a point in thechain of events at which internal control canbe exercised. Simply put, they can be foundby stating the end result and keep asking“why?” until you have found a factor that canbe corrected by the application of a regula-tion/policy/standard at the governing/man-agement, implementing, or individual level,or you have reached a non-correctable situ-ation. There may also be insufficient data toproceed further.

There is a strong link between rootcauses, decision-making, and lessonslearned, especially in• establishment and communication of aregulation or policy,• application of a regulation or policy,• establishment and communication ofmonitoring and oversight, and• enforcement of that regulation or policy,based on monitoring and oversight.

System safetyIn commercial aviation, a single accident isoften disastrous. One obvious lesson from theshort history of aviation is that most acci-dents are not the result of unknown scien-tific principles but more likely result fromthe failure to apply well-known engineeringpractices. A valuable lesson is that technol-ogy alone will not provide a solution; anotherlesson from history is that the non-technicalissues cannot be ignored. Safety requirescontrol of all aspects of the development andoperation of a system. System safety coversthe entire spectrum of risk management,from design of hardware to the culture andattitudes of the people involved.

Safety is a property of a system. For ex-ample, determining whether an aircraft isacceptably safe by examining the landinggear, or any other component, is not pos-sible. Talking about the “safety of the land-ing gear” out of context of the aircraft andhow it operates is really meaningless. Safetycan only be determined by the relationshipbetween the landing gear and other aircraftcomponents, that is, in the context of thewhole aircraft and its environment.

A systems approach provides a logicalstructure for problem solving. It views theentire system as an integrated whole. Tomake the system safe, we must managesafety (risk) and we must assess safety.Management is what is done to ensuresafety (limit risk), and assessment (surveil-lance, in this case) is what is done to deter-

mine whether the results are satisfactory.One cannot be practiced without the otherto have a positive impact on safety.

System safety is characterized by thesystematic identification and control of haz-ards throughout the lifecycle of a system.It calls for the timely identification of sys-tem hazards before the fact and emphasizesthe designing an acceptable level of safetyinto the system.

Some basic concepts of system safety arethat• safety should be built into the system, notadded on to a completed design.• safety is a property of the system, not acomponent.• accidents are not always caused by fail-ures and all failures do not cause accidents.• analysis to prevent the accident is em-phasized instead of reacting to the accident.• emphasis is on identifying hazards asearly as possible and then designing toeliminate or control those hazards (morequalitative than quantitative).• tradeoffs and compromises in system de-sign need to be recognized.• system safety is more than just systemsengineering.

Design safety conceptsAviation safety begins with safe aircraft.The safety of large transport airplanes op-erating in commercial service throughoutthe world has steadily improved over thelast several decades. Many techniques areused to achieve a safe design and include• design integrity (will not fail or has veryhigh margins, e.g., propellers, landinggears, turbine rotor discs) and quality,• redundancy,• isolation,• reliability,• failure indication,• flight crew procedures,• checkable/inspectable,• damage tolerance,


• failure containment,• designed failure path,• margins/factors of safety, and• error tolerance.

Four basic elements of designsafety (U.S. transport-categoryaircraft)ELEMENT NO. 1. Basic Design Philoso-phy and MethodologyThe design philosophy governs the overalldesign approach, establishes design criteria,and dictates failure assumption. The fail-safephilosophy is the chosen basic design philoso-phy and from this has emerged the fail-safedesign concept, i.e., “no single failure or prob-able combination of failures during any oneflight shall jeopardize the continued safeflight and landing of the airplane.”Design safety precedence:• Design to minimum hazard—Design thehazard out. If it cannot be eliminated, mini-mize the residual risk.• Use safety devices—Do this by incorpo-rating a fail-safe mode, safety devices, orfault-tolerant features.• Use warning devices—Done throughmeasuring devices, software, or othermeans. The warning should be unambigu-ous and attract the operator’s attention.• Use special procedures—Used when theabove means are unable to control the hazard.

ELEMENT NO. 2. The Official Code ofAirworthiness Design Standards for Trans-port-Category Aircraft, Engines, Propel-lers, and APUsThis is the legal codification of Element No.1 and is usually referred to as the type cer-tification code. The legal design safety codespecifies how the design safety methodol-ogy is to be applied; what general or spe-cific design safety methods are to be incor-porated; what, if any, specific exceptions areto be allowed; and any specific additions.

FAR Parts 25, 33, and 35 are the legalcodifications of the basic “fail-safe designconcept” that was developed by the U.S.aircraft transport industry over a periodfrom the days of the Ford Trimotor of the1920s until the present day.

ELEMENT NO. 3. The Type Design CheckThe purpose of the “design safety check” isto verify or validate that the design does, infact, meet the required minimum safetystandards embodied in Elements 1 and 2.The “Type Design Safety Check” is formallycompleted with the issuance of an FAA typecertificate. The design safety check also in-cludes the manufacturer’s in-house safetyassessments, flight, and laboratory test pro-grams, qualification test programs, and theFAA Type Design Certification Program.

ELEMENT NO. 4. The Official AccidentInvestigation and the Finding of ProbableCauseThis includes an official public report of theaccident findings. The knowledge containedin the findings, especially the lessonslearned, is used to improve and strengthenthe design philosophy, code, and checks ofElements 1, 2, and 3.

Safety and reliabilitySystem safety and reliability are often con-fused. Although similar, it is important to firstunderstand the difference between the two.Fundamentally, the two disciplines ask andseek to answer two different questions abouttwo different concepts. Reliability asks, “Howoften does something fail?” System safetyasks, “What happens (to the system) whensomething fails or behaves unexpectedly?”Although it is obviously concerned with sys-tem failure, reliability is usually concernedwith individual parts. Remember, a reliablesystem is not necessarily a safe system.

As applied to civil aircraft designed to FAR

25, safety is not reliability. As standards, theyare related but distinctly different conceptswith different objectives. Both are concernedwith the causes of failure. The difference is,briefly, reliability is concerned with the fre-quency of failure and safety is concerned withthe impact of failure. An aircraft design canbe safe but unreliable, it can be reliable butunsafe, and it can be safe and at the same timereliable. Safety and reliability are essentiallyrelated, independent design parameters thattend to complement or oppose each other, butone cannot be substituted for the other. Thetype certification process finds an aircraft de-sign to be in compliance only with safety stan-dards; it does not and cannot establish thereliability level of the design.

Design integrityThe probability of failure of an aircraft com-ponent is controlled by its design specifica-tion, including its qualification testing, andis a measure of its design integrity. The con-cept of design integrity is concerned withthe quality of the design and its ability toperform its intended functions as requiredby the design specification and FAR25.1309(a). Design integrity is generallyestablished through the qualification test-ing of individual aircraft components totheir design specification requirements.Design integrity is an integral part of thebasic aircraft safety concept. The achievedreliability of a component in service is ameasure of its design integrity. Theoperator’s approved maintenance programand the operator’s/manufacturer’s productimprovement program control the reliabil-ity of an approved aircraft design.

It is necessary to adopt amore rigorous and syste-matic approach to lessonslearned safety training andmanagement. A first stepis awareness and atransition to a differentway of making decisionsfor regulatory and industrypersonnel at all levelsdoing their job.


Aircraft-centered systemAs discussed earlier, accidents, and conse-quently the lessons learned, are productsof system interactions. Therefore, it is criti-cal to have at least a minimal understand-ing of all the subordinate elements and howthey behave as a system in order to iden-tify, understand, and apply lessons learned.

The hierarchical breakdown used here isconsistent with and adds to the Air Trans-port Association (ATA) index. This break-down provides a familiar structure and isconsistent with normal systems engineer-ing practice. It is convenient for lessonslearned because it groups subsystems to-gether technologically. The aircraft is bro-ken down as• Airframe—This element includes wing,fuselage, and empennage.• Mechanical—This element includes land-ing gear, hydraulics, flight controls, andcargo loading equipment.• Electrical—This element includes elec-trical power and lighting.• Propulsion—This element includes theengine pod and pylon and their components,fuel components, and thrust managementcomponents.• Avionics—This element includes commu-nication, navigation, and aircraft monitor-ing equipment.• Environmental—This element includescabin pressure, air conditioning, and oxy-gen equipment.• Interior—This element includes crewand passenger accommodations.• Auxiliary, other—This element includesauxiliary electrical and pneumatic powersupplies.

Other factors in aircraftaccidentsAging aircraft—The average age of theU.S. commercial aircraft fleet today alreadyexceeds 75 percent of the typical nominal

20-year design life of a passenger aircraft.Significant attention must accordingly begiven to better understanding and quanti-fying the mechanisms of aircraft aging. Ifthese failure mechanisms are left un-checked, the significantly longer times inservice that can be anticipated could leadto a significant increase in the accident rate.Human factors—Basic automated flightcontrol systems and electromechanical dis-plays are giving way to new generations ofjet transport aircraft equipped with highlyautomated flight management systems andflat panel or liquid crystal displays. The newtechnology has significantly changed thework of airline pilots and has implications forall elements of the aviation system, especiallydesign and safety regulation. Air safety in-vestigators and researchers worldwide havewitnessed the emergence of new human fac-tors problems related to the interaction ofpilots and advanced cockpit systems.Environment—This is the environmentexternal to the aircraft. Weather is prob-ably the most prominent factor.Maintenance, operations—Maintenanceand operational events are the primarysource of information for accident precur-sors and lessons learned.Regulations, policies, standards—Pastlessons learned are often captured in regu-lations, policies, and standards. Most acci-dents have factors related to the absence ofor misapplication of such guidance and di-rection. Accident precursor information andlessons learned are a valuable source to aidin interpretation, implementation, and cer-tifications decisions.Software—All commercial transport air-craft designed and built within the last 15years have some computer technology,mostly in the cockpit. The computers are in-tended to make flying easier and safer, andin general they do. But when things don’thappen as expected, it can be hard to figure

out quickly what’s going on and how to dealwith it. The safety of an aircraft depends ondesigning and building it to the highest stan-dards of safety we know, and the same goesfor its computer systems. Careful attentionmust be paid to how well we design and buildthose computer systems.

Most accidents will have lessons learnedin more than one of the previously men-tioned elements and involve one or more ofthe concepts and factors discussed.

ConclusionLessons learned are defined as knowledgeor understanding gained by experience.Aviation experience and knowledge nowspans several generations of safety manag-ers and engineers. It is no longer possiblefor comprehensive knowledge to be ex-changed from experienced safety individu-als to the next generation of safety person-nel through on-the-job training alone. Thesystem is so complex that it is unlikely thatany one individual can possess truly com-prehensive system safety understanding.Advances in technology and demands forhigher levels of safety dictate that standardsand the methods used to apply them mustcontinually evolve.

The role of lessons learned in the inves-tigate, communicate, educate cycle for com-mercial aviation cannot be overstated. It isa necessary part of the organizational safetystrategy involving continuously improvingstandards, validating design assumptions,identifying precursors, mitigating risk insafety-related decision-making, and cor-recting underlying sources of problemssystemwide. It is necessary to adopt a morerigorous and systematic approach to lessonslearned safety training and management.A first step is awareness and a transition toa different way of making decisions forregulatory and industry personnel at alllevels doing their job. ◆


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Cirrus Training Effort Is Recognized

ISASI ROUNDUP

ISASI President Frank Del Gandiorecognized the Cirrus Aircraft Corpora-tion with an award at ISASI 2005 for itsdevelopment of “First Responder”training seminars. In making the awardpresentation Del Gandio said, “Cirrus,one of the leading general aviationaircraft manufacturers, has made aremarkable commitment to generalaviation safety awareness presenting‘First Responder’ seminars.”

He added, “On its own initiative, thecorporation has initiated hundreds ofseminars and workshops across thecountry. These presentations are beinggiven to familiarize and educate FirstResponders, which include rescuepersonnel and accident investigators whomay respond to an accident involving anaircraft equipped with a Ballistic Recov-ery System (BRS). This training isinvaluable,” he concluded.

Cirrus is a pioneer in an innovative andrevolutionary general aviation safetyenhancement known as the CirrusAirframe Parachute System (known asCAPS.) CAPS is a “ballistic parachute”system created by Ballistic RecoverySystems for Cirrus Design to safely lowera light airplane from an emergency in theair to the ground. A solid-fuel rocket,housed in the aft fuselage, is used to pullthe parachute out from its housing andfully deploy the canopy within seconds.The CAPS system is designed into all ofthe aircraft Cirrus builds—SRV, SR20,and SR22.

In the recent past, two different Cirruspilots encountered inflight emergenciesand brought their planes safely to theground by deploying their onboardparachutes—only the second and thirdemergency uses of CAPS. This technol-ogy was first used in an emergency inOctober 2002.

Cirrus has been instrumental inassisting the Federal Aviation Adminis-tration in modifying its aircraft accidentschool’s curriculum to ensure that

aviation safety inspectors are also awareof the safety precautions involvingBallistic Recovery Systems installed onother types of aircraft, Del Gandionoted.

The Ballistic Recovery Systems, Inc.was named a recipient of a prestigiousLaureate Award by Aviation Week &Space Technology magazine as the topbusiness and general aviation company in2004. The award was made in April. ◆

Kapustin Scholarship Is-sues 2006 Application CallThe ISASI Rudolf Kapustin MemorialScholarship Committee has issued its callfor scholarship applications to universitiesand colleges whose students are eligibleto participate in the program, accordingto the Fund’s administrators, RichardStone, ISASI Executive Advisor, and RonSchleede, ISASI vice-president. Thedeadline for applications is April 1, 2006.

The goal of the Fund is to encourage

and assist university and college-levelstudents interested in the field of aviationsafety and aircraft occurrence investiga-tion. All members of ISASI enrolled as afull-time student in an ISASI-recognizededucation program, which includescourses in aircraft engineering and/oroperations, aviation psychology, aviationsafety, and/or aircraft occurrence investi-gation, etc., with major or minor subjectsthat focus on aviation safety/investigation,are eligible for the scholarship. A studentwho has once received the annual ISASIRudolf Kapustin Memorial will not beeligible to apply for it again. One or morestudents will be selected in this process.

The scholarship consists of a $1,500award to help cover travel, registration,lodging, and meal expense in attendingISASI’s annual seminar, which will beheld in Cancun, Mexico, Sept. 11-14, 2006.

Bill King (left) and Mike Busch (center)accept recognition plaque fromISASI President Del Gandio.

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Application requirements• A full-time college or university studentin courses in aircraft engineering and/oroperations, aviation psychology, aviationsafety, and/or aircraft occurrence investi-gation, etc., with major or minor subjectsthat focus on aviation safety/investigationof minimum duration of 1 year. The

student must be a member of ISASI.• The student is to submit a 1,000 (+/- 10percent) word paper in English address-ing “The Challenges for Air SafetyInvestigators.”• The paper is to be the student’s ownwork and must be countersigned by thestudent’s tutor/academic supervisor as

authentic, original work.• The papers will be judged on theircontent, original thinking, logic, andclarity of expression.• The student must complete theapplication available at the university orat ISASI headquarters and submit it toISASI with his/her paper by April 1, 2006.• Completed applications should beforwarded to ISASI, 107 Holly Ave., Suite11, Sterling, VA 20164-5405 USA. E-mailaddress: [email protected], Telephone: 703-430-9668.• Applicants will be notified of ISASI’sdecision by May 1, 2006.• The judges’ decision is final. ◆

Athens Reachout WorkshopTeaches 36 AttendeesISASI’s 14th Reachout Workshopconducted in Athens, Greece, July 18-29,covered aircraft accident investigationand safety management systems. TheHellenic Aircraft Accident Investigationand Aviation Safety Board (AAI & ASB)hosted the workshop. Capt. AkrivosTsolakis, chairman of the AAI & ASB,opened the popular training session.

Held in the facilities of the AAI & ASBat the Athens International Airport, the7-day-long accident investigation modulewas conducted by Ron Schleede and CajFrostell. This module presented ICAOrequirements and international obliga-tions, Annex 13, selection and training ofinvestigators, planning and organizationto conduct an investigation, proceduresand checklists, wreckage recovery, fieldinvestigation, accident site management,group organization, flight recorders,technical investigation, operationsinvestigation, off-scene testing, crashwor-thiness, witness interviewing, pathology,family assistance, avoidance and protec-tion of biohazards exposure, news media,factual reports and public records, writingthe final report, identification of safetydeficiencies, making safety recommenda-

Winners of the ISASI KapustinScholarship Fund to date. All attendedthe ISASI 2005 seminar and are shownhere with the two Fund administrators.Left to right, R. Schleede, C. Reil,Noelle Brunelle, Shannon Harris,M. Schuurman, and R. Stone.

Call for Papers—ISASI 2006The International Society of Air Safety Investigators

Presents its 37th International Seminar Sept. 11-14, 2006,at the Fiesta America Grand Coral Beach Hotel,

Cancun, MexicoTheme: “Incidents to Accidents: Breaking the Chain”

If you wish to offer a presentation inline with the seminar’s theme, pleaseadhere to the below schedule:Indication of interest: Jan. 31 2006Abstracts due: March 31, 2006Selected papers due in electronicformat: July 31, 2006

Topics soughtThe Technical Committee is looking forabout 16 papers on current investiga-tion experience, techniques, andlessons learned with particularemphasis on international investiga-tion challenges. In keeping with thetheme, papers directed towardemphasizing how we can maximize thelessons learned from accident investi-

gation and translate those lessons toeffective prevention will be considered.

PowerPoint presentations are notacceptable for publication in seminarProceedings or seminar CDs. Submit-tal of an abstract implies agreementthat the author authorizes publicationof the completed paper in the seminarProceedings and the ISASI Forum.

Send indication of interest andabstracts to Jim Stewart, TechnicalProgram Chair, e-mail [email protected], or mail to307-1500 Riverside Drive, OttawaOntario, Canada, K1G4j4.Phone: 613-736-1491.

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Continued . . .

ISASI ROUNDUP

tions, and nine interactive case studies.Jim Stewart and Frostell conducted the

3-day safety management systems (SMS)module. It contained presentations on theinternational and national requirementsfor SMS, statistics and the need for data,the safety eras, the SHELL model, theReason model, the MEDA/PEAT analysistools, safety management evolution,building a non-punitive reporting pro-gram, SMS processes, lessons from theChallenger accident, risk management,safety culture, dealing with change,regulating SMS, assessing an SMSprogram, and three case studies.

The instructors prepared the trainingmaterial for their modules consisting ofpaper handouts and CD-ROM libraries ofpublished manuals and booklets. Eachparticipant received copies of documentsand CD-ROMs with considerable back-ground materials for future reference

Thirty-six persons attended theworkshop. They represented the AAI &ASB, Athens International Airport,Hellenic ATA, Hellenic Coast Guard,Hellenic Police, Hellenic Fire Corp.,Hellenic Air Force, Hellenic Army,Hellenic Navy, Cyprus AAIB, OlympicAirlines, and Aegean Airlines. All

participants received ISASI certificatesfor the accident investigation module, theavoidance and protection of biohazardsexposure course, and the safety manage-ment systems module.

Caj Frostell reports that AAI & ASBand the participants were appreciative ofthe ISASI initiative to bring the ReachoutWorkshop program to Greece. ISASImembership forms and corporatemembership forms were made availableto the participants. Capt. Tsolakisannounced that the AAI & ASB was

Biohazards students shown in protectiongarb during course work. Also shown isNikos Pouliezos (left), Ron Schleede(center), and John Papadopoulus (right).

ISASI Annual Report 2004—Profit & Loss Budget

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Jan.-Dec. 04 Budget $ Over Budget % of BudgetOrdinary Income/ExpenseIncome601 Dues-New Individual Member 11,650.00 10,000.00 1,650.00 116.5%603 Dues-New Corporate Member 4,183.00 5,000.00 -817.00 83.66%611 Dues-Renewal Individual Member 65,700.00 71,000.00 -5,300.00 92.54%613 Dues-Renewal Corporate Member 63,356.00 50,000.00 13,356.00 126.71%614 Dues-Late Fees 1,460.00 500.00 960.00 292.0%615 Dues-Upgrade Fees 185.00 300.00 -115.00 61.67%616 Dues-Reinstatement Fees 150.00621 Contrib.-Unres. Membership 1,950.00 2,000.00 -50.00 97.5%631 Publication Subscriptions 792.00 500.00 292.00 158.4%632 Publication Income 1,451.00 500.00 951.00 290.2%634 Library Services 58.06 150.00 -91.94 38.71%642 Membership Services 187.37 400.00 -212.63 46.84%643 Membership Regalia Sales 268.57 400.00 -131.43 67.14%650 Seminar-Proceedings 0.00 5,000.00 -5,000.00 0.0%651 Seminar-Net Proceeds 32,951.79 10,000.00 22,951.79 329.52%652 Seminar-Reimbursed Advance 3,000.00 3,000.00 0.00 100.0%Total Income 187,342.79 158,750.00 28,592.79 118.01%

Expense700 Condo Fees 3,968.60 2,800.00 1,168.60 141.74%705 Mortgage Interest 5,719.14 9,500.00 -3,780.86 60.2%711 Repairs and Maintenance 969.76 1,000.00 -30.24 96.98%712 Storage Rental 1,620.00 1,000.00 620.00 162.0%801 P/R Exp.-Office Mgr. Salary 41,237.92 37,000.00 4,237.92 111.45%802 P/R Exp.-Health Insurance 11,182.00 9,000.00 2,182.00 124.24%803 P/R Exp.-SEPP 1,864.02 1,800.00 64.02 103.56%804 P/R Exp.-Trng. Misc. and Benefits 0.00 300.00 -300.00 0.0%808 P/R Expense-Bonus 0.00 500.00 -500.00 0.0%811 Accounting-Payroll 880.55 850.00 30.55 103.59%812 Accounting-Tax Prep. 405.00 500.00 -95.00 81.0%814 Insurance 3,166.00 1,500.00 1,666.00 211.07%817 Licenses and Permits 140.00 150.00 -10.00 93.33%821 OPS-Rent 233.38822 OPS-Telephone & Telex 3,465.87 2,400.00 1,065.87 144.41%824 OPS-Equip Maint. & Repair 2,148.44 1,800.00 348.44 119.36%825 OPS-Other Utilities 3,065.79 3,000.00 65.79 102.19%826 OPS-Postage and Shipping 7,136.00 6,500.00 636.00 109.79%827 OPS-Printing and Reproduction 3,211.38 1,600.00 1,611.38 200.71%828 OPS-Office Supplies 4,293.97 3,000.00 1,293.97 143.13%830 OPS-Computer Tech. Support 2,932.50 250.00 2,682.50 1,173.0%831 OPS-Equipment Purchase 0.00 4,000.00 -4,000.00 0.0%832 OPS-Equipment Lease 3,948.04 1,000.00 2,948.04 394.8%833 OPS-Petty Cash 200.00 200.00 0.00 100.0%


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Forum in China in order to assist ourChinese colleagues in the aviation safetyinvestigation field. We wish Ms. Yangsuccess in her endeavors in promotingISASI, aviation safety, and accidentinvestigation in China.”

Ms. Yang graduated in 1994 with a BSin electronics engineering from ShandongUniversity in China. She joined the flightsafety group of the Civil Aviation SafetyResearch Center, which later became theCAAC’s Accident Investigation Labora-tory (CASTC). Ms. Yang is now a seniorengineer. She has also translated severalflight crew operations manuals intoChinese for airlines in China, as well asa flight data monitoring manual. ◆

Transportation FatalitiesDecrease In 2004Transportation fatalities in the UnitedStates decreased slightly in 2004, accord-ing to preliminary figures released by theNational Transportation Safety Board.Deaths from transportation accidents inthe United States in 2004 totaled 44,870,down from the 45,158 fatalities in 2003.

“Although it is always gratifying to seetransportation fatalities decline,” NTSBActing Chairman Mark Rosenker said,“the yearly toll, especially on our high-ways, continues to be unacceptable. Weneed to do more at all levels—federal,

Jan.-Dec. 04 Budget $ Over Budget % of Budget

vs. Actual

becoming an ISASI corporate member.Also, three workshop participants joinedISASI as individual members.

Olympic Airlines, Aegean Airlines,Athens International Airport, Hellas Jet,Air BP, Karayannis Group of Companies,and the Hellenic Flight Safety Foundationprovided local sponsorships. All travel anddaily subsistence costs for the three in-structors were covered by AAI & ASB. ◆

International CouncillorShares MailISASI’S International Councillor, CajFrostell, shares mail he received from aSociety member in China. He wrote:

“I recently received a very interesting

communication from one of our membersin China. Ms. Lin Yang wrote: ‘I will neverforget a day 10 years ago when I read theISASI Forum for the first time. Theauthors with their valuable and diversifiedexperiences gave me insights and inspira-tions. From then on, I have read everyarticle in every issue of the ISASI Forumand I have never been disappointed.’

“Ms. Yang further suggested: ‘As amember of ISASI in China, I think I couldpromote the ISASI mission in China andget more Chinese colleagues aware ofISASI, and to participate in the sharing ofair safety investigation findings, investi-gation techniques, and experiences.’ Inthis respect, she is planning to translateand distribute each issue of the ISASI

Invoices for the 2006 annual dues(January 1 through December 31) toISASI have been mailed. All individualmembers are asked to check individualidentification information and updatewhere necessary. Members are remindedthat the deadline for payment is Jan. 31,2006. A fee of $20 will assessed for latepayments. Credit card payment may bemade. See the mailed invoice for creditcard use. Checks should be made payableto ISASI and forwarded to ISASI, 107 E.Holly Avenue, Suite 11, Sterling, VA20164-5405 USA. ◆

DUES NOTICE840 OPS-Temp. Help 384.00 500.00 -116.00 76.8%844 Publications-Forum Expense 36,523.28 38,000.00 -1,476.72 96.11%845 Publications-Proceedings 6,324.95 5,000.00 1,324.95 126.5%848 Publications-Handbook Expense 1,069.00 1,000.00 69.00 106.9%856 Membership-Regalia Items 0.00 500.00 -500.00 0.0%861 Membership-Service Expense 4,860.48 1,500.00 3,360.48 324.03%871 Library Expenses 592.69 1,000.00 -407.31 59.27%881 Management Council-Travel 12,324.43 16,500.00 -4,175.57 74.69%882 Management Council-Admin. Exp. 951.83 1,300.00 -348.17 73.22%883 Management Council-Other 3,911.74 3,000.00 911.74 130.39%886 Management Council-Rep. Travel 93.84 500.00 -406.16 18.77%887 Management Council-Rep. Admin. 0.00 200.00 -200.00 0.0%891 Rebate-Natl./Reg./Corp. 0.00 2,000.00 -2,000.00 0.0%901 Seminar-Advances 0.00 3,000.00 -3,000.00 0.0%903 Seminar-Lederer Award 173.90 500.00 -326.10 34.78%911 Bank Fees 290.48 400.00 -109.52 72.62%912 Credit Card Charges 2,862.97 2,500.00 362.97 114.52%Total Expenses 172,151.95 167,050.00 5,101.95 103.05%

Net Ordinary Income 15,190.84 -8,300.00 23,490.84 -183.02%

Other Income/ExpenseOther Income661 Rent-Tenant Rental Income 7,465.00 8,460.00 -995.00 88.24%671 Interest-Checking Acct. 200.62 500.00 -299.38 40.12%681 Other Income-Miscellaneous 30.00682 Other Income -Refunds 10.70 Total Other Income 7,706.32 8,960.00 -1,253.68 86.01%

Other Expenses926 Penalties 1.58922 Misc.-Other Reimb. Exp. 976.88924 Misc.-Death/Illness Exp. 154.20925 Misc. Refunds 259.40930 Depreciation 11,039.00

Total Other Expense 12,431.06

Net Other Income -4,724.74 8,960.00 -13,684.74 -52.73%

Net Income 10,466.10 660.00 9,806.10 1,585.77%


ISASI Information

OFFICERSPresident, Frank Del Gandio

([email protected])Executive Advisor, Richard Stone

([email protected])Vice-President, Ron Schleede

([email protected])Secretary, Keith Hagy

([email protected])Treasurer, Tom McCarthy

([email protected])

COUNCILLORSAustralian, Lindsay Naylor

([email protected])Canadian, Barbara Dunn

([email protected])European, Max Saint-Germain

([email protected])International, Caj Frostell

([email protected])New Zealand, Ron Chippindale

([email protected])United States, Curt Lewis

([email protected])

NATIONAL AND REGIONALSOCIETY PRESIDENTSAustralian, Kenneth S. Lewis

([email protected])Canadian, Barbara M. Dunn

([email protected])European, Ken Smart

([email protected])Latin American (Vacant)New Zealand, Peter Williams

([email protected])Russian, V. Venkov

([email protected])SESA-France Chap.,Vincent Fave

([email protected])United States, Curt Lewis

([email protected])

Continued . . .

ISASI ROUNDUP

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state, and local—to protect our travelingpublic.”

The number of persons killed in allaviation accidents dropped from 710 in

This seminar will be an educationalevent with emphasis on contemporaryregional issues in aircraft accidentinvestigation and prevention.

The Asia-Pacific Cabin SafetyWorking Group is expected to meet onFriday, June 2, and there will be a visitto the Defence Science and TechnologyOrganization at Fishermen’s Bend on

Australian and New Zealand Societies ofAir Safety Investigators

PRELIMINARY NOTICE andCALL FOR PAPERS

2006 Regional Air Safety SeminarHilton on the Park, Melbourne, Victoria

Friday, Saturday, and Sunday, June 2–4, 2006

the Friday afternoon.If you wish to offer a presentation

for the seminar, please provide anabstract (approximately 100 words)plus personal details by Feb. 1, 2006, toPaul Mayes, e-mail: [email protected], phone: +64 9 256 3402, fax:+64 9 256 3911, post: ASASI, P.O. Box588, Civic Square ACT 2608

2003 to 651 in 2004. There were nofatalities on commuter carriers in 2004.The number of general aviation fatalitiesalso decreased from 632 in 2003 to 556 in2004. There were 14 airline fatalities, 13 ofwhich occurred in a crash of a Jetstreamaircraft in Kirksville, Mo. Air taxifatalities increased from 42 to 65.

Highway transportation, whichaccounts for the largest portion offatalities, decreased from 42,884 in 2003to 42,636 in 2004. The number of fatalitiesincreased in the motorcycle, light trucksand van, and medium and heavy truckscategories. However, there was a decreasein the number of deaths occurring in thepassenger car category, which recorded634 fewer fatalities in 2004 than in 2003.

Total rail fatalities increased from 760 in2003 to 802 in 2004, reflecting a rise inevery category except passenger fatalities,which remained at 3. Fatalities occurringon light rail, heavy rail, and commuter railincreased from 165 to 186. ◆

Richard F. Healing, NationalTransportation Safety Boardmember, has retired from govern-ment service. He left his position asmember of the National Transpor-tation Safety Board on August 1.Jim LaBelle has been named asdirector of the National Transporta-tion Safety Board’s regional aviationoffice in Anchorage, Alaska. He is asenior NTSB air safety investigatorwho has been working in the Alaskaoffice for the last 10 years. For thepast year, he has been actingdirector of the office. ◆

Who is Where?


UNITED STATES REGIONALCHAPTER PRESIDENTSAlaska, Craig Beldsoe

([email protected])Arizona, Bill Waldock ([email protected])Dallas-Ft. Worth, Curt Lewis

([email protected])Florida, Ben Coleman ([email protected])Great Lakes, Rodney Schaeffer

([email protected])Los Angeles, InactiveMid-Atlantic, Ron Schleede

([email protected])Northeast, David W. Graham ([email protected])Pacific Northwest, Kevin Darcy

([email protected])Rocky Mountain, Gary R. Morphew

([email protected])San Francisco, Peter Axelrod

([email protected])Southeastern, Inactive

COMMITTEE CHAIRMENAudit, Dr. Michael K. Hynes

([email protected])Award, Gale E. Braden ([email protected])Ballot Certification, Tom McCarthy

([email protected])Board of Fellows, Ron Chippindale

([email protected])Bylaws, Darren T. Gaines ([email protected])Code of Ethics, John P. Combs

([email protected])Membership, Tom McCarthy ([email protected])Nominating, Tom McCarthy ([email protected])Reachout, James P. Stewart ([email protected])Seminar, Barbara Dunn ([email protected])

WORKING GROUP CHAIRMENAir Traffic Services, John A. Guselli (Chair)

([email protected])Ladislav Mika (Co-Chair) ([email protected])

Cabin Safety, Joann E. Matley([email protected])

Corporate Affairs, John W. Purvis([email protected])

Flight Recorder, Michael R. Poole([email protected])

General Aviation, William (Buck) Welch([email protected])

Government Air Safety, Willaim L. McNease([email protected])

Human Factors, Dr. Robert C. Matthews([email protected])

Investigators Training & Education,Graham R. Braithwaite([email protected])Positions, Ken Smart([email protected])

CORPORATE MEMBERSAccident Investigation Board, FinlandAccident Investigation Board/NorwayAeronautical & Maritime Research LaboratoryAeroVeritas Aviation Safety Consulting, Ltd.Air Accident Investigation Bureau of SingaporeAir Accident Investigation Unit—IrelandAir Accidents Investigation Branch—U.K.Air Canada Pilots AssociationAir Line Pilots AssociationAir New Zealand, Ltd.Airbus S.A.S.Airclaims LimitedAircraft Accident Investigation Bureau—

SwitzerlandAircraft Mechanics Fraternal AssociationAircraft & Railway Accident InvestigationCommissionAirservices AustraliaAirTran AirwaysAlaska AirlinesAll Nippon Airways Company LimitedAllied Pilots AssociationAmerican Eagle AirlinesAmerican Underwater Search & Survey, Ltd.ASPA de MexicoAssociation of Professional Flight AttendantsAtlantic Southeast Airlines—Delta ConnectionAustralian Transport Safety BureauAviation Safety CouncilAvions de Transport Regional (ATR)BEA-Bureau D’Enquetes et D’AnalysesBoard of Accident Investigation—SwedenBoeing Commercial AirplanesBombardier Aerospace Regional AircraftBundesstelle fur Flugunfalluntersuchung—BFUCathay Pacific Airways LimitedCavok Group, Inc.Centurion, Inc.China AirlinesCirrus DesignCivil Aviation Safety Authority AustraliaComair, Inc.Continental AirlinesContinental ExpressCOPAC/Colegio Oficial de Pilotos de laAviacion ComercialCranfield Safety & Accident InvestigationCentreDCI/Branch AIRCODelta Air Lines, Inc.Directorate of Aircraft Accident Investigations—

NamibiaDirectorate of Flight Safety (Canadian Forces)Directorate of Flying Safety—ADFDutch Airline Pilots AssociationDutch Transport Safety BoardEL AL Israel AirlinesEMBRAER-Empresa Brasileira de Aeronautica

S.A.Embry-Riddle Aeronautical UniversityEmirates AirlineEra Aviation, Inc.European Aviation Safety Agency

EVA Airways CorporationExponent, Inc.Federal Aviation AdministrationFinnair OyjFlight Attendant Training Institute at Melville

CollegeFlight Safety FoundationFlight Safety Foundation—TaiwanFlightscape, Inc.Galaxy Scientific CorporationGE Transportation/Aircraft EnginesGlobal Aerospace, Inc.Hall & Associates, LLCHoneywellHong Kong Airline Pilots AssociationHong Kong Civil Aviation DepartmentIFALPAIndependent Pilots AssociationInt’l. Assoc. of Mach. & Aerospace WkrsInterstate Aviation CommitteeIrish Air CorpsJapan Airlines Domestic Co., LTDJapanese Aviation Insurance PoolJetBlue AirwaysKLM Royal Dutch AirlinesL-3 Communications Aviation RecordersLearjet, Inc.Lockheed Martin CorporationLufthansa German AirlinesMyTravel AirwaysNational Air Traffic Controllers Assn.National Business Aviation AssociationNational Transportation Safety BoardNAV CanadaPhoenix International, Inc.Pratt & WhitneyQantas Airways LimitedRepublic of Singapore Air ForceRolls- Royce, PLCRoyal Netherlands Air ForceRoyal New Zealand Air Forcerit, LLCSandia National LaboratoriesSaudi Arabian AirlinesSICOFAA/SPSSikorsky Aircraft CorporationSingapore Airlines, Ltd.SNECMA MoteursSouth African AirwaysSouth African Civil Aviation AuthoritySouthern California Safety InstituteSouthwest Airlines CompanyStar Navigation Systems Group, Ltd.State of IsraelTransport CanadaTransportation Safety Board of CanadaU.K. Civil Aviation AuthorityUND AerospaceUniversity of NSW AVIATIONUniversity of Southern CaliforniaVolvo Aero CorporationWestJet ◆


WHO’S WHO

VNV: Dutch Airline Pilots Association

ISASI107 E. Holly Ave., Suite 11Sterling, VA 20164-5405USA

NON-PROFIT ORG.U.S. POSTAGE

PAIDPermit #273

ANNAPOLIS, MD

WHO’S WHO

(Who’s Who is a brief profile of, and pre-pared by, an ISASI corporate member toenable a more thorough understandingof the organization’s role and functions—Editor.)

The employment terms and laborconditions for pilots, taken forgranted at the moment, have not

come about automatically. In its 75 yearsof existence, the Dutch Airline PilotsAssociation (VNV) has largely contrib-uted to the promotion of interests andprofessionalization of pilots. And the VNVstill stands for attention for flight safety,employment terms, and labor conditionson behalf of the professionals it repre-sents. From their daily activities, mem-bers contribute valuable knowledge andexperience to the union and the profes-sional group, which marks the VNV.

The following practical objectives arecharacteristic of the VNV:• advancing safety in aviation,• creating good terms of employment,• increasing pilots’ professionalism,• promoting individual member’sinterests.

The VNV pursues its objectives with thesupport of 3,000 members, almost allemployed by Dutch airline companies. Ahigh degree of organization is a majorfactor in issues such as promoting interestsand exercising influence. But power fromthe number of members is not the meansby which VNV achieves its aims. The VNVprefers the power of the argument becausesubstantively better results can beachieved through constructive negotia-tions. Three thousand members form arich source of knowledge of and experiencewith aviation. Several active members arehighly qualified in other areas as well.Through them, the VNV has a range ofdisciplines at its disposal, varying fromtechnology and economics to medicalaspects and accident analysis. And whenexpertise is not available internally, theVNV provides it by having its members

attend courses or by calling in know-howfrom external sources.

A real labor unionThe VNV is a real union, which stands forabove-average employment terms andconditions for pilots. It is successful as well.Since the first collective labor agreementwith KLM in 1969, a number of laboragreements have been concluded for VNVmembers. The VNV has also managed tocollectively regulate employment termsand conditions with smaller companies.

When collective labor agreements areconcerned, salary always takes firstpriority. But in the course of years, the

does not avoid a confrontation. Severaltimes in the history of the VNV, actions havebeen necessary to enforce negotiations.

A committed professionalassociationAs a professional association, the VNV hasdedicated itself to a continuous improve-ment of flight safety and professionalism ofpilots. This is a technical matter as well asa professional one. And the VNV is an up-to-date knowledge center for thesematters. Commissions concerned withflight technical matters, work and resttimes, training and assessing, flightmedical matters, and accident/incidentinvestigations make contributions. TheVNV also provides effective individual andlegal support for its members.

The VNV has contributed to theformation of legislation in the flighttechnical sphere to finding a solution tocollisions of airplanes with birds and toturbulence caused by buildings surroundingthe airport. Through its internationalcontacts, the VNV has made contributionsfrom a pilot’s perspective to Boeing andAirbus to the design and use of newairplanes. The VNV also maintains contactswith sister organizations abroad and is co-founder of the International Federation ofAir Line Pilots Associations and theEuropean Cockpit Association. ◆

VNV has managed to lay down several, forpilots, important rules in labor agree-ments. Examples are the pilot careerscheme, pension scheme, work and restregulation, legal assistance, and legalprotection in case of disciplinary measures.In many labor agreements, regulationsgoverning redundancy, function proficiencyinvestigation, and flight safety investiga-tion have been included.

If necessary, and if convinced of thereasonableness of its demands, the VNV

Documents

OCTOBER–DECEMBER 2005 Cow Town Corrals ISASI … · By Carly Reil—The author’s winning essay entry that gained her the 2005 ISASI Rudy Kapustin Scholarship, ... B-737-300 in