Air Accident Investigation Research Articles

MAJOR AIR DISASTERS: ACCIDENT INVESTIGATION AS A TOOL FOR DEFINING ERAS IN COMMERCIAL AVIATION SAFETY CULTURE

The air transport evolution has been littered with major air disasters, the occurrence of which has not only had the negative effects inherent to any disaster. Air accident investigation has provided a wealth of knowledge that has advanced the aviation industry and its safety. International Civil Aviation Organization has exercised international regulatory leadership since 1947, developing tools with international cooperation, such as the air accident investigation methodology. ICAO has forged a change in perspective on safety attributions or factors in different historical eras, using this methodology to deepen the understanding of the causes and thereby achieve aviation safety improvement. Authors aimed to analyze, through a detailed study of the world’s worst aviation accidents, their contribution to understanding the details of aviation safety culture. Beyond the technical issues and fatality rates, the necessary analysis is what knowledge researchers have gained from the beginning, exploring the attributions of reports and knowing what diverse factors have predominated in different eras. Descriptive analyzes of air disaster investigation have two objectives: to identify the beginnings of a global safety culture resulting from evolution in operational safety and to relate the different eras to the attributions of air accident investigations.

Meteorological causes of air accidents

This paper is devoted to analysis and statistical summarization of data on air accidents, incidents, and serious incidents, where meteorological factors contributed to their development or directly caused the specific aviation event. The aim of this paper is to raise awareness about current issues related to the impact of adverse weather conditions and specific factors on aviation, despite the continuous development of technological and informational aspects. There were applied final reports from official internet sources, namely the Air Accidents Investigation Institute of the Czech Republic and the Ministry of Transport of the Slovak Republic, especially the Aviation and Maritime Investigation Authority. Those official reports were used for the implementation of statistical processing and detailed analysis of aviation accidents in the territory of the Czech and Slovak Republic.

APPLICATION OF HFACS-HFIX FRAMEWORK IN NTSC’S FINDINGS AND RECOMMENDATIONS: WAMENA AIR ACCIDENTS’ CASE STUDY

Wamena airport experienced accidents in 2002, 2008, 2009, 2013, 2015, and 2016. All accidents were cargo flights and in approach and landing flight phases. As the Swiss Cheese concept, accident happened when errors penetrated safety defenses’ layers in straight line. Structuring NTSC’s investigations, under HFACS framework to understand the human factor failures type and HFIX strategy to close the failures by applying the recommendations, need to be done in air accident investigation. Eleven aviation experts and practitioners were interviewed in this study, to validate the framework. There were layers without any failures in accident 2008, 2013, and 2016. Accident in 2016 has no recommendation due operators’ safety actions were considered relevant to block failures. Accidents in 2002, 2009, 2013, and 2015 have failure in a layer which intervened by two or more recommendations. There were failures remain open in accident 2002, 2009, 2013, and 2016. Repetitive failure, error or violation of repetitive accidents in 2002, 2009, 2013, 2015, and 2016 is un-stabilized approach and has not been blocked with effective interventions. HFACS and HFIX are useful to framework the accident investigation, preventing similar accident happened in the future.

The role of augmented reality in air accident investigation and practitioner training

The aim of this paper is to describe the application of digital visualization tools to assist air accident investigators, including both their investigation activities and as a training resource. Augmented Reality technology is used to re-create a real aircraft crash scene, both in terms of wreckage distribution and features of the surroundings, in a full-scale 3D representation. A case study shows both potentials and limitations of the approach, and recommendations on how to improve the methodology are also proposed. Overall, it is concluded that Augmented Reality has achieved a maturity stage sufficient to consider it as an effective tool for training of air accident investigators and, to some extent, to support the investigation process itself, although more developments are required to address some current limitations and fully exploit the capabilities of this technology.

Testing the Process of Evacuation from the Passenger Aircraft with the Use of Computer Simulation

Aim: The main aim of the study was to investigate the possibility to use the Pathfinder simulation software to determine the duration of an evacuation and to plan its course for various scenarios of evacuation organisation, for specific profiles and behaviours of passengers and on-board personnel, and for a specific geometrical arrangement of the passenger cabin of a selected passenger aircraft. In addition, the paper discusses selected factors that affect the evacuation from the passenger aircraft. Project and methods: The Pathfinder software used in the research has the graphical interface to create an evacuation simulation model (2D and 3D) as well as tools to visualise the results. Pathfinder is based on artificial intelligence algorithms, in which each passenger has a number of individual features that can influence his/her movements and decisions during the simulation. The simulation of people's movement is determined by their profiles and behaviours, the parameters of which can be entered by means of probability distributions, which makes it possible to take into account the stochastic nature of the evacuation process. Results: The Boeing 787 Dreamliner was selected for the study, for which six options for simulating the evacuation of 252 passengers and eight members of on-board personnel were conducted. The shortest evacuation time was achieved by changing the even distribution of the number of passengers to the individual emergency exits, thus avoiding congestions in sensitive areas of the passenger cabin. The increase in passengers' maximum speed has paradoxically increased evacuation times, as it has increased the intensity of passenger collisions. It was found that one of the key issues affecting the timing of an evacuation is the proper organisation of the evacuation by on-board personnel, who, by guiding passengers through the geometrically most advantageous passageways, results in the fastest possible evacuation. The simulations in variants five and six have achieved satisfactory evacuation times, which are within the emergency aircraft evacuation time limit required in a certification process. Conclusions: The presented simulation models, the results obtained, and the wide range of possibilities of three-dimensional visualisation of research results give a rational basis for the use of Pathfinder software for testing the evacuation process and thus: for the usage in the aircraft design process, for preparing aircrafts for tests, for shaping evacuation procedures, for on-board personnel training and for air accident investigation.

A Series of Three Aircraft Emergency Public Health Alerts at an International Airport Over a Six Week Period due to Suspected Contaminated Cabin Air

Air travel is a safe, common mode of transport for both work and leisure activities. It can be associated with health risks, with exposure to toxic compounds or fumes in the aircraft cabin resulting in a variety of clinical symptoms. We report on three aircraft incidents which resulted in passenger and crew illness and necessitated emergency landings at Dublin International Airport. We obtained details on the three incidents from the National Ambulance Service Operations Centre dispatch system and staff, regional public health specialists and the National Air Accident Investigation Unit (AAIU). We conducted a chart review of all passengers and crew who attended the hospital Emergency Department (ED) and consulted with the attending ED physician. Twenty-three crew and passengers reported feeling unwell on the three flights over a six week summer period. Symptoms included dizziness, headache, and throat and eye irritation. On one flight there was a severe odour. Fifteen crew and passengers from the first two incidents were treated at a hospital ED. One case had a low oxygen saturation, and another required oral steroids and nebulised bronchodilator. The AAIU did not find a cause for illness on assessment of all three aircraft. The three aircraft incidents described highlight the potential safety risk of air quality alterations. While there is no evidence that serious health events occurred in these events, sharing of experiences on similar events may lead to increased understanding of these complex events and ensure that aircrafts are a safe environment in which to travel and work.

Air Accident Investigation Findings and Recommendations: Aircraft Contaminated Air Events

Air Accident Investigation Findings and Recommendations: Aircraft Contaminated Air Events

Accident Investigators Are the Guardians of Public Safety: The Importance of Safeguarding the Independence of Air Accident Investigations as Illustrated by Recent Accidents

The sole objective of an air accident investigation is the prevention of future accidents; its purpose is not to apportion blame or liability. This mantra of air accident investigators combined with requirements to ensure the independence of investigations – all contained in ICAO Annex 13 to the Chicago Convention – affords investigators the opportunity to review crucial evidence and reach conclusions on the cause of an accident without fear of recrimination or the presence of undue pressure. Ultimately, these provisions allow the proper and independent investigation of accidents and encourage aviation safety to be furthered. Recent high profile accidents have laid bare the pressures faced by investigators from within the investigation itself and external sources including the media, victims’ representatives, manufacturers, operators, and the spectre of blame proceedings. This article will study these stress points in the context of recent accidents and seek to illustrate why it is of fundamental importance to the independence of future air accident investigations, and the quality of the resultant safety outcomes, that such pressures are recognized and addressed by the International Civil Aviation Organization (ICAO). It will also consider whether the recently issued 11th edition of Annex 13 incorporating Amendment 15 achieves these aims.

A case study of high sea salt aerosol (SSA) concentrations as a hazard to aviation

ABSTRACTOn the night of 2 January 2014, an aircraft on approach to Cork airport was required to abort a landing attempt due to sea salt aerosol (SSA) accretion on the windscreen. The salt reduced forward‐facing visibility to dangerously low levels and prohibited a safe approach by the aircraft. A landing was eventually effected on the 3rd attempt after a light rain shower cleared enough of the contaminant to allow the pilot to view the runway lights and markings. This was the first time such an incident was recorded by Ireland's Air Accident Investigation Unit. This paper elaborates the meteorological conditions present at the time the SSA became a visibility hazard. The atmospheric boundary layer was thermodynamically unstable and had a relatively dry airmass and the surface and upper level winds were high. SSA formation mechanisms are described in terms of the relationship between SSA concentration enhancement and meteorological variables. A brief comparison between the meteorological conditions surrounding this and another notable event documented by the US naval service is made. The potential for SSA to be a significant hazard to aviation and the recommendations for further research are considered.

THE GHOST OF THE RULE IN HOLLINGTON v HEWTHORN: EXORCIST REQUIRED

AT an airfield in Dorset, a vintage aircraft took to the air and then – as too often seems to happen – fell out of it. The fatal consequences led to Rogers v Hoyle [2014] EWCA Civ 257, [2014] 3 W.L.R. 145 – proceedings brought on behalf of the dependants of the deceased passenger, Orlando Rogers, against the pilot, Scott Hoyle, whose negligence they claimed had caused the crash. As required by law, the accident had been officially investigated by the Department of Transport's Air Accident Investigation Department (the AAID). Its report contained findings about the cause of the accident which were helpful to the claimants' case, so they sought to adduce it as evidence. To this the defendant objected and sought to persuade the courts to exclude it. That he failed in his attempt is unsurprising because, as Leggatt J. put it at first instance, “If any non lawyer was told that the law does not permit a court to have regard to the AAIB report when deciding how the accident was caused, I am sure that he or she would express astonishment at the suggestion”. But if the sensible outcome was so obvious, why were lengthy judgments at two levels, with over 70 authorities cited and discussed, needed to produce it?

The Future of Aircraft Feedback Information: Maintainability Allocation Methodology

In this paper, the author looks at certain areas of maintainability prediction process where missteps or misapplications most commonly occur. This research attempts to utilise the aircraft maintenance historical data and information (i.e. feedback information systems). Aircraft feedback information such as Service Difficulty Reporting System (SDRS) and Air Accidents Investigation Branch (AAIB) contains various types of information that could be used for future improvement rather than just the failure elements, as well as to help identify the critical and sensitive components that need more attention for further improvement. The study shows that the aircraft maintenance related feedback information systems analyses are very useful for deciding the maintainability effectiveness; these include planning, organizing maintenance and design improvement. There is no doubt that historical data information has the ability to contribute an important role in design activities. The results also show that maintainability is an importance measure that can be used as a guideline for managing efforts made for the improvement of aircraft components.

The Decision of the English High Court in Rogers & Anor v. Hoyle: Clipping the Wings of the Principles of Air Accident Investigation

The Decision of the English High Court in <i>Rogers</i> &amp; <i>Anor v. Hoyle</i>: Clipping the Wings of the Principles of Air Accident Investigation

Investigating the Truth of Heinrich's Pyramid in Offshore Helicopter Transportation

Several hazardous industries have embraced Heinrich's premise that incidents of negligible safety consequences are precursors to accidents in a statistical sense. However, in few such industries has research verified the truth of that assumption. This paper explores the relationships between accidents and reported incidents in the context of oil and gas–related offshore helicopter operations by using the accident investigation reports published by the UK Air Accident Investigation Branch and the incidents filed under the British Mandatory Occurrence Reporting Scheme between 1997 and 2010. Classification frameworks were developed to enable the independent analysis of accidents and incidents in relation to specific variables of interest. Frequencies and statistical associations that could have indicated the precursor relationship were explored. From the results of the analysis, the paper highlights potentially severe shortcomings in the assumptions underpinning incident data collection as well as the process with which incident data are generated. For example, the paper unveils the existence of sudden failures that cannot be reliably anticipated or reported and draws attention to a potentially flawed incident-reporting culture. Given the results, the paper informs stakeholders in the industry of specific initiatives to ensure that the right lessons are learned from past occurrences (e.g., through ways of collecting incident data that will not rely solely on reporters) and how these could be used to inform future interventions, for example, through the analysis of potential consequences of incidents, as a complement to the analysis of frequencies.

A Two-Phase Method of Detecting Abnormalities in Aircraft Flight Data and Ranking Their Impact on Individual Flights

A two-phase novelty detection approach to locating abnormalities in the descent phase of aircraft flight data is presented. It has the ability to model normal time series data by analyzing snapshots at chosen heights in the descent, weight individual abnormalities, and quantitatively assess the overall level of abnormality of a flight during the descent to a given runway. The method models normal approaches to a given runway (as determined by the airline's standard operating procedures) and detects and ranks deviations from that model. The approach expands on a recommendation by the UK Air Accident Investigation Branch to the UK Civil Aviation Authority. The first phase quantifies abnormalities at certain heights in a flight. The second phase ranks all flights to identify the most abnormal, each phase using a one-class classifier. For both the first and second phases, i.e., the support vector machine (SVM), the mixture of Gaussians and the K-means one-class classifiers are compared. The method is tested using a data set containing manually labeled abnormal flights. The results show that the SVM provides the best detection rates and that the approach identifies unseen abnormalities with a high rate of accuracy. The feature selection tool F-score is used to identify differences between the abnormal and normal data sets. It identifies the heights where the discrimination between the two sets is largest and the aircraft parameters most responsible for these variations. The method presented adds much value to the existing event-based approach.

Air accident investigation among regulatory agencies

The aim of this manuscript is to describe and compare regulatory aviation agencies according to their subordination and attributions to investigate air accidents. Possible consequences in identifying the contributory factors are also presented. Distinct procedures investigating air accidents among agencies lead to a lack of standardization of the statistics, making it difficult to analyze the data globally. Separately the information does not configure the entire scenario of what occurred, affecting the analysis and subsequent interventions. We recommend a joint and collaborative work between the different committees that operate in the investigation of air accidents.

Work of the UK Helicopter Task Group

This article, written by Assistant Technology Editor Karen Bybee, contains highlights of paper SPE 140760, ’The Work of the UK Helicopter Task Group,’ by Jessica Burton, Oil &amp; Gas UK, originally prepared for the 2011 SPE European Health, Safety, and En vironmental Conference in Oil and Gas Exploration and Production, Vienna, Austria, 22-24 February. The paper has not been peer reviewed. The Helicopter Task Group (HTG) was created by the UK oil and gas industry in April 2009 to address helicopter-safety issues, including those arising from the tragic helicopter crash off the northeast coast of Scotland on 1 April 2009. The task group included representatives from offshore operators and contractors, including those involved in the incident, as well as Oil &amp; Gas UK, the offshore workforce, helicopter-operator companies, regulators, emergency-response organizations, and trade unions. Introduction The HTG was created to address cross-industry issues about helicopter safety, including those arising from the fatal helicopter crash off the northeast coast of Scotland on 1 April 2009. The purpose of the HTG was to act on behalf of the industry as a communications focal point for sharing information, advice, and learning across the industry and with other stakeholders on matters arising from this and other helicopter accidents, including assisting the implementation of any recommendations from the Air Accidents Investigation Branch (AAIB) inquiries. The group also defined possible policies and practices to be recommended to the Board of Oil &amp; Gas UK for approval and consequent implementation on a pan-industry basis. In doing this, it was supported by existing industry workgroups and advisory teams. The group met every 4 weeks from April 2009 to June 2010. The full-length paper is designed to summarize the key issues that the task group was involved in over that period, some of which had been ongoing work for a number of years, and what changes have been made to the offshore industry and aviation safety as a result of the cooperation between the task group, wider aviation community, existing industry bodies, regulators, and emergency-response organizations. HTG Work Plan The HTG identified a number of key aviation-safety issues at its first meet-ing in April 2009, which would form the basis of its work plan. Although many potential projects could have been chosen, it was decided that—to ensure that the group could work effectively and deliver results in a manageable time frame—only a set number of priority items would be focused on. These work areas initially were linked to recommendations arising from the lessons learned in the two helicopter incidents that occurred in the UK continental shelf (UKCS) in early 2009. As the group progressed, other work areas were identified, including some linked to lessons learned in other incidents around the world. Summary of Key Work Areas and Progress Made The following is a summary of each of the key work areas or projects overseen by the task group, and the status of each by June 2010 when the group was closed formally and its work was handed over to a new group.

Robinson R22 and R44 Helicopters Analysis of Incidents 1996–2007

SUMMARYIncident data is made available by AAIB (Air Accident Investigation Board) and CAA (Civil Aviation Authority) on both flying hours and aircraft incidents in the UK. This paper makes inferences and comparisons from the incident and accident statistics. The Robinson R22 is a two seat light helicopter used largely (although not exclusively) for training. The R44 is a very similar but four seat craft used for leisure and charter flights.

Credible investigation of air accidents

Within the United Kingdom the Air Accidents Investigation Branch (AAIB) has been used as a model for the other transport modes accident investigation bodies. Government Ministers considered that the AAIB’s approach had established the trust of the public and the aviation industry in its ability to conduct independent and objective investigations. The paper will examine the factors that are involved in establishing this trust. They include: the investigation framework; the actual and perceived independence of the accident investigating body; the aviation industry’s safety culture; the qualities of the investigators and the quality of their liaison with bereaved families those directly affected by the accidents they investigate.

The AASK Database V3.0: A Database Of Human Experience During Aircraft Evacuation Incidents

This paper describes recent developments with the Aircraft Accident Statistics and Knowledge (AASK) database. The AASK database is a repository of survivor accounts from aviation accidents developed by the Fire Safety Engineering Group of the University of Greenwich with support from the UK CAA. Its main purpose is to store observational and anecdotal data from the actual interviews of the occupants involved in aircraft accidents. Access to the latest version of the database (AASK V3.0) is available over the Internet. AASK consists of information derived from both passenger and cabin crew interviews, information concerning fatalities and basic accident details. Also provided with AASK is the Seat Plan Viewer that graphically displays the starting locations of all the passengers – both survivors and fatalities - as well as the exits used by the survivors. Data entered into the AASK database is extracted from the transcripts supplied by the National Transportation Safety Board in the US and the Air Accident Investigation Branch in the UK. The quality and quantity of the data was very variable ranging from short summary reports of the accidents to boxes of individual accounts from passengers, crew and investigators. Data imported into AASK V3.0 includes information from 55 accidents and individual accounts from 1295 passengers and 110 crew.

Flight deck indication of health monitoring data—a critique

In September 1995 there was an incident involving an AS332L Super Puma helicopter over the North Sea. This followed the onset of high vibration due to the fatigue failure of a tail rotor blade retaining hinge. This was the first major vibration incident involving a helicopter fitted with a health and usage monitoring system (HUMS). The UK Air Accidents Investigation Branch made a number of recommendations. One was that the UK Civil Aviation Authority (CAA) should develop the concept of providing a flight deck display of health monitoring information to the flight crew. The CAA asked the Helicopter Health Monitoring Advisory G roup (HHM AG) (an industry body that advises the CAA) to consider the issue. This paper will examine the findings of the H HMAG working group and discuss the practicality of such systems in an operational environment.