Upload
maverick7227
View
216
Download
0
Embed Size (px)
Citation preview
7/27/2019 Aviation Accident Investigation
1/77
Presented by : Sianturi, MBA Avi Mgt
7/27/2019 Aviation Accident Investigation
2/77
NAME : B. R. PARDOMUAN SIANTURI, MBA AVI MGT
RANK : MAYOR TEK / 520232
DOB : BANDUNG / 21 JUNI 1973
POSITION : KASIBINPALLAMBANGJA
UNIT : DISLAMBANGJAAU
ADDRESS : GEDUNG B-1 LT. 3 MABESAU
PHONE : 8709254 / FAX 8714523
MOBILE : 081319132662/083850900538
E-MAIL : [email protected]
7/27/2019 Aviation Accident Investigation
3/77
MILITARY COURSES
A A U 1995
Sesarcabpa Teknik XI 1996
Susfam F27 dan C-130 1997
Remotely Piloted Vehicle Operator Course, France 2000
Dikkualsus JMU F27 2001
37th Qualified Aero Engineering Instructor Course, India 2001
SF260 Marchetti Mechanic Course, Singapore 2002
Sekkau 76 2004
Targadik 2005
49th Flight Safety and Accident Investigation Course, India 2008
Peace Support Operations Instructor Course 2009
Indonesian Military Landworthiness Inspector Course 2009
FORMAL EDUCATIONS
SD 012 Tarakan 1985
SMPN I Tarakan 1988
SMAN 4 Medan 1991
Post Graduate (S2) RMIT Australia 2007
7/27/2019 Aviation Accident Investigation
4/77
Employment History
Skadron Teknik 021 Lanud Halim PK 1996 - 2000
Skadron Udara 2 2000 - 2002
Skadron Udara 17 2002 - 2003
Skadron Udara 2 2004 - 2005
Skadron Pendidikan 303 Wingdiktekkal 2005 - 2007
Dislambangjaau 2008 - NOW
7/27/2019 Aviation Accident Investigation
5/77
SCOPE1. INTRODUCTION
2. PURPOSE OF INVESTIGATION AND INVESTIGATION
3. INITIAL FIELD INVESTIGATION
4. GATHERING EVIDENCE
5. PRESERVATION OF EVIDENCE
6. DETERMINATION OF ACCIDENT SITE AND
RECONSTRUCTION OF FLIGHT PATH
7. SAFETY PRECAUTIONS
7/27/2019 Aviation Accident Investigation
6/77
INTRODUCTION
7/27/2019 Aviation Accident Investigation
7/77
CRASH SITE INVESTIGATIONThe remains of a crashed aircraft
are not necessarily mute, and may
have a story to tell, if properly
investigated.
7/27/2019 Aviation Accident Investigation
8/77
7/27/2019 Aviation Accident Investigation
9/77
INVESTIGATION
A PROCESS CONDUCTED FOR THE
PURPOSE OF ACCIDENT PREVENTIONWHICH INCLUDES THE GATHERINGAND
ANALYSIS OF INFORMATION, THE
DRAWING OF CONCLUSIONS, INCLUDING
THE DETERMINATION OF CAUSES AND,
WHEN APPROPRIATE, THE MAKING OF
SAFETYRECOMMENDATIONS.
7/27/2019 Aviation Accident Investigation
10/77
DEFINITIONS AIRCRAFT ACCIDENT
An occurrence associated with the operation of
an aircraft which takes place between the timeany person boards the aircraft with the intentionof flight until such time as all such personshave disembarked, in which: A person is fatally or seriously injured as a result
of direct contact with the aircraft or its jet blast.
The aircraft sustains substantial damage, theaircraft is missing or completely inaccessible.
7/27/2019 Aviation Accident Investigation
11/77
DEFINITIONS AIRCRAFT INCIDENT
An occurrence other than an accident,associated with the operation of an aircraft,
which affects or could affect the safety of
operations.
FATAL INJURYAny injury that results in death within 30 days
of the accident.
Contd...
7/27/2019 Aviation Accident Investigation
12/77
DEFINITIONS SERIOUS INJURY
An injury which is sustained by a person in an accidentand which: Hospitalization for more that 48 hrs, commencing within
seven days from the date the injury was received.
Fracture of any bone (except simple fractures).
Lacerations which cause severe hemorrhage, nerve,muscle, or tendon damage.
Injury to any internal organ.
Second or third degree burns, or an burns affecting morethan 5% of the body surface.
Verified exposure to infectious substances or injuriousradiation.
Contd...
7/27/2019 Aviation Accident Investigation
13/77
DEFINITIONS
SUBSTANTIAL DAMAGE
Damage or failure which adverselyaffects the structural strength,
performance, or flight characteristics of
the aircraft, and which would normallyrequire major repair or replacement of the
affected component.
Contd...
7/27/2019 Aviation Accident Investigation
14/77
TYPE OF INVESTIGATION
STATE / DOMESTIC INVESTIGATION
Done by country (NTSC, ATSB, etc)
IN-HOUSE INVESTIGATION
Done by special agency (PPKPU)
INTERNATIONAL INVESTIGATION
7/27/2019 Aviation Accident Investigation
15/77
SCOPE OF INVESTIGATION The extent of the investigation depends on the
actual or potential consequences of the
occurrence or hazard. The depth of investigation should be that which
is required to clearly identify and validate the
underlying hazards.
Line between relevance and irrelevance is often
blurred, so it needs better understanding.
7/27/2019 Aviation Accident Investigation
16/77
INVESTIGATION METHOD Used to identify and validate perceived
safety hazards.
Competent analysis.
Effective communication.
All above: INTEGRATED APPROACH.
7/27/2019 Aviation Accident Investigation
17/77
Hazard or occurrence
notification and assessment
Data collection process
Sequence of events
Integrated investigation
Risk assessment process
Defense analysis
Risk control analysis
Safety communication process
Assess notification and decide to
investigate or not
Identify events and underlying factors
Reconstruct logical progression of
occurrence events
Analyze facts and determine
findings regarding underlying
factors and hazards
Estimate risk and determine
acceptability for each hazard
Identify defenses that are missing
or inadequate
Identify and evaluate risk control
options
Communicate safety message to
stakeholders
INTEGRATED SAFETY INVESTIGATION
METHODOLOGY
7/27/2019 Aviation Accident Investigation
18/77
GOOD Investigators:
They are not afraid to be wrong. They will
accept facts that are contrary to their presenttheory.
They readily admit that they dont knoweverything. When they need help, they seek
help.They listen to the other investigators. Theydont necessarily believe them, but they listento them.
INVESTIGATION TECHNIQUE
7/27/2019 Aviation Accident Investigation
19/77
QUALIFIED PEOPLE
PROMPTNESS
RESPONSIBILITYORGANISATION
THOROUGH
ACCURATE
OBJECTIVE
COMPREHENSIVEREPORTING
7/27/2019 Aviation Accident Investigation
20/77
The National Transportation Safety Board (NTSB).
The Federal Aviation Administration (FAA).
International Civil Aviation Organization (ICAO). The National Transport Safety Committee (NTSC).
Panitia Penyelidik Kecelakaan Pesawat Udara
(PPKPU).
INVESTIGATIVE ORGANISATIONS
7/27/2019 Aviation Accident Investigation
21/77
PURPOSE OFINVESTIGATION
ANDINVESTIGATOR
7/27/2019 Aviation Accident Investigation
22/77
INITIAL TEAM TO ARRIVE AT THE CRASH SITE
INITIAL COORDINATION AND ACTION
PRESERVE PERISHABLE EVIDENCES
SECURING THE CRASH SITE
MAPPING & PHOTOGRAPHS THE CRASH SITE
DETERMINE FACTS, CONDITIONS AND
CIRCUMSTANCES OF THE ACCIDENT SITE
LIAISON OF DISLAMBANGJAAU
PURPOSES
7/27/2019 Aviation Accident Investigation
23/77
PREPARATION BEFOREHAND
INITIAL FIELD INVESTIGATION
REPORTING
INITIAL INVESTIGATIONPROCESS
7/27/2019 Aviation Accident Investigation
24/77
INITIAL COORDINATION
INVESTIGATION EQUIPMENTS
PERSONAL SURVIVAL ITEMSDIAGRAM & PLOTTING EQUIPMENTS
WITNESS INTERVIEWING EQUIPMENTS
EVIDENCE COLLECTION EQUIPMENTS
PHOTOGRAPHIC EQUIPMENTSREPORT WRITING EQUIPMENTS
TECHNICAL DATAS
PERSONAL ITEMS
PREPARATION
7/27/2019 Aviation Accident Investigation
25/77
ESTABLISH A BASE OF OPERATIONS
ESTABLISH LIAISON WITH AUTHORITIES
SECURE AND PROTECT CRASH SITEDETERMINE WHAT HAS HAPPEN SO FAR
CONDUCT AN ORGANISATIONAL MEETING
ESTABLISH SAFETY RULES
INITIAL WALKTHROUGH
TAKE INITIAL PHOTOGRAPHSCOLLECT PERISHABLE EVIDENCE
INVENTORY WRECKAGE
DIAGRAMING AND PLOTTING
INITIAL ON-SITE ACTIONS
7/27/2019 Aviation Accident Investigation
26/77
INITIAL FIELDINVESTIGATION
7/27/2019 Aviation Accident Investigation
27/77
ESTABLISH SAFETY RULES
CHEMICAL HAZARDS
PRESSURE VESSELS
MECHANICAL HAZARDS
PYROTECHNIC HAZARDS
HYGIENE HAZARDS
MISCELLANEOUS HAZARDS
7/27/2019 Aviation Accident Investigation
28/77
GATHERING
EVIDENCE
7/27/2019 Aviation Accident Investigation
29/77
INITIAL SITE SURVEYINITIAL WALKTHROUGHPHOTOGRAPHIC & DIAGRAMMINGRECORD ALL OBSERVATIONSCOLLECT EVIDENCE
GATHERING EVIDENCE
7/27/2019 Aviation Accident Investigation
30/77
GATHERING EVIDENCE
Initial Site Survey
Use helicopter to orbit site at various altitudes.
Aerial photography.Make a pass down the flight path vector to
impact point.
Conduct walk through inspection starting fromimpact point.
7/27/2019 Aviation Accident Investigation
31/77
GATHERING EVIDENCE
Initial Walkthrough
Locate all major components (TESTED)
Tag and identify all possible parts.DO NOT move wreckage unless necessary.
Advice supplementary personnel.
Make thorough attempt to locate FDR.Record objects that are not a part of aircraft.
7/27/2019 Aviation Accident Investigation
32/77
Record all observations in a Tape Recorder &
Video Camera.
Questioning witnesses.
GATHERING EVIDENCE
7/27/2019 Aviation Accident Investigation
33/77
Fluid samples (Fuel, Oil, Hydraulic, etc).
Loose papers, maps and charts.
Evidence of icing.Runway condition.
Switch positions and instrument readings.
Control surface and trim tab positions.FDRs and CVRs.
Ground scars.
GATHERING EVIDENCE
7/27/2019 Aviation Accident Investigation
34/77
CRITICAL TIME EVIDENCE:
SAMPLES.
FIRE PATTERN.
LIGHT BULBS.
WITNESSES.
RETRIEVABLE DATA:
CSFDR.
AC LOADING RECORDERS.
HEAD-UP DISPLAY VIDEOS.
AC VIDEO TAPE RECORDER.
PERSONAL RECORDERS.
TYPES OF EVIDENCE
7/27/2019 Aviation Accident Investigation
35/77
Use appropriate containersFluid container compatibility
AircraftFuel
Oil (Each engine)
Hydraulic fluid (Each system)
Servicing EquipmentImpound until samples taken
Take atleast two samples One for investigation team
One for immediate analysis
FLUID SAMPLING
7/27/2019 Aviation Accident Investigation
36/77
VARIES WITH THE ACCIDENTS.
VITAL IN SOME CASES.
DEFERENTIATE BETWEEN WHAT THE WITNESSSAY AND THE FACT.
INTERVIEW NOT INTEROGATION.
WITNESSES
7/27/2019 Aviation Accident Investigation
37/77
COMMON ERRORS
LACK GOOD INTERVIEWING SKILLS.
TEND TO INTERROGATE THAN INTERVIEW.INTERRUPT.
DONT LISTEN TO THE ANSWERS.
HUMILIATION.
INHIBITIVE.
NOT EASILY ESTABLISH RAPPORT WITH
PEOPLE WE DONT KNOW WELL.
WITNESSES
7/27/2019 Aviation Accident Investigation
38/77
PLANNING THE INTERVIEWSet priorities
Obtain contacts
Select locationPrepare for the interview
CONDUCTING THE INTERVIEWMake the witness feel at ease (tell the right and
purpose)Qualify the witness
Encourage to tell a story
Repeat the story to ensure the facts
Thank the witness / reward
IDEAL INTERVIEW
7/27/2019 Aviation Accident Investigation
39/77
WITNESS BACKGROUND IN AVIATION / IQ
PERCEPTION OF WITNESSEMOTION / EXCITEMENTS
INTERPRETATION OF THE AMBIGUOUS
AGREEMENT WITH OTHER WITNESS
ENVIRONMENTALPHYSIOLOGICAL
PSYCOLOGICAL
FACTORS AFFECTING
WITNESS REPORTING
7/27/2019 Aviation Accident Investigation
40/77
Crash survivable Flt data recorder
AC loading recorder
HUD video
AC video tape recorder
Personal recorder
RETRIEVABLE DATA
7/27/2019 Aviation Accident Investigation
41/77
COCKPIT.
AIRFRAME.
POWER PLANTS.SYSTEMS:
FUEL SYS
HYDRAUL IC SYS
ELECT SYSINSTRUMENTATION
EJECTION SYS
FIRE.
WRECKAGE PATTERN.
DETAILED ON-SITE EXAMINATION
7/27/2019 Aviation Accident Investigation
42/77
Traces disappear by evaporation
Precipitation
Carelessness
Nature
Souvenir hunters
Site Clearance
DANGERS TO EVIDENCE
7/27/2019 Aviation Accident Investigation
43/77
All efforts to preserve evidence should be
understood.
Evidence gathering exercise must becontrolled.
Deliberate plan to be made to examine
site.
Formulate story with out drawing
conclusions.
GATHERING EVIDENCE
7/27/2019 Aviation Accident Investigation
44/77
Cordon off.
Photograph.
Identification/questioning of witnesses.
Samples.
Preservation of ground traces.
Completeness of wreckage.
MEASURES TO SAVE
EVIDENCE
7/27/2019 Aviation Accident Investigation
45/77
PRESERVATION
OF
EVIDENCE
7/27/2019 Aviation Accident Investigation
46/77
Bodies to be photographed and examined
by doctor before moving.
Physical evidence must be protected from
further damage:
Edges of broken surfaces contamination.
Do not wash, clean, brush off parts.
Do not mate together broken pieces.
PRESERVING EVIDENCE
7/27/2019 Aviation Accident Investigation
47/77
Gather all evidence from cockpit:
Check all controls, selectors, switches &handles.
Note readings of all instruments.
Photograph all items.
PRESERVING EVIDENCE
7/27/2019 Aviation Accident Investigation
48/77
Wreckage documentation:
Accurate wreckage distribution diagram.
Full photographic record.Record damage during wreckage movement .
Record and protect evidence likely to disappear
or change (Critical time evidence):Samples of all POL and gases.
Fire pattern.
Fragile items like bulbs.
PRESERVING EVIDENCE
7/27/2019 Aviation Accident Investigation
49/77
All recording devices like FDR, AFTR, CVR, DVR etc.
Impounding of documents (All records pertaining to
Man, Machine & Flight)
Pilot Blue Books & Log Books
Training records of pilot
FDR data of previous ten sorties
Engine Log books
ATC records
PRESERVING EVIDENCE
7/27/2019 Aviation Accident Investigation
50/77
DETERMINATION OFACCIDENT SITE
&
RECONSTRUCTION OF
FLIGHT PATH
7/27/2019 Aviation Accident Investigation
51/77
7/27/2019 Aviation Accident Investigation
52/77
Accident Photograph.
Impact sketch.
RECORDING OF SITE
7/27/2019 Aviation Accident Investigation
53/77
Forethought brief SAR crew & photographer.
Request.Overlay giving:
Approach direction.
Point of first contact.Direction and elevation.
AERIAL PHOTOGRAPH
7/27/2019 Aviation Accident Investigation
54/77
7/27/2019 Aviation Accident Investigation
55/77
SUGGESTIONS
Fly in something that has an open window ordoor.
Dont touch the camera to any part of the aircraftor helicopter.
Arrange for something of known dimension to bevisible in the wreckage scene
Get at least one picture as close to vertical aspossible.
Always take two shots in rapid succession foreach picture.
Note the altitude for each picture taken.
AERIAL PHOTOGRAPH
7/27/2019 Aviation Accident Investigation
56/77
7/27/2019 Aviation Accident Investigation
57/77
7/27/2019 Aviation Accident Investigation
58/77
7/27/2019 Aviation Accident Investigation
59/77
7/27/2019 Aviation Accident Investigation
60/77
7/27/2019 Aviation Accident Investigation
61/77
PHOTOGRAPHIC PRIORITIES
PERISHABLE EVIDENCE
AERIAL OVERVIEWS
OVERVIEWS OF THE SCENESIGNIFICANT SCENE ELEMENTS
WRECKAGE INVENTORY
CLOSE-UPS
DOCUMENTS
WITNESS VIEWS
EXEMPLARS
7/27/2019 Aviation Accident Investigation
62/77
In addition to accident photograph.
Starts with point of first impact.Types:
Grid System
Polar SystemSingle Point System
Straight Line System
IMPACT SKETCH
7/27/2019 Aviation Accident Investigation
63/77
Have details of:
Crater depth.
Ground markings.Traces of skidding and sliding.
All essential parts.
Compass direction.
Obstacles.
Wind direction and velocity.
Inspite of this, should not be cluttered.
IMPACT SKETCH
7/27/2019 Aviation Accident Investigation
64/77
7/27/2019 Aviation Accident Investigation
65/77
7/27/2019 Aviation Accident Investigation
66/77
Tenerife 747s Collision
7/27/2019 Aviation Accident Investigation
67/77
GR
ID
TYPE
7/27/2019 Aviation Accident Investigation
68/77
POLA
R
TYPE
7/27/2019 Aviation Accident Investigation
69/77
RECONSTRUCTION OF FINAL FLIGHT PATH
7/27/2019 Aviation Accident Investigation
70/77
SAFETYPRECAUTIONS
7/27/2019 Aviation Accident Investigation
71/77
Visiting site in a hurry without preparation.
Ignoring safe investigating practices andcommon safety precautions.
Arriving at conclusions before startinginvestigation.
Disturbing the wreckage before collecting
evidences/ documentation.
AVOID COMMON ERRORS
7/27/2019 Aviation Accident Investigation
72/77
Cordon area
Security arrangements
Make cartridges safeIdentify Crash site hazards
Bioenvironmental hazards
Toxic substances
Mechanical hazards
Pressure vessels
Radioactive hazards
Fire/Explosive hazards
SITE SECURITY & SAFETY
7/27/2019 Aviation Accident Investigation
73/77
Hazard control
Scene control
Neutralisation of known hazardsSafety awareness brief all personnel
Personnel Protective Equipment
Surgical glovesLeather gloves
Exposure suits, etc.
PERSONNEL SAFETY
7/27/2019 Aviation Accident Investigation
74/77
Theaccuracyand thoroughnesso f
invest igat ion determ ines the adequa-cy of u l t imate act ion taken
to remove or el iminate
factors that cause or
contr ibu te tomishaps
CONCLUSION
7/27/2019 Aviation Accident Investigation
75/77
7/27/2019 Aviation Accident Investigation
76/77
BIDANG MISI
PROGRAM OPERASI/LATIHAN.
SYLABUS LATIHAN.
PROGRAM SIMULATOR.
BIDANG MANUSIA
KESEHATAN (MEDICAL/ILA).
PSIKOLOGI.
BIDANG MATERIIL
TINGKAT/MACAM KERUSAKAN YANG DIAKIBATKAN DARIBENTURAN/IMPACT.
PENGUJIAN MATERIIL/FUEL/OLI MESIN/HIDROLIK.
KERUSAKAN BENDA LAIN (DILUAR PESAWAT/ALUTSISTA).
KONDISI DARI SYSTEM PESAWAT/ALUTSISTA PASCAACCIDENT.
PENYELIDIKAN PPKPU
7/27/2019 Aviation Accident Investigation
77/77
BIDANG MEDIA
LINGKUNGAN KERJA/KANTOR.
LINGKUNGAN KELUARGA.
BIDANG MANAJEMEN
ORGANISASI SATUAN/LANUD/KOTAMA/MABESAU/MEBES TNI.
PENGADAAN SUKU CADANG.
PEMELIHARAAN SUKU CADANG.
PENYELIDIKAN PPKPU