ISASI 2008
Technical Program

Accident off the Coast of Moorea, French Polynesia

Alain Bouillard
Investigator-in-Charge, Special Advisor to the BEA

Arnaud Desjardins
Safety Investigator, Engineering Department
Bureau d’Enquêtes et d’Analyses pour la Sécurité de l’Aviation Civile français (BEA) France

On 9 August 2007, a DHC-6 Twin Otter crashed into the sea shortly after take-off from Moorea Enroute to Papeete in Tahiti. Though experienced in undersea recovery methodology, the BEA investigators were faced with limited resources in a remote site. Alain and Arnaud will discuss how they adapted techniques for signal triangulation and for lifting the wreckage out of the water in the on-site phase and, during subsequent examinations, had to develop specific models for assessing cable resistance. A new method to determine the airplane’s trajectory, based on the EGPWS alarms recorded on the CVR, added a further dimension to the management of the investigative tasks.

Approaches of Accident Investigation in Different Cultural Contexts

Wen-Chin Li
Assistant Professor
National Defence University
Republic of China (Taiwan)

Visiting Fellow
Department of Systems Engineering and Human Factors
Cranfield University
United Kingdom

The paper will present the results of a study of European and Asian accident investigators and discuss what effect culture may have on the conclusions drawn while conducting an accident investigation.

Causation: What is it and does it really matter?

Michael Walker
Senior Transport Safety Investigator
Australian Transport Safety Bureau
Australia

Mike will discuss some of the difficulties the ATSB has had with the concept of cause and how they are addressing them. The paper will look at related concepts such as standard of proof, and how different types of investigations define and approach causation and standard of proof, as well as put forward how the ATSB we think it should be done for safety investigations.

SMS as a Safety Tool

John Gadzinsky
Air Safety Chairman
Southwest Airlines Pilots Association
USA

The paper will review lessons learned related to how root causes can be found by looking at how organizations behave within their safety management programs. As the goals and objectives of pilot associations, operators, and regulators can be different, an investigator who knows where to look and what questions to ask can uncover how data is viewed differently, how risk is assessed differently, and how the communication between these groups can in fact create the safety issues that set the stage for the accidents being investigated.

International Support for Developing Organizations

Syed Naseem Ahmed
Technical Investigator
Safety & Investigation Board
Pakistan Civil Aviation Authority
Pakistan

The paper will review the experience of an international team of investigators following a crash of a Fokker F 27 Crash on 10th July 2006 in Pakistan, which killed 45 passengers and crew.

Use of Model Helicopter and Precise Differential GPS on the Occurrence Site survey

Michael Guan
Director of Investigation Lab
Aviation Safety Council
Republic of China (Taiwan)

In contrast to the traditional usage of tape-measures, protractor and compass as occurrence site measuring and recording tools to the impact points, tire marks and wreckage distribution, new technologies and modern equipments like handheld GPS, laser ranger and digital camera are now used on site survey for their advance reliabilities and accuracies. The paper will discuss the latest techniques and equipment developed at the ASC.

Managing the Complexities of a Major Aviation Accident Investigation

Bruce Coury
Office of Research and Engineering
National Transportation Safety Board
USA

The paper will describe a project being conducted at NTSB to model the accident investigation process, and develop a methodological framework that can be used to manage investigative tasks and information. It will specifically focus on the nonlinearities in accident investigation that make the typical structured and linear approaches to accident investigation inappropriate and ineffective for managing the complexities and uncertainties of a major aviation accident investigation. The paper will conclude with a discussion of the implementation challenges of such a model-based strategy, and the accident investigation methods that are being developed to support NTSB aviation
accident investigation.

Cockpit Information Recorder for Helicopter Safety

Roy Fox
Chief, Flight Safety
Bell Helicopter Textron
USA

The paper will present the Bell, designed new low-cost, non-intrusive, Cockpit Information Recorder (CIR) designed specifically for the existing Bell helicopter fleet. The CIR meets the needs of helicopter investigations and helicopter crash survivability criteria and consists of a high-resolution digital camera, GPS, self-contained sensor package, and a microphone.

Investigating Unmanned Aircraft Systems Accidents

Tom Farrier
Senior Analyst
Aerospace Safety and Operations Analytic Services
USA

The paper will explore the challenges facing investigators with the introduction of UAS. Tom will offer case studies in past accidents and current design directions. The presentation will also include how the author is exploring these issues with military and other public-use operators of unmanned aircraft systems.

Conversations in the Cockpit: Pilot Error or a Failure to Communicate?

Noelle Brunelle
H-53/S-61/Legacy Models Team
Aviation and Product Safety
Sikorsky Aircraft Corporation
USA

This paper will explore the conversations between the automation and the crew: how aircrew mental models are developed, maintained and used to support both situational awareness and decision-making, current display philosophies, and challenges to effective communication between aircrew and the aircraft. The author will also propose a method for evaluating these conversations so investigators may provide feedback to designers to improve these interfaces.

What can we Learn?

Graham Braithwaite
Head, Department of Air Transport
Cranfield University
United Kingdom

The author will explore the subject of what experienced investigators can learn from the experiences of new investigators. The paper will draw on the many experiences of brand-new investigators from military, civilian, airline, regulator, national investigation agency, insurers, ALPA’s and so on that have come through Cranfield and the experiences they have shared with the university when they first start doing the job. It will cover both the techniques (science) and approach (art) of the new role they are playing.

Problems in operating emergency evacuation slides: Analysis of accidents and incidents with passenger aircraft

Gerard van Es
Senior Consultant
NLR-Air Transport Safety Institute
Netherlands

This paper presents an analysis of historical emergency evacuations in which slides were used. The factors that have hampered the use of emergency evacuation slides are identified from these data and are analysed in-depth.

Bringing the Worldwide Helicopter Accident Rate Down by 80%

Jack Drake
Helicopter Association International
USA

The paper will discuss the International Helicopter Safety Team effort to reduce the worldwide helicopter accident rate by 80% in 10 years. The paper will discuss how the JHSAT is analyzing the cases and getting much more from the data (125 recommendations from the first year of accident data analyzed) than is typical of worldwide investigative and regulatory authorities.

Analyzing Accidents To Assess The Effects of Rapid Technological Change on General Aviation Safety in Four Countries

Bob Matthews
Senior Safety Analysts
Federal Aviation Administration
USA

This paper analyzes 10 years of fatal General Aviation and air taxi accident data from Australia, Canada, the UK and the US to document the effect of these changes on the frequency of various types of accidents. The analysis uses accident data and accident investigation reports as its primary source material. The methodology maps several key characteristics of the new technology to each fatal accident in each of the four countries. The paper also forecasts net effects on safety over the coming decade and will note how some of those effects might differ among the 4 countries reviewed. Findings could help decision makers to identify appropriate targets in their use of finite
safety resources.

Accident Investigation—A Complete Service?

Philip Taylor
Senior Inspector of Air Accidents
Air Accident Investigation Branch
United Kingdom

The paper will question whether Air Accident Investigation is a ‘complete service’. Consideration will be given to what the expression ‘complete service’ might mean. Then the paper will consider the ingredients involved in the process, from Notification to Safety Recommendation action, and those who benefit, in whatever sphere of interest. Examples will be used to illustrate the content of the paper, and some which confirm or challenge the notion of completeness will be offered. The paper will discuss the improvements that could be made to enhance the process, including advances in technology. Finally the paper will look at the aspects of accident investigation that seem fundamental to its success, and completeness.

Occupant Protection/Cabin Safety

Nora Marshall
Chief, Survival Factors Division
National Transportation Safety Board
USA

The speaker will discuss occupant protection/cabin safety issues for corporate and air taxi flights and recommendations issued for air taxi operations in the Gulf of Mexico and crew training and cabin safety in
corporate aviation.

Swissair 111 Update—Modi-Plus Modification

Timothy Crowch
ASSM Switzerland

Timothy will discuss the Swissair "Modi-Plus" modification programme which included the installation of 8 IR cameras in the First Class Galley and Cockpit overhead and an accompanying Halon extinguishant piping feed.

Weather Risk Management Through a Systematic Approach to the Investigation of Weather Events

John W. Dutcher
Dutcher Safety & Meteorology Services
Canada

G. Mike Doiron
Cirrus Aviation Safety Services
Canada

Can we manage the risk and impact of weather on safety and operations? This paper will advocate the concept of a weather management system (WMS) to manage the impact of weather in the operational environment.

Applying HFACS to Major Aircraft & Railway Accidents

Yukiko Kakimoto
Director, Aviation & Railway Safety Promotion
ARSAP, Japan

The presentation will report on a project to apply HFACS and SHEL to major aircraft and railway accidents and will discuss some problems encountered when analyzing the results. Dr. Kakimoto will relate the study findings relative to the use of HFACS and the SHELL in investigation and prevention activities.

Gas Turbines & Ice—The Mysterious Culprit

Al Weaver
Southern California Safety Institute
USA

The paper describes the many sources of ice that can involve gas turbine engines leading to abnormalities and failure conditions and describes the sources of ice, its symptoms and investigative techniques and experience towards identifying probable sources.