This issue is devoted to ISASI 2008 events In · PDF fileThis issue is devoted to ISASI 2008 events. ... or FADEC and trend monitors. ... seminar and to share your considerable expertise

OCTOBER–DECEMBER 2008

In MemoriamPRINCIPLED PROFESSIONALISM

Ronald “Ron” Chippindale(1933-2008)

This issue is devoted toISASI 2008 events

2 • ISASI Forum October–December 2008

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Volume 41, Number 4Publisher Frank Del Gandio

Editorial Advisor Richard B. StoneEditor Esperison Martinez

Design Editor William A. FordAssociate Editor Susan Fager

Annual Report Editor Ron Schleede

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

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

Copyright © 2008—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 ISASI 2008 Speakers Meld Investigation Art, ScienceBy Esperison Martinez, Editor—In aggregate, the 24 technical papers presentedat ISASI 2008 validated selection of the seminar’s theme: “Investigation: The Artand the Science.”

10 Advancing Aviation Safety One Investigation at a TimeBy Wendy Tadros, Chair, Transportation Safety Board of Canada—Remarkspresented by Tadros in her keynote address to the ISASI 2008 air accident investigationseminar delegates on Sept. 9, 2008, in Halifax, Nova Scotia, Canada.

14 C. Donald Bateman Receives Lederer AwardBy Esperison Martinez, Editor—A giant in his field and a long-time ISASImember receives ISASI’s most coveted award.

16 Silver Dart SaluteBy John A.D. McCurdy aka Capt. Gerry Davis—The author dons the personaof John A.D. McCurdy to recap the aviation pioneer’s life and to give a “first person”account of the famous Silver Dart flight and its many achievements.

18 Council Names Three ‘Kapustin’ ScholarsBy Esperison Martinez, Editor—Students from Embry-Riddle Aeronautical Univer-sity, Fla., USA; the University of Limerick, Ireland; and the University of SouthernCalifornia’s Viterbi School of Engineering are the 2008 recipients of the ISASI RudyKapustin Memorial Scholarship Fund.

22 Remembering Swissair Flight 111By Esperison Martinez, Editor—ISASI’s president and a contingent of seminardelegates visit the Baywater Swissair 111 memorial where the remains of the 229persons who perished in the crash are interred.

DEPARTMENTS2 Contents3 President’s View

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

General Aviation Manufacturers Association

ABOUT THE COVERA replica of the Silver Dart as it hangs suspended from the customs clearing hall inthe Halifax Stanfield International Airport. ISASI 2008 used the aero plane in itsseminar logo to commemorate its history and its 100th anniversary construction date.Photo: E. Martinez

CONTENTS

October–December 2008 ISASI Forum • 3

Welcome to Metro Halifax and to ISASI 2008!By Frank Del Gandio, ISASI President

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PRESIDENT’S VIEW

(President Del Gandio’s September 9 openingremarks to the delegates of ISASI 2008 havebeen abbreviated. His entire presentation isavailable in ISASI Proceedings 2008, whichwill soon be placed on the ISASI website atwww. isasi.org.—Editor)

Our theme is “Investigation: The Art and Science.” Mostpeople would agree that the science of accident investiga-tion is better than ever.

Today, we routinely apply precise data from digital flight datarecorders, quick access recorders, GPS and radar overlays,onboard voice recorders, FADECs, and so on. Even the once-humble general aviation aircraft may offer some onboard data,GPS data, or FADEC and trend monitors.

Given all the science available to us today, does art reallycontinue to play a role? The short answer is, “yes.” Accidentinvestigation continues to be a mix of art and science. Just askanyone who visually scans an accident site or anyone who convertsthe digital data to an animated simulation; we know fairlyprecisely what the various parameters are, but we do not neces-sarily know what the airplane was really doing, or what washappening during the fractions of seconds between recordings.

At each of our annual seminars, I briefly note the majoraccidents of the preceding year to remind us that there is stillwork to do. Though some major accidents occurred in the 12months since we met in Singapore, the past year has been a goodyear for aviation safety. By my count, we had 12 fatal accidents,and 8 major fatal passenger accidents. Once again, carriers fromAfrica and central Asia accounted for a disproportionate share ofthose accidents, but the good news is that we had just one majoraccident in air carrier passenger operations in the 30 Organiza-tion for Economic Cooperation and Development (OECD)countries, plus China and India. Those 32 countries account forabout 90 percent of all air carrier operations in the world.

One of the year’s most significant accidents in those 32countries was the non-fatal B-777 accident at Heathrow. When Ifirst heard that both engines had lost partial power at essentiallythe same time after a long flight from Beijing to London, Ithought to myself, “Let me guess, they were running out offuel.” Well, it turned out to be much more complex and moreinstructive. The B-777 investigation is a good example of themarriage between art and science, and of the internationalcharacter of aviation accident investigation. The aircraft took offfrom China, flew a third of the way around the world, andcrashed in the air carrier’s home country in an aircraft that wascertified in a third county.

In short, our profession will always remain at the front line ofaccident prevention, whether we investigate well-understood

accident scenarios or new and complex scenarios.Before I close, I want to make a few comments about our hosts.

Ten years ago last Tuesday, 229 people died in the Swissair Flight111 accident in ocean waters just a few miles from here, nearPeggys Cove. Recalling that crash reminds us about the skill andprofessionalism shown by the Transportation Safety Board ofCanada in a very complex investigation. It also taught us some-thing about the people of Peggys Cove and of Nova Scotia. Theaccident occurred at 9:30 at night. Yet, in the darkness, scores oflocal fishermen and other boat owners voluntarily accepted real

Our profession will always remain at thefront line of accident prevention, whether

we investigate well-understood accidentscenarios or new and complex scenarios.

risk to themselves in setting out to rescue any survivors. Theaccident was non-survivable, but that does not diminish the deep-felt concern displayed by the local would-be rescuers. (See“Remembering Swissair Flight 111,” page 22.)

Also, let’s not forget the Sept. 11, 2001, aviation tragedy. Inaddition to the trauma associated with those events, we Ameri-cans were again reminded of the skill and the generosity of theCanadian people, particularly the people of eastern Canada.

When the U.S. closed its airspace that day, 39 aircraft and6,000 to 7,000 passengers and crew were diverted to Gander inNew Foundland. Nearly as many passengers were diverted toHalifax International Airport. In both communities, the localpeople showed incredible generosity.

The story in Gander was especially impressive. A communitywith perhaps 2,500 homes had to figure out—and quickly—whatto do with 7,000 unexpected guests. Their answer was wonder-fully simple: local people opened their homes to give shelter andfeed and even entertain all 7,000 people for several days, and atno small expense to residents. The hospitality was impressive inHalifax, as well. But, after what we saw at Peggys Cove severalyears earlier, we really should not have been surprised. Onceagain, words like decency and kindness come to mind.

Finally, I will remind everyone that whatever your particularinterest may be in aviation safety or accident investigation, oneor more people in this room will know all there is to know aboutthe topic. I urge everyone, but especially any students or youngaviation professionals who have joined us here today, to takeadvantage of the wealth of knowledge and experience that is inthis room. I also urge everyone to participate actively in theseminar and to share your considerable expertise with anyonewho seeks it out. ◆


Many of the ISASI 2008 attendees, all aviation devotees,who passed through customs at the Halifax Stanfield In-ternational Airport may have felt a twinge of awe or, at

the minimum, surprise, when after departing from the aircraft,traversing the muted terminal passageway into the cavernous cus-tom clearing complex, the first thing that struck their sight was afull-sized fabric and wood bi-wing aero plane suspended from theceiling. Emblazonedunder the aircraft wasa sign declaring “Wel-come to Nova Scotia,”almost as if the displaywas directed to arriv-ing ISASI 2008 del-egates. The biplanewas a replica of the Silver Dart, which made the first controlledpower flight in Canada and the British Empire, and which ISASI2008 chose to honor in recognition of its 100th anniversary con-struction date (see “Silver Dart Salute,” page 16).

By any measure, ISASI’s 39th annual international conferenceon air accident investigation was a success. With the theme of “In-vestigation: The Art and the Science,” the event drew 284 air safetyinvestigators, instructors, regulators, students, and other aviationsafety professionals from 33 countries. Not only were they alltreated to an excellent program, but the venue location and con-ference accommodations also lent an ease to the Monday throughThursday program, which began on September 8 with two 1-day-long tutorials.

Held at the Halifax Marriott Harbourfront Hotel, Halifax, NovaScotia, the conference was provided ample space to conduct itsranging list of activities that included, in addition to the tutorials, atechnical seminar, morning and noon meals, coffee networkingtimes, a welcome reception, ISASI society and chapter meetings,and an awards dinner that seated nearly 300 persons.

And for those precious few evening hours when a delegate couldshed the conference seat, the hotel—sited smack on the HalifaxBay waterfront’s Harbour Walk—allowed one to stroll a line thatflows through the history of its waters: privateers, pre-settlementfishermen, 1749 colonization, immigration administration, Titanicrescue efforts, and a good many more absorbing events.

The air accident investigation conference was organized andpresented by the Canadian Society of Air Safety Investigators(CSASI). Barbara Dunn, Society president, served as chairper-son of the ISASI 2008 committee. Other members included tech-nical program, Jim Stewart and Nick Stoss; sponsorship, RonSchleede and Joe Jackson; companion program, Gail Stewart andPaula Demone; and seminar registration, Sharon Morphew andGary Morphew.

Halifax was selected as the conference location because of itsstrong civil and military aviation history coupledwith its role in the development of transatlantic andinternational civil aviation. Two significant anniver-saries occurred during the conference’s duration:the 10th anniversary of the Swissair Flight 111crash in the waters off Nova Scotia on Sept. 2, 1998,and the terrorist attacks of Sept. 11, 2001, on thetwin towers of New York City. In both instances,citizens of those townships just outside Halifax per-formed extraordinary voluntary rescue and hospi-tality services to those involved in the aftermath ofthe events. (See “Remembering Swissair Flight111,” page 22 and “President’s View,” page 3.)

During the opening ceremonies, President DelGandio introduced C. Donald (Don) Bateman, theselectee for the 2008 Jerome F. Lederer Award (see“C. Donald Bateman Receives Lederer Award,”page 14). Also introduced were the winners of the 2008 ISASIRudolph Kapustin Scholarship: Catherine Rae T. Ricafort, USC;Micheál Ryan, University of Limerick; and Jennifer Gritton, ERAU(see “Council Names Three ‘Kapustin’ Scholars,” page 18).

His opening remarks welcomed all to metro Halifax and thanked“Our hosts, the Canadian Society of Air Safety Investigators. I

ISASI 2008 Speakers MeldInvestigation Art, ScienceIn aggregate, the 24 technical paperspresented at ISASI 2008 validated selectionof the seminar’s theme: “Investigation:The Art and the Science.”By Esperison Martinez, Editor

Photos of ISASI 2008 seminar ac-tivities are available for viewing online at isasi.org. (Photo link is foundin ISASI 2008 promotion box.)

During the 2-day registration period, 339 people registeredto participate in some part of the seminar.

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give special thanks to the president of the Canadian Society, Bar-bara Dunn, who has organized more annual seminars for ISASIthan any other member. Special thanks also to Jim Stewart andNick Stoss for organizing the technical program, to Gail Stewartfor organizing the companion program, and to everyone who helpedto organize yesterday’s tutorials. Lots of other people deservethanks as well, but I will ask their forgiveness if I simply moveonto the seminar.” (See “President’s View,” page 3.)

His talk recapped the great benefit technology and science havebrought to the reduction of aircraft accidents and noted how “acci-dent investigation continues to be a mix of art and science.” Inspeaking about the accident rate for the past year and some of theensuing investigations, he said: “Our profession will always remainat the front line of accident prevention, whether we investigatewell-understood accident scenarios or new and complex scenarios.”

In concluding his talk, President Del Gandio spoke of the tre-mendous investigative effort put forth by the Transportation SafetyBoard of Canada and the humanitarian efforts by citizens of themaritime provinces in the aftermath of the Swissair Flight 111crash, and of the massive show of hospitality Canadians demon-strated when thousands of passengers descended upon their citiesfollowing the grounding of 39 aircraft in the wake of the terrorist

attacks on Sept.11, 2001.

Wendy Tadros,chair of the TSBof Canada, gavethe seminar’sopening keynoteaddress. In speak-ing of advancingaviation safetyone investigation

at a time, she said, in part, “I want to talk to you about the sci-ence behind some key TSB investigations and the contributionthey have made to aviation safety worldwide. In particular, I wantto talk to you about our Morningstar and Air Transat investiga-tions, which have resulted in positive change, thanks to solid in-vestigative work and prompt action by regulators and industryin Canada and abroad.

“I also want to practice the gentle art of persuasion and talk inmore detail about MK Airlines, Air France, and Swissair. Theseare three investigations where we would like to see greater uptakeof our recommendations. With your support, together we couldmake air travel even safer.” (See “Advancing Aviation Safety OneInvestigation at a Time,” page 10.)

ABOVE: Tutorial 1 morning speakers panel, left to right, D. King,panel moderator; H. Mawji; J. Gadzinski; and B. Fisher.ABOVE RIGHT: Tutorial 2 afternoon speakers panel, left to right,T. Baker, H. Harris, and A. Lemishko.

LEFT: Tuesday morning panel, left to right, A. Bouillard, A.Desjardin, T. Crowch, and M. Walker. ABOVE: Thursday afternoonpanel, left to right, A. de Kock, R. Wever, and F. Hilldrup.BELOW: Delegates in assembly at ISASI 2008.


TutorialsNick Stoss, tutorial coordinator, said that the tutorial sessions alsofollowed the seminar theme and added that 121 persons attendedtutorial 1 and 71 tutorial 2. Tutorial 1, in presenting “ConductingSafety Investigation in a Safety and Management Systems (SMSs)Environment,” posed this quandary for discussion: “As the avia-tion industry, worldwide, starts to embrace the concepts of SMS,many are still wondering whether this new approach (which in-cludes confidential and non-punitive reporting, fewer regulatoryaudits, and greater reliance on companies auditing themselves)will be beneficial in advancing safety, or will such an approach ac-tually result in greater risks and potentially more accidents?”

The nine speakers who filled the three segments of the day-long session offered answers to these questions: “What will theimpact of SMS be on safety investigations?” “How do we investi-gate under the shadow of SMS?” Speakers included—Session 1:Bryce Fisher, TSB Canada; Hanif Mawji, Transport Canada; JohnGadzinski, SWAPA; Dave King, UK AAIB (panel moderator). Ses-sion 2: Nick Seemel, ALPA and Air Canada Jazz; Larry Lachance,NAV CANADA; Jacques Mignault, Air Transat; Thomas Dodt,

Boeing (panel moderator). Session 3: Christopher Courtenay, Air-bus; Bryon Mask, Air Canada Pilots Association; Mike Doiron,Moncton Flight College; Danny Ho, EVA Air (panel moderator).

Tutorial 2 subject matter, “Investigating General Aviation Acci-dents” was a meaningful departure from the usual topics of majorinvestigations into accidents involving modern, large transport air-craft. Stoss explained that “ISASI truly believes that there are alsovery valuable lessons that can be learned from investigating smalleraccidents involving general aviation aircraft and helicopters.”

Hence, speakers addressed subjects such as• manufacturers’ safety mandate—how do they achieve it?• balancing the safety mandate and product support mandates• safety board and regulator challenges in conducting generalaviation investigations• investigating general aviation accidents in an environment whereoversight is difficult• what are the challenges facing general aviation investigations?How do we meet these challenges?

Speakers included Vikki Anderson, FAA, tutorial coordinator;Bradley T. Miller, Cirrus Design Corporation; Randy Mainquist,

Speakers and Technical Papers Presented at ISASI 2008

SEPTEMBER 9Welcome Remarks:Frank Del Gandio, President ISASIKeynote Address:Wendy Tadros, Chair, TransportationSafety Board of CanadaDHC-6 Twin Otter Accident off theCoast of Moorea French PolynesiaAlain Bouillard and ArnaudDesjardins, BEA, FranceSW111 and the Modi-PlusModificationTimothy Crowch, Advanced SystemSafety Management, SwitzerlandCausation—What is it? Doesit Matter?Michael Walker, ATSB, AustraliaInvestigator’s Culture IssuesWen-Chin Li, Asst, Professor, NationalDefense University, ROCInternational Investigative SupportSyed Naseem Ahmed, TechnicalInvestigator, Pakistan CAALearning from OthersGraham Braithwaite, Head,Department Air Transport, CranfieldUniversity, UKInvestigation—A Complete Service?Philip Taylor, Senior Inspector ofAir Accidents, AAIB, UK

SEPTEMBER 10Silver DartCapt. Jerry Davis, ALPA CanadaModelling the Investigative ProcessBruce Coury, Transportation ResearchAnalyst, NTSB, USAWeather Risk ManagementJohn Dutcher, Aviation Consultant, andMike Doiron, Aviation Consultant,CanadaApplying HFACS to Major AccidentInvestigations—A ReportYukiko Kakimoto, NPO, Aviation &Railway, JapanExploring Cockpit ConversationsNoelle Brunelle, Product Safety TeamLeader, Sikorsky, USACockpit Information RecorderRoy Fox, Chief, Flight Safety, BellHelicopter Textron, USAOccurrence Site SurveyMichael Guan, Director InvestigationLab, ASC, TaiwanGas Turbines & Ice—The Mysterious CulpritAl Weaver, Instructor, SCSI, USATurbine Engine Risk ManagementRichard Greenwood, Flight SafetyInvestigator, Pratt & Whitney, USA

SEPTEMBER 11What is SMS?Michael DiLollo, Executive Vice-President, Transat Tours CanadaAnalyzing General Aviation AccidentsBob Matthews, Senior Safety Analyst,FAA, USAReducing the Helicopter Accident RateJack Drake, Aviation Safety Consultant,USAInvestigating Organizations with SMSJohn Gadzinsky, Safety Chairman,SAPA, USAUnmanned Aircraft SystemsTom Farrier, Senior Analyst, ASOAS,USAOccupant ProtectionNora Marshall, Investigator, NTSB,USAPresented by Frank HilldrupAnalysis—Evacuation Slide ProblemsGerard van Es, Senior Consultant, NLR,NetherlandsPresented by Rombout WeverAccident Prevention &Investigation ICAOAndre de Kock, ICAO ◆


Cessna Aircraft Company; Andy McMinn, TSI; Ron Schleede,Session 1 panel moderator; Alex Lemishko, NTSB; Doug Baker,TSB Canada; Hooper Harris, FAA; Barry Holt, TSB Canada, Ses-sion 2 panel moderator; Roy Fox, Bell Helicopter Textron; PeterHildebrand, TSB Canada; Andre de Kock, ICAO; Bob Matthews,FAA, Session 3 panel moderator.

Technical seminarThe old adage “If it ain’t broke, don’t fix it” was taken to heartby ISASI seminar planners, as the format for the annual eventremained fixed: 1 day of tutorials and 3 days of technical paperpresentations interspersed with ample coffee breaks and socialtimes to ease professional networking and rekindling of friend-ships. Attendees, who proved extremely faithful in attendingsessions, began their day with a 7 a.m. buffet breakfast, an 8:30-4:30 session broken by coffee time-outs and lunch, and then so-ciety or working group meetings after the daily session.

In announcing the seminar’s Call for Papers in support of the

theme “Investigation: The Art and the Science,” Jim Stewart said,“We are looking for papers that will deal with the hard and softaspects of investigation—in particular, new ideas that will lead usto improved investigation, whether it be techniques, management,process, technology, factual analysis, high tech or low tech…. Forthe art side, we are interested in subjects ranging from dealingwith the news media and relatives to interview techniques and theart of communication.”

The heart of the international conference on air accident inves-tigation, which saw 33 countries represented, was the 3-day tech-nical paper session of PowerPoint presentations displayed on twolarge screens on either side of a raised lectern that looked out onthe row upon row of delegates. In all, 24 papers were presented,although some 30 persons stood before the microphone to makerelated remarks. Each speaker was allotted 30 minutes speakingtime. Before the start of each session, a briefing of the moderatorand speakers was conducted: PowerPoint presentations wereloaded onto computers, trials were run, voice levels were attained,and cautions to “stay on time” were given. After each morning andafternoon session, respective speakers assembled in a panel toanswer questions from the floor, which in most cases were manyand meaningful. (See “Speakers and Technical papers Presentedat ISASI 2008,” page 6.)

Throughout the 3 days of listening and taking notes, the del-egates gained some relief from the need for intense concentrationwhen Barbara Dunn would announce “drawing time” for some ofthe many door prizes made available by sponsoring organizations(see “ISASI 2008 Sponsors,” page 9). Many hats, airplane models,writing tools, etc., were carried away by happy winners.

North Atlantic lobster is the specialty of the house.

In the conference room are coffee breaks and networking time—essential to help hold seminar attendees’ concentration.

In the costal town of Lunenburg, a world heritage site, compan-ions’ visits begin with the Lunenburg Academy—considered oneof Canada’s outstanding examples of a 19th century publicschool architecture.


Other valuable relief came once each morning and afternoonwhen all spilled out into the hallways to fill coffee and tea cups,sample bakery goods, stroll about the product displays, and en-gage in some solid exchange of talk, one professional to another.

Camaraderie timeFor attendees arriving from all parts of the globe, nothing is moregreatly appreciated than a place and time when all can gather andexchange greetings while shaking off the weariness of travel. Thepresident’s Welcome Reception, held on the evening before thestart of the technical session, amply filled that role. For the avail-able few hours, attendees took advantage of the informal environ-ment, enjoyed refreshments and the tasty delicacies that filledbuffet tables, and engaged in greetings, cluster talk, and othernetworking activity.

Following the first day of attendees’ sitting and absorbing theessence of speeches, technical papers, and powerful PowerPoint pre-sentations, the evening’s planned event was a welcome relief and anunforgettable experience for those who had never before been askedto partake of a bright red crustacean with beady eyes and long an-tennae: lobster, boiled, was the order of the evening and was servedwith the pageantry of a bagpipe player in full kilt regalia leading aparade of waiters hefting lobster-filled platters among the seatedguests. Those diners who had no idea how to get at the sweet meatencased in the thick claws received instruction from tablemates.

But it was the companions of the delegates who really got tosample the geography and ocean delicacies of this cold-water land.The 2-day companion program included tours of three coastal vil-lages necessitating travel along the area’s winding seacoast thatone guide said could best be described by looking at the back ofone’s hand with fingers outstretched. A city tour of Halifax andthe Eastern Passageway included historic locations such as the19th century fortification now named the Halifax Citadel. It wasonce the command post and landward bastion of the city’s defenses.It sits atop the highest point in the city, behind heavy masonrywalls and is surrounded by a ditch up to 29 feet deep.

Peer to peerWith an exhaustive 3 days of investigative arts and science discus-sion just hours behind them, seminar attendees made a rapid tran-sition to “dinner guests” at the annual Awards Banquet. This isthe evening reserved for peer-to-peer recognition, to present thecoveted Jerome F. Lederer Award, and to acknowledge otherachievements and efforts.

The dinner refreshment hour carried over to dinner table con-versations raising the din of talk, banter, and laughter to ceilingheight. After dessert, President Del Gandio extended the attend-ees’ thanks to all the planners and the companions’ gratitude to Gail

Stewart for the planning and execution of the companion program.He then announced the winners of the ISASI Award of Excellencefor development of what is judged to be the best technical seminarpaper. The paper “DHC-6 Twin Otter Accident off the Coast ofMoorea, French Polynesia,” which will be published in January/March issue of Forum, was authored by Alain Bouillard, investiga-tor-in-charge, special advisor to the BEA (Bureau d’Enquêtes etd’Analyses pour la Sécurité de l’Aviation civile) and ArnaudDesjardin, safety investigator, BEA Engineering Department.

The selection carries a $500 award from an anonymous mem-ber who wishes to acknowledge a paper at the annual seminar thatmakes an outstanding contribution to the advancement of techni-cal methodologies in aircraft accident investigation. The authorshave announced that they are contributing the $500 to the ISASIRudolph Kapustin Memorial Scholarship Fund.

Special recognition was bestowed upon Jim Stewart for con-verting a vision into a highly successful program. President DelGandio put it like this:

“Reachout was a vision of one-time ISASI President Olof Fritich.In 1999, the International Council adopted the vision and JimStewart became chairman and developer of the program. Basi-cally, its intended purpose is to hold workshops in various loca-tions worldwide to benefit areas having high accident rates by lead-ing to improved accident investigations higher quality reportingand analysis of incidents and reducing risk—that is to improve airsafety. The Czech Republic, through the efforts of Ladislav Mika,became the host for the first Reachout. It was held in Prague inMay 2001. That first seminar had 100 attendees and was a totalsuccess. Since then, there have been 31 Reachout workshops at-tended by more than 1,700 participants who included regulators,airlines, manufacturers, and others.

“Reachout has become a total success for all the right reasons.A cadre of our members has made this happen. However, the mo-tivating and driving force behind Reachout was Jim Stewart. Jimtransformed a vision to a reality. His background, training, skill,

President Del Gandio presents the Award of Excellence to theBEA team for its “best technical paper.” Left to right: F. DelGandio, A. Desjardin, M. Del Bono, and A. Bouillard.


ISASI 2008 SPONSORSGOLD

Air CanadaAirbusBoeing

EmbraerFlightScape

Southern California Safety Institute (SCSI)Bombardier

Transportation Safety Board of Canada

SILVERPratt & Whitney

University of Southern California (USC)Honeywell

Southwest AirlinesDirectorate of Defence Aviation and Air Force Safety

within the Australian Defence ForceAir Canada Pilots Association

BRONZEGE Aviation (GEAC)

Parker AerospaceWestJet

Provincial Airlines

WRIGHT BROTHERSU.S. ALPA

Cranfield UniversityNAV CANADA

Transportation Safety InstituteRTI Group, LLC

and experience, coupled with his can-do attitude, made it happen….Jim, we are indebted to you; thanks for a job well done.”

Stewart hesitatingly stepped to the microphone and said softly,“You don’t do this for this type of recognition, but I certainly ap-preciate it.” When the applause quieted, he added, “When we de-cided it should happen, there is one person I could not have donewithout—Ladi Mika. Thank you.” Before departing the stage, heasked all in the room who may have participated in any of the 31Reachout programs to stand. It was surprising how many peoplehad volunteered their time and knowledge.

Jim Stewart, along with Gary Morphew and Lindsay Naylor,were recognized with the award of “Fellow” membership pins, fol-lowing their acceptance into the coveted class of membership thatnow numbers 24 (see “ISASI ‘Fellows’ Program Makes FreshStart,” page 24).

Corporate members that joined ISASI over the year were alsocited. They included Finnish Military Aviation Authority; KoreaAir Force Safety Center; Qartar Airways; Curt Lewis & Associ-

ates, LLC; Cyprus Aircraft Accident and Incident InvestigationBoard; Northwest Airlines; Dombroff Gilmore Jaques & FrenchP.C.; General Aviation Manufacturers Association; Safe Flight So-lutions; Baines Simmons Americas; Ethad Airways; and NationalAerospace Laboratory, NLR, which was present and accepted itscorporate membership plaque.

Student membership and student interest in ISASI appears tobe growing, albeit slowly. The Society scholarship program hascertainly made an impact. President Del Gandio spoke about theprogram and its need for continued funding through donations sothat it could continue to attract the interest of students such as thethree who were selected to receive the 2008 scholarship awards(see page 18). He also introduced Marissa LaCoursiere, who was a2007 selectee but was unable to attend last year’s seminar.

The evening finale of peer recognition was the presentation ofthe Jerome F. Lederer Award to Don Bateman for fulfilling therequirement of “outstanding lifetime contribution in the field ofaircraft accident investigation and prevention.” The Award wascreated by the Society to honor its namesake for his leadershiprole in the world of aviation safety since its infancy.

President Del Gandio opened his remarks by saying: “I am hon-ored to present the annual Jerome Lederer Award to C. DonaldBateman. He has been a member of ISASI since 1992, and Don canfairly be described as the person who invented the ground proxim-ity warning system (GPWS) and, later, the forward-looking enhancedGPWS (EGPWS). If Don never did anything else in his career, thesetools alone might allow him to say that he has saved more lives inaviation than any other single person who has ever worked in thefield.” Don’s accomplishments include being a pioneer in the devel-opment of angle-of-attack indicators, autothrottle systems,windshear detection, and altitude awareness systems (see “C. DonaldBateman Receives Lederer Award” page 14).

In closing the evening, President Del Gandio exuberantlythanked the seminar’s sponsors. He added that 21 attendees had

joined ISASIand one attend-ing airline be-came a corpo-rate member.He then calledfor the tradi-tional transferof the “cowbell”from Dunn toJayme Nichols,chair of theISASI 2009seminar. ◆

The traditional transfer of the “cowbell” fromDunn to Jayme Nichols, chair of ISASI 2009.


(Remarks presented by Chair Tadros in her keynote address to theISASI 2008 air accident investigation seminar delegates on Sep-tember 9 in Halifax, Nova Scotia, Canada.—Editor)

As chair of the Transportation Safety Board of Canada, it is apleasure for me to speak to the world’s leading safety inves-tigators. In my 12 years at the TSB, I have come to admire

the work you do. I am impressed by both your dedication and yourattention to detail. Today, we have an opportunity to share ourideas and experiences. It is also a great opportunity to discuss thelatest investigative techniques and to foster the strong workingrelationships that are absolutely essential to advancing transpor-tation safety.

This year’s ISASI theme is “Investigation: The Art and the Sci-ence.” I want to talk to you about the science behind some keyTSB investigations and the contribution they have made to avia-tion safety worldwide. In particular, I want to talk to you about ourMorningstar and Air Transat investigations, which have resultedin positive change—thanks to solid investigative work and promptaction by regulators and industry in Canada and abroad.

I also want to practice the gentle art of persuasion and talk inmore detail about MK Airlines, Air France, and Swissair. Theseare three investigations where we would like to see greater uptakeof our recommendations. With your support, together we couldmake air travel even safer.

I want to start by telling you about some very positive interna-tional efforts on two fronts: firstly with Cessna 208 aircraft andsecondly with inspections for composite materials.

Morningstar—loss of control and collision with terrainIn the early morning hours on Oct. 6, 2005, a Cessna 208 cargoplane took off clean from Winnipeg with one pilot aboard. It climbednormally, but within minutes the performance of the aircraft di-minished as ice built up on its critical surfaces. The situation quicklyworsened and the aircraft crashed, killing the pilot.

The TSB did not wait until the investigation was complete tocommunicate with our international partners and to make oursafety recommendations. In January 2006, both the TSB and theNTSB made the following recommendations to advance safety forthe more than 1,600 Cessna 208s flying worldwide: Cessna 208pilots: (1) do not take off into anything more than “light” icingconditions and (2) maintain 120 kts minimum speed in icing con-ditions. Action taken: the FAA issued airworthiness directives(ADs) stating Cessna 208 pilots must: (1) maintain 120 kts mini-

mum speed in icing conditions and (2) immediately exit icingconditions exceeding “light.” Transport Canada adopted both ADs.

The actions taken by Transport Canada, the FAA, and the manu-facturer on design, training, and procedures are positive. I hopethey will mean no more inflight icing accidents with Cessna 208s.

Air Transat—Flight 861, loss of rudderOn March 6, 2005, an Airbus A310 took off from Varadero, Cuba.Seventeen minutes later, the crew heard a loud bang, followed byvibrations. Then the aircraft started to Dutch roll. The crew man-aged to descend, stabilize the aircraft, and return safely to Varadero.Once on the ground, the problem quickly became obvious: The rud-der was missing. This occurrence did not garner a lot of attentionwith the public. After all, the aircraft landed safely and nobody died.

But it certainly intrigued TSB investigators, and they were de-termined to figure out what caused the rudder to fall off a modernaircraft. The Air Transat investigation is another stellar example

Advancing Aviation SafetyOne Investigation at a TimeBy Wendy Tadros, Chair, TransportationSafety Board of Canada

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of international cooperation resulting in positive and concrete ac-tion to advance aviation safety.

What was learned in the initial days of the investigation into therudder’s composite material regarding disbands, hinge damage,and fluid ingress led to Airbus issuing an all operators telex callingfor the inspection of all aircraft equipped with these compositerudders. Four hundred and eight Airbus widebody aircraft wereinspected worldwide. These fleet checks suggested inspection pro-grams may not always find defects in composite materials.

When we learned this, the Board urgently recommended thatTransport Canada, the European Aviation Safety Agency (EASA),and industry come up with an inspection program to detect damagebefore it progresses. In the United States, the NTSB took similaraction, reflecting the importance of international voices. TransportCanada and EASA heard us. Transport Canada is working with theNational Research Council on inspection techniques to detect fail-ures in composite materials, and EASA is working with Airbus.

What followed was the development of early, consistent, andreliable detection programs for composite materials. This ab-solutely could not have been accomplished without solid inves-tigative work and international cooperation. The implementa-tion of the Morningstar and Air Transat recommendations aretwo of our successes.

Now, let’s start by tackling a number of the hard issues in avia-

tion safety today by talking about some areas that need moreimprovement. I would like to see greater uptake of the recom-mendations flowing from the MK Airlines, Air France, andSwissair investigations. These are not easy issues—if they were,they would have been fixed a long time ago. They are the toughissues, and I would like to try to make the case for why I believethese recommendations are so important. Perhaps if I can dothat—if I can gain your support—we can get the ball rolling in-ternationally and make aviation even safer.

MK Airlines—reduced power at takeoffand collision with terrainLet’s look at the investigation of the MK Airlines crash on Oct. 14,2004, at the airport right here in Halifax. A Boeing 747 cargo flighttook off using speed and thrust settings that were too low for itsweight. It hit a berm at the end of the runway, crashed into theforest, and burned. All seven crewmembers died.

Major air investigations are often global in scope, and this onewas no exception. This accident involved an American-built air-craft, registered in Ghana, operated by a Ghanaian-licensed crewworking for a U.K.-based airline. Equally international were theinvestigators. Investigators from the United Kingdom, Ghana, andIceland participated in this TSB investigation.

What’s interesting about this investigation and the reason it’sworth talking about is it was not a “one off.” Indeed there were12 similar accidents worldwide in which four aircraft were de-stroyed and 297 lives lost. When you see one performance acci-dent, the inclination is to say, “Well, the pilot should have fol-lowed the SOPs.” When you see multiple accidents around theworld where actual takeoff performance differed from expectedperformance, you come to the conclusion that additional defensesare needed in the system.

That is why the TSB recommended that Canadian and interna-tional regulatory authorities require a takeoff performance moni-toring system to ensure that crews of large aircraft will be alertedin time when there is not enough power to take off safely. Trans-port Canada committed to working with industry on the develop-ment of a takeoff performance monitoring system. This is a step inthe right direction. The Board is hopeful that a solution can befound to eliminate this safety deficiency.

Air France—runway overrun and fireThis accident took place at Canada’s busiest airport, besideCanada’s busiest highway at rush hour. It would be an understate-ment to say the overrun of an Air France A340 at Toronto caughtthe world’s attention.

On Aug. 2, 2005, with 297 passengers and 12 crew on board, AirFrance Flight 358 approached Toronto in a severe and rapidlychanging thunderstorm with shifting winds and limited visibility.It came in too high and too fast. Touching down 3,800 feet alongthe 9,000-foot wet and slippery runway, it simply ran out of room.The aircraft came to a stop in a ravine; and while the evacuationwas not without its difficulties, everyone got out before fire de-stroyed the aircraft.

The TSB is grateful to the people from the Bureau d’Enquêtes

Wendy Tadros’s keynote address opensISASI 2008, the Society’s 39th annual airaccident investigation conference.


et d’Analyses (BEA), EASA, Airbus, AirFrance, Transport Canada, and manyother organizations for providing informa-tion and invaluable assistance to our in-

vestigators. Thanks to your participation, we developed a compre-hensive analysis of the causes and contributing factors that led toseven recommendations to make air travel safer.

So, what did we learn? We learned this crew was not alone. Sincethe Air France accident in Toronto, at least 10 large aircraft havegone off runways around the world in bad weather. This tells usthat the potential for landing accidents in bad weather remains. Tomake air travel safer, the TSB made seven recommendations. Fiveof them focus on crews and the need for mandatory standards,training, and procedures, and two are aimed at reducing the riskof injury following an accident.

The Board made recommendations asking that TransportCanada and the world’s regulatory bodies limit landings in thun-derstorms and require enhanced pilot training. Our investiga-tion revealed that the Air France crew, like many others, did notcalculate the landing distance required for the conditions at thedestination. That is why we recommended that regulators re-quire these always be calculated, so crews will know their mar-gin of error. The NTSB made a similar recommendation follow-ing an accident in which a B-737 left the runway at Chicago’sMidway Airport.

We also made two recommendations aimed at reducing the riskof injury following an accident.

We took a good, hard look at the terrain at the end of Canada’srunways and found it can increase the risk of injuries to passen-gers and crews. To address this risk, the TSB recommended thatTransport Canada require 300-meter runway-end safety areas oran alternate means of stopping aircraft. This will bring all ofCanada’s major airports in line with international benchmarks.

Lastly, we examined the evacuation. As you know, successful evacu-ations are measured in seconds. We found, despite directions to thecontrary, many passengers stopped during the emergency to taketheir carry-on baggage with them. To improve evacuations, the TSBasked Transport Canada to require that passenger safety briefingsinclude clear direction to leave all carry-on baggage behind.

While the response to many of these recommendations has beenpositive, we are concerned about the response on our recommen-dation calling for runway end safety areas (RESAs) or EMAS(Engineered Materials Arresting System). Let’s not forget that inthe past 25 years, at least one aircraft a month overran a runwaysomewhere in the world. It is my conviction that until this problemis faced squarely, the trend is bound to continue. I believe thisimportant issue deserves more attention from the world’s regula-tors, including Transport Canada.

Swissair—inflight fire leading to collision with waterHere in Nova Scotia, September 2 marked the 10th anniversary ofthe night Swissair Flight 111 crashed off Peggys Cove. It is onlyfitting that I end with this investigation.

On that evening in 1998, Swissair Flight 111, a McDonnell Dou-glas MD-11, departed New York City on a scheduled flight toGeneva, Switzerland, with 215 passengers and 14 crew on board.

About 53 minutes later, while cruising at Flight Level 330, thecrew smelled an abnormal odor in the cockpit. Their attention wasdrawn to the area behind and above them, and they began to in-vestigate the source, which they thought was the air conditioningsystem. After further troubleshooting, they assessed there wasdefinitely smoke and decided to divert to Halifax.

While the flight crew was preparing to land, they were unawarethat a fire was spreading above the cockpit ceiling. Soon thereaf-ter, the aircraft’s FDR logged a rapid succession of system fail-ures. The crew declared an emergency and an immediate need toland. About one minute later, radio communications and radar con-tact were lost, and the flight recorders stopped functioning. Aboutfive-and-a-half minutes after that, the aircraft crashed into theocean with the loss of all 229 souls on board.

The crew did what made sense to them at the time. Knowingwhat they knew, we pieced together the sequence of events. Weran a number of detailed scenarios and concluded that based onthe time available before the fire disabled the aircraft, the crewcould not have landed the plane safely.

The Swissair investigation took four-and-a-half years. It wasthe largest and most complex safety investigation ever undertakenby the TSB. I continue to be heartened by the way in which somany people—from so many places—helped provide this investi-gation with its strength and purpose. Coordinated national and


international efforts and the contributions of many hardworkingpeople like you were absolutely invaluable.

This investigation led to a comprehensive report with the po-tential to change the face of aviation safety. The TSB made 23recommendations, 14 during the investigation and 9 in our finalreport.

These recommendations fall into five broad categories: onboardrecorders, circuit breaker resetting procedures, supplemental typecertification process, material flammability, and inflight firefighting.

We are pleased to see that the Swissair investigation led to im-provements that make flying safer. However, there are areas wherewe think there still needs to be more progress. Let me talk to youabout three of those.

The first material to ignite in the Swissair accident was MPETinsulation. When we discovered this we advised regulators. Canada,the United States, and France required the removal of MPET in-sulation from many aircraft. The TSB learned that, at the time,the flammability test to approve insulation materials was not rig-orous enough. We were pleased to see this test replaced by theradiant panel test.

We would like it if MPET was removed from all aircraft or wewould like to know how the FAA’s alternative means of compli-ance will ensure insulation materials will not propagate fires. Wewould also like to see more stringent testing for all existing insu-lation materials.

Since the Swissair accident, crews routinely divert to land im-

mediately at the first hint of fire or smoke in an aircraft, and theInternational Air Transport Association and the Flight SafetyFoundation have worked together to develop industrywide guid-ance on more effective checklist procedures for smoke and fire.This in turn resulted in some aircraft manufacturers makingimprovements to their aircraft flight manuals. These are posi-tive steps.

What we would really like to see is international adoption of theemergency checklist template. We will also continue to focus at-tention on two areas: the need for designated fire zones and a sys-tematic approach to inflight firefighting.

In the transportation world, aviation has led the way with re-quirements for FDRs and CVRs. With each investigation, we re-fine what data we need to figure out what happened. The Swissairrecommendations are aimed at ensuring crucial data will be avail-able to investigators. The upshot is the FAA now requires that anysingle electrical failure not disable both CVR and FDR. By 2012,the FAA will also require 2-hour CVRs and an independent powersupply providing 10 more minutes of recording time. There hasbeen progress for sure in this important area, and the FAA is lead-ing the way. We would like to see 2-hour CVRs and an independentpower supply as the international standard. We are looking toTransport Canada to harmonize these rules for all Canadian-reg-istered aircraft.

One other outstanding recommendation we feel strongly aboutis the installation of image recorders. These recorders will helpinvestigators to better understand what went on in the cockpitand with the aircraft. The NTSB also made this recommendation.That being said, the cockpit is a pilot’s workplace and I under-stand why they would oppose greater surveillance. This resistancecan be overcome only if the international community protects theconfidentiality of all recordings. We must ensure they will not bereleased and will only be used to advance transportation safety.

Our success depends on supporting each other’s work. I inviteyou to go to our website—www.tsb.gc.ca. There you can learn moreabout the recommendations we have made during the TSB’s 18years. After taking a closer look at these reports, and where youfind similar safety deficiencies, I urge you to carry the flag foraviation safety and adopt the TSB’s recommendations as your own.

Earlier, I spoke to you about how the Morningstar and AirTransat investigations changed the face of aviation safety. And wehave looked at how, as a result of the MK Airlines, Air France, andSwissair investigations, there has been much progress. This wouldnot have been possible without your cooperation and dedication toaviation safety.

And while many recommendations have been implemented, Iwould like to see the face of aviation safety changed even moredramatically. I would like to see all of the recommendations fromthe MK Airlines, Air France, and the Swissair investigations effec-tively implemented.

International cooperation and information sharing are criticalto advancing transportation safety. Let’s work together to makesure that happens.

Tadros’s keynote address opened ISASI 2008, the Society’s 39thannual air accident investigation conference. ◆


Quiet, unassuming, soft-spoken, mannerly, in demeanor verymuch like Jerry Lederer is how this year’s selectee for thecoveted ISASI Jerome F. Lederer Award is best described.

C. Donald Bateman, who prefers “Don,” received the coveted awardat the ISASI 2008 Awards Banquet held September 11 in Halifax,Nova Scotia, Canada.

All readers know the high esteem in which a person selected forthe Award is held, so it might be expected that the person receivingthe Award might be a bit piqued by lack of special attention at theplace of the presentation. In an incident that perfectly reveals Don’snature, President Frank Del Gandio related to the awards dinnerattendees how Don, upon his arrival at the seminar hotel after atiring flight, was told that his room would not be ready for severalhours—so without any complaints or demands, he and his wife settledthemselves in comfortable lobby chairs to wait. “Which is where Istumbled onto them,” said Frank, “and profusely apologized for anymix-up that may have caused the long delay. Don wouldn’t hear of it,and said he ‘enjoyed the rest.’” As the reader can imagine, a properroom was quickly made available for the Batemans.

President Del Gandio went on to introduce Don and make thepresentation of the Award. The president’s remarks very muchillustrate the tremendous effort Don Bateman has put forth in ful-filling the requirement to receive the Jerome F. Lederer Award,

which was created by the Society to honor its namesake for hisleadership role in the world of aviation safety since its infancy:“outstanding lifetime contribution in the field of aircraft accidentinvestigation and prevention.”

President Del Gandio remarked: “I am honored to present theannual Jerome Lederer Award to C. Donald Bateman. He has beena member of ISASI since 1992, and Don can fairly be described asthe person who invented the ground proximity warning system(GPWS) and, later, the forward-looking enhanced GPWS(EGPWS). If Don never did anything else in his career, these toolsalone might allow him to say that he has saved more lives in avia-tion than any other single person who has ever worked in the field.

“That is not an overstatement; Don’s work has saved lives, andlots of them. To give you a sense of scale, from 1945 through 1974the United States alone had 80 fatal CFIT accidents, which killednearly 2,000 people. Since 1974, when GPWS was finally requiredon air transport aircraft in the U.S., we have had just three suchaccidents, all of which occurred abroad in developing countries.Since enhanced GPWS was required some 13 years ago, we havehad no fatal CFIT accidents involving aircraft with an operatingEGPWS unit on board. Don personally deserves much of the creditfor virtually eliminating CFIT accidents in much of the world.

“But GPWS is not all that Don has accomplished. He also was apioneer in the development of angle-of-attack indicators, autothrottlesystems, windshear detection, and altitude awareness systems.

“So how did Don accomplish this impressive list? He did it bybecoming a real student of certain kinds ofaccidents. For example, he is well known forhaving investigated scores of CFIT acci-dents not by kicking tin on site, but by fly-ing the estimated flight paths of every ci-vilian CFIT accident and many near-CFITaccidents that occurred in the U.S., Canada,and Mexico from the late 1940s through thelate 1960s when CFIT accidents were bru-tally common. He filmed every flight path,collected original data, and noted where andwhen warnings could have averted eachaccident.

“Don did this work as an employee ofHoneywell’s Flight Safety Technologies,where he is the chief engineer. In effect, Donoperated a unit at Flight Safety Technolo-gies that can be compared to Lockheed’sfamous Skunk Works.

“In the 1970s Don began to publish hisfindings and his data and began developingthe downward-looking GPWS. As computer

C. Donald BatemanReceives Lederer Award

A giant in his field and a long-time ISASI member.

By Esperison Martinez, Editor

1977—Samuel M. Phillips1978—Allen R. McMahan1979—Gerard M. Bruggink1980—John Gilbert Boulding1981—Dr. S. Harry Robertson1982—C.H. Prater Houge1983—C.O. Miller1984—George B. Parker1985—Dr. John Kenyon Mason1986—Geoffrey C. Wilkinson1987—Dr. Carol A. Roberts1988—H. Vincent LaChapelle1989—Aage A. Roed1990—Olof Fritsch1991—Eddie J. Trimble1992—Paul R. Powers1993—Capt. Victor Hewes

1994—U.K. Aircraft AccidentsInvestigation Branch

1995—Dr. John K. Lauber1996—Burt Chesterfield1997—Gus Economy1998—A. Frank Taylor1999—Capt. James McIntyre2000—Nora Marshal2001—John Purvis and The Transpor-

tation Safety Board of Canada2002—Ronald L. Schleede2003—Caj Frostell2004—Ron Chippindale2005—John Rawson2006—Richard H. Wood2007—Thomas McCarthy2008—C. Donald Bateman ◆

Past Lederer Award Winners


and satellite technology improved, Don later was able to incorpo-rate very accurate topographical maps that became the basis for“forward looking” enhanced GPWS. Don even convincedHoneywell to give customers free access to updates of the terraindatabase to ensure the continued effectiveness of the equipment.

“By honoring Don here today, ISASI joins a long list of organi-zations that have recognized his unsurpassed contributions to safetyaround the world.

“He is a two-time winner of the Flight Safety Foundation’s Ad-miral Luiz de Florez Award (1975 and 1998). He was recognized asa Laureate by Aviation Week in 1994. He received the New ZealandAir Safety Foundation Award in 2002. In 2003, Don was named a“Pathfinder” at the Museum of Flight in Seattle. He was recog-nized yet again by the Flight Safety Foundation in 2006 when hewon the Laura Taber Barbour Air Safety Award.

“Don also has been inducted into the National Inventor’s Hall

President Del Gandio,left, introducesBateman to the assem-bly. Inset shows theLederer Award pre-sented to Bateman.

Bateman spends time with scholarship winners, MelissaLaCoursiere, center, and Catherine Rickafort.

of Fame and he is a Fellow at the Royal Aeronautical Society. Don’scurrent title as Corporate Fellow at Honeywell demonstrates therespect that his peers have for his contributions.

“It is always an honor to introduce a giant in his field. It is espe-cially a pleasure to do so when that giant has been a long-timemember of ISASI. Ladies and gentlemen, please welcome DonBateman.”

Throughout the president’s remarks, the audience could observeDon’s discomfort as his accomplishments, one after the other, weretold. As he walked to the microphone, the 250 dinner guests arosein unison and gave a thunderous applause.

In keeping with his character, Don chose not to make a lengthydiscourse about his selection, rather he recounted a story from hisdays as a youth, about 8, that he says was foretelling of his futurecareer and was his introduction to accident investigation. In tak-ing his audience back to the early 1940s, he told how he and a com-panion were looking out the window and saw a very bright flash oflight. Being young and curious, they eventually went to see what itwas, skipping school to do so.

The next day when his teacher asked why he hadn’t been inschool, he was very forthright and said he spent the time at theplane crash scene, looking at the debris and watching the events.To prove his story, he pulled a piece of fabric from his pocket andhanded it to the teacher, saying he had picked it up at the scene.The teacher examined the fabric, then looked sternly at him andscolded: “You did a terrible thing—you moved some evidence froman accident.”

“As punishment,” he said, “she had us write a two-page reporton what we did, and what we saw. When she read it, she said to me‘You know, you are going to be an engineer because you can’t spell.’”

When the laughter subsided, he closed by saying: “Thanks toall of you for the selfless work that you do. You are all true profes-sionals, and it is a great honor to be here.” ◆

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(The ISASI 2008 Seminar Committee honored the 100th anniver-sary of the construction of the Silver Dart at Baddeck, Nova Scotia,in late 1908, by featuring the biplane in the seminar’s logo design.Made of steel tube, bamboo, friction tape, wire, and wood, the Dartwas powered by a V-8 engine supplied by Glenn Curtis, which de-veloped 35 horsepower at 1,000 rpm. John A.D. McCurdy pilotedhis design on its first Canadian flight from the frozen expanse ofthe Bras d’Or Lake on Feb. 23, 1909. It logged more than 200 flights.The legacy of the Silver Dart continues to live on, and was certainlyenhanced by a special presentation made at ISASI 2008.

Capt. Gerry Davis, an ISASI and ALPA member, donned thepersona of John McCurdy and delighted the audience with a re-cap of the aviation pioneer’s life and a “first person” account ofthe famous Silver Dart flight described above and its many achieve-ments. He has flown more than 18,000 hours in 28 aircraft typesover 31 years and has investigated or participated in three majorfatal accidents including Swissair Flight 111 and a number ofsmaller non-fatal accidents. For 5 years, he served as the vice-chairman of ALPA’s Accident Investigation Board.—Editor)

Iwas born at Baddeck, Nova Scotia, where I spent the earlyyears of my life. In 1906 I graduated from the University ofToronto with the degree of mechanical engineer. Early on I be-

came interested in aviation and in the construction of a machinethat would fly. Dr. Alexander Graham Bell also had a home atBaddeck, Nova Scotia, where he carried on experiments with fly-ing machines. I grew up in the company of the Bell family and wasa familiar presence at Beinn Bhreagh, the Bells’ summer estate. Iwas later among a group of four young men recruited by Bell andhis wife, Mabel Hubbard Bell, to form the Aerial Experiment As-sociation (AEA). As a boy, I had become interested in Bell’s workand assisted him in his experiments.

At that time he was assisted by Simon Newcomb, the eminentmathematician, and Samuel P. Langley, secretary of theSmithsonian Institution. During the course of my studies at TorontoUniversity, I used to return to Baddeck during my vacations andcontinued at these times to work with Mr. Bell and his associates.

The Aerial Experiment Association was formed in the summerof 1907. The members were Dr. Bell, F.W. Baldwin, LieutenantThomas Selfridge, U.S.A., Glenn H. Curtiss, and me. The UnitedStates Army was interested in the development of flight and there-fore had Lt. Selfridge serve as its observer in the Association.

The AEA conducted experiments during the summer and fallof 1907 at Baddeck with tetrahedral kites, with motors, and withserial propellers mounted on boats. The first experimental flight

carried out by the group took place on Dec. 6, 1907. The test air-craft, piloted by Selfridge, was a large, tetrahedral kite placed onpontoons called the Cygnet I. It was pulled by the steamboat BlueHill on Bras d’Or Lake, Nova Scotia. Cygnet I reached a height of51 meters and remained in the air for 7 minutes, but when it landedon the lake the towline was not released and the kite with Selfridgewas pulled below the water’s surface. The kite was destroyed, butSelfridge was rescued.

In December 1907, we decided to move to Hammondsport, NewYork, where Mr. Curtiss had a factory, to build a glider. This movewas made on December 24. We proceeded at Hammondsport toexperiment with gliders and then to build machines that would fly;the members of the Association worked together, although eachone in turn had general charge of the design of a machine.

The first machine built by the Association was called the RedWing because of its color. The first engine Curtiss designed spe-cifically for aircraft was used in the Red Wing. Casey Baldwin suc-cessfully flew it on March 12, 1908, for 97 meters. His second flighttook him 37 meters, but ended with heavy damage to the aircraft.The Red Wing had no controls except an elevator (a control usedto adjust the up and down motion, or pitch, of an aircraft’s nose ortail), and it was this lack of control that led to its destruction.

Following the construction of the Red Wing, other machines weremade. The next aircraft was named the White Wing, and the mem-bers of the Association developed controlled flaps on the wings,which improved stability. These control flaps were soon called aile-

Silver DartSaluteBy John A.D. McCurdy aka Capt. Gerry Davis


rons by anotherwell-known avia-tion pioneer, HariFarman.

T h e W h i t eWing was flownfour times in

1908: first by Baldwin on May 18, for 82 meters; by Selfridge onMay 19, for 73 meters; by Curtiss on May 20, for 310 meters; andfinally on May 23 by myself for 183 meters, landing with a destruc-tive crash in which I was slightly injured. The Association’s nextaircraft was the June Bug. It was flown many times between June21 and August 31, with the longest flight lasting more than 3 kilo-meters. When it was flown by Curtiss on July 4, 1908, it set therecord for being the first aircraft to fly one kilometer in the west-ern hemisphere and received the Scientific American Trophy.

The one called the Silver Dart was designed by me. In this ma-chine I made a flight on Dec. 12, 1908; however, it was the Dart’sfirst Canadian flight, from the frozen expanse of the Bras d’Or Lakeon Feb. 23, 1909, that drew the attention of the world. I rememberthe circumstances of that flight as if it were yesterday. It was a bril-liant winter day and the ice of Baddeck Bay was completely free ofsnow. We wheeled the aircraft out of its shed on the shore amidst theincredulous stares and remarks of a couple of hundred spectatorswho had gathered to witness the event. Having taken my seat, themachine was released by men on skates. After a run of about 100feet, it took to the air. I lifted the biplane about 9 meters off the ice,and I flew the entire length of Baddeck Bay.

I landed on the ice about one-half a mile away and taxied back tothe starting point. One thing that impressed me was the look ofabsolute astonishment on the faces of the spectators, but the thingthat stands out most in my mind of that event was the great plea-sure and animation in Dr. Bell’s face at the completion of the flight.

The younger members of our group did not im-mediately recognize the historic significance of thisflight; however, Dr. Bell, being of mature judgmentin these matters, seemed to have grasped its full sig-nificance and he therefore preserved a permanentrecord of the event by sending telegrams to the newscenters of the world. These were the first publicflights that had ever been made in aero planes. Thefollowing day, I flew the Silver Dart in a graceful 7-kilometer circle.

I continued flying the machine through the win-ter of 1909, making many flights and covering in allmore than 1,000 miles. The flights that I made withthe Silver Dart in Canada were the first flights thathad ever been made in the British Empire.

In 1909 the Curtiss Exhibition Company was formed, and I tookpart in the work of this Company. For several years, I gave exhibi-tion flights in practically every state of the United States east ofthe Mississippi River and also in Mexico. The purpose of theseexhibitions was to advertise Curtiss machines and to obtain fundswith which to carry on the further development of the aero plane.In 1909 I conducted the first wireless experiments at SheepsheadBay Race Track and for the first time sent from an aero plane awireless message.

After the first of January 1910, I carried on these experimentsin Florida and succeeded in both sending and receiving messages.In 1910, I made the first flight across water out of sight of landflying from Key West, Fla., to Havana, Cuba, a distance of 110miles. During this time, I frequently carried messages and pas-sengers for the purpose of demonstrating the uses to which theaero plane could be put.

In the fall of 1914, I moved back to Canada and at the request ofthe government organized a training school for aviators for ser-vice in the war. This was the only aviation school in Canada, and wetrained more than 600 men. I also organized as a subsidiary of theCurtiss Motor Company, the Curtiss Aeroplanes and Motors, Lim-ited, of which I was president and general manager, and ran theschool in conjunction with this Company, the students using themachines that were manufactured by us. This school was carriedon for 2 years and during that time not a single man was hurt.

In later years, I worked in the aviation supply business. DuringWorld War II, I became assistant director of aircraft productionfor the Canadian government, and in 1947 I was named lieutenantgovernor of Nova Scotia.

Depending upon your viewpoint, I surmise that I have, out ofpure interest and childhood fascination with all things mechanical,participated in some “watershed” events in the history of aviationin Canada. ◆

LEFT: John A.D. McCurdy atthe wheel of the Silver Dart atHammondsport, New York.ABOVE: “McCurdy,” akaGerry Davis, relates his storyto ISASI delegates.

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Council Names Three‘Kapustin’ ScholarsStudents from the University of SouthernCalifornia’s Viterbi School of Engineering; theUniversity of Limerick, Ireland; and Embry-RiddleAeronautical University, Fla., USA, have beennamed as the 2008 recipients of the ISASI RudyKapustin Memorial Scholarship Fund.By Esperison Martinez, Editor

It is my pleasure to notify you on behalf of ISASI that you havebeen selected as one of three winners of the ISASI 2008 RudyKapustin Memorial Scholarship…,” read the e-mail message

transmitted by Richard Stone, ISASI executive advisor and one ofthe two scholarship fund administrators, to Catherine Rae T. Ricafort,USC; Micheál Ryan, the University of Limerick; and JenniferGritton, ERAU. The three selectees attended ISASI 2008 and wereintroduced by President Frank Del Gandio to the assembly duringopening ceremonies as was a 2007 winner, Marissa LaCoursiere.

Ricafort is a senior at the USC Viterbi School of Engineering,majoring in industrial and systems engineering, with a minor inmusical theatre. She is a Presidential Scholar and has been work-ing with the USC Merit Research Program for two-and-a-halfyears, conducting research on human factors and runway incur-sions. Her work on runway safety has been published in the LosAngeles Times. Her proposal to create a “master plan for runwaysafety at LAX” has led her research to be recognized and sup-ported by the USC Rose Hills Foundation.

Ryan is an ISASI student member in his third year at the Uni-versity of Limerick seeking a degree in aeronautical engineering.To date he has completed courses in engineering mathematics,mechanics, electronics, air transportation, aircraft vibrations, air-craft design, flight mechanics, industrial organization, finite ele-ment analysis, CAD, mechanics of solids, aerodynamics, thermo-dynamics, engineering materials, fundamentals of aerospace en-gineering, chemistry, and fluid mechanics. He is on an 8-monthcooperative education placement with the Air Accident Investiga-tion Unit of Ireland.

Gritton is in her second year of a masters of aeronautical sci-ence program at Embry-Riddle in Daytona Beach, Fla., USA. Sheexpects to achieve her degree in May 2009 with a dual concentra-tion in human factors and safety systems. She lives in St. Louis,Miss., USA.

The Kapustin Fund was established in memory of all ISASImembers who have died and was named in honor of the formerISASI Mid-Atlantic Regional Chapter president, Rudy Kapustin.The scholarship is intended to encourage and assist college-levelstudents interested in the field of aviation safety and aircraft oc-

currence investigation, according to Stone. Contributions have andwill continue to provide an annual allocation of funds for the schol-arship. Contributions are tax-deductible in the U.S., and may bemade in the name of a specific deceased member payable to theISASI Kapustin Fund and sent to the ISASI home office.

ISASI Vice-President Ron Schleede and Stone serve as execu-tors and administrators of the Fund. They review all applications,which include a 1,000 (+/- 10%) word essay in English addressing“the challenges for air safety investigators.” The scholarship con-sists of an annual $2,000 award, a one-year ISASI membership,fee-free attendance at an accident investigation course at FAA’sTransportation Safety Institute, the Southern California SafetyInstitute, and at Cranfield Safety and Accident Investigation Cen-tre, Cranfield, England.

The scholarship essays of the awardees follow.

The Challenges for Air Safety Investigators:A Human Factors AngleBy Catherine Ricafort

This past year has seen a dramatic increase inair traffic, fuel prices, and delays. Most alarm-ingly, however, there has been a rise in the num-ber of safety risks due to an increasing numberof airlines that fail to follow safety guidelines.These lapses in safety culture are extremelygrave, because they have the potential to killmany people. Air safety is no laughing matter;

“

The 2008 scholarship winners and one from 2007 pose withscholarship fund administrators. Shown, left to right, are R.Stone, C. Ricafort, J. Gritton, M. LaCoursiere (2007), M. Ryan,and R. Schleede.

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for example, aviation history’s most infamous accident led to thedeath of 583 people in Tenerife in 1977, when two Boeing 747 air-liners collided on the runway.

For passengers, pilots, crews, or passerbys, both our key to un-derstanding and our strongest line of defense against future acci-dents lies in the people who dedicate themselves to the role of airsafety investigator. As defined in the ISASI By-Laws, “An ‘air safetyinvestigator’ is a person who is or has been actively engaged in theinvestigation of aircraft accidents or incidents or in accident pre-vention activities designed to identify, eliminate, or control avia-tion hazards before they result in accidents or incidents.” How-ever, this role is not one that is easy to fulfill—it is fraught withnumerous challenges, from difficulty in examining spread-out de-bris as evidence to obtaining credible accounts from witnesses. Themost difficult thing of all is that there is no single cause or answerto be found leading to an accident. The investigator must dive intoa complex system of interacting factors that all intertwine togetherto create an environment of safety risks and hazards. There is onecommon thread among all of these: human factors.

The web of contributing factors to an accident can be capturedby the SHEL Model (Figure 1), which is used in the ICAO’s (In-

ternational Civil Aviation Organization)Manual on the Prevention of RunwayIncursions released in 2007. The Modelillustrates the interaction of Software,Hardware, Environment, and Liveware(humans) in the aviation environment.As noted, any disjoint between theblocks “can be a source of human er-ror.” Thus, human factors issues tie allcontributing components together. Thechallenge to investigators is that theymust analyze all of these blocks to-

gether: Software, Hardware, Environment, and Liveware in or-der to recreate a storyline that explains the cause of a safety breach.In taking all of these into account from a human factors perspec-tive, investigators can help prevent future accidents by controllingaviation hazards.

Environment blockWhen examining the cause of an accident that occurred on or neara runway, investigators must consider the cramped and usuallycomplex configurations of runways and taxi routes at airports.Investigators need to identify every source of confusion in aero-drome layout for pilots, such as runways that were already in use,were under construction, were too short for the plane, or wereintersecting other active runways.

Another major part of the environment is the weather. Investi-gators have to take into account the visibility pilots had due to fog,the slickness of the runways due to rain or snow, and the externalforces due to high winds. Another challenge from the environmentlies in the location of plane wreckage. Crashes may occur anywhere:over jungle terrain, oceans, or snowy mountains. Pieces of debrisor evidence can be spread out over an entire location and can bedifficult for investigators to find. Investigators must navigate alltypes of difficult environments in order to get a full understandingof an accident location.

Software/hardware blockInvestigators have the challenge of trying to understand the situ-ation leading to an accident from cockpit voice recorders and flightdata recorders. While these may offer important evidence, the re-corders are often difficult to understand, damaged from the im-pact, or are completely lost. In addition, new materials such ascomposites that are being used in planes are not as functional foraccident investigation, as they burn much more easily than tradi-tional materials and are not as easy to read for fatigue cracks.Another challenge to investigators is that the use of digital tools inthe cockpit causes data to be lost after the crash. Gauges used inthe past, which are now considered less innovative, actually aremore helpful to investigators as they can be analyzed for their read-ings during the time of flight.

The data that investigators collect from all of these accidentsare implemented into runway surface accident prevention tech-nologies, such as the Airport Movement Area Safety System(AMASS) and the Airport Surface Detection Equipment-Model X(ASDE-X). However, these technologies often fail to aid investiga-tors with actual prevention, as they have to date proven inconsis-tent and unreliable, either issuing false alarms, sounding alarmsseconds too late, or not at all. Also, investigators are also chal-lenged because while there are upcoming promising technologiesthat could help in accident prevention such as runway status lightsand in-cockpit guidance systems, they are not being implementedfull scale due to strapped budgets.

Liveware blockWhen examining an accident, investigators must take into accountall human parties involved in the incident, both before and afterthe actual crash. The investigator is faced with understanding thecultural and language difference among interacting cockpit crewsand air traffic controllers. Investigators also need to examine “airtraffic controller fatigue, which may result from regularly work-ing overtime,” and which “continues to be a matter of concern forthe National Transportation Safety Board” (GAO, Aviation Run-way and Ramp Safety). Controller staffing, workload, and stress,which can lead to the “losing the picture” phenomenon, leave roomfor critical errors. Investigators can also find roots of accidents incontrollers’ communication practices, such as switching and hand-ing over and call-sign changes.

After the crash, investigators have to work with witnesses, po-lice teams, insurance agents, family members, and airline repre-sentatives. This is extremely challenging, as investigators must beprepared to keep an unbiased mind in creating the accidentstoryline while understanding these different parties’ perspectives.While it may be difficult in such a diverse setting with many agen-das and influential energies, investigators must stick to the barefacts in order to create credible reasoning for accident occurrence.

ConclusionAs noted in ISASI’s document entitled “Positions on Air SafetyInvestigation Issues,” “Human Factors: An investigation of an ac-cident or serious incident should include an examination of all fac-tors influencing human performance. This investigation shouldinclude all persons whose decisions and actions could have influ-enced the occurrence.” Investigators are challenged with the need

Figure 1: SHEL Model


to understand human performance in re-lation to all aspects of the SHEL Model:Software, Hardware, Environment, andLiveware. By taking all of these facets intoaccount from a human factors perspective,accident investigators save multiple lives

by effectively collecting incident data to create a repository of in-valuable prevention information. ◆

The Challenges for Air Safety InvestigatorsBy Micheál Ryan

It could be argued that Aesop’s Daedalus becamethe first accident investigator when, in Greek my-thology, he observed the treacle of molten wax,heated by the sun’s rays, which lead to the fail-ure of his son Icarus’ makeshift wings. Unfortu-nately, modern accident investigation rarely leadsto such a simple prognosis. Investigators facemany challenges as they strive to uncover the

cause of an accident. These challenges can be categorized as tech-nical challenges and professional challenges.

Technical challenges arise from the continuous manufacturingadvances made in the aviation industry. While the advent andincorporation of new technologies into aircraft design have un-doubtedly lead to safer, more efficient aircraft, they have madethe job of the accident investigator more complicated when some-thing does go wrong.

Each new generation of aircraft has exponentially more compli-cated systems than the previous generation. This requires acci-dent investigators to expand their capabilities and skills as newaircraft come into service. This century has already seen some ofthe most innovative steps in the history of aviation. Light aircraftsuch as the Cirrus SR-22 and Diamond Twinstar incorporate cock-pit displays akin to those of a modern jet. Aircraft such as theBoeing 787 Dreamliner and Airbus A380 incorporate the latestadvances in composite materials.

Even the most trivial technological advances can have a seriouseffect on an investigator’s ability to investigate an accident effec-tively. In many new aircraft, light emitting diodes have replacedconventional bulbs in navigation lights and annunciator panels.Analysis of a light bulb under a microscope can tell the investiga-tor if the bulb was illuminated at the moment of impact, dependingon the nature of the filament fracture. Thus, very important dataon the condition of the aircraft can be determined. Was the “lowfuel” light on? Was the oil pressure low? LEDs do not contain afilament and as such cannot be analyzed in this way, thus any suchdata on the aircraft condition prior to impact is lost. This makesthe investigator’s task even more difficult.

The widespread use of modern composites in aircraft structuresallows elegant, aerodynamically efficient designs. This comes at acost to the investigator tasked with investigation of an accident tosuch an aircraft. Composites will burn or melt in the presence offire, destroying any evidence of pre-existing structural damage inthe process. This can leave an investigator with no leads as to thecause of an accident.

Returning to the story of Icarus and Daedalus, further paral-lels can be drawn between this myth and the harsh reality of mod-ern accident investigation. Daedalus had the gruesome task of re-covering his son’s body for burial. This personal involvement maybe present in any modern investigation and is a personal challengethat must be overcome by the professional investigator. An occur-rence to a large airliner may result in multiple casualties. At theend of the day, all accident investigators are human and as a resultmay be affected emotionally by such an accident. This makes thetask of investigating the accident even more difficult as all emo-tions must be cast aside in order to conduct the investigation in aprofessional manner.

During the course of an investigation, evidence may be uncov-ered that may alter the course of an investigation considerably.This leads to a further challenge—that of flexibility. An investiga-tor must be able to see the big picture and keep it in mind at alltimes throughout the investigation. He or she must be capable ofreassessing the course of the investigation in the light of new evi-dence and presenting this evidence in accordance with the require-ments of ICAO Annex 13.

One further aspect of flexibility that investigators must contendwith is the ability to deal with rapidly changing circumstances oninitial notification of an accident. On receipt of a call, a normal day’swork in the office can become a journey across the country, oracross the world if appointed as an accredited representative. Thedestination may be inhospitable terrain in inclement weather con-ditions. An investigator must be able to adapt to these circum-stances rapidly and be able to begin the field investigation imme-diately on arrival at the scene. This presents a significant chal-lenge to the investigator, as coordination between various aspectsof the investigation must be completed on the move. It is thereforeimportant that an investigator be a good communicator in order tominimize the stress caused in dealing with this challenge.

An investigation requires the involvement of numerous inter-ested parties ranging from the deceased’s family, legal teams, thenews media, manufacturers, and airlines—each with a reputationand their own agenda. An investigator faces the constant challengeof balancing these agendas against each other. A professional atti-tude must be maintained toward individuals who may make en-quires about confidential information relating to an accident. Inthis news-media-hungry society, this may present a greater chal-lenge than one might perceive.

The prevention of reoccurrences of the same accident scenariois the ultimate challenge facing any accident investigator. The is-suing of safety recommendations designed to prevent reoccur-rences is the investigator’s ultimate goal in any investigation. SRsmust be logical and originate from the findings of the investiga-tion. Recommending a design amendment to a popular aircrafttype may cost millions in installation and recertification costs. Thusa professional attitude must be taken when considering what safetyrecommendations are to be issued. Uneconomical or illogically is-sued SRs may be challenged and rejected by their respective re-cipients. This can negate the overall goal of the investigation andcan be frustrating for the investigators concerned.

The ultimate goal, and the greatest challenge, facing the mod-ern accident investigator is to educate the aviation community aboutthe dangers involved in flying and how these dangers can be re-


duced to an acceptable level of risk through proper planning and aprofessional attitude toward flying at all levels. Unfortunately, thesewarnings can sometimes fall on deaf ears, as was the case whenIcarus was warned of the danger of flying too close to the sun. ◆

The Challenges for Air Safety Investigators:People Want AnswersBy Jennifer Gritton

People want answers. And this statement couldnot be truer concerning air safety and accidentinvestigation. Air safety investigators face pres-sure to find the contributing and leading causesof aircraft accidents. The determination that aninvestigator makes often leads to recommenda-tions for increased safety in the aviation commu-nity. However, the journey to the answers of how

an accident happened is never easy. Many factors contribute tohardships that air safety investigators face on a day-to-day basis,such as the environment, the location of an accident, witness rec-ollection, and preserving evidence. But the most important issuesair safety investigators face in today’s world are pressures fromthe news media and the public to provide answers quickly. Air safetyinvestigators are subjected to enough pressure attempting to ac-curately diagnose the who, what, where, why, and how of an acci-dent. Adding news media speculation and pressure from the pub-lic puts additional, unneeded demands on investigators who alreadyhave enough to worry about.

In today’s technologically savvy world, the public has access to news24 hours a day, 7 days a week. And the news media outlets pride them-selves on being up-to-date on the hour, every hour. However, thisalmost impatient need for information raises questions as to how farreporters will go for fast, quick, and sometimes inaccurate informa-tion. Whether it’s a plane that must burn fuel before landing due toa landing gear problem or an aircraft lost in the deep forest of theRocky Mountains, the news is always “there.” The pressure of al-ways having a reporter “looking over your shoulder” is just the be-ginning for investigators. Almost as quickly as the rescue squads,news media personnel arrive on scene, microphones in hand, search-ing for information. This creates a hectic environment for everyone.It raises concerns about securing the scene, preventing the tamper-ing of evidence, and most importantly the premature release of in-formation. Because investigators do not necessarily arrive on thescene immediately after an accident or incident, these issues areimportant to keep in mind and factor into an investigation.

Following the initial scene investigation and “no comment” in-terviews with the news media, investigators begin the most im-portant part of the investigation process—determining the causeof the accident. When this time arrives, the news reporters havealready released stories stating the vague where and when de-tails. However, they are still left lusting for more information toprovide to the public. That desire creates even more strain on in-vestigators because the pressure then shifts from the basics ofwhat happened to the more complicated procedure of determiningwhy the accident occurred. At this point, investigators themselvesmay be evaluating several possible causes to the accident but those

are merely parts to formulate a larger picture. It’s difficult to ex-plain to the public that even though days or weeks have passed, ananswer is still not available.

The public and news media are not trained as investigators, andit is difficult for them to understand that the most important phaseof accident investigation is gathering all of the evidence for evalu-ation. This creates a sort of “feeding frenzy” environment for thenews media. Every tiny piece of information provided by investi-gators is formulated, twisted, and combined to provide the publicwith what they want despite the fact that the information may lackauthenticity and accuracy. The misconstrued picture the newsmedia can paint can lead parties involved to second-guess whatactually happened. For instance, a witness who provides a state-ment to local authorities at the scene may begin to incorporate theinformation the news media provide. Further into the investiga-tion, that same witness may change his or her statement becausenow he or she has included not only what was seen but also whatthe news media alleged was seen.

The misconception that the news media provide plays a crucialrole once the investigation is complete as well. The news media chooseto present what supposedly happened instead of what actually hap-pened; and since it was the only story available to the public at thetime, it was the opinion that was accepted. What happens now whenthat original judgment differs from the actual probable cause? Un-fortunately, many times the public takes this misconceived causeand seeks to have justice served on whomever they were made tobelieve is responsible. In addition, the investigators find themselvesfacing scrutiny because the informed, accurate conclusion that wasdeveloped differed from the news-media-speculated opinion providedearlier. This scrutiny can cause the public to question the judgmentof investigators and question the timeliness of his or her conclu-sions. Situations like this may eventually cause a rift between orga-nizations like the FAA and NTSB with the public because peoplemay feel that the news agencies take too much of a “relaxed”approach toward determining the cause of an accident.

Lastly, the news media and the public attempt to play a largerole in the safety recommendations suggested after an accidentoccurs. Because the news media lack the formal training that in-vestigators have, the suggestions news outlets provide to the pub-lic are at times uneducated opinions of how the government agen-cies could completely prevent similar accidents from occurring.The news media forget to incorporate pertinent facts such as pilottoxicology, spatial disorientation issues, or aircraft performancespecifications into their initial opinion of what happened. There-fore it is impossible to create a useful and preventative safety rec-ommendation. In addition, once the NTSB or FAA suggests safetyrecommendations, the news media want to scrutinize and implythat what was suggested was not enough.

All of these complications combined have a negative effect oninvestigators’ ability to thoroughly, accurately, and efficiently con-duct an investigation. The pressures experienced by air safety in-vestigators as a result of the news media are excessive and unnec-essary, especially when factoring in the other unavoidable stresses.It is important for investigators to keep in mind the issues thatnews media involvement can create. From this, they can formulateways to keep the public informed with accurate and useful infor-mation without sacrificing the integrity of the investigation. ◆


During ISASI 2008, President Frank Del Gandio led a con-tingent of 25 delegates to the Bayswater Swissair Flight111 memorial to honor the memory of the 229 persons who

perished in the crash of the aircraft in the North Atlantic waters offthe coast of Peggys Cove, Nova Scotia, on Sept. 2, 1998. Del Gandioalso gave thanks to the Canadian citizens for their steadfast supportand hospitality extended to the thousands of passengers who wereforced to land on Canadian soil following the terrorist attacks ofSept. 11, 2001, on the Twin Towers in New York City.

Joining in the remembrance were Wendy Tadros, chair, TSBCanada; the Honorable Geoff Regan, Parliament member; andLaura McCue, rector of the Parish of Blandford, along with sometownsfolk of the area and the ISASI 2008 companions who were atthe shrine as part of their historic tour day. Tadros added a wreathof flowers to the 28 that graced the memorial. Both Regan andMcCue told about the creation and meaning of the memorial.

The Canadian government erected the memorial in memory of“those who perished off these shores,” and in recognition of “thosewho worked tirelessly to provide assistance in the recovery opera-tion and comfort to the families and their friends during a time ofdistress.” Etched into the granite slabs are the names of thosewho participated in the recovery operation and those who perished.The memorial also serves as the interment grounds for the re-mains of passengers and crew. While the communities of PeggysCove and Blandford were central to the recovery operation fol-lowing the crash, Bayswater Beach was selected as a memorialsite because it and a similar memorial in Whaleback have views tothe crash site and to each other, forming a triangular shape that isreflected in the design of the memorials.

Speaking to the assembled group, Del Gandio said, in part:“Thank you for the opportunity to make some comments here to-day on behalf of the International Society of Air Safety Investiga-tors. Ten years ago, 229 people died near by in the Swissair acci-dent. That accident was investigated by our members and theircoworkers from three countries, under the leadership of the Trans-portation Safety Board of Canada.

“We learned a lot from that accident and we were reminded ofsome hard-taught lessons of the past. We learned once again theimportance of getting the aircraft on the ground immediatelywhenever a flight crew has reason to believe they have a fire onboard. We also learned again about the importance of accurateand adequate information in the cockpit. With better informa-tion in the cockpit, the Swissair crew almost certainly would havelanded much sooner in Boston or Portland…. The important thingis that …the learning did not fade with time. The aviation com-

munity really has internalized the core lesson of Swissair 111.“The accident also reminded us of the competence, thorough-

ness, and professionalism of the Transportation Safety Board ofCanada. I say sincerely that all Canadians can be proud of theTSB; it is a world-class organization.

“We also learned something about the good people of PeggysCove and other communities in Nova Scotia. The accident occurredat 9:30 at night, and it was even later before word began to spreadin the local area. Yet, in the darkness, scores of local fishermen andother local boat owners, one by one, voluntarily accepted real risk

Remembering SwissairFlight 111By Esperison Martinez, Editor

to themselves and set out to try to rescue any survivors. We soonlearned that the accident was non-survivable—no victims weresaved, but that does not diminish the heroic efforts of lots of localpeople that night.

“Air safety investigators also learned that the people of PeggysCove would remain hospitable throughout the long investiga-tion… ‘Decency’ and ‘kindness’ were among the words that Iheard at the time.

“Finally, I want to acknowledge the anniversary this week of an-other aviation tragedy: Sept. 11, 2001. Among other things, the eventsof that day caused the United States to close its airspace for severaldays. As a result, 39 aircraft heading across the Atlantic enroute tothe U.S. landed in Gander with nearly 7,000 people on board. Nearlyas many people had to land at Halifax International. In both com-munities, the local people showed incredible generosity.

“But, after what we had seen a few years earlier in Peggys Coveand Blandford during Swissair 111, we really should not have beensurprised by the generous response on 9/11.

“I will close by saying that the International Society of Air SafetyInvestigators and its members continue to have great respect forthe people of Peggys Cove and Blandford. I thank you for the op-portunity to speak here today. I thank you for what the people ofHalifax and Gander did on 9/11, and I thank the people of thisregion for the dignity they showed to those who died in Swissair111, and for the decency and kindnesses they showed to the ISASImembers who worked long and hard on that investigation.” ◆

“We learned a lot from that accident andwe were reminded of some hard-taughtlessons of the past…. The importantthing is that…the learning did not fadewith time. The aviation community reallyhas internalized the core lesson ofSwissair 111.”


ABOVE: Townsfolk and others take part in the memorial cer-emony. INSET: The memorial is situated atop a knoll overlookingthe sea and is flanked by the interment field. LEFT: Reverend L.McCue opens the ceremony with prayer. From left are the Hon-orable G. Regan, L. McCue, President Del Gandio, and W. Tadros.BELOW: President Del Gandio makes his address.

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‘Air Accident Investigation in theEuropean Environment’

ISASI ROUNDUP

The European Society held its inauguralair safety seminar at Cranfield University,Bedfordshire, UK, on April 24-25. Morethan 100 delegates attended. Seminarplanners call it “an overwhelmingresponse to the new event that was aimedprimarily at European members.”Attendees came from all over the world,as far away as the U.S., Africa, and Japan.The emphasis of the technical programwas on current European issues in theinvestigation and prevention of accidentsand incidents.

The program began with the changing

legal framework in the Europeanenvironment and presentations fromregulators and government investigators.There was a lively exchange of views.Rolls Royce and Airbus demonstratedEuropean collaboration in accidentinvestigation—a case study on an AirbusA340 accident that occurred at Quito,Ecuador, in 2007.

Presentations covered the variedchallenges in accident investigation; thechallenges of scale, for example, the A380;the challenges of investigations involvingcomplex systems on board new-genera-

tion aircraft; and the challenges ofaccident investigation in hostile environ-ments. Presenters came from variousEuropean countries, including France,Switzerland, Ireland, and the UnitedKingdom. The seminar was a very usefulforum for members to exchange ideas oncurrent techniques and future develop-ments in accident investigation.

The feedback from attendees was verypositive in terms of the length and extentof the technical program, and ESASIhopes to follow this very successfulinaugural seminar with an annual event.

The main seminar was followed by asocial program that included a visit to theShuttleworth Collection at Old Warden inBedfordshire. About 20 delegates madethe journey to see the unique flyingcollection, which showcases the first 100years of flight and is famous for itsregular flying displays. The visit includeda tour of the workshops, which gave afascinating insight into the painstakingrestoration techniques necessary tomaintain the original Edwardian aircraft.

The seminar also coincided with theopening of the Cranfield AccidentLaboratory facility, part of the CranfieldSafety and Accident Investigation Centre.The opening by Dr. Eddie Trimblemarked the end of his long involvementwith the successful Accident InvestigationCourse run by Cranfield University. ◆

ISASI ‘Fellow’ ProgramMakes Fresh StartPresident Frank Del Gandio has ap-pointed “Fellow” Ludwig Benner chair-man of the ISASI Fellow Board, whichoversees and judges applications forappointment to the coveted membershipstatus. He succeeds Ron Chippindale,who “flew west” in February.

In 1991, ISASI’s Council established anew membership classification of Fellowto provide a vehicle for the Society to givepeer recognition to achievements of those

ABOVE: BernardBourdon from EASAspeaks to the seminarattendees.LEFT: Dr. Eddie Trimbleand Professor GrahamBraithwaite at theopening of theCranfield AccidentLaboratory facility.


members. TheCouncil alsoadopted qualifica-tions and anapplication processfor promotion tothe new Fellowmembership classand established aBoard of Fellows

made up of five or more current Fellowsto administer the program, which becameeffective in 1993.

At ISASI 2008 in Halifax in September,three members of ISASI were honoredwith promotion to Fellow: LindsayNaylor, James Stewart, and GaryMorphew. Since the program’s inception,25 members have been recognized byISASI as meriting this prestigious

membership classand have beenpromoted to Fellowand inducted at theannual seminar.Members fromcountries around theworld, includingAustralia, Canada,Ireland, Israel, NewZealand, the UnitedKingdom, and theUnited States havebeen so honored(see “Fellows”listing, left).

Fellow classifica-tion is a permanentmember status.Whenever you seemembers wearing

the distinctive Fellow lapel pin, know thattheir contributions to air safety andISASI have been judged to merit thisspecial peer recognition.

Chairman Brenner said in speaking ofthe program, “The membership of ISASIundoubtedly includes many moreindividuals whose achievements andcontributions to air safety investigation,to accident prevention, and to ISASImerit the esteem of their peers. ButFellow status is not bestowed: it is anearned status for which application mustbe initiated by members wishing toreceive such recognition. To date, only a

smallnumberofISASI’sworthymembershassubmittedanapplica-tionapplyingfor thispromo-tion. Forthose who

have not yet applied, the “Application forPromotion to Fellow” containing thequalifications for promotion to Fellow, andinstructions for its use, are available onthe ISASI website at http://www.isasi.org/about_fellow.html.

“Applications can be completed andsubmitted electronically. Applicantsshould be aware that none of the qualifica-tions can be waived and incompleteapplications or those lacking supportingdocumentation will not be accepted. TheBoard of Fellows determines from theapplication whether the applicant’scontributions and achievements meritpromotion to Fellow.

“We encourage all ISASI members tobe aware of the Fellow program, and to

Fellow Members

Ludwig Benner, Jr.Dr. Robert O. BescoJohn G. BouldingRon ChippindaleKevin A. DarcyFrank S. Del GandioBarbara DunnDr. David S. HallTerry W. HeaslipCapt. B. Victor HewesKevin HumphreysCurtis L. LewisGary R. MorphewCapt. Lindsay A. NaylorCapt. Mike P. PapadakisJohn W. Purvis

John RawsonItzhak RazIra J. RimsonMax Saint GermainKen SmartJames P. StewartCapt. Richard B. StoneA. Frank TaylorFrank E. Yeend

Members of the BoardLudwig Benner, Jr., ChairmanCurtis L. LewisLindsay A. NaylorIra J. RimsonA. Frank Taylor◆

ABOVE: President Del Gandio (left)announces “Fellow” status for JimStewart and Gary R. Morphew. LindsayNaylor (inset) was unable to attendthe seminar.

“Ludi” Benner, Board chair.

Fellow lapel pin

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Dues Notice

Continued . . .

ISASI ROUNDUP

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either encourage other members whothey think merit recognition to apply forFellow promotion, or apply themselves toreceive recognition for their own achieve-ments. We look forward to receiving theseapplications.” ◆

Reachout Gains NewChairmanPresident Frank Del Gandio has ap-pointed John Guselli chairman of theReachout Committee and its highly

successfulprogram ofprovidingworkshop ininvestigativemethods.Guselli succeedsJames Stewart,who served asthe program’sfirst chair andguided itthrough its

development, growth, and workshops thathave reached more than 1,700 profession-als in the aviation investigative field.

One of the new chairman’s first taskswas to introduce himself to the ISASIcorporate membership. In a letter tothem, he said: “As the newly appointedchairman of the ISASI ReachoutCommittee, I wish to acquaint myselfwith the growing corporate membershipof ISASI. The participation of yourorganization represents more than justa token cash contribution toward theSociety. Indeed, it should be an activeand mutual effort from which yourorganization receives a dividend inaviation system safety and ultimatelythe efficiencies that flow from it.

“The Reachout Committee is seekingnew challenges. It is embarking upon aprocess of confirmation and alignmentwith the safety aspirations of ourcorporate sponsors. In simple terms, the

Com-mittee wants you to determinepriorities for your Committee toconsider.”

He went on to list the aims of theCommittee:• To provide inexpensive training toindividuals and organizations in areas ofthe world where gains in accidentprevention may be achieved.• To advertise the availability of theReachout program to target statesthrough a variety of methods.• To identify members who displayadvanced technical knowledge and whohave a record of successful teaching.• To ensure the high quality of materialsand teaching tools prior to presentation.• To solicit the needs of the recipientparty and to structure and deliver theseminar to fulfill those needs.• To develop methods of financing theseminars to maintain low costs.

He also notified corporate membersthat ISASI has “a broad base of current,confident, and competent instructors whoare equipped with both experience andcultural sensitivity to provide servicesvoluntarily in order to enhance aviationsafety.” Guselli may be contacted [email protected]. ◆

Nominations SoughtFor the Jerome F. LedererAwardThe ISASI Awards Committee is seekingnominations for the 2009 Jerome F.Lederer Award. For consideration, theCommittee chairman must receive thenomination letter before May 31, 2009.

In making the announcement, Chair-man Gale Braden said: “Each year, at ourannual seminar, we recognize positiveadvancements in the art and science of airsafety investigation through the JeromeF. Lederer Award. The criteria for theAward is quite simple. The LedererAward recognizes outstanding contribu-tions to technical excellence in accidentinvestigation. Any member of the Societymay submit a nomination, and thenominee may be anyone in the world. TheAward may be given to a group of people,an organization, or an individual, and thenominee does not have to be a Societymember. The Award may recognize asingle 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.”

He added, “With nominations at an all-time low, I urge you to look at yourassociates in the field of aircraft accidentinvestigation and determine if any meetthe criteria of a nominee.

“Each nominee competes for three

John Guselli

Society BiennialElections Complete

The Society’s biennial election of itsExecutive and the U.S. and interna-tional councillor positions is complete,and all incumbents have beenreturned to office for a 2-year period.

Returned to office through 2010were president, Frank Del Gandio;executive advisor, Richard Stone;vice-president, Ron Schleede; trea-surer, Tom McCarthy; secretary,Chris Baum; U.S. councillor, CurtLewis; and international councillor,Caj Frostell. ◆

Invoices for the 2009 annual dues(January 1-December 31) to ISASIhave been mailed. All individualmembers are asked to checkindividual identification informationand update it, if necessary. Mem-bers are reminded that the deadlinefor payment is Jan. 31, 2009. A feeof $20 will be assessed for latepayments. Credit card paymentmay be made. See the mailedinvoice for details. Checks should bemade payable to ISASI andforwarded to ISASI, 107 E. HollyAvenue, Suite 11, Sterling, VA USA20164-5405. ◆


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CORPORATESafe Flight Solutions

Capt. Majeed Panahi, CEOHassan Al Mousawi, Advisor

Baines Simmons AmericasJerry P. Allen, Managing DirectorJames W. Smith, Managing Director

Etihad AirwaysJohn Downey, Head of Corporate SafetyAhsan Naseer, Manager Safety Investigation

Pakistan International Airlines (PIA)Capt. Mohsin A. Khan, Deputy GeneralManager

INDIVIDUALAdamson, Judith, E., Etobicoke, ON, CanadaAhmed, Riaz, Karachi, District Centre,

PakistanAidukas, Sean, M. Lompoc, CA, USAAnglin, Lori, M., Renton, WA, USAAwbery, Natalie, Godalming, Surrey, United

KingdomBarth, Thomas, H., Denver, CO, USABattison, Irene J., Lake Country, BC, CanadaBeck, Steven, C., Samford, OLD, AustraliaBenassi, Stefano, Calmasino di Bardolino,

VR, ItalyBernhardt, Anna, Kent, WA, USABernhardt, Christian, Munich, GermanyBertaccini, Francesco, Piacenza, ItalyBolton, David, R., Kentville, NS, CanadaBonnassie, Fabien, Montreuil, FranceBrannigan, Laura D, Bexley, NSW, AustraliaBrowning, Jill, G., Ithaca, NY, USACaceres, Claudio, D., Sils Baselgia, GR,

SwitzerlandCalkins, Christopher, P., Miramar, FL, USACalladine, Robert, H., Toowoomba, OLD,

AustraliaCalvert, Alison, Unley, SA, AustraliaCalvert, Fred A., Cold Spring, KY, USACarney, Paul J., Chichester, United KingdomCastellano, Benedict, D., Gambrills, MD,

USAClitsome, Mark, Gloucester, ON, CanadaCollins, Franklin S., Pensacola, FL, USAComeau, Marcel, Guelph, ON, CanadaCreamer, Donald, G., Anchorage, AK, USACullen, Imogen, Auckland, New ZealandDavey, Gareth, E., Palm Cove, QLD,

AustraliaDavie, Bruce F., Vestal, NY, USADavies, Jan, M., Calgary, AB, CanadaDe Bruyn, Maximilian, S, Ternate, Italyde Kock, André L., Montréal, QC, CanadaDecatur, Danielle, M., Ocean , NJ, USADeLandre, Joanne, M., Jerrabombera, NSW,

AustraliaDenison, Joanie, M., Bonney Lake, WA,USADeWaal, Os, J.E., Pretoria, South Africados Santos, Luis, S., Levallois-Perret, FranceDunks, Kristi L., Butte, MT, USAEisenman, Nathaniel B., Manassas, VA, USAFarmiga, Samuel, R., West Chester, OH, USAFoot, James, E., Ottawa, ON, Canada

New Members

Fox, Julianne, M., Los Altos Hills, CA. USAFragoso, Jefferson V., Bairro Sao Joao-

Jacarel-SP, CEP, BrazilFrank, Mark, W., Parker, CO, USAFraser, Robert A., Hollywell, QLD, AustraliaGardon, John, A., Wardell, NSW, AustraliaGarfoot, Kevin, P., Huntingdon, Great BritainGarforth, Anthony, J., Leigh-on-Sea, United

KingdomGaumann, Toby, C., Emerald, VIC, AustraliaGelinas, Raymond, G., Rockland, ON, CanadaGirard, William G., Westwood, LA, USAGopalakrishnan, Vinod, M., Mumbai, IndiaGreaves, Matthew, J., Olney, EnglandGritton, Jennifer J., Saint Louis, MO., USAHarmon, Hobart ,M., Bridgewater, NH, USAHeck, Christian, B. Herndon, VA, USAHietanen, Mikko T., Tikkakoski, FinlandHilldrup, Frank F., Centreville, VA, USAHines, Timothy C., Norfolk, VA, USAHodgson, George L., New Berlin, WI, USAHolt, Barry, W., Spruce Grove, AB, CanadaHorne, B. Eng., M.A.Sc, P. Eng, Vince, H.,

Ottawa, ON, CanadaHorton, Richard E., Virginia Beach, VA, USAHull, Stephen E., Camberley, Surrey,

EnglandJackson, Robert J., Issaquah, WA, USAJamison, Lynette, M., Chantilly, VA, USAJohn, Stephen L., Brisbane, QLD, AustraliaJolicoeur, Yves, Gatineau, QC, CanadaJudge Paddy, Howth, Co., Dublin, IrelandKako, Doma, L., Abidjan 07, Republic of Cote

D’IvoireKaufman, Terry, G., St. Martinville, LA, USAKavoliunas, P. Eng. Michael, A.J.,

Pierrefonds, QC, CanadaKerr, Alasdair, Guelph, ON, CanadaKhan, Mohsin, D.A, Karachi, PakistanKoger, Thomas, H., Bellevue, WA, USAKomlodi, Chris, E., Gilbert, AZ, USALaCoursiere, Marissa P., Lee, NH, USALammas, Janet, I., Wellington, New ZealandLande ,Knut, Royneberg, NorwayLankford, Michael, J., Prospect, KY, USALawrence, Mark, J., Karalee, QLD, AustraliaLawson, Robert, M., Bolton, ON, CanadaLewis, Jeff, L., Toronto, ON, CanadaLovetro, Catherine, A., Queens, NY, USALulkovich, Thomas, J., Scottsdale, AZ, USAMacDonald, Brian, Orleans, ON, CanadaMainquist, Randall, S., Wichita, KS, USAMartinez, Fernando, Candor, NY, USAMattes, William, R., Stafford Heights, QLD,

AustraliaMcCoy, Allen, H., Norfolk, VA, USAMcMartin ,Sandra, K., Lambton, NSW,

AustraliaMeyer, Hans, J., Unley, S.A., AustraliaMiller, Andrew, B., Christchurch, New

ZealandMiller, Bradley, T., Duluth, MN, USANagy, Sanoor, Veszprem, HungaryNizar, Malayeb, Jeddah, Kingdom of Saudi

Arabia

Noe, II, Ronald, E., Rhome, TX, USANortaja, Kimmo, T., Jamsa, FinlandNutter, Christopher, G., Federal Way, WA,

USAOrdor, Maria, U., Mafoluku-Lagos, NigeriaOutlaw, Bert, G., Pace, FL, USAPaase, Justin, T., Kaduna, NigeriaPickering, Robert, E., Derbyshire, United

KingdomPost, Dennis, G., Daytona Beach, FL, USAPoulin, Dan, J., Gatineau, QC, CanadaQuant, Graham, P., Woodbridge, United

KingdomRahman, PM., Khalid, Karsaz Karachi,

PakistanRay, Alan, W., Memphis, TN, USARemmo, Christine, P., Flower Mound, TX,

USARicafort, Catherine, Rae T., Thousand Oaks,

CA, USARichter, Mark, W., Hanover Park, IL, USARivera, Carlos, R., Canyon Lake, TX, USARoberts, James, W., St. Charles, MO, USARobinson, Matthew, G., Chesapeake, VA, USARogachuk, Ted, M., Bay Village, OH, USA,Ross, David, M., Winnipeg, MB, CanadaRussell, Jr., James, F., Centennial, CO, USARyan, Micheál, Thurles, Co. Tipperary,

IrelandSabel, John V., Moon Township, PA, USASachdev, Ashvani K., Bangalore, IndiaSachs, Andrew, W., Renton, WA, USASarwar, PN, Jahangir, Sharea-e faisal,

Karachi, PakistanSawatzky, Jan, J., Federal Way, WA, USASchreuders, Linda, Amsterdam, The

NetherlandsSeemel, Nicholas, S., Fall River, NS, CanadaSerber, Mitchell, L., Springfield, VA, USASingh, Shailender, Southall, United KingdomSjöblom, Hans, M., Linköping, SwedenStimpson, Douglas, E., Cherry Hill Village,

CO, USATamura, Keiichi, Toyonaka, Osaka, JapanThibeault, Serge, Chateauguay, QC, CanadaThomson, Susan, J., Insch, United KingdomTolley, Samuel, J., Cambridgeshire, United

KingdomTripp, Terrance, R., Minneapolis, MN, USATruong, Brian, M., Prescott, AZ, USAUdgir, Prasanna, A., Thane (West), IndiaUngermann, Lee, C.A., Queanbeyan, NSW,

AustraliaVirgin, David, R., Guelph, ON, CanadaWakulchyk, James, D., Calgary, AB, CanadaWard, Stephen, F., Karalee, QLD, AustraliaWatts, William, L., Aurora, CO, USAWestcott, Harry, F., Gig Harbor, WA, USAWheeler, David, K., Sunbury, AustraliaWhipple, Ronald, J., Bedford, TX, USAWhite, Keith, Albion, QLD, AustraliaWin, David, B., Christchurch, New ZealandZanolli, Stefano, Roma, ItalyZappia, Peter, R., Trinity Gardens, SA,

Australia ◆


Continued . . .

ISASI ROUNDUP

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years unless selected. If not selectedduring that time, the nominee can benominated after an intervening year foranother three-year period. This is aprestigious award usually resulting ingood publicity for the recipient and mightbe beneficial in advancing a recipient’scareer or standing in the community.”

Nomination letters for the LedererAward must be limited to a single page.Nominations should be mailed, or e-mailed, to the ISASI office or directly tothe Awards Committee Chairman, GaleBraden, 13805 Edmond Gardens Drive,Edmond, OK 73013, USA; e-mail address,[email protected]. ◆

ISASI Participates inICAO AIG/08 MeetingISASI participated in the all-importantICAO AIG/08 meeting in Montreal,Quebec, Canada, October 13-18 as anInternational Observer Organization. Themeeting was attended by the majority ofinvestigation authorities from around theworld. The agenda included discussionson amendments and improvements toAnnex 13 to the Chicago Convention andother important topics related to accidentinvestigation and prevention. ISASI wasrepresented by Ron Schleede, vice-president, and Olof Fritsch, former presi-dent of ISASI and former chief of theICAO AIG Section. A summary report ofthe meeting will be prepared by Schleedeand Fritsch for an upcoming issue of theForum. Information regarding themeeting agenda and discussion items canbe found at www.icao.int/aigdiv08. ◆

Collective ReachoutReportsMumbai, IndiaA 4-day Reachout workshop program washeld in Mumbai April 15-18. It was thesecond ISASI Reachout seminar to beheld in India. Hosted by Jet Airways, the

seminar was formally opened with acultural ceremony involving the directorgeneral of civil aviation, K. Gohain; thejoint director general of civil aviation,A.K. Chopra; Jet Airways chief executiveofficer, Wolfgang Prock-Schauer; andseminar coordinator, Capt. Hassan Al-Mousawi.

Workshop content included emergencyresponse, safety management systems,human factors, and airline level investiga-tions. John Guselli, Lindsay Naylor, andBrent Hayward from ASASI deliveredthe material.

Organizations represented included theMinistry of Civil Aviation, major Indianair carriers, air traffic control, theAirports Authority of India, AirbusIndustrie, regulatory management,business and general aviation, flyingtraining, service providers, and engineer-ing and maintenance organizations.Attendees exceeded 100 each day.

Generous sponsorship was provided byJet Airways in the form of the Reachoutvenue. This generosity extended to the

conduct and comprehensive administra-tive support for the seminar as well astravel and accommodation for JohnGuselli and Lindsay Naylor.

Manama, Kingdom of BahrainConducted from May 25-29, Gulf Airhosted a Reachout on safety managementsystems and aircraft accident and incidentinvestigation. The program was openedby Björn Näf, Gulf Air’s chief executiveofficer, and Capt. Paolo Fitze, Gulf Air’svice-president of safety.

The lead ISASI instructors were CajFrostell, Joe Jackson, and Mike Dorion.Topics included international require-ments and obligations in ICAO Annex 13,planning and organization for a majorinvestigation, the airline’s rolein a major accident investigation, accidentsite procedures and management, fieldinvestigation, TSB Canada procedures,crisis management, off-scene follow-upwork, flight operations investigation,crashworthiness, human factors, witnessinterviewing, and other related topics.

O. Fritsch, left, and R. Schleede at their delegates table during the AIG meeting.


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A special half-day executive manage-ment introductory SMS briefing waspresented to the CEO, vice-presidents,and 26 (of 30) senior managers. Fullworkshop instruction was given to 33participants, who included safety manag-ers from Bahrain Air, Bahrain AirportServices, Bahrain CAA, Bahrain RoyalFlight, Royal Jet-Abu Dhabi, andEmbraer Aviation Europe. Gulf Airprovided full sponsorship for the work-shop, including transportation, accommo-dations, and workshop lunches.

Jeddah, Kingdom of Saudi ArabiaSaudi Arabian Airlines hosted two ISASIReachout workshops on safety manage-ment systems that spanned 5 days eachfrom June 7-18. Capts. Talal Ageel, vice-president flight operations, and EssamYeslam, general manager of flight opsstandards and QA, opened the firstworkshop.

During the first workshop, ISASIinstructors provided a one-hour executivemanagement introductory SMS briefingto His Excellency, the director general ofSaudi Arabian Airlines, Engineer KhalidAlmolhem, and approximately 20 execu-tive vice-presidents and vice-presidents.Completing the top-level presentation,the instructors retuned to the general

workshop instruction provided by MikeDoiron and Caj Frostell. Workshopcontent included the ICAO requirementsand principles for SMS, SMS lessonslearned, SMS human factors in organiza-tions, stress, fatigue, SMS incident review(including the SHEL model), incidentreporting and in-house investigations aspart of SMS, SMS hazard identification,SMS risk management, and other SMS-related topics.

The second SMS workshop wasopened by Capt. Mohammed AliJamjoom, general manager of corporatesafety for Arabian Airlines. Technicalcontent of the workshop mirrored that ofthe previous instruction that began onJune 7. Participants of both workshopstotaled 47, representing differentdepartments within Saudi ArabianAirlines, which provided full sponsorshipof both workshops—including transpor-tation, accommodations, and workshopbuffet lunches.

PakistanWorkshops were conducted in Hyderabadand Karachi in November 2007. Hostedby the Civil Aviation Authority of Paki-stan, the training was done at the CAATraining Institute in Hyderabad and atKarachi (Jinnah) International Airport

for CAA management and serviceproviders. ISASI instructors were Capt.Elaine Parker and John Guselli.

The CAA Safety and InvestigationBoard sought workshop content todevelop an increased awareness ofcontemporary safety management systempractices in a number of fields. Topicincluded ICAO SMS promulgation inPakistan, establishment of a regionalcontext for SMS use, translation issues,corporate interpretation of SMS, andinstructor consolidation. In Karachi,instructional topics included safetymanagement systems, safety manage-ment system implementation, and safetymanagement system integration.

CAA Pakistan accounted for fullsponsorship with strong support fromWing Commander Syed Naseem Ahmed,technical investigator, the Safety andInvestigation Board, and Beyond RiskManagement of Calgary, Canada, andJCG Aviation Services of Sydney,Australia. ◆

Changes Affect ThreeRegional ChaptersThree of ISASI’s regional chapters haveexperienced changes of officers, who arenow all in place. Changes include—Dallas-Ft. Worth: President, Tim J.Logan; Vice-President, Toby Carroll;Treasurer, John Darbo; and Secretary,Erin Carroll.Rocky Mountain: President, David W.Harper; Vice-President New Mexico,James C. Johnson; Vice-PresidentKansas, Donald F. Knutson; Vice-President Utah, Richard B. Stone;Secretary, Tracy G. Dillinger; Treasurer,vacant.Southeastern: President, Robert J.Randzio; Vice-President, Jayme E.Nichols; Secretary/Treasurer, Dan M.McCune. This Chapter and the FloridaChapter merged, resulting in the reacti-vation of the Southeastern Chapter. ◆

ANZSASI 2009 IssuesCall for Papers

The Australian and New ZealandSocieties of Air Safety Investigatorshave issued their preliminary noticeand Call for Papers for the 2009regional air safety seminar to be heldin New Zealand, June 6-7, 2009, at theDistinction Rotorua Hotel, Rotorua.The regional air safety seminarshosted alternately by the New Zealandand Australian Societies of ISASI havebeen very popular and successful.

Rotorua is at the heart of NewZealand’s volcanic and thermal regionand is a center of Maori culture. Thereis a wide range of adventurousactivities available year round.Rotorua has good domestic airconnections and is a pleasant 3-hourdrive from Auckland.

Papers that address the challengesof modern air safety investigations,operational developments, and currentthinking on safety managementsystems and associated subjects areneeded for the seminar.

Persons wishing to submit a paperfor consideration should provide anabstract (approximately 100 words)plus a brief biography by Feb. 1, 2009, toPeter Williams [email protected];Phone: +64 4 473 3112; Fax: +64 4 4991510. (Please note that NZ time isUTC+13 hours until April, thenUTC+12 hours.)

The abstract can be mailed toNZSASI, 40 Fergusson Road,Halcombe RD9, Fielding, NewZealand. ◆


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, Peter Williams

([email protected])United States, Curt Lewis

([email protected])

NATIONAL AND REGIONALSOCIETY PRESIDENTSAustralian, Lindsay Naylor

([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 Chapter,Vincent Fave

([email protected])United States, Curt Lewis

([email protected])

UNITED STATES REGIONALCHAPTER PRESIDENTSAlaska, Craig Bledsoe

([email protected])Arizona, Bill Waldock

([email protected])Dallas-Ft. Worth, Tim Logan

([email protected])Great Lakes, Matthew Kenner

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

([email protected])Northeast, David W. Graham

([email protected])Pacific Northwest, Kevin Darcy

([email protected])Rocky Mountain, David Harper

([email protected])San Francisco, Peter Axelrod

([email protected])Southeastern, Robert Rendzio

([email protected])

Continued . . .

ISASI ROUNDUP

NTSB Updates ‘MostWanted’ List of SafetyImprovementsThe National Transportation SafetyBoard on October 28 issued its 2009“Most Wanted” list of safety improve-ments. Newly added to the list of 15 areasof concern were improve emergencymedical services (EMS) flight operations,restrict use of cell phones by motorcoachdrivers, and require electronic onboardrecorders by all motor carriers. Amongthe aviation issues removed from the listwas aircraft fuel tank flammability.

The Board believes that a concertedeffort must be made to improve the

safety of emergency medical servicesflights. In 2006, the Safety Board issueda special investigation report addressingthe safety issues involved in theseoperations. Although the Board hasissued recommendations to improveEMS safety, the FAA has not imple-mented the changes. In the last 11months, there have been nine EMSaccidents resulting in 35 fatalities.

The Safety Board believes thatimplementing a safety system for groundmovement with direct warnings to flightcrews will improve runway safety. Alsoissued is a recommendation that wouldrequire pilots to conduct landing distanceassessments before every landing basedon existing performance data, actualconditions, and incorporating a minimumsafety margin of 15 percent. A newrecommendation was added that wouldprovide pilots with information or alertsin the cockpit regarding attemptedtakeoffs from a taxiway or the wrongrunway.

The Board believes that actions need tobe taken to improve flight safety in icingconditions. The FAA has yet to completeefforts to revise icing certification criteria,testing requirements, and restrictions onoperating in icing conditions. A recom-mendation added this year on deice bootsaddresses a widely held, but incorrect,belief that activation of deice boots bedelayed rather than started immediatelyupon entering icing conditions.

Conventional CVRs and FDRs do notshow the initial cockpit environmentleading up to a crash. The Safety Boardbelieves that image recording systemswould provide critical information aboutthe actions inside the cockpit and immedi-ately before and during an accident.

The Board removed the area “eliminateflammable fuel/air vapors in fuel tanks ontransport category aircraft” from the list.

The Board kept “improve crewresource management training for on-demand Part 135 carriers” on the list withno changes. ◆

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 USA 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.

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COMMITTEE CHAIRMENAudit, Dr. Michael K. Hynes

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

([email protected])Board of Fellows, Ludi Benner

([email protected])Bylaws, Darren T. Gaines ([email protected])Code of Ethics, Jeff Edwards ([email protected])Membership, Tom McCarthy ([email protected])Nominating, Jayme E. Nichols

([email protected])Reachout, John Guselli

([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])

Unmanned Aerial Systems, Tom Farrier([email protected])

CORPORATE MEMBERSAAIU Ministry of Transport BulgariaAccident Investigation Board, FinlandAccident Investigation Board/NorwayAccident Investigation & Prevention BureauAeronautical & Maritime Research LaboratoryAeroVeritas Aviation Safety Consulting, Ltd.Aerovias De Mexico, S.A.De C.V.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.

AmSafe AviationAramco Associated CompanyASPA 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.Charles Taylor Aviation, SingaporeChina 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 CentreCurt Lewis & Associates, LLCDCI/Branch AIRCODefence Science and Technology Organization (DSTO)Delta Air Lines, Inc.Directorate of Aircraft Accident Investigations—

NamibiaDirectorate of Flight Safety (Canadian Forces)Directorate of Flying Safety—ADFDombroff Gilmore Jaques & French P.C.Dutch 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 OyjFinnish Military Aviation AuthorityFlight Attendant Training Institute at Melville CollegeFlight Safety FoundationFlight Safety Foundation—TaiwanFlightscape, Inc.Galaxy Scientific CorporationGeneral Aviation Manufacturers AssociationGE Transportation/Aircraft EnginesGlobal Aerospace, Inc.Gulf Flight Safety Committee, Azaiba, OmanHall & Associates, LLCHellenic Air Accident Investigation

& Aviation Safety BoardHoneywellHong Kong Airline Pilots AssociationHong Kong Civil Aviation DepartmentIFALPAIndependent Pilots Association

Int’l Assoc. of Mach. & Aerospace WorkersInterstate Aviation CommitteeIrish Air CorpsIrish Aviation AuthorityJapan Airlines Domestic Co., LTDJapanese Aviation Insurance PoolJeppesenJetBlue AirwaysJones DayKLM Royal Dutch AirlinesKorea Air Force Safety Ctr.Korea Aviation & Railway Accident Investigation BoardKreindler & Kreindler, LLPL-3 Communications Aviation RecordersLearjet, Inc.Lockheed Martin CorporationLufthansa German AirlinesMyTravel AirwaysNational Aerospace Laboratory, NLRNational Air Traffic Controllers Assn.National Business Aviation AssociationNational Transportation Safety BoardNAV CanadaNigerian Ministry of Aviation and Accident

Investigation BureauNorthwest AirlinesParker AerospacePhoenix International, Inc.Pratt & WhitneyQantas Airways LimitedQatar AirwaysQwila Air (Pty), Ltd.Raytheon CompanyRepublic 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 CompanySouthwest Airlines Pilots’ AssociationStar 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 ◆


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WHO’S WHO

The General AviationManufacturers Association

ISASI107 E. Holly Ave., Suite 11Sterling, VA 20164-5405 USACHANGE SERVICE REQUESTED

NON-PROFIT ORG.U.S. POSTAGE

PAIDPermit #273

ANNAPOLIS, MD

WHO’S WHO

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(Who’s Who is a brief profile of, and pre-pared by, the represented ISASI corporatemember organization to enable a morethorough understanding of the organiza-tion’s role and functions.—Editor)

The General Aviation ManufacturersAssociation (GAMA) represents morethan 60 of the world’s leading manu-

facturers of fixed-wing general aviationairplanes, engines, avionics, and compo-nents. In addition to building nearly all ofthe general aviation airplanes flying world-wide today, GAMA member companiesalso operate fleets of airplanes, fixed-basedoperations, pilot/technician training centers,and maintenance facilities worldwide.

Headquartered in Washington, D.C.,GAMA represents the interests of itsmembers to government agenciesthroughout the world. These interestsinclude legislation, safety regulationsand standards, market access, develop-ment of aviation infrastructure, andaviation security.

GAMA also engages with the Interna-tional Civil Aviation Organization (ICAO)on behalf of its members and works withnational and international industrygroups to promote the interests ofgeneral aviation worldwide.

Through its public information andeducation programs, GAMA promotes thebetter understanding of general aviationand the important role it plays in eco-nomic growth and in serving the trans-portation needs of communities, compa-nies, and individuals worldwide.

As part of GAMA’s active committeestructure, the Accident InvestigationSubcommittee is a proactive industryorganization that aggressively promotesaviation safety through effective andethical investigation of aircraft accidents,quality training, and education. This isaccomplished by enhancing communicationand technical excellence among GAMAmembers, government agencies, and otherpublic organizations. GAMA also sponsors

and organizes the General Aviation AirSafety Investigators (GAASI) annualadvanced technical workshop. The work-shop provides general aviation air safetyinvestigators with the most timely anduseful training available on current trendsand “best practices” in the field to ensurethat investigators can perform their safetytasks as optimally as possible.

GAMA’s highest priority is reducing theworldwide number of accidents involving

general aviation air-planes. Using syste-matic, data-drivenanalysis of accidentcauses and factors,GAMA worksdiligently to identifyadverse trends,develop and imple-

ment appropriate interventions, updatetraining standards and materials, anddisseminate safety information. GAMAalso facilitates manufacturers’ interactionwith non-U.S. accident investigationauthorities and works to improve thetimely notification of accident occurrenceand enhanced working relationships.

On other fronts, GAMA strives to refinethe FAA’s data collection for general avia-tion, including the General Aviation Air TaxiActivity and Avionics (GAATAA) survey,and the agency’s general aviation forecast.Working with national aviation authorities,GAMA has also helped to identify accident

precursors and implement appropriateSafety Management Systems (SMSs).GAMA believes in the value-addedintroduction of SMS for entities that haveestablished organizational managementstructures while promoting risk-manage-ment tools for light general aviation.

The Association also works to modern-ize pilot training education standards, akey link in the aviation safety chain. Mostrecently, GAMA has been working to up-date pilot training to properly address theintegrated “glass” cockpits in piston air-planes including working with the FAA ona comprehensive rewrite of its traininghandbooks, as well as working with theFAA to strengthen the biannual flightreview requirements, including the recentissuance of a new biannual flight review aid.

General aviation manufacturers continu-ously invest in the development of newproducts and technologies that increasethe margin of safety. Electronically con-trolled engines, anti-ice systems, enhancedand synthetic vision systems, satellite-based navigation and weather, terrainawareness warning systems, and newcommunications and surveillance technolo-gies all significantly contribute to makinggeneral aviation safer. In fact, the FAAreported that in calendar year 2007, thenumber of fatal general aviation accidentsdropped 6 percent, which is the safest yearon record for general aviation since theFAA began tracking safety statistics. ◆

Documents

This issue is devoted to ISASI 2008 events In · PDF fileThis issue is devoted to ISASI 2008 events. ... or FADEC and trend monitors. ... seminar and to share your considerable expertise