Aircraft Accident Investigation Research Articles

RISK MANAGEMENT IN AIR NAVIGATION SERVICES

The need to develop and adopt legal standards for safety management was identified at the Conference of General Directors of Civil Aviation dedicated to the global strategy of aviation safety (Montreal, March 20-22, 2006) and additionally supported by the recommendations of the Safety Conference (Montreal, March 29 - April 1, 2010). The year 2006 saw the introduction of issues related to the safety management system to the Convention’s annexes. The existing fundamental rules related to SMS were included in the annexes: 1 - Personnel licensing, 6 - Operation of Aircraft, 8 - Airworthiness of Aircraft, 11 - Air Traffic Services, 13 - Aircraft Accident and Incident Investigation, and 14 - Aerodromes. In addition, due to the dynamic development of aviation and, at the same time, the growing need to create the highest standards in the field of safety management systems, the Air Navigation Commission established the Safety Management Panel (SMP) to develop the content of Annex 19. After several years of reconciliation and consultation, this document was finally adopted by the ICAO Council in 2013. It has become the ipso facto document that provides the basis for creating an effective safety management system, as it is compatible and also adapted to the most effective practices indicated in the ICAO Doc 9859 Safety Management Manual. Annex 19 sets out the responsibility of States, the safety management system and the collection of information related to safety. The National Civil Aviation Safety Programme and the structure of this system were also dealt with. The whole idea is to support states in the process of hazard identification and risk management. The purpose of the article was: to highlight selected elements of the risk management process in a practical dimension, to present the principles for assessing the degree of risk by an air navigation service provider, and to identify ways of improving this process. Searching for an answer to the main research problem contributed to achieving this goal. The research problem was expressed in the form of a question: How does the air navigation service provider manage the risk under the air traffic safety management system in order to achieve compliance with regulatory requirements and to achieve the assumed parameters (indicators) in the area of safety? With regard to the main research problem, the following research hypotheses were formulated: 1. I believe that an air navigation service provider undertakes an assessment of the degree of possible danger in civil aviation to identify hazards in air traffic as part of a safety management system. 2. I suppose that the air navigation service provider manages the risk in a manner consistent with the provisions of law and by using procedures included in normative documents.

Further Improving General Aviation Flight Safety: Analysis of Aircraft Accidents During Takeoff

Data from the National Transportation Safety Board (NTSB) reveal that general aviation (GA) accounted for 76% of total air transport related accidents and incidents in the U.S. between 2014 and 2019. The identification of causes is one of the most important tasks in aircraft accident investigation and a critical strategy for proactive aircraft accident prevention. Aircraft and flight crew perform differently in each phase of flight given the changes of aircraft configuration, flight operation environment and flight crew workload, therefore, the causes of aircraft accident may vary by phase of flight. Most accidents occur in the phases of final approach and landing have been investigated by many researchers from various perspectives. Few studies, however, have been published on flight safety for the phase of takeoff, which has the second-highest number of GA aircraft accidents and incidents. A good understanding of the causes of GA aircraft accidents during takeoff is crucial to develop more effective countermeasures for aircraft takeoff risk mitigation and accident prevention. The objective of this study is to understand the causes of GA aircraft takeoff accidents by analyzing aircraft accident investigation reports published by the NTSB. To better understand the causes of GA aircraft takeoff accidents, the following research design has been implemented. First, comparative analysis was applied to depict the statistical features of GA takeoff accidents compared to other air transport categories. Temporal change of GA takeoff accidents was analyzed using a linear-by-linear association test. Secondly, primary accident causes were identified by analyzing the NTSB investigation reports. Text mining techniques were applied to further explore contributing factors associated with the identified causes to enrich discovered knowledge. Finally, logistic regression analysis was applied to explore risk factors for fatal GA aircraft takeoff accidents. Lists of key causal and contributing factors were revealed and discussed from the analytical results. The identification of causal factors, contributing factors and risk factors for GA aircraft takeoff accidents are expected to be a valuable supplement to existing knowledge for aircraft accident prevention.

How Can an Ab-Initio Pilot Avert a Future Disaster: A Pedagogical Approach to Reduce The Likelihood of Future Failure

Safety is the primary concern of the civil aviation industry. This study aimed to explore the importance of learning from failures and improving the future performance of students by teaching this notion during an undergraduate course in the curriculum of the pilot training program. A questionnaire study was conducted with students of the pilot training program of the Faculty of Aviation and Aeronautical Science after the completion of a newly introduced elective undergraduate course, Aircraft Accident and Incident Investigation. Furthermore, for the first time, the contributing factors in accidents and incidents were analyzed and classified in an undergraduate pilot training program by using the Human Factors Classification and Analysis System (HFACS) as an analytical framework. The objective of the study was to find out if the “aspects of the accident investigation course at universities” were effective on “Technical Pilot Skills,” “NonTechnical Pilot Skills” and “Program-Specific Outcomes.” Correlation and Hierarchical regression analyses were conducted for this purpose. In the regression analysis, the variables were entered into the model and controlled. The results showed that the aspects of the accident investigation course improved technical and non-technical skills of the students, as well as their program-specific outcomes, and they were actively encouraged to extend their knowledge and skills beyond that required for the Airline Transport Pilot License (ATPL). It was revealed that this new undergraduate course does not only help learn the importance of non-technical skills (Crew Resource Management, Situational Awareness, etc.) but also develops and improves the technical abilities of ab-initio pilots.

Selected cases of failure analysis and the regulatory agencies in Brazil. Part 1: Aviation, railway and health

Abstract Three cases of failure analysis (aircraft landing gear, cast railway wheel and unalloyed Ti orthopaedic implant) representing three different industry sectors were selected to compose a critical study of their respective regulatory agency in Brazil. The implementation and achieved transparency of the National Civil Aviation Agency (ANAC) for the investigation of aircraft accidents are recognized as state of the art and is consistent with the economic importance of this sector for the country. In contrast, the transparency of the National Land Transportation Agency (ANTT) for the investigation of railway accidents is considered to be deficient. The current organization and transparency of the Brazilian Health Regulatory Agency (ANVISA) for the investigation and prevention of the failure of orthopaedic implants can be criticised as severely flawed. This agency should take immediate actions to adopt the compulsory notification and investigation of the failures of orthopaedic implants and implement a more reliable certification procedure of implants to ensure the protection of the Brazilian health care patients. The transparency of information might play an important role in the trade-off between the independence and the political control of the regulatory agencies in Brazil. In this sense, the publication of conducted failure analyses and general access to their reported findings are seen as a valuable driving force to improve the impact the regulatory agencies have on the general welfare of the country.

Legal and Engineering Aspects of Deployable Black Boxes with Video Recording Capability

Black box is a compilation of data produced by on-board and ground communications, specifically and inherently in digital nature; therefore it is a digital database and part of a discussion on protection of digital databases. The Existing Black box technology used in Commercial Aircraft is accommodated with Affixed type black boxes. However, if the Deployable black boxes are implemented with fixed black boxes as a dual combined recorder system, the discovery of crash location can be determined with more effectually than the present technology. The lives of the survivors, initiation of aircraft accident and investigation progression obtain safety recommendations to avoid similar happenstances will depend upon the accessibility to the crash location immediately by search and rescue organizations with the reliable information they achieved through satellite communications. Deployable Recorders will provide a backup source of flight data other than the fixed black box data; assist the investigators to carry out their investigations with more trustworthy information while implementing the video recording capability. A new idea has been introduced in this research to implement a mechanism to deploy a parachute with the ejection of the deployable recorder from the aircraft to minimize the impact during its dwindling to the ground. Not only in engineering but also the legal aspects of Deployable black boxes work along with the rights of the human beings. The legal aspect of the Deployable black boxes connect with aircraft accident and an incident investigation process can be discussed in the preview of domestic and international law; for example under the Convention on International Civil Aviation. Annex 13 of the Chicago Convention is endowed with the international requirements for the investigation of aircraft accidents and incidents. The protection over digital databases can be achieved through legal and technological means (Technological Protection Mechanisms-TPMs). The paper investigates the legal and engineering aspects of Black box technology used in Commercial Aircraft. KEYWORDS: Black Box, Deploy, Chicago Convention, Databases, International Air Law

An examination of aviation accidents in the context of a conflict of interests between law enforcement, insurers, commissions for aircraft accident investigations and other entities

An examination of aviation accidents in the context of a conflict of interests between law enforcement, insurers, commissions for aircraft accident investigations and other entities

Airplane pilot mental health and suicidal thoughts: a cross-sectional descriptive study via anonymous web-based survey.

BackgroundThe Germanwings Flight 9525 crash has brought the sensitive subject of airline pilot mental health to the forefront in aviation. Globally, 350 million people suffer from depression–a common mental disorder. This study provides further information on this important topic regarding mental health especially among female airline pilots. This is the first study to describe airline pilot mental health–with a focus on depression and suicidal thoughts–outside of the information derived from aircraft accident investigations, regulated health examinations, or identifiable self-reports, which are records protected by civil aviation authorities and airline companies.MethodsThis is a descriptive cross-sectional study via an anonymous web-based survey administered between April and December 2015. Pilots were recruited from unions, airline companies, and airports via convenience sampling. Data analysis included calculating absolute number and prevalence of health characteristics and depression scores.ResultsOne thousand eight hundred thirty seven (52.7%) of the 3485 surveyed pilots completed the survey, with 1866 (53.5%) completing at least half of the survey. 233 (12.6%) of 1848 airline pilots responding to the Patient Health Questionnaire 9 (PHQ-9), and 193 (13.5%) of 1430 pilots who reported working as an airline pilot in the last seven days at time of survey, met depression threshold–PHQ-9 total score ≥ 10. Seventy-five participants (4.1%) reported having suicidal thoughts within the past two weeks. We found a significant trend in proportions of depression at higher levels of use of sleep-aid medication (trend test z = 6.74, p < 0.001) and among those experiencing sexual harassment (z = 3.18, p = 0.001) or verbal harassment (z = 6.13, p < 0.001).ConclusionHundreds of pilots currently flying are managing depressive symptoms perhaps without the possibility of treatment due to the fear of negative career impacts. This study found 233 (12.6%) airline pilots meeting depression threshold and 75 (4.1%) pilots reporting having suicidal thoughts. Although results have limited generalizability, there are a significant number of active pilots suffering from depressive symptoms. We recommend airline organizations increase support for preventative mental health treatment. Future research will evaluate additional risk factors of depression such as sleep and circadian rhythm disturbances.Electronic supplementary materialThe online version of this article (doi:10.1186/s12940-016-0200-6) contains supplementary material, which is available to authorized users.

Employing supercomputer technology for aircraft accident investigation

We consider a software package for simulation and visualisation of surface-to-air guided missile flight and target defeat. We illustrate the research with the results of investigating the aircraft accident that took place in July 2014 in Ukraine.

Legal Considerations about the Loss of Malaysia Airlines Flight MH 17 in Eastern Ukraine

On 17 July 2014, Malaysia Airlines flight MH 17 from Amsterdam to Kuala Lumpur was lost in the Donetsk Oblast, Ukraine, while cruising at an altitude of 33,000 feet. All 298 persons on board were killed. Although the investigation is still ongoing, it can be deemed certain that the aircraft was downed as the result of the current armed conflict in Eastern Ukraine. The case of MH 17 shows how the established international order for the safe, regular and efficient navigation of international civil aviation can crumble, if a State cannot warrant its international obligations. The Chicago Convention1 is built upon the monolithic principle of State sovereignty. However, when a State cannot fully exercise its executive control over its entire territory, there are serious effects on the protection of civil aviation, aircraft accident investigation and the closing of airspace for security purposes.

Application of the Cognitive Interview for Aircraft Accident Investigation

Application of the Cognitive Interview for Aircraft Accident Investigation

What fatal occupational accident investigators can learn from fatal aircraft accident investigations

Our aim is to provide an overview of what international aircraft accident investigation practises could teach fatal occupational accident (FOA) investigators. The main purpose of an accident investigation is to prevent future accidents. This aim is easier to achieve if investigations are independent; biases and external pressures can place undue influence on particular recommendations. So far, independence has been easier to achieve in aviation investigations than in fatal occupational accident investigations. In FOAs, tensions often arise between different stakeholders including but not limited to industry regulators, police agencies, industry bodies, trades unions, insurance companies, etc. There are also a host of practical problems that complicate key activities in FOA investigations, including the need to prevent the contamination of evidence in the immediate aftermath of an accident. We argue that greater emphasis needs to be placed on the independence of FOA investigations and that this will help move the emphasis of recommendations from the worker level (sharp end) to the workplace and community system level (blunt end).

Fatal drowning as a result of an airplane crash—Case report

An ULM (Ultra Light Motorized) plane Aeroprakt 22-L with two men on board dived unexpectedly into the Dworackie lake near the town of Olecko in Warmia and Mazury district, Northeastern Poland. The pilot and the passenger had multiorgan blunt injuries, including subdural and subarachnoid hemorrhage, fractured ribs, fractured thigh (in one of the deceased) and pulmonary contusions as a result of the impact with the lake. The multiorgan injuries and unconsciousness resulting from head trauma prevented the casualties from saving themselves. The underlying cause of the death was the crash into the lake, however drowning was assessed as the proximate cause of death. The accident was analyzed together with an account prepared by State Commission on Aircraft Accident Investigation and with the Human Factor Analysis and Classification System – HFACS (the standardized method of analysis of flight accidents, the tool originally developed and tested within the U.S. military).

Experimental Improvements of Accident Investigation Report

Accident investigation is critical to the success of an effective safety program. The causes of the accidents have to be determined. A proper accident investigation report will also lead to a proper determination of whether an accident was preventable or not. The purpose of this study is to adopt the advantages from aircraft accident investigation report format. The prudent report format of accident is to enhance system and system safety. This study emphasizes the importance and necessity of element through studying an accidental investigation report. The results indicate that the conclusions to be raised and the forms of safety recommendations are best in all situations.

Relationships between Observer and Kalman Filter models for human dynamic spatial orientation1

How does the central nervous system (CNS) combine sensory information from semicircular canal, otolith, and visual systems into perceptions of rotation, translation and tilt? Over the past four decades, a variety of input-output ("black box") mathematical models have been proposed to predict human dynamic spatial orientation perception and eye movements. The models have proved useful in vestibular diagnosis, aircraft accident investigation, and flight simulator design. Experimental refinement continues. This paper briefly reviews the history of two widely known model families, the linear "Kalman Filter" and the nonlinear "Observer". Recent physiologic data supports the internal model assumptions common to both. We derive simple 1-D and 3-D examples of each model for vestibular inputs, and show why - despite apparently different structure and assumptions - the linearized model predictions are dynamically equivalent when the four free model parameters are adjusted to fit the same empirical data, and perceived head orientation remains near upright. We argue that the motion disturbance and sensor noise spectra employed in the Kalman Filter formulation may reflect normal movements in daily life and perceptual thresholds, and thus justify the interpretation that the CNS cue blending scheme may well minimize least squares angular velocity perceptual errors.

Aircraft accident investigation: the decision-making in initial action scenario

In the complex aeronautical environment, the efforts in terms of operational safety involve the adoption of proactive and reactive measures. The process of investigation begins right after the occurrence of the aeronautical accident, through the initial action. Thus, it is in the crisis scenario, that the person responsible for the initial action makes decisions and gathers the necessary information for the subsequent phases of the investigation process. Within this scenario, which is a natural environment, researches have shown the fragility of rational models of decision making. The theoretical perspective of naturalistic decision making constitutes a breakthrough in the understanding of decision problems demanded by real world. The proposal of this study was to verify if the initial action, after the occurrence of an accident, and the decision-making strategies, used by the investigators responsible for this activity, are characteristic of the naturalistic decision making theoretical approach. To attend the proposed objective a descriptive research was undertaken with a sample of professionals that work in this activity. The data collected through individual interviews were analyzed and the results demonstrated that the initial action environment, which includes restricted time, dynamic conditions, the presence of multiple actors, stress and insufficient information is characteristic of the naturalistic decision making. They also demonstrated that, when the investigators make their decisions, they use their experience and the mental simulation, intuition, improvisation, metaphors and analogues cases, as strategies, all of them related to the naturalistic approach of decision making, in order to satisfy the needs of the situation and reach the objectives of the initial action in the accident scenario.

Stephen Anthony Cullen

Air Commodore Stephen Anthony Cullen (“Tony”) was an aviation pathologist of international repute. Tony, himself the son of a doctor, was born in Liverpool in 1939 and qualified in medicine...

On-site aspects of a major aircraft accident investigation

This paper describes the background to a major accident involving a Royal Australian Navy helicopter, and discusses the scientific and technical aspects involved in the on-site accident investigation. This particular investigation was a particularly complex one which highlights a number of difficulties involved in conducting technical investigations in a remote location, and the paper will focus on describing the broad progress of the on-site investigation while highlighting the key issues and those where it was possible to overcome major hurdles and reach sound conclusions.

Improvement of Aircraft Accident Investigation Through Expert Systems

Research has been conducted at the Royal Melbourne Institute of Technology University in Melbourne, Australia on the improvement of aircraft accident investigation through expert systems. The aim of this research is to pursue a thorough analysis of the aircraft accident investigation, followed by identifying areas where significant improvements could be achieved, and finally demonstrating an expert system tool for improving investigation outcomes. Discussion on the development of applied methodology for aircraft accident investigation is presented.

基調講演OS6]鉄道事故調査の動向と最近の鉄道事故事例

I introduce topics related to the investigation of railway accidents and some examples of accidents which happened after the serious accident in Hibiya line of Teito Rapid Transit on March of 2000. In the first part I describe the countermeasures and activities after the Hibiya accident and the "Aircraft & Railway Accident Investigation Commission", that was organized officially from this October. In the main part I introduce several examples of railway accidents during this one-year, such as train head-on collisions in Keifuku Electric Railway, and try to consider the causes and backgrounds of the accidents from the point of view of safety engineering. Especially redundancy and fail-safe of brake system are considered.

Navier-Stokes Analysis of Flowfield Characteristics of an Ice-Contaminated Aircraft Wing

An analytical study was performed as part of the NASA Lewis support of a National Transportation Safety Board (NTSB) aircraft accident investigation. The study was focused on the performance degradation associated with ice contamination on the wing of a commercial turbo-prop-powered aircraft. Based upon the results of an earlier numerical study conducted by the authors, a prominent ridged-ice formation on the subject aircraft wing was selected for detailed flow analysis using 2-dimensional (2-D), as well as, 3-dimensional (3-D) Navier-Stokes computations. This configuration was selected because it caused the largest lift decrease and drag increase among all the ice shapes investigated in the earlier study. A grid sensitivity test was performed to find out the influence of grid spacing on the lift, drag, and associated angle-of-attack for the maximum lift (C(sub lmax)). This study showed that grid resolution is important and a sensitivity analysis is an essential element of the process in order to assure that the final solution is independent of the grid. The 2-D results suggested that a severe stability and control difficulty could have occurred at a slightly higher angle-of-attack (AOA) than the one recorded by the Flight Data Recorder (FDR). This stability and control problem was thought to have resulted from a decreased differential lift on the wings with respect to the normal loading for the configuration. The analysis also indicated that this stability and control problem could have occurred whether or not natural ice shedding took place. Numerical results using an assumed 3-D ice shape showed an increase of the angle at which this phenomena occurred of about 4 degrees. As it occurred with the 2-D case, the trailing edge separation was observed but started only when the AOA was very close to the angle at which the maximum lift occurred.