Lederer Award Recipient: ‘Independence And Integrity’ … and Don Harris was ... ICAO member...

OCTOBER–DECEMBER 2007Welcome to Singapore! (Page 3)

Sharing Experience and Knowledge (Page 4)ISASI 2007 Trumpets Cooperation in ‘Lion City’ (Page 8)

‘Best in Seminar’ (Page 15)International Cooperation and Challenges:

Understanding Cross-cultural Issues (Page 16)To Break the Chain Use AQP (Page 22)

Lederer Award Recipient:‘IndependenceAnd Integrity’ MarkTom McCarthy(Page 6)

2 • ISASI Forum October–December 2007

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Volume 40, Number 4Publisher Frank Del Gandio

Editorial Advisor Richard B. StoneEditor Esperison Martinez

Design Editor William A. FordAssociate Editor Susan Fager

Annual Report Editor Ron Schleede

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

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

Copyright © 2007—International Societyof Air Safety Investigators, all rights re-served. Publication in any form prohibitedwithout permission. ISASI Forum regis-tered U.S. Patent and T.M. Office. Opinionsexpressed by authors do not necessarily rep-resent official ISASI position or policy. Per-mission to reprint is available upon applica-tion to the editorial offices.

Publisher’s Editorial Profile: ISASI Fo-rum is printed in the United States and pub-lished for professional air safety investiga-tors who are members of the InternationalSociety of Air Safety Investigators. Edito-rial content emphasizes accident investiga-tion findings, investigative techniques andexperiences, regulatory issues, industry ac-cident prevention developments, and ISASIand member involvement and information.

Subscriptions: Subscription to members isprovided as a portion of dues. Rate for non-members is US$24 and for libraries andschools US$20. For subscription informa-tion, call 703-430-9668. Additional or re-placement ISASI Forum issues: membersUS$3, nonmembers US$6.

FEATURESSpecial Section: ISASI 2007—Singapore3 Welcome to Singapore!By Frank Del Gandio—ISASI president’s opening address to the 303 delegatesattending ISASI 2007.

4 Sharing Experience and KnowledgeBy Mark V. Rosenker—Keynote address to the ISASI 2007 assembly.

6 Lederer Award Recipient: ‘Independence andIntegrity’ Mark Tom McCarthyBy Esperison Martinez, Editor—ISASI 2007 award recipient has for 54 yearsdedicated his talents to the improvement of aviation safety.

8 ISASI 2007 Trumpets Cooperation in ‘Lion City’By Esperison Martinez, Editor—The seminar theme “InternationalCooperation: From Investigation Site to ICAO” received a thorough airingfrom high-level regulators to field tinkickers.

15 ‘Best in Seminar’By Esperison Martinez, Editor—Paper by Wen-Chin Li, Hong-Tsu Young, ThomasWang, and Don Harris was judged best technical paper at ISASI 2007 .

16 International Cooperation and Challenges:Understanding Cross-cultural IssuesBy Wen-Chin Li, Hong-Tsu Young, Thomas Wang, and Don Harris—The technicalpaper selected as “Best in Seminar” provides an insight into the role thatnational cultural characteristics play in aviation safety.

22 To Break the Chain Use AQPBy Claudio Pandolfi—In demonstrating that the Advanced QualificationProgram (AQP) breaks the present tendencies related to aviation accidents,the author gives meaning to an age-old quote.

DEPARTMENTS2 Contents

26 ISASI RoundUp30 ISASI Information32 Who’s Who—A brief corporate member profile of Jones Day

ABOUT THE COVERGerald “Tom” McCarthy displays his pride and the plaque that denotes his selectionas the recipient of the ISASI 2007 Jerome F. Lederer Award, given for outstandinglifetime contribution in the field of aircraft accident investigation and prevention.(Photo by Kelly Chong, senior photographer, AAIB Singapore)

CONTENTS

October–December 2007 ISASI Forum • 3

Welcome to Singapore!By Frank Del Gandio, President

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PRESIDENT’S VIEW

At a minimum, all the accident investigationauthorities and civil aviation authorities

represented here today seek to preventaccidents in their respective countries, butwe also seek to prevent accidents elsewherein the world.

(President Del Gandio’s August 28opening remarks to the delegates ofISASI 2007 have been abbreviated.—Editor)

ISASI thanks our seminar hosts,Chan Wing Keong, director of theAir Accident Investigation Bureau ofSingapore, and Barbara Dunn, who,as always, worked hard to ensurethe success of this seminar. Also, ourthanks to all the members of the

seminar committee for their work and to everyone who helpedto organize last week’s tutorial programs at the SingaporeAviation Academy.

Five years ago, ISASI met in Taipei. That was the first timewe had met in Asia, and I made the point then that Taipei was apowerful indication that the International Society of Air SafetyInvestigators was indeed an international organization. Thisweek’s meeting in Singapore introduces ISASI to South Asia.Much like Taipei, this is a powerful confirmation that ISASI istruly an international professional society.

Our theme is “International Cooperation: From InvestigationSite to ICAO.” The point of the theme is this: whatever we learnby investigating accidents will be of little practical use unlessthat learning is effectively shared with everyone in aviation.

The theme also suggests that all of us in this room today arereally in the business of accident prevention as well as accidentinvestigation. At a minimum, all the accident investigationauthorities and civil aviation authorities represented here todayseek to prevent accidents in their respective countries, but wealso seek to prevent accidents elsewhere in the world. We do thisfor basic moral reasons, but we also do it because we understandthat a major accident anywhere in the world reflects on all of us.We also do it because we understand that aviation was a trulyglobal industry long before the term became popular, and werecognize that everyone’s citizens fly in aircraft operated underforeign flags.

Today, the process of accident prevention employs a widerange of new tools or at least older tools that have been mademuch more capable by still relatively new data processingcapacities, communication technology, data mining tools, etc.These new analytical tools hold real promise for the entireaviation safety community. One result is that, for the first time,we really have begun to analyze incidents and routine operationsto identify new risks before they lead to accidents.

Yet, acquiring a fundamental understanding of accidents andserious incidents still begins at the accident site. In fact, theknowledge we have amassed from accident investigation has

been the foundation for defining risk in the first generations ofFOQA programs and voluntary reporting programs. What welearn in accident investigations will continue to be the first stepin accident prevention and mitigation. Investigations oftenconfirm well-understood issues, but they also produce newknowledge and new recommendations for corrective action.

However, to be useful, any understanding we achieve must beshared with the entire aviation community, based on detached,professional investigation of all accidents and serious incidents.It also requires that such investigations are not complicated bythe still far-too-common practice of criminalizing accidents.

“From Investigation Site to ICAO” also requires that theICAO member states make their data and investigative findingsavailable to the rest of the world. The vehicle for that datasharing is ICAO. The aviation community has come impressivelyclose to eliminating those accident scenarios that, not manyyears ago, explained most major accidents. The task now is todrive risk even lower. The only way we can do that is by sharing

information in a manner that makes it useful to everyone in ourcommunity.

Since we met last year, we have had nine major accidents,resulting in 857 fatalities.

This does not mean that aviation safety is on the verge ofcrisis; it is not. In fact, as IATA recently reported, 2006 was thesafest year on record. By IATA’s count, air carrier accidentsdecreased worldwide from 110 in 2005 to 77 in 2006, despite anincrease in operations.

As all of us recognize, accidents can occur anywhere.That is why we seek new approaches and new tools for accidentprevention in those countries where major accidents really arerare events. Yet, we also understand that many countries canstill benefit greatly from more basic approaches. For eithergroup of countries, sharing and using information from theaccident site and from operational experience will make thesystem safer everywhere. ICAO remains the best vehicle bywhich sovereign countries can share data, safety knowledge, andgood safety practice.

With that, I will close, but allow me to remind you that ISASIis proud to be in Singapore and we sincerely thank our hosts. ◆


ISASI 2007—SINGAPORE: KEYNOTE ADDRESS

SharingExperience andKnowledgeBy Mark V. Rosenker, Chairman, U.S. NationalTransportation Safety Board

(Remarks presented by Chairman Rosenker in his keynote ad-dress to the ISASI 2007 air accident investigation seminar del-egates on Aug. 28, 2007, in Singapore.—Editor)

Minister for Transport and Second Minister for ForeignAffairs, Raymond Lim, distinguished visitors, ladiesand gentlemen, members of ISASI, and guests—on be-

half of the organizers of ISASI 2007, Wing Keong Chong (who alsogoes by Chan Wing Keong) and the staff at the Singapore AirAccident Investigation Bureau, please allow me to welcome you toour venue here in Singapore and to the lovely Stamford hotel.

It is always a pleasure to return to Singapore; and since my firstvisit more than 20 years ago, each time I return, I am amazed atthe continued growth and technical advancements that are takingplace. Yesterday, I visited with corporate officials at Singapore Air-lines to view some of that new technology. I was briefed on thechallenges of integrating the A380 into the airline route structure.We are all aware of how big the airplane is, and it is equally inter-esting to observe the maintenance and crew training issues as theypresent themselves in the airline environment.

I’m also interested in viewing another transportation modehere in Singapore, the maritime sector. Of course, we are allinterested in the surface movement of aircraft—and there is asimilar challenge at the Singapore Port Facility. Singapore isNo. 1 in the world for handling the movement of container shiptraffic. The seaport traffic issues are very similar to those inaviation, where aviation is faced with ever-increasing air trafficvolume and limited airport arrival and departure rates, withrunway incursion and excursion risks; the marine sector hassimilar challenges with narrow ship channels and limited dockside berths. Singapore leads the industry with a tracking sys-tem equal to our aviation methods. In fact, it is already usingtechnology similar to the automatic surveillance broadcast ofthe ship’s GPS position for marine ship movement. So congratu-lations to you, Singapore, for showing such leadership in inte-grating a variety of new technology into our everyday lives.

Now it is time to talk about ISASI 2007. Let’s start with theseminar title: “International Cooperation: From InvestigationSite to ICAO.” I believe we can take that title to mean workingwithin the cooperative framework of international standards

Chairman Rosenker addresses the assembly.

and recommended practices, and, further, to transfer vital infor-mation from an accident site anywhere in the world, with carefulanalysis along the way, to the offices and the staff of the Interna-tional Civil Aviation Organization (ICAO) in Montreal. I’ve lookedat the delegate list and note that we have representation from allcontinents of the globe. We know right away that our friends fromSouth Asia and North Asia are well represented. And we see rep-resentation from all of Europe, the Mid East, and Russia. Lookingfurther, Africa and Australia are here, and for the Americas, fromChile to Canada we have representation. This representation istruly the global approach desired by ICAO to permit the greatestexchange of ideas and international cooperation.

Now what do we do with these ideas? There are ample opportu-nities to apply multiple aviation safety initiatives through variousavenues. There are local nation state opportunities, as well as ac-tion by regional organizations, and within the global framework.My agency, the U.S. NTSB, maintains an Internet website postingour “Most Wanted” list of safety recommendations. We try andkeep the focus on those issues that offer the greatest potential forsaving lives and avoiding a major disaster. As one example, wegive the highest priority to reducing the risk of a runway collision.And we are certainly not alone. Just last month, the president ofthe ICAO Council, Roberto Kobeh Gonzalez, during an address tothe Strategic Aviation Safety Summit in Bali, Indonesia, declared,“There is an urgent need to implement a concrete, realistic, andachievable plan of action.” I fully endorse the words of PresidentKobeh. His personal attention to such issues will have lasting im-pact. And I believe we all can fully endorse ICAO’s Global AviationSafety Plan, and the industry developed the Global Aviation SafetyRoad Map to support the plan.

But I have to add something about the ICAO Road Map. Asaviators, I believe you will be quick to recognize my point. Whenwe discuss the roadmap, or any map, we know it will show you thedirection to take—but it requires a commitment to reach your des-tination. In the case of the Global Aviation Safety Plan, we have to

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Chairman Rosenker speaks informally with Minister RaymondLim (left). Looking on are ISASI 2007 host Chan Wing Keong andISASI President Del Gandio.

address the commitment of states and operators to reach the in-tended safety objectives. That is where the ICAO Universal SafetyOversight Audit Program (USOAP) plays a very important part.The ICAO USOAP audit results provide identification of a state’scapabilities to provide adequate safety oversight. As the audit cyclebecomes complete in 2008, and with the agreement among statesto release ICAO audit information to the public in 2009, the statesnot meeting their safety oversight responsibilities, those requir-ing assistance to improve their infrastructure and technical com-petence, will be well known. Thereafter, we should be looking to-ward each and every state’s high-level commitment to its long-term sustainable safety responsibilities … and to meet themilestones along the safety roadmap.

Let’s take a moment to view the record of the aviation indus-try—and the ongoing safety efforts around the world. Considerfor a moment the number of travelers—or the number of depar-tures—that take place around the world every day. More than 2billion passengers traveled by commercial air transportation in2006. Certainly, we recognize the accidents that took place—andyou will hear more about some of them during the seminar; how-ever, we should also recognize that many of the safety improve-ments that aviation safety professionals and groups such as ISASIhave promoted over the years are now providing the benefits wepredicted. I’m referring to the professional crew training and theelevated standards of SOPs, adherence to the stabilized approachcriteria, improved reliability of aircraft powerplants, and the veryspecific enhancements such as satellite navigation systems, mov-ing map airport displays, and Enhanced Ground Proximity Warn-ing and Traffic Collision Avoidance Systems. What we have to donow, …today’s challenge, is to maintain that momentum for anever-increasing level of aviation safety.

As the industry moves to adopt the Safety Management Sys-tems (SMS) approach, we have a unique opportunity to increasethe level of safety—and to involve all the stakeholders in the solu-

tion. The industry has readily endorsed SMS objectives to findmore efficient methods of safety data collection and to analyzethat incident data in a proactive way to reduce the accident po-tential in our operations. With the SMS approach, the objectiveis to identify multiple risk factors and reduce or eliminate thoserisks, thereby providing intervention in the causal chain ofevents, with the end result to prevent major accidents beforethey occur.

However, we must be realistic—aviation is a human endeavor;unfortunately, air accidents and serious incidents will continueto occur. And related safety recommendations originating fromthose unfortunate events will be necessary. At every level ofgovernment and industry, we must be prepared for major acci-dents. We can see from the most recent occurrences that a ma-jor accident can quickly become a national crisis—with inter-national consequences far beyond aviation interests.

So, we are gathered here today to share our experiences andknowledge in order to produce the best possible air safety inves-tigations. We have a unique opportunity at ISASI 2007 to gainfurther insight into aviation safety initiatives from an outstand-ing group of presenters. And the topic list holds some very valu-able subjects for each of us. We will hear about some recent in-vestigations from a variety of locations, from Africa, from Indo-nesia, from Brazil, and from the oceanic area, to name a few. Theairframes discussed will range from the general aviation Cessnaand Cirrus to include the very light jets (VLJs) and extend to themost modern commercial transport airplanes—the completespectrum of our industry.

As members of this unique professional Society, ISASI, I’mcertain you are interested in the advancing investigative tech-niques. You won’t be disappointed. Of course, flight recorderswill be addressed, with views from several different perspec-tives. Also, there are several papers on the techniques and pro-tocols of investigation with particular emphasis on the aspect ofinternational cooperation. The cultural challenges of our vari-ety of social systems that combine during an investigation arepresent in almost every investigation. National borders havebecome transparent in many ways—in the manufacture of theairframe and the various components, in the crew makeup andtraining of our personnel, in maintenance facilities, and with airtraffic service providers. We are truly a multinational and fullyglobal industry. Several speakers will discuss these cross-cul-tural challenges as they affect the workings of an air safetyinvestigation.

Before closing, I’d like to make added mention of the im-portance of international cooperation and the need for har-monized best practices in investigation. This is especially truefor those of us representing airplane-manufacturing states.Our industries desire to provide the most airworthy aircraftpossible for the market place. To do this, we need to know howthe aircraft perform in the market place, and when deficien-(continued on page 30)


ISASI 2007—SINGAPORE

The many ASIs who know or have worked with TomMcCarthy are familiar with his warm, bright smile anddeportment, which signal the nature of the man: friendly,

soft-spoken, patient, disciplined, deliberate, confident, andstaunch integrity. Those who never heard of Tom before, butsat in the audience at the ISASI 2007 Awards Banquet whenhe accepted the ISASI 2007 Jerome F. Lederer Award, wereable to quickly discern for themselves his nature, includinghis exuberance.

ISASI President Frank Del Gandio declared it an “honor anda privilege” to present the Lederer Award to the man who hasserved at ISASI’s treasurer for the past 12 years. In truth, thatis probably the lesser of his service to the Society. As PresidentDel Gandio told it, Tom joined ISASI in 1981 and his achieve-ments “are nothing short of phenomenal.” He has chaired theMembership and Nominating Committees for more than twodecades; serves with the Ballot Certification Committee; wasthe ISASI 2003 seminar technical chairman; and is “Mr. Ready”at the headquarters office, doing jobs such as plumber, windowwasher, box mover, maintenance man, etc. All because “It hasto get done.”

Add to all of this the acumen Tom has demonstrated in re-ducing by thousands of dollars the operational costs the Soci-ety incurs for office space and taxes and in his development of ahighly effective financial and budget reporting system and a

person can understand why President Del Gandio told the as-sembled audience, “I really can’t exist in ISASI without him, andhe knows I mean that from the bottom of my heart.”

But the Lederer Award isn’t about serving ISASI—the Awardis conferred for outstanding lifetime contribution in the field ofaircraft accident investigation and prevention. It was created bythe Society to honor its namesake for his leadership role in theworld of aviation safety since its infancy. Tom McCarthy also fillsthat requirement.

President Del Gandio tells why: “For the past 54 years, Tom hasdedicated his talents, endless energy, in-depth technical expertise,and ‘can do’ spirit to improve aviation safety, through accident in-vestigation and in support of investigator mentoring programs.He was a command fighter pilot in the U.S. Air Force who servedfor 22 years and retired as a lieutenant colonel. For more than adecade of that time, he was an aviation safety officer who performedin-depth accident investigations, which resulted in numerous safetyregulations effecting technical refinements, operational policies,and procedures that are still current to this day in the Air Force.

“Following his retirement, he joined the National Transporta-tion Safety Board, eventually moving to senior investigator incharge of major ‘go team’ investigations. During his NTSB ten-ure, he investigated approximately 100 aircraft accidents, result-ing in numerous safety recommendations and noteworthy improve-ments to the National Airspace System, which caused proceduralchanges to flight operations, dispatch, air traffic, airport opera-tions, CFR response, as well as highlighting issues concerning air-craft engineering, maintenance processes, and policies. Later, hejoined NASA, becoming the director of the Aircraft Management

Lederer Award Recipient:

‘IndependenceAnd Integrity’MarkTom McCarthy“…two things an investigator must have:independence and integrity. Independenceto do the work without outside influenceor pressure.… Integrity, without it trueprogress in accident investigation andprevention is not possible.”—Gerald “Tom” McCarthyBy Esperison Martinez, Editor

President Del Gandio (right) presents the Lederer Award to TomMcCarthy. With the formalities over, Tom exhibits the exuberantside of his nature.

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Office. Again, analytical skills and lifelong experiences helped bringnumerous changes to the operation and maintenance of the NASAfleet. Many of Tom’s safety recommendations were adopted bythe Interagency Committee for Aviation Policy and applied to allfederally operated aircraft.”

President Del Gandio closed his talk this way: “Tom’s actionshave shown him to be deeply dedicated to aviation safety, to acci-dent investigation, and to safety mentoring programs to help pre-vent aircraft accidents. His contributions to the National AirspaceSystem and our Society are monumental and make him truly wor-thy of being selected as the recipient of the coveted 2007 Jerome F.Lederer Award presented annually by ISASI.

A thunderous applause filled the banquet hall as the Award pre-sentation ceremony took center stage. Then Tom took his place atthe lectern. Following is his acceptance address, abbreviated:

“Thank you very much! To say that I am honored would be anunderstatement. I am a bit overwhelmed. It is truly a privilege tobe in the estimable company of past selectees such as John Purvis,Ron Schleede, Ron Chippindale, and Caj Frostell who are allpresent here tonight. “The very first Society of Air Safety Investi-gators (SASI) international seminar was held in November 1970at the Sheraton-Park Hotel in Washington, D.C., with 159 delegatesin attendance. Jerry Lederer, SASI’s second president, openedthe seminar. These are his words:

“I want to welcome you to the first international seminar on airaccident investigation. It’s an experiment, which we hope will gofar. It is an idea that meetings such as this would have positiveeffect by getting people to know one another before accidents hap-pen in foreign lands. You’ll have an opportunity to meet with peopleand discuss mutual problem areas. In addition, we will be able toexchange ideas on new techniques as well as old proven techniqueson aircraft accident investigations.

“Much of the progress in the development of aviation safety hascome from lessons learned from accident investigation. There isreason to believe that this will continue and that new techniqueswill be developed to aid the investigator to determine probablecauses in less time with greater accuracy than in the past in spiteof the incredible growth and complexity of aviation. The use ofrecorders, X-ray, improved photography, improved search and res-cue, better training, formalized safety engineering, and the sys-tem approach to investigation are some techniques developed inthe past decade or two that are transforming accident investiga-tion from an art to a science. But it still remains a considerable art.We are here to help each other uncover and disseminate new ideason developments in both the art and science of aircraft accidentinvestigation.”

“As I sat at the opening of this 2007 seminar, I marveled atthe intuition of Jerry Lederer and the growth of the seeds thathe planted. Here we are, gathered in one of the premier citiesof the world with hundreds of international delegates refiningthe art and science of aircraft accident investigation and pre-vention. The progress I’ve seen is astounding.

“Over the years’ seminars, the demonstrated improvementsin accident investigation and prevention are gratifying. I’mproud to be a part of all this. Let me give you a feel for JerryLederer. Did you know, for instance, that he inspectedLindbergh’s aircraft before the history-making flight? ThatJerry was a founder of the Flight Safety Foundation? That hebecame NASA’s safety director as a result of the Apollo mod-ule fire and helped save the to-the-moon program? And thathe was designated by the U.S. Congress as the Father of Avia-tion Safety?

“My own career in the business started in the early 1960s. Iwas stationed in Minot, N.D., flying a wonderful new fighter, theF-106 Delta Dart. We got a new squadron commander, Col. JackBroughton. He observed for a short while, had a meeting, andlaid out his plan for the squadron’s future. I agreed with his ideasexcept for one that Capt. McCarthy was to be the flight safetyofficer. I approached him after the meeting and asked to be re-lieved of that job since I was about to become a flight commander.He looked me in the eye and said, “You work for me, and I want

you to be the FSO.”I answered, “Yessir,” and have beeneternally gratefulever since. I joineda group of trulybright folks whoare dedicated tosaving lives.

“George vanEpps, New Yorkoffice, hired me atthe NTSB. He wasa great and hum-ble man. He said,“This job is easy—all you have to dois work hard andtell the truth.” I

have never forgotten that. There are two things an investigatormust have: independence and integrity. Independence to do thework without outside influence or pressure and the indepen-dence that comes when the investigator has the knowledge andwherewithal to accomplish the required task. Integrity speaksfor itself. Without it, true progress in accident investigation andprevention is not possible.

“I want to thank Frank; my fellow Council members, pastand present:, Ann: and the Awards Committee for their help inmaking this possible.

“There is truly no way to express my feelings. I’m humbled,I’m honored, I’m extremely grateful. But most of all, I’mpleased that you are all here to share this wonderful momentwith me. Thanks!” ◆

“Independence and integrity are allimportant,” says the Award winner.



The Society’s 38th annual international conference on airaccident investigation attracted a well-mixed internationalgroup of accident investigators and related profession-

als. Final tally by the Air Accident Investigation Bureau ofSingapore (AAIB Singapore), host for the near-week-long event,shows attendance of 303 delegates and 34 companions. Of thosetotals, 114 persons were from 19 Asian countries. During the3 days of technical-paper presentations, the nagging issue of“cooperation,” which when withheld or grudgingly given canacutely affect aircraft accident investigations, was quieted byhigh-level regulators and field “tinkickers.”

In his opening address, Raymond Lim, Singapore Minster forTransport and Second Minister for Foreign Affairs, told the group,“I am heartened to see so many of you here, as it underscores theimportance of international cooperation in aircraft accident inves-tigation and your endless pursuit in honing the skills required inthis area.” Commenting on the expected Asia passenger growth of7.9 percent annually over the next 5 years and a doubling of thecurrent 4.2 billon global passengers in the next 20 years, he said,“We must not allow ourselves to be lulled by the euphoria of abuoyant air travel industry and lose our focus on air safety....” Hecontinued, “it is imperative that we strengthen our safety and acci-dent investigation frameworks.…In addition, the willingness toopenly and professionally share ideas, experiences, and lessonslearned from accident investigations is an important element inupgrading the safety standards in the aviation industry….”

He then spoke of the complexity of aviation-related accidentinvestigations and the need for “governments and industry play-ers to collaborate closely.” Doing so, he noted, “will help smooth

problems that an individual country’s investigation bodies may en-counter as a result of the complexity of aircraft and air transportsystems.…It is also worthwhile for those which lack resources oftheir own to tap into an international network of investigators andsafety professionals who can support them in their investigations,as well as share and exchange views on experiences, techniques,best practices, and relevant issues.” He closed by noting thatSingapore is “continually striving to contribute to such coopera-tion initiatives.”

Globally, the need for, and manner of, collaborations and coop-eration is outlined by ICAO’s Annex 13 to which all signatory statespledge adherence. That Annex was no doubt in the mind of key-note speaker Mark V. Rosenker, U.S. NTSB chairman, who said ofthe seminar’s theme “International Cooperation: From Investiga-tion Site to ICAO,” “I believe we can take that title to mean work-ing within the cooperative framework of international standardsand recommended practices, and, further, to transfer vital infor-mation from an accident site anywhere in the world, with carefulanalysis along the way, to the offices and the staff of the Interna-tional Civil Aviation Organization (ICAO) in Montreal.”

He proceeded to speak to industry actions that effect coopera-tion and in closing noted the “importance of international coopera-tion and the need for harmonized best practices in investigation…especially… for those of us representing airplane-manufacturingstates. Our industry’s desire is to provide the most airworthy air-craft possible for the market place. To do this, we need to knowhow the aircraft perform in the market place, and when deficien-cies do become apparent, to move swiftly to correct them—andavoid recurrence.”

In closing, he urged all to attend the ICAO Accident Investiga-

ISASI 2007TrumpetsCooperation in‘Lion City’The ISASI 2007 theme “InternationalCooperation: From Investigation Site toICAO” received a thorough airing during the3-day assembly held in Singapore, which—according to legend—was once knownas Singapura (Lion City).By Esperison Martinez, Editor

According to legend, Singa-pore was named by the visit-ing 14th century SumatranMalay prince, Sang NilaUtama, who called the islandSingapura (singa—lion, pura

—city) when he thought he spotted a lion. But since lionshave never lived there, he probably saw one of the manytigers that used to roam the island.

The ISASI 2007 logo is known asthe Merlion Statue. It is a symbol ofSingapore and guards the entranceto the Singapore River. First de-signed as an emblem for the Singa-pore Tourism Board in 1964, the lion head with a fish body(i.e., mermaid body) resting on a crest of waves quickly be-came Singapore’s icon to the rest of the world. The lion headsymbolizes the legend of the rediscovery of Singapura; thefish tail symbolizes Singapore’s humble beginnings as a fish-ing village. ◆

Legend of the city

Photos of ISASI 2007seminar activities areavailable for viewing online at isasi.org (followscreen instructions).


tion and Prevention Divisional meeting (AIG 2008) in the fall of2008. (See page 4 for his full text).

Behind the sceneStanding at an elevated platform flanked by two giant video screensand looking out upon the more than 300 assembled delegates seatedin a cavernous but comfortable conference hall in a 70-story ultra-luxury hotel, it is easy for both speakers and listeners to not givethought to the many challenges overcome by those who make theSociety’s annual international conference happen—and there aremany. Among them are the• Executive Council—evaluating and accepting host/venue bidsthat stretch 3 to 5 years ahead.• Executive Council Seminar Chairperson—inviting, securingbids, investigating venue locations, and overseeing progress.• Host—determining that it can accomplish the myriad tasks tomake a successful seminar and related work to develop the com-mittee, secure venue, sponsors, and venue support.• Authors—developing and presenting technical papers.

• Committee—evaluating and accepting papers.• Delegates/companions—committing to a costly attendance.

This list is greatly abbreviated and diminishes the number ofpersons involved and the actual work that requires almost twoyears to complete to achieve the success delivered by ISASI2007 and all past annual international conferences.

And a success it truly was, particularly from the perspectiveof Jerry Lederer who uttered his vision upon the opening ofthe Society’s very first conference in 1970: “It is an idea thatmeetings such as this would have positive effect by getting peopleto know one another before accidents happen in foreign lands.You’ll have an opportunity to meet with people and discussmutual problem areas. In addition, we will be able to exchange

ideas on new techniques as well as old proven techniques onaircraft accident investigations.”

All his hopes were experienced: In the assembly room, whis-pered conversation was restricted to near seat mates, questionswere jotted on paper to pose to panel members, presentationswere followed and mentally filed for later discussions with“friends” yet to be met, and others tapped notes into laptopcomputers for future use. But the meaningful conversation oc-curred at those times designed for networking: coffee/teabreaks, group breakfasts and lunches, bus trips, social hours,and banquet night.

Chan Wing Keong, chairman of the seminar committee, said,“The AAIB would like to express its gratitude to the speakersfor the high quality of the papers they produced and to the mod-erators for their able steering of the session. Credit must alsobe given to the support of the seminar participants without

Sharon Morphew (not shown) takes a last-minute registra-tion, while volunteers help hand out welcome and programmaterial to attendees.

T. Wang holds the audience’s attention with his GeographicalInformation System (GIS) browsing program on Internet platformpresentation.

Attendees pay raptattention and take notes.

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whom the seminar would not have been such a success. We aremost heartened by the kind words of encouragement that theparticipants have unstintingly heaped on the AAIB team.”

ProgramISASI 2007’s program schedule kept to the traditional format:tutorials on Monday, technical programs the following 3 days,and a post-seminar social day on the fifth day. In all, a full weekis devoted to the program. For many of the attendees, the timestretches to 7-plus days with travel included.

Seminar registration opened Sunday afternoon to accommo-date the 137 persons who would attend the Monday tutorials.They departed the hotel at 7:30 a.m. for travel to the SingaporeAviation Academy (SAA), where the two day-long tutorials wereconducted. For those persons who had not visited Singapore be-fore, the 1-hour bus trip was a good opportunity to get a“commuter’s” view of the city’s green landscape, its modernisticarchitecture, the Western-dress pedestrian scene, and the late-model auto and truck traffic along its highways and byways.Conspicuous by absence was bicycle and motor-scooter traffic.The city’s skyline shows a significant number of high-rise hous-ing and towering office buildings. The conference hotel, SwissotelThe Stamford, soared up 70 floors.

Twenty-six presentations filled the technical program sched-ule. For this conference, the planners divided the available timeinto six sessions, two per day, four to five talks per session. Pre-sentations included actual investigation discussions, use of in-novative processes to aid investigations, and findings of studiesrelated to investigation tools and processes. Most talks, in oneway or another, delved into the international cooperation theme.Some spoke directly to the subject, such as the paper selectedas “Best in Seminar” (see page 15.) Also, speaking directly tothe theme were Russia’s Alexey N. Morozov, Interstate Avia-tion Committee, and Sylvain Ladiesse, BEA France, who spoke

of the cultural challenges in international investigation. All speak-ers, as a panel, took questions at the end of their given session. Alisting of speakers and paper topics is located on page 11.

Marcus Costa, chief of the Accident Investigation and Preven-tion Section, ICAO, gave the program’s concluding remarks. Heechoed and agreed with Lim’s and Rosenker’s (see page 4) com-ments regarding the need for vigilance of investigators and con-tinued need for safety recommendations. He said, “Investigatorsare truly one of the main pillars to the advancement of the indus-try, as … accidents are, in fact, catalysts to progress!”

He added, “Investigators sometimes do the unthinkable to prop-erly and thoroughly identify the root causes and contributing fac-tors of mishaps, no matter the potential pressures they might beforced to face. In the ‘hierarchy of needs’ of mankind, investiga-tors are at the very peak of the triangle, where one pursues thetruth: this is what we do when we investigate mishaps; we look forthe truth no matter the consequences that might ensue. I wouldsay that the aviation industry should never be allowed to overlookor underestimate our efforts, as the importance of investigationsis timeless.”

He also commented on the October 2008 AIG Divisional meet-ing, saying that “Annex 13, Aircraft Accident and Incident Investi-gation, actually belongs to states and it is up to states to improveits provisions, and ICAO should be seen as the custodian of theAnnex.” He reminded the audience of President Del Gandio’s open-ing remarks (see page 3) that “the vehicle for data sharing is ICAO.”

ABOVE: T. Jen as she presents her “Aftermath of a Sea Crash”to the tutorial audience. BELOW: A tutorial group is shown amodel of the Aviation Academy of Singapore and its grounds.

Breaks between sessions offer the perfect networking andinteraction opportunities.


Noting the need for states to have a more comprehensive exchangeof safety data among themselves, he encouraged all to use a datasystem comparable to the ECCAIRS/ADREP system of ICAO.

TutorialsSingapore Aviation Academy is looked upon as an oasis for learn-ing. Its setting puts one at ease and relaxes the mind. ISASI del-egates marveled at the courtyard that separated the pavilion inwhich the tutorials were conducted. The meeting rooms were indifferent wings, separated by a shimmering, deep blue-water-filledpool in which instruction is given. Nearby is a water/stone gardenthat creates a serene atmosphere. Good use was made of the areaduring the breaks of the two tutorials, which whetted the wits ofthe attendees. Each of the two tutorials was in a panel format offour and six members.

Tan Siew Huay, CAA Singapore, led the tutorial titled “ICAOAnnex 13 Investigation in a Litigious Environment,” which per-mitted speakers to describe how their agency’s procedures metand interfaced with Annex 13 provisions. Speakers and topics dis-cussed were Alan Stray, Australian Transport Safety Bureau, “In-

vestigation Reports.” He also spoke on the conduct of thecoroner’s investigation in concert with the state investigation.Gary L. Halbert, general counsel, U.S. NTSB, addressed liti-gation and the trial, centering on use and misuse of investiga-tion reports, admissibility of reports and records, discovery andthe subpoena, and testimony by agency employee/agent.

Y.P. Tsang, deputy chief inspector of accidents, Hong KongCivil Aviation Authority, described the state’s Board of Reviewprocess, which is triggered by any interested party reading find-ings and conclusions of the report “from which it appears thathis reputation is likely to be adversely affected.” Tsang used anactual accident with fatalities to trace the Board’s actions asrequired under regulations.

Remi Jouty, head of the Investigations Department, BEAFrance, discussed the “Relationship Between Safety Investi-gation and Judicial Inquiry in France.” Lok Vi Ming, a partnerin Rodyk and Davidson LLP, Singapore, received riveted audi-ence attention when he discussed “Air Accident Investigatorsas Witnesses in Court Proceedings,” relating the differencesbetween the categories of “expert” witness and “factual” wit-

Welcome Remarks: Frank Del Gandio, President, ISASIOpening Address: Raymond Lim, Minister for Transport and Second

Minister for Foreign AffairsKeynote Address: Mark V. Rosenker, Chairman, U.S. National Transporta-

tion Safety Board

SESSION 1—Moderator David McNairRoyal Australian Navy Sea King Accident Investigation Indonesia April

2, 2005—Nicholas Athiniotis and Domenico Lombardo, DefenceScience and Technology Organisation, Australia

Russia/France: Safety an Cultural Challenges in InternationalInvestigations—Alexey N. Morozov, Interstate Aviation Committee,Sylvain Ladiesse, and Martine Del Bono, BEA

International Cooperation Paves the Runway for a Safer Sky—Guo Fu,East China Administration, CAAC

SESSION 2—Moderator Sue BurdekinWinter Operations and Friction Measurements—Knut Londe, Accident

Investigation Board NorwayUtilisation of the Web-Based GIS to Assist Aviation Occurrences

Investigation—Dr. Michael Guan, Tian-Fu Yeh, and Dr. Hong T.Young, ASC

Use of Reverse Engineering Techniques to Generate Data for Investiga-tors—Peter Coombs, AAIB U.K.

Using Checklists as an Investigation Tool—Al Weaver

SESSION 3--Moderator Alan StrayFinding Nuggets: Cooperation Vital in Efforts to Recover Buried Data—

Christophe Menez, Jerome Projetti, and Martine Del Bono, BEAInternational Investigation: General Aviation Accident in Atlantic

Waters—Joseph Galliker, ASC International, Inc.Standardizing International Taxonomies for Data-Driven Prevention—

Corey Stephens, Air Line Pilots Association; Kyle Olsen, FAA;Oliver Ferrante, BEA; and Vivek Sood, FAA

Mid-air Collision Over Brazilian Skies—A Lesson To Be Learned—Col.Rufino Ferreira, Col. Carlos Pellegrino, and Col. Jose Mounir,Aeronautical Accident Investigation Commission (CENIPA); andWilliam English, NTSB; and Nick Stoss, TSB Canada

SESSION 4—Moderator Richard BreuhausConvair 580 Accident Investigation: A Study in Synergy—Ian

McClelland, TAIC, New ZealandTenerife to Today: What Have We Done in 30 Years to Prevent

Recurrence?—Ladislav Mika, Ministry of Transport, CzechRepublic, and John Guselli, JCG Aviation Services

Flight Data: What Every Investigator Should Know—MichaelPoole, Flightscape, Inc.; and Simon Lie, Boeing

Sound Identification and Speaker Recognition for Aircraft CVR—Yang Lin, Centre of Aviation Safety Technology, CAAC; LiuEnxiang; and Wu Anshan, Office of Aviation Safety, CAAC

SESSION 5—Moderator Danny HoInternational Cooperation and Challenges: Understanding Cross-

Cultural Issues—Dr. Don Harris, Cranfield University; Dr. Wen-Chin Li, National Defence University; and Thomas Wang andDr. Hong T. Young, Taiwan ASC

Very Light Jets: Implications for Safety and Accident Investiga-tion—Dr. Robert Matthews, FAA

Enhanced Airborne Flight Recorder (EAFR): The New BlackBox—Jim Elliot, Smiths Aerospace

RSAF: Analysis and Investigation—Tools and Techniques—Lt.Col. Suresh Navaratnam, Republic of Singapore Air Force(RSAF)

Wet Runway Accidents: The Role of Fatigue and Coercive Habits—Capt. Mohan Ranganathan

SESSION 6—Moderator David KingISASI International Working Group on Human Factors: A Progress

Report—Capt. Richard Stone, ISASI, and Dr. Randy Mumaw,Boeing

Three Nigerian Investigations—Dennis Jones, NTSBCritical Aspects of International Incident Investigations—Robert

van Gelder, Deborah Lawrie, and Jan Smeitink, IndependentSafety Investigation & Consultation Services

Remarks on International Cooperation: An Indonesian Perspec-tive—Tatang Kurniadi, Chairman, National TransportationSafety Committee, Indonesia (scheduled speaker) ◆

Speakers and Technical Papers Presented at ISASI 2007



ness. He traced the roles of each, demonstrating what can beasked of each and what cannot, in court.

The second tutorial was of a totally different nature, dealingwith matters pertaining to the “Aftermath of a Sea Crash.”Chaired by David McNair, TSB Canada, Tracy Jen, of the Avia-tion Safety Council, Taiwan, used two underwater crash ex-amples to relate the experiences of the ASC: a B-747-200 thatcrashed on May 25, 2002, killing 225 off Penghu Islands and anATR 72-200 that crashed on Dec 21, 2002, killing two pilots inthe Taiwan Strait. It was a lengthy PowerPoint presentation inwhich she used the two crashes as case studies to underwaterrecovery operations to provide the group the lessons learned inthe areas of emergency response; intragovernment coordina-tion; technical, logistic, and cost issues; and working with thenews media and crash victim family issues.

Michael Kutzleb, CEO of Phoenix International, a companythat provides underwater solutions worldwide, provided hiscompany’s impressive history relative to underwater recovery.He gave an overview of the equipment it used and its capabilityand provided operational examples of the company’s methodsin successful recoveries. He noted the 59 overwater mishapsthat have occurred between 1970 and 2007. Phoenix has beeninvolved in 23 aircraft and 1 spacecraft recovery effort. Amongthe roles Phoenix filled in investigations during the search phasewere loss analysis, target location, and mapping, and in wreck-age recovery the company is active in rigging, heavy lift, andhuman remains recovery, among other areas.

Hans van Rooij, of SMIT Salvage, also presented a companyprofile of its worldwide services with 25 strategically located of-fices and 3,000 employees that permit 1-day emergency response,salvage, and wreckage removal in which it has been most involved.

Rooij’s presentation covered the lot, but theaudience seemed most attentive to thecompany’s involvement with TWA 800 recov-ery operations in July 1996. Rooij providedextensive details of SMIT’s victim and de-bris search as well as its victim and wreck-age recovery work all done at depths of 125feet.

As if to demonstrate the evolution ofISASI’S 2007 theme, Jurgen Whyte, chiefinspector of air accidents, Air Accident In-vestigation Unit (AAIU) Ireland, took thetutorial audience back to a 1985 crash. Hetitled his presentation “A Truly Interna-tional Effort.” He recapped the totality ofthe event and its investigation, from thetime of the Air India’s B-747 (Flight AI182)plunge into the international waters of theAtlantic 100 miles southwest of Ireland onJune 23, 1985, at 07:14 GMT with a crew of23 and 307 passengers. All perished. India

assumed responsibility of the investigation under the provisionsof ICAO Annex 13 and coordinated and ran the entire investiga-tion with international assistance. The success and magnitude ofthat assistance can best be assessed from the words of the thenIndia Prime Minister Rajiv Gandhi to Ireland’s Prime Minister.He conveyed his government’s and people’s “deep gratitude” toIreland “for coming so readily to our assistance.” He made specialmention of thanks to the Cork Regional Hospital, the police, andthe airport.

Dennis Jones, U.S. NTSB, brought some low-tech reality to thetutorial when he noted that not all water recovery work is in theoceans. He held everyone’s close attention with his talk regardingthe recovery work involving an aircraft that crashed into a Kenyaswamp on May 5, 2007. Because the investigation is still ongoing,his presentation centered on the recovery of the aircraft and vic-tims in a “swamp during the rainy season from a water hole thesize of a 737.” His photos of the “local low-cost recovery equip-ment” at work amazed all.

Getting acquaintedThe positive effect of getting people to know one another beforemeeting at an accident site is an intangible until it happens, butfew can argue against the merits of making it possible. That is whyISASI conference hosts work so diligently at creating such oppor-tunities. And the AAIB Singapore team did an exceptionally finejob, if the nods, handshakes, cluster conversations, and relaxedmood of the networking activities were any indication.

While the timing of a seminar event is dictated by the schedule,the nature of the event, before it happens, is always a questionmark. ISASI 2007 dispelled any doubts of “nature” with its firstsocial event held in the 70th floor “sky room” of the Stamford ho-

ISASI 2007 Sponsors

PLATINUMQatar Airways

GOLDAerobytes Ltd.AirbusBoeingCivil Aviation Authority of Singapore(CAAS)EmbraerFlightScapeMessier Services AsiaSouthern California Safety Institute (SCSI)Singapore Technologies Aerospace

SILVERALPA SingaporeCASA AustraliaIECO/Rolls Royce/SASELPanasonic Avionics Corp.

Pratt & WhitneySingapore Airlines CargoTaikoo Aircraft Engineering Co.University of Southern California (USC)

BRONZEAirTran AirwaysAir Foil Technologies InternationalU.S. ALPAAsian Surface TechnologiesGE Aviation (GEAC)HoneywellSilkAirSingapore Test ServicesSIA Engineering CompanyTiger Airways

WRIGHT BROTHERSPratt & Whitney CanadaSingapore Air Show ◆


tel. The panoramic view of Singapore afforded to the guests wasmerely a prelude to the culinary Asian and Western delicacies thatadorned the serving tables around which greetings and talkabounded. The evening social lasted only several hours, but longenough to make attendees feel bonded at the opening of the ISASI2007 program the next day.

A presidential prerogative during opening remarks is to an-nounce the year’s Jerome Lederer Award selectee (see page 6)and introduce winners of the ISASI Rudolph Kapustin MemorialScholarship (see page 3, Forum July/September 2007). Both an-nouncements received rousing audience response. The crowd’senthusiasm was no surprise to ISASI Vice-President Ron Schleede,who believes that “the ISASI Rudy Kapustin Memorial Scholar-ship program is one of the Society’s best efforts in years and maybe expanded.” He intends to work closely with the InternationalCouncil, the individual and corporate members, and other aviationindustry officials to promote and expand the program to bring moreyouth to ISASI. “It just takes funding, which must come from do-nations of cash or in kind (airline tickets, etc.), and more excellentstudent applicants.”

After a full day of sitting, relieved only by the much-appreci-ated extended coffee/tea breaks that more resembled a continen-tal breakfast, attendees wonderingly looked forward to theevening’s planned activity of a “night safari.” With little time tochange from conference dress to loose clothes, the group boardedbusses for an evening of unexpected sights. First stop was the re-nowned Singapore zoo, where all walked along lighted paths pastan array of wildlife. Many stopped to pose with a “petting” Asianelephant or watch the placid-looking, very large Orang Utans cling-ing to a tree perch. The walk led to a buffet-style meal under tarp

cover to ward of threatening rain. Many were still wonderingwhat the “safari” would bring. At nightfall, the answer came.All boarded open trams that wheeled along a 3.2 km trail cover-ing terrain resembling the rocky Himalayan foothills to thegrassy plans of Equatorial Africa. The entire setting was bathedin shadowy half-light so that the uncaged rhinos, elephants, gi-raffes, tapirs, tigers, and lions were largely oblivious to thoseriding in the trams and gasping at the sights a stone’s throwaway from them.

The enchantment of the evening was repeated in all the so-cial events planned by the seminar hosts—the climax of whichwas the highly entertaining dancing exhibitions in traditionalcostume dress displayed during the Awards Banquet. The post-seminar daytrip was also a marvel, filled with the wonders ofSingapore’s island resort, Sentosa. Just getting there in the cablecar system that moved 90 meters above the water and gavebreathtaking sights of tropical forests, city skyscrapers, and aship-filled harbor dotted with small islands was an unforget-table experience. The island resort offered many other equallyabsorbing sights and events.

But it is the companions who really get to see the city and itsattractions. In addition to the all-group events, companions weretreated to a 2-day program filled with excursions through mu-seums and botanic gardens offering a massive array of bloomsand colors, such as 20,000 orchid plants of more than 1,000 dif-ferent species. Also on the schedule was a river boat trip, whichgave a different perspective than one gets from a bus windowor walking. Still, walking through Chinatown, with its endlessstalls of merchandise, makes for an forgettable experience asdid the tour through Singapore’s Indian community with itsspice-scented streets. Also making an impression was the un-predictable weather that more often than not brought show-ers. Other not-to-be-forgotten experiences were the delicatetastes of the local lunch dishes and, for some, the manipulationof chop sticks in lieu of Western dinnerware.

Seminar finaleIt is the evening before the post-seminar experience that is the“social” event of the seminar: Awards Banquet night. The morethan 300 attendees and companions were ready to relax andhonor peers.

Relaxation came with the considerable milling about and en-

Panel members respond to questions. ABOVE: Session panel,left to right, L. Anthinotas, D. Lombardo, S. Ladiesse, A.Morozov, G. Fu, and D. McNair (moderator); BELOW: Left to right,S. Burdkin, K. Londe, T. Wang, P. Coombs, and A. Weaver.

President DelGandio offerscongratulationsto scholarshipwinners PhilipGregory and RuthMartin (left).



thralling dance exhibitions in native costume that preceded the9-course dinner prepared and served Chinese style.

Later in the evening, President Del Gandio recognized thethree recipients of the ISASI Rudolf Kapustin Memorial Schol-arship Fund. They were Ruth Sylvia Martin, University ofSurray, Farnborough College of Technology, U.K.; MarissaLaCoursiere, Clarkson University, Potsdam, New York, U.S.A.;and Philip Gregory, Embry-Riddle Aeronautical University,Daytona Beach, Florida, U.S.A. LaCoursiere was unable to at-tend the conference, and Gregory was necessarily absent fromthe awards presentation, but the recognition included all three.President Del Gandio also announced contributions made tothe Fund during the week: Capt. Sameer S. Gabsair $80; ISASI’sFort Worth Regional Chapter, $1,000; and the winners of theBest Seminar paper contributed the $500 prize to the Fund.The Fund was established in memory of all ISASI memberswho have died, and was named in honor of the former ISASIMidAtlantic Regional Chapter president.

Kevin Humphreys, director safety regulations, Irish Avia-tion Authority, was inducted into the honored Fellow member-ship, marking him ISASI’s 22nd member to reach that plateau.Another special recognition was the “Best in Seminar Award”for the best technical paper of the seminar. This year the win-ning paper, “International Cooperation and Challenges: Under-standing Cross-cultural Issues” was prepared by four persons:Dr. Wen-Chen Li, Thomas Wang, Dr. Hong T. Young, and Dr.Don Harris. (See page 16.)

President Del Gandio then welcomed ISASI’s new corporatemembers and awarded plaques to David Longstaff, Jones Day,LLP; Christine Negroni, Kreindler & Kreindler, LLP; KevinHumphreys, Irish Aviation Authority; John Gadzinski,Sourthwest Airlines Pilots’ Association; Atanas Kostov, AAIUMinistry of Transport Republic of Bulgaria; Joe Gillesspie, GulfFlight Safety Committee; Richard Breuhaus, Jeppesen; WonYung, Korea Aviation & Railway Accident Investigation Board;Mark Scott, Charles Taylor Aviation; Tracy Dillinger, ReytheonCompany; and Eric Mayett, Aerovias De Mexico S.A.De C.V.

Chan WingKeong,seminarchair, (left)accepts onbehalf of thecommitteea “well done”gift fromPresidentDel Gandio.

AAIB seminar committee, left to right, Michael Toft, Arik Tan,Chee Ping Swee, Tan Hak Soon, Ho See Hai, Chan Wing Keong(chairman), Chong Chow Wah, David Lim, and Goh Kay Boon.

Traditional handoff of the “seminar cowbell” is made fromChairman Chan to Barbara Dunn, chair of ISASI 2008, to beheld in Halifax, Canada.

The crowning finale to the evening of peer recognition was thepresentation of the prestigious Jerome F. Lederer Award. Presi-dent Del Gandio called Tom McCarthy to the stage and the roomquieted. In describing the Award selectee, the president said:“Tom, a patriarch of aviation safety and accident investigation,has dedicated his life to government service, ISASI aviation safety,to accident investigation, and to safety mentoring programs tohelp prevent aircraft accidents. His contributions to the NationalAirspace System and our Society are monumental and make himtruly worthy of the coveted Jerome Lederer Award.” Filled withpride, Tom accepted and spoke to the audience about the stupen-dous growth experienced by ISASI and what it means to avia-tion safety (see page 6 for presentation ceremony).

In closing the evening, President Del Gandio paid specialthanks to the industry sponsors of ISASI 2007 and to the at-tendees who traveled from 52 nations to attend a truly “inter-national” event. As always, the closing seminar action was thetransfer of the “Cowbell” from Chan Wing Keong to BarbaraDunn and the Canadian Society, host of ISASI 2008. ◆

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I nternational Cooperation andChallenges: Understanding Cross-cultural Issues is the technical pa-

per judged to be “Best Seminar Paper”of those papers presented at the annualISASI 2007 Singapore seminar on avia-tion accident investigation held inSingapore, August 27-31. Of the paper’sfour co-authors, two made the verbalpresentation to the assembly. Present-ers were Dr. Wen-Chen Li and ThomasWang, who accepted the Award of Ex-

Seminar’By Espersion Martinez, Editor

‘Best in cellence plaque during the Awards Banqueton the last evening of the seminar. The othertwo co-authors are Dr. Hong T. Young andDr. Don Harris

The award was established through ananonymous donation by an ISASI memberwho wished to acknowledge a paper at theannual seminar that made an outstandingcontribution to the advancement of techni-cal methodologies in aircraft accident inves-tigation. For the first time since its incep-tion, the “Best Paper” selection carried withit a monetary award of $500. At the awardpresentation, the winners announced thatthe $500 was being contributed to the ISASIRudolph Kapustin Memorial ScholarshipFund, established in the memory of all de-ceased ISASI members.

For the ISASI 2007 selection, a judgingpanel was made up of four ISASI members.ISASI co-chairs of the selection panel were

Dr. Graham Braithwaite and Capt. Ri-chard Stone (Ret.). Other members were20007 ISASI Memorial Scholarship win-ners Ruth Martin and Philip Gregory.The young scholars were selected in thebelief that they would provide a freshperspective to the process of evaluatingtechnical papers based on the cited cri-teria and on reflecting the overall themeof the seminar “International Coopera-tion: From Investigation Site to ICAO.”

Dick Stone commented that the cri-teria used for the selection were thatit had to provide new methodology foraccident investigation, it had to be use-ful for a field investigator, and the pa-per and graphics had to be profes-sional. He noted that the selected pa-per reflects outstanding work and willadd a new dimension to internationalaccident investigation. ◆

ABOVE: Thomas Wang (left) accepts congratulations and theaward plaque from ISASI President Frank Del Gandio. Dr.Wen-Chen Li (center) beams his delight with the selectionof the authors’ work. RIGHT: Award of Excellence plaquepresented to “Best Seminar Paper” authors.

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Dr. Hong T. Young Dr. Don Harris



(In the publication of this award-winning technical paper, Fo-rum is departing from its usual style format and is publishingthe following as a “technical paper” as accepted by the ISASI2007 seminar technical committee.—Editor)

AbstractThe idea that national cultural characteristics play a part in avia-tion safety had been suggested by Helmreich and Merritt (1998).This research involved around 45 aviation accident investigatorsfrom different cultural backgrounds and investigated attributionof causal factors in the Ueberlingen accident report through theapplication of the Human Factors Analysis and Classification Sys-tem (Wiegmann and Shappell, 2003). Hofstede’s (1991 and 2001)cultural dimensions draw a clear picture of the attributable pat-terns of human errors based on cultural differences. As a result, itis necessary to develop a better understanding of the differencesin attribution of accident causes and contributory factors acrosscultures to promote both aviation safety and international coop-eration for accident investigation to be achieved. Furthermore,when suggesting safety enhancements resulting from accident in-vestigations it needs to be noted that the same remedy may notwork in different cultures. Remedial actions must be “culturallycongruent.” This process starts with understanding the culturalfactors at work in the accident investigation process itself.

IntroductionThere has been a great deal of research regarding the relation-ship between national culture and aviation safety (e.g.,Braithwaite, 2001; Helmreich and Merritt, 1998; Jing, Lu, andPeng, 2001; Lund and Aaro, 2004; Merritt and Maurino, 2004;Patankar, 2003; Rose, 2004). Culture is at the root of action; itunderlies the manner by which people communicate and developattitudes toward life. Accident investigation is supposed to be anobjective exercise, but different cultures may produce differentinterpretations for human factors issues based upon different

cultural preconceptions. In the aviation industry, pilots not onlyfly in foreign airspace transporting passengers around the world,but also in multicultural crews. Furthermore, according to ICAOAnnex 13, the accident investigation team should include repre-sentatives from the state of the aircraft’s design and manufac-ture, the state of the occurrence, the state of the operator, andthe state in which the aircraft was registered. As a result, by itsvery nature, accident investigation is a multicountry, multiculturalundertaking. International cooperation has always been a greatchallenge for accident investigation as a result of the many cul-tures often involved in an accident. It only requires a little imagi-nation to demonstrate how culture may impact upon the acci-dent investigation process. Take a hypothetical example, wherean Airbus aircraft, operated by a Chinese airline, equipped withGeneral Electric’s engines crashes in Japan.

There are many definitions of culture. Kluckhohm (1951) pro-posed one well-known definition for culture—“culture consists

International Cooperationand Challenges:

UnderstandingCross-culturalIssuesBy Wen-Chin Li, Hong-Tsu Young, Thomas Wang,and Don Harris

Dr. Wen-Chin Li is assistant professor in the NationalDefense University, Republic of China, and Visiting Fellowin the Department of Human Factors, Cranfield University,United Kingdom. He is an aviation human factors specialistin the European Association of Aviation Psychology and aregistered member of the Ergonomics Society (MErgS).Contact e-mail: [email protected].

Professor Hong-Tsu Young is the managing director of theExecutive Yuan, Aviation Safety Council, Republic ofChina. He was the coordinator of the National TaiwanUniversity Commercial Pilot Training Program by theCivil Aviation Authority (CAA) and deputy chairman ofthe Department of Mechanical Engineering, NationalTaiwan University.

Thomas Wang is currently the director of the Flight SafetyDivision, Aviation Safety Council. He is a former ChinaAirlines Airbus A300 pilot. He joined ASC as an aviationsafety investigator in 2000. He was the investigator-in-charge of the China Airlines CI611 accident investigationand was the Singapore Airline SQ006 accident investigationHuman Factors Group chairman.

Dr. Don Harris is the director of the Flight Deck Design andAviation Safety Group in the Hu-man Factors Department,Cranfield University. He was an aircraft accident investiga-tor (specializing in human factors) on call to the BritishArmy Division of Army Aviation. He sits on the editorialboards of the International Journal of Applied AviationStudies (FAA) and Cognition, Technology, and Work(Springer-Verlag). He is also co-editor in chief (with HelenMuir) of the journal Human Factors and Aerospace Safety(published by Ashgate).


in patterned ways of thinking, feeling, and reacting, acquired andtransmitted mainly by symbols constituting the distinctive achieve-ments of human groups, including their embodiments in artifacts;the essential core of culture consist of traditional ideas and espe-cially their attached values.” If the majority of people in a societyhave the same way of doing things, it becomes a constituent com-ponent of that culture (Jing, Lu, and Peng, 2001). A culture is formedby its environment and evolves in response to changes in that en-vironment; therefore, culture and context are really inseparable(Merritt and Maurino, 2004).

Cultures can be divided into different levels: families, organiza-tions, professions, regions, and countries. The power of culture of-ten goes unrecognized since it represents “the way we do thingshere.” It is the natural and unquestioned mode of viewing the worldas national cultural characteristics play a significant part in aviationsafety (Helmreich and Merritt, 1998). Johnston (1993) suggestedthat regional differences have a major impact on CRM implementa-tion and crew performance. There is a marked difference in howcrew resource management (CRM) training is perceived outside theUnited States. In the United States, CRM is normally seen as theprimary vehicle through which to address human factors issues.Other countries, notably those in Europe, see human factors andCRM as overlapping, viewing them as close but distinct relatives.Orasanu and Connolly (1993) have suggested that a great deal ofdecision-making occurs within an organizational context, and thatthe organization influences decisions directly (e.g., by stipulatingstandard operating procedures) and indirectly through theorganization’s norms and culture. Culture fashions a complex frame-work of national, organizational, and professional attitudes and val-ues within which groups and individuals function.

To a certain degree, aviation human factors has been domi-nated by research into psychological and psycho-physiologicalattributes such as motor skills, visual perception, spatial abili-ties, and decision-making (Hawkins, 1993). This may crudelybe classified as the “hardware” of human factors. However, foroperating hardware, codes and instructions are required thatmay be referred to as the “software of the mind.” This softwareof the mind may be considered to be an indication of culturebecause culture provides “a toolkit” of habits, skills, and stylesfrom which people construct “strategies of action” (Hofstede,1984). National cultures provide a functional blueprint for agroup member’s behavior, social roles, and cognitive process.Culture provides rules about safety, the basis for verbal andnonverbal communication, and guidelines for acceptable socialbehavior. Culture also provided cognitive tools for making senseout of the world. National culture was rooted in the physicaland social ecology of the national groups (Klein, 2004).

Hofstede (1984, 1991, and 2001) proposed four dimensions ofnational culture:• Power distance (PDI) focuses on the degree of equality, orinequality, between people in the country’s society. In countrieswith a large power distance, subordinates are subordinate totheir superiors. A relatively small power distance between su-perior and subordinate results in informal relationships and agreat deal of information and discussion. If necessary, the sub-ordinate will contradict his superior.• Uncertainty avoidance (UAI) is the extent to which the mem-bers of a society perceive a threat in uncertain or unfamiliarsituations, and the extent to which they subsequently try toavoid these situations by means of regulations and bureaucraticsanctions, among others actions. Uncertainty avoidance con-cerns the situations of unclearness events, preferred more pre-dictable, and which risks are more clearly defined events.• Individualism (IDV) focuses on the degree that society re-inforces individual or collective achievement and interpersonalrelationships. In a highly individualistic society, rights are para-mount. Individuals in these societies may tend to form a largernumber of moderately distant relationships. A society withlow individualism is typical of a society of a collectivist naturewith close ties between individuals.• Masculinity (MAS) exemplifies the traditional masculine workrole model of male achievement, control, and power. Expressionsof this are an orientation toward competition and performanceand the desire for recognition of one’s performance. A highlymasculine social order is one in which males dominate a signifi-cant portion of the power structure, with females being controlledby male domination. A low masculinity ranking indicates the coun-try has a low level of differentiation and discrimination betweengenders. Women are treated equally to men in all aspects.

More individualist cultures show a lower probability of total-loss accidents; collectivist cultures exhibit a greater chance ofaccidents. A high level of uncertainty avoidance in a national

Figure 1. Layers of influence and categories comprising theRipple Model of safety culture (Morley and Harris, 2006).



culture has also been found to be associated with a greaterchance of accidents (Soeters and Boer, 2000). As aircraft havebecome increasingly more reliable, human performance hasplayed a proportionately increasing role in the causation of ac-cidents. Recently, research comparing the underlying patternsof causal factors in accidents comparing Eastern and Westerncultures has suggested underlying differences attributable toculture. Using the Human Factors Analysis and ClassificationSystem (HFACS), it was observed that issues concerning inad-equate supervision at higher managerial levels and a subopti-mal organizational process were more likely to be implicated inaccidents involving aircraft from Eastern cultures (Li, Harris,and Chen, 2007). It was suggested that small-power-distancecultures with a high degree of individualism seemed to be supe-

and Helmreich (1995) and Glendon and Stanton (2000) propose thatsafety culture is a subculture of organizational culture, which is it-self a subculture of the industry culture, which in turn is a subcul-ture of national culture. If attempts to separate safety culture fromorganizational culture are difficult enough, trying to fully separatethese entities from national culture is almost impossible.

Culture has already been demonstrated to have a considerableimpact upon aviation safety and accident causation; however, asalluded to earlier, the effects of national culture have yet to beconsidered as part of the multinational, multicultural accident in-vestigation process. It needs to be established if culture has aneffect on the interpretation of the underlying causes of accidentsas well as their causation. To this end, the manner in which acci-dent investigators from Eastern and Western (high power distanceversus low power distance) cultures attributed the underlyingcauses of the Ueberlingen midair crash of a Boeing 757 and Tu-154were investigated using the HFACS analytical framework.

The inter-rater reliability of HFACS has been demonstrated tobe quite good both by using a simple percentage rate of agreementand Cohen’s Kappa (e.g., Wiegmann and Shappell, 2001; Gaur, 2005;Li and Harris, 2005 and 2006). However, in all these cases reliabilitywas established between two raters coding multiple accidents. Inthis study, a different approach is undertaken to evaluate reliability.In this case, many raters (from two different cultures—a high-power-distance and a low-power-distance culture) code a single accident.

MethodParticipantsThere were 29 Chinese accident investigators including pilots,air traffic controllers, airlines safety managers, and maintenancestaff and 16 British accident investigators consisting of pilots, airtraffic controllers, airlines safety officers, and maintenance staff.

Stimulus materialThe data were derived from the narrative descriptions of accidentreports occurring at Ueberling on July 1, 2002. The synopsis ofthe accident is as follows (BFU: AX001-1-2/02).

The investigation was carried out in accordance with the inter-national standards and recommended practices contained in ICAOAnnex 13 and the German investigation law under the responsibil-ity of the BFU. The Kingdom of Bahrain, the Russian Federation,Switzerland, and the United States were involved in the investiga-tion through their accredited representatives and advisers. In thefirst phase of the investigation, the investigation team worked si-multaneously in a headquarter at the airport Friedrichshafen, atACC Zurich, at the different accident sites in the area around thecity of Ueberlingen, and at the BFU in Braunschweig. On July 1,2002, at 21:35:32 hours, a collision between a Tupolev Tu-154M,which was on a flight from Moscow to Barcelona, and a Boeing B-757-200, on a flight from Bergamo to Brussels, occurred north ofthe city of Ueberlingen (Lake of Constance). Both aircraft flewaccording to IFR (instrument flight rules) and were under control

rior to collective, high-power-distance cultures for promotingaviation safety, especially in terms of the processes and proce-dures at the higher organizational levels. Such an analysis mayprovide additional explanatory power to elucidate why nationaldifferences in accident rates occur.

Morley and Harris (2006) developed an open system model ofsafety culture—the Ripple Model (see Figure 1). This Model hasbeen used to interpret the wider influences underlying severalmajor accidents (e.g., the China Airlines 747 accident—Li andHarris, 2005; Dyrden Fokker F28 accident at Dryden—Harris,2006). This Model identified three threads running throughoutthe personnel within (and without) an organization, irrespectiveof their level and role. These were labelled “Concerns,” “Influ-ences,” and “Actions” and were evident in line personnel, middlemanagement, senior management, the industry regulator, gov-ernment, and society as a whole.• Concerns were associated with threats to the needs of theindividual and worries about meeting the requirements placedon them by others.• Influences were concerned with the factors that dictated themethods by which safety needs could be accomplished.• Actions described the behaviors that directly impacted uponsafety, in either a positive or negative manner.

In this Model, the authors argued that elements outside anorganization have a profound effect on safety culture. The bound-aries for the conceptualization of safety culture must be extendedbeyond the organization if a comprehensive model of the evolu-tion of safety culture is to be developed. Authors such as Merritt

The effects of national culture haveyet to be considered as part of the multi-

national, multicultural accident investi-gation process. It needs to be establishedif culture has an effect on the interpretationof the underlying causes of accidents aswell as their causation.


of ACC Zurich. After the collision, both aircraft crashed into anarea north of Ueberlingen. There were a total of 71 people on boardthe two airplanes, and none survived the crash.

The following immediate causes have been identified: (1) Theimminent separation infringement was not noticed by ATC in time.The instruction for the Tu-154M to descend was given at a timewhen the prescribed separation to the B-757-200 could not be en-sured anymore; (2) The Tu-154M crew followed the ATC instruc-tion to descend and continued to do so even after TCAS advisedthem to climb. This maneuver was performed contrary to the gen-erated TCAS RA.

The following systemic causes have been identified: (1) The inte-gration of ACAS/TCAS II into the aviation system was insufficientand did not correspond in all points with the system philosophy. Theregulations concerning ACAS/TCAS published by ICAO and as aresult the regulations of national aviation authorities, operations, andprocedural instructions of the TCAS manufacturer and the operatorswere not standardized, were incomplete, and were partially contra-dictory. (2) Management and quality assurance of the air navigationservice company did not ensure that during the night all open work-stations were continuously staffed by controllers. (3) Management

Figure 2. The HFACS framework—each upper level would affectdownward level, proposed by Wiegmann and Shappell (2003).

and quality assurance of the air navigation service company toler-ated for years that during times of low traffic flow at night only onecontroller worked and the other one retired to rest.

Classification frameworkThe Human Factors Analysis and Classification System isbased upon Reason’s (1990) model of human error in whichactive failures are associated with the performance of front-line operators in complex systems and latent failures arecharacterized as inadequacies or mis-specifications thatmight lie dormant within a system for a long time and areonly triggered when combined with other factors to breachthe system’s defenses. HFACS was developed as an analyti-cal framework for the investigation of the role of human fac-tors in aviation accidents. This study used the version of theHFACS framework described in Wiegmann and Shappell(2003). The presence (coded 1) or the absence (coded 0) ofeach HFACS category was assessed in each category ofHFACS. To avoid over-representation from any single acci-dent, each HFACS category was counted a maximum of onlyonce per accident. The count acted simply as an indicator ofpresence or absence of each of the 18 categories in theUeberlingen accident.

The first (operational) level of HFACS classifies events un-der the general heading of “unsafe acts of operators.” The sec-ond level of HFACS concerns “preconditions for unsafe acts.”The third level is “unsafe supervision,” and the fourth (and high-est) organizational level of HFACS is “organizational influ-ences.” This is described diagrammatically in Figure 2.

ProcedureAll participants were trained for 2 hours by an aviation humanfactors specialist in the use of the Human Factors Analysis andClassification System. This was followed by a debriefing and asummary of the events in the Ueberlingen midair crash. Fi-nally, all participants received a blank form for coding theirHFACS data before watching the film of Ueberling midair crashaccident investigation to code the contributing factors underly-ing this accident.

Results and discussionsThe frequency of participants indicating that a particularHFACS category was a factor in contributing to the Ueberlingenaccident is given in table 1.

According to Wiegmann and Shappell (2001) and Li andHarris (2006), factors at the level of “unsafe acts of opera-tors” were involved in 63.4% of accidents in U.S. sample and41.1% in Taiwan; factors at the level of “preconditions for un-safe acts” were involved in 26.8% of accidents in United Statesand 31.3% in Taiwan; at the level of “unsafe supervision,” 4.5%of causal factors were associated with accidents in UnitedStates and 12.5% in Taiwan; at the level of “organizational in-



fluences,” 5.3% of causal factors were associated with acci-dents in United States and 15% in Taiwan. However, it is diffi-cult to suggest with any certainty if the true explanation forthe differences in the data were attributable to the U.S. databeing taken from civil aviation or if it was a national, culturaldifference between the United States and Taiwan.

As Hofstede (1991) pointed out, the culture of the United Statesis characterized as small-power-distance and individualist. Sub-ordinates acknowledge the authority of their superiors but donot bow to it, and emphasis is firmly placed on individual initia-tive (and reward). This supports the findings of Wiegmann andShappell (2001) that individual operators have greater bearingon accidents in the United States. On the other hand, in Taiwan,a high-power-distance collectivist culture, it has been found inthis research that supervisory and organizational influences havea greater influence in accidents. The U.K., from which the com-parison data in this study were derived, is also a low-power-dis-tance culture (according to Hofstede’s classification system).

The results in Table 1 show that at HFACS Levels 3 and 4(the higher organizational levels) there were significant differ-ence between the Taiwanese and U.K. sample in two catego-ries: “Organizational Climate” and “Planned Inadequate Op-erations.” In both cases, participants in the U.K. sample weremore likely to attribute shortcomings at the organizational levelthan were their Taiwanese counterparts. This may reflect thedifferences on Hofstede’s power-distance dimension, where, asa result of being a low-power distance culture, U.K. participantswere more likely to be critical of higher level management thanthe Taiwanese participants who are more likely to defer to su-periors.

According to Hofstede’s classification, the Taiwanese cultureis predisposed toward organizations with tall, centralized deci-sion structures and that have a large proportion of supervisorypersonnel. In these cultures, subordinates expect to be told whatto do. However, members of these high-power-distance culturesfrequently experience role ambiguity and overload. Group de-cisions are preferred, but information is constrained and con-trolled by the hierarchy and there is resistance to change. Mem-bers of society in high-power-distance countries are also un-likely to speak out when their opinions may contradict those oftheir superiors. Confrontation is generally avoided. Low powerdistance and high individualism promote greater autonomy ofaction at the lower levels of an organization. The Taiwaneseculture, on the other hand, which is less reactive as a result ofits preferred organizational structures that discourage au-tonomy, is also resistant to change.

U.K. participants were also more likely to attribute “ad-verse mental state” as a psychological precursor to the acci-dent, whereas the Taiwanese participants were predisposedto attributing the accident to a perceptual error (see Table 1).This may reflect some reluctance on the part of Eastern par-ticipants to utilize the category of “adverse mental state,”

which may have a certain degree of stigma attached to it. In-stead, they opted to use the (perhaps) less blameworthy cat-egory of “perceptual error.”

In all previous studies, the reliability of HFACS has been dem-onstrated using just two raters coding multiple accidents. Inter-rater reliability, calculated either by simple percentage agreementor Cohen’s Kappa, has demonstrated the categorization system tobe moderately highly reliable. The method for demonstrating reli-ability in this study, however, suggests that reliability estimated

HFACS Categories Taiwan U.K. Overall Chi-Square(n=29) (n=16) (n=45) (df=1)

Decision Error 29 15 44 χ2=0.093*;(100%) (93.8%) (97.8%) p=0.760

Skill-Based Error 24 14 38 χ2=0.000*;(82.8%) (87.5%) (84.4%) p=1.000

Perceptual Error 24 5 29 χ2=11.939;(82.8%) (31.3%) (64.4%) p=0.001

Violation 20 13 31 χ2=0.988; (62.1%) (81.3%) (68.9%) p=0.320

Adverse Mental State 15 15 30 χ2=8.195; (51.7%) (98.3%) (66.7%) p= 0.004

Adverse 9 2 11 χ2=1.046*;Physiological State (31.0%) (18.2%) (24.4%) p=0.307

Mental/Physical 17 10 27 χ2=0.000;Limitation (58.6%) (62.5%) (60.0%) p=1.000

Crew Resource 28 15 43 χ2=0.000*;Management (96.6%) (93.8%) (95.6%) p=1.000

Personal Readiness 15 5 20 χ2=1.751;(51.7%) (31.3%) (44.4%) p=0.186

Physical Environment 11 5 16 χ2=0.201; (37.9%) (31.3%) (35.6%) p=0.654

Technological 23 11 34 χ2=0.182*;Environment (79.3%) (68.8%) (75.6%) p=0.670

Inadequate 25 12 37 χ2=0.285*;Supervision (86.2%) (86.2%) (82.2%) p=0.593

Planned Inadequate 12 12 24 χ2=4.683;Operations (41.4%) (75.0%) (53.3%) p=0.030

Failed to Correct a 25 10 35 χ2=2.121*;Known Problem (86.2%) (62.5%) (77.8%) p=0.145

Supervisory Violation 18 12 30 χ2=0.776;(62.1%) (75.0%) (66.7%) p=0.378

Resource Management 22 13 35 χ2=0.002*;(75.9%) (81.3%) (77.8%) p=0.967

Organizational 12 12 24 χ2=4.683;Climate (41.4%) (75.0%) (53.3%) p=0.030

Organizational 27 15 42 χ2=0.000*;Process (93.1%) (93.8%) (93.3%) p=1.000

HFA

CS

Lev

el 1

HFA

CS

Lev

el 2

HFA

CS

Lev

el 3

HFA

CS

Lev

el 4

Table 1. Number (and percentage) of participants who indi-cated an HFACS category was a factor in contributing orcausing the Ueberlingen accident, broken down by country andoverall. In instances where the expected cell count for one (ormore) cells was less than five, Yates’s correction was applied(designated by *).


using multiple raters and a single accident is somewhat lower. Look-ing at the third column in Table 1, it can be seen that the overall per-centage use of each category differs across the categories. However,some care should be taken when interpreting this table.

For example, in instances where the overall count for a categorywas low (e.g., “Adverse Physiological States”), this was indicativeof agreement across the raters that a particular category was not

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a factor (i.e., high rater reliability). Nevertheless, reliability calcu-lated this way is significantly lower than that calculated the moreconventional manner. However, this could be a product of eitherthe degree of training received on the HFACS framework or theclarity of the factors in the stimulus material or HFACS itself.Further research is required to clarify this issue.

ConclusionThere seems to be some evidence that there are cultural differ-ences in the manner in which participants from different culturesinterpret the same factors in a sequence of events leading to anaccident. This is something that investigators from different cul-tures need to be aware of as the same events will be interpretedquite differently by representatives from different cultures, espe-cially when interpreting human actions. This demonstrates thatdespite the best efforts of all concerned, there is sometimes nosuch thing as an objective truth when analyzing and interpretingthe events leading to an accident. These cultural differences areevident in the interpretation of the influences and subsequent ac-tions (as described in Figure 1) surrounding an accident. Investi-gators need to understand this when working in multiculturalteams, not only when interpreting the events leading to an acci-dent but also when suggesting remedial actions to ensure that theyare congruent with the national culture of the operators. ◆

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There seems to be some evidence that thereare cultural differences in the manner in

which participants from different culturesinterpret the same factors in a sequence ofevents leading to an accident. This issomething that investigators from differentcultures need to be aware of as the sameevents will be interpreted quite differently byrepresentatives from different cultures,especially when interpreting human actions.


(This article was adapted, with permission,from the author’s presentation entitled TheAdvanced Qualification Program (AQP) asa Tool to Break the Chain of Accidents, pre-sented at the ISASI 2006 seminar held inCancun, Mexico, Sept. 14-17, 2006, whichcarried the theme “Incidents to Accidents:Breaking the Chain.” The full presentationincluding cited references index is on theISASI website at www.isasi.org.—Editor)

Dr. Thomas Longridge (1998) definesthe basic concept of Advanced Quali-fication Program (AQP) as “The sys-

temic methodology in the development ofinstruction, training, and evaluation pro-grams for crews and air dispatchers, in-cluding skills in CRM [crew resource man-agement].”

But in reality, what is the AQP programand what is it for? Will AQP break the cur-

rent accident barriers? Is this model a van-guard system? The answer to these ques-tions is undoubtedly YES, as a systemic wayto face the instruction, based on the tech-nology available in the 21st century, andusing CRM skills and tools. Another openquestion would be: Is the AQP model basedon human factors? Here, too, the answer ispositive; in order to apply and develop thisprogram, it is essential that companies ap-ply the systemization of the different hu-man factors concepts that are based on themodels published by Shell (Hawkins, 1975)and TEM (Helmreich and the InternationalCivil Aviation Organization).

This AQP program has been appliedsince the early nineties and reveals itself asa proposal for the U.S. air industry, underthe supervision of the Federal Aviation Ad-ministration (FAA). Its main lines have beenled by T. Longridge and D. Farrow fromthe FAA, which certainly allowed to be cre-ated the most efficient way of operationaltraining at a global level, and in my opin-ion, has permitted the breaking of barriersand trends in accident rates, thus generat-ing a more efficient and secure system.

What is AQP? What makes it distinctfrom the traditional programs? When weanalyze and check the distinct models ap-plied at a global level, be it by Europe orthe United States, we can acknowledge im-portant differences through which the AQPsystem demonstrates a more systemic and

efficient application to the real world of op-erations. A comparison shows that the JAR1978 regulations only include tendenciesand general application requirements of anAQP style model, while a detailed analysisof the standards defined by the FAA’s AC120-54 shows a complete and systemic ap-plication of this model to commercial airoperations.

Origins and genesisFirst, an analysis of AQP shows its genesisto be a need by the companies in NorthAmerica for a deep and auto-critical studyof the various failures and accident trendslabelled “operator error.”

Moreover, this study was oriented to theresearch of operational trends that mightbring systemic improvements into the airindustry. The origin of AQP followed withthe constitution of several multitask workgroups under the leadership of the aeronau-tical industry, the FAA, NASA, and com-mercial companies in order to optimize airsafety factors and achieve scale economiesthat allowed the latter to be the safest andmost efficient transport means in the eyesof the public.

It is this voluntary work, around 1988,that generated an advanced knowledge thatgrew in 1989 to what many consider the firsttraining profiles in environments that aretypical or adapted to the real world of op-erations, or typical evaluations (LOFT/LOS) for the air business.

The instruction theory was defined byBloom’s taxonomy, the latter being the ba-sis of this descriptive study, which described

Claudio Pandolfi is thehead of the AircraftAccident Prevention Department at theDGAC, Chile. He has 30years’ experience as aprofessional pilot and

served with the Chilean Air Force. Heholds an MBA (environment andquality) from IDE Institute of Spain,attended the USAF Flight Safety OfficersCourse, and completed the administra-tion of air safety systems requirementsat USC. He is a recipient of the SirDouglas Bauer Award and is a memberof ISASI and LARSASI.

In demonstrating that the Advanced Qualification Program (AQP) breaks thepresent tendencies related to aviation accidents, the author gives meaning tothe age-old quote: “How many things, too, are looked upon as quite impossibleuntil they have been actually effected?”—Pliny the Elder (A.D. c. 23–A.D. 79)

TO BREAK THE CHAIN

Use AQPBy Claudio Pandolfi (AO4028)Safety Manager, DGAC–Chile


in detail every move to be performed orexpected to be used in operational training.

In 1990, under FAA supervision, the pro-gram begins and AC 120/54 is created, as isSFAR 58 special regulation (now obsolete).The new program is based upon a voluntaryapplication by different companies. It aimsto obtain validated and free access data fromthe FAA, under a defined chronogram ofevents that considers five stages in order toachieve the final qualification of the completeapplication and chosen AQP program.

After analyzing the statistics at a world-wide level, ICAO signals in its C-302-AN/175that the United States and Canada maintainat global level a rate of 0.5 accidents per mil-lion flights, taking into account that over halfthe world’s air traffic takes place in the areaincluded between Mexico, Canada, and theUnited States. Under this perspective, flightoperations in this area undoubtedly show adefinite leadership, as this region is the onlyone that uses this innovative program, andis based on the systemic application of hu-man factors as an essential component of thetheoretical and practical training.

The AQP program plays a vital role inair business, as this program allows an in-direct control and it compels the operatorsto apply the human factors tools togetherwith an objective assessment of the behav-iors and skills of the CRM, which are anintegral part of the instruction and continu-ous evaluation programs for air crews.

During the IATA meeting held in Santi-ago, Chile, at the FIDAE 2006 aerospacefair, the phenomenon generated by low-costcompanies was pointed out, as the latterhave to respect two variables that the pub-lic is not ready to give up: the cost of theticket and air safety factors. “Who does notunderstand this will fail.” With this state-ment, the ICAO President Bisignani clearlyexpressed the new model that the air busi-ness has to face.

AQP program goalsThe operational purpose of this innovativeprogram seeks excellence in the instruction

processes, which have to be clearly definedat all stages and clearly describe each oneof the events to be assessed by using thetechnology currently available. In the ini-tial stage of the process, it is compulsory todefine the formula and the way to use thetechnological level at hand, where basictraining computers (CBTs) are the perfecttools when used in conjunction with the syl-labus concept or e-learning.

A second stage is defined by the use ofmore advanced programs in flight trainingmachines (FTDs), which allow the perfor-mance of hundreds of maneuvers, and acti-vation of systems such as hydraulics, FMS,or typical failures. The third stage is re-served for the application of theoretical aswell as practical knowledge in full level, orCategory D simulators; these are called full-flying simulators (FFS) and allow integrallyqualifying the pupil and operating an air-craft without actually having to fly it.

During this essential third stage, a pu-pil is able to achieve an efficiency thattranslates to actually being able to oper-ate an aircraft without having previouslyflown it physically, though this generatesdoubts among some flight instructors. Thisconstitutes a new paradox in advancedsimulation. In this case, the AQP programpermits one to objectively assess everystage of CRM behaviors and skills becauseof the high level of realism in the simula-tion of real situations under specific char-acteristics. Not only does AQP lead us toapply theoretical and practical concepts,but also their interaction among all thecrew members, such as language, commu-nication factors, situational awareness, anddecision-making among others.

The latter is used in Europe and allowsus to analyze the strategies applied underan operational context. The AQP programalso shows the importance of training re-garding the dilemma of shared situationalloss of awareness, which under high stressprovokes the appearance of typical culturalproblems that are not fully instructed, suchas the typical “macho pilot” concept, so char-

acteristic of our Latin American operationalenvironment, and which requires specialattention.

The AQP program’s major goal is toachieve quality training based on the con-tinuous improvement concept in which theinstruction is assessed and checked at ev-ery stage, thanks to a permanent analysisthat generates a real knowledge of the in-struction level status in the company. Theapplication of this type of program is to-tally based on free will of the companies,so its development will exclusively dependon the company will to choose this excel-lence qualification.

In regard to the Chilean aeronauticalauthority, this kind of supervision is carriedout by a unique bureau, Office 230, in a simi-lar way to what the FAA does. This depart-ment centralizes the information and allowsa permanent supervision of the differentstages involved by the companies in theimplementation of the AQP program.

This program aims at theoretical andpractical training levels to be actually ap-plied at the various stages determined by acompany, and at being an integral formwithin the latter’s instruction and trainingprograms. It also allows the developmentof its operational culture and leads to a qual-ity standard that is its main target, togetherwith the creation of a system that can toler-ate operational error, as stated by the ICAO,as well as Helmreich (1998) in his Threatsand Errors Management Model (TEM),and Reason (1996) through his concept ofthe human error in his famous Swiss cheese.

AQP program integral conceptThe AQP program’s integral concept isbased on the SHEL Model (Hawkins, 1975)describing the interaction among man, ma-chine, and environment, and how under cer-tain operational circumstances human beingsmake stupid mistakes. Moreover, when wecarry out a reactive exam according to theICAO’s Annex 13 regarding the investiga-tion of an accident, this Model allows us tovisualize a part of the equation regarding this

The AQP program’s major goal is to achieve quality training based on thecontinuous improvement concept in which the instruction is assessed andchecked at every stage, thanks to a permanent analysis that generates a realknowledge of the instruction level status in the company.


We insist in stating that the AQP program is a valuable tool that permits us to“break the accident chain and change our traditional paradigms in the airbusiness environment.”

problem. Nevertheless, and in spite of ergo-nomic improvements to come, operationalerrors are and will be a part of the opera-tional world. It is not enough to use and ap-ply all the operational resources allowed byour organizations (CRM) as these ensureonly a certain air safety level. But throughthe implementation of the AQP program, itwill be possible to reach better operationallevels, which will match the technologicallevel that we operate in this century of com-munications.

In this 21st century, the old saying:“There are two kinds of pilots, the ones wholand with the undercarriage up, and theones who will” remains valid. It is notenough to have a standard operational pro-cedure (SOP) and isolated programs thatdo not interact and are copied from differ-ent operational cultures.

From the application of Helmreich’sTEM Model, we may state that as long aswe maintain a real training level by apply-ing and assessing behaviors, or CRM skills,the latter will avoid opening opportunitywindows, and let us focus on the operationalerror itself. The AQP is precisely that, a toolthat allows us to break traditional para-digms in conventional instruction and sup-plies us with a friendlier system, with amajor error tolerance for the operator, andthus reduces our present operationaltrends, at a regional or global level.

The first-generation CRM focused on thecrews or the cockpit; the present evolutionnaturally integrates the Threats and ErrorsManagement Model, which seeks to man-age the undesirable situations known asTEM, thus allowing a more holistic visionof this problem.

Man can now manage his own errors andescape from an event that carries possiblecatastrophic effects by being able to avoidthe event or “successfully manage a deter-mined event,” thanks to his capacity to con-trol undesired situations. This is known as3M, the management of threats or lapses,and thus the ability to avoid an undesiredsituation and its catastrophic effects.

The new paradigm should now consist oflearning from successful operations, whichrepresent more than 98% of the eventsworldwide, instead of focusing as we cur-rently do on the accidents and having a morereactive than proactive vision. Our greatchallenge? Stop being reactive, as reflectedby the Heinrich pyramid (1930) and be ableto invert or at least modify its base so thatour actions are more proactive.

Through our present knowledge, we de-fine as an expect level that of a crew thatstill makes operational errors of any kind,but is able to manage them and return to anormal or low-risk level. This is what AQPis giving to our crews who are training inan operational environment that is com-pletely similar to the real operational world(LOS/LOE) and generates an environmentof efficiency and safety, which leads to achange in our current trends, avoids lossesto the air business, and consequently makesthe world air system more efficient andeventually safer and more cost efficient.

The tools provided by the AQP programallow training that is based on what actu-ally happens in the real operational worldand feeds with action a reliable report sys-tem (SARSEV, BASIS), an operationalquality verification program (FOQA), anda line operational audit system (LOSA) thatall permit, thanks to a common language,their interaction in an air Safety Manage-ment System (SMS). This global framefeeds the instruction processes by access-ing a standard based on a continuous im-provement, with an empirically validatedmodel that allows applying coherent strat-egies to the distinct instruction processesdestined for our air crews.

AQP model certification stagesAmong AQP’s qualities is that it describesin full detail the distinct characteristics,skills, and achievements expected to be ap-plied in the instruction process based onBloom’s taxonomy (1948), which allowsmultitasking. This stage forms the basis ofthe AQP program. It requires the longest

time to develop in the company, as it callsfor the application of the distinct agree-ments that tend to define the résumés andthe standards the company will use for itsoperational system.

Experts are needed in all the areas in-volved, such as instructors, pilots, systemsengineers, programmers, technicians, psy-chologists, and teachers. This working teamwill have to define the typical résumé to beimplemented in this phase, as well as thefeedback method. This stage will also haveto explain how to instruct the personnel in-volved, as well as the chronogram of definedevents, for operational reality. Airbus isimplementing this procedure in its A340fleet as an initial stage.

The second stage checks and correctsthe system with its basis being the recol-lection of objective evidence, applying theDeming purpose together with the distinctobservations found. From there, the cur-ricular models will be corrected and thechanges performed, completely or par-tially. As an example of the latter is a typi-cal maneuver in which the council or in-structors committee objectively deter-mines that the required action has beenbadly assessed and does not match theprogram’s specific goal, after which thelatter is corrected and a new standard isredacted. Maneuvers that result from thedaily operational experience will also beadded or modified, based on the informa-tion recollected by other parallel programsunder SMS. These parallel programs in-clude the flight safety anonymous reportsystem (SARSEV), the flight operationsquality system (FOQA), and in-line safetyaudits (LOSA), together with the integra-tion of a flight safety voluntary anonymousreporting system, which is at the officialpublication stage by our national aeronau-tical authority.

A third stage will seek the updating ofall the programs. These systems are work-ing and integrated in reality and based on acommon language of an SMS-type system.The creators and the council of instructors


will analyze the global information togetherwith their respective aeronautical author-ity (DGAC inspectors) and define thechanges that will bring a real continuousimprovement. This information will helpprovide feedback to the company and up-date the latter’s databank, mostly throughthe coordinated work that will tend to over-come the deficiencies of the previous stagesand establish a continuous improvement asa quality standard.

To pass the fourth stage of this program,an empirical experience and minimum op-erations times will be required, which is fun-damental to be able to compare the distinctobservations from the previous events.These events may include, for example, adeficiency in FMA operation or ACARS, theconfiguration of unexpected approxima-tions, or the non-respect of standards dur-ing the stabilized approximations of theFlight Safety Foundation’s ALAR program,or the deficient use of language at criticalmoments, among others.

Eventually, once all the previous stagesare concluded, the fifth stage is reached,after which the AQP program certificationis obtained. We have assessed that it willtake 24 to 36 months to achieve certifica-tion, so the process will always remain un-der the constant supervision of the respec-tive authority. In the case of Chile, an initialprogram has been launched and is now atthe closing stage for the A340 fleet, afterwhich the corrections will be applied to in-struction courses and the distinct deviationscorrected by applying the Deming cycle—aiming for a continuous improvement be-fore directing the efforts to the Boeing B-767 fleet, and then to other models.

Operational cases and challengesIn our experiences, we have known casesthat after takeoff and during the climbingphase, the crew has seen all the screens ofthe glass cockpit remain dark and displayonly the mention “Please Wait.” After hav-ing tried to solve this problem without anypractical results, the captain has made the

right decision to turn back and land manu-ally, achieving a successful landing. But theanalysis showed that the system initializa-tion (INS) had not been performed cor-rectly on the ground—a clear case of hu-man factors and CRM skills; so it has beendecided to give a higher emphasis to theFTS and FFS phases, through more theo-retical as well as practical instructionhours.

It is important to point out the situationexperienced by our crews when operatingin extreme or high-latitude areas, which isthe case in the most southern sector ofChile, specifically in the Magellan Straits,where spring and summer are seasons ofstrong winds of hurricane strength averag-ing 28 to 35 knots with evening peaks up to55 knots, generating tempest conditions.

There exists the case of a high-technol-ogy aircraft that could not land normallythree times in a row because its automaticsystem caused it to abort at low altitude dueto an excess of crosswind. The situationgenerated some uncertainty among thecrew, which eventually decided to landmanually, with all the limits involved. Oncethe data of this case were analyzed, it re-sulted that the man/machine interaction(Shell), made of human factors and CRMskill, had not been correct, which generateda reinforcement of theoretical and practi-cal training, including typical applicationsin FTD and FFS simulators.

The distinct challenges involved in theimplementation of the AQP program in ouroperational system have generated newrequirements and operational standards inthe use of such systems as ILS Cat III-B,EGPWS, TWAS, TCAS II, WAAS/LAAS,RNP, ATM, and ADS-B. The instructionprocesses are fundamental in achieving areal man-machine-environment integrationand to use it in a safe and friendly way. Aslong as our practical formation and qualifi-cation processes lead to a systemic imple-mentation of AQP, as close as possible fromthe operational reality, we will eventuallyavoid the classic operator or human error

and break the present trends that causeaccidents with catastrophic effects at re-gional level.

ConclusionsWe have pointed out the importance ofimplementing skills in the CRM behaviors,and human factors checking in the distinctinstruction processes, based on the SHELand TEM Models and the application of dif-ferent levels of basic or advanced simula-tion through the AQP prism. This will al-low us to obtain quality training with a de-gree of objectivity in the differenttheoretical and practical training processes,leading to apply a systemic application tothese processes and to the friendly use ofthe technology available in our century.• From the above, we may state that theAQP program is a new standard that al-lows a quality training to be dispensed,using the technological discoveries of the21st century.• The kind of assessment, the methods,the innovation, and the instruction tech-niques constitute a process that generatesvaluable synergies leading to the produc-tion of a safer and more efficient air busi-ness system.• The evolution of the behaviors andskills in CRM and human factors are es-sential to achieve success in this kind ofAQP.• In AQP, the programs and distinctstages are clearly defined and adapted tothe company, allowing us to have clear andachievable goals.• In its implementation, the aeronauti-cal authority as well as the companyform a team that, thanks to a proactivework, will jointly generate a safer and moreefficient system to be acknowledged as aleader system, at the regional level as wellas worldwide.

Finally, we insist in stating that the AQPprogram is a valuable tool that permits usto “break the accident chain and changeour traditional paradigms in the air busi-ness environment.” ◆


ISASI ROUNDUP

ISASI Accorded ‘Observer’ Status atICAO AIG Divisional MeetingISASI has been accorded observer statusat ICAO’s 2008 AIG Divisional meeting.AIG is presently establishing prioritiesfor discussion. ISASI will plan on sendingone to two representatives to the AIGmeeting. The AIG08 is planned only as a1-week meeting, and the consensus of theInternational Council members is that isinsufficient time to effectively address allthe issues that need to be discussed. TheAIG99 meeting was 2-week’s long andthat proved to be just barely enough time,according to ISASI representatives whoattended.

Among the subjects that ISASI hasproposed to ICAO for discussion in theAIG meeting is the need for a worldwidesafety recommendation repository—thatis, a single centralized source for catalogu-ing recommendations from investigativeagencies around the world. To that end,ISASI would like to see states forwardsafety recommendations and safety actionstaken to ICAO for posting on an ICAOwebsite. Also, ISASI says there is a needfor ICAO to establish an Internet-basedmeans for the collection and distribution ofall safety recommendations and safetyactions taken by member states. ◆

Great Lakes Chapter GainsActing PresidentMatthew Kenner has been named asacting president of the Great LakesRegional Chapter due to the retirementof Rodney Schaeffer, former president.

While the regional activity has beendormant for a number of years, Kennersays that resurrection efforts include• identifying members who might like tobecome active again.• scheduling a meeting in the Chicagoarea to present information on the Cirrusairframe parachute system and AmSafeaircraft inflatable restraints.• continuing a regular meeting schedulefor the Chapter.

Regional members wishing to become

reengaged with the Chapter’s activitiesare asked to contact Matthew at [email protected], work phone 630-851-4566. ◆

By-Laws AmendmentVoting Deadline ClosesAt press time, the by-laws amendmentvoting period was preparing to close(October 27). In early August, PresidentFrank Del Gandio mailed to each memberin good standing information regardingthe voting process.

He noted that the InternationalCouncil (IC) had directed By-LawsCommittee Chairman Darren Gaines “torevise our by-laws that have been in effectsince our founding in 1964. The revisionswill allow us to use modern-day tools andprograms for everyday Society adminis-tration at significant monetary savingsand will provide guidelines for responsiblefiduciary and business practices.”

The IC has approved the revisionsafter extensive review and had themposted on the ISASI website, www.isasi.org, for members’ perusal. The member-

ship voting process to approve the revisedby-laws was accomplished confidentiallyby electronic e-vote. The open votingperiod for all eligible members wasAugust 25 through October 25. ◆

Election NominationsDue April 1The ISASI Nominating Committee hasissued a early call for nominations for theExecutive officer and councillor positionsthat will be open to election for the years2009-2010. The nomination deadline isApril 1, 2008. The positions to be filled arepresident, vice-president, secretary,treasurer, U.S. councillor, and interna-tional councillor. Nominations in the pastseveral years have been very low.

Each potential candidate whose name issubmitted to the Nominating Committeemust have consented to the submission.The nominator must submit a short bio-graphical sketch of the nominee. Nomineesmust be at least a full member to beeligible for office within ISASI. Nomina-tions should be sent to the ISASI office,attention Nominating Committee. ◆

Tom McCarthy provides the treasurer’s report to Society members during the ISASIgeneral business meeting conducted at the ISASI annual seminar. Looking on are, leftto right, President Del Gandio, Vice-President Schleede, and Secretary Baum.

ISASI ROUNDUP

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International CouncilorMaintains Heavy ContactScheduleCaj Frostell, ISASI international councilor,is maintaining a frequent contact scheduleboth in conjunction with Reachoutseminars and stand-alone meetings withvarious groups of prospective members.From October 2006 through April 2007, hehas traveled to seven countries anddelivered ISASI promotional material aswell as Reachout training information toaudiences with attendees from morethan 60 countries.

He has found that ISASI’s website isnow a valuable source of information fornew and potential members. In reportingthis information to the InternationalCouncil last May, discussion was gener-ated about what motivates people to join

ISASI, remain in ISASI, and/or leaveISASI. Frostell said, “There is typically amembership ‘spike’ after a Reachout orseminar. Some of those people join onimpulse, and so some degree of attritionamong those members is to be expected.”Further discussion showed what theCouncil believes to be ISASI’s top fiveproducts. These are• annual seminar,• Forum magazine,• Reachout,• ISASI website, and• networking among safetyprofessionals. ◆

ATS Working GroupProvides UpdateThe Air Traffic Services Working Groupdelivered its paper titled “Tenerife toToday—What Have We Done in Thirty

Years to Prevent Recurrence?” duringISASI 2007. As the only ATS-specificpaper accepted for presentation by theSingapore organizing committee, itcontained varied global contributionsfrom the Group relating to the status ofcontemporary runway safety. TheWorking Group co-chair John Guselli’slate withdrawal from the seminar led toDarren Gaines stepping in at short noticeto successfully present the paper.

On the personal side, John said, “TheWorking Group is delighted to report thatVice-Chairman Ladislav Mika is recover-ing well from major surgery conducted inlate August. He is convalescing at home inPrague and expects to be back at workvery soon. We wish him well in hisrecovery.” Projected ATSWG initiativesrelate to supporting the ISASI Reachoutprogram around the world on request. ◆

ASASI Posts New Officers;Issues Call for PapersThe Australian Society announces theposting of two new officers and a call forpapers for the 2008 Australasian SafetySeminar.

Following the resignation of Ken Lewis,Lindsay Naylor, former vice-president,was appointed president. A subsequentelection places Lieutenant CommanderRichard (Rick) Sellers (RAN) in the office

New Members

CORPORATEAerovias De Mexico, S.A.De C.V.

Andres Conesa,Eric Mayett

Raytheon CompanyGreg AlstonJason Elwood

Defence Science and TechnologyOrganisation (DSTO)Nicholas Athiniotis

INDIVIDUALAlmaskari, Saif, N., Seeb, OmanAlrashid, Abdullah, A., Riyadh, Saudi ArabiaBaldursson, Bragi, Reykjavik, IcelandBaldwin, Robert, M., Guildford, Surrey,

United KingdomChikosi, Forbes, F., Harare, ZimbabweCollins, Anthony, W., Auckland, New ZealandD’Oliveira, Lisa, J., Wellington, New ZealandDigance, Jason, Asuington, West Sussex,

United KingdomFarrell, Paul, J., Dublin, IrelandFlanagan, Viti, M., Auckland, New ZealandGregory, Philip, Ringoes, NJ, USAHarris, Benjamin, H., Alexandria, VA, USAHo, Lye, H., Singapore, Republic of

SingaporeIskandar, Peter, Rome, ItalyJunckerstorff, Reimar, C., Karrinyup, WA,

AustraliaKo, Samuel, Singapore, Republic of

SingaporeLaine, Sami, P., Helsinki, Finland

Letchman, Hunter, S., Columbus, MS, USALewis, Kent, B., Watauga, TX, USALusch, Patrick, D., Pompano Beach, FL, USAMackrell, Stuart, J., Farnham, Surrey,

EnglandMacPherson, Ian, J., Palmerston North, New

ZealandMcGraw, Nathan, L.V., Christchurch, New

ZealandParata, Gary, R., Auckland, New ZealandPavlovcic, Gabriel, T., Castelar (N), ArgentinaPuntillo, Ronald, U., Palm Coast, FL, USARandell, Edward, J., Wellington, New

ZealandRanganathan, Ananthakrishnan, Chennai,

IndiaRebbapragada, Dhruv, Uttar Pradesh, IndiaRichardson, Don, S., Auckland, New ZealandRitter, Thomas, J., Neuried, GermanySanitioso, A. Toos, Cimahi, West Java,

IndonesiaSaunders, David, Wellington, New ZealandSiswosuwarno, Mardjono, Bandung,

IndonesiaThacker, Ron, M.R., Palmerston North, New

ZealandTorres, Roberto, H., Ormond Beach, FL,

USAUsman, Muhtar, S., Kaduna, North, Kaduna,

NigeriaWalsh, Mary, T., Republic of SingaporeWiener, Morris, J., Cherry Hill, NJ, USAWong, P., F., Hong Kong, ChinaYasin, Rayhana, Cape Town, South Africa ◆

Dr. Walter Tye (HO0005), Cobham,Surrey, U.K. Dr. Tye was one of afew Honorary members.

Howard C. Craft (LM0373), Clare-mont, Calif., U.S.A., Jan. 13, 2007

Theodore A. Faber (LM2452), Al-pharetta, Ga., U.S.A., May 26, 2007

Preston K. Higgins (LM0485),Burbank, Calif., U.S.A. ◆

In Memoriam


Continued . . .

ISASI ROUNDUP

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of vice-president. The secretary/treasureris Paul Mayes.

Sellers has had a flying career span-ning 27 years. He started his flying careerin light GA aircraft after leaving school.He has operated a wide variety of civiland military aircraft from multiengine jettransport aircraft through turboprops topiston- and single-engine jet trainers. Hehas also operated a mix of military rotarywing types from the Bell UH1B Iroquoisto the Sea King. He has approximately6,500 hours of flying experience and hasheld a number of squadron executive andinstructional positions.

He has enjoyed postings with RAN,RAAF, RAF, USN, and USAAC. He holdsan ATPLA and CPLH and has qualifica-tions in Safety Systems Management andair accident investigation from the U.S.Navy postgraduate school in Monterey,Calif., and from Cranfield University(U.K.). He is also a graduate of the RAAFAviation Safety Officers Course and theADF Aircraft Accident Inquiry Manage-ment Course. He is trained in humanfactors, CRM, and AVRM and holds amaster’s degree in aviation managementfrom the University of Newcastle.

In addition, a “call for papers” has beenposted for the joint Australian and NewZealand Societies 2008 Australasin SafetySeminar to be held in Adelaide, May 30 toJune 1. The seminar theme is “TransportSafety--Past, Present, Future.” Papersare being sought on contemporarytransport safety including recent investi-gation (road, rail, marine, aviation) and onthe issues facing the safety investigatorsin the future. An abstract and a shortauthor’s biography should be sent to PaulMayes at e-mail address [email protected]. ◆

Failure Analysis ofComposites Gets AiringAt ISASI 2006, Dr. Joseph Rakowpresented a technical paper entitled

“Failure Analysis of Composite Struc-tures in Aircraft Accidents.” The paper,one of 20 presented, was selected for“special consideration” honors by theseven-member panel that reviewedpapers for the “Best in Seminar” award.Forum published the paper in its Janu-ary-March 2007 issue and received thegreatest number of “reprint” requests for

it than for any other paper published inthe past 9 years.

Since then, Dr. Rakow, teamed up withDr. Alfred M. Pettinger, has produced amanual designed especially for aircraftaccident investigators titled FailureAnalysis of Composites.

The authors prepared this manual tosummarize some of the fundamental

Jan.-Dec. 06 Budget $ Over Budget % of BudgetOrdinary Income/ExpenseIncome601 Dues-New Individual Member 11,770.00 11,000.00 770.00 107.0%603 Dues-New Corporate Member 4,180.00 5,000.00 -820.00 83.6%611 Dues-Renewal Individual Member 56,790.00 68,000.00 -11,210.00 83.52%613 Dues-Renewal Corporate Member 40,305.00 54,000.00 -13,695.00 74.64%614 Dues-Late Fees 900.00 1,000.00 -100.00 90.0%615 Dues-Upgrade Fees 510.00 300.00 210.00 170.0%616 Dues-Reinstatement Fees 160.00 200.00 -40.00 80.0%621 Contrib-Unres Membership 1,338.00 2,000.00 -662.00 66.9%631 Publication Subscriptions 776.00 700.00 76.00 110.86%632 Publication Income 650.00 1,500.00 -850.00 43.33%634 Library Services 70.60 100.00 -29.40 70.6%642 Membership Services 262.39 300.00 -37.61 87.46%643 Membership Regalia Sales 354.49 300.00 54.49 118.16%650 Seminar-Proceedings 6,310.55 6,000.00 310.55 105.18%651 Seminar-Net Proceeds 43,918.43 10,000.00 33,918.43 439.18%652 Seminar-Reimbursed Advance 0.00 3,000.00 -3,000.00 0.0%Total Income 168,295.46 163,400.00 4,895.46 103.0%

Expense700 Condo Fees 3,241.46 4,800.00 -1,558.54 67.53%705 Mortgage Interest 5,012.35 8,500.00 -3,487.65 58.97%711 Repairs and Maint 0.00 1,000.00 -1,000.00 0.0%712 Storage Rental 1,620.00 1,620.00 0.00 100.0%801 P/R Exp-Office Mgr Salary 41,767.43 41,000.00 767.43 101.87%802 P/R Exp-Health Insurance 12,250.00 10,000.00 2,250.00 122.5%803 P/R Exp-SEPP 1,989.75 1,800.00 189.75 110.54%805 P/R Expense Employers FICA 3,195.38 3,000.00 195.38 106.51%807 P/R Expense-VA UIC Tax 23.20 40.00 -16.80 58.0%811 Accounting-Payroll 1,026.48 850.00 176.48 120.76%812 Accounting-Tax Prep 430.00 450.00 -20.00 95.56%813 Audit Expense 0.00 150.00 -150.00 0.0%814 Insurance 1,935.00 3,000.00 -1,065.00 64.5%816 Legal Fees 0.00 140.00 -140.00 0.0%817 Licenses and Permits 125.00 3,000.00 -2,875.00 4.17%822 OPS-Telephone & Telex 2,785.01824 OPS- Equip Maint & Repair 104.95 2,000.00 -1,895.05 5.25%825 OPS-Other Utilities 2,162.31 3,000.00 -837.69 72.08%826 OPS-Postage and Shipping 8,759.90 6,500.00 2,259.90 134.77%827 OPS-Printing and Reproduction 2,019.81 2,200.00 -180.19 91.81%828 OPS-Office Supplies 2,809.83 4,000.00 -1,190.17 70.25%829 Website 1,785.00830 OPS-Computer Tech Support 2,458.50 1,000.00 1,458.50 245.85%831 OPS-Equipment Purchase 0.00 3,500.00 -3,500.00 0.0%832 OPS-Equipment Lease 4,588.67833 OPS-Petty Cash 0.00 200.00 -200.00 0.0%840 OPS-Temp Help 435.75 1,000.00 -564.25 43.58%844 Publications-Forum Expense 36,868.50 37,000.00 -131.50 99.65%

ISASI Annual Report 2006—Profit & Loss Budget ○

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concepts related to the failure analysis offiber-reinforced composites, as applicableto the investigation of aircraft accidents.The manual is based upon existingliterature and the experience and trainingof the parties.

The purpose of the manual, which wasmade available at no charge to attendeesof ISASI 2007 in Singapore, is “to provide

aircraft accident investigators, who maynot be engineers, with an introduction tofailures in basic composite aircraftstructures.” The basic composite struc-tural components addressed in themanual are laminates, sandwich struc-tures, joints, and repairs.

Discussions contained in the manualare “intended to help investigators to,

first identify these structural componentswith an understanding of their purposeand, second, to recognize their basicfailure modes.

The authors expressly note that “thescope and level of detail may not ad-equately address the needs of allinterested parties, and any use of thismanual is at the sole risk of the user.”The manual is considered a “work inprogress” with updates and revisionsbeing published as appropriate. Acautionary note is added, “While greatcare was taken in the compilation of thismanual, no warranties express or

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vs. Actual

845 Publications-Proceedings 6,310.55 5,000.00 1,310.55 126.21%848 Publications-Handbook Expense 210.00 100.00 110.00 210.0%856 Membership-Regalia Items 0.00 500.00 -500.00 0.0%861 Membership-Service Expense 5,873.80 1,500.00 4,373.80 391.59%871 Library Expenses 0.00 1,000.00 -1,000.00 0.0%881 Management Council-Travel 23,034.58 15,000.00 8,034.58 153.56%882 Management Council-Admin Exp 1,850.17 1,000.00 850.17 185.02%883 Management Council-Other 123.85 3,000.00 -2,876.15 4.13%886 Management Council-Rep Travel 656.51 300.00 356.51 218.84%887 Management Council-Rep Admin 0.00 200.00 -200.00 0.0%891 Rebate-Natl/Reg/Corp 0.00 2,000.00 -2,000.00 0.0%901 Seminar-Advances 0.00 3,000.00 -3,000.00 0.0%* 902 Seminar-Reimbursable Cur Exp 158,905.33903 Seminar-Lederer Award 0.00 500.00 -500.00 0.0%905 Seminar/Reachout 590.26 1,000.00 -409.74 59.03%906 Scholarship Fund 2,813.64911 Bank Fees 264.00 200.00 64.00 132.0%912 Credit Card Charges 8,475.99 2,500.00 5,975.99 339.04%Total Expense 346,502.96 176,550.00 169,952.96 196.26%

Net Ordinary Income -178,207.50 -13,150.00 -165,057.50 1,355.19%

Other Income/ExpenseOther Income661 Rent-Tenant Rental Income 8,030.00 8,780.00 -750.00 91.46%671 Interest-Checking Acct 3,398.20 400.00 2,998.20 849.55%672 Interest-Other 228.28 500.00 -271.72 45.66%681 Other Income-Miscellaneous 56.82682 Other Income-Refunds 734.96**683 Other Income-Reimbursements 169,646.45***685 Memorial Scholarship Fund 2,670.00Total Other Income 184,764.71 9,680.00 175,084.71 1,908.73%

Other Expense922 Misc-Other Reimb Exp 0.00924 Misc-Death/Illness Exp 173.10925 Misc-Refunds 0.00930 Depreciation 5,361.00Total Other Expense 5,534.10

Net Other Income 179,230.61 9,680.00 169,550.61 1,851.56%

Net Income 1,023.11 -3,470.00 4,493.11 -29.48%

* Vehicle to reimburse seminar registrations.** Vehicle to receive seminar registrations and members dues.*** Deposits to Rudy Kapustin Scholarship Memorial Fund. Funds kept in a separate account.

Jan.-Dec. 06 Budget $ Over Budget % of Budget

MOVING?Please Let Us KnowMember Number_____________________

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

Old Address (or attach label)

Name _____________________________

Address ___________________________

City _______________________________

State/Prov. _________________________

Zip _______________________________

Country ___________________________

New Address*

Name _____________________________

Address ___________________________

City _______________________________

State/Prov. _________________________

Zip _______________________________

Country ___________________________

E-mail ____________________________

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


ISASI Information

OFFICERSPresident, Frank Del Gandio

([email protected])Executive Advisor, Richard Stone

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

([email protected])Secretary, Chris Baum

([email protected])Treasurer, Tom McCarthy

([email protected])

COUNCILLORSAustralian, Lindsay Naylor

([email protected])Canadian, Barbara Dunn

([email protected])European, Anne Evans

([email protected])International, Caj Frostell

([email protected])New Zealand, Ron Chippindale

([email protected])United States, Curt Lewis

([email protected])

NATIONAL AND REGIONALSOCIETY PRESIDENTSAustralian, Lindsay Naylor

([email protected])Canadian, Barbara M. Dunn

([email protected])European, David King

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

(Mexico)New Zealand, Peter Williams

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

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

([email protected])United States, Curt Lewis

([email protected])

Sharing Experience and Knowledge (from page 5)

cies do become apparent, to move swiftlyto correct them—and avoid recurrence. Asan effort to harmonize and promote effi-ciency in air safety investigation, in the fallof 2008, ICAO will convene an Accident In-vestigation and Prevention Divisionalmeeting (AIG 2008) for all ICAO state andinterested organizations. The chief of theAIG Division, Marcus Costa, is with us forthis seminar. He will make an address tous during the seminar. I would ask all at-tendees to pay particular attention to themessage from Mr. Costa. AIG 2008 will bean opportunity for all of us to refine andmodernize ICAO Annex 13 and our accident

investigation process to be as efficient aspossible.

And now, as delegates to ISASI 2007, Ihope I have addressed some of your objec-tives in attending the seminar—and that Ihave addressed some of the safety chal-lenges facing our aviation industry. I encour-age everyone to take advantage of the mul-tiple opportunities throughout the seminarto exchange and gather information, andequally important, to meet your colleaguesin this productive environment.

I thank you for your attention, and Iwish you the most stimulating and fruitfulseminar. ◆

Continued . . .

ISASI ROUNDUP

implied, are given in connection with theaccuracy or completeness of this docu-ment.” Copies of the manual may beobtained by contacting Dr. Rakow at e-mail address [email protected].

In a related and more recent occur-rence, Dr. Rakow recently appeared in atelevised “Dan Rather Reports” program.The episode, entitled Plastic Planes,centered on the risks and benefits ofusing composite materials in the nextgeneration of aircraft. ◆

Curt Lewis & AssociatesDelivers On-site SafetyTraining CoursesCurt Lewis & Associates, a multi-discipline technical and scientificconsulting firm, has announced theaddition of safety training courses to itsservice offerings. The courses will bedelivered on site by instructors who haveextensive field experience and safetytraining.

As companies continue to expand theirsafety culture, they should be proactive inoffering employee safety training andorientation, according to Curt Lewis,principal of Curt Lewis & Associates.Education is a necessary step in creating

awareness of safety risks. “We’vedeveloped a series of safety trainingcourses that provide a solid overview ofworkplace risks and a systematic ap-proach to controlling those risks,” saysLewis. “Our courses are beneficial forboth managers and employees, new hires,and company veterans. Regardless of thedevelopment of a company’s safetyculture, it’s important to review bestpractices and provide ongoing safetytraining.”

Course titles include Safety Manage-ment Systems, Safety and InvestigationTraining, Managing Workers’ Compensa-tion, and Occupational Safety and HealthAdministration (OSHA) 10-Hour and 30-Hour Certificates of Training. Course-work is designed to assist a company ineither implementing or supplementingsafety processes that identify potentialworkplace risks. The OSHA courseworkprovides a broad overview of OSHA’s rolein the workplace along with personalresponsibilities that employees shouldassume. The investigation courseworkincludes training on root cause analysisand specific accident analysis techniques.For more information, companies cancontact the firm at 817-303-9096 or by e-mailing Curt Lewis at [email protected]. ◆

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UNITED STATES REGIONALCHAPTER PRESIDENTSAlaska, Craig Beldsoe

([email protected])Arizona, Bill Waldock ([email protected])Dallas-Ft. Worth, Curt Lewis

([email protected])Florida, Ben Coleman ([email protected])Great Lakes, Matthew Kenner

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

([email protected])Northeast, David W. Graham ([email protected])Pacific Northwest, Kevin Darcy

([email protected])Rocky Mountain, Gary R. Morphew

([email protected])San Francisco, Peter Axelrod

([email protected])Southeastern, Inactive

COMMITTEE CHAIRMENAudit, Dr. Michael K. Hynes

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

([email protected])Board of Fellows, Ron Chippindale

([email protected])Bylaws, Darren T. Gaines ([email protected])Code of Ethics, John P. Combs

([email protected])Membership, Tom McCarthy ([email protected])Nominating, Tom McCarthy ([email protected])Reachout, James P. Stewart ([email protected])Seminar, Barbara Dunn ([email protected])

WORKING GROUP CHAIRMENAir Traffic Services, John A. Guselli (Chair)

([email protected])Ladislav Mika (Co-Chair) ([email protected])

Cabin Safety, Joann E. Matley([email protected])

Corporate Affairs, John W. Purvis([email protected])

Flight Recorder, Michael R. Poole([email protected])

General Aviation, William (Buck) Welch([email protected])

Government Air Safety, Willaim L. McNease([email protected])

Human Factors, Richard Stone([email protected])

Investigators Training & Education,Graham R. Braithwaite([email protected])

Positions, Ken Smart([email protected])

CORPORATE MEMBERSAAIU Ministry of Transport BulgariaAccident Investigation Board, FinlandAccident Investigation Board/NorwayAccident Investigation & Prevention BureauAeronautical & Maritime Research LaboratoryAeroVeritas Aviation Safety Consulting, Ltd.Aerovias De Mexico, S.A.De C.V.Air Accident Investigation Bureau of SingaporeAir Accident Investigation Unit—IrelandAir Accidents Investigation Branch—U.K.Air Canada Pilots AssociationAir Line Pilots AssociationAir New Zealand, Ltd.Airbus S.A.S.Airclaims LimitedAircraft Accident Investigation Bureau—SwitzerlandAircraft Mechanics Fraternal AssociationAircraft & Railway Accident Investigation CommissionAirservices AustraliaAirTran AirwaysAlaska AirlinesAlitalia Airlines—Flight Safety Dept.All Nippon Airways Company LimitedAllied Pilots AssociationAmerican Eagle AirlinesAmerican Underwater Search & Survey, Ltd.AmSafe AviationAramco Associated CompanyASPA de MexicoAssociation of Professional Flight AttendantsAtlantic Southeast Airlines—Delta ConnectionAustralian Transport Safety BureauAviation Safety CouncilAvions de Transport Regional (ATR)BEA-Bureau D’Enquetes et D’AnalysesBoard of Accident Investigation—SwedenBoeing Commercial AirplanesBombardier Aerospace Regional AircraftBundesstelle fur Flugunfalluntersuchung—BFUCathay Pacific Airways LimitedCavok Group, Inc.Centurion, Inc.Charles Taylor Aviation, SingaporeChina AirlinesCirrus DesignCivil Aviation Safety Authority AustraliaColegio De Pilotos Aviadores De Mexico, A.C.Comair, Inc.Continental AirlinesContinental ExpressCOPAC/Colegio Oficial de Pilotos de la Aviacion ComercialCranfield Safety & Accident Investigation CentreDCI/Branch AIRCODefence Science and Technology Organisation (DSTO)Delta Air Lines, Inc.Directorate of Aircraft Accident Investigations—

NamibiaDirectorate of Flight Safety (Canadian Forces)Directorate of Flying Safety—ADFDutch Airline Pilots AssociationDutch Transport Safety BoardEL AL Israel AirlinesEmbraer-Empresa Brasileira de Aeronautica S.A.Embry-Riddle Aeronautical UniversityEmirates AirlineEra Aviation, Inc.European Aviation Safety AgencyEVA Airways CorporationExponent, Inc.Federal Aviation AdministrationFinnair OyjFlight Attendant Training Institute at Melville College

Flight Safety FoundationFlight Safety Foundation—TaiwanFlightscape, Inc.Galaxy Scientific CorporationGE Transportation/Aircraft EnginesGlobal Aerospace, Inc.Gulf Flight Safety Committee, Azaiba, OmanHall & Associates, LLCHellenic Air Accident Investigation

& Aviation Safety BoardHoneywellHong Kong Airline Pilots AssociationHong Kong Civil Aviation DepartmentIFALPAIndependent Pilots AssociationInt’l Assoc. of Mach. & Aerospace WorkersInterstate Aviation CommitteeIrish Air CorpsIrish Aviation AuthorityJapan Airlines Domestic Co., LTDJapanese Aviation Insurance PoolJeppesenJetBlue AirwaysJones DayKLM Royal Dutch AirlinesKorea Aviation & Railway Accident Investigation BoardKreindler & Kreindler, LLPL-3 Communications Aviation RecordersLearjet, Inc.Lockheed Martin CorporationLufthansa German AirlinesMyTravel AirwaysNational Air Traffic Controllers Assn.National Business Aviation AssociationNational Transportation Safety BoardNAV CanadaNigerian Ministry of Aviation and Accident

Investigation BureauParker AerospacePhoenix International, Inc.Pratt & WhitneyQantas Airways LimitedQwila Air (Pty), Ltd.Raytheon CompanyRepublic of Singapore Air ForceRolls-Royce, PLCRoyal Netherlands Air ForceRoyal New Zealand Air ForceRTI Group, LLCSandia National LaboratoriesSAS BraathensSaudi Arabian AirlinesSICOFAA/SPSSikorsky Aircraft CorporationSkyservice Airlines, Ltd.Singapore Airlines, Ltd.SNECMA MoteursSouth African AirwaysSouth African Civil Aviation AuthoritySouthern California Safety InstituteSouthwest Airlines CompanySouthwest Airlines Pilots’ AssociationStar Navigation Systems Group, Ltd.State of IsraelTransport CanadaTransportation Safety Board of CanadaU.K. Civil Aviation AuthorityUND AerospaceUniversity of NSW AviationUniversity of Southern CaliforniaVolvo Aero CorporationWestJet ◆


WHO’S WHO

Jones Day Serves Clients Globally

ISASI107 E. Holly Ave., Suite 11Sterling, VA 20164-5405USA

NON-PROFIT ORG.U.S. POSTAGE

PAIDPermit #273

ANNAPOLIS, MD

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CHANGE SERVICE REQUESTED

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

With more than 2,200 attorneys in30 offices around the globe,Jones Day has broad capabilities

to provide legal services to the aviationindustry in every major legal discipline.Jones Day acts as a single entity on behalfof its clients, and its global reach andintegrated technologies permit the firm toassemble the team, strategy, and interdis-ciplinary experience to serve its clientsbest. Jones Day has a tradition ofrepresenting aviation industry clientsacross myriad legal disciplines, includinglitigation, business combinations andmergers, banking and finance, govern-ment regulation, environmental, tax, andlabor and employment. Whether it’sproviding counsel on ever-changinginternational or domestic competition,advising on environmental or tax laws,negotiating a labor contract, bidding onairport construction contracts, or defend-ing product liability claims involvingcommercial airline or general aviationaccidents, Jones Day has substantialexperience in every major practice areatouching the aviation industry, in virtuallyevery corner of the world.

Aviation litigation has become increas-ingly high-profile, factually complex, andlegally complicated. Jones Day hasconsiderable experience representingclients in claims involving commercialairline and general aviation aircraft. Thefirm has defended clients in litigationarising from the crashes of USAir Flight427, SilkAir Flight 185, Swissair Flight111, Flash Air Flight 604, and EgyptAirFlight 990. Jones Day also has repre-sented clients in a variety of generalaviation litigation cases in state andfederal court across the United Statesinvolving various aircraft types. Our

aviation lawyers have firsthand experi-ence with aircraft piloting, operations,and engineering.

Jones Day’s aviation litigation experi-ence ranges from crash site investigationto accident reconstruction, arbitration andmediation of disputes, litigation defense,and trial and appeal. Many of the firm’scases involve close work with accidentinvestigators to identify, preserve, and

John D. Goetz and Dana Baiocco areJones Day’s contacts for its corporatemembership in ISASI. John and Dana arepartners resident in the Pittsburgh, Pa.,office of Jones Day, and their practice isconcentrated in the area of complexproduct liability and aviation litigation.John and Dana have appeared in stateand federal trial and appellate courtsacross the United States. They haveappeared in multidistrict andmultijurisdiction litigation and havespecial expertise defending generalaviation cases. They were part of thedefense trial teams in the USAir Flight427 litigation and the case involving theair crash death of a former Missourigovernor. They also have counseledclients in crash site investigations, FAAadministrative matters, corporate flightdepartment procedures, and airport-related construction.

John and Dana have published articleson aviation litigation, litigation strategy,and product liability issues. They havespoken on a variety of legal topics,including legal issues relating to the useand operation of business jets. They areactive members of the ABA AviationSection and the Pennsylvania Bar Associa-tion Aeronautical and Space Law Section.They are pilots and members of the Air-craft Owners and Pilots Association. ◆

assess the physical evidence from a mishapto determine the possible cause(s) andprovide advice to clients. Jones Daylawyers have worked with a variety ofaccident investigators from the privatesector to marshal evidence in support of itsclients, defend cases, appear in court, andinterface with NTSB or FAA officials. Thefirm has developed relationships withformer NTSB and other governmentofficials who act as aviation consultants onaccident investigation protocol or toprovide expert testimony in court.

WHO’S WHO

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