ISASI WEB ROUNDUP NEWS

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1 International Society of Air Safety Investigators Issue No. 6 October 2014, Editor: Esperison Marty Martinez Robertson Family, ISASI Form Fellowships The ISASI - Robertson Family Aviation Safety and Security Archive Endowed Assistantships and Fellowships in Crashworthiness at Embry-Riddle Aeronautical University at Prescott, AZ, has been created and established according to an announcement by ISASI President Frank Del Gandio. In making the announcement, President Del Gandio said: I am extremely happy and proud to announce the creation of the ISASI - Robertson Family Aviation Safety and Security Archive Endowed Assistantships and Fellowships in Crashworthiness at Embry- Riddle Aeronautical University s campus in Prescott, Arizona. I can think of no better way to begin our 51st year as the aviation industry s only organization devoted solely to the interests of aviation air safety investigators. Dr. S. Harry Robertson, a founding member of ISASI and recipient of its ISASI Jerome F. Lederer Award, is the inventor of the Robertson Crashworthy Fuel System, and a pioneering engineer with a tireless devotion to aviation safety. Through an endowment, expanding on Robertson s life work in aviation safety research, which is preserved at Embry-Riddle Prescott s Aviation Safety and Security Archives, the fellowship program intends to provide financial resources to further the field of crashworthy research and safety development in partnership with ISASI. The purpose of the ISASI Robertson Fellowship Program is to support Embry Riddle (Prescott Campus) graduate students in the Master of Science in Safety Science (MSSS) degree program at Embry-Riddle Prescott, and provide research opportunities and funding to further the field of crashworthy research and safety development. The Fellowship Program will achieve these goals by providing wellqualified and highly motivated graduate students an opportunity to conduct thesis research on crashworthy safety topics of interest while working with Robertson Safety Institute, (RSI). In addition to stipend aid, fellowship participants will have access to research funding for approved crashworthiness projects. This fund shall also be used to support student assistantship positions within the Robertson Aviation Safety Center Archives, located on the Embry- Riddle Prescott Campus. President Del Gandio noted that The crashworthiness fellowship program will make an noteworthy impact on the primary purpose of the Society, which is to promote that part of the aeronautical endeavor wherein lies the moral obligation of the Air Safety Investigator to the Public, and to promote the education of its members, of those directly associated with aeronautical problems, and of the general public concerning those problems peculiar to the work of the Air Safety Investigator. In coordination with the Office of Financial Aid, a selection committee comprised of faculty and administrators of the Safety Science Department and ISASI members will review applications and make recommendations of the recipients for the fellowship awards for final selection and approval. The fellowship stipends will be awarded annually and paid on a semester basis to one or two graduate students meeting the established criteria as funds are available. Program procedures and details are now being developed. At the appropriate point, a call for applications for Fellowships and Assistantships will be posted on the ISASI website, and in its publications. ISASI s Newly Elected Executive Officers The Ballot Certification Chairman Tom McCarthy and Nominating Committee Chairman, Troy Jackson, have certified that 64 votes were cast and certified in the election of the 2014 Executive Officers' and U.S Councillor, and International Councilor s election. Those elected for a two year term ( ) are as follows: President, Frank Del 1 Gandio; Vice President, Ron Schleede; Secretary, Chad Balentine; Treasurer Robert (Bob) MacIntosh; U. S. Councilor, Eugene (Toby) Carroll, Jr.; and International Councilor, Caj Frostell. All, except for Balentine were incumbents and returned to their positions. To refresh long term members and for the benefit of newer members, a short recap of each individual s experience is provided. PRESIDENT: Frank Del Gandio retired in 2011 from the Federal Aviation Administration after 38 years in various positions as an aviation safety inspector, air safety investigator, and manager. He served in the FAA Office of Accident Investigation and Prevention as the Deputy Manager of the Accident Investigation Division and then as Manager of the Recommendations and Analysis Division. Frank investigated more than 45 major catastrophic accidents/incidents as the FAA IIC, and 25 general aviation accidents in the same capacity. He is a retired Colonel in the New Jersey Air National Guard where his last assignment was the Deputy Commander for Maintenance. Prior to his federal service, Frank worked for the Falcon Jet Corporation and Pan American World Airways. He holds a Commercial Pilot s License with Single- Engine, Multi-Engine, Land, and Sea ratings, an Instructor Pilot s license for Single-Engine Land and Sea, and an Airframe and Powerplant Mechanic. VICE PRESIDENT: Ron Schleede, has been a member and strong supporter of ISASI for over

2 38 years. In April 2009, he was designated an ISASI Fellow and in 2002, was awarded Jerome F. Lederer Award.. He also serves as the President of the U.S. Mid Atlantic Chapter. A fighter pilot in the U.S Air Force, he later served with the U.S. National Transportation Safety Board (NTSB) for 29 years. He held a variety of positions, including the position of Chief of Major Aviation Investigations from 1985 until 1995, and was Deputy Director of the Office of Aviation Safety, when he retired in In December 1999, Ron was designated Director of Investigations Air at the Transportation Safety Board of Canada as part of an exchange program, where he worked until he retired. TREASURER: Robert Bob MacIntosh has been active in ISASI for over 30 years including participation as a seminar session chair, author and speaker. He served with the U.S. NTSB staff as the Chief Advisor, International Safety Affairs from 2001 until his retirement in He was responsible for providing management expertise for United States government and industry technical participation in accident investigations on foreign soil, oversee travel budget allocation and representation at relevant ICAO meetings, and manage Safety Board activities included in the U.S. Interagency Group on International Aviation. From 1988 to 2001, Bob was an Investigator-in-Charge and Accident Report Writer with the NTSB Major Investigations Division. In that position he led many high profile domestic air safety investigations (Aloha, Sioux City, LAX collision) and represented the United States NTSB in numerous international cases (Lauda, AirInter, LAPA, Concorde) as the U.S. Accredited Representative. SECRETARY: Chad Balentine is a Senior Staff Engineer in the Engineering and Air Safety Department of the Air Line Pilots Association, International (ALPA). He is the lead for ALPA s staff support of all accident and incident investigations involving any ALPA-represented US or Canadian carrier. Chad holds an Air Transport Pilot rating and has flown more than 5,000 hours. Prior to joining ALPA he was with Atlantic Coast Airline (ACA)/ Independence Air flying the Canadair Regional Jet and for one year flying the Airbus A320 for JetBlue. He is a graduate of Embry-Riddle Aeronautical University with a Bachelor of Science in Aeronautical Science with a Minor in Aviation Safety, as well as a Masters, Aeronautical Science with an Emphasis in Aviation Safety. INTERNATIONAL COUNCIL- LOR: Caj Frostell is the ISASI 2003 Jerome F. Lederer Award recipient and has served as the International Councillor of ISASI since From 1967 to 1980, Caj was Chief of Accident Investigation with the Board of Aviation in Finland. In 1980, he joined ICAO and the Accident Investigation and Prevention Section in Montreal. In 1996, he was appointed Chief of the Section. He retired from ICAO in December He received his flight training in the Air Force in Finland, and holds a Master of Applied Science degree (1971) from the Institute of Aerospace Studies, University of Toronto, Canada. Caj has been extremely influential in the success of the ISASI Reachout Committee, both as an instructor and as an administrative organizer. As ISASI international councillor, he has been instrumental in the communication with the ISASI members world-wide and in supporting the establishment of ISASI societies in 2 Asia, Pakistan, Korea and the Middle East. U.S. COUNCILLOR, Toby Carroll has been a member of ISASI for 31 years. He is an instructor in ISASI s Reachout Program. From 1982 to 1985, he served as an air safety investigator with the NTSB. In 1985, he joined Continental Airlines, retiring in 2012 as director of Flight Safety with direct responsibility for all flight safety investigations, FOQA, LOSA, ASAP, flight safety databases, and team leader of the Corporate Safety Investigation Team. He has participated in or was in charge of overseeing 400 accidents and incidents involving air carriers, military and general aviation. Glenn Jones is New Chair Reachout Committee Glenn Jones, a member of the Australian Society has been named chairman of the ISASI Reachout Committee by President Frank Del Gandio. As the chairman he is responsible for establishing the agenda, meeting dates, locations and procedures of the committee. Upon assuming the position, he said: Firstly, I thank John Guselli for his excellent work in chairing the committee before me, and to acknowledge the success of the most recent Reachout conducted in Seoul in April This was yet another example of the high standard of targeted training from expert presenters that can be delivered by the Reachout Workshops. Secondly, recently when I was in Bangkok I met informally with ICAO s Cooperative Development of Operational Safety and Continuing Airworthiness Program (COSCAP) s Chief Technical Advi-

3 sor for the Asia-Pacific Region, Capt. David Biehn. We discussed the opportunity for Reachouts to address a training gap that exists not only in the Asia-Pacific region but worldwide. We agreed that there is a need for the type of training that Reachouts deliver and David advised that COSCAP has a budget that could be applied towards supporting the Reachout program and would be able to assist in identifying specific training needs that may be met by Reachouts. Further, by invitation, I expect to attend the next ICAO Asia Pacific Regional Aviation Safety Team (APRAST) meeting to present on the Reachout program and to progress the idea of ICAO support for the program. Also, I will be developing, with the assistance of the regional societies and committee members, a database that effectively records the skills and availability of all members that may be able to assist with the delivery and coordination of the Reachout program. I will also be developing, with the assistance of regional societies and ICAO, a training needs analysis to which Reachout workshops can be applied. I am very conscious of the demands that the program places on volunteers in the delivery of the Reachout workshops but hopefully these initiatives will assist in delivery of Reachout workshops with minimal demand on the finances of ISASI and the regional societies and in keeping with the goals of the Reachout Workshop Program. ISASI members of the committee serving as instructors include: Steve Corrie (USA), accident investigation and safety management systems; Vic Gerden (Canada), accident investigation; Elaine Parker (Canada), safety management systems; Caj Frostell (Canada), accident investigation; Ron Schleede (USA), accident investigation; Nick Stoss (Canada); and Joe Jackson (Canada). Glenn s extensive experience in aviation safety began at the age 17 when he joined the Australian Army. He became an aircraft engineer, and his ladder of progress moved him to flight service officer with the then Department of Aviation, as a fixed wing pilot holding an ATPL with chief pilot and check and training approvals for a regional RPT Operator through to becoming the Aviation Safety Officer and Aircraft Accident Investigator for Boeing Australia before joining CASA as a safety inspector. There he led the team of inspectors assessing all Australian RPT operators safety management systems. He holds a Master s Degree in Aviation Management and is a Human Factors, Safety Management Systems and Aviation Safety Lead Auditor Instructor. 3 Alaska Airlines Honors ISASI s RuthAnn Bledsoe The exceptional commitment to safety demonstrated by RuthAnn Bledsoe has earned her Alaska Airlines Safe Operations Award and Recognition (SOAR) award. RuthAnn is a long term ISASI member, a flight attendant at Alaska Airlines, and a strong air safety advocate. The presentation commendation reads: Alaska Airlines holds the safety of our employees and customers as our highest priority. A few of Alaska Airline's outstanding people are selected to receive the Safe Operations Award and Recognition (SOAR) award for exhibiting their exceptional commitment to safety. It is our distinct privilege to present you with this award and communicate our deepest gratitude for your invaluable contribution to the success of our mission, to be number one in safety and compliance. You have been selected for this award because of your work and perseverance in motivating the Ted Stevens Anchorage International Airport to have a formal emergency action plan in place. Thank you for your exemplary pursuit of operational excellence and your outstanding dedication to our Alaska Airlines safety culture. In a note of congratulations, ISASI President Frank Del Gandio said: You have come a long way since TWA and we are very proud of you. You represent our organization in the highest of standards. Congratula ng Ruthann, center, are, le, Seth Heiple, Associa on of Flight A endants Chair of the Air Safety and Health Security Commi ee, and Andy Schnider, Alaska Airlines, Vice President, Inflight Services.

4 Pakistan SASI Instrumental in Pakistan International Airlines Gaining CAA Approvals Shown conversing a er the presenta on of the ANO 145 and 147 are le to right Shujaat Azeem, adviser to the Prime Minister for avia on; DG CAA Air Marshall Muhammad Yousaf ; Director AW Munawar Jamal, Amir Ali Director MRO PIA; MD PIA Shahnawaz Rehman; and Maqsood Hussain Director Engineering PIA. 4 Engr Munawar Jamal Qureshi, an active member of SASI Pakistan played an important role for the aviation industry in Pakistan. SASI Pakistan, through efforts of its members assisted Pakistan International Airlines (PIA) to implement the procedures and processes required by the new Pakistani Civil Aviation Authority (CAA) requirements ANO-145 and ANO- 147, which are based on the European EASA Regulations. Munawar Jamal, Director Airworthiness, Pakistan CAA has for the first time granted approvals to both PIA Engineering and Maintenance under Regulation ANO-145, and PIA Training Centre under Regulation ANO-147. With these approvals, the PIA became the first operator in Pakistan to meet the new CAA regulations, which are in line with the European EASA regulations. In a ceremony held in August at the Pakistani CAA headquarters and presided over by Mr. Shujaat Azeem (Adviser to the Prime Minister for Aviation), the Approval Certificates were handed over to the Managing Director of PIA Mr. Shahnawaz Rehman by the Director General CAA Air Marshal (Ret.) Muhammad Yousaf. Other senior officials from Pakistan CAA and PIA were also present at the ceremony. Engr. Munawar Jamal Qureshi highlighted the efforts of the CAA Airworthiness Directorate during the approval process, which comprised a series of audits, scrutiny of relevant manuals, verification inspections and review meetings with the PIA Engineering & Maintenance. After evaluations of the operator implemented procedures and processes by CAA Airworthiness Directorate, PIA was granted the approvals. ANO-145 and ANO-147 are the new regulations that the Pakistan CAA has introduced in line with the corresponding EASA regulations, in which the quality assurance function and culture is given a prime importance. The senior management of PIA has asked Wing Commander Syed Naseem Ahmed to use the ISASI connections to obtain assistance for PIA in the internal auditing of PIA by an audit organization recognized by EASA for this purpose. Wg Cmdr Ahmed, as the President of SASI Pakistan, covered this issue during ISASI International Council Meeting in Washington DC in May. The SASI Pakistan initiative, a first step in this direction, was appreciated as one of the contributory activities in improving aviation safety in Pakistan and Asia. SASI Pakistan is determined to continue supporting these activities in Pakistan.

5 NZSASI Holds Biennial Elections The New Zealand society held its biennial elections in June. Alister Buckingham was returned as President and also elected as the New Zealand Society Councilor. Russell Kennedy continues in the role of Secretary/Treasurer, and Graham Streatfield is the new Vice- President. Membership numbers remain stable, with new sign-ups being roughly equal to the dropoffs. Planning is under way for the Australian/New Zealand Societies regional seminar to be held at the Crowne Plaza Hotel, Auckland, New Zealand on the weekend of 6-7 June The seminar will follow the traditional format of the welcome reception on the Friday night, the seminar proper on Saturday and Sunday, with the seminar dinner to be held on the Saturday night. The Seminar Committee is chaired by Peter Williams, Anyone requiring further information can either Peter or Alister Buckingham, Visitors, and especially presenters, from outside the region are most welcome. A call for papers and registration details will be issued in the near future. Anthropometric Hazards in Aircraft Incidents and Accidents Robert Joslin, FAA, Chief Scientific & Technical Advisor, Flight Deck Technology Integration, and ISASI member offers some information relative to what he believes may be a hidden hazard in aircraft incidents/accidents. He writes: Although anthropometric body measurements (e.g. sitting eye height; functional reach; buttock-knee length, etc.) of the intended pilot population are required to be considered in the design of all certified aircraft cockpits, anthropometric accommodation has not been explicitly highlighted as a causal factor or hazard in the Federal Aviation Administration (FAA) Accident/Incident Database, National Transportation Safety Board (NTSB) database, or the FAA sponsored Aviation Safety Reporting System (ASRS) database. Not surprisingly, the terms anthropometrics or anthropometry have not appeared in the narratives of incidents/accidents, hence the specific hazards that can be directly attributed to anthropometric design are difficult to identify without a detailed analysis of narratives from the aircraft incident/accident reports. A brief information synthesis of archival publically available narratives of anomalous events that were voluntarily and anonymously self-reported by pilots through the Aviation Safety Reporting System yielded the following incidents directly related to anthropometric cockpit design. B Captain reported mistakenly selecting flaps 10 when flaps 5 were called for, leading to an overspeed. I cannot see gate settings from Captain's seat and must have moved the handle too far and into the gate for Flaps 10, when Flaps 5 was called for. ASRS -ACN BE the student's knee touched the gear handle while he was operating the rudder pedals. The gear handle switched into the up position. The gear lever in the BE-76 is located on the pilot's side - right above where the pilot's right knee would be when the pilot is using the rudder pedals. If the pilot is tall enough, the right knee could easily touch the gear handle from below. ASRS-ACN C560XL... PIC is [taller than average] and during preflight determined that he could not safely operate the aircraft with the left seat in any position. In the far aft and down [seat] position, his eyes were level with the top of the windows and he could not see one third of the engine instrument gauges. Also, he had to spread his knees apart to keep the control yoke from hitting them during full aileron deflection. 5 His eye line was above the Design Eye Reference Point (DERP) sight line and he could not get it to go lower. The problem exists among most pilots who are 5 ft 09 inches or taller. ASRS-ACN / Air Carrier... The alt reminder/ warning system did not give the aural horn when went through /- 100 and the warning light was located just under the glareshield out of my 6' 1" tall view. ASRS-ACN The aforementioned incidents highlight the need to explicitly identify anthropometric cockpit design as causal factor. Although the anomalous events reported through ASRS may not have met the threshold for a corroborated NTSB or FAA formal report, they should be considered precursors to more serious incidents and accidents. As such, identification of these hazards by including anthropometric design as a required reporting item during the investigation of all aircraft accidents and incidents, will ensure those data can be readily utilized to develop mitigation strategies and enhance aviation safety for the flying public. MENASASI Sets First Society Seminar The Middle East North Africa Society in conjunction with the General Civil Aviation Authority (GCAA) of United Arab Emirates will conduct its first society wide air safety and accident investigation seminar November 9 and 10. It will be held at Abu Dhabi. Fourteen speakers are scheduled to address the two-day event. ISASI President Frank Del Gandio will present a key-note address and speak about the fifty years of ISASI. GCAA Executive Director of the Air Accident Investigation Sector, and MENASASI chairman, will open the program. Some of the topics to be presented include: ICAO Accident Investigation, B737 Accident at Beirut, Criminalization of Aircraft Accidents, and Future of MENASASI.

6 NTSB Releases Preliminary Aviation Statistics for 2013 In 2013, general aviation accidents decreased, and the first fatalities on U.S. airlines and commuters in three years were recorded, according to the National Transportation Safety Board. Released preliminary aviation accident statistics show an overall decline in the number of US registered civil aviation accidents. The number of civil aviation accidents fell from 1,539 in 2012 to 1,297 in Although there has been a decrease in accidents involving scheduled Part 121 operations (commercial air transport), the first fatal accident in three years occurred. On Aug. 14, 2013, UPS Airlines flight 1354, an Airbus A , crashed on approach to Birmingham-Shuttlesworth International Airport in Birmingham, Alabama, resulting in two fatalities of the flight crew. Although the crash of Asiana Airlines flight 214 occurred in the United States, it is not reported in the NTSB statistics because it is a foreign registered carrier operating under Part 129 operations. The number of accidents involving scheduled Part 135 operations (commuter) increased from four in 2012 to eight in 2013 with three fatal accidents. On-demand Part 135 operations, which include charter, air taxi, air tour, and air medical flights, showed increases in all categories in The number of total accidents (44), fatal accidents (10), and fatalities (27) all increased, and the accident rate per 100,000 flight hours increased to 1.24 from 0.99 in The NTSB report notes that with regard to general aviation accidents, there has been a decrease in all measures. The total number of general aviation accidents decreased by 249 in 2013, bringing the number to 1,222. The number of fatal accidents (221), fatalities (387) and the accident rate per 100,000 flight hours (5.85) also declined from the previous year. CORPORATE Civil Avia on Safety Inves ga on and Analysis Center, Nicolae Stoica, General Director Dubai Air Wing Rory Fagan, Safety Manager Air Accident Inves ga on Sector, GCAA, United Arab Emirates Ismaeil A. Wahed, Assistant Director General INDIVIDUAL Asako, Yoshiaki, Frisco, TX, USA Bittinger, Mark, E. Deland, FL, USA Carter, Simon, C. Perth, WA, Australia Changazi, Riasat, Ali Karachi, Pakistan Chow, Stephanie, D. San Marino, CA, USA Cubilete, Nicholas, J. Daytona Beach, FL, USA Doukellis, Apostolos, Larissa, Greece Hill, Dennis, K. Oyster Bay, NSW, Australia Hince, Perry, A. Chelsea, VIC, Australia 6 NEW MEMBERS Johnson, Trevor, J. Frisco, TX, USA Kelly, Maria, E., Daytona Beach Shores, FL, USA Kent, John, A. Co. Meath, Ireland Khaiat, Emmanuel, J. Central Hong Kong Malik, Sanaullah, Karachi, Pakistan Marshall, Paul, D., Nicholls, ACT, Australia Marshall, Stephen, W., Prescott Valley, AZ, USA Millimet, Mark, P. Daytona Beach, FL, USA Moore, Dean, A., Adamstown, NSW, Australia Nori, MSC, ASM, FRAeSHani A. Doha, Qater Raaz, Neil, A., North Richland Hills, TX, USA Rogers, Stephen, Christchurch, New Zealand Schoepke, Devin, R., Daytona Beach, FL, USA Sims, Bradley, A., Newnan, GA, USA Trachalakis, Manousos, Gerakas, Greece Urso, Luca, Geilenkirchen, Germany