Air Safety Through Investigation OCTOBER-DECEMBER 2015 … · OCTOBER-DECEMBER 2015. Augsburg, Germany: ISASI 2015 ‘Independence Does Not Mean Isolation’ Page 5. Divorcing the

Air Safety Through InvestigationJournal of the International Society of Air Safety Investigators

OCTOBER-DECEMBER 2015

Augsburg, Germany: ISASI 2015 ‘Independence Does Not Mean Isolation’Page 5

Divorcing the Regulator: The Establishment of an Independent Investigative AuthorityPage 14

Ladislav Mika Is ISASI’s 2015 Lederer Award Recipient Page 11

ISASI Scholarship Recipients Receive AwardsPage 16

Towards the Next Generation of HUMS SensorPage 19

Change Point Analyses Applied to SMSPage 26

“Many thanks to ISASI for awarding me this honor and to Jerry for dedicating his life to aviation safety. I accept this award in appreciation of my entire life’s professional activities in aviation safety….”—Ladislav Mika, Jerome F. Lederer Award Recipient

2 • October-December 2015 ISASI Forum

CONTENTS

Publisher Frank Del Gandio Editorial Advisor Richard B. Stone

Editor Esperison Martinez Design Editor Jesica Ferry

Associate Editor Susan Fager

Volume 48, Number 4

ISASI Forum (ISSN 1088-8128) is published quar-terly by the International Society of Air Safety Investigators. Opinions expressed by authors do not necessarily represent official ISASI position or policy.

Editorial Offices: Park Center, 107 East Holly Avenue, Suite 11, Sterling, VA 20164-5405. Tel-ephone 703-430-9668. Fax 703-430-4970. E-mail address [email protected]; for editor, [email protected]. Internet website: www.isasi.org. ISASI Forum is not responsible for unsolicited manuscripts, photographs, or other materials. Unsolicited materials will be returned only if submitted with a self-addressed, stamped enve-lope. ISASI Forum reserves the right to reject, delete, summarize, or edit for space con- siderations any submitted article. To facilitate editorial production processes, American Eng-lish spelling of words will be used.

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Publisher’s Editorial Profile: ISASI Forum is print-ed in the United States and published for profes-sional air safety investigators who are members of the International Society of Air Safety Inves-tigators. Editorial content emphasizes accident investigation findings, investigative techniques and experiences, regulatory issues, industry ac-cident prevention developments, and ISASI and member involvement and information.

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INCORPORATED AUGUST 31, 1964

Air Safety Through InvestigationJournal of the International Society of Air Safety InvestigatorsFEATURES

DEPARTMENTS

ABOUT THE COVER

5 Augsburg, Germany: ISASI 2015 ‘Independence Does Not Mean Isolation’By Esperison Martinez, Editor—Hosted by the ISASI European Society of Air Safety Investigators, the annual ISASI conference drew 344 delegates and guests from 43 countries.

11 Ladislav Mika Is ISASI’s 2015 Lederer Award Recipient By Esperison Martinez, Editor—The 2015 presentation marks the 39th year that ISASI has presented the award.

16 ISASI Scholarship Recipients Receive AwardsBy Esperison Martinez, Editor—ISASI 2015 awards banquet attendees loudly rec-ognized the four recipients of the ISASI Kapustin memorial scholarships.

14 Divorcing the Regulator: The Establishment of an Independent Investigative AuthorityBy Capt. Ibrahim S. Koshy, Director General, Aviation Investigation Bureau, Kingdom of Saudi Arabia—This paper received the Best of Conference Award of Excellence for technical papers presented at ISASI 2015.

26 Change Point Analyses Applied to SMSBy Paulo Manoel Razaboni, Embraer Air Safety Department—The author offers a method to better understand the behavior of safety-related items, using a statisti-cal approach to support strategic decisions like resources assignment or product change requests.

19 Towards the Next Generation of HUMS SensorBy Dr. Matthew Greaves (MO5700), Head, Safety and Accident Investigation Centre, Cranfield University—The author describes a research program that aims to inform the next generation of helicopter health and usage monitoring systems (HUMS) by identifying and proving feasibility for new and newly applied sensing technologies, with a specific focus on internal sensors for rotating systems of helicopters.

2 Contents3 President’s View—Aviation’s Global Impact on Improving Air Safety32 Who’s Who—Flight Data Systems: A Multi-Avionics Product and Service Provider

ISASI President Frank Del Gandio, right, presents the prestigious ISASI Jerome F. Lederer Award to Ladislav (Ladi) Mika, the 2015 recipient (see page 11), before a banquet audi-ence of 280 ISASI delegates and guests.

October-December 2015 ISASI Forum • 3

emerging chal-lenges that really do not recognize national borders and that are shared in varying degrees by all of us. This is simply my shopping list, and the items are not in any particular order.

Labor Shortage.A serious pilot shortage has been pre-dicted for years, and it has arrived. The same shortages were developing on the maintenance side, and those shortages also have arrived. The entire industry faces significant shortages in both fields. Most people in this room can list several reasons to explain the shortages: (1) pay structures, especially in the regional industry; (2) fewer well-trained pilots and mechanics migrating to the airlines from military organizations; (3) the cost of pri-vate training; (4) the challenges and costs of training employees with no experience; (5) the shrinking world of general aviation and more.

Some of the causes, such as pay structures, have fairly obvious solutions, at least in theory. Other causes are not so easily fixed. Either way, shortages of skilled workers could raise serious chal-lenges for regulators and operators.

Cargo AccidentsMost of us recognize the enormous improvements that have been achieved in safety over the past 15 years or so, especially in passenger transport. The story is less impressive in the cargo world. Though rates also have improved in cargo operations, accident rates by any measure remain far too high. Depending on who is counting, the cargo hull loss rate is rou-

PRESIDENT’S VIEW

Aviation’s Global Impact on Improving Air Safety

Welcome back to Europe. This is the first ISASI accident investigation and prevention conference on the European

continent since Barcelona, Spain, in 1998 and the first anywhere in Europe since Shannon, Ireland, in 2000. The good news for ISASI is that we have returned to one of Europe’s oldest cities whose story can-not be outlined in just a few minutes; but I will try at least to offer a sense of what this city has witnessed in its long history.

Keep in mind that I come from a rela-tively young country, the United States. In my country, people often fight hard to save buildings that are 100 years old or less because they are thought to be inher-ently “historic.” Compare this kind of per-spective to a community like Augsburg. It was named after Roman Emperor Augus-tus, and its origins date to at least 15 BC when it was founded by the Romans as a military base. Augsburg was established as a provincial capital of the Roman Em-pire 1,900 years ago. It was sacked by the Huns 1,600 years ago and by Charlemagne 1,300 years ago. It became an imperial city nearly 750 years ago, which means it was essentially autonomous and subject only to the emperor.

Like many cities in Germany, Augsburg also was a central player in the Protestant Reformation, and it lent its name to the Treaty of Augsburg, which temporarily ended religious conflict in Germany in 1555. The city then was a central player in the 30 Years War. It also is home to the first effort to establish what we today would call social housing, with the walled district of Fuggerei—which was estab-lished almost 500 years ago and is still part of this city.

All this and more about Augsburg likely is well known by every German in the audience and by many other Europeans here today. However, I really cannot hope to do justice to this city’s long history, so I will excuse myself from this topic and move on to the reasons for which we are here: to share our knowledge and insights about accident and incident investiga-tion and to continue improving aviation safety.

The theme of this year’s seminar is a good one: “Independence Does Not Mean Isolation.” At a minimum, the theme reminds us that aviation is among the oldest of truly global industries, and it becomes more globalized every day.

For example, most major accidents to-day remind us that nationals from all over the world can be found on any interna-tional flight or long-haul domestic flights. Several recent crashes illustrate this point. The 150 fatalities from the German-wings Fight 9525 accident were from 18 countries. Malaysia Airlines Flight MH17 had fatalities from at least 12 countries, while Malaysia Airlines Flight MH370 car-ried people from at least 14 countries.

Even if a major accident is a rare event for a country or especially if a country has persistently high accident rates, all of us can be affected. Our aircraft operate to and from other countries, fly over third countries, and can have a major accident in any one of those locations. Even a domestic flight is likely to carry nationals from more than a single country.

In short, though each country may indeed be independent, the nature of aviation means that we really are in this together. No one operates in isolation, and safety risks or problems are not con-tained by national borders. One country’s chronic problems or newly emerging challenges are everyone’s problems and challenges.

Here is my short list of chronic or newly

By Frank Del Gandio, President

(ISASI President Del Gandio’s opening re-marks to the delegates of ISASI 2015 on Aug. 25, 2015, at Augsburg, Germany, have been abbreviated.—Editor)


tinely computed to range between 10 to 20 times higher than the rate in passenger transport. That has to change.

The cargo industry often cites older fleets, back-side-of-the-clock flying, and flights into remote and ill-equipped airports. Older fleets have an obvious if costly cure. The argument about remote locations has some merit, but most cargo hull losses in fact occur in typical airspace and at the same airports that are fre-quented by passenger operators. Back-side-of-the-clock also has some merit, but it’s overstated. The bottom line is that the commonly cited factors cannot hope to explain tenfold to twentyfold disparities. Something needs to change.

AutomationAutomation has produced huge net gains in safety. However, the very success of automation has introduced new risks. As automation becomes ever more sophis-ticated and effective, pilots have less and less experience flying by hand. This has been recognized for years, but changes in the pilot population and changes in how we learn to fly and how we structure recurrent training have brought the issue front and center today. Though major ac-cidents have become rare events, several of those rare events over the past eight years or so have involved software that flight crews did not fully understand or displayed pilots’ inability to transition to manual flying.

For good reason, pilots tend to rely extensively and, in practice, sometimes exclusively on automation to handle not just normal flight but any emergency that

may arise. The good reason is that things usually work out because the automa-tion really is remarkable. The down side is that when crews need to intervene, they may simply fail to recognize that they need to do so, or they may wait too long to take action, or they mishandle the transition to manual flight.

This is not an easy problem to solve. It suggests that changes are needed in the type and quantity of training. It may mean changing routine flight regimes to ensure at least some hands-on flying, and it might require more line flying and more hands-on time for instructors. Whatever the appropriate fixes might be, they will not come cheaply, but some-thing has to change.

Managing Rapid GrowthThe shortage of skilled pilots and skilled mechanics is coming at a time in which much of the aviation world is experi-encing amazing growth rates. Even if the world economy slows down a bit in the next couple of years, many markets already have grown so much that even slower growth will continue to put severe pressure on the labor pool. It also will put pressure on operators who may lack experience in managing large fleets, large workforces, and so on. It also will add pressure to an urgent need to improve the competence and the de facto authority of regulatory bodies in some countries, and the need to improve the capacity and independence of accident investigation authorities in some cases.

Unmanned Aerial SystemsUnmanned aerial systems (UAS) have huge promise for entire economies, and they should deliver significant improve-ments in safety. For example, UAS might replace a lot of high-risk flying in aerial applications, surveillance, traffic moni-toring, news coverage, and a host of other low and slow flight regimes. I suspect none of us can yet imagine all the applica-tions of UAS that may seem routine in just 20 years or even 10 years from now.

However, the technology is still in its relative infancy. UAS has come a long way quickly, but the aviation community is struggling to incorporate the technology because that technology still has some distance to go before it is ready for full integration into civil airspace.

Rapid expansion of this technology poses challenges for accident investiga-tion authorities, but especially for regula-tors who face contradictory challenges. Regulators are being told to get out of the way—but make sure nothing goes wrong. The demand to make sure nothing goes wrong helps to explain caution by many regulators. Yet regulatory decisions need to be made, and soon. Some decisions have been made, but many more remain. In short, integrating this new technology is imperative, but it will require a difficult balancing act.

SuicideFinally, at least in my estimation, pilot suicide has become the new issue of the day. Germanwings and speculation about MH370 are the obvious sources of this new issue. The aviation community is hearing demands that we figure out how to identify pilots who are vulnerable to suicidal behavior. I recognize that more than a little work has been done in this area, and I fully understand that every-one could benefit from identifying those pilots. But I simply do not see how the aviation community is to become the first sector of society to successfully screen everyone.

This short list is not comprehensive nor is it likely the best short list around. Every- one in this room could add to the list or find good reason to delete one or more of my items. I also recognize that more than a few folks here might strongly disagree with a comment or two that I’ve made.

My real point is simple. We cannot get complacent with the success of the recent past. We still have challenges to address, and we will continue to have some ac-cidents. Our job is to minimize those acci-dents, and I hope this conference makes at least a modest contribution to that effort.

I close with a few short remarks. First, please participate fully in this conference. Share your knowledge and be willing to learn from the knowledge and expertise that everyone else brings here. If you are a student or if you are new to the field, take full advantage of the knowledge that you see walking around here. Ask questions. Whatever question you might have, someone here can give you an authorita-tive answer. Finally, enjoy this conference, enjoy this beautiful city, and enjoy its environs.

“No one operates in isolation, and safety risks or problems are not contained by national borders. One country’s chronic problems or newly emerging challenges are everyone’s problems and challenges.” ISASI President Del Gandio


Augsburg, the city venue for the confer-ence, is the third-largest city in Bavaria and one of Germany’s oldest cities. It was founded by the Romans in 15 BC under Caesar Augustus, after whom the city is named. It also has an equally long tradi-tion as a city of aviation and aerospace technology, as its Lord Mayor Dr. Kurt Gribl told conference attendees at a wel-coming reception held in the Golden Hall of City Hall.

It was only at social functions such as the lord mayor’s reception that del-egates were able to see and enjoy the flavors of the city and its attrac-tions. Their days at the cavernous convention center were steady labor from 9 a.m. to 5 p.m., with official social functions following in the evening.

The conference

Augsburg, Germany: ISASI 2015 ‘Independence Does Not Mean Isolation’Hosted by the ISASI European Society of Air Safety Investigators, the annual ISASI conference drew 344 delegates and guests from 43 countries.

By Esperison Martinez, Editor

Of the 344 delegates and guests attending the 46th annual international accident investiga-tion and prevention conference

in Augsburg, Germany, on Aug. 24–27, 2015, 119 were first-time attendees. The annual conference, featuring the theme “Independence Does Not Mean Isolation,” was the first to be held on the European continent since Barcelona, Spain, in 1998 and the first anywhere in Europe since Shannon, Ireland, in 2000.

program followed those of past years: a full day of two tutorial workshops, three days of technical paper presentations, three evening social events, three days of companion tours, and a full day of sight-seeing after the conference closed follow-ing the awards banquet. The sightseeing day is an add-on and at an additional cost.

The hosting European Society’s Plan-ning Committee stayed involved over a two-year effort to locate and confirm the venue, hotel, and conference center and develop the budget and technical and social programs, review and adopt techni-cal papers, and oversee registration tasks. The committee members included Keith Conradi, society president and confer-ence chairman; Alistair Mann (IT); Klaus Ardey (Augsburg liaison); Olivier Ferrante, Simon Lie, and Brian McDermid (Techni-cal Committee); Matt Greaves (treasurer); Jens Friedemann (German liaison); and Martine Del Bono (public relations).

Tutorial workshopsThe conference’s tutorial workshops keep growing in popularity. The workshops generated an attendance of 173 individu-

Conference committee members. Left to right, A. Mann, K. Ardey, O. Ferrante, M. Greaves, J. Friedmann, M. Del Bono, and K. Conradi.

Registration morning was busy.

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als. Of this total, 90 attended the Social Dimension of a Safety Investigation Work-shop, and 83 attended the Military In-vestigations Workshop. Both workshops shied away from audience interactive activities and instead relied upon speaker PowerPoint presentations. The social dimension workshop had eight speakers, while the military workshop had 12.

Presenters at the social dimension workshop included Marcus Costa, chief, Accident Investigation Section, Interna-tional Civil Aviation Organization (ICAO); Olivier Ferrante, European Commission; Barbara Crolow, HIOP AF447; Martine Del Bono, BEA France; Wieslaw Jedynak, SCAAI Poland; Linda Tavlin, LJT Associ-ates, Inc.; Capt. Adrian Jenkins, Air Asia; and Michel Guerard, Airbus.

Speakers at the Military Investigations Workshop included Mike Gamlin, Rolls-Royce; Jens Friedemann, the BFU; Mike Buran, Lockheed; Andreas Kern, German military; Maciej Lasek, SCAAI Poland; Luis Garcia, Airbus military; Robout Wever, RNLAF; Pete McCarthy, Cranfield University; Jim Roberts, Boeing military; Dave Harper, U.S. Air Force; Bret Tesson, Boeing military; and Wing Commander Neil Bishop, UK military, AAIB.

In summarizing the papers presented at the Social Dimension of a Safety Inves-tigation Workshop, Ferrante noted that the social dimension has grown in impor-tance and has become more and more de-manding with each succeeding year. The

social aspects are the “nontechnical” ones that complement the technical actions conducted by safety investigation au-thorities after an accident. They notably encompass victims/families (relatives)/colleagues; politicians; news media/the public; and legal/insurance—individuals and organizations.

From a global framework, Ferrante said that states that have faced major civil aviation disasters have, based on their experience, reinforced their procedures in relation to their national emergency plans, most notably regarding the assis-tance to the victims and their relatives.

He went on to say: “ICAO recently re-leased its Policy on Assistance to Aircraft Accident Victims and their Families and updated other related documents (as well as a number of SARPs in Annex 9 and An-nex 13). In Europe, member states have the obligation to establish civil aviation accident emergency plans at the national level. These plans must cover assistance to the victims of civil aviation accidents and their relatives. EU air carriers also have the obligation to adopt a plan, which must be audited by the member states, to assist the victims of civil aviation acci-dents and their relatives.

“After fatal civil aviation accidents, there are generally two, and sometimes three, separate investigations that need to be closely coordinated since they share the same evidence:

• An accident (or safety) investigation

is conducted by the national acci-dent investigation authority (or by an ad-hoc investigation commission if the state does not have a permanent investigation authority) to prevent future accidents. (This is also known as the Annex 13 investigation.)

• An investigation may arise from civil litigation, the results of which are intended to compensate victims.

• A judicial/criminal investigation may be opened with the aim of adminis-tering justice to punish wrongdoers.

“Victims and their relatives need to be informed about the respective objectives of the different processes (safety versus civil litigation versus judicial investiga-tions). It must be emphasized that the sole objective of a safety investigation is the prevention of accidents and incidents.”

Turning to the issues and challenges, he said, “Despite policies and procedures, it remains quite difficult to meet the needs of the victims and their relatives after a major air accident, as well as to anticipate the political dimension all of this entails. It is important to remember that the families have a very limited understand-ing of what the many different agencies are doing, who is in charge, and what is expected from them [the families.] They want to know what happened; they want to visit the crash site and get their loved ones back.

“The new ICAO guidance details roles for governmental and nongovernmental organizations with emphasis on the role of a national coordinator, which should interface with all entities. However, when dealing with the progress of the safety investigation, it is essential that, where possible, families are directly informed about the safety investigation by the safety investigation authority. Organiz-ing a visit to the accident site can pose a number of difficulties.

“The wave of solidarity triggered by the tragedy and embraced by the politi-cal world through the various steps of an investigation contributes to raising different levels of expectations and may lead to frustration in the long run. The final report prepared by safety investiga-tion authorities generally describes and explains a complex chain of events, and remains primarily addressed to aviation professionals for prevention purposes.

Some of the 90 attending the Social Dimension of a Safety Investigation Workshop.


Communicating the results of an inves-tigation to victims and their relatives, as well as to the public, remains challenging.

“In some cases, alternative [or con-spiracy] theories can dispute the official report. These theories, which some-times can be quite sophisticated, may sometimes be triggered and spread by individuals with specific motivations not necessarily linked to improving aviation safety.” An example of political motivation was given during the tutorial.

“Factors such as geographic loca-tion and language barriers can become challenges when the authorities interact with victims and their relatives of various nationalities and religious/cultural back-grounds. Communicating with victims and their relatives often must be under-taken in more than the six ICAO lan-guages. In the aftermath of an accident, victims and their relatives have various needs and wants, which are related to the different phases of the safety and the judicial investigations:

• They need to have their privacy re-spected, and this must be considered a question of ethics and integrity.

• They need access to psychological and legal support as well as access to a victims’ family association for as long as necessary. More guidance [psychological and legal] is required.

• They need demonstration of the inde-pendence of the safety investigation and the results.

• They want those individuals having a role in the accident to be account-able in accordance with their level of responsibilities.

• They want the judicial investigation to be easier to follow, especially when considering all the victims’ nationali-ties.

“The operator is on the front line deal-ing with passengers, families, and crew and can sometimes struggle to survive the accident, especially when faced with operational factors. Families have formal relations with authorities and the opera-tor but not with the manufacturer, which nevertheless has a role in the Annex 13 investigation for prevention purposes. This lack of relationship and the manufac-turer’s role may contribute to suspicions

on the part of victims and their families, as well as the public.

“Through the judicial investigation and also through civil litigation, operators, manufacturers, and sometimes regula-tors can be placed in a defensive mode and face indirect attacks from parties not governed by Annex 13. Such a situation can impact the credibility of operators, manufacturers, and regulators as com-munication about the accident and its safety investigation belongs to the state of occurrence.”

In summarizing the workshop pres-entations dealing with social challenges from a number of perspectives, Ferrante noted, “A major air accident is a human tragedy. Operators’ communication people should be prepared for the envi-ronment of a safety investigation. They should incorporate this aspect in their communication strategies. If or when an operator seeks emergency response support from a service provider, it should not hire away its responsibility in the handling of an accident. If the operator is part of an alliance, as the main operating partner, it should still maintain its duty to provide primary support and com-

A portion of the 299 delegates who filled the plenary session.


munication. The credibility of the safety investigation authority conducting the investigation is essential, especially when operators, manufacturers, or regulators become targets after an accident. The in-dependence and competence of the safety investigation authorities involved in the investigation contribute to reinforce the credibility of the final report.”

Speaking about the communications aspects, Ferrante noted, “Developing additional communication expertise and skills in handling the aftermath of a major accident is essential, as well as encourag-ing liaison between authorities and better knowing each other’s roles. The accident investigation authority responsible for the investigation should immediately be in charge of communication about the investigation. This is vital for long-term credibility. Planning and conducting regular training and exercises involving support and communication staff in that process is paramount. Planning must anticipate and be based on what other agencies will be doing to avoid duplica-tion or contradiction.”

Concluding his summary of the workshop, he said, “The tutorial/work-shop recommends the development of a practical guide in the form of a manual or leaflet for frequent or regular use. This guide should be specifically prepared for victims and their relatives to facilitate their understanding of the role and the different phases of a safety investigation, as well as its relationship to the other entities involved in dealing with the accident.”

The objective of the military acci-dent investigations tutorial was to have international military accident investiga-tors share knowledge on their respective capabilities, experiences, processes, and procedures with a view to the develop-ment of future relationships and common practices and to benefit from the experi-ence gained by the civil counterparts over the years. A sampling of the workshop’s presentations shows that both objectives were amply met: “Military/civil coopera-tion and industrial partnerships.” “Pre- parations to support multinational mis-hap investigations.” “Accident/major inci-dents investigation process within Airbus DS and its relationships with Airbus commercial.” “Flight data monitoring as a proactive approach to improving safety.” “Practical application of incorporating

changes that result from an accident investigation.”

Technical programThe conference center’s huge convention hall presented a very large center screen for PowerPoint presentations. Acoustics proved to be adequate, holding the atten-tion of back-row attendees, and the room temperature was always comfortable. In all, the 299 delegates who filled the hall paid rapt attention to the 20 technical papers presented and to the 3 keynote speakers as well as the welcoming ad-dress from Eva Webber, the city’s deputy lord mayor.

Day oneChairman Conradi began the program promptly at 9 a.m. by welcoming the delegates and covering the housekeep-ing details pertinent to the program. ISASI President Frank Del Gandio then welcomed all; but before making his welcome address, he asked Ladislav (Ladi) Mika to join him on stage. Obvi-ously wondering why, Ladi was greatly surprised when Del Gandio announced, “Meet the ISASI 2015 Jerome F. Lederer recipient.” Thunderstruck, but smiling broadly, Ladi shared a congratulatory embrace with the president, who next introduced the four students who were awarded the 2015 ISASI Kapustin memo-rial scholarships.

In his opening remarks (see page 3), Del Gandio spoke of Augsburg history, about the pilot shortage that is upon the indus-try and the reasons for is existence, about the need for change in the commonly cited factors causing the high accident rate of air cargo carriers, and about how automation has brought both “huge net gains in safety and introduced new risks” through the reduced hand-flying experi-ence of pilots. He also addressed the is-sues involved in managing the industry’s rapid growth in light of labor shortages. Unmanned aerial systems, he said, hold economic promise and significant improvements in air safety, but regula-tory decisions need to be made soon. And lastly, he spoke of how pilot suicide has become the “new issue of the day.”

Guest speaker Deputy Lord Mayor Webber bid all a great

welcome to Augsburg, which is “interna-tionally known for its aerospace compe-tence.” She went on to outline the past and present status of the city’s aerospace endeavors, saying its “success is the net-working of research and business.” Speak-ing directly about the ISASI conference, she said, “In addition to the exchange of experiences, this conference is also a networking source for those authorities and industry representatives who have to cooperate effectively on cross-border in-vestigative activities…to increase aviation safety in the future.”

First-day keynote speaker Ulf Kramer, head of the BFU and president of ENCASIA, said the conference theme of “Independence Does Not Mean Isolation” is “much more complicated” than it sounds. He pointed out that the word “independence” has mixed meanings in various dictionar-ies, but that the term “independence of investigation authorities” may only be found in related laws. Still, he said that in general the word independence almost has a positive connotation. He added that in looking at the dictionary definition of the word “isolation” and its many uses, it almost has a negative connotation. He delved into the many examples that investigators may encounter that involve independence and isolation and the ensuing results.

He concluded, saying, “If we work to-gether and do our work impartially with some included self-isolations, we will reach good results; we will not be isolated and stay [independent within] our enti-ties, companies, and authorities….”

Day twoThe keynote speech from Rémi Jouty, direc-tor of the BEA of France, also addressed the words independent and isolation based on the BEA’s experience. He noted that judging by BEA’s recent news media exposure, the agency does not work in isolation. Referencing independence, he rhetorically asked, “Why should a safety investigation be independent?” adding, “Is there a difficulty or some issue in hav-ing an independent safety investigation?”

Noting that the Annex 13 charge to


a safety investigation is to “prevent ac-cidents,” he posed three questions: “What could the obstacles to an independent investigation be?” “Could anybody want to oppose the goal of preventing future accidents?” and “Who could want to influence our investigation activity and why and how?”

The remainder of his presentation (which will appear in the January–March 2016 issue of ISASI Forum) provided insight into those questions.

Day threeKeynote speaker Yan-nick Malinge, vice president and chief product safety officer of Airbus, addressed the topic of “communication,” noting that for those involved in major investigations communication was found to be “the biggest challenge we all face, whatever our role.” He went on to briefly outline what the term may mean to air-craft manufacturers, to authorities, and to investigators. He took the audience back to the time when communicating was done by phone, fax, or a pager, noting how then everything moved much slower and quieter. That time contrasts with to-day’s digital world of communication that brings “a new era of investigation; the required level of reactivity becomes more and more demanding due to the com-munication means becoming faster and open to a far bigger audience.” Through examples, he showed the challenges in communicating with affected and

nonaffected operators, with passengers’ relatives, and most notably with the news media and its speculation-filled “buzz” that follows an accident.

Malinge concluded, saying: “Commu-nicating the big picture in the shortest possible time seems to be the sole means that has proven to be efficient to bring back a reasonable noise level during an investigation. Communicating is also a required means to ensure the families and the public will keep trust in the official investigation agencies by showing trans-parency in a timely manner.”

Program contentThe three-day technical program, which was filled with the presentations of 20 technical papers, flowed evenly between subjects that directly addressed the theme and those that discussed specific investigations and investigation issues. All presented technical papers will be posted on the ISASI website, www.isasi.org. The attendees’ interest in the techni-cal subjects was noted by the conference hall being filled to capacity throughout the presentations and by the questions posed to each speaker following a pres-entation. Each day allowed for two tea/coffee breaks, which provided much-needed time for the attendees to stretch and interact with each other. One of the prime benefits of the conference is the opportunity to make new professional acquaintances and renew old friendships. The importance of this interaction is often revealed through the experience of arriving at an accident scene and work-

ing with a known person rather than a stranger.

Business meetingA short ISASI business meeting was also conducted. Del Gandio reported that membership numbers were holding steady—as many new members are re-cruited as are lost. He urged each member to promote the society’s achievements and to work at retaining members.He singled out corporate members for special praise, noting that new members have been recruited. Two ISASI programs are in need of new applicants: ISASI Fel-low and the Lederer Award. He recounted the importance of both, asking members to consider applying for Fellow status and to make a nomination for the Lederer Award.

Vice President Ron Schleede spoke of the need to raise funds for the ISASI Kapustin Scholarship Fund. He outlined the fundraising procedures used by the Mid-Atlantic Chapter.

Chad Balentine, secretary and newly appointed chair of the Scholarship Com-mittee, reported that the scholarship se-lection process is being revised and that details will be made available soon.

Treasurer Robert MacIntosh said the society’s financial health was good and that the annual audit was done by a pro-fessional firm. The last report showed no issue with bookkeeping procedures.

Program social eventsThree conference-sponsored special social events were held: a welcome recep-

Some of the delegates who posed questions to the speakers.


(Continued on page 31)

tion, a casual dinner, and the awards banquet. Each has a specific role. The welcome reception is held the evening be-fore the conference starts. It is intended to help attendees get rid of jet lag and to make new friendships and rekindle old ones. This year rain intruded into what was to be an outdoor event, so mingling was done in close quarters. But that did not deter attendees from enjoying the evening, as was evident by the group clus-ters throughout the room.

The highlight of the Tuesday even-ing event was a reception hosted by Augsburg’s Lord Mayor Dr. Kurt Gribl and held in the Golden Hall of City Hall. Attendees were taken with the splendor of the ballroom’s gilded ornamentation, marvelous ceiling and wall painting, and stained windows. In his welcoming talk, Gribl related some of the city’s history: Founded by the Romans in 15 BC and source of religious freedom via its 1555 Peace of Augsburg document that ena-bled Christianity to take a decisive turn in its development—giving birth to a unique public holiday known as the High Peace Festival.

He then turned his attention to the city’s long tradition in aviation and aero-space technology: In the early 1600s, a failed flying machine attempt by Salomon Idler; in 1931, the launch of an air balloon by Auguste Piccard to record altitude; and later Professor Willy Messerschmitt’s development of aircraft, followed in 1989 by Deutsch Aerospace, now EADS and part of the Airbus group. In closing, he said, “I wish you an intensive and produc-tive conference, as the topic of air safety that you are dealing with is of interest and importance for everyone in these times of mobility. A warm welcome to all.”

Following the reception, the dinner venue was Bahnpark Augsburg, a rail locomotive mu-seum. It was a fascinating place, with many full-size vintage en-gines available for viewing. The most eye-catching element was the great many model railroad trains that moved about the entire span of the dining room. The entire setting made for a very relaxing evening.

The third social event was the awards banquet. Its role is to

give peer recognition to those who have achieved a deed that merits presentation of an award. Because of the peer-to-peer recognition aspects, it is the most awaited and most formal of all the social events (see “Awards banquet).

Special eventsThe conference program included two special events: the companion program and the extra-cost, post-conference one-day excursion.

Companions boarded their first bus at 9:00 a.m. for a full day of touring the city of Munich with time to stop at selected shops. Also included was a visit to the Lenbachhaus, which houses the world’s largest collection of the Blauer Reiter (the Blue Rider). An “on-your-own” lunch was taken at the art center’s restaurant.

Wednesday was monastery day, with visits to the monasteries in Ottobeuren and Irsee. At each location, the group was provided a full explanation of the history and purpose of the religious facility. Com-panions had lunch at a neighboring town,

and a Bavarian-style meal was served. Thursday’s event was a walking tour of

Augsburg’s historic section, which is filled with many sidewalk cafes and specialty shops that line the street. Except for the heat of the day, the group’s exposure to the very historic location was greatly enjoyed.

Two choices were available for the Friday post-conference program. The first was a visit to Bavarian castles complete with interior and garden visits. The sec-ond tour was a visit to Airbus Helicopters, which included an insight into the final assembly of the EC135 helicopter, the Military Support Center, and manufactur-ing of helicopter doors.

Awards banquetThe technical program closed on Thurs-day, and the hotel staff wasted no time getting the banquet hall ready for the evening’s awards dinner banquet and its 280 guests. As they filled the room and took their seats, six Bavarian perform-ers, complete with lederhosen dress and feathered hats, played their gigantic Alpenhorns, much to the delight of the audience. Many had never seen such an array of musical instruments, so photo taking was much in order.

Immediately after dinner, President Del Gandio quieted the room and began the formal part of evening designed to rec-ognize individuals who have contributed to the well-being of the society. He first expressed appreciation for the seminar’s success by recognizing the many people who were responsible: organizers, confer-

A networking event during the seminar.

Table one of the 28 that filled the banquet hall and provided seating for280 guests.


LADISLAV MIKA IS ISASI’S 2015 LEDERER AWARD RECIPIENT

The 2015 presentation marks the 39th year that ISASI has presented the award.


The International Society of Air Safety Investigators crowns its annual three-day international conference on air accident investigation by presenting its highest honor, the Jerome F. Lederer Award, at the Society’s

award banquet. Ladislav Mika (Ladi), senior officer of the Air Operation Technology and Development Division of the Czech Ministry of Transport, is the year 2015 recipient of the award. ISASI, an organization dedicated to enhancing aviation safety through the continuing development and im-provement of air accident investigation techniques, only con-siders candidates for its highest award whose careers reflect outstanding lifetime contributions to technical excellence in furthering aviation accident investigation and achieving ISASI objectives.

In introducing the award winner to the banquet guests, President Frank Del Gandio said, “Ladi stands out for his dedication, perseverance, energy, professionalism, and leader-ship among the world’s experts in aviation safety, particularly regarding accident/incident investigation and prevention. ”

Outlining Ladi’s background, Del Gandio noted that in 2014 Ladi received the International Civil Aviation Organiza-tion (ICAO) Award of Certificate of Outstanding Achieve-ment for 30 years of activities and outstanding personal contribution to the sustainable development and safety of international civil aviation within the framework of ICAO’s European Air Navigation Planning Group (EANPG). His experiences in aviation encompass 44 years, including 7 years with Czechoslovak Airlines and 37 years with the Czech Ministry of Transport. During his time with the ministry, Ladi was also a member of the Permanent State Commission for the Investigation of Aircraft Accidents.

Ladi was instrumental in the preparations to establish the Air Accident Investigation Institute in the Czech Republic in 2002, an independent aircraft accident investigation agency set up to meet Euro-pean Union requirements. During his career, Ladi has worked very closely and successfully with a number of key organizations, such as

• ICAO—as the chief delegate representing the Czech Republic at the first High Level Safety Con-ference in 2010 (HLSC 2010) and at HLSC 2015 in February 2015.

• European Civil Aviation Conference (ECAC) Group Experts on Accident Investigation (ACC)—as a member of the group that meets annually to resolve safety matters related to international aviation safety within Europe.

• EUROCONTROL—as a member of the CNS/ATM Consultancy Group (ACG) and Stakeholder Con-sultation Group (SCG), Agency Advisory Body

(AAB), and EUROCONTROL Provisional Council.

• ISASI—as vice chairman of the ATS Working Group.

• Southern California Safety Institute (SCSI)—as co-founder and instructor for international safety courses and workshops in Prague for the past 13 years with more than 600 worldwide participants.

In 1987, Ladi established the Helicopter Emergency Medi-cal Service (HEMS) in Czechoslovakia. He also served as the former president of the Association of the Air Rescue Services in Czech Republic. Since its founding, more than 200,000 people have been saved because of HEMS.

Ladi was one of the founders of the ISASI Reachout Workshop program. He facilitated the first ISASI Reachout Workshop held in Prague in 2001, at which more than 100 aviation safety specialists attended. They represented all Eastern European countries and Russia. He was instrumental in bringing the SCSI training courses to Prague, beginning with aircraft accident prevention and accident investigation courses in 2002. The SCSI courses have expanded and are ongoing to this day, with offerings of various aviation safety subjects each year.

He was also instrumental in bringing the European Cabin Safety and Security and Health Symposium to Prague in 2004 and 2006. These programs provided a new venue for those unable to travel far distances from their country for their continued safety training. He has also brought to Prague a number of other safety-related courses and workshops, including ramp and maintenance, operational risk manage-ment, safety management systems, and air traffic control investigation.

President Del Gandio (left) presents the Jerome Lederer Award plaque to 2015 receipient Ladislav (Ladi) Mika.


Ladi’s nomination submission states, “Ladi’s gifts are his energy, professionalism, leadership, and organizational abilities. Through dedication and perseverance in his work, he has gained the respect of his colleagues in the field. He has the unique ability to bring together people of many nationalities, the Central and Eastern European countries in particular, in order to work harmoniously toward the common goal of worldwide aviation safety. He was one of the first active ISASI members from the Central/Eastern Europe region and has expanded ISASI membership in this region.”

In closing his comments, Presi-dent Del Gandio said, “ISASI is indeed blessed to have such an outstanding individual in its ranks. His contribution to global aviation safety is outstanding, and there is no doubt that the contributions made by Ladi have improved aviation safety through accident/incident investigation and prevention in Central/Eastern Europe. His native Czech Republic has an excellent aviation safety record—no fatal accidents with transport-category aircraft for more than 39 years. Ladislav Mika is uniquely qualified to receive the honor of being named the Jerry Lederer Award recipient. We are very proud to have such a widely recognized aviation safety expert among our membership. He is a most deserving recipient of the ISASI Jerry Lederer Award.”

Throughout President Del Gandio’s introduction, Ladi, calm faced, stood nearby. But upon being presented the award and after the handshake, his exu-berance burst through with a huge smile. Holding the award plaque high, he quick stepped to the center of the stage as a photo of himself with Jerry Lederer filled the stage’s large screeen. The 280 banquet guests responded to his enthusiasim with a resounding standing ovation.

Taking the lecturn, Ladi, after acknowl-edging the assembled group, turned his head, looked at the large screen behind him, and began his acceptance address in a unique way: “Good evening Mr. Avia-tion Safety. Dear Jerry, I am very happy that you can be with us during this award

ceremony.” He continued, “It is a great honor for

me to be here today with you and hold the prestigious award bearing the name of Jerome Fox Lederer in my hands. It might be a suprise for you, as it was for me, to learn that the Lederer family has roots in the Czech Republic. We are situ-ated about 300 kilometers from the place where Jerry’s father was born. The place is called Prašný Újezd, a small village located about 30 kilometers from the city of Pilsen, where for a long time one of the best beers in the world is produced. Another important person in American aviation, with roots in the Pilsen region, is Jim Lowell—thanks to his grandfather from his mother’s side. Also the ancestors of Kim Novak, the actress, come from this region.

“How did I discover the evidence and facts about Jerry’s ancestors? When Jerry was celebrating his 100th birthday in 2002 at that year’s ISASI conference, he stepped up on the stage and made a short reflection on the professional as well as a personal part of his life. He brought up

important and unexpected infor-mation about his father, who was born and studied at the medical facility at the Charles University in the Czech Republic. He also men-tioned that his father taught him the Czech language. Jerry said that he still remembered one sentence and said in perfect Czech: ‘Pretty girl kiss me. ’ I was the only person who understood what he said, and we both smiled. Jerry’s father de-parted Prašný Újezd in 1890 to the U.S.A., where Jerry was born in New York City in September 1902.

“This experience motivated me to learn more about Jerry’s heritage. First, I had to research his father’s first name, which with the help of Frank Del Gandio led me to his daughter Nancy and the discovery of the name Zygmund. I then visited the Charles University archives, where past examination records proved that Zygmund Lederer, Jerry’s father, had studied at the medical facility in Prague.

“When I first met and talked to Jerry, he was happy to meet some-one who was from the same coun-try his family came from. I invited him to visit these places personally

together. The idea excited him, and he was keen to visit the homeland of his father. Unfortunately, at the age of 101 in February 2004 he flew west, and his visit never materialized. But Jerry’s daughter Nancy Cain visited Prašný Újezd last July; it was the first return of a member of Jerry’s family to his father’s homeland.

“I also recall that we spoke about Jerry‘s inspection of Charles Lindberg’s Spirit of St. Louis before crossing the North Atlantic in May 1927. I asked him whether he knew that then Czechoslo-vakia also participated in the success of this flight. He replied that he did not. I then explained that the crankshaft—the heart of the aircraft’s engine—was made in Czechoslovakia. Coincidently, I was born on the same day, 20 years later, that Charles Lindberg completed his flight across Atlantic Ocean.

“When I look at the past Lederer Award winners, I note that the majority have participated in dozens of aviation ac-cident and incident investigations in their professional lives. For me, the situation

An exuberent Ladi holds his award high.


is completely different. I participated in the investigation of only two aviation ac-cidents of transport aircraft. The first one in 1975, an accident of a Czechoslovak Airlines aircraft IL-62M near Damascus [Syria] and the second one in 1976 of the IL-18 aircraft at the airport of Bratislava [Slovakia]. It is a true that since then, for 39 years, no fatal accident of transport aircraft in the Czech Republic has oc-curred. I am proud to have been able to contribute to this great result.

“During my professional career I have focused on improving aviation safety, accident prevention, and education of investigators and safety professionals in aviation. When I first met ISASI’s Ron Schleede and Jim Stewart at the annual conference in Barcelona, Spain, in 1998, I suggested that an ISASI conference be organized in Prague. But I had no idea how complex the organization of such an event is and that venues are chosen several years in advance, much like the Olympics. So I then suggested organizing a seminar, local to Prague, for safety ex-perts and investigators with the empha-sis on keeping the costs low in order to provide the greatest number of experts the opportunity to participate. From that idea sprang ISASI’s Reachout Workshop program, which took firm form during the ISASI conference in Boston [Massa-chusetts] where we began organizing the first Reachout Workshop in Prague. It was held in 2001, with 100 participants from 14 countries attending.

“The workshop’s feedback was very positive, resulting in the decision to continue with this very important in-ternational ISASI activity. Key persons were Ron Schleede, Jim Stewart, and Caj Frostell. To the present day, the Reachout Workshop program has been conducted in 46 locations.

“Another important moment in my professional life was meeting Dr. Peter Gar-diner, director and CEO of the Southern California Safety Institute. We immediately “hit it off ” and initiated the launch of the international courses for the investigators and safety experts. Peter, Ron, Caj, and I delivered in 2002 the first international aircraft accident investigation and safety course in Prague. It has now been coduct-ed 13 times, with more than 600 aviation safety experts from different countries and continents attending.

“I am glad I could devote my entire professional life of 44 years to increasing the level of safety and training of the new aviation safety experts. That’s why I was very pleased when I received the Cer-tificate of Outstanding Achievement in recognition of 30 years of continous and unconditional support to ICAO activities and outstanding personal contribution to the sustainable development and safety of international civil aviation in particular within the European Air Navigation Plan-ning Group from the regional office of ICAO EUR/NAT in Paris in October 2014.

“Millions of people now fly safely to vast and far reaches of the world. The number of passengers travelling on schedule ser-vices has grown by more than 3.3 billion. This figure represents almost half of the world’s population being carried by air-craft in 2013, on just more than 32 million departures.

“All of us here and hundreds of other aviation specialists share the same goal: to improve the level of aviation safety. Like Jerry, we believe that flight without risk was flight without progress—we all must minimize this risk.

“I thank all my colleagues and friends who have supported me in the effort to increase the level of international aviation safety. A deep appreciation goes to my parents who gave me the opportunity to study the wonderful field of aviation, and at last but not least my thanks goes to my family for their understanding and sup-port throughout the years. I am grateful to those who nominated me as a candidate for this very prestigious international aviation award. I highly appreciate being the first one from the countries of Central and Eastern Europe to be awarded ISASI’s Jerome F. Lederer Award.

“Many thanks to ISASI for awarding me this honor and to Jerry for dedicating his life to aviation safety. I accept this award in appreciation of my entire life’s profes-sional activities in aviation safety and at the same moment in appreciation of the civil aviation in my country.“

Past Lederer Award Winners 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 Hewes1994—UK Aircraft Accidents

Investigation Branch1995—Dr. John K. Lauber1996—Burt Chesterfield1997—Gus Economy1998—A. Frank Taylor1999—Capt. James A. McIntyre2000—Nora C. Marshal2001—John W. Purvis and the

Transportation Safety Board of Canada

2002—Ronald L. Schleede2003—Caj Frostell2004—Ron Chippindale2005—John D. Rawson2006—Richard H. Wood2007—Thomas McCarthy2008—C. Donald Bateman2009—Capt. Richard B. Stone and the

Australian Transport Safety Bureau

2010—Michael Poole2011—Paul-Louis Arslanian2012—Curt L. Lewis 2013—Frank Del Gandio and Myron

Papadakis2014—David King

Ladi in coversation with Jerry Lederer during the 2003 ISASI conference.


(This paper received the Best of Conference Award of Excellence for technical pa-pers presented at ISASI 2015 in Augsburg, Germany, Aug. 24–27, 2015. The conference theme was “Independence Does Not Mean Isolation.”—Editor)

By Capt. Ibrahim S. Koshy, Director General, Aviation Investigation Bureau, Kingdom of Saudi Arabia

DIVORCING THE REGULATOR: THE ESTABLISHMENT OF AN INDEPENDENT INVESTIGATIVE AUTHORITY

Like the majority of the International Civil Aviation Organization (ICAO) signatory states, the Kingdom of Saudi Arabia assigned the authority

and responsibility of investigating aviation occurrences to the regulator, the General Authority of Civil Aviation (GACA). To be in line with ICAO standards and recom-mended practices, a decision was made in 2009 to transfer the authority for aviation occurrence investigation to an agency independent from the regulator; this was the impetus for the birth of the Aviation Investigation Bureau (AIB).

Many actions took place before the AIB was born, including the senior government decision in the form of a royal decree for the establishment of an independent aviation occurrence inves-tigative agency, the regulator (the GACA) amending articles of the Civil Aviation Act transferring the authorities from the regulator, and the GACA making internal amendments by resolutions.

In 2012, Capt. Ibrahim S. Koshy was tasked to establish and head the AIB and was appointed as its first director gen-

eral. A very important first step was the establishment of the AIB regulation. The AIB regulation was required to define the authorities officially for operators, service providers, pilots, air traffic controllers, air-ports, and other regulators to understand who the AIB was and to understand the authorities of the AIB. The AIB regulation was approved in January 2013 and became effective in November 2013.

ChallengesGetting the right people on board in any startup, including a government agency, is very important. Not only do they have to know how to do it right, but they have to know how to build it. In addition to investigating occurrences, the team being put together would be responsible for building a system, policies, procedures, and processes.

The first person brought on board was Serge Lemire, who had years of experience as an investigator with the Transportation Safety Board (TSB) of Canada. Lemire was also familiar with aviation in Saudi Arabia, as he had been assigned to GACA aviation safety through ICAO. Lemire was brought on board as the first AIB director of inves-tigations, and bringing other investigators on board created a core team that could conduct occurrence investigation in a professional manner.

Having a team “look inside” and “tend the house” allowed the director general to “look outside” and determine required regulatory changes, determine desired capabilities, determine a long-term strategy, and define an organizational structure that would be effective for the current situation as well as fit in with the projected level of aviation activity in the kingdom.

Many tasks were required, includ-ing getting an approved organizational structure, getting job descriptions and authorities for each position, applying for a budget, getting financial authorities for the office and staff, getting a budget for the desired lab facilities, getting vehicles and equipment, and most importantly a temporary facility as well as an approval for a permanent facility that would be the

home of the AIB. In the first year, the of-fice walls were covered with many project charts that were being run simultane-ously. There were many late nights at the office as well as working outside of the office during the first year.

Actual levels of independence and prioritiesAlthough independence was very im-portant, it was also important to decide how to achieve the appropriate levels of independence that would serve the interest of the AIB. The strategy looked at three areas in detail: functional independ-ence, administrative independence, and financial independence.

A five-year strategy was set by the AIB in which 100% functional independence was required from day one. In relation to financial and administrative independ-ence, however, it was decided by the AIB that in order to concentrate efforts in building the desired investigative and lab capabilities, the AIB would utilize finan-cial and administrative support that was available initially from the GACA while the AIB gradually built its own financial and administrative department in ac-cordance with the government’s require-ments. This was still considered by the AIB to have a level of independence as the administrative authority resided with the AIB while the execution of administrative functions would be with another govern-ment agency (the GACA). The AIB strat-egy calls for developing its own financial and administrative capabilities in 2018.

Working together—investigative authoritiesWhile building an organization, it’s not enough to just do it the way you think it should be done; you need to get out there and see how others are doing business. Take time to visit others who have been

A lesson learned is “Don’t isolate yourself. To be effective, you need to go out and work with others locally, regionally, and internationally.”

Capt. Ibrahim S. Koshy is the director general of the Aviation Investigation Bureau (AIB) of the Kingdom of Saudi Arabia, a member of the board of the newly established MENASASI Chapter. He is an IOSA senior lead audi-

tor and evaluator with more than 25 years as an airline pilot with experience in E170, G-IV, B-737, A300-600, B-777, and A330 types. He has served in various management positions in airline flight operations safety and corporate safety. He is a graduate in aeronautical science (aviation safety and accident investigation) from ERAU in the United States and is working on an MSc in safety and accident investigation at Cranfield University in the United Kingdom.


in this business for a while. The AIB had a familiarization project that entailed visiting various investigative authori-ties. From 2013 through 2015, the project entailed visits to the the AAIB–UK, the BEA–France, the TSB–Canada, the ATSB–Australia, the NTSB–U.S.A., and the BFU–Germany.

Sitting down to hear what worked for the various agencies as well as what didn’t work helped the AIB in deciding several changes to what its organizational struc-ture should look like. The visits also let the AIB better understand the processes they used to stay on top of things, which gave us additional insight into some capabili-ties that we felt should be established in our ops room design as well as in our recorder labs.

There are a large number of interna-tional carriers overflying Saudi Arabia due to the size and geographical location of the state as well as the political develop-ments and economic and aviation growth in the region. The reachout to other safety boards helped the AIB build a good rap-port quite fast.

Working together—regional cooperationReaching out and coordinating with our regional counterparts has been very beneficial for the AIB. States like the United Arab Emirates (UAE) have taken initiatives and reached out to bring other investigative authorities in the region together in a way that has helped the in-vestigative authorities in the region better understand each other’s capabilities. This has allowed the AIB to better understand what capabilities and resources to invest in. The initiatives by the UAE have also improved regional coordination in train-ing by offering seats to states. This is now being reciprocated by other states in the region, including the AIB of Saudi Arabia.

The lead initiative by the UAE in estab-lishing a local ISASI chapter for the Mid-

dle East and North Africa (MENASASI) has brought aviation safety professionals and investigators together on a regular basis in another forum to discuss cur-rent issues and improve cooperation and understanding of current issues among safety investigators.

Working together—Saudi ArabiaThe theme of ISASI 2015 was “Independ-ence Does Not Mean Isolation,” and the realization of how closely the AIB found it was required to work with the GACA to be effective is a perfect example of how the investigative authority and the regulative authority cannot work in isolation if they are to be effective.

One of the main challenges the AIB initially faced was in spite of press releases and circulars issued to the operators, ser-vice providers, and the aviation communi-ty, there was a problem with notifications and awareness of who the AIB was. Coor-dination with the GACA through frequent reminders on the new requirements and reachout programs at 28 airports in the country with all stakeholders—including airlines, service providers, airport manage-ment, air traffic control, fire rescue ser-vices, civil defense, police, airport security, customs, etc.—raised the awareness level of who the AIB was, and the notifications situation improved considerably.

The concept of first responders, which appeared to be working well for the BEA of France, was appealing to the AIB. Working with the GACA, the AIB created its own “first responders” by utilizing safety and quality personnel at each airport who were briefed and trained in the requirements of the AIB in the event of an occurrence until the AIB arrived on site. Furthermore, the AIB now participates in all airport emer-gency drills to give its input in regards to preservation of evidence and investigative requirements and to continue the reach out. The GACA had previously developed a software database for occurrence tracking that the AIB now utilizes for its own occur-rence tracking.

Establishing memorandums of under-standing (MOUs) with other agencies that an investigative authority requires to coor-dinate with in an accident investigation is an important task. The GACA previously had entered into MOUs with agencies, and utilizing those MOUs, rather than starting from scratch, as a basis for some of the AIB’s required MOUs was quite helpful. There are many MOUs that still require up-dating, including those between GACA and the AIB. The importance of MOUs cannot

be underestimated.

Working together—coast guard, re-search institutes, and universitiesGetting to know what capabilities were available in the country that the AIB might require in the course of an investigation was necessary. The AIB reached out to universities, colleges, and research centers and found the following capabilities:

• Supercomputers—which with data could be used for predicting wreck-age scatter patterns in the event of a mid-air collision or an explosion in flight (like the Lockerbie event). This capability was also found to be ben-eficial to assist in locating underwater wreckage by using sea current data and mathematical formulas. These supercomputers could also be used in safety studies for visualization of airway and an analysis in visualization labs (the cave).

• Material and fluid analysis—the AIB also identified other capabilities in the country where material and fluid analysis was available and to what standards the labs were being oper-ated. This allowed the AIB to identify areas where it could either use the facilities or would have to develop its own in-house capability. A strategic partnership is in the making with a European world-class certification and inspection company for bring-ing material-analysis capabilities and competency, including technology and skills transfer.

• Marine search and recovery—In reaching out to the faculty of marine science in Jeddah, we found that it had projects like mapping the floor of the Red Sea and studying sea currents and that it had some of the most-advanced equipment and teams available in the field that could be utilized in the event of an aviation occurrence in our waters to help locate wreckage.

We reached out to the Coast Guard to come to an understanding on roles in wreckage recovery. We also realized that the experience and capabilities to locate recorders wasn’t adequate and would have to be built. The AIB plan to build the expe-rience and capabilities to locate recorders begins in late 2015, with the first exercises expected to be conducted in 2016.

A lesson learned is “Don’t isolate yourself. To be effective, you need to go out and work with others locally, regionally, and internationally.”

Capt. Koshy (left) accepts the Award of Excel-lence from ISASI President Frank Del Gandio.


Take, for example, Schiphol airport located near Amsterdam in the Netherlands. Although serious accidents do not often happen at this airport and other airports, there are regular occurrences of incidents that could be classified as risky. Two such regular incidents are runway incursion and collisions/taxi incidents during ground traffic.

In 2010, the Dutch Safety Board, Onderzoeksraad voor Veilig-heid, did an extensive investigation into a runway incursion, focusing on the incident of Dec. 18, 2010, and similar incidents. These incidents involved incursion of aircraft that had been cleared for takeoff or landing and bird controller vehicles with permission to operate on the runway. The conclusion of this investigation was that the method of communication between bird controller and ATC was insufficient to avoid dangerous situations. Also, the communication between the runway controller and ground controller, as in the case of December 18, was insufficient to convey the needed awareness of the bird controller to the runway controller. A technical issue within this problem was the runway system that shows the occupancy of the runway; it only indicates if the runway is empty or occupied. No information is provided regarding the number of occupants on the runway. As a result, it is incapable of giving a warning in case of runway incursion. This investigation called for a real-istic and practical way to safely operate runways and stop the insufficient risk control. However, on Jan. 12, 2014, a similar case of runway incursion with a bird controller occurred, indicating that the problem is not yet fully solved.

Other runway incursion cases at Schiphol airport involve mul-tiple aircraft (e.g., incidents on Apr. 18, 2012, Dec. 11, 2012, and Dec. 6, 2013). In these incidents, communication between the ATC and pilots resulted in the pilots’ believing they were cleared for takeoff, while in fact they were not. This led to runway incursions between crossing traffic and the arriving/departing flights. These cases illustrate the need for a system in which the pilots can get clearer information and/or a way to check if they understood the information correctly (DSB 2014 & DSB 2013-4 & DSB 2014-1).

In addition to safety, preventable ground traffic incidents can also cost a lot of money. One of these cases at Schiphol airport is the collision between two Boeing aircraft on Dec. 13, 2013. This case was a gate management problem: a B-737 was delayed at its designated gate while a B-757 came in for docking. The B-757 was designated a gate adjacent to the delayed B-737. Docking of a B-757 at its designated gate, however, is only possible if its dock and one of its neighboring docks are empty. The Gate Management System showed the dock of the B-737 planned as unoccupied, and bad weather conditions limited visibility, making it impossible for the gate planner to see the B-737. This

ISASI awarded four ISASI Kapustin memorial scholarships in 2015. Recipients included Nicolaus Dmoch, Berlin, Germany, Emery-Riddle Aeronautical University (ERAU), Berlin cam-pus; Mario Pierobon, Conegliano, Italy, Cranfield University,

UK; Kiki Faber, the Netherlands, Delft University of Technology, Delft, Netherlands; and Amy LaRue, Los Flores, California, Uni-versity of Southern California, Los Angeles, California, U.S.A.

The July–September issue of the Forum (see page 28) intro-duced all the winners and published the essays authored by Micolaus Dmoch and Mario Pierobon. The remaining two essays by Kiki Faber and Amy LaRue follow this introductory text.

Kiki Faber, 24, is pursuing a master of aero-space engineering degree with a specializa-tion in aerospace control and operations at Delft University of Technology. She holds a bachelor’s degree in aerospace engineering and expects to graduate in 2016. Kiki calls Hoorn, Netherlands, home. Her hobbies and interests include classical and jazz music and singing. She sings in the Delft student choir and enjoys traveling and experiencing other cultures. After graduation, Kiki will seek work in the aviation safety investigation arena. She said, “I hope to become a specialist on aircraft safety and be able to work on challenging projects on international teams to improve aircraft and aviation.”

The Challenges for Air Safety Investigators: Dangers of Busy Airports—SchipholBy Kiki Farber, Master of Aerospace Engineering Candidate, Delft University of Technology, Delft, Netherlands

The demand for air travel is growing worldwide. The rapid economic growth in regions such as China and South America is fueling the greatest increases in demand; however, substantial growth is also expected for regions such as Europe and the Unit-ed States with already established markets. The negative impact of this growth is more traffic. This will increase the demand on current airport infrastructure, resulting in the potential for over-crowding. What will be the impact of increased traffic on the safety of airports? And what can we do to maintain and improve upon current airport ground safety?

Increasing traffic usually also means increased risks of incidents and accidents. These dangers at large airports can result in high damages and in the worst cases even loss of lives. The challenge for air safety investigators is to prevent this from happening without stifling the growth of the air travel industry (Okwir 2014 & Airbus 2014).

ISASI Scholarship Recipients Receive AwardsISASI 2015 awards banquet attendees loudly recognized the four recipients of the Kapustin memorial scholarships.



Navigation and Surveillance (ICNS) Conference, 2014, p.1-15. http://ieeex-plore.ieee.org/xpls/icp.jsp?arnumber=6819989.

De Arruda, A.C., Weigang, L. & Milea, V., 2015. A New Airport Collaborative Deci-sion Making Algorithm Based on Deferred Acceptance in a Two-Sided Market. Expert Systems with Applications, 42(7), pp.3539–3550. http://linkinghub.elsevier.com/retrieve/pii/S0957417414007593.

European Airport CDM, 2015. Airport Collaborative Decision Making. http://www.euro-cdm.org/index.php.

Airbus, 2014. Global Market Forecast: Flying on Demand 2014–2033. Airbus http://www.airbus.com/company/market/forecast/.

Amy LaRue, 20, is pursuing a bachelor’s of aerospace engineering degree at the Viterbi School of Engineering at the University of Southern California. She expects to graduate in 2016. Amy plays a trombone in the universi-ty’s marching band. Her other interest include volunteering at an all-women’s community service organization and participating in the aerodesign team where she is helping build a radio-controlled airplane for the AIAA Design, Build, and Fly competition. Amy is also taking flying lessons and enjoys exploring Los Angeles and reading.

About her future, she said, “Aviation safety is a field that I encountered as a result of my participation on the AeroDesign Team. USC’s Aviation Safety and Security Program was avail-able as a resource to undergraduate students from our team, particularly emphasizing the ISASI scholarship. I jumped at the opportunity to learn more about aviation outside of the field of engineering. I hope to carry the educational experience of the ISASI Kapustin scholarship through to my senior year of school as well as into my career. Having a well-rounded view of all fac-ets of aviation will allow me to be more versatile as well as fulfill my personal curiosities.”

The Tactical Use of Camera-Equipped UAVs in The Field of Aviation SafetyBy Amy LaRue, Undergraduate Degree in Aerospace Engineer-ing, University of Southern California, U.S.A

The current system in use for investigating crash sites, seen most recently in the Germanwings Flight 9525 tragedy in the French Alps, emphasizes the use of human capital, which requires large amounts of personnel, resources, and money—challenges better met by expanding use of unmanned air vehicles (UAVs) to air safety investigation. Drones can endure harsher conditions, fit in smaller spaces, and report back to the command center with presumably more accuracy than an investigation performed without them. The use of drones would have been incredibly beneficial in the case of Flight 9525 as sources of aerial pho-tography to better understand the site before ground-level in-formation gathering happened. Helicopters, the primary means of accessing the site, were once the most modern technology available; however, the natural progression of technology has led drones to now be most practical. The FAA, the EASA, and the BEA will be conquering the age-old challenges of time and money by using UAVs to support their aircraft investigations.

Though drones have already been introduced as a means of observation, they are not yet being fully capitalized in the field of aviation safety. In the United States, their capabilities

resulted in the B-737 losing its winglet and the B-757 having severe wing damage.

Another case is the use of an unavailable runway by multiple aircraft in sequence (e.g., June 16, 2012). Luckily the runway was cleared of debris and birds, but an incident like that could also have made a turn for the worst. This was also a simple matter of miscommunication (DSB 2014-2 & DSB 2012-2).

All of these cases allow us to evaluate the current safety at airports and find ways to improve it—not only at Amsterdam Schiphol airport but also at other busy airports around the world. Air safety investigators evaluate incidents and accidents in order to identify ways to improve the safety of the current systems, but also to help with implementing these changes. The recommendations given by the Dutch Safety Board are about changing the current system to improve safety. The current ground control system at many airports has grown from smaller starting airport systems into bigger systems—without a cen-tral information system and with its functions scattered over different disciplines, allowing for miss communication. What could greatly improve the communication and safety of ground control at airports is the introduction of a centralized airport vehicle monitoring system.

Currently there are new developments around airports called collaborative decision making (CDM) where airports centralize information to improve the operational speed of the airport. In this development, mainly the ATC and airlines are in-cluded while recommendations are urging for using more input of the air traffic flow management. Further improvements on harmonization, situational awareness, collaboration, and opera-tions in adverse conditions can be made. As a result, this system has not yet reached its full potential for improving airport safety. European Airport CDM is an initiative that includes IATA, EUROCONTROL, the European Union, and Airports Council International (ACI).

Air safety investigators can make a valuable contribution by using their knowledge to take on the challenge of incident prevention, collaborating and proposing ways to include safety developments in this new initiative. The system, which is al-ready partially implemented in Europe and America, can then be developed to be safe and solve some of our current safety issues. An association as ISASI, or any national safety board, can be involved in the project evaluation and in pointing out the improvements that can be made to create a safe system. These entities could also help to develop the safety of the system as a partner. By collaborating and acting proactively on these new developments, they can prevent dangers in the future and con-tribute to safe flying, arrival, and departure of aircraft at airports throughout the world (Okwir 2014 & De Arruda 2015 & Europe-an Airport CDM 2015).

ReferencesDutch Safety Board, 2013. Runway incursion baan 24, Amsterdam Airport

Schiphol. Onderzoeksraad voor Veiligheid. http://onderzoeksraad.nl/nl/onderzoek/977/runway-incursion-baan-24-boeing-737-18-december-2010/fase/1386/onduidelijkheid-leidde-tot-runway-incursion-op-schiphol.

Dutch Safety Board, year-quarter. Quarterly reports of the Dutch Safety Board Aviation Department. Onderzoeksraad voor Veiligheid http://onderzoeksraad.nl/Okwir, S., 2014.

Collaborative Decision Making (CDM) in Airport Surface: Europe vs. U.S.A. Implementations, Challenges, and Best Practices. Integrated Communication


are continually being explored and defined. Law enforcement agencies, such as the Grand Forks Police Department (GFPD) in North Dakota, have taken it upon themselves to use drones to mitigate dangerous situations in which suspects are believed to pose threats. Rather than sending officers into a potentially dan-gerous situation with little background on the area, the police send in a Qube quadcopter to procure all applicable information beforehand. Using the thermal imaging capabilities of the Qube, the police department searched for suspects: “The field was quickly traversed and found to be empty. Though the suspects were not there, the automated search freed up police officers to look elsewhere, and the suspects were soon picked up in the sur-rounding area.”1 The efficiency of the GFPD should be something that other agencies strive for. This forward-thinking approach to urban observation can, with extended-range capabilities, also be applied to the search for downed aircraft.

Drones’ systematic observance is more thorough than the human eye, as can be proven by capabilities such as thermal imaging, and can more quickly identify hard-to-find wreckage in places such as the French Alps or a forest. Though Flight 9525’s A320 remains were found relatively quickly via manned helicop-ter search, this cannot always be counted on. The use of cameras will positively benefit the search mission as a supplementary investigation technique. For instance, Malaysia Flight 370 has spent upwards of $100 million dollars on reconnaissance mis-sions, which have been unsuccessful thus far. These costs could be greatly reduced if unmanned vehicles were sent.

In addition to search missions, quadcopters have been proven in the field at hand. USC’s Aviation Safety and Security Program has been making strides toward investigating aircraft wreckage with drones by recording videos of wreckage in its aircraft in-vestigation lab. Signs of human life and location of the aircraft’s data recorders are time-critical pieces of information that need to be determined as soon as possible. Sending a drone with the endurance required to fulfill the mission and the visual capa-bilities to do so would speed up the recovery and investigation process once people arrive on site, which benefits everyone involved. These drones are equipped to provide an equivalent, if not greater, amount of information regarding the investiga-tion than the human eye, and can do so in conditions not fit for human search-and-rescue operations.

The FAA, the EASA, and the BEA recognize that drones play a large role in the future of aviation safety. The EASA voiced its

concerns stating, “Currently the expansion of the RPAs market is inhibited by the absence of an adequate regulatory framework.”2 Sharing the same sentiment, the FAA has recently launched research initiatives in six areas of the United States to test the technology.

Nevada has been assigned to “look at how air traffic control procedures will evolve with the introduction of UAS into the civil environment and how these aircraft will integrate with the modernization of the national airspace system,”3 which address-es the concern of the lack of definition regarding shared air-space. Ideally, pending the completion of the two-year program, the FAA will have a defined system of rules for unmanned flight that all regulated airspaces can follow.

The best way to move forward with the utilization of drones in aircraft investigations is to establish a set of guidelines for their use, similar to what is being done in Nevada. This set of guide-lines needs to be all-encompassing and specific to the field of aviation safety by including a clause about what protocol is for the drone’s activity when personnel arrive on scene. To have the operations run smoothly, it would be best to have the controller fly to the scene with the other professionals who traditionally attend to the crash. This would allow the person most familiar with the drone to operate it safely around others and review footage as necessary. If space in the aircraft flying to the site is an issue, the drone’s flight capabilities can be shut down when the investigation team is on site, but video can remain enabled. The safety of the interactions among the UAVs, manned aircraft, and personnel cannot be overlooked, as one problem will quickly result in another.

Humans will always be involved in rescue operations, but the deployment of a drone in advance of their arrival can minimize their time on scene. An argument can be made for retaining the current system of gathering a team upon notification of a crash, setting a mental plan, and executing each specialized job that is assigned, but that kind of wait time can be deadly to any survivors. To alleviate the delay of search-and-rescue operations arriving on site and the funds that it currently takes to back such operations, the largest problems that exist in aviation safety, it’s readily apparent that UAVs should be used.

References1. Pilkington, Ed. “’We See Ourselves as the Vanguard’: The Police Force Using

Drones to Fight Crime.” The Guardian. Oct.1, 2014. Web. Apr. 4, 2015. 2. Brussels. “Communication from the Commission to the European Parliament

and the Council.” European Commission, Aug. 4, 2014. Web. Apr. 3, 2015.3. Dorr, Les, Jr., and Alison Duquette. “Research to Examine UAS Integration

with Air Traffic Control Procedures and NextGen.” Press Release—FAA An-nounces Nevada UAS Test Site Now Operational. Federal Aviation Administra-tion, June 9, 2014. Web. Apr. 5, 2015.

Kapustin scholarship recipients receive banquet attendees’ applause after accepting scholarship cer-tificates. Shown, left to right, are Nicolaus Dmoch, Mario Pierdon, Amy LaRue, Kiki Faber, and ISASI President Frank Del Gandio.

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Towards the Next GenerationOf HUMS Sensor

This adapted article describes work undertaken as part of European Aviation Safety Agency (EASA) project EASA.2012.OP.13 VHM and outlines

the project phases, the work undertaken, and some of the achievements. The project was initiated in response to two recommenda-tions from the UK Air Accidents Investigation Branch (AAIB), namely:

1. UNKG-2011-041: It is recommended that EASA research methods for improving the detection of component degradation in heli-copter epicyclic planet gear bearings.

2. UNKG-2010-027: It is recommended that EASA, with the assistance of the Civil Avia-tion Authority, conduct a review of options for extending the scope of health and usage monitoring systems (HUMS) detection into the rotating systems of helicopters.

BackgroundSince the 1980s, the use of onboard sen-sors for helicopter HUMS has been increas-ingly popular for benefits of enhanced safety. Through the years, a wide range of sensors and methodologies have been developed for monitoring and fault detection across heli-copter rotor, drivetrain, and engine systems. Vibration health monitoring equipment is now commonplace on large helicopters, and the technology has matured and can claim a number of successes with respect to accident prevention.

However, despite these successes, ac-cidents, such as the one involving a Super

Puma, registration G-REDL, in the North Sea in 2009, have raised questions about the efficacy and limitations of HUMS. In light of technological advances since the develop-ment of the early HUMS, it is appropriate that the issue of detecting incipient failure is reex-amined. The research program described here aims to inform the next generation of HUMS by identifying and proving feasibility for new and newly applied sensing technologies, with a specific focus on internal sensors.

Overview of vibration health monitoring (VHM) systemsHUMS was developed in North Sea op-erations, motivated in part by the crash of a Boeing Vertol 234 in 1986 that was caused by disintegration of the forward main gearbox. After HUMS development in the 1990s, the UK Civil Aviation Authority (CAA) mandated that HUMS be fitted to certain helicopters. A Rotor & Wing article suggests that HUMS “successes” are found at a frequency of 22 per 100,000 flight hours.

Several surveys have been carried out by different authors and agencies into the ef-fectiveness of HUMS sensors and analysis methods. The FAA carried out one of the first surveys for helicopter HUMS in an effort to develop certification requirements. NASA performed several surveys examining the application of HUMS in areas ranging from gearbox to engine health monitoring. The UK CAA has also conducted a review of extend-ing HUMS to rotor systems. Those surveys

By Dr. Matthew Greaves (MO5700) Head, Safety and Accident Investigation Centre, Cranfield University

The author describes a research program that aims to inform the next generation of helicopter health and usage monitoring systems (HUMS) by identifying and proving feasibility for new and newly applied sensing technologies, with a specific focus on internal sensors for rotating systems of helicopters.

(Adapted with permission from the author’s technical paper entitled Towards the Next Generation of HUMS Sensor presented at ISASI 2014 held in Adelaide, Australia, Oct. 13–16, 2014, which carried the theme “Investigations and Safety Management Systems.” The full pres-entation, including cited references to support the points made, can be found on the ISASI website at www.isasi.org under the tag “ISASI 2014 Technical Papers.”—Editor)

Matthew Greaves is the head of the Safety and Accident Investigation Centre at Cranfield University. Prior

to joining Cranfield, he worked for the science and technology organiza-tion QinetiQ. He holds an engineer-ing degree and a Ph.D. in aircraft engine noise and vibration. His research deals with the application of technology to aviation safety and the accident investigation process. He is an ESASI committee member.


provide a good overview of existing sen-sor technology and methods and their implementation in a HUMS program.

Signal processing—There is an extensive range of possible signal processing tech-niques available with which to analyze HUMS vibration signals. Over the years, processing has evolved from simple indi-cators such as root mean square (RMS) to more developed techniques such as data mining. Another development is the implementation of an advanced anomaly detection algorithm, developed by Gen-eral Electric under a UK CAA-sponsored program. This algorithm expands the concept of condition indicators to estab-lish a “normal” vibration set that allows alerts to be raised using a data-mining approach.

The main aim of any signal-processing technique is to “expose” the signal that characterizes the degradation or incipi-ent failure from the general noise of the platform and ordinary gear meshing and bearing noise. However, the ultimate success of any signal-processing strategy depends on the quality of the signal un-der analysis. If the signal-to-noise ratio is too small then no amount of processing will allow detection.

The initial aim of this research project was to focus on the sensing technolo-gies available for fault detection, with a particular emphasis on increasing the signal-to-noise ratio of the “defect signal” measured against the background noise

level, rather than on improved process-ing of existing signals. However, as the project progressed, both aspects were explored.

Accident review and failure modes—A review of accidents and failure modes was conducted to understand the types of degradation that cause catastrophic failures and to help select case studies for benchmarking candidate technologies. The fundamental generic degradation and failure mechanisms for gears and bearings are well understood and include effects such as wear, spalling, adhesion, fretting, etc.

Roberts, Stone, and Turner, in “Deriv-ing Function-Failure Similarity Informa-tion for Failure-Free Rotorcraft Compo-nent Design,” analyzed more than 1,000 accident reports for the Bell 206. They discovered 29 accidents involving engine and powertrain failures, involving 10 dif-ferent failure types. These were listed as bond failure, corrosion, fatigue, fracture, fretting, galling and seizure, human, stress rupture, thermal shock, and wear.

For this project, a thorough search was conducted, via various available databas-es and data sources, to form a compre-hensive population of relevant helicopter accident and incident formal reports. Candidate accident reports were selected according to strictly specified criteria:

• Final official formal reports.

• Of sufficient technical detail to estab-lish an adequate sequence of events.

• Either of events within the main gearbox (MGB) and transmission systems or of external events that influence these systems (including human input).

• Of relevance to existence and appli-cation of HUMS.

• Written in English (there was no access to the whole group of Eastern helicopters for instance or to West-ern reports written in other languag-es due to time limitations).

Applying the above criteria, a total of 12 reports were selected out of an initial screening input of 413. The selected acci-dents can be summarised by registration as G-REDW/CHCN, C-FHHD, G-REDL, G-BJVX, C-GZCH, G-BBHM, G-CHCF, GASNL, G-PUMI, 9M-SSC.G-JSAR, and LN-OPG. To support these selections, interrogation of the European Helicopter

Safety Analysis Team (EHSAT) database used different criteria, aiming to capture any significant accidents that had been missed. However, no new accidents were discovered, thereby providing some con-fidence that the earlier sort process did not miss any significant accidents.

Detailed fault-tree analysis was performed to identify various primary and secondary failures of the MGB and transmission systems for each of the se-lected cases. The fundamental aim of the fault-tree analysis was to develop detailed understanding of triggers, causes, and event sequences for the selected acci-dents and incidents.

The analysis showed no general pat-tern or sequence to the accidents. Some similarities may exist between events, but the overall sequence, nature, depth, or importance of each event was found to be different either up- or downstream of the accident. The key failure modes identified from the above analysis were

• Small corrosion pits as triggers of cracks.

• Small machining defects as triggers of cracks.

• Subsurface cracks.

• Possible spalling of gears/bearings.

• Material defects/manufacturing anomalies.

• Galling of studs/bolts.

• Wear due to load variations/move-ments.

• Fracture/rupture under overload.

• Deformation under overload of bearing rollers/raceways/gear teeth/shafts/splines.

• Internal residual hoop/tension/tor-sion/compression/buckling stresses.

• Permanent distortion (creep) of casings.

• Seizure of roller bearing.

• Improper coating of hard metal (carbide grains size, porosity, coating thickness, etc.).

• Lamination of the hard metal coating.

• Defective bonding between hard metal and coating.

Given the difference of each examined accident, an argument could be made for using all of the accidents as test cases. However, available time and funding made this impracticable. It also risked di-

The main aim of any signal-processing technique is to “expose” the signal that characterizes the degradation or incipient failure from the general noise of the platform and ordinary gear meshing and bearing noise.


luting the focus of the research. Instead, the focus centered on the monitoring of planetary gears and bearings as moti-vated by the recommendation stemming from the accident to G-REDL (UNKG-2011-041). This accident is considered to be the most complex case; hence, any monitoring solution that can be effective-ly applied to this scenario stands a good chance of being successful in monitoring, say, bevel gear shafts or possibly being transferred to other rotating systems on the aircraft.

Sensing technology review and selectionIn order to review the potential sensing technologies, all options were initially considered. Opinions and technologies were sought from a range of subject areas, including wind turbines, mot-orsport, rail, and marine. While some innovative practices were discovered, no entirely new technologies were discov-ered. A down-selection process was then undertaken, leaving vibration, strain, temperature, acoustic emission (AE), and audible acoustics as potential sensing technologies.

Operating conditions—Clearly any solu-tion will need to function correctly in an operational environment. Therefore,

it was necessary to establish baseline operating requirements for any proposed sensor. Precise conditions differ on each platform so, in general, a “worst case” as-sessment was used. To limit the possible solution, a number of constraints were imposed:

• No mechanical signal connection (e.g., slip rings)—wireless only.

• Limited space (of the order of cm at most).

• Useful temperature range -10˚C to +130˚C.

• Sensor weight below 10g.

• Tolerant of gearbox mineral oil.

• Power inside MGB is generated—no battery.

• Guaranteed attachment or no risk from sensor if detached.

Based on these requirements, AE was selected as the sensing technology. AE measurement is the capture of high-frequency (hundreds of kilohertz) surface stress waves that are produced in struc-tures by applied forces. The potential of this technology has increased dramatical-ly over the last 10 years, due to improve-ments in sensor and data-acquisition technology, so that it is now established as a condition-monitoring tool.Wireless transmission

With the selection of a potential sensing technology, it was necessary to ensure that a suitable wireless transmission technique that could operate successfully inside the gearbox could be found or de-veloped to complement the technology.

Existing systems—There are a range of established technologies that might pro-vide a starting point for such a system, including Wi-Fi, Bluetooth, and ZigBee. Table 1 details some of the key param-eters of these three protocols.

One key feature of AE is the frequency range of interest, typically around 100 kHz to 1 MHz. Therefore, to produce an unaliased signal at 16-bit resolution would require a data rate of 32 Mbps. ZigBee offers low power consumption and short join time, which are useful in this application, but it also has a limited network speed that will not handle sam-pling rates in the order of MHz (ZigBee can support around 16 kHz sampling rates at 16-bit resolution). Bluetooth can offer higher transmission rates and hence support higher sampling rates (64 kHz at 16-bit resolution), although this would still not permit real-time MHz sampling rates. The 32 Mbps (2 MHz at 16-bit resolution) would be challenging for even Wi-Fi standards. Therefore, any of these wireless protocols will require preproc-essing or caching to work at high AE sam-pling rates. However, typical vibration sampling rates can be easily supported.

There is an additional factor of shield-ing that greatly complicates the use of wireless transmission. The MGB casing acts as a Faraday cage, defeating attempts to pass an electromagnetic wave through the casing. This means that placing an an-tenna outside the gearbox will not allow a signal to be transmitted into the gearbox. There will also be shielding and modu-lating effects from the rotating metallic components inside the gearbox, mean-ing that any transverse electromagnetic (TEM) field may be affected or defeated inside the gearbox. Within an enclosed metal cavity, the use of high frequencies produces a standing wave pattern, where the field falls to zero at regular intervals, typically every half wavelength (about 6 cm at 2.4 GHz). If the receive coil passes through these standing wave nulls, the recovered power will vary and unwanted modulation will be superimposed on the recovered baseband signal.

Wi-Fi Bluetooth ZigBee

Standard IEEE 802.11 IEEE 802.15 IEEE 802.15

Max range 50-100m 10-100m 10-100m

Frequency 2.4 and 2.5 GHz 2.4 GHz868 MHz Europe

900 - 928 MHz US2.4 GHz World

Power consumption High Medium Low

Max network speed >11 Mbps700 kbps –

1 Mbps 20 kbps -250 kbps

Network join time 3 s 30 ms

Table 1. Candidate wireless communication protocols


Alignment in the gearbox also intro-duces complexity. Using a high-gain antenna would produce a spot beam where the power density is very high, so the rotating part must remain in the spot at all times. Additionally, unless circular polarization is used on both transmit and receive antennas, the recovered power will vary at the rotation rate.

A further consideration is the avail-ability of power; it would be preferable if power were transferred wirelessly along with the data. RF scavenging to supply DC power wirelessly in tags has been carried out at the relatively high RF frequencies of 800 MHz and 2.4 GHz. Using an antenna with high gain allows useful power to be transmitted over a long range, in the order of many tens of meters, using a few watts of RF. Note that these systems are termed “far field” and energy transfer is by TEM wave. Huang, Paramo, and Desh-mukh, in “Unpowered Wireless Transmis-sion of Ultrasound Signals” demonstrated the transfer of AE signals and power using far-field waves at 2.4 GHz.

A final consideration is the genera-tion of sufficient RF power and licensing. For these reasons, it was decided to use the 13.56 MHz ISM band, used by other near-field, short-range devices, such as ISO14443 contactless cards, e.g., Master-Card PayPass and TFL Oyster cards.

Newly developed system—In an attempt to meet the demands outlined in the previous section, a new approach was developed to wireless transmission of AE signals. The system uses a so-called “homodyne” (same–frequency) receiver with a “modulated back-scatter” com-

munications link to pass the analogue signal across the wireless link. Operation at 13.56 MHz allows the use of magnetic coupling, where the “antennas” are two tuned loops of wire or pipe. Such cou-pling is termed “near field” and relies purely on magnetic coupling, as seen in a conventional transformer for AC mains. The magnetic loop does not produce a TEM propagating wave, as in a normal broadcast transmitter. By using two paral-lel, coaxial coils in close proximity, the coupling remains consistent as one coil rotates with respect to the other.

Method of operation—Modulated back-scatter is a technique that relies on periodic damping of the resonant circuit of the rotating loop. When magnetically coupled to a receiving loop, the modula-tion can be detected. In contactless cards, the data are transmitted digitally by modulating a carrier signal with a square wave. However, in this ap-plication, there is a need to transmit a linear analogue signal over a bandwidth extending from 100 kHz to 1 MHz, to preserve the time domain waveform generated by the sensor.

Contactless cards use a “load” modulation scheme, where a damping resistor is switched periodically in parallel with the coil. This is accomplished with a simple on/off transistor switch, but the technique is not suitable for a linear system.

As previously discussed, digital trans-mission of sensor data up to 1 MHz band-width would occupy too much bandwidth for a back-scatter technique and would make the sensor circuitry quite complex. A better analogue approach is to modu-late the resonant frequency of the loop using a varactor diode. Such a diode is a variable capacitor controlled by a “tun-ing” voltage and has a linear response over a certain voltage range. The electrical change so induced by the varactor diode produces a combination of amplitude and phase modulation of the back-scattered signal.

The back-scattered signal can be “tapped off ” the illuminating coil, so a single coil functions both as transmitter and receiver simultaneously. Using a high-quality (low-noise) crystal oscillator as both transmit source and receiver refer-ence enables the use of homodyne receiv-er architecture. A portion of the transmit-ted signal (which is free of modulation) is multiplied with the back-scattered signal from the tap at the same carrier frequen-cy in a coherent demodulator. The output of the demodulator, which responds to both amplitude and phase modulation, is filtered to remove the RF signal at 13.56 MHz leaving the baseband signal.

Lab-scale sensor testIn order to understand, test, and vali-date the performance of AE as a sensing technique, a range of lab-scale tests were performed. By seeding faults in a repre-sentative setup, it was possible to identify the detection potential of AE, for a range

Figure 1. Lab-scale gear rig.

Figure 2. Triaxial accelerometer and AE sensor mounted on idler shaft.


of faults, in a controlled condition, par-ticularly in comparison with more-estab-lished vibration techniques. To provide the most representative test conditions with which to study a helicopter gearbox,

an existing rig was heavily modified as shown in Figure 1.

The rig uses three gears—an input gear, an idler gear, and an output gear—to ap-proximate a single planet of an epicy-clic setup. The input gear is driven by a fixed-speed motor, and the output gear is loaded by a variable dynamometer. The idler gear was allowed to rotate about a fixed idler shaft by two taper roller bear-ings.

A miniature triaxial accelerometer was mounted on the idler shaft next to a min-iature AE sensor as shown in Figure 2.

Three levels of damage were introduced to one of the bearings using electro-dis-charge machining (EDM): gross (a 2 mm

wide, 1 mm deep slot in the outer race), marginal (2 mm diameter spot, 0.5 mm deep), and slight (1 mm diameter spot, 0.25 mm deep).

Enhanced signal processingWhile the gross damage was easily detected using traditional techniques, the more subtle damage was much more difficult to detect. The use of taper roller bearings may have limited the detect-ability of the small damage because of the capacity of the roller to bridge the “hole.” In addition, the use of EDM may have removed the rough edges, often seen in damage, that can help to provide AE events. As a result, enhanced signal processing was used to try and extract useful information, using signal separa-tion and spectral kurtosis.

Spectral kurtosis was employed to extract the filter characteristics that were used for envelope analysis on the

nondeterministic component of the AE signature. A comparison of the vibration and AE analysis showed both measure-ments were able to identify the presence of the large bearing defect based on observations in the enveloped spectra. For the small defect condition, however, the enveloped spectrum was dominated by the gear mesh frequencies and their harmonics—hence, the bearing defect frequencies were not evident in the vibra-tion signal. However AE analysis was able to identify both the small and large defect conditions. Detection of the small bearing defect gives the AE measurement a diag-nosis advantage over the vibration signal. Figure 3 shows the enveloped spectrum

with the outer race defect (ORD) fre-quency shown.

Lab wireless systemIn order to test the approach described in the above wire-less transmission section, a proto-type system was constructed. This consisted of two coils (to replicate a fixed and rotating coil) with one at-tached to a sensor conditioning board, which accepts a signal input, and

the other attached to a demodulator pro-ducing an output signal.

A high-stability oscillator is used as the transmit source. And to ensure that the oscillator is not adversely loaded, a buffer amplifier is used to drive a power ampli-fier producing approximately 1 watt of RF output into the illuminator coil. The buffer amplifier is also required to ensure that the carrier signal has no back-scatter modulation present on it, as a pure sine wave carrier is needed as a reference in the coherent demodulator. This testing showed that both power and signal could be transferred wirelessly.

Full-scale testingTo test and validate the approach out-lined by the lab-scale testing, it was nec-essary to perform full-scale testing of the AE and wireless transmission concept. While the lab-scale approach tentatively proved the concept, many of the issues surrounding new techniques are only

Figure 3. Enveloped spectrum of AE signal with small bearing defects.

Figure 4. Sensor position on dish of planet carrier.

Figure 5. Moving coil mounted on the planetary carrier.


revealed when implemented at full scale.For this phase of testing, an SA 330

Puma gearbox was acquired. While this gearbox is an older design, it was the basis of the design of the current EC225 main gearbox and shares many of the same design features. Most importantly for this project, it has a final two-stage epicyclic reduction utilizing a combined planet gear/outer bearing race design. Airbus Helicopters provided technical support and access to its test bench facili-ties and testing was conducted in May/June of 2014 (see Figure 7).

AE sensor selectionHaving selected AE as the detection mechanism, it was necessary to select a sensor for use inside the MGB. All of the sensors considered required signal con-ditioning and/or pre-amplification. Ph.D. research by A. Pickwell in “Design and Development of Micro-electromechanical Acoustic Emission Sensors” showed that the development of a functioning micro AE sensor (approximately 20 µm thick) was possible, and comparison with commercial AE sensors provided some confidence in the performance of the sen-sor. However, this research work focused more on the design and physical produc-tion of these sensors than on the detail of their performance.

The piezoelectric-wafer active sen-sor (PWAS) is a small sensor often used for nondestructive evaluation (NDE) testing and condition monitoring. A 7 mm diameter, 0.2 mm thick sensor was selected for comparison. The s9225 sen-sor is a miniature (3.6 mm x 2.4 mm) AE sensor from Physical Acoustics weighing less than 1 gram, with an operating range from 300 kHz upwards. The Physical Acoustics PICO sensor is a miniature (5

mm diameter, 4 mm height) AE sensor weighing less than 1 gram. This was the sensor used in the lab-scale testing and is shown in Figure 2 (see page 22).

There was a need to balance reliabil-ity and stability against the potential damage if released. The PICO is a reliable commercial off-the-shelf (COTS) sensor but would cause significant damage if released into a planet bearing. The micro sensor is the smallest of the sensors but is experimental and susceptible to noise. Therefore, a comparison between the PWAS and s9225 sensors was conducted on the lab-scale rig. With the PWAS prov-ing to be more effective, this sensor was used for the full-scale test program. An additional feature of the PWAS sensor is its very broadband performance ( from low kilohertz up to megahertz). This means that it is able to function to detect more traditional vibration frequency ranges as well as AE ranges.

Experimental setupFor full-scale testing, a program was devised consisting of tests in three conditions—an undamaged planet bearing, a heavily dam-aged planet bearing, and a slightly damaged planet bearing. The dif-ferent conditions were achieved by swapping a planet gear between each test. Each of these three conditions was tested at a range of loads.

The damage geome-

try was approximated as a rectangle with fixed depth and width. The fault-to-rolling element length ratio dictates whether the fault is extended (major) or not (minor). The defect length for the major damage was 30 mm and 10 mm for the minor damage and around 0.3 mm deep for both cases.

In its current form, the wireless transfer system is only able to support a single sensor; therefore, it was necessary to select a single location at which to attach the sensor. One of the restrictions to the positioning of the sensor was the need to keep the sensor clear of the main upper face of the planet carrier to allow it to be used as pressure face when changing the planet gears. The sensor was bonded in a position on the “dish” of the planet carrier, as shown in Figure 4 and Figure 5 (see page 23).

For the full-scale wireless system, the prototype system was modified and rebuilt for operation inside the Puma gearbox. While the principles and transfer mechanisms of the lab-scale design remained the same, there were changes to most aspects of the system. One of the most significant changes from the lab-scale system was that the space avail-able to mount coaxial coils on the planet carrier and the gearbox casing is limited. The full-scale system comprised two single-turn brass coils of approximately 400 mm diameter, which were cut to size

Figure 6. Coils in position before rejoining top cover.

Figure 7. MGB installed on the test bench.


using water jets for accuracy. The station-ary (upper) coil was suspended from two clamping rings that were attached to the top case of the gearbox with a spacer through the holes to retain location. The moving (lower) coil was attached to a circular mounting ring, which in turn was mounted on top of the oil caps on the planet carrier (see Figure 5, page 23).

Figure 6 shows the two coils in position before the top cover was pressed onto the planet carrier.

Electrical isolation of the coils from the mounts and surrounding metallic structure was achieved through the use of nylon washers and bushes. The main electrical difference between the lab-scale coils and the full-scale coils is their proximity to metal and, in particular, the mounting ring that forms a “shorted turn.” The proximity causes a drastic reduction in inductance, which then re-quires an increase in loading capacitance to maintain tune at 13.56 MHz.

In addition to the reduction in induct-ance comes a large reduction in the Q factor of the coupled circuit. Fortunately, the electrical power transfer requirement in the gearbox was significantly reduced compared to the prototype, as the spacing between the coils was relatively close. This meant that even with reduced Q, there was enough power transferred to run the opamp buffer circuit. One advan-tage of reduced Q factor is that dispersion is reduced in the baseband signal. This is because the steepness of the phase/fre-quency response is reduced in the vicinity

of the resonance at 13.56 MHz.Once installed in the gearbox, it was

possible to temporarily attach a signal generator to the sensor boards. The time delay of the system was measured by comparing the input signal with the output signal of the system transmit-ted through the coils. From 100 kHz to 1 MHz, there was very little delay variation with frequency. The system behaved as a length of cable, providing about 1 µs delay at all frequencies. This means that in this range it is linear phase and nondispersive, i.e., there is no variation in wave speed with frequency. Below 100 kHz, there is significant dispersion. But since most “low frequency” analysis techniques ignore phase, this is not a significant limitation.

To replicate a typical HUMS setup, ac-celerometers were attached to the case of the gearbox, including on the ring gear, using a mixture of bonded and bolted attachments.

Preliminary resultsThe rig was run at power settings ranging from 80% of maximum continuous power (936 kW) to 110% of maximum takeoff power (1760 kW) for 20 minutes at each setting. During testing, the maximum oil temperature was 97.6 °C.

The low-frequency portion of the signal from the internal sensor (of the order of kilohertz) contains clear peaks at typical gear mesh frequencies, showing that a meaningful signal is being transferred from the sensor. Signal energy levels

varied enormously with frequency; typical Fourier amplitudes at 10 kHz are four orders of magnitude larger than those at 1 MHz. It is unusual to be able to make these comparisons since many AE sen-sors are only useful in a limited frequency range. However, the broadband sensitivity of the PWAS sensor also presents chal-lenges since the large energy levels at low frequency present within the gearbox can affect the sensor.

Figure 8 shows the enveloped random signal for the case of minor damage at 110% maximum takeoff power. The outer race defect frequencies and harmonics are clearly visible, whereas the undam-aged case contained no such harmonics. It can be concluded from this that the sensor is providing useful information across the wireless link at a wide range of frequencies, opening the potential for improved detection.

ConclusionThis research program has resulted in successful proof of concept of broadband wireless transmission, including power scavenging, coupled with small-scale broadband sensors, working successfully in an operational environment. This result presents a new range of potential fault diagnosis opportunities for the future of HUMS. Future publications will release further results from the testing.

Acknowledgements: The work described in this paper was conducted as part of EASA.2012.OP.13 VHM. The support of Airbus Helicopters in the full-scale testing is gratefully acknowledged.

Figure 8. Power spectrum for enveloped random signal for minor damage.


Dealing with on-site accident investigation will always be a significant part of every safety system. Nevertheless, as aircraft

systems become even more precise and reliable, thus pushing safety performance indexes to higher standards, the need for ways to improve event precursor’s detec-tion becomes paramount in order to keep absolute numbers within an acceptable limit despite the ever-increasing volume of flight operations.

Since no one could wait for an accident to occur to start fighting its contributors, a proven way to cut these rates is to work in the “base of the pyramid,” exploring incidents, reports, or even routine opera-tions in search for the so-called “lower-consequence indicators.”

The present challenge is how to share the always limited efforts among all probable issues and, especially inside the safety management system (SMS), how to generate reliable safety performance indexes related to the “never happened” events. While the experience gathered in the field is very relevant to the preven-tion job, monitoring selectively identified items is essential to ensure adequate risk mitigation, which in turn collaborates in achieving an acceptable level of overall safety performance.

In this adapted article, an objective tool to monitor selected events rates will be shown, using statistical ways to positively identify changes in their behavior, spe-cially focused on “low occurrence” events. Detected changes may be assigned to the negative effect of some factor getting out

of control or to the positive effect of an applied countermeasure. In the first case, an alert can be issued. In the second case, the effectiveness of the actions can be better understood and measured, and a very accurate index can be assigned to a safety performance key indicator.

Embraer, as do other aircraft manu-facturers, gathers information about events related to air safety from opera-tors’ reports and other sources, such as government authorities and specialized companies. These reports are grouped by their nature—for example, ATA chapter or FAA nature of condition codes.

Monthly, or as per some special requirement, the information is summa-rized and sent to a distribution list, which includes mainly people from customer support, systems engineering, and an air safety team responsible for “safety health” monitoring. These summaries include, besides the data grouped in Pareto and

The author offers a method to better understand the behavior of safety-related items, using a statistical approach to support strategic decisions like resources assignment or product change requests.

Paulo Razaboni has a degree in electronic engi-neering, with a specializa-tion degree in air safety, production management, and administration. He is a certified mem-ber of the Aeronautical Accidents Prevention and

Investigation System (SIPAER–Brazil). After joining Embraer in 2007 in the technical support area, he moved to the Air Safety Department in 2010, where he is the Safety Programs manager. His team is responsible for analyzing flight data either on a regular basis or providing support to investigations. Other roles include generating safety-related statistics for the fleet and helping in the development of specifications for future aircraft data recorders. SMS implementation and safety officers’ support are also part of the team’s role.

Change Point Analysis Applied to SMS(Adapted with permission from the author’s technical paper entitled Change Point Analysis Applied to SMS presented at ISASI 2014 held in Adelaide, Australia, Oct. 13–16, 2014, which carried the theme “Investigations and Safety Management Systems.” The full presentation, including cited refer-ences to support the points made, can be found on the ISASI website at www.isasi.org under the tag “ISASI 2014 Technical Papers.”—Editor)

By Paulo Manoel Razaboni, Embraer Air Safety Department

Figure 1. Typical data input, as a rate against time (in months). Vertical axis data were intentionally hidden.


pie charts, the history and a statistical trend analysis, developed specially for these kinds of data. This analysis eliminates the subjective interpretation of data, supporting resource alloca-tion for crucial tasks, as well as confirming the effectiveness of some corrective action taken, thus closing the loop for a change initiative.

The techniques were chosen among several sources as per the specific data nature as a way to gather the information that would better fit the decision process. The main tool is a “change point analysis” approach, as described by Wayne A. Taylor in “Change-Point Analysis: A Powerful New Tool for Detecting Changes.” This analysis allows estimating the precise point where the “process” represented by the input data changed its behavior, thus calculating representative figures for the average and deviations for each segment (before and after the change itself).

Each confirmed change point found brings up another ques-tion: Could there be another “minor” change point that would become relevant after isolating the primary one? So each seg-ment can be recursively checked for the presence of a secondary point that fulfills the same requirements. During the analysis validation, it was assumed that only the change points with at least a 95% confidence level would be considered, with the method for calculating this index to be explained also.

To summarize this information, a process-like chart was

chosen as outlined by Tim Stapenhurst in Mastering Statistical Process Control—A Handbook for Performance Improvement Using Cases, using symbols and colors to make it friendly enough for all users.

Average and deviation lines are drawn for each data segment, thus evidencing the changes detected, as well as short- and long-term trend lines. A distribution profile helps support the process chart analysis. Seasonality can be assessed by calculating the monthly stratified average for the last three years, then interpolating a sinusoidal curve that would better fit to data.

MethodologyFor the change points detection, an algorithm “cumulative sum of differences” to the average, outlined in John S. Oakland’s Sta-tistical Process Control, was used. Then for a particular data set, one could get a typical history chart as shown in Figure 1.

Although seemingly simple, determining a change point from the above data can be very challenging. Several trend analyses may be tried—for instance, some points sequentially above or below the average. Although all techniques could be implement-ed by software, some of them would result in different outcomes, and a numeric value for the change itself would be hard to get. Calculating the cumulative sum would produce the output shown in Figure 2.

The chart (see Figure 2) begins with the difference between the first reading and the average and necessarily ends at zero because by definition the sum of all differences to the average is zero. The x-coordinate where the value is the farthest from the average (last “Mar” month) defines a change point candidate. Conceptually, from this point on, readings shall contribute in an opposite way to the average.

It then becomes necessary to check whether the original readings present a distribution pattern of enough significance, not just a mere sequence of random values that might produce a peak somewhere. The most straightforward way to do so is to force this situation, shuffling the data and determining if some

Figure 3. Cumulative sum of differences to the average, shown here for the original data set (the thicker line with markers) and for 20 other calculations. Amplitude of each curve should be compared to the original one for confidence level determination.

Figure 2. Cumulative sum of differences to the average for the data set.


(before/after it), as represented in Figure 4. Then the same proceeding is applied to each segment, recursively.

Assuming that data revealed a be-havior change, a similar analysis can twice be run—as now two distinct data segments exist, one before and, another after the change point. Applying the same technique recursively will reveal other change points, if any, up to a practical limit, which may be one of the two following cases: no more candidates could be found with at least 95% confi-dence or there are not enough points left

in the segment to drive a significant analysis. From the knowl-edge about change points for the parameter under study, one can better decide about resources allocation as well as check the effectiveness of some action taken.

This technique, according to Taylor, is resilient enough against spurious readings. To help evidence the behavior, a process chart called “u-chart” allows variable opportunity for the events to happen (as flight hours usually vary from month to month).

The deviation “s” as devised by Stapenhurst in Mastering Sta-tistical Process Control—A Handbook for Performance Improve-ment Using Cases can be calculated as below:

is the average for the data segment (as identified from the change point analysis); “n” are the flight hours for that specific month. As “n” may vary, 2-s and 3-s limit

curves are not purely horizontal, but they show amplitude

random distribution would be able to generate comparable results (in this case, a higher amplitude in the cumulative sum curve). As per Taylor’s “Change-Point Analysis: A Powerful New Tool for Detecting Changes,” proceeding this way a thousand times would be fair enough to classify the candidate as a change point or not. For example, if data are randomly shuffled and the cumulative sum curve amplitude is calculated 1,000 times, and for 950 times the amplitudes remain below the original one, the candidate can be considered a change point with 95% confidence. In an analog way, if no other distribution was able to produce higher amplitudes, the candidate would be considered a change point with 100% confidence. In this example, a change point could positively be assigned to the process, as shown in Figure 3 (see page 27).

As the candidate was positively classified as a change point, an average calculation is performed for both data segments

Figure 4. Initial data set, now showing two different averages, as identified by the change point detection algorithm.

Figure 5. Proposed chart containing all elements with a brief description for each one. Styles were chosen to be intuitive, using standard representation when practical.


Figure 6. Real data plotting, along with a short-term trend line based on the rolling average for the last three readings. Although some visual clues may suggest trends, the subjectivity must be taken away in order to get an accurate analysis.

Figure 7. Same data set plotted using change detection algorithm. One “level 1” change was detected in February 2013 (with 96% confidence). Short-term behavior has become more stable (less scattering), while long-term curve presents a downtrend. Distribution is not normal for the whole set, but the peak is under the average, probably due to the recent readings. No seasonality was evidenced, as correlation factor is very poor (R=0.10).

variation that is inversely proportional to the hours flown dur-ing each month. These two limits are usually called “warning threshold” (2-s) and “action threshold” (3-s) for processes under control.

In order to provide a consistent view over the “process chart” (as it is valid only for “normal-like” distributions), it is neces-sary to know the readings’ frequency distribution, which may be done by plotting a histogram, in this case drawn 90 degrees rotated and placed aside the control graph using the same verti-cal scaling, a very common practice for simultaneous viewing, as outlined by Stapenhurst.

In order to evidence seasonality, a sinusoidal interpolation with a fixed 1-year period can be plotted over monthly-stratified average readings. This means that three Januarys, three Febru-arys, and so on are averaged representing one typical month as a way to get rid of long-term trends. A correlation coefficient is calculated as well as the sinusoidal interpolation amplitude referred to as the global average, which together will serve as

a measure for the seasonality fitness and de-pendence for each parameter. This would help someone take countermeasures in advance, as a bonus.

Putting all information together may seem challenging so the correct choice for colors and symbols is evident. As it is usually not required for all the recipients to deal with such level of details, a brief comment in plain text from the analyst for each plot would be ap-preciated. The curves will remain an analysis tool for the specialists and a source for deeper information, if required (see Figure 5).

The main advantage is that calculations are made automatically and the analyst expertise

is focused on data interpretation supported by statistical tools, assertively documenting the process already done and gener-ating targets for the next improvement cycle. Actions can be requested inside the company or from suppliers in an unam-biguous way. In the case of SMS implementation, performance indexes can be tracked to achieve established levels.

While the results for the manufacturer are clear and the documentation would be concise enough to attend to SMS requirements, the final client would also have benefits, as safety as a whole would be closely monitored and improved. The same technique may also be applied for monitoring items not directly related to safety —such as the ones related to maintenance, which can give expressive payback, like engines, landing gears, avionics subsystems, etc.

All processing can be implemented by software using dedicat-ed routines in a database system, or even an ordinary spread-sheet for proof-of-concept evaluation where macro routines can


be programmed (macros are necessary, mainly because of the intense and recur-sive calculation, but will take only a few seconds to run).

ExamplesAs it is impossible to control something that is not known, looking at the behavior of selected monitored items over time can give a rough idea about whether an inter-vention is necessary, as well as whether some action was successful (see Figures 6 and 7 on page 29 and Figures 8 and 9).

People with knowledge of the subsys-tem would be able to illustrate this analy-sis with elements from product history. As an example, average changes might

Figure 8. Again, real data plotting. How many changes would be assigned to this data set?

Figure 9. Using the above data set, the algorithm reveals three changes, the latest one in July 2013 (96% confidence), earlier ones in October 2011 and in July 2012. Short-term behavior is stable, and long-term presents a downtrend. Distribution is not normal, considering the whole set. Some level of season-ality may be assigned as the sinusoidal curve roughly fits the data; the worst month identified as August (42% above the average).

suggest deviations or improvements, while seasonality might be associated with climate changes. The decision for as-signing engineering resources or sending communications (service bulletins, news-letters, etc.) to the operators would be facilitated and supported. This would also happen to the negotiations with suppliers as a way for enforcing corrective actions, writing dispositions, or even evaluating contract clauses.

ConclusionThis adapted article offers a method to better understand the behavior of safety-related items using a statistical ap-

proach to support strategic decisions like resources assignment or product change requests. A spreadsheet with macro routines for fast data processing is avail-able from the author. It was created to fit specific data characteristics, which are a common sense for commercial aircraft operations, and has its own benefits and limitations.

Although it is a belief that this is a valuable tool, the suitability for solving specific tasks, related or not to safety, must be adequately evaluated by the analyst. Statistical methods, if adequately implemented, will provide reliable indicators that can be used to keep processes under control and, of course, to document the relevant actions taken in any quality system, including SMS.

Acknowledgements: This work is part of Embraer’s permanent commitment to the product safety at all levels, from concept to operation. I wish to acknowledge the opportunity provided by ISASI for sharing this information, believing this can offer a means to help improve aviation safety levels worldwide. My special thanks are extended to the staff of Embraer for the valuable feedback on the reports that my team has provided.


Augsburg, Germany: ISASI 2015 ‘Independence Does Not Mean Isolation’ (Continued from page 10)

Thorkell Augstsson accepts from Keith Conradi the “cow bell,” which will open ISASI 2016.

ence committee members, fundraisers, transportation providers, behind-the-scene workers, and hotel management and staff. He gave special attention to the 13 cohost corporate sponsors, the companies that exhibited product booths, and the companies that contributed door prizes. The highlight of the evening would be the presentation of the Jerome F. Lederer Award.

He then began the presentation of plaques and certificates. New corporate member representatives came on stage and accepted a specially designed plaque: Luis Garcia with Airbus Defence & Space and Alister Buckingham with Massey University. New corporate members not represented included Human Factors Training Solutions Pty Ltd, Executive Development & Management Advisory, and ATR Airlines.

The surprise recognition of the even-ing was the announcement of the Best of Seminar Award of Excellence for techni-cal papers presented at ISASI 2015. The selected paper, Divorcing the Regulator: The Establishment of an Independent Investigative Authority, was authored by Capt. Ibrahim S. Koshy, director general of the Aviation Investigation Bureau of the Kingdom of Saudi Arabia. In its tenth year of existence, the Award of Excel-lence carries with it a $500 stipend, which Koshy contributed to the ISASI Kapustin Memorial Scholarship Fund. The best paper selection was made by members of the conference Technical Committee (see page 14).

The next group to be recognized was the inductees into the society’s Fellow membership class. Graham Braithwaite and Alan T. Weaver, two long-term ISASI members, were pinned on stage by Presi-dent Del Gandio.

Then Del Gandio introduced the indi-viduals he calls “ISASI’s future.” The four ISASI Rudolph Kapustin Memorial Schol-arship recipients came on stage one by one, as their names were called. Receiving certificates of scholarship were Nicolaus Dmoch, ERAU-Berlin; Kiki Faber, Delft University of Technology; Amy LaRue, University of Southern California; and Mario Pierobon, Cranfield University, UK.

Closing the awards ceremony was the

presentation of the Jerome F. Lederer Award to Ladislav (Ladi) Mika, senior officer of the Air Operation Technology and Development Division of the Czech Ministry of Transport and the ISASI Air Traffic Service Working Group co-chair. Ladi had earlier been introduced during the opening plenary session, but this was the first opportunity for his peers to give him full recognition, which they did with a standing ovation.

Del Gandio spoke of Ladi’s accomplish-ments and contributions to air safety and ISASI, concluding by noting that “ISASI is indeed blessed to have such an outstanding individual in its ranks. His contribution to global aviation safety is outstanding, and there is no doubt that the contributions made by Ladi have im-proved aviation safety through accident/incident investigation and prevention in Central/Eastern Europe. His native Czech Republic has an excellent aviation safety record—no fatal accidents with trans-port-category aircraft for more than 39 years. Ladislav Mika is uniquely qualified to receive the honor of being named the Jerry Lederer Award recipient for 2015. We are very proud to have such a widely recognized aviation safety expert among our membership. He is a most deserv-ing recipient of the ISASI Jerry Lederer Award.” (See page 11.)

In accepting the Lederer plaque, Ladi said, “It is a great honor for me to be here today with you and hold the prestigious award bearing the name of Jerome Fox Lederer in my hands.”

He went on to share his quest to affirm the birthplace of Jerry’s father in the Czech Republic, then known as Czechoslovakia. He also shared parts of the 44 years he has experienced in the aviation safety field. In closing he said, “I thank all my colleagues and friends who have supported me in the effort to increase the level of international aviation safety. A deep appreciation goes to my parents who gave me the opportunity to study the wonderful field of aviation, and at last but not least my thanks goes to my family for their understanding and sup-port throughout the years. I am grateful to those who nominated me as a candidate for this very prestigious international aviation award. I highly appreciate being the first one from the countries of Central and Eastern Europe to be awarded ISASI’s Jerome F. Lederer Award.”

With the room stilled, Conradi made the traditional passing of the “cow bell” to Thorkell Agustsson, chair of ISASI 2016 to be held in Reykjavik, Iceland. The passing of the bell signaled the close of the banquet. The crowd then milled about saying their farewells until 2016.


ISASI

WHO’S WHO

INCORPORATED AUGUST 31, 1964

Flight Data Systems (FDS) is an avion-ics product manufacturer and service provider with facilities located in

Melbourne, Australia; London, United Kingdom; and Sarasota, Florida, USA. FDS’s core business centers on all areas of flight recorder systems, including product manufacture such as flight data acquisition units and quick access recorders currently operating on military and civil aircraft. Our flight recorder ground support equipment, such as the popular handheld multipur-pose interface unit and return to service automatic test equipment products, have become the industry standard for many major airlines, maintenance organizations, aircraft manufacturers, and investigation authorities.

FDS’s flight data services include flight data monitoring and analysis for airline and corporate aircraft operators through a web-based FDM service. In addition, FDS performs in excess of 1,500 manda-tory flight data recorder (FDR) and cockpit voice recorder (CVR) readouts through our three locations using our FDR and CVR replay software product sensor test and replay system (STARS). Our products are used worldwide by many leading aviation organizations, such as crash investigation

Flight Data Systems: A Multi-Avionics Product and Service Provider

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

laboratories; airlines; maintenance, repair, and operations facilities (MROs); flight recorder original equipment manufacturers (OEMs); and defense organizations.

FDS recently expanded its military unmanned aerial systems (UAS) business to the civil market. We offer online remotely piloted aircraft systems (RPAS) theory train-ing as a registered training organization with practical flight training at the FDS dedicated flight range and UAS subsystem design as well as manufacturing. In col-laboration with universities, FDS conducts development of UAS-related products to aviation standards and leverages our avion-ics design, manufacturing, and qualifica-tion facilities to meet the more demanding aviation standards currently not required in the UAS industry. A recent development project working with an Australian uni-versity through a government-sponsored In-novative Manufacturing CRC grant includes development of a UAS-specific crash flight recorder system that meets current Euro-pean and FAA standards.

FDS operates a fleet of Elbit Skylark un-manned aerial vehicles (UAV) along with its own multi-rotor units and conducts flight testing and training at our Civil Aviation Safety Authority (CASA) approved flight

(Who’s Who is a brief profile prepared by the represented ISASI corporate member organization to provide a more thorough understanding of the organization’s role and function.—Editor)

range located in Victoria, Australia. The UAV range has a CASA-designated perma-nent danger zone of 316 kilometers².

FDS offers defense and aerospace customers the ability to design, qualify, and manufacture rugged and complex electron-ics-based systems in one facility. Further strategic expansions include establishment of our environmental testing laboratory to qualify products to military and civilian standards.

The FDS environmental testing labora-tory includes

• impulse shock and vibration systems (up to a 500 kilogram payload).

• three-meter-diameter centrifuge for sustained shock testing up to 50 g’s.

• temperature and humidity controlled environmental chambers.

• altitude chamber and rapid decompres-sion testing.

• highly accelerated life testing and stress screening for products (HALT & HASS).

• lightning test facility.Our Melbourne-based electronics

manufacturing facility uses advanced automated electronics assembly and production equipment with quality-control processes targeted to niche defense and aerospace products. Major customers include aircraft manufacturers, interna-tional military electronics systems manu-facturers, mining industry suppliers, and a number of diverse industry component suppliers.

Documents

Air Safety Through Investigation OCTOBER-DECEMBER 2015 … · OCTOBER-DECEMBER 2015. Augsburg, Germany: ISASI 2015 ‘Independence Does Not Mean Isolation’ Page 5. Divorcing the