JANUARY–MARCH 2007 · vestigating a “Minor” Incident Using Les-sons Learned From A Major...

JANUARY–MARCH 2007‘Best in Seminar’(Page 4)

Applying Learned Investigation Lessons Anew (Page 5)Improving the Quality of Investigation

Analysis (0)Enhancing the Investigation of Human

Performance Issues (Page 14)Failure Analysis of Composite Structures in

Aircraft Accidents (Page 17)))))

2 • ISASI Forum January–March 2007

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

Volume 40, Number 1Publisher 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 © 2007—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.

FEATURES4 ‘Best in Seminar’By Dr. Graham Braithwaite—The “Best in Seminar” technical paper presented atISASI’s annual seminar is selected on the basis of “outstanding contribution to theadvancement of technical methodologies in aircraft accident investigation.”

5 Applying Learned Investigation Lessons AnewBy Stéphane Corcos and Alain Agnesetti, BEA France—Virtual airlines, like genuinetoadstools, can jeopardize the safety and stability of the air transport industry wheninsufficient oversight is practiced.

10 Improving the Quality of Investigation AnalysisBy Dr. Michael B. Walker, TSB Australia—The Safety Investigation InformationManagement System (SIIMS) developed by the Australian Transport Safety Bureaufor its investigation activities holds promises for a significant increase in capability,particularly with complex investigations.

14 Enhancing the Investigation ofHuman Performance IssuesBy Dr. Randall J. Mumaw, Aviation Safety, Boeing—An industry working group isformed to develop better guidance for investigating human performance.

17 Failure Analysis of Composite Structuresin Aircraft AccidentsBy Joseph F. Rakow, Ph.D., P.E. (AO4926) and Alfred M. Pettinger, Ph.D., P.E.,Exponent Failure Analysis Associates—The authors introduce some of the basicconcepts involved in analyzing failed composites under a variety of fundamentalloading conditions such as tension, compression, bending, impact, and fatigue.

DEPARTMENTS2 Contents3 President’s View

24 ISASI RoundUp30 ISASI Information32 Who’s Who—A brief corporate member profile

of the Transportation Safety Board of Canada

ABOUT THE COVERIn November 2001, American Airlines Flight 587’s composite stabilizer failed. As apotential harbinger of the failures discussed in “Failure Analysis of Composite Struc-tures in Aircraft Accidents,” the failure of this composite structure is discussed in thearticle on page 17. (Photo: ISASI 2006)

CONTENTS

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

January–March 2007 ISASI Forum • 3

ISASI Accepts International Human Factor RoleBy Frank Del Gandio, President

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

PRESIDENT’S VIEW

Our Society has been asked to accept amajor role in assisting you, the field

accident investigators, in using humanfactor tools to understand, guide, and reportthe role the human played in an accidentor incident.

E. M

AR

TIN

EZ

Our Society has been asked to accept a majorrole in assisting you, the field accident investiga-tors, in using human factor tools to understand,guide, and report the role the human played inan accident or incident. At our May 2006 Councilmeeting, Vice-President Ron Schleede reportedthat he had been contacted by Dr. Randy

Mumaw, a human factors specialist for Boeing, with an invitationfor ISASI to join the recently formed International HumanFactors Working Group. This Working Group had begun toprepare guidance material for accident and incident investiga-tors and others in the field of human factors. The InternationalHuman Factors Working Group wanted the endorsement andassistance of ISASI in preparing and distributing the guidancematerial. The Council considered this a “heads up” contact andasked that more information be provided for the fall meeting.

Accident statistics show that issues associated with humanperformance are major contributors to incidents and accidents incommercial aviation. Ideally, an investigation will seek tounderstand the context of human performance and how itcontributes to the observed behaviors and decisions. Worldwide,investigations vary significantly with respect to the beliefs aboutthe role of humans and appropriate methods for developing anunderstanding. Because of this, these investigations can becomethe subject of controversy. Accident and incident investigationpresents a real opportunity to determine how humans haveaffected the outcome of an operation.

Understanding that improving comprehension of humanfactors in accident investigation is an important contributionISASI can make to assist the field investigator in using humanfactor tools to understand, guide, and report the role the humanplayed in the accident/incident, the Council, at its fall meeting inSeptember, accepted the invitation, but went beyond that.

Ron Schleede, vice-president (left), prepares to brief the Council and putforward the resolution creating the ISASI International Working Group on HumanFactors (IIWGHF). Looking on is President Frank Del Gandio.

Research and discussion showed that this effort directly affectedour membership and deserved the fullest participation. Hence,the Council established the ISASI International Working Groupon Human Factors (IIWGHF) and proposed to the Boeingcontingent that ISASI assume sponsorship of the internationalindustry Working Group that aims to develop better guidancefor investigating human performance.

The genesis of this effort is described in Randall Mumaw’s article“Enhancing the Investigation of Human Performance Issues,” onpage 14 of this issue. He also discusses the early-on efforts of theindustry Working Group and provides some insight into the role

ISASI would play in the effort.To head our effort, I turned to our

long-time Executive Advisor Dick Stone,who has extensive experience in the HFfield, dating back to the years he servedin the Air Line Pilots Association’s airsafety structure. He accepted the charge,and with MikeWalker, Australian TSB,and Randy Mumaw acting as members ofa steering committee began to structurethe IIWGHF in a configuration that couldenhance existing guidance documents forinvestigation of human performanceissues in accidents and incidents nowavailable to investigators, and that wouldhelp establish clear standards for suitablemethods of investigating contributingfactors of human performance. Whilehuman factors expertise is available, thisexpertise is not uniformly applied. In thenext issue of Forum, Capt. Stone willdiscuss the work of IIWGF. ◆


(Described below by the panel chairman is the process summaryused in the selection of the “Best in Seminar” technical paperpresented at ISASI 2006. The panel enlarged the scope of thereview and identified three papers for “special commendation.”All the papers, as adapted for publication, are presented on thefollowing pages. Readers are encouraged to view the full presen-tations including all images, references, and acknowledgementson the ISASI website.—Editor)

The “Best in Seminar Award” was established through ananonymous donation by an ISASI member who wishedto acknowledge a paper at the annual seminar that made

an outstanding contribution to the advancement of technicalmethodologies in aircraftaccident investigation.The Award was to begiven on the basis of pub-lication of new or uniqueapplication methods to beused by today’s accidentinvestigators.

For ISASI 2006, ajudging panel was madeup of seven ISASI members from civil, military, education, gov-ernment, and manufacturer backgrounds to grade each paperbased on the above criteria and reflecting the overall theme ofthe seminar, “Incidents to Accidents: Breaking the Chain.”

Some presentations would be of particular interest to some ofthe audience, and the panel recognized that selecting an overallbest presentation was going to be difficult. Based on the inde-pendent assessment of the papers and subsequent debate by thepanel, three papers were selected for special commendation• Dr. Randy Mumaw’s (Boeing) presentation on the ISASI-sponsored initiative to develop guidance material for the inves-tigation of human performance issues was felt to represent agreat, practical development for investigators, and the resultsof the project will be awaited with anticipation.• Dr. Mike Walker’s (ATSB) paper on the ATSB’s approach toimproving the quality of investigation analysis highlighted theconsiderableeffort thatthe Austra-lian Trans-port SafetyBureau hasput into de-veloping itsapproach to

investigation and promises a significant increase in capability, par-ticularly with complex investigations.• Dr. Joseph Rakow also presented a paper that helped manyinvestigators to better understand the nature of composite fail-ure in aircraft structures—a growing area of interest withincivil and military aviation.

The winning presentation was Stéphane Corcos and AlainAgnesetti’s paper detailing the French BEA’s investigation of aserious incident that had many parallels with a previous fatalaccident investigation. The content was a fascinating insight intothe application of a systemic investigation approach in a part ofthe industry where the “virtual airline” presents growing chal-lenges for safety professionals. Good investigative judgment inunderstanding the factors behind the incident provided a clearillustration of the Society’s aim of “Safety through investigation,”and the paper was a worthy winner of “Best in Seminar.” ◆

‘Best in Seminar’By Dr. Graham Braithwaite, Selection Panel Chairman

ABOVE: Stéphane Corcos,right, on behalf of himself andcoauthor Alain Agnesetti,accepts the Award of Excel-lence from ISASI PresidentFrank Del Gandio during awardceremonies at ISASI 2006, inCancun, Mexico.LEFT: Alain Agnesetti.

Doctors Mumaw, Walker, and Rakow

The judging panel wasmade up of seven ISASImembers from civil,military, education,government, and manu-facturer backgrounds. P

HO

TO

S: E

. MA

RT

INE

Z


(This article was adapted, with permission,from the authors’ presentation entitled In-vestigating a “Minor” Incident Using Les-sons Learned From A Major Accident pre-sented at the ISASI 2006 seminar held inCancun, Mexico, September 11-14, whichcarried the theme “Incidents to Accidents:Breaking the Chain.” The full presentationincluding cited references index is on theISASI website at www.isasi.org. The authorsreceived ISASI’s Award of Excellence for de-velopment of the “Best in Seminar” paper.The Award was created in 2005.—Editor)

Last summer was a terrible one for avia-tion safety, with several fatal accidents,in which more than 500 passengers

died in just 2 months. Most investigationsare still ongoing, but it is likely many ofthem will highlight shortcomings in the way

oversight of various operators was per-formed by their national authorities. TheBEA has been involved in a number of in-vestigations to various extents, as state ofthe manufacturer, state having citizensamong the victims, but also by assistingseveral countries in their investigations, in-cluding flight recorder readout.

Although most of these fatal accidentsoccurred outside the western hemisphere,any given citizen of a western country mayone day be a passenger on a domestic flightin a less developed country, or between twoof them. Moreover, an investigation into anincident that occurred during takeoff fromParis’s Charles-de-Gaulle in July 2005showed that it is not necessary to travelabroad to be at risk.

In Europe, airlines from countries wheresafety oversight is weak can operate on awet-lease basis for national flag carriersfrom EU states, where leasing conditionsare somewhat overlooked. According toICAO findings (35th assembly, September2004), there are almost 30 states where

safety deficiencies still prevail, where cor-rective actions have not been implemented.Rogue airlines know this situation and ex-ploit these breaches, eventually makingtheir way into Western countries. “Virtualairlines,” made up of parts that are ofteninconsistent, and which should actually becalled “ticket sellers,” rather than “airlines,”are created there. Then, like genuine toad-stools, they jeopardize the safety and sta-bility of the air transport industry.

The world aviation community has iden-tified the problem, but implementation ofsolutions is very slow. ICAO has limitedpower, since its system is based on sover-eignty. Many states commit themselves toimplement ICAO standards but often havenot taken appropriate action to enforce thestandards through regulations, procedures,and proper staffing.

But, mostly, such states lack the politicalwill to move forward. Instead, technicalexpertise is often superseded by politicalconsiderations for various reasons. Safetyregulations are often seen as hindrances tothe prosperous operation of an airline, andboth authority and airline technical staff areunder pressure from politics or financialmanagers. In such cases, safety is not at-tractive because it may ultimately confrontone with the taboo of canceling a flight. Inaviation culture, especially in a fiercely com-petitive environment, canceling a flight isseen as a failure. Consequently, safety per-sonnel end up being blamed for their ac-tions and are seen as “the bad guys.”

Above all, it is our terrible experience insociety that sometimes it seems as if a pricemust be paid in blood before lessons arereally accepted and the situation changed,before those concerned are convinced by thelessons derived from other occurrences andare willing to overcome the inevitable costsand putting aside of prestige considerations.When the aviation community says it willimprove its level of safety, accident investi-gators are too often their “efficiency sen-sor,” who demonstrate that the picture re-mains imperfect.

Stéphane Corcos at thetime of ISASI 2006 wasthe head of the BEA(Bureau d’Enquêtes etd’Analyses pour la Sécuri-té de l’Aviation Civile)Investigations Depart-

ment. Prior to joining the BEA, he workedfor the DGAC (French civil aviationauthority) for 8 years. He was graduatedfrom the French National Civil AviationSchool (ENAC) with a masters degree inaeronautical engineering in 1987 includ-ing an internship period at the FlightSafety Foundation in Arlington, Va. He iscurrently employed as head of Safety andSecurity Oversight for Charles-de-Gaulle

Applying Learned InvestigationLessons Anew

and Le Bourget Airports by the DGAC(Direction Générale de l’Aviation Civile).

Alain Agnesetti is aformer Air Force pilotinstructor. As a flightsafety officer andaccident investigator inthe French Air Force, heled various military

accident investigations. A retired majorwith more than 6,000 flying hours, hejoined the BEA in 1999 as a safetyinvestigator. He has been IIC on anumber of national and foreign investi-gations and an accredited representativeon major investigations abroad.

By Stéphane Corcos andAlain Agnesetti, BEA (Bureaud’Enquêtes et d’Analyses pour laSécurité de l’Aviation Civile)

Virtual airlines, like genuine toadstools, can jeopardizethe safety and stability of the air transport industry wheninsufficient oversight is practiced.


Traceability of airplanes can be impos-sible across borders, except with the helpof private companies or individuals, whosewebsites may include interesting informa-tion on a given situation. Thanks to Internetsearch engines, which are more and morefrequently used in difficult investigations,some achievements are possible. But trace-ability of pilots, their initial and recurrenttraining, their ratings and their actual ex-perience, is almost impossible especiallywhen, de facto, they act as mercenaries.Such pilots often move from airline to air-line and have no time to become familiarwith the airline, the working environment,the standard operating procedures, the net-work, and they are not always in a positionto perform at an acceptable safety level.

To illustrate this, we could reiterate theoccurrence the BEA presented at ISASI2005. The investigation into this incident inNantes (approach flown well below and out-side normal final approach path) had shownthat the captain lacked knowledge on instru-ment approach procedure principles andlimitations and on the autopilot of his air-plane. This pilot, who held a Venezuelan li-cense but flew with an Egyptian airline, wassacked before the investigation was com-pleted. He, quite probably, has now trans-ferred his inadequacies to another country,to another employer who has no reason tobelieve his knowledge is inadequate. No onehas any way of knowing where he is now,much less to have him enrolled in additionaltraining.

Finally, traceability of airline managers,and even of airlines themselves, is no easier,all the while this situation is increasinglybecoming a safety concern as well.

Safety oversightThrough safety oversight, a state ensuresthat national actors in the aviation indus-try (airmen, operators, maintenance orga-nizations) perform their duty in a safe man-ner and meet the applicable requirementsand standards.

The responsibilities and international

obligations of states in relation to safetyoversight are derived from the Conventionof Dec. 7, 1944, on international civil avia-tion, known as the Chicago Convention: “inorder that international civil aviation maybe developed in a safe and orderly mannerand that international air transport servicesmay be established on the basis of equalityof opportunity and operated soundly andeconomically.” The Convention recognizes(Article 1) that “each state has complete andexclusive sovereignty over airspace aboveits territory.”

Furthermore, the Convention stipulates(Article 12) that a state should ensure thatany aircraft flying over its territory or ma-neuvering thereon, as well as any aircraftwith its registration mark, wherever it maybe found, should be in conformity with therules and regulations applicable in the placewhere the flight or the maneuver is takingplace. The Convention also specifies (in Ar-ticles 31 and 32) that states of registry mustissue certificates of airworthiness to aircraftundertaking international flights and cer-tificates and licenses to their crews. How-ever, Article 83b authorizes the partial ortotal transfer of these responsibilities, aswell as those relating to Article 12, to thestate of operator of the aircraft.

To ensure harmony between these vari-ous obligations, the Convention introduces,in Article 12, an obligation for national regu-lations to be in conformity with the rules es-tablished pursuant to the Convention and,in Article 33, the international recognitionof documents issued by the state of registryinsofar as they correspond to the standards.

This implies that each state commits it-self to adopt a law or a civil aviation code,completed by the necessary rules of appli-cation, to put into place and apply the in-ternational standards. This also implies thateach state may ascertain that other statesare satisfactorily undertaking their commit-ments. Specifically, if the rules adopted byother states are inferior to internationalstandards, Article 38 stipulates that thecouncil be notified of these differences.

Throughout the past 15 years, aviationhas experienced rapid and steady growthand has always been ahead of global eco-nomic growth, which it has accompaniedeffectively, as a fundamental tool for devel-opment of exchanges. But this economicgrowth has been characterized by increasedglobalization, which has also affected avia-tion. The system has become so complexthat in order to maintain an acceptable levelof safety, increasing human, financial, orga-nizational, and technological resources arerequired. Not all contracting states can copewith this challenge, and ICAO has notedthat more and more contracting states arefaced with difficulties in exercising theiroversight function.

The concern that all states keep up withtheir responsibilities has been shared bymore and more states. In August 1992, theU.S. Federal Aviation Administration (FAA)established the International AviationSafety Assessments (IASA) program. Theforeign assessment program focuses on theability of a country, rather than that of anindividual air carrier, to adhere to interna-tional standards and recommended prac-tices for aircraft operations and mainte-nance established by ICAO. It was recog-nized that in order to ensure that all foreignair carriers that operate to or from theUnited States were offering an acceptablelevel of safety, it was necessary to ascertainthat safety oversight of these carriers wasprovided by a competent civil aviation au-thority (CAA) in accordance with ICAOstandards.

In 1996, ICAO set up a voluntary pro-gram for safety assessment of national avia-tion authorities within contracting states.In 1998, this was replaced by a UniversalSafety Oversight Audit Program (USAOP),adopted by resolution A32-11 of the 32nd

Assembly.These audits started in 1999 and covered

airworthiness, personnel licensing, and op-erations. Their purpose was to assesswhether a given contracting state wasimplementing critical elements of oversight

According to ICAO findings, there are almost 30 states where safety deficiencies stillprevail, where corrective actions have not been implemented. Rogue airlines know thissituation and exploit these breaches, eventually making their way into Western countries.“Virtual airlines,” made up of parts that are often inconsistent, and which shouldactually be called “ticket sellers,” rather than “airlines,” are created there.


in pertinent standards and recommendedpractices or SARPs in an acceptable man-ner, following established procedures.

Meanwhile, in 1995, the BEA issued asafety recommendation requesting that theFrench DGAC (French civil aviation author-ity) play a lead role in the reinforcement ofsafety oversight of foreign states and car-riers, both through ICAO and the EuropeanConference for Civil Aviation (ECAC). TheDGAC was designated coordinator of thenew European Safety Assessment of For-eign Aircraft (SAFA) program, whichstarted in 1996 as a complement to USOAPaudits.

The Puerto Plata accident (a Boeing 757operated by Birgenair, a Turkish operatorwith mostly German citizens on board) in1996 accelerated this process. Both theSAFA and USOAP programs are interre-lated through a memorandum of under-standing.

Although the SAFA inspections are lim-ited and seldom thorough, they give a gen-eral overview of the foreign operator’ssafety. Furthermore, these inspections maylead to mandatory repairs, which contrib-ute to safety on a given airplane. Finally,inspections foster cooperation between theinspecting state and the competent author-ity of the inspected operator to solve safetyissues almost in real time.

UTA Boeing 727 accident

The above discussed oversight issue was sig-nificantly brought to light in the course ofthe investigation into an accident that oc-curred in Cotonou (Benin) on Dec. 25, 2003.History of flight—A Boeing 727-223, regis-tered 3X-GDO and operated by Guinean Air-line UTA (Union des Transports Africains),was on its second leg of its Conakry (Guinea)–Cotonou–Kufra (Libya)–Beirut (Lebanon)–Dubai (United Arab Emirates) route. Dur-ing the takeoff run, the airplane experienceda long, delayed, and shallow angle of liftoff.It struck an ILS building located 118 meterspast the runway end on the extended run-way centerline and crashed onto the beachwith most parts ending up in the ocean. Therewere at least 160 people on board, amongwhom 22 survived the accident, including thecaptain and the airline’s general manager.The Benin government delegated the inves-tigation to the BEA.Accident description—The investigationshowed that the airplane weight was 7 to 8tons above the maximum allowable weightand that the cargo compartments wereloaded by poorly managed employees, in ananarchic way. The aircrew was unable to ob-tain precise data concerning passengers andluggage, nor for possible freight on board.

Furthermore, the aircrew was lackingdocumentation to establish a precise loadsheet: they were not informed that the for-ward cargo hold had been heavily loaded,which significantly displaced forward thecenter of gravity. Therefore, the crew tookinto account a weight of 78 tons with a stan-dard loading, and a configuration of flaps25°, trim setting 6¾, packs off, brakes re-lease on takeoff thrust. At V1-VR callout,the airspeed was 137, which is in fact a V1-VR for 85.5 tons. On reaching this airspeed,the copilot (who was the pilot flying) pulledback on the column but the airplane failedto pitch up. The airplane rotated slowly andlifted off in the very last meters of the run-way. The main landing gear struck a 2.45-meter-high building containing the localizersystem. The right main landing gear brokeoff and ripped off a part of the underwing

flaps on the right wing. The airplane bankedslightly to the right and crashed onto thebeach. It broke into several pieces andended up in the ocean.Operational failings—The overall opera-tion of the airplane, both at its base and atthe various destinations it served, was notorganized, undertaken, or overseen in anappropriate manner.

In Cotonou, the station manager had noaeronautical knowledge. The resources(counters, vehicles, and staff) were rentedfrom a company based at Cotonou airport,but this company was not tasked with anyduty related to dispatch or handling, in par-ticular providing the crew with performancedata. Basic loading elements (number ofpassengers, estimated weight of luggage)were provided to the aircrew by a repre-sentative of the airline, flying on board theairplane.

At its main base in Conakry, apart froma rented check-in counter, the airline hadtwo containers in which spares, drinkingwater, and the printed paperwork requiredfor operations were stored.

There was no competent technical man-agement and operational and maintenanceactivity were non-existent (no maintenancedocuments could be supplied to the investi-gators), and no training was provided forground crew.

History of operationsThe airline, UTA, was initially based in Si-erra Leone and operated as West CoastAirlines. In 1997, its home base was trans-ferred to Guinea under the name of UTA.It started operating rather light airplanes:a Let 410 and an Antonov 24. Both airplanesbelonged to a Russian citizen, who was alsothe technical director of the airline. The air-line was owned by a Lebanese citizen livingin Guinea; several family members wereamong top managers of the airline, includ-ing the director general and the operationsmanager.

UTA performed local flights in westernAfrica up to 2003. In April 2003, the airline


elected to extend its range of operationsand, in June of the same year, long-distanceflights to Lebanon and the UAE were or-ganized using a Boeing 727. When theBoeing 727 was added to the airline fleet,none of the technical staff had any knowl-edge about the airplane. In April 2003, arequest to open a Conakry–Abidjan–Cotonou–Beirut route was made to the au-thorities in the various countries concerned.On June 28, 2003, the route was openedbetween Conakry, Cotonou, and Beirut. InNovember, it was extended to Dubai.

The Boeing 727 was leased from FAG(Financial Advisory Group), formerly basedin Miami (Florida), then allegedly based inthe Virgin Islands. Except for the airplanelease, the sole interface was through its of-fice in Sharjah (United Arab Emirates). Theleasing contract included the aircrew andtechnical maintenance of the airplane. Italso stated that insurance and wages wereto be paid by the airline. FAG did not holdan air operator certificate.• The airplane was first delivered to Ameri-can Airlines (USA) in 1977. It had normalflying activity in the USA until 2001.• Between 2001 and 2003, it was stored inthe Mojave desert. In 2003, the B-727 be-came the property of a bank, still with a U.S.registration.• In January 2003, it was operated byAriana Afghan Airlines, Kabul (registeredYA-FAK). The owner was based in Sharjah(UAE).• In June 2003, it was operated by AlphaOmega Airways—the same owner, regis-tered in Swaziland (3D-FAK).• In July 2003, it was “operated by UTA,”under wet lease from Alpha Omega, thesame registry.• In October 2003, it was newly leased toUTA, this time from FAG, same registra-tion. Two days later, it was transferred toGuinea registry and became 3X-GDO.• From October 2003 till the day of theaccident, it remained leased by FAG andoperated by UTA as 3X-GDO on a Guinearegistry.

UTA operations actually began with an-other B 727, registration 3X-GDM, also theproperty of FAG, which was grounded inLebanon at its first flight for a number ofmajor deficiencies. The airplane was thenreplaced by the 3D-FAK and FAG got itback. The BEA deeply regrets that, due totime constraints and since this was not apart of the investigation, this airplane wasnot tracked after it returned under FAGresponsibility.Organizational failings—BEA’s investi-gation brought to light the inadequacy ofboth the airplane’s and the airline’s man-datory documentation. The airline’s opera-tions manual was a “cut-and-paste” job,seemingly based on that of a Jordanian air-line. The manual contained descriptions ofsystems, human resources, and equipmentthat the airline, UTA, did not possess. Asthe operator had no knowledge of the worldof aviation, it could neither organize nor planany operational follow-up at all, much lessensure the safety of its flights. The airline’sonly office was a ticket office in downtownConakry. Overall, the airline was hardlymore than purely a commercial structure.Oversight—The DNAC (Direction Nation-ale de l’Aviation Civile), the Civil AviationAdministration of Guinea, exercised over-sight of the airline. An air operator certifi-cate was issued in November 2001. Whenthe airline expanded with the leasing of aBoeing 727, the Guinea civil aviation author-ity stipulated that the airplane had to bemaintained according to a program ap-proved by the DNAC and in accordancewith the manufacturer’s maintenancemanual.

The DNAC could get no information onthe maintenance for the first of the twoBoeing 727s. For the second, 3X-GDO, main-tenance had been scheduled to occur inKabul, Afghanistan, in January 2004, a fewweeks after the accident.

The Guinea CAA failed to exercise, inpart under pressure from economic andemployment issues, its normal duties. Itprovided almost no safety audit upon ap-

plication to operate, no checks on opera-tions, documentation, flight time limitation,crew or airplane activity follow-up.

During stopovers in Beirut, the Lebanesecivil aviation authority conducted ramp in-spections on 3X-GDM and 3D-FAK/3X-GDO. Although limited in time and depth,a ramp check showed such deficiencies that3X-GDM was banned from flying with pas-sengers and was replaced by 3D-FAK. Onthis second plane, the ramp check revealed18 deficiencies. The plane was grounded inturn. It took at least three iterations to theLebanese CAA to have all deficiencies even-tually corrected.Causes—The direct cause of the accidentwas a forward center of gravity, unknownto the crew.The root causes of the accidents were• The operator’s lack of competence, or-ganization, and regulatory documentation,which prevented it from appropriately or-ganizing line operation and checking theairplane’s loading.• Insufficient monitoring exercised by theCivil Aviation Administration of Guinea, andSwaziland prior to it, in the area of safetyoversight.

Several contributory factors were noted,among which were a spread of responsibili-ties between the parties that made checksall the more difficult, as well as the failureto use proper dispatch or handling agentsat the Cotonou station.Safety recommendations—A first set ofsafety recommendations was addressed tocivil aviation authorities, in particularGuinea, to reorganize safety oversight andimplementation of ICAO SARPs.

Another set was addressed to ICAO, rec-ommending fostering a comprehensive en-hancement of safety oversight within allmember states, to include clarification ofduties of state of the operator, harmoniza-tion between scheduled and non-scheduledflights, identification of one operator so asto limit the spread of responsibilities, pub-lication of guidelines to be used by civil avia-tion authorities….

Satisfactory investigations are essential, since in some cases they now mostlyconsist of an audit on the safety structures, rather than an identification of previouslyunknown safety weaknesses. This implies that confidence and cooperation be totalbetween accident investigation authorities and that nobody be influenced duringan investigation by economic, political, or image considerations.


Lockheed Tristar incidentIn July 2005, almost as a precursor to thetragic summer, an incident to a LockheedTristar operated by StarJet, registered A6-BSM, occurred in Paris CDG.

Olympic Airlines was struggling to keepup with its maintenance, and it was short ofairplanes. It contracted StarJet on awet-lease basis through a broker to performthe scheduled flight OA202 from Paris toAthens.

The airplane arrived late at the gate.When passengers boarded, loud bangscould be heard, produced by mechanics lit-erally hammering on the cargo door to closeit before flight. Several passengers pan-icked, some of them rebelled, and half ofthem left the airplane, which eventually leftthe gate 4 hours and 40 minutes late. Ontakeoff, just after gear retraction, loudthumps could be heard. The crew noticedturbine gas temperature rising above lim-its, along with vibrations from engine No.3. In several cabin rows, passengers saw aflame behind the engine and panic spread.The flames were also seen from the groundby plane spotters.

The crew applied the appropriate proce-dure, shut the engine down, requested avisual approach, and returned to ParisCDG, with an uneventful landing. The newsmedia splurge that followed was amplifiedby residents neighboring the airport. TheBEA started an investigation to determinethe facts.

Beyond a “mere” engine surge followedby exhaust pipe fire, numerous deficiencieswere brought to light. Maintenance was notundertaken by an approved facility, and thelack of documentation made it impossible toconduct a proper follow-up of maintenance

operations. More generally, the investigationrevealed several shortcomings in the opera-tions as set up by StarJet: no logbook en-tries for several flights, several pieces ofequipment were not airworthy, and the docu-mentation was not appropriate (OPS manualoutdated and inadequate, MEL replaced bythe MMEL, although this was agreed as anexemption by the CAA of the UAE).

The oversight from the United ArabEmirates, state of registry, and of the op-erator revealed shortcomings in the areaof operations. Although they were awarethe operation failed to meet the applicablesafety standards, an exemption wasgranted so they could fly for Olympic. Thesupervision and checks conducted by thecivil aviation authority of Greece and Olym-pic Airlines could not prevent this airplanefrom being operated within the EuropeanUnion.

The history of activity for the Boeing 7273X-GDO and the Tristar L-1011 A6-BSMare very similar. In both cases, the patternof the geographical spread of the respec-tive owners, operators, registry, and over-sight authorities—and therefore of respon-sibilities—is similar.• 1981: BWIA (West Indies Airways),Trinidad• 2003: stored in Port-of-Spain, then reg-istered in Sierra Leone (9L-LED) with a 1-year validity certificate of airworthiness.• October 2004: bought by Star Air in Si-erra Leone. The base was in Gibraltar andthe headquarters in Amman (Jordan). Theairplane was ferried to Amman.• October 2004: withdrawn from Trinidadregistry.• June 2005: registered A6-BSM in theUAE. New owner: StarJet, company basedin Sharjah. Same president as Star Air. Noformal purchase or sale document formal-ized this transfer of property.• July 2005: StarJet was operating on a wet-lease basis for Olympic Airlines (Greece).

Although the aircraft was grounded mostof the time, the airplane was registered inmore than one state between November

2003 and October 2004. The above are onlya few of the failings found, and the investi-gation is still ongoing; more details will befound in the final report.

The experience gained during the inves-tigation into the Cotonou accident helpedinvestigators operate more effectively andexplore more precisely the apparent areasof deficiency, addressing in an even morepertinent way the root issues of failings inthe oversight process.

The two investigations showed that avia-tion safety faces at least two challenges. Thefirst one is a sound and organized imple-mentation of international standards foroperation of airplanes, and an appropriatelevel of supervision to ensure this standard.The second challenge is that Western air-lines, usually subject to a more stringentoversight from their authority, may dele-gate transport activity to operators who aresubject to a much weaker monitoring activ-ity. Action taken to guarantee an equivalentlevel of safety is not robust enough. Ulti-mately, fare-paying passengers may “le-gally” end up flying with a much lower de-gree of safety.

Among the challenges of the comingyears, safety oversight is certainly one forwhich every country has a part to play, andshould go beyond the concept of “black-lists”: strengthening of oversight, rampchecks extended as far as possible to areassuch as aircrew training, cooperation be-tween states, exchange of information,training, assistance to less developed coun-tries, and use of accident or incident inves-tigation reports to be part of the safety as-sessment, to name but a few.

In this respect, satisfactory investiga-tions are essential, since in some cases theynow mostly consist of an audit on the safetystructures, rather than an identification ofpreviously unknown safety weaknesses.This implies that confidence and coopera-tion be total between accident investigationauthorities and that nobody be influencedduring an investigation by economic, politi-cal, or image considerations. ◆


Dr. Michael B.Walker is a senior transportsafety investigator with the Australian Trans-port Safety Bureau (ATSB) and has been at theATSB since 1995. (Prior to July 1999, theaviation investigation section of the ATSB wasknown as the Bureau of Air Safety Investiga-tion.) His primary role has been to investigate

the human and organizational aspects of aviation accidentsand incidents. He has substantially contributed to more than 20significant investigations and has been actively involved indeveloping investigation methodology at the ATSB. Mike has aPh.D. in organizational psychology, a masters degree in humanfactors, a BSc honors (1st class) in psychology, and a diplomaof transport safety investigation.

Improving theQuality ofInvestigationAnalysisThis described Safety Investigation Informa-tion Management System (SIIMS) developedby the Australian Transport Safety Bureau forits investigation activities holds promisesfor a significant increase in capability,particularly with complex investigations.By Dr. Michael B. Walker, Senior Transport SafetyInvestigator, Australian Transport Safety Bureau

(This article was adapted, with permission, from the author’s pre-sentation entitled The ATSB Approach to Improving the Quality ofInvestigation Analysis, presented at the ISASI 2006 seminar heldin Cancun, Mexico, September 11-14, which carried the theme “In-cidents to Accidents: Breaking the Chain.” The full presentationincluding cited references index is on the ISASI website atwww.isasi.org. Dr. Walker’s paper received “special commendation”in the seminar’s “Best in Seminar” screening by the selection panel.The panel said the paper “promises a significant increase in capa-bility, particularly with complex investigations.”—Editor)

In 2004, the Australian Transport Safety Bureau (ATSB) ob-tained substantial Australian government funding to replaceits existing occurrence database (OASIS). There were several

reasons for the change: OASIS was based on a very complex datamodel, which made trend analysis and research difficult; it alsohad limited functionality beyond being an occurrence database.

The ATSB wanted to take advantage of developments in infor-mation technology to build a system that could enhance the qual-ity of the investigation process. To meet this aim, ATSB is devel-oping a Safety Investigation Information Management System(SIIMS) for its investigation activities. A key component of theSystem is a set of tools for the analysis phase of a safety investiga-tion, which were developed as part of a broader framework forimproving the quality of investigation analysis activities.

SIIMS overviewSIIMS will provide a workspace for each investigation with thefollowing components:• Investigation log: a form to record and categorize significantevents and decisions made during the investigation.• Document management: a structured set of folders to store andorganize all of the evidence collected during the investigation, in-cluding text documents, images, and other multimedia files.• Evidence tracking: a tool to manage the movement and exami-nation of original items of evidence (e.g., logbooks, wreckage, re-corders) held by the investigation team.• Analysis: a set of tools to help guide the analysis phase of theinvestigation, as well as document the results of analysis activities.• Project management: a tool to identify and manage risks to theinvestigation, as well as project management software to formallymanage the tasks and resources of an investigation.• Report workflow: tools to assist the development of an investiga-tion report and its modification through the different stages of review.

• Search: tools to search the investigation documents and forms inthe workspace, as well as tools to search the occurrence database.• Contact lists: a means to organize all relevant contacts for theinvestigation and therefore facilitate communication with exter-nal parties about the investigation.• Access to a reference library (i.e., a set of documents and linksthat provides useful reference material to investigators, such asICAO Annexes, ATSB manuals, and technical manuals).• Access to the occurrence database.

The System is being developed in consultation with a multidisci-plinary team of investigators, and discussions with the CanadianTransportation Safety Board (TSB) have aided in its design.SIIMS’s expected operational date is early 2007.

Developing a new analysis frameworkThe analysis phase of a safety investigation is where the availabledata are reviewed, evaluated, and then converted into a series ofarguments, which produce a series of relevant findings. The qual-ity of an investigation’s analysis activities obviously plays a critical

role in determining whether the investigation’s findings are suc-cessful in enhancing safety.

The analysis phase is also rarely easy. Safety investigations re-quire analysis of complex sets of data and in situations where theavailable data can be vague, incomplete, and misleading. Thereare no detailed, prescriptive rules that can be applied in all situa-tions and provide guaranteed success, and analysis activities ulti-mately rely on the judgment of safety investigators.

Despite its importance, complexity, and reliance on investigators’judgments, analysis has been a neglected area in terms of standards,guidance, and training of investigators in most organizations. Manyinvestigators seem to conduct analysis activities primarily using in-tuition rather than any structured process. It also appears that muchof the analysis is typically conducted while the investigation reportis being written. As a result, the writing process becomes difficult,


supporting arguments for findings may be weak or not clearly pre-sented, and important factors can be missed.

To help address this situation, the ATSB wanted to introduce acomprehensive framework (including tools in SIIMS) to guide andsupport the analysis activities of its investigators. The ultimate aimsof this framework were to improve the rigor, consistency, anddefendability of investigation analysis activities and to improve theability of investigators to detect safety issues in the transportationsystem. Such a framework, the ATSB believed, would have a directrole in more effectively “breaking the chain” of accident development.

The ATSB initially reviewed existing analysis frameworks andmethods applicable to safety investigation. None were found tomeet the ATSB’s needs: Common limitations included applicabil-ity to a narrow domain (e.g., aircraft maintenance), focus on a lim-ited part of the analysis process, lack of flexibility to handle novelsituations, lack of flexibility to deal with both small and major in-vestigations, and lack of guidance material about the process.

Consequently, the ATSB developed its own analysis framework,borrowing useful ideas from other organizations’ existing processeswhere appropriate, but also substantially adding to this materialin many areas. The result is a framework with• standardized terminology and definitions for analysis-relatedterms.• an accident development model.• a defined process or workflow.• analysis tools in SIIMS.• policies, guidelines, and training.

Standardized terminologyThe ATSB recognized the need for clear definitions and consistentusage of analysis-related terms. It determined that rather thanuse terms based on “cause,” which are associated with a range ofsemantic and communication problems, it would use “safety factor,”“contributing safety factor,” and “safety issue.”• Safety factor—defined as an event or condition that increasessafety risk, e.g., something that, if it occurred in the future, wouldincrease the likelihood of an occurrence, and/or the severity of theadverse consequences associated with an occurrence. Safety fac-tors include a wide range of events and conditions, such as acci-dent events, technical failures, individual actions, local conditions,and a range of organizational or systemic conditions. Safety fac-tors can be classified in terms of whether they contributed to theoccurrence of interest or in terms of their future influence on safety.• Contributing safety factor—defined as a safety factor that, ifit had not occurred or existed at the relevant time, then (1) theoccurrence would probably not have occurred; (2) adverse conse-quences associated with the occurrence would probably not haveoccurred or have been as serious; or (3) another contributing safetyfactor would probably not have occurred or existed. This defini-tion is based on a counterfactual conditional (i.e., if “A” did not hap-pen, then “B” would not have happened), which is a common wayof defining cause. However, the ATSB has expanded the definitionto more easily allow the reasoning process to move in steps fromone contributing safety factor to the next. This mechanism pro-vides a clearer basis for identifying organizational conditions ascontributory to an occurrence. The definition also specifically in-cludes the term “probably,” which the ATSB defines as meaning aprobability of 75% or more. This ensures that the standard of proofused in safety investigations is a practical compromise between a

low standard such as “on the balance of probabilities” (which couldproduce factors that may be considered weak by external parties)and a high standard such as “beyond a reasonable doubt” (whichwould usually produce few factors other than those involving tech-nical failures or the actions of flight crew).• Safety issue—is defined as a safety factor that (1) can reason-ably be regarded as having the potential to adversely affect thesafety of future operations and (2) is a characteristic of an organi-zation or a system, rather than a characteristic of a specific indi-vidual or characteristic of an operational environment at a specificpoint in time.

Not all contributing safety factors will be safety issues (e.g., pi-lot handling and fatigue during approach may contribute to a land-ing accident but are not safety issues). Similarly, not all safety is-sues will be contributing safety factors (e.g., an investigation mayidentify problems with an operator’s fatigue-management systembut cannot conclude that these problems probably contributed tothe flight crew’s fatigue). Accident and incident investigations havetraditionally focused on identifying the contributing safety factors,as this is of most interest to stakeholders, the news media, and thepublic. However, for safety-enhancement purposes, investigationsshould also focus on identifying safety issues, regardless of whetherthey can be demonstrated to have contributed to the occurrence.

Although the definition of contributing safety factor uses theterm “probably,” the definition is not the same as “probable cause.”In the ATSB framework, contributing safety factors are not rankedin terms of the degree to which such factors contributed to an oc-currence. If safety factors are to be ranked in any way, it should bein terms of the safety risk level for future operations: e.g., onlysafety issues should be ranked, and the ranking should be in termsof the risk level associated with the issue.

Accident development modelMany different proposals of models or theories exist of how acci-dents develop. Such models can play a useful role during an inves-tigation by helping investigation teams identify potential safetyfactors and by providing a framework for classifying safety fac-tors in a database. Unfortunately, some analysis methods provideno guiding model to assist with the identification of factors, whileother methods focus too much on a model and not enough on theidentification process.

In recent years, the ATSB and other safety investigation agen-cies successfully used the Reason Model of organizational acci-dents (Reason 1990, 1997) to guide the analysis phase of some in-vestigations. Although the Reason Model is widely accepted, someof its features limit its usefulness. The ATSB has adapted the Modelto better suit the requirements of safety investigation and to makethe Model more applicable to a wider range of investigations.

The primary changes to the Reason Model include broadeningthe scope beyond a focus on human factors, and to more functionallydefine the components of the model so as to reduce overlaps andconfusions when categorizing a factor. In particular, ATSB’s modelclearly distinguishes between the things an organization puts in placeat the operational level to minimise risk (i.e., “risk controls” such astraining, procedures, warning alarms, shift rosters) and the condi-tions that influence the effectiveness of these risk controls (i.e., “or-ganizational influences” such as risk-management processes, train-ing needs analysis processes, regulatory surveillance).

The resulting model can be arranged into a series of levels, as


Figure 1 Figure 2

Figure 3

shown in Figure 1. Representing the model in this format facili-tates the identification of safety factors, and can also help the in-vestigation team maintain awareness of their progress when iden-tifying potential factors during the investigation.

The analysis processA major part of the ATSB analysis framework is a defined processor workflow to be used when conducting analysis activities. Theoverall process is divided into five separate processes, each of whichcomprise a set of stages. The relationship between the below de-scribed five processes is shown in Figure 2.• Preliminary analysis: A range of activities to convert data into aformat suitable for the analysis of safety factors. This involves theuse of techniques to interpret and organize data, including the sys-tematic review of the sequence of events associated with an occur-rence. Preliminary analysis may require the use of arguments todevelop intermediate findings on a range of topics (e.g., angle ofimpact, handling pilot, wind speed during approach).• Safety factors analysis: A structured process to determine whichevents and conditions were safety factors, with an emphasis ondetermining the contributing safety factors and safety issues. Fur-ther information on safety factors analysis is provided below.• Risk analysis: A structured process to determine the risk levelassociated with any verified safety issues. This involves determin-ing the worst feasible scenario that could arise from the safetyissue and ranking the consequence and likelihood levels associ-ated with such a scenario. The resulting risk level is classified as“critical,” “significant,” or “minor.”• Safety action development: A structured process of facilitatingsafety action by communicating safety issues to relevant organi-zations. The nature and timeliness of the ATSB communication isdetermined by the risk level associated with the safety issue.• Analysis review: A review of the analysis results to identify gapsor weaknesses. This process involves checking the investigation find-ings for completeness and fairness. It also involves reorganizing thefindings into a more coherent format and sequence (if required).

As indicated in Figure 2, safety factors analysis is the heartof the analysis process. It consists of two main components:safety factor identification and safety factor processing. An over-view of safety factors analysis is presented in Figure 3.

During safety factor identification, potential safety factors are

identified by asking a set of generic questions about the occur-rence (based on the accident development model) and asking a setof focussed questions to explain specific factors. In some situa-tions, specialized techniques may also be useful to identify expla-nations for specific types of factors (e.g., barrier analysis, problemanalysis, failure mode effects analysis).

Safety factor identification activities start early in the investi-gation and are repeated at regular intervals until there is suffi-cient data available to conduct safety factor processing. Investiga-

tors are encouraged to use charting techniques to display the rela-tionships between potential factors and to regularly review the listof potential factors to determine if there may be critical safetyissues that need to be urgently addressed, as well as to determineneeds for additional data collection.

Safety factor processing focuses on each potential safety factorthat has been identified and selected for further analysis. This fur-ther analysis involves defining and testing the factor. Each veri-fied factor is then classified in the occurrence database. The finalstage is to ensure that, where possible, the factor has been poten-tially explained by other factors (i.e., a revision and extension ofsafety factor identification).

The “test” stage of safety factor processing is an area where theATSB framework has placed substantially more emphasis thanother analysis frameworks. For every potential safety factor thatis identified as needing further analysis, a series of tests are per-


(continued on page 29)

Figure 4

Process Tool Purpose

Preliminary Basic evidence Tests the supporting argument for aanalysis table non-safety factor finding

Sequence of Records summary data of key eventsevents list associated with an occurrence, and produces

various types of charts of this sequence

Safety factors Safety factors list Records summary data of potential safetyanalysis factors identified during the analysis

Safety factor form Records the results of the define, test, classify,and explain stages of safety factor processing

Safety factor Tests the supporting argument for a safety factorevidence table finding (built in to the safety factor form)

Risk analysis Risk analysis Records the results of each stage of a riskform analysis conducted on a safety issue

Safety action Safety action Records details of communications with externaldevelopment form organizations regarding a safety issue, as well as

any proposed or completed safety action

Analysis Summarize Reorganizes key findings of an investigationreview findings form into a more coherent format for the final report

(if required)

Table 1

formed to determine whether the factor can be “verified.” Thesetests include the test for existence, test for influence, and test forimportance. An overview of the flow of the testing process is pre-sented in Figure 4.

The result of the testing process will determine whether a po-tential safety factor is a contributing safety factor (existence plusinfluence), another safety factor of interest (existence plus impor-tance), or of no consequence to the investigation. The existenceand influence tests are based on concepts presented in an ICAOhuman factors document (ICAO 1998). However, the ATSB hasextensively expanded the guidance for conducting the tests. Forexample, to help conduct the test for influence, investigators areprovided guiding questions on the following criteria: relative tim-ing, reversibility, relative location, magnitude of proposed factor,plausibility, known history of influence, presence of enhancers,presence of inhibitors, characteristics of the problem (i.e., factorbeing explained), required assumptions, alternative explanationsfor the problem, and directionality of influence.

SIIMS analysis toolsSIIMS tools support each of the five analysis processes, as sum-marized in Table 1. The tools provide a broad level of guidancewhen conducting the analysis process. They also provide a meansfor the investigation team members to document their thoughtsand activities when doing analysis activities. This documented trailof reasoning is invaluable when reviewing the investigation or keep-ing track of its progress.

Evidence tables are a critically important part of the ATSB analy-sis framework. Before discussing these tables further, it is usefulto discuss the different types of findings produced by an investiga-tion. Borrowing a concept from the Canadian TSB, the ATSB hasstarted dividing the findings section of its investigation reportsinto three subsections:• Contributing safety factors (as defined in the section on stan-dardized terminology above).• Other safety factors: safety factors identified during the inves-tigation that did not meet the definition of contributing safety fac-tor, but which were still considered to be important (i.e., they passedthe test for importance).• Other key findings: any other finding considered relevant to in-clude in the findings section of the final report. This may includefindings to resolve ambiguity or controversy, and findings aboutpossible scenarios or safety factors when firm safety factor find-ings were not able to be made. It may also include positive safetyfactors or events or conditions that “saved the day” or played animportant tole in reducing the risk associated with the occurrence.

The intention of this format is to more clearly communicate theimportant safety messages from the investigation. In addition tothe “key findings,” an investigation may also develop a number ofintermediate findings (during preliminary analysis) to help facili-tate the process of moving from the collected data to a key finding.

In the past, investigators have not always clearly presented thesupporting arguments for their findings, other than in paragraphform in an investigation report. Such a format can be ambiguous,incomplete, and time consuming to finalize. The ATSB wanted in-vestigators to present their supporting arguments in a more struc-tured and understandable way prior to writing up the analysis sec-tion of a report.

Evidence table developmentThe traditional way of presenting arguments in the field of criticalreasoning is use a series of statements—premises followed by thefinding. Developing an argument in this format can be a difficultprocess, particularly when dealing with complex sets of data, orsituations where there are concerns regarding the credibility orrelevance of items of evidence. The ATSB developed the evidencetable to be a more flexible and easier-to-use format.

Basic evidence tables are used to test proposed “other key find-ings” and proposed intermediate findings. The tables consist ofthree columns: one for the items of evidence or information thatmay be relevant to the finding, one for clarifying comments abouteach item, and one for rating how the item may impact on the find-ing (i.e., supports, opposes, no effect, or unsure). Based on the in-formation in the three columns, an overall assessment can be madeas to whether the proposed finding is supported. A simple exampleof a basic evidence table is provided in Figure 5. In SIIMS, inves-tigators will also be able to provide links to supporting evidence in


(This article was adapted, with permission, from the author’s pre-sentation entitled Industry Working Group for Enhancing theInvestigation of Human Performance Issues, presented at theISASI 2006 seminar held in Cancun, Mexico, September 14-17,which carried the theme “Incidents to Accidents: Breaking theChain.” The full presentation including cited references index ison the ISASI website at www.isasi.org. Dr Mumaw’s paper re-ceived “special commendation” by the panel selecting the “Best inSeminar” paper. The panel said the paper “represented a great,practical development for investigators….”—Editor)

Each new or revised summary of accidents and incidents incommercial aviation reemphasizes the significance of the roleof humans. Accidents attributed to failures in airplane sys-

tems have decreased over the years as those elements have be-

come more reliable. Flight crews, maintenance technicians, air traf-fic controllers, airplane system designers, and others are identi-fied as significant contributors to an event 60-70% of the time (e.g.,see Boeing annual statistical summary as one index: http://www.boeing.com/news/techissues/pdf/statsum.pdf).

In fact, even in cases where there are failures in airplane sys-tems that precede a tragedy, accident investigations have revealedthat human performance contributed to degraded system perfor-mance. This is not only true in commercial aviation; mishaps inother highly complex sociotechnical systems also reveal the im-portant role of humans in the accident chain. This influence on theaccident chain may have links to system design, operational proce-dures, training, and organizational policies and practices.

To “break the chain,” we need to become even better at under-standing and addressing issues in human performance (HP). Mypersonal accident investigation experience, and the experience ofseveral colleagues at Boeing, suggests that approaches to investi-gating HP issues around the world can vary widely and are some-times ineffective.

To understand the current situation better, a small research teamat Boeing surveyed major accident investigation agencies to docu-ment their approaches to HP issues in accidents and incidents.Below are some key results from this survey, after which is de-scribed a proposed response to the current situation—specifically,the establishment of an industry working group to develop betterguidance for investigating human performance.

Current practiceTwelve groups were interviewed (those listed below plus a majorairline) to attempt to establish the current state of investigatingHP issues (note that there is a mix of commercial aviation andother modes of transportation):• Air Accidents Investigation Branch (UK),• Railway Safety & Standards Board (UK),• National Air Traffic Services (UK),• National Transportation Safety Board (USA),• Bureau d’Enquêtes et d’Analyses (France),• Bundesstelle für Flugunfalluntersuchung (Germany),• Transportation Safety Board (Canada),• Civil Aviation Department (Hong Kong),• Aviation Safety Council (Taiwan),• Australian Transport Safety Bureau, and• Transport Accident Investigation Commission (New Zealand).

Each interview covered a range of topics, including the following:• The framework used for addressing HP issues.• Existing guidelines, checklists, and procedures used for investi-gating HP issues.• Types of HP expertise available to them.• How they assign HP specialists to investigations.

Dr. Randy Mumaw is a human factors special-ist and associate technical fellow in the AviationSafety Group at Boeing Commercial Airplanes.Dr. Mumaw received his M.S. and Ph.D. incognitive psychology from the University ofPittsburgh. He has studied human performanceand safety in nuclear power plant control room

operations, air traffic control, and military and commercialaviation. He is the author of more than 80 technical papers,most of which address human performance and error incomplex, high-risk systems.

Enhancing theInvestigationOf HumanPerformanceIssuesAn industry working group is formed todevelop better guidance for investigatinghuman performance.By Dr. Randall J. Mumaw, Aviation Safety, Boeing


• HP-related data-gathering techniques.• HP-related analysis techniques.• How HP accident data are structured for input to an accidentdatabase.• What gaps have been identified in investigating HP issues.

The following are summaries of the findings for two of theseissues: HP expertise and HP guidance materials.HP expertise and training—One question concerned the numberof investigators or staff formally trained as HP experts. More spe-cifically, we identified the number of people with an M.S., M.A., orPh.D. in a human factors-related (HF) field of study. The result—

0 HF investigators 5 agencies1 HF investigator 1 agency4 HF investigators 2 agencies6 HF investigators 2 agencies10 HF investigators 2 agencies

The above shows that responses varied considerably. While therewere five agencies that had no investigators trained in an HF field,there were two agencies that each had 10 people with HF training,and another two with six HF investigators. Those agencies that haveno HF expertise in house often hire consultants with that expertise.However, our investigation experience also indicates that agenciesthat may not have a full-time existence (but come together when anaccident occurs) may have no ready access to this type of expertise.

What types of training do agencies provide their investigatorson HP issues? Most agencies reported that all investigators re-ceive some HF-related training. For four agencies, the HF train-ing is part of a broader investigation course. Four other agenciesexpose each investigator to a dedicated HF course (usually a weekin length). The remaining four agencies have no HF training thatis required of all investigators; instead, a few investigators mayget some HF training. So, the overall picture is a mixed bag—some pockets of strong HP expertise and other agencies with littletraining or in-house expertise.HP guidance documents—A key question concerned the proce-

dures that agencies have in place to guide the investigation of HPissues. Guidance can take many forms; for example, checklists(types of data to collect, HP issues to consider); methods/techniquesfor data gathering; a framework for identifying important actions,decisions, and conditions; a system for classifying human errors;methods for identifying contributing factors that may have influ-enced performance; or analysis techniques.

The responses spanned a wide range. Four of the 12 investiga-tion agencies had no guidance documents at all for HP investiga-tions. Four agencies had one or more checklists (typically one) thatinvestigators could use for identifying potentially important issues.The remaining four agencies actually had an accident investiga-tion manual or a general guidance document that aided them ininvestigating HP issues.

Interestingly, there was more development of guidance for agen-cies that had more expertise. We believe that the reason for thisfinding is that the expertise is required to develop the guidance.Agencies with no expertise are unable to develop the types of guid-ance that could benefit their investigators, and they are unable toobtain guidance from other sources.

One potential solution to this apparent dilemma is to get guid-ance from an outside source. However, when we looked at potentialsources—the ICAO HF Digest (ICAO 1993) and several recent bookson the topic (Dekker 2002; Strauch 2002)—we found little guidancethat could be readily adopted by an investigation agency.

The ICAO document provides guidance at a very high level andfocuses on the checklist from the SHELL Model. Strauch’s bookprovides some background knowledge on a number of potentiallyrelevant topics (e.g., computer displays) but little in the way ofguidance for conducting an investigation. He does offer some prac-tical guidance for various aspects of field work. The Dekker bookfocuses on describing inappropriate ways to conduct an investiga-tion but offers little guidance on conducting an investigation.

Thus, there are several agencies with strong skills in HP inves-tigation that are leading the way in defining how to conduct an HPinvestigation: what questions to ask, what data to collect, how toframe the data and identify the underlying causes, etc. In addition,there are investigation agencies outside of aviation (e.g., nuclearpower) that are also establishing more detailed guidance, espe-cially in the area of organizational factors. Unfortunately, the workof these few groups is not easily conveyed to other agencies thatlack HP expertise.

Boeing responseOur data gathering reinforced our beliefs that• HP expertise exists primarily within the larger investigationagencies and is not readily acquired from a consistent source whenit is needed. Those with training both in accident investigation andHP issues are too rare for today’s needs.

Four of the 12 investigation agencieshad no guidance documents at allfor HP investigations. Four agencieshad one or more checklists (typicallyone) that investigators could usefor identifying potentially importantissues. The remaining four agenciesactually had an accident investigationmanual or a general guidancedocument that aided them ininvestigating HP issues.


• HP guidance is either insufficiently detailed or is being devel-oped within the agencies that have the most expertise (and it is notformally shared outside of that agency).• There is no shared framework across agencies for understand-ing and describing HP issues; the Reason (Swiss cheese) Modelhas been influential but falls short of creating a unifying approach.Without this shared framework, the findings from individual acci-dents cannot be easily compiled and analyzed as a set.

The initial Boeing response was to begin developing the HP in-vestigation guidance that most agencies are missing. We laid out aplan to develop a set of individual modules on specific HP topics.These modules would cover a range of topics—• Data-collection techniques (e.g., cognitive interview).• Human performance issues (e.g., spatial disorientation).• Factors that contribute to human performance problems (e.g.,fatigue, stress).• Analysis techniques (e.g., speech frequency analysis).• Safety-assessment techniques (e.g., barrier analysis).

Each module would provide a brief background on the issueand then lead into practical guidance for investigators on tech-niques, references for more information, names of experts in thearea, and training that is available. We targeted each module toabout five pages; the idea was to have a quick, easy-to-use refer-ence document for investigators on key HP topics.

Further, we wanted to ensure that the topics covered were tiedto actual performance data—that is, areas in which there are dataon the effects of a factor on human performance. For example,quite a bit is known about how inadequate sleep affects task per-formance. By limiting our topics to those that can be backed upwith data, we hope to avoid the speculative arguments made aboutwhat “may have” influenced actions and decisions. This is not tosay there is no place for speculative arguments when there is littlehard data about performance, but this type of account needs to beclearly labeled as such.

Industry working groupAs we proceeded with module development, we realized that itwas important to create guidance that would be acceptable to allmajor stakeholders in commercial aviation accident investigation.Expertise is distributed across these stakeholders, and a consen-sus position is required to make a significant change to industrypractice. These stakeholders include the following:• Airplane manufacturers.

• Accident investigation agencies.• Aviation regulators.• Those representing the people who may be “blamed” (pilots,ATC, maintenance technicians).• Airlines.• Aviation safety organizations.• Training organizations.

Therefore, we turned our attention to organizing stakeholderrepresentatives to develop an industry solution to this problem.We started by seeking and being granted sponsorship from ISASI.ISASI appointed Capt. Dick Stone as the ISASI chairman of anindustry working group; Capt. Stone has since added an advisoryboard that, under Capt. Stone, will approve our development planand review guidance material before it is distributed. The Grouphas been named the ISASI International Working Group on Hu-man Factors (IIWGHF).

The next step was to bring together the HP expertise in theindustry. We have a team of 10 human factors professionals withaccident investigation experience who are continuing to developguidance modules. This team will work with a set of reviewers (in-dustry representatives) who will make an early evaluation of amodule to ensure that it is fair and useful for the work of investiga-tors. Through a number of review-and-rewrite cycles, we hope toproduce a significant set of guidance modules that we can thenpackage and distribute through ISASI.

Another potential role of the IIWGHF is to put forward posi-tion statements that can establish a standard on how HP issuesshould be investigated. There are a number of potential issues tobe addressed here. An example being considered is the following:• The collection of human performance data should not be seenas implying that human error is a working hypothesis for the in-vestigation. Initial interviews of operational personnel involved inthe accident or incident (e.g., pilots, air traffic controllers, mainte-nance technicians) should be conducted in a way to maximize theretrieval of information about the event; they should not focus onfinding fault with the actions taken or decisions made.

As of this writing, the IIWGHF is just ramping up. We plan todeliver a number of guidance modules by mid-2007. After a core setof materials is developed and approved, we will use ISASI to dis-tribute the materials to key industry stakeholders. If these materi-als achieve a good level of acceptance within the industry (and per-haps within other areas of accident investigation), they will start toshape how investigations are conducted and reports are written.Ideally, we will eventually establish a well-defined set of expecta-tions about the policies and practices of HP investigations. ◆

(Acknowledgments: Many thanks to the following Boeing peoplewho made significant contributions to this project: Simon Lie,Hans-Juergen Hoermann, Richard Kennedy, and Rich Breuhaus.)

By limiting our topics to those that canbe backed up with data, we hope toavoid the speculative arguments madeabout what “may have” influencedactions and decisions.


(This article was adapted, with permission,from the authors’ presentation entitled Fail-ure Analysis of Composite Structures in Air-craft Accidents , presented at the ISASI 2006seminar held in Cancun, Mexico, Septem-ber 11-14, which carried the theme “Incidentsto Accidents: Breaking the Chain.” The fullpresentation including cited references indexis on the ISASI website at www.isasi.org. Thispaper received “special commendation” inthe seminar’s “Best in Seminar” screen-ing by the selection panel. The panel saidthe paper “helped many investigators tobetter understand the nature of compos-ite failure in aircraft structures—a grow-ing area of interest within civil and mili-tary aviation.”—Editor)

Composites are not new. Compositestructures have been developed andused for military aircraft for more

than 50 years. Composite aircraft have beencommercially available to homebuilders fordecades. Even an all-composite spacecraft,SpaceShipOne, has flown to space with re-petitive success. Continuing with this his-tory, aircraft structures of the current de-cade are progressing through a major tran-sition from metallic structures to composite

structures, similar to the transition fromwood to metal in the 1920s.

Historically reserved for control surfacesand secondary structures, composites arenow being employed for primary structuresin major aircraft programs. The airframeof the Boeing 787, currently scheduled toenter service in 2008, will be approximately50% composite structure by weight, withnearly 100% of the skin, entire sections ofthe fuselage with integral stiffeners, and thewing boxes constructed of composites. Thiscan be compared to the Boeing 777, whichentered the market just more than a decadeago with an airframe of 10% compositestructure by weight. Powering the B-787will be the GEnx turbofan engine with fanblades and containment casing made ofcomposites, rather than traditional metals.

The Airbus 380 is scheduled to enter ser-vice in the coming year with an airframethat is approximately 25% composite struc-ture by weight. One notable feature of theA380 is an all-composite central wing box.Complementing this transition in the largetransport market are the all-composite air-frames for very light jets, such as the AdamA700 and parallel advances with militaryaircraft. The F-22, for example, contains

Dr. Joseph Rakow is anengineer with ExponentFailure AnalysisAssociates, a leadingscientific and engineer-ing consulting firm. Hespecializes in aeronauti-

cal structural engineering, structuralfailure, and the design of mechanicalcomponents. Dr. Rakow’s work hasaddressed products, failures, andinitiatives of a variety of commercial andgovernment organizations. He has

published a number of articles inscientific journals and frequently speaksat international conferences.

Dr. Alfred Pettinger is a managingengineer with Exponent Failure Analy-sis Associates. He specializes in theevaluation and design of metal as well ascomposite aerospace components. Dr.Pettinger has been retained in numerousaccident investigations and designreviews for transportation-categoryaircraft. (Photo not available)

Failure Analysis of CompositeStructures in Aircraft AccidentsThe authors introduce some of the basic concepts involved in analyzingfailed composites under a variety of fundamental loading conditions suchas tension, compression, bending, impact, and fatigue.By Joseph F. Rakow, Ph.D., P.E. (AO4926), Engineer, Exponent Failure Analysis Associates, andAlfred M. Pettinger, Ph.D., P.E., Managing Engineer, Exponent Failure Analysis Associates

Historically reserved forcontrol surfaces andsecondary structures,composites are now beingemployed for primarystructures in major aircraftprograms.


approximately 60% composite structure,compared with slightly more than 20% forthe F/A-18C/D, which entered productionjust a decade earlier.

With the increased use of composites inprimary structures, accident investigatorswill likely encounter failed composite struc-tures with increasing frequency in the com-ing decades, and these structures may beprimary structures of significance to the in-vestigation. Why may these composite struc-tures fail? First, we are building compositestructures on a scale never before achieved.The B-787 fuselage will be the largest com-posite pressure vessel ever built. Second, weare building composite structures throughrelatively new, automated techniques ratherthan relying on traditional methods of con-structing composites by hand (conversely,automation will eliminate some sources oferror associated with traditional construc-tion methods). And third, our inspection andmaintenance requirements will no longer bedriven by fatigue and corrosion performance,as they are for metallic structures, becausecomposites are not as susceptible to thesefailure mechanisms (accidental subsurfacedamage and subsequent failure progressionwill be more important).

These advances, a collective departurefrom applications, techniques, and methodsof the past, may lead to landmark lapses insafety with subsequent “lessons learned”for composites, in the manner that theComet accidents provided lessons learnedregarding stress concentrations and metalfatigue and Aloha Airlines Flight 243 pro-vided lessons learned regarding aging air-

craft structures and multiple-site damage.Through more than 80 years of accidentsinvolving metallic aircraft, the communityof aircraft accident investigators has devel-oped a considerably mature understandingof failure in metallic structures. This ac-crued knowledge and experience must beextended to composite structures.

This article is intended to contribute tothat effort by introducing some of the basicconcepts of failure in composite structuresas a result of a variety of loading conditions—tension, compression, bending, impact, andfatigue. The analysis is frequently discussedwith respect to corresponding failures inmetallic structures. Select failure character-istics are then illustrated through a discus-sion of the failure of the composite verticalstabilizer of American Airlines Flight 587.

Examination of failed metallicstructuresThe science and art of analyzing failed me-tallic structures has matured in part as aresult of the analysis of accidents involvingmetal aircraft. Employing knowledge ac-crued during this period of time, investiga-tors often rely heavily on their ability toanalyze failed structures in an effort to de-termine the cause and events of an accident.Some investigators, such as M.P. Papadakis,S. Taylor, and B.W. McCormick, have em-phasized the role of such analysis as “Thebent metal speaks.” “The story is writtenin the wreckage.” “You have to learn howto read the bent metal.”

This article refers to the evidence con-

tained within the wreckagein two categories—macro-structural evidence and mi-crostructural evidence.Macrostructural evidencerefers to the overall defor-mation of failed struc-

tures—a buckled fuselage panel, a twistedpropeller blade, a dented leading edge. Fig-ure 1 shows an example of macrostructuralevidence, deformation of the spinner, verti-cal stabilizer, and leading edges.

The value of macrostructural evidence infailed metal structures is enhanced by thefact that typical aircraft metals, such as alu-minum, are ductile, which means they un-dergo significant deformation prior to finalfailure. Ductility allows for the permanentbending, twisting, and denting of structures,which essentially records evidence of eventsin the accident. The evidence contained inFigure 1 (deformation of the spinner, verti-cal stabilizer, and leading edges) immedi-ately identifies impact as a factor in thisaccident. The evidence also identifies thepossible size, shape, and energy associatedwith the impactor or impactors. Accordingto the NTSB, this aircraft impacted a set ofpower lines on approach (NTSB 1995).

Ductility in metals provides macrostruc-tural evidence in a variety of ways. Onemethod for determining whether a jet en-gine was powered at the time the aircraftimpacted the ground is to examine the fanblades. Metallic fan blades of a poweredturbofan will generally bend upon impactin a direction opposite the direction of rota-tion. This deformation can reveal whetherthe engine was powered at the time of theaccident. Another example is the deforma-tion produced by an explosion occurringinside a metallic fuselage. The bulging offuselage panels, the curling of ruptured

Figure 1 (the 3 photos above). Theductility of metal structures providesmacrostructurally visible informationregarding an accident (Wanttaja 1994).

Figure 2. Indications offatigue cracking in thelower right wing spar capof the Chalks OceanAirways GrummanMallard G73 that crashedduring takeoff Dec. 19,2005. This is an exampleof using accumulatedknowledge and experi-ence with metallicstructures to identifypotential factors in anaccident (NTSB 2005).


wing spar cap reveals beach marks, whichis evidence widely accepted to be indicativeof fatigue failure. As a result of this estab-lished analysis, the microstructural evi-dence, supported by an accrued body ofknowledge regarding the interpretation offracture surfaces in metals, rapidly estab-lished the wing spar cap as a critical com-ponent to consider in this investigation.

The analysis of failed composite structurescannot rely solely on the knowledge and ex-perience accrued for metallic structures. Theanalysis of failed composite structures in-volves terms such as fiber pullout, delami-nation, and interfacial failure. These termsdo not even exist in the analysis of failedmetallic structures. These and other rudi-mentary elements of knowledge must beunderstood by accident investigators in or-der to analyze failed composite structures.

Examination of failedcomposite structuresTransitioning from failed metallic struc-tures to failed composite structures re-quires, in many ways, a new mindset. Al-though composites are often considered tobe materials and are generally classified asengineered materials, composites are actu-ally structures, made of multiple materials.Typical aircraft composites are made of twomaterials: (1) long fibers that are stiff andstrong (typically carbon or glass) and (2) amatrix, essentially hardened plastic glue,that holds the fibers together. The glued fi-bers are typically assembled layer by layer,called plies. The fibers in each ply typicallyrun parallel to each other or are woven to-gether in the manner of a textile. Ply-wisevariations in fiber orientation and othervariables often exist in a composite.

In contrast to typical aircraft metals, thephysical properties of composites vary from

Figure 3. Tension failure in composites.Macroscopically, even simple tension canproduce fractures with a wide variety offeatures. Microscopic analysis becomesimportant (Ginty and Chamis 1987).

edges away from the explosion, and thestretching and unzipping of panels alongrivet lines all indicate the presence of anexplosion in an accident.

Typical aircraft composites, however, arenot ductile; they are brittle, which means theyundergo relatively minor permanent defor-mation prior to final failure. Without ductil-ity, without permanent deformation, the mac-rostructural evidence from an accident, suchas the examples discussed above, may nolonger be available. What evidence would beproduced by a GEnx engine, with its compos-ite fan blades, impacting the ground? Whatevidence would be produced by an explosioninside a B-787 composite fuselage?

With changes in macrostructural evidenceassociated with the loss of ductility in brittlestructural materials, the analysis of micro-structural evidence becomes paramount.Microstructural evidence refers to local de-formation and damage in the structure, suchas fracture surfaces, that typically requireclose visual or microscopic analysis. To in-terpret microstructural evidence in failedmetallic structures, investigators rely upona well-established and widely used body ofknowledge, which has, in the past, often pro-vided rapid and insightful results.

One example is the recent crash of ChalksOcean Airways Flight 101 in December2005 off the coast of Miami, Fla. Initial evi-dence indicated that the right wing hadseparated in flight. Within days, the NTSBhad identified fatigue damage in metallicstructural components in the right wing(Figure 2), with corresponding damage inthe structure of the left wing. As shown inFigure 2, an unaided visual inspection of the

Figure 4. Example of fiberpullout as a result of tensileloads (Friedrich and Karger-Kocsis 1989).

Transitioning from failedmetallic structures tofailed compositestructures requires, inmany ways, a newmindset.


location to location, and their response to loadsusually varies with the direction in which theload is applied. Composites can respond toloads in ways aircraft metals cannot. A simpletensile load, for example, can cause a compos-ite to twist; a simple twisting load can cause acomposite to bend. While designers know of,understand, and can predict these phenom-ena, accident investigators must be able torecognize and reconstruct them.

Composites have design variables thatare not available in metals. Some of thesevariables are fiber orientation, fiber-to-ma-trix volume ratio, ply thickness, and plystacking sequence, among others. With newvariables come new opportunities for manu-facturing errors or imperfections. Some ofthese imperfections are fiber waviness, pooradhesion between fibers and matrix, pooradhesion between plies, excessive voids inthe matrix, and an improperly cured ma-trix, among others. Changes in design vari-ables and accumulated imperfections di-rectly affect the failure of a composite.

As an example, consider Figure 3, whichshows 20 failed composite specimens. Eachspecimen was subjected to simple tensileloading. Despite the similarity in loading,the failure in each specimen has a uniqueappearance. Some of the failed specimenshave a shredded appearance with a veryrough fracture surface; some of the speci-mens have a smoother, angular appearance.Some specimens even broke into severalpieces, while others broke into only two.

The differences in the appearance of thesefailures are a result of two primary sourcesof variation among the specimens. The firstsource of variation is the intentional varia-tion in design variables among the speci-mens, such as fiber orientation. The secondsource of variation is the accumulation of im-perfections, as discussed above. The result

is that these composites, all of which failedin tension, demonstrate a wide variety ofappearances. This is one of the challenges ofanalyzing failed composites. In many cases,this challenge can be addressed by perform-ing a microscopic analysis of the failure sur-faces to identify common features that indi-cate failure in tension. These features, alongwith features associated with other loadingconditions, are introduced below.

TensionTensile fractures of fibrous composites typi-cally exhibit common characteristics thatcan help identify failure under tensile loads,even in the presence of large variations inthe macroscopic appearance. One charac-teristic is that the fracture surface gener-ally has a rough appearance, as can be seenin the failed specimens in Figure 3.

Figure 4 shows a microscopic view of afracture surface of a composite that failedunder tensile load, with the fibers alignedwith the direction of the load. One clear char-acteristic of the fracture surface is that frac-tured fibers are sticking out of the fracturedmatrix, contributing to the rough appearanceof the fracture surface. Called fiber pullout,this characteristic is a typical indication oftension failure in a composite. Fiber pulloutis the result of a fiber breaking and beingextracted from the matrix. Close inspectionof Figure 4 reveals, in addition to pulled-out

fibers, holes in the matrix that were createdby other pulled-out fibers.

In some cases of tensile failure, the fibersdo not completely fracture and only the ma-trix completely fractures. The fibers thenspan the matrix fracture in a phenomenoncalled fiber bridging. In either case, the in-vestigator can use the pulled-out fibers toidentify tensile loading, and in the case ofstacked laminates, identify those plies thathave been loaded in tension. The length ofthe pulled-out fibers can indicate importantconditions present in the composite at thetime of fracture, such as temperature, expo-sure to moisture, and rate of loading.

As long, thin members, the fibers are de-signed to carry tensile loads, and compos-ites are nominally designed such that the fi-bers run parallel to the tensile loads. How-ever, in the common case of composites withply-wise variations in fiber orientation, ten-sion loads do not run parallel to the fibers,and failure can occur in the matrix. Commonmatrix failures associated with such loadingconditions are tension failures between fi-bers, particularly at the fiber-matrix inter-face, and shear failures in the matrix-richregion between plies, typically associatedwith rough features on the fracture surfacecalled hackles. Such inter-ply shear failurescan also be produced under compression.

CompressionUnder compression, the fibers are structur-ally less effective than they are in tension.One common characteristic of the compres-

Figure 5. (right) Example offiber kinking as a result ofcompressive loads (Bolick

et al 2006). Figure 6.(below) Chop marks can be

produced on the ends ofbroken fibers that have

buckled and failed undercompressive loads

(Stumpff 2001).

Figure 7. (above) Composite specimenthat failed in bending. The relativelyrough area of tension failure and therelatively smooth area of compressionfailure are clearly identifiable (Beaumontand Schultz 1990).


sive failure of fibrous composites is the for-mation of kink bands, as shown in Figure 5.Kink bands are a result of structural insta-bility, much like a person standing on andeventually crushing a soda can. The fibersbuckle as the compressive load approachesa critical level, which is primarily a functionof material and geometric factors.

Fiber buckling can also be identified byexamination of the fiber ends. As shown inFigure 6, chop marks indicate fibers thathave buckled and have bent to failure. Thechop marks coincide with the neutral axis ofthe fiber in bending, separating the tensionside from the compression side of the fiber.

Often associated with kink bands is ma-trix splitting, which can be seen in Figure 5as gaps in the matrix. Matrix splitting oc-curs at weak points in the matrix or at ar-eas of high stress concentration, such as atthe fiber-matrix interface and the interfacebetween plies. Matrix splitting at the inter-face between plies is referred to as delami-nation and is discussed further in the para-graphs below regarding impact.

BendingThe difference between tensile and compres-sive fracture surfaces is readily demon-strated in composites that have failed inbending, such as the specimen shown in Fig-ure 7. Divided by a neutral bending axis, onepart of the fracture surface contains pulled-out fibers and the other part is relatively flat.This is a result of the fact that, in bending,one part of the cross-section is in tension andthe other part is in compression.

The characteristics of bending failurecan readily translate to a macroscopic level.Figure 8 shows a composite aircraft wingthat has reportedly failed in bending(Stumpff 2001). The bottom surface of thewing, which was subjected to tension in

bending, has a very fibrous texture relativeto the top side of the wing, which was sub-jected to compression in bending.

ImpactAs discussed above, ductile metal structuresundergo relatively high levels of permanentdeformation prior to final failure, and thisdeformation provides information regard-ing the events preceding structural failure.The metallic aircraft discussed above andshown in Figure 1 clearly indicates impactby a foreign object. Since composites, on theother hand, exhibit relatively little perma-nent deformation prior to final failure, suchimpact evidence may not be as readily ob-served in a composite aircraft.

Impact loading can cause damage to acomposite without any visible evidence on thesurface. Consider an aircraft mechanic drop-ping a wrench on the top surface of a wing.If the wing is made of aluminum, the impactmay leave a dent, essentially recording theimpact and providing some rudimentary in-dication of the significance of the resultantdamage. If the wing is a composite, the im-pact of the wrench may produce local crush-ing of the fibers and matrix or it may notproduce any damage on the surface at all. Ineither case, the level of damage below thesurface of a composite can be much moreextensive than that indicated on the surface.

One common type of sub-surface dam-age from impact is delamination. A delami-nation is a split between plies in a compos-ite. The split can propagate along the inter-

Figure 8. (right) Com-posite wing that

reportedly failed inbending. The relatively

rough area of tensionfailure with significant

fiber pullout, and therelatively smooth areaof compression failureare clearly identifiable

(Stumpff 2001).

Figure 9. (right) Exampleof composite failure in-

volving delamination (Bas-com and Gweon 1989).

Figure 10. (right above)Striations at the interfacebetween fibers and matrix

(Stumpff 2001).

Impact loading can causedamage to a compositewithout any visibleevidence on the surface.


face at which neighboring plies were joinedduring manufacturing or it can propagatealong the fiber-matrix interface. Figure 9shows a couple views of the cross-section ofa composite plate after impact.

As indicated in the figures, the impactcaused extensive delamination among mul-tiple plies. Such damage can dramaticallydegrade the load-bearing capability of thecomposite even though the fibers may re-main intact. Moreover, the damage, if un-noticed, can continue to propagate uponfurther loading of the composite.

Without visible evidence on the surface,delaminations must be identified by cross-sectioning the composite in the location ofthe delamination or by employing non-de-structive techniques such as ultrasonics orX-ray tomography. If destructive tech-niques are employed, delaminations may beidentified visually. In graphite-epoxy com-posites, delaminations can be identified bya dull, whitish appearance, relative to theshiny, black appearance of neighboring ar-eas free from delamination.

FatigueOne of the attractive qualities of compositesis that they generally have better fatigueperformance than typical aircraft metalssuch as aluminum. Despite this fact, compos-ites can fail under fatigue loading and suchfailures result in identifiable failure features.

Fatigue failure in metals can be readilyidentified, in many cases, by an unassistedvisual inspection. A typical fatigue failurein metals will produce a fracture surface

with beach marks, an example ofwhich was already discussed and shown inFigure 2. Fatigue fracture surfaces in com-posites, on the other hand, do not typicallyhave visible beach marks. In fact, fatiguefractures in composites typically do not ap-pear any different from a correspondingoverload failure.

While fatigue fractures lack macroscopicevidence, some evidence may be identifiedmicroscopically. Figure 10 shows striationsat the fiber-matrix interface of a composite.

One striation typically corresponds to oneload cycle. Although these striations indicatefatigue failure, they can be difficult to find.Areas containing striations are typicallysmall in size, few in number, and may be dis-persed over multiple locations in the com-posite. In addition, the striations are oftenidentifiable only under high magnificationand oblique lighting (Figure 10 was capturedunder a magnification of 2000x). In short, theidentification of fatigue failure in compositescan be very challenging. One macroscopicfeature that can provide evidence of fatigueis abrasion between mating fracture sur-faces. With repeated loading, the growingfracture surfaces may rub against each otherand leave abrasive marks on the ends of bro-ken fibers and in the matrix.

American Airlines Flight 587Soon to be eclipsed by the center wing boxof the A380 and the fuselage of the B-787,the vertical stabilizer of the Airbus A300-600 is one of the largest composite primarystructural elements in commercial aviation.

Figure 11. (above) Along with several other fractures, the fractures ofthe right aft lug were rough, consistent with tensile loading (NTSB

2002). Figure 12. (right) Fractures in multiple locations exhibited chopmarks (marked with a “c”) on the ends of fractured fibers, consistent

with compressive loading and buckling of fibers (NTSB 2002).

Although the structure was originally de-signed with metallic materials, the metallicdesign was eventually replaced by a com-posite design employing carbon fibers in anepoxy matrix. Since that time, the compos-ite stabilizer has accumulated more than 20years of service. In November 2001, Ameri-can Airlines Flight 587’s composite stabi-lizer failed. As a potential harbinger of thefailures discussed in this article, the failureof this composite structure is discussed inthe paragraphs below. The discussion fre-quently refers to the features of failed com-posites discussed above.

The vertical stabilizer of the A300-600 isattached to the fuselage by three pairs ofcomposite lugs—forward, middle, and aft—along the union between the stabilizer andthe fuselage. The lugs transfer bendingmoments applied to the stabilizer throughlarge-diameter bolts. Between each pair oflugs is a composite transverse load fittingthat transfers to the fuselage lateral loadsapplied to the stabilizer. Analysis of flightrecorder data by the NTSB indicates thatthe aircraft was subjected to a violentlychanging oscillatory sideslip motion, caus-ing loads in excess of the ultimate designloads of the stabilizer. The NTSB deter-mined that the right rear lug of the stabi-lizer suffered a tensile overload failurethat caused the progressive failure of theremainder of the attachment points.

As discussed above, tensile failures in com-posites generally produce rough fracture sur-faces. Figure 11 shows the fracture surface


Figure 13. Interlaminar fractures inmultiple locations exhibitedhackles, consistent with failure inshear (NTSB 2002).

of the right aft composite lug. Similar roughfracture surfaces were found on the other twolugs on the right side of the stabilizer. As aresult, the NTSB concluded that the lugs onthe right side of the stabilizer failed due tooverstress under tensile loading.

According to the analysis by the NTSB,after the lugs on the right side failed, the dam-aged stabilizer deflected from right to left,loading the lugs on the left side of the stabi-lizer in bending. In bending, tension developedon the inboard side of the lugs and compres-sion developed on the outboard side of thelugs. The NTSB identified evidence consis-tent with tension failure on the inboard sideand compression failure on the outboard sideof the lugs on the left side of the stabilizer.This is consistent with failure in bending.

As discussed above, when fibers are sub-jected to compressive loads, they can buckleand the fracture surface on the end of a failedfiber may indicate chop marks. The left aft,left center, and left forward lugs of the failedstabilizer each contained fractured fiberswith chop marks, as shown in Figure 12. Alsofound on the left aft lug were hackles associ-ated with shear failure in the matrix-richregion between plies (Figure 13). Hackleswere found on the left forward lug as well.

Evidence consistent with bending wasalso found in the aft transverse fitting. Frac-tures on the attachment points on the rightside of the transverse fitting were rough inappearance, indicating tensile failure, whilethe fracture on the left-most attachmentpoint had a relatively smooth appearance,indicating compressive failure. This evi-dence was found by the NTSB to be consis-tent with bending of the stabilizer fromright to left. Finally, it must be noted that

the NTSB did not find any indication of fa-tigue damage in the vertical stabilizer.

Looking aheadWith the impending generation of compos-ite aircraft, the analysis of failed compositestructures will be of significance to aircraftaccident investigators. The introduction ofcomposites presents new variables, such asfiber orientation, geometric variationsamong plies, and curing processes, whichin turn present new failure modes, such asfiber pullout, fiber kinking, and delamina-tion. Contributing to these relatively newconcepts is the prevalence of brittle failurein composites, as opposed to ductile failurein metals, and the potential reduction inmacrostructural evidence. Consequently,the analysis of failed composite structurescannot rely solely upon the body of accruedknowledge and experience related to failedmetallic structures.

This article has introduced some of thebasic concepts involved with analyzing failedcomposites under a variety of fundamentalloading conditions. Fractographic detailshave been presented and subsequently il-lustrated by a brief discussion of the analy-sis by the NTSB of the failed compositevertical stabilizer from American AirlinesFlight 587. With a broad range of associ-ated design variables, the investigation ofcomposite structural failures requires par-ticular expertise. It is likely that, given suchcomplexity, future investigations involvingcomposite primary structures will requiresignificant input from accident investigatorswith expertise in the analysis of failed com-posite structures, as was required in the in-vestigation of Flight 587. ◆

With a broad rangeof associated designvariables, the inves-tigation of compositestructural failuresrequires particularexpertise.


ISASI ROUNDUP

Singapore AAIB Hosts ISASI 2007○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

ISASI 2007, the Society’s 38th annualinternational seminar, will be held inSingapore from Monday, August 27 toThursday, August 30. Hosted by the AirAccident Investigation Bureau ofSingapore (AAIB), the seminar will carrythe theme “International Cooperation:From Investigation Site to ICAO.”

Chan Wing Keong, seminar chairman,says that the seminar will follow theestablished format of past seminars, with1 day devoted to tutorial workshops and 3days of technical paper presentations.The technical program will addresscurrent safety and investigation issues,including recent air safety occurrencesand investigations, with particularemphasis on international cooperationefforts demonstrated during the variousinvestigative endeavors.

The issued “Call for Papers” seeksabstracts by March 31 with final elec-tronic submission in early July. Membersof the technical papers selection commit-tee include Chan Wing Keong (AAIBSingapore, chair), Michael Toft (AAIBSingapore), Caj Frostell, Jim Stewart,Keith McGuire, Ken Smart, Capt.Mohammed Aziz, Dr. Rob Lee, and Y.P.Tsang (Hong Kong CAD).

Tutorials to be presented are aftermathof a sea crash and investigation in alitigious environment. The tutorial daywill be held at the Singapore AviationAcademy. Arrangements have been madeto also provide tutorial participants a tourof the Academy’s excellent facilities,which received the 1996 Flight Interna-tional Aerospace Industry Award fortraining. In addition, the Academy waspresented the prestigious EdwardWarner Award by the ICAO Council in2000.

The venue for the seminar will be theSwissôtel The Stamford, Singapore, in acity that is billed as being dynamic andrich in contrast and color where one findsa harmonious blend of culture, cuisine,arts, and architecture. A bridge between

the East and the West for centuries,Singapore, located in the heart of fasci-nating Southeast Asia, continues toembrace tradition and modernity today.Singapore is slightly more than 3.5 timesthe size of Washington, D.C. Its climate istropical. The wetter northeast monsoonseason is from December to March, andthe drier southwest monsoon season isfrom June to September. Singapore isalso considered the Asia Pacific air hub, asit is connected to more than 180 cities in57 countries by more than 80 airlines withover 4,100 weekly flights. Singapore willbe a convenient gateway to the manyinteresting tourist destinations inSoutheast Asia, for example, Angkor Watin Cambodia, Bali and Borobudur inIndonesia, Langkawi and Malacca inMalaysia, and Cebu in the Philippines.

Registration for ISASI 2007 is ex-pected to open by March. Final details arenow being completed. It is expected thatregistration fees will be between US$400-500 and tutorial fees about US$80-100.Delegate registration will includebreakfasts, lunches, and morning/afternoon teas on the 3 days of theseminar, as well as the off-site visit/dinnerand the awards banquet. A CD-ROM ofthe technical papers will also be providedto the delegates.

The social program and the optionaltour scheduled for Friday are also beingfinalized and will be reported in the nextissue. ISASI 2007 went on line at presstime. It can be accessed atwww.isasi07.org. ◆

International CouncilMeets in CancunThe Society’s International Council metin Cancun on Sept. 10, 2006, in conjunc-tion with its 37th annual internationalseminar. Among its actions was accep-tance of a certified copy of the Societyelection ballot results (see page 24 of theOctober/December Forum, ) selection of

the venues for ISASI annual seminarsthrough 2010, adoption of a new humanfactors effort (see page 3 and 14), reviewof ISASI By-Laws revision, acceptance ofa comprehensive review of ReachoutProgram history and current status.Routine reports of Executive members,societies, and working groups andcommittees were also received.

Representatives of the SingaporeAAIB discussed preparations for ISASI2007. The Canadian Society’s bid to hostISASI 2008 in Halifax, Nova Scotia,Canada, was accepted as was Japan’sAircraft and Railway Accidents Investiga-tion Commission bid to host ISASI 2010in Sapporo, Japan. The ISASI FloridaRegional Chapter provided an update onits previously accepted bid to host ISASI2009 in Orlando, Fla.

Jim Stewart, chairman of theReachout Program, provided a compre-hensive review of the Program’s historyand its current status. He reported thatthere are now five instructors, theoriginal “core” of himself, Caj Frostell,and Ron Schleede, plus the recentaddition of Steve Corrie and Vic Gerden.Stewart and Corrie are now “ICAOcertified” SMS instructors.

Stewart said the goal of Reachoutremains getting accident investigationexpertise and the Society’s affiliation toparts of the world that are not affected byISASI’s annual seminar. The Programlength is tailored and has evolved into avariable length—from 2 days to 2 weeks.ICAO is committed to the Reachoutprocess. Program successes have beenwell noted on pages of the ISASI Forum.He stated that Reachout has, in general,exceeded initial expectations and urgedall the councillors and internationalofficers to participate.

In addition to a detailed roundup ofSociety activities since the last meeting,President Frank Del Gandio set the nextInternational Council meeting for May 4,2007, in the Washington, D.C., area to be


○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

held in conjunction with the May 3 MARCdinner and meeting.

Treasurer Tom McCarthy reported acurrent bank balance of $63,443.65 in theprimary CAP account. The ISASI RudyKapustin Memorial account has a balanceof $4,308.00. He also reported on the finalproceeds of ISASI seminars from 1997through 2005, which can be found on theappropriate section of the ISASI website.Mike Hynes, audit chair, reported that hisreview of accounting data for the years2004 and 2005, including an on-site reviewof ISASI records in 2006, showed that thedata reviewed reflected proper account-ing practices and successful managementof funds.

The full minutes of the September 10meeting are available to the membershipon the ISASI website: www.isasi.org. ◆

Kapustin ScholarshipIssues Application CallThe ISASI Rudolf Kapustin MemorialFund has issued its call for scholarshipapplications to universities and collegeswhose students are eligible to participatein the program, according to the Fund’sadministrators, ISASI Executive AdvisorRichard Stone and ISASI Vice-PresidentRon Schleede. The deadline for applica-tions is April 3, 2007.

The purpose of the Fund is to encour-

age and assist college-level studentsinterested in the field of aviation safetyand aircraft occurrence investigation.Applicants enrolled as full-time studentsin a recognized (note ISASI recognized)education program, whichincludes courses in aircraft engineeringand/or operations, aviation psychology,aviation safety and/or aircraft occurrenceinvestigation, etc., with major or minorsubjects that focus on aviation safety/investigation are eligible for the scholar-ship. A student who has received theannual ISASI Rudolf Kapustin MemorialScholarship will not be eligible to applyfor it again. This year the seminar will beheld at the Swissotel The Stamford,Singapore, August 27–31.

Continued funding for the MemorialFund is through donations, which in theUnited States are tax-deductible. Anaward of $1,500 is made to each studentwho wins the competitive writing require-ment, meets the application require-ments, and who registers to attend theISASI annual seminar. The award will beused to cover costs for the seminarregistration fees, travel, and lodging/meals expenses. Any expenses above andbeyond the amount of the award will becovered by the recipient. In addition, thefollowing are offered to the winner(s) ofthe scholarship.• A 1-year membership to ISASI.• The Southern California SafetyInstitute (SCSI) offers tuition-freeattendance to ANY regularly scheduledSCSI course to the winner of the ISASIScholarship. This includes the 2-weekaircraft accident investigator course orany other investigation courses. Travel to/from the course and accommodations arenot included. More information can befound at http://www.scsi-inc.com/.• The Transportation Safety Instituteoffers a tuition-free course for thewinner of the scholarship. Travel to/fromthe course and accommodations are notincluded. More information is available

Call for Papers—ISASI 2007The International Society of Air Safety Investigators Presents

its 38th International Seminar Aug. 27-30, 2007Swissôtel The Stamford, Singapore

Theme: “International Cooperation: From Investigation Site to ICAO”

The Technical Committee is looking for 20-30 papers on current investigation experi-ence, techniques, and lessons learned withparticular emphasis on international inves-tigation cooperation, coordination, andchallenges.

If you wish to offer a presentation inline with the seminar’s theme, please pro-vide a brief abstract (approximately 200words) plus personal details by March 31,2007. Please indicate in your abstract thekey points you wish the audience to takeaway with them from your presentation.

You are welcome to indicate your in-terest before you provide the abstract.

Selected papers should be providedin electronic format no later than July 5,2007. Please note that PowerPoint presen-tations are not acceptable for publicationin seminar Proceedings or seminar CDs.Submittal of an abstract implies an agree-ment that the author authorizes publica-tion of the complete paper in the seminarProceedings and the ISASI Forum.

Selected papers will be produced ona CD-ROM before the seminar com-mences. Please note that although a pre-senter may need to withdraw at short no-tice from a scheduled presentation, thewritten material will remain part of theCD-ROM if already produced.

Please send indication of interest and ab-stract to

Chan Wing KeongTechnical Program ChairE-mail: [email protected]: (65) 6541-2800

or mail to

Air Accident InvestigationBureau of SingaporeChangi Airport Post OfficeP.O. Box 1005Singapore 918155Republic of Singapore


Continued . . .

ISASI ROUNDUP

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

at http://www.tsi.dot.gov/.Last year, two awards were presented.

They went to Leonardo Ferrero,Politeenico di Torino, Italy, and Sheena D.McCune, Embry-Riddle AeronauticalUniversity, Florida, USA.

The Fund is administered by anappointed committee and oversight ofexpenditures is done by the ISASItreasurer. The committee ensures that theeducation program is at an ISASI-recognized school and applicable to theaims of the Society, assesses the applica-tions, and determines the most suitablecandidate(s). Donors and recipients willbe advised if donations are made in honorof a particular individual.

Students who wish to apply for thescholarship may acquire the applicationform and other information at the ISASIwebsite: www.isasi.org. Students may alsorequest applications by e-mail [email protected]. The ISASI officetelephone number is 1-703-430-9668.

Application requirements• Applicants must be enrolled as full-timestudents in a recognized (note ISASIrecognized) education program, whichincludes courses in aircraft engineeringand/or operations, aviation psychology,aviation safety and/or aircraft occurrenceinvestigation, etc., with major or minorsubjects that focus on aviation safety/inves-tigation are eligible for the scholarship.• The student is to submit a 1,000(+/- 10 percent) word paper in Englishaddressing “The Challenges For AirSafety Investigators.”• The paper is to be the student’s ownwork and must be countersigned by thestudent’s tutor/academic supervisor asauthentic, original work.• The papers will be judged on theircontent, original thinking, logic, andclarity of expression.• The student must complete theapplication form and submit it to ISASIwith the paper by April 3, 2007.

• Completed applications should beforwarded to ISASI, 107 Holly Ave., Suite11, Sterling, VA 20164-5405 USA. E-mailaddress: [email protected]; Telephone: 1-703-430-9668.• The Judges’ decision is final. ◆

Lederer AwardNominations SoughtThe ISASI Awards Committee is seekingnominations for the 2007 Jerome F.Lederer Award. For consideration thisyear, nominations must be received by theend of May, noted Committee chairman,Gale Braden

He added that “the purpose of theJerome F. Lederer Award is to recog-nize outstanding contributions totechnical excellence in accident investi-gation. The Award is presented eachyear during our annual seminar to arecipient who is recognized for positiveadvancements in the art and science ofair safety investigation.”

The nomination process allows anymember of ISASI to submit a nomination.The nominee may be an individual, agroup of individuals, or an organization.The nominee is not required to be anISASI member. The nomination may befor a single event, a series of events, or alifetime of achievement. The ISASIAwards Committee considers such traitsas duration and persistence, standingamong peers, manner and techniques ofoperating, and of course achievements.Once nominated, a nominee is consideredfor the next 3 years and then dropped.After an intervening year, the candidatemay be nominated for another 3-yearperiod. The nomination letter for theLederer Award should be limited to asingle page.

This award is one of the most signifi-cant honors an accident investigator canreceive; therefore, considerable care isgiven in determining the recipient. ISASImembers should thoughtfully review their

association with professional investiga-tors, and submit a nomination when theyidentify someone who has been outstand-ing in increasing the technical quality ofaccident investigation.

Nominations should be mailed ore-mailed to the ISASI office at 107 HollyAve., Suite 11, Sterling, VA 20164-5405USA. E-mail address: [email protected];Telephone: 1-703-430-9668.

Nomination may also be sent directly tothe Awards Committee Chairman, GaleBraden at 13805 Edmond Gardens Drive,Edmond, OK 73013-7064 USA; e-mailaddress, [email protected]. Home phone:1-405-359-9007, cell: 1-405-517-5665. ◆

Reachout ProgramContinues Winning WaysThe ISASI Reachout Program that beganin May 2001 with the goal of gettingaccident investigation expertise, as well asthe ISASI name, to parts of the world thatare not affected by the Society’s annualseminars ended its sixth year withcontinued success in its final two trainingworkshops, held in Larnaca, Cyprus, andJeddah, Saudi Arabia, according to reportsfiled by the two lead ISASI trainers, RonSchleede and Caj Frostell. Other recentsuccesses were recorded in India; SriLanka; Pakistan; China; and Helsinki,Finland (for the Nordic countries).

Schleede reported that the Air Acci-dent and Incident Investigation Board(AAIIB) of Cyprus hosted the 17th ISASIReachout Workshop, held on May 29-June 9. It was organized under theleadership of AAIIB Chairman Costas

In Memorium

Samuel E. Brodie (MO22504), Bakers-field, CA, USA

George D. Butler (Life Member 2831),April 10, 2006, Sun City, FL, USA

Capt. Harold R. Miller (Life Member0169), July 2006, Dallas, TX, USA

Frank T. Taylor (Life Member 2513),August 2006, Ellicott City, MD, USA

Frances M. Wokes (AO4025), Nov. 11,2006, Winnipeg, Manitoba

(continued on page 28)


○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

(Reprinted from Airliner Accident Statistics 2006, Jan. 1, 2007, with permission of Harro Ranter, Aviation Safety Network; Copyright1996-2007. Source of data is regulatory transportation safety boards, including ICAO, insurance companies, and regional news media.The full document is available on the ASN website, which can be accessed at http://www.aviation-safety.net/pubs.—Editor)

• The 2006 death toll of 888 was far below the 1986-2005 averagedeath toll of 1,088 casualties.

• The 2006 death toll of 888 was well below the 1996-2005 averagedeath toll of 1,005 casualties.

• The 2006 number of occupants involved in fatal airliner accidentsof 1,156 was lower than the 1996-2005 average of 1,379.

• The 2006 fatality rate (percentage of occupants killed in fatalairliner accidents) of 77% was slightly lower than the 1996-2005average of 79%.

• The 2006 number of 27 fatal airliner accidents was far below the1986-2005 average number of fatal airliner accidents of 43.2 peryear.

• The 2006 number of 27 fatal airliner accidents was far below the1996-2005 average number of fatal airliner accidents of 36.3 peryear.

• The 2006 number of accidents resulting in 100 or more fatalitieswas high: 4, which is the ninth highest number in aviation history.

• The 2006 number of 9 fatal jet airliner accidents was below the

1976-2005 average of 15.3 accidents per year.• The 2006 number of 18 fatal prop airliner accidents was lower

than the 1976-2005 average of 23.3 accidents per year.• The 2006 number of 0 fatal piston airliner accident was far be-

low the 1976-2005 average of 8.5 accidents.• The 2006 number of 0 fatal piston airliner accident was below

the 1996-2005 average of 2.9 accidents.

Statistical summary regarding fatal multiengine airliner accidentsThe year 2006 recorded 27 fatal airliner hull-loss accidents, causing 888 fatalities and 4 fatalities on the ground. Last year recorded the first Boeing 737NG written off in afatal accident. Around 1,700 Boeing 737-600, -700, -800 and -900 series have been built since 1997. Below, statistics shown in the following order: Date, Aircraft Type,Operator, Location, Fatalities.

Number of fatal airliner accidents per country [where the accident happened] 2006 (2005, 2004, 2003, 2002 in parentheses)In 2006, the United States suffered the highest number of fatal airliner accidents: six. Despite the measures taken by the Congolese Ministry of Transport in 2005, threeaircraft still crashed in the Democratic Republic of Congo. Having suffered two serious accidents in 2005 and another one in 2006, Nigerian authorities continued takingsteps to make aviation safer. A new civil aviation act was signed into law. The new law seeks to establish aviation safeguards, enforce safety guidelines, improve securitychecks, prescribe ministerial powers during emergencies, define offenses that endanger safety, and also enact penalties for violation. Almost immediately four airlineshad their air operator certificates (AOC) suspended pending recertification.Afghanistan 1 (2 0 0 0)Algeria (0 1 1 0)Argentina (0 0 1 0)Australia (1 0 0 0)Azerbaijan (1 1 0 0)Benin (0 0 1 0)Bolivia 1Brazil 2 (0 2 0 2)Canada 1 (0 1 1 0 1)Central African Rep. (0 0 0 1)China (0 2 0 1)Colombia 1 (1 1 1 3)Comoros (0 0 0 1)

Congo (Brazzaville) (1 0 0 0)Congo (Dem. Rep.) 3 (4 0 0 0)Djibouti (0 0 0 1)East Timor (0 0 1 0)Egypt (0 1 0 0)Equatorial Guinea (1 0 0 0)Estonia (0 0 1 0)France—incl. overseas (1 0 1 0)Gabon (0 1 1 0)Germany (0 0 0 1*)Greece (1 0 0 0)Guyana (0 0 1 0)Haiti (0 0 1 0)

Indonesia 1 (2 1 1 2)Iran 1 (1 0 0 2)Italy 1 (3 0 0 0)Kenya (0 1 2 1)Liberia (0 0 0 1)Luxembourg (0 0 0 1)Mexico (0 0 0 1)Morocco (0 0 0 1)Nepal 1 (0 1 0 2)New Zealand (1 0 1 0)Nigeria 1 (2 0 0 2)Norway 1Pakistan 1

Papua New Guinea (1 1 0 0)Peru (1 0 1 0)Philippines (0 0 0 1)Romania (1 0 0 0)Russia 2 (1 1 1 2)Sao Tomé et Principe 1Spain (0 0 0 2)South Africa (0 0 0 1)South Korea (0 0 0 1)Sudan (3 3 2 0)Sweden 1Taiwan (0 0 0 1)Tanzania (1 0 0 0)

Tunisia (0 0 0 1)Turkey (0 0 2 0Uganda (1 0 0 0)Ukraine 1United Arab Emirates (0 1 0 0)USA 6 (2 4 3 3)Uzbekistan (0 1 0 0)Venezuela (1 1 1 0)Atlantic Ocean (0 1 0 0)Pacific Ocean (0 0 0 1)Total 27 (35 26 25 37)*) collision

Number of fatal airliner accidents per region 2006 (2005, 2004 2003, 2002, 5-yr avg, 10-yr avg in parentheses)The moving 10-year average trends show a decrease in the average number of fatal accidents for all regions. All regions have recorded a steadily decreasing accident rateover the past 7 years, except for Africa. In 2006, Africa was again the most unsafe continent: 18.5% of all fatal airliner accidents happened in Africa, while the continentonly accounts for approximately 3% of all world aircraft departures.Africa 5 (13 7 7 10 8 7.4)Asia 5 (6 7 2 10 5.8 8.3)Australia 0 (3 1 1 0 1 1.2)

Central America 0 (0 1 1 0 0.6 1.2)Europe 6 (7 1 5 7 5.8 6.5)North America 7 (3 5 4 4 4.2 5.9)

South America 4 (3 4 5 5 4.6 5)Int’l waters 0 (0 0 0 1 0.6 0.8)Total 27, 35, 26, 25, 37, 30.6, 36.3

Flight nature [number of fatal airliner accidents per flight nature] 2006 (2005, 2004, 2003, 2002, 5-yr avg, 10-yr avg in parentheses)Eleven fatal passenger flight accidents in 2004 was an all-time low. After a brief spike in 2005, the number of accidents in 2006 decreased to 15, which is below the 5-yearaverage of 17 accidents. Where in 2004 cargo planes were reason for concern, 2006 showed a continuing decrease in cargo plane crashes to 6.Scheduled passenger 11 (14 8 8 13 10.4 13.8)Non-scheduled passenger 3 (5 3 5 4 4.8 5,8)Passenger 2) 1 (2 0 0 4 1.8 1.3)

Cargo 6 (8 13 7 9 8,4 10,4)Ferry/positioning 1 (0 1 2 5 1.6 1.7)Training 2 (1 0 0 0 0.6 0.5)

1. February 5, Shorts 360, Air Cargo Carriers, near Watertown, 32. February 8, Swearingen Metro II, TriCoastal Air, near Paris, 13. March 18, Beechcraft C.99, Ameriflight, near Butte, 24. March 31, Let 410, TEAM, near Saquarema, 195. April 16, Fokker F-27, TAM, Guayaramerín, 16. April 24, Antonov 32, U.S. Department of State, Lashkar

Gah, 2+37. April 27, Convair CV-580, LAC-SkyCongo, Amisi, 88. May 3, Airbus A320, Armavia, off Adler/Sochi, 1139. May 14, Convair CV-580, Saskatchewan gov., near La Ronge, 110. May 23, DHC-6 Twin Otter, Air São Tomé, off São Tomé

Island, 4

11. June 21, DHC-6 Twin Otter, Yeti Airlines, near Jumla, 912. July 7, Antonov 12, Mango Airlines, near Sake, 613. July 9, Airbus A310, S7 Airlines, Irkutsk, 12514. July 10, Fokker F-27, PIA, near Multan, 4515. July 29, DHC-6 Twin Otter, Quantum Leap Skydiving,

Sullivan, 616. August 3, Antonov 28, TRACEP, near Bukavu, 1717. August 4, Embraer 110 Bandeirante, AirNow, near

Bennington, 118. August 13, Lockheed L-100, Hercules Air, Algérie near

Piacenza, 319. August 22, Tupolev 154, Pulkovo near Donetsk, 170

20. August 27, Canadair CRJ100ER, Comair, Lexington, 4921. September 1, Tupolev 154, Iran Air Tours, Mashad, 2822. September 29, Boeing 737-800, GOL, near Peixoto Azevedo, 15423. October 10, BAe 146-200, Atlantic Airways, Stord, 424. October 26, CASA 212 Aviocar, Kustbevakning,

Falsterbokanalen, 425. October 29, Boeing 737-200, ADC Airlines, Abuja, 96+126. November 17, DHC-6 Twin Otter, Trigana Air Service,

Puncak Jaya, 1227. November 18, Boeing 727, Aerosucre, Colombia, near Leticia 5Total Fatalities 888+4

Flight phase: Number of fatal airliner accidents per flight phase 2006 (2005, 2004, 2003, 2002, 5-yr avg, 10-yr avg in parentheses)The number of approach and landing accidents decreased to nine. As the September 1 accident involving an Iranian Tupolev 154 showed, the survival rate of approachand landing accidents is relatively high. The airplane swerved off the runway in landing and caught fire. Of the 148 occupants, 120 survived the crash. Statistics show thatin the last 10 years 33% of all occupants survived approach and landing accidents. Most accidents happened in the enroute phase of flight; 14 accidents was higher thanthe 5- and 10-year averages.

Airliner Accident Statistics 2006

Date, Aircraft Type, Operator, Location, Fatalities1. November 9, Let 410, Goma Air, Walikale, 0+12. December 8, Boeing 737-700, Southwest Airlines, Chicago, IL, 0+1

Other fatal occurrencesOne occurrence resulted in a ground casualty, without any fatal injuries to the occupants of the airplane. This accident has not been included in the analysis.

Standing (STD) 0 (0 0 0 0 0.2 0.1)Takeoff (TOF) 1 (1 2 2 2 2.2 2.3)Initial climb (ICL) 3 (5 2 4 0 2.4 3)

Enroute (ENR) 14 (14 8 9 14 10.8 11.9)Maneuvering (MNV) 0 (1 0 2 2 1 1.1)Approach (APR) 4 (8 9 8 17 11 13.2)

Landing (LDG) 5 (4 3 0 2 2 3.5)Unknown (UNK) 0 (2 2 0 0 1 1.2)Total 27, 35, 26, 25, 37, 30.6, 36.3

Average survival percentage per flight phase: Phase 2006, 10-yr avgStanding (STD)Takeoff (TOF) 2%, 50.1%

Initial climb (ICL) 7%, 14.5%Enroute (ENR) 0.5%, 9.2%

Maneuvering (MNV) 0%, 31.4%Approach (APR) 0%, 17.7%


Landing (LDG) 61.3% 82%Total 23.2%, 25.9%

The year 2006 in historical perspectiveFrom a historical perspective, 2006 was an average year. Although the number of fatal accidents (27) was significantly lower than the 10-year average (36),the number of fatalities was almost equal to the 1996-2005 10-year average.

Other 3) 3 (2 1 3 2 2.2 1.9)Unknown 3 (1 0 0 0.8 0.9)Total 27, 35, 27, 25, 37, 30.6, 36, 3

Accident classification: Type 2006 (2005, 2004, 2003, 2002, 5-yr avg, 10-yr avg in parentheses)Number of fatal airliner accidents per accident type. The probable cause for most accidents has not been established yet. However, for most accidents the factual informationknown at this stage makes it possible to classify these accidents. The number of “loss of control” accidents shows a marked increase to 17. Controlled flight into terrain (CFIT)accidents remained very low at 5.

Loss of control 17 (13 14 11 15 12.6 [54%]15.6 [59%])

CFIT—hill, mountain 4 (6 3 5 12 5.6[24%] 5.4 [21%])

CFIT—level ground 1 (2 2 4 1 2.8 [12%] 2.8 [11%])CFIT—water 0 (0 0 0 0 0 0.3 [1%])Emergency/forced landing—ditching 0 (1 2 0 2 1.2

[5%] 0.9 [3%])

Emergency/forced landing—outsideairport 0 (0 1 2 2 1 [4%] 0.5 [2%])

Runway mishap 0 (1 0 0 0 0.2 [1%] 0.8 [3%])

Unknown 5 (12 4 3 5)Total 27, 35, 26, 25, 37


Continued . . .

ISASI ROUNDUP

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

New Members

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

○

Orphanos and his team, with considerableassistance from Capt. Akrivos Tsolakis,chairman of the Hellenic Air AccidentInvestigation & Safety Board (HAAISB).Workshop sponsors included OlympicAirways, Cyprus Airways, and Air BP.

Content of the workshop was aboutequally divided into accident/incidentinvestigation and prevention (AIIP)conducted by Schleede and safetymanagement systems (SMS) conductedby Jim Stewart. Other instructorsproviding considerable support includedDr. Loukia Loukopolous from Greece(NASA employee), who covered humanfactors; Dr. Ioannis Markou from Greece,who covered aeromedical factors; Capt.Vangelis Demosthenos from Cyprus, whocovered SMS and related topics; andCapt. Elias Nikolaides from Greece, whoaddressed European regulatory require-ments and operational safety oversight(internal and external audits).

In all, 45 persons attended represent-ing the Cyprus AAIIB, the Cyprus DCA,Hellenic AAIASB, an aviation magazine

All participants received certificates oftraining completion at a closing dinner,which featured the minister of Communi-cations and Works, and the director-general of the DCA, as guest speakers,among others.

Recruiting effectiveness of ISASI’seffort was again proven by the gain of 22new ISASI members. Also proven wasthe workshop’s value, as the trainedgroup now plans to “organize a futuremeeting among themselves and isconsidering forming a local chapter,” saidSchleede.

Eighteenth WorkshopCaj Frostell noted the 18th ISASIReachout workshop ran from November4 to 15 and was hosted by Saudi ArabianAirlines (SVA) in Jeddah. Capt. FareedAlshingiti, general manager–FlightOperations Standards and QualityAssurance, opened the program held inthe facilities of Saudi Arabian Airlines,the CRM and human factors trainingauditorium of the Prince Sultan AviationAcademy. It was Reachout’s second visitto the group.

The technical content of the workshopcomprised three modules: aviationmedicine conducted by Dr. Anthony Evans,

IndividualsMuñoz, Juan, M., MO5322, Mexico D.F.,

MexicoNicholl, Heath, K., MO5274, Wayne, MI, U.S.A.Nicolaou, Nicos, P., AO5305, Latsia, CyprusObumselu, Julie, N., AO5283, Logos, NigeriaO’Donnell, James, P., ST5317, Bay Village,

OH, U.S.A.O’Donnell, Jennifer, ST5264, South Wirral,

United KingdomOnken, Jenna, E., ST5339, Lawrenceville,

GA, U.S.A.Öztürk, Ahmet, ST5273, Istanbul, TurkeyPafitis, Kyriakos, P., MO5296, Limassol,

CyprusPapanastasiou, Georgios, MO5297, Paphos,

CyprusPark, Won Beom, ST5279, Daytona Beach,

FL, U.S.A.Pattides, Andreas, C., MO5298, Nicosia,

CyprusPilalis, Dina, FO5321, Melbourne, VIC,

AustraliaPitsillides, Constantinos, MO5302, Larnaca,

CyprusRahman, Iad, MO5335, Mississauga, CanadaReed, Jeffrey, J., AO5320, Spokane Valley,

WA, U.S.A.Reinhart, Paul, S., AO5327, Pensacola, FL,

U.S.A.Renshaw, Robert, MO5325, Thornton, CO,

U.S.A.Ribeiro, Paulo, M., MO5324, Davie, FL,

U.S.A.Ryan, John, R., FO5286, Robertson, OLD,

AustraliaSalvestrini, Jarrod, A., ST5265, Daytona

Beach, FL, U.S.A.Schwarz, Scott, A., MO5275, Ocean City, NJ,

U.S.A.Slaven, Walter, J., MO5266, Glen Forrest,

W.A., AustraliaTagarino, Bose, T., AO5271, Lagos, NigeriaTehrani, Morteza, AO5333, Castle Hill, NSW,

AustraliaTritschler, Kristjof, AO5269, Bonn, GermanyWandall, Edward, H., MO5290, North Wales,

PA, U.S.A. ◆

Mike Dorion cuts the ISASI logo cake as Dr. Osama Bahannan—director, AviationMedicine, General Authority of Civil Aviation, Saudi Arabia (3rd from left)—andCapt. Talal Ageel—vice-president, Flight Operations Department (with plate inhand)—look on.

from Greece, the Egyptian Air TrafficServices, Cyprus Airsports Federation,Cyprus Intercollege, Cyprus FireService, Cyprus Ministry of Defence,Helios Airways, Eurocypria Airlines,Cyprus Airways, Cyprus Police Depart-ment (aviation department), and theMinistry of Communications and Works.


Improving the Quality of Investigation Analysis (from page 13)

Figure 5

chief of the Aviation Medicine Section inICAO; safety management systems (SMS),conducted by Mike Doiron; and aircraft

the document-management system for each of the items or com-ments in the table.

Safety factor evidence tables are used to test proposed safetyfactors. They have separate parts for the test for existence, testfor influence, and test for importance. The existence and influenceparts are essentially the same as the basic evidence table. The in-fluence part (if required) is simply a free-text box allowing investi-gators to justify why they think the safety factor should be ana-lyzed further.

Investigators are provided with guidance for developing an evi-dence table in four stages: review related information, identify rel-evant items of information, evaluate the strength of each item, andevaluate the overall strength of the potential finding. The guid-ance consists of a series of questions or criteria to consider at eachstage.

Policies, guidelines, and trainingTo emphasize the importance of using the terminology, model, pro-cess, and tools in the analysis framework, the ATSB has devel-oped a set of policies for its investigators. Examples of these poli-cies include requiring a sequence of events analysis for each occur-rence investigation, completing an evidence table for each keyfinding, conducting a risk analysis of each verified safety issue,and encouraging external organizations to initiate safety actionprior to the ATSB issuing any recommendations.

The policies are supported by a comprehensive set of guide-

lines. These guidelines provide information on analysis terminol-ogy, accident development models, and principles of critical rea-soning (e.g., components of arguments, deductive versus induc-tive arguments, common fallacies of reasoning, characteristics ofevidence that influence its credibility and relevance, preferred ter-minology to use for describing probabilities, and similar concepts).The guidelines also provide detailed guidance on how to conducteach of the processes and stages of the analysis phase. For manyof the stages in the analysis process, the guidance is presented inthe form of a series of questions or criteria to consider. This ap-proach breaks down the general “why” question into more usefuland manageable components.

The guidelines and tools are being introduced and reinforcedthrough a 4-day training course for all investigators at the ATSB.The training involves a large component of practical experience inapplying the framework’s concepts, process, and tools.

One feature of the guidelines and training is a strong emphasison teamwork. Investigators have excellent skills and knowledgeof particular domains, but it is unlikely that any one investigator isgoing to have sufficient knowledge in all relevant domains to dealwith the complexity that arises during investigations. As the rangeof experience that contributes to analysis judgments is broadened,then the quality of the resulting findings will improve.

Concluding commentsAnalysis activities ultimately rely on the judgment of investi-gators. The ATSB analysis framework is designed to guide andsupport these difficult judgements, rather than replace the cen-tral role of its investigators. By providing standardized termi-nology, a generic accident development model, a defined pro-cess, tools, policies, guidelines, and training, the ATSB believesits analysis framework will improve the rigor, consistency, anddefensibility of its investigation analysis activities, and improvethe ability of its investigators to detect safety issues in the trans-portation system.

The new ATSB analysis framework is just a starting point. Theintention is that, as investigators become more familiar with it,they will actively contribute to its ongoing improvement. In otherwords, the framework is a platform for documenting the ATSB’sorganizational learning about analysis methods. Any feedbackanyone has for enhancing the quality of the ATSB framework wouldbe gratefully received. ◆

accident investigation, conducted byFrostell and assisted by Alain Guilldoufrom BEA, France, and Mike Dorion.

A majority of the 31 participants werefrom within Saudi Arabian Airlines. Otherattendees included inspectors with the

○

○

○

○

○

○

○

○


ISASI Information

OFFICERSPresident, Frank Del Gandio

([email protected])Executive Advisor, Richard Stone

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

([email protected])Secretary, Chris Baum

([email protected])Treasurer, Tom McCarthy

([email protected])

COUNCILLORSAustralian, Lindsay Naylor

([email protected])Canadian, Barbara Dunn

([email protected])European, Anne Evans

([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, David King

([email protected])Latin American, Guillermo J. Palacia

(Mexico)New Zealand, Peter Williams

([email protected])Russian, Vsvolod E. Overharov

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

([email protected])United States, Curt Lewis

([email protected])

General Authority of Civil Aviation(GACA). The participants received ISASIcertificates for the combined accidentinvestigation and safety managementsystems workshop.

At the closing ceremony completioncertificates were presented by Capt. TalalAgeel (vice-president–Flight OperationsDepartment). Other executive andmanagerial-level participation from SVAincluded Capt. Fareed Alshingiti (generalmanager–Flight Operations Standardsand Quality Assurance) and Capt.Mohammed Hersi (manager–TechnicalQuality Assurance). During the workshop,ISASI membership forms and corporatemembership forms were made availableto the participants who were not alreadyISASI members. ◆

Continued . . .

ISASI ROUNDUP

ISASI By-Laws BeingRevisedAt its fall 2005 meeting the Society’sInternational Council, noting that the lastrevision to the important document was inAugust 1993, established a committee,chaired by Darren Gaines, to undertakethe daunting task of revising the docu-ment, which contained a significant num-ber of outdated requirements. The By-Laws set goals, philosophy, give direction,and provide intent. Council and officeprocedures to implement the By-Lawsrequirements are more appropriatelyspelled out in the ISASI Policy Manual.

The By-Laws Committee work is nearcompletion, and the process to present therevised document to the membership forapproval is being put into place. The votingvehicle, Vote Net, can be accessed throughthe Internet, and eligible members will beable to vote through a link from the ISASIwebsite. Members without access to the In-ternet will be provided with a printed ballotand a copy of the By-Laws revision upon re-quest to the ISASI office. Dates for postingthe revision have not yet been determined;however, the Council wants all members tobe aware of this important work product sothey may be prepared to act. ◆

NTSB Names Clark,Haueter to New PostsNational Transportation Safety BoardChairman Mark V. Rosenker has namedJohn Clark, formerly director of AviationSafety, as the agency’s chief scientist foraeronautical engineering. Tom Haueter,deputy director of aviation safety, hasbeen named acting director of the office.

Clark joined the Board in 1981 as anaeronautical engineer and served in severalinvestigative capacities. He has served asdirector of aviation safety for the last 6years. Haueter came to the Board in 1983and has served as a structures investigator,an investigator-in-charge, as head of themajor investigations division, and as deputydirector of aviation safety for 6 years. ◆

MOVING?Please Let Us KnowMember Number_____________________

Fax this form to 1-703-430-4970 or mail toISASI, Park Center107 E. Holly Avenue, Suite 11Sterling, VA 20164-5405

Old Address (or attach label)

Name _____________________________

Address ___________________________

City _______________________________

State/Prov. _________________________

Zip _______________________________

Country ___________________________

New Address*

Name _____________________________

Address ___________________________

City _______________________________

State/Prov. _________________________

Zip _______________________________

Country ___________________________

E-mail ____________________________

*Do not forget to change employment ande-mail address.


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, Richard Stone([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 LaboratoryAccident Investigation & Prevention BureauAeroVeritas 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 Investigation

CommissionAirservices AustraliaAirTran AirwaysAlaska AirlinesAlitalia Airlines—Flight Safety Dept.All 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 AustraliaColegio De Pilotos Aviadores De Mexico, A.C.Comair, Inc.Continental AirlinesContinental ExpressCOPAC/Colegio Oficial de Pilotos de la

Aviacion ComercialCranfield Safety & Accident Investigation CentreDCI/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 AgencyEVA 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, LLCHellenic Air Accident Investigation

& Aviation Safety BoardHoneywellHong Kong Airline Pilots AssociationHong Kong Civil Aviation DepartmentIFALPAIndependent Pilots AssociationInt’l. Assoc. of Mach. & Aerospace WorkersInterstate 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 CanadaNigerian Ministry of Aviation and Accident

Investigation BureauParker AerospacePhoenix International, Inc.Pratt & WhitneyQantas Airways LimitedQwila Air (Pty) Ltd.Republic of Singapore Air ForceRolls-Royce, PLCRoyal Netherlands Air ForceRoyal New Zealand Air ForceRTI Group, LLCSandia National LaboratoriesSAS BraathensSaudi Arabian AirlinesSICOFAA/SPSSikorsky Aircraft CorporationSkyservice Airlines Ltd.Singapore 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

Transportation Safety Board of Canada (Bureaude la Sécurité des Transports du Canada)

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, andprepared by, the represented corporatemember organization to enable a morethorough understanding of the organi-zation’s role and functions.—Editor)

The Transportation Safety Board ofCanada (TSB) is an independentagency, created by an act of

Parliament (the Canadian TransportationAccident Investigation and Safety BoardAct). The TSB’s mandate is to advancetransportation safety• by conducting independent investiga-tions into selected transportation occur-rences in order to make findings as totheir causes and contributing factors,• by identifying safety deficiencies, asevidenced by transportation occurrences,• by making recommendations designedto eliminate or reduce any such safetydeficiencies, and• by reporting publicly on its investiga-tions and on the findings in relationthereto.

In making its findings as to the causesand contributing factors of a transporta-tion occurrence, it is not the function ofthe Board to assign fault or determinecivil or criminal liability, but the Boardshall not refrain from fully reporting onthe causes and contributing factorsmerely because fault or liability might beinferred from the Board’s findings.

In respect to aviation occurrences, theAct applies in or over Canada, in or overany place that is under Canadian airtraffic control, and in or over any otherplace, if Canada is requested to investi-gate the aviation occurrence by anappropriate authority, or if the aviationoccurrence involves an aircraft in respectof which, or that is operated by a personto whom, a Canadian aviation documenthas been issued under Part I of theAeronautics Act.

To instill confidence in the publicregarding the transportation accidentinvestigation process, it is essential that

the TSB be independent and free fromany conflicts of interest when investigat-ing accidents and incidents. TSB’sindependence enables it to be fullyobjective in making findings as to causesand contributing factors, and in makingtransportation safety recommendations.

The TSB consists of up to five Boardmembers, including a chairperson, andhas approximately 220 employees. TheTSB head office is located in Gatineau,Quebec; however, most investigation staffare located in various regional and fieldoffices across Canada, where they are

better able torespond quickly totransportationoccurrencesanywhere in thecountry.

Approximately2,000 aviationtransportationoccurrences

(accidents and incidents) are reported tothe TSB each year. Practical consider-ations dictate that only a small proportionof these be investigated. Consequently,when notified of an occurrence, the TSBwill assess the circumstances to deter-mine if an investigation is warranted. Anindividual occurrence will be investigatedwhen there is high probability that the

investigation will advance Canadiantransportation safety, and that doing sohas the potential for reducing future riskto persons, property, or the environment.

In effect, the TSB, for the most part,will focus its efforts on occurrences in theCanadian federally regulated, commercialtransportation sector. In addition, inaccordance with ICAO Annex 13 stan-dards and recommended practices, theTSB is responsible for ensuring Canadiansafety interests in foreign investigationsinvolving aircraft that are registered,licensed, operated, or manufactured inCanada. In this regard, the TSB supportsforeign investigations and internationalaviation safety by contributing itsexpertise and resources.

The TSB also contributes to interna-tional flight safety through its closeassociation and involvement with ICAO,the International Transportation SafetyAssociation, the Nordic AccidentInvestigation Group, and ISASI; throughits participation in aviation safetyworking groups, seminars, and meetings;and by providing training opportunitiesto other investigation agencies andsafety associations.

For more information on the TSB, itsinvestigations, recommendations, andsubscription services, visit its website athttp://tsb.gc.ca. ◆

JANUARY–MARCH 2007 · vestigating a “Minor” Incident Using Les-sons Learned From A Major...

Documents

Transcript of JANUARY–MARCH 2007 · vestigating a “Minor” Incident Using Les-sons Learned From A Major...