Aviation Accident Investigation Research Articles

False carbamazepine positives due to 10,11-dihydro-10-hydroxycarbamazepine breakdown in the GC-MS injector port.

During the investigation of aviation accidents, postmortem specimens from accident victims are submitted to the Federal Aviation Administration's Civil Aerospace Medical Institute (CAMI) for toxicological analysis. A case recently received by CAMI screened positive for the anticonvulsant medication carbamazepine (CBZ; Tegretol(®)) by gas chromatography-mass spectrometry (GC-MS). The CBZ found during this routine screening procedure was subsequently confirmed using a CBZ-specific GC-MS procedure. It was later discovered that the accident victim had been prescribed oxcarbazepine (OXCBZ; Trileptal(®)). OXCBZ is structurally similar to CBZ and is metabolized by cytosolic enzymes in the liver to an active metabolite, 10,11-dihydro-10-hydroxycarbamazepine (DiCBZ). It was determined that the CBZ initially found in this case was present due to the thermal breakdown of DiCBZ in the GC-MS injector port. In the current study, this conversion was investigated and the percentage of CBZ formed at various injector port temperatures was determined. Additionally, these three compounds were quantified in nine fluid and tissue specimens from the case in question. Liquid chromatography-mass spectrometry was also incorporated to further demonstrate the absence/presence of CBZ in these samples.

Radiological analysis of hand and foot injuries after small aircraft crashes.

Medico-legal investigation of fatal aviation accidents should contribute to the reconstruction of the accident in addition to providing the usual information about cause and manner of death. In cases with more than one fatality, the question of who was flying the plane at the time of the crash may need to be answered. In such cases the identification of "control injuries" plays an important role. This study aims to investigate whether specific patterns of skeletal hand and foot injuries could assist in the identification of the pilot. The analysis of radiological investigations of hands and feet of 27 fatalities from 18 accidents showed that foot injuries are more frequent than hand injuries in pilots and passengers, dislocations of feet were more frequent in passengers, and right-sided injuries were more frequent in pilots. Injuries of the distal parts of the hand were slightly more frequent in the pilot group. The limited numbers in the study do not allow definitive conclusions and further investigations are needed. However, the study yields interesting results and shows that radiological examination should be included in the medico-legal air crash investigation.

New European Union Approach to Civil Aviation Accident Investigation and Prevention

S INCE the early 20th century, safety has been a constant byword in aviation development [1]. Data published by the ICAO (International Civil Aviation Organization) show that the safety of aviation has substantially improved from 1945 onward [2]. In 2009, according to the International Association of Transport Airlines, the western-built hull-loss accident rate was one accident per 1.4 million flights. This means that if youwere to take a flight everyday, the odds are that you could go 3859 years without an accident. However, with air traffic steadily increasing, accidents do happen, despite the best efforts of regulators and industry. The investigation of accidents and the determination of the causes and contributing factors, aswell as producing recommendations for preventing similar situations in the future, are essential elements in the process of continuous safety improvement. For this reason among others, this transport mode retains a globally low accident rate [3–8]. To make flying safer, independent investigation into accidents is essential, as it is the surest way of identifying the causes of an accident and answering the fundamental questions of what really happened and what can be done to prevent similar incidents in the future [9–11].

Information Processing of the Broken Tape of Flight Data Recorder

For the requirement of the department for aviation accident investigation, a computer information system of processing the broken tape of flight data recorder has been designed. The main principles of the system are that magnetic track images are first preprocessed using image processing techniques, furthermore, the position coordinates of tracks are obtained using image recognizing techniques, finally, the data corresponding to track coordinates are obtained by encoding the track coordinates using the serial-parallel scanning method that is specially designed. The accurate ratio of automatic encoding is 99.3%. The times of automatic encoding are reduced to proximate 5 seconds from about 4 hours of two operators for one frame track image. This system is significant for aviation accident investigations.

Learning from accidents: Updates of the European regulation on the investigation and prevention of accidents and incidents in civil aviation

Civil aviation has a longstanding tradition of investigating accidents and reporting incidents, which contributes to making aviation one of the safest forms of transport. To make flying safer, independent investigation into accidents is essential as it the surest way of identifying the causes of an accident and answering the fundamental questions “What really happened?” and “What can be done to prevent similar incidents in the future?”. The obligation to investigate accidents is enshrined in the Chicago Convention of 1944. Recognizing the importance of accident investigation, the European Union adopted Council Directive 94/56/EC establishing the fundamental principles governing the investigation of civil aviation accidents and incidents and later on Directive 2003/42/EC on occurrence reporting. They both significantly contributed to harmonization of accident prevention. But with air traffic steadily increasing, accidents do happen despite the best efforts of regulators and industry. The organization of the air transport sector is much more complex now than it was a decade ago. Today there is significant divergence in the investigating capacity of the EU Member States compared to 1994. Furthermore nowadays investigating air accidents take new kinds of expertise and more resources than a decade ago. At the same time there is a new legal and institutional environment in Europe derived from the adoption of European aviation safety rules. Also the organizational set-up has changed substantially with the establishment of the European Aviation Safety Agency (EASA), which is now responsible for certifying aircraft in the EU. The EU rules on investigating air accidents need to be updated to reflect the current realities of Europe's aviation market and the complexity of the global aviation industry. Accordingly, over the last few years the European Commission has been working on a Regulation on the investigation and prevention of accidents and incidents in civil aviation, with the intention of updating and replacing the existing Directive. With this new regulation the Commission aims to promote more efficient and independent inquiries into the causes of air accidents and also expects to strengthen the rights of the victims of air accidents. Today the end is in sight, once that the Commission and European Parliament have reached an agreement about the content and text of this new regulation. Reasons behind this new regulation are presented in this paper together with a detailed explanation of its main contents, an assessment of their impact and their expected benefits.

The Screening of Forensic Blood, Urine, and Tissue Specimens for Xenobiotics Using Ion-Trap Liquid Chromatography-Tandem Mass Spectrometry

During the investigation of aviation accidents, postmortem specimens from accident victims including blood, urine, and tissue are submitted to the Federal Aviation Administration's Civil Aerospace Medical Institute (CAMI) for toxicological analysis. The first, and perhaps most important, step in the analysis process is the initial screening of biological specimens for illicit, medically prescribed, and over-the-counter compounds that may be present and potentially be a cause and/or factor in the accident. Currently, our general unknown screening (GUS) procedure involves, in part, both gas chromatography-mass spectrometry (GC-MS) and liquid chromatography (LC) with both diode-array detection (DAD) and fluorescence detection. Both GC and LC techniques have inherent limitations that prevent the detection of certain types of compounds. The decreased specificity and sensitivity of LC-DAD has been an impediment to the existing GUS procedure. Therefore, our laboratory set out to develop and validate an LC-MS-MS procedure that is superior to LC-DAD. The limits of detection of 359 forensically important xenobiotics have been established following solid-phase extraction from whole blood and analysis by LC-MS-MS. Although whole blood was used as the matrix during instrument validation, the method has been successfully applied to both forensic urine and tissue specimens as well.

Vitreous Fluid and/or Urine Glucose Concentrations in 1335 Civil Aviation Accident Pilot Fatalities*

During aviation accident investigations, vitreous fluid and urine samples from pilot fatalities are analyzed for glucose and blood for hemoglobin A(1c) (HbA(1c)) to monitor diabetic pilots and to discover other pilots with undiagnosed/unreported diabetes. The prevalence of elevated glucose concentrations in fatally injured pilots was evaluated by searching the Civil Aerospace Medical Institute's Toxicology Database for the period 1998-2005. Out of 1335 pilots involving 363 vitreous fluid, 365 urine, and 607 vitreous fluid and urine analyses, 43 pilots had elevated glucose in vitreous fluid (>125 mg/dL) and/or in urine (>100 mg/dL). Of the 20 pilots whose blood samples were analyzed, nine had >6% HbA(1c)--four were known diabetics, and five were unknown diabetics. Urinary glucose levels were elevated in all 13 known hyperglycemic pilots. A considerable number of pilots (30 of 43) had elevated glucose and HbA(1c) (5 of 20), suggesting undiagnosed/unreported diabetic conditions.

The Central Role of Principal Issues in Aviation Accident Investigation

Major aviation accident investigations conducted by the National Transportation Safety Board involve uncertainties in cause, complexities in avenues of inquiry, multiple stakeholders, and no obvious solution path. As a result, investigations can be difficult, time consuming, and resource intensive. This paper will describe a project being conducted at NTSB to develop an approach to accident investigation that takes into consideration the complexities, uncertainties, and nonlinearities in accident investigation. The paper concludes by discussing the implications of this approach for the typical linear, structured approaches to accident investigation.

A abordagem sociotécnica na investigação e na prevenção de acidentes aéreos: o caso do vôo RG-254

Este artigo apresenta estudo de caso do acidente ocorrido com o vôo RG-254 da Varig, em setembro de 1989. Partindo de informações de investigações oficiais, publicações, material audiovisual, entrevistas com envolvidos no acidente e especialistas em segurança de vôo, os autores re-analisam o acidente com enfoque sociotécnico referenciado na teoria ator-rede e no conceito de acidente "normal". O texto apresenta novo entendimento para a investigação de acidentes na aviação criticando a tradicional repartição de causas entre os chamados fatores "humanos", "técnicos" e "operacionais" e sugere aplicação do conceito de multicausalidade que não se restringe à mera listagem de "fatores contribuintes", mas que analisa as relações entre atores-redes envolvidos no sistema de aviação em que ocorreu o acidente. O acidente do RG-254 é descrito como sintoma do rompimento de relações entre os atores que atuam no sistema.

Quantitative Determination of Sildenafil (Viagra®) and Its Metabolite (UK-103,320)in Fluid and Tissue Specimens Obtained from Six Aviation Fatalities*

During the investigation of aviation accidents, postmortem samples from victims are submitted to the Federal Aviation Administration's Civil Aerospace Medical Institute for toxicological analysis. This report presents a rapid and reliable method for the identification and quantitation of sildenafil (Viagra) and its active metabolite, UK-103,320. This procedure utilizes sildenafil-d(8) as an internal standard for more accurate and reliable quantitation. The quantitation of sildenafil and UK-103,320 in postmortem fluid and tissue specimens obtained from victims from six separate aviation fatalities is described. The method incorporates solid-phase extraction and liquid chromatography-tandem mass spectrometry (LC-MS-MS) and MS-MS-MS utilizing an atmospheric pressure chemical ionization ion trap MS in the positive chemical ionization mode. Solid-phase extraction provided an efficient sample extraction yielding recoveries ranging from 79 to 88%. The limits of detection for sildenafil and UK-103,320 were 0.39 and 0.19 ng/mL, respectively. The linear dynamic range for both compounds was 0.78-800 ng/mL. The current method proved to be simple, accurate, and robust for the identification and quantitation of sildenafil and UK-103,320 in postmortem fluids and tissues.

Failures in military aircraft

The severe operating conditions for components in military aircraft lead to a wide range of failure modes and introduce many factors which can influence those failures. As a result, the accident investigator or failure analyst may need to explore issues more widely than might be the case with systems operating in more benign or controlled environments. Complicating factors are the increasing age of military fleets, as a result of the rising cost of fleet replacement, increasing reluctance or inability of OEMs to provide impartial technical support, and the widespread use of materials and processes near their stress and environment limits, in an effort to achieve that last little bit of operational performance. DSTO provides failure analysis and accident investigation support to the Australian Defence Force (ADF) and has developed a strong capability as an impartial adviser on aviation failures, in part because of the absence of major manufacturer support, but also because of a long history of ADF self-reliance. This presentation provides a brief overview of military aviation accident investigation and failure analysis in Australia, and then uses two recent examples to illustrate a fundamental tenet of failure analysis i.e., “all damage must be explained”. The examples also illustrate how a full investigation can be required, even in cases where operational factors appear to be the likely principal factors. The first example is drawn from an accident investigation into the collision of two ADF helicopters, which demanded one of the most technically challenging investigations DSTO has ever undertaken, and one in which ultimately, by developing new methods, it was possible to provide a remarkable level of certainty about the event. The aspect chosen as an example illustrates the approach adopted to resolve some apparently anomalous features in the wreckage. Resolution of these features drew heavily on an understanding developed over many years of the failure modes of carbon-fibre composite materials and components. The second example illustrates the growing emphasis on taking a “whole system” view, and relates to a serious incident in which fuel in a tank was ignited as a result of a wiring system failure. The investigation illustrates the problem of resolving failure sequences when a number of possible scenarios need to be assessed. In this case, earlier development, over a number of years, of a capability for assessment of wiring system failures paid off, when a very detailed investigation opened up a wide range of wiring system issues elsewhere in the fleet.

Ethanol formation in unadulterated postmortem tissues

During the investigation of aviation accidents, postmortem samples obtained from fatal accident victims are submitted to the FAA’s Civil Aerospace Medical Institute (CAMI) for toxicological analysis. During toxicological evaluations, ethanol analysis is performed on all cases. Many species of bacteria, yeast, and fungi have the ability to produce ethanol and other volatile organic compounds in postmortem specimens. The potential for postmortem ethanol formation complicates the interpretation of ethanol-positive results from accident victims. Therefore, the prevention of ethanol formation at all steps following specimen collection is a priority. Sodium fluoride is the most commonly used preservative for postmortem specimens. Several studies have been published detailing the effectiveness of sodium fluoride for the prevention of ethanol formation in blood and urine specimens; however, our laboratory receives blood or urine in approximately 70% of cases. Thus, we frequently rely on tissue specimens for ethanol analysis. The postmortem tissue specimens received by our laboratory have generally been subjected to severe trauma and may have been exposed to numerous microbial species capable of ethanol production. With this in mind, we designed an experiment utilizing unadulterated tissue specimens obtained from aviation accident victims to determine the effectiveness of sodium fluoride at various storage temperatures for the prevention of microbial ethanol formation. We found that without preservative, specimens stored at 4 °C for 96 h showed an increase in ethanol concentration ranging from 22 to 75 mg/hg (average 42±15 mg/hg). At 25 °C, these same specimens showed an increase ranging from 19 to 84 mg/hg (average 45±22 mg/hg). With the addition of 1.00% sodium fluoride, there was no significant increase in ethanol concentration at either temperature.

FRENCH LEGAL SYSTEM FOR SAFETY CONCERNING AVIATION ACCIDENT

Concerning the legal response to accidents in a large-scale system, how to balance the appropriate measures for the investigation for fact fiding and the legal sanctions is the point at issue. In this article, we discuss the legal system of aviation accident investigation in France, and investigate the duties and competence, institutions, the number of investigation, staffs, the process of investigation of BEA, GTA, and DGAC. BEA has the investigation system with expertise from various secotrs. GTA has the special police organization of aviation accidents, and cooperate in the investigation, for example, on the exchange of evidence with BTA. Through comparative analysis of Japan, the United States, and France, we analyze the options of legal systems for aviation accidents, and present the example of views to choose them. Language: ja

Maintenance-Related Accidents: A Comparison of Amateur-Built Aircraft to all Other General Aviation

In a previous study, Goldman, Fiedler, and King (2002) found that a little over 7% of the 1983–1999 National Transportation Safety Board general aviation (GA) accident investigation reports listed at least one maintenance-related error as the primary cause or factor. Amateur-built aircraft accounted for an average of 14% of these same general aviation maintenance-related accidents, even though amateur-built aircraft account for less than 3% of the GA hours flown. Using the 1983–2001 National Transportation Safety Board GA accident investigation reports, this study compares maintenance-related accidents for amateur-built and all other GA aircraft by type of maintenance procedure, airframe hours, phase of operation, and time since last inspection. For this 18-year sample of maintenance-related accidents, 413 involved amateur-built aircraft, and 3,262 involved all other types of GA aircraft. General aviation flight hours continue to increase: Amateur-built aircraft flight hours, alone, increased from under 300,000 hours in 1993 to about 900,000 in 2000.

US LEGAL SYSTEM FOR SAFETY CONCERNING AVIATION ACCIDENT

In the United States, the National Transportation Safety Board (NTSB) conducts aviation accident investigation to determine the probable causes and prevent recurrences. NTSB adopts the party system, in which NTSB integrates expert knowledge by involving parties to the investigation. NTSB also issues effective safety recommendations and supports victims and their families. In the US, criminal prosecution is virtually nonexistent in the case of aviation accidents, however, punitive damages (civil liability) and heavy civil penalties (administrative sanctions) substitute as sanctions against airlines and manufacturers. It is hoped that a debate will take place in Japan over the improvement of the framework for investigating aviation accidents and for pursuing the liability of those responsible. Language: ja

Forensic Radiology: Response to the Pentagon Attack on September 11, 2001

HomeRadiologyVol. 223, No. 1 PreviousNext EditorialForensic Radiology: Response to the Pentagon Attack on September 11, 2001H. Theodore Harcke, Joseph A. Bifano, Kelly K. KoellerH. Theodore Harcke, Joseph A. Bifano, Kelly K. KoellerAuthor Affiliations1From the Department of Radiologic Pathology, Armed Forces Institute of Pathology, Washington, DC (H.T.H., K.K.K.), and 436th Medical Group/SGSAR, Dover Air Force Base, Del (J.A.B.). Received November 20, 2001; accepted November 24. Address correspondence to H.T.H., Department of Medical Imaging, Alfred I. duPont Hospital for Children, 1600 Rockland Rd, Wilmington, DE 19803 (e-mail: [email protected]).H. Theodore HarckeJoseph A. BifanoKelly K. KoellerPublished Online:Apr 1 2002https://doi.org/10.1148/radiol.2231011850MoreSectionsFull textPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked In References 1 Arlington National Cemetery. Tomb of the Unknowns at Arlington National Cemetery. Available at: www.arlingtoncemetery .org/visitor_information/tomb_of_the_un knowns.html.. Accessed December 27, 2001. Google Scholar2 Mulligan ME, McCarthy MJ, Wippold FJ, Lichtenstein JE, Wagner GN. Radiologic evaluation of mass casualty victims: lessons from the Gander, Newfoundland, accident. Radiology 1988; 168:229-233. Link, Google Scholar3 Lichtenstein JE, Madewell JE, McMeekin RR, Feigin DS, Wolcott JH. Role of radiology in aviation accident investigation. Aviation Space Environ Med 1980; 51:1004-1014. Medline, Google Scholar4 Armed Forces Institute of Pathology. Armed Forces Repository of Specimen Samples for the Identification of Remains: repository history. Available at: www.afip.org/Departments /oafme/dna/history.htm. 2001. Accessed November 15. Google Scholar5 Smith BC. Introduction to DNA analysis. Forens Odontol 2001; 45:229-235. Google ScholarArticle HistoryPublished in print: Apr 2002 FiguresReferencesRelatedDetailsCited ByInternational Journal of Legal Medicine, Vol. 134, No. 4Forensic Imaging, Vol. 23Journal of Forensic Radiology and Imaging, Vol. 12Forensic Science International, Vol. 278Journal of Forensic Radiology and Imaging, Vol. 3, No. 2Journal of Forensic Sciences, Vol. 58, No. 4Forensic Science, Medicine, and Pathology, Vol. 8, No. 3The Egyptian Journal of Radiology and Nuclear Medicine, Vol. 43, No. 2Radiography, Vol. 17, No. 3Journal of Trauma: Injury, Infection & Critical Care, Vol. 65, No. 3Journal of Forensic Sciences, Vol. 1Journal of Forensic Sciences, Vol. 0, No. 0Recommended Articles RSNA Education Exhibits RSNA Case Collection Vol. 223, No. 1 Metrics Altmetric Score PDF download

Formation of an Interfering Substance, 3,4-Dimethyl-5-Phenyl-1,3-Oxazolidine, During a Pseudoephedrine Urinalysis

During fatal aviation accident investigations, biosamples from the victims are submitted to the FAA Civil Aeromedical Institute (CAMI) for drug analysis. In the process of one such analysis by CAMI, an unknown substance was found in a urine sample. Simultaneous screening by thin layer chromatography (TLC) and gas chromatography/FID (GC/FID) suggested the presence of pseudoephedrine. A subsequent routine confirmation analysis of a separate urine aliquot by GC Fourier transform infrared (GC/FTIR) and GC mass spectrometry (GC/MS) indicated that the retention times of the unknown substance matched with those of pseudoephedrine. However, its infrared and mass spectra were different--the -OH and -NH groups were missing, a C-O-C group was present, and the molar mass was 12 atomic mass units (amu) more than that of pseudoephedrine. A subsequent literature search suggested that ephedrine-like amines react with aldehydes to form oxazolidines. Therefore, the 12-amu increase could be accounted for by condensation of pseudoephedrine with formaldehyde. Since this aldehyde is present in various grades of methanol and ethyl acetate, and these solvents were used during the solid-phase extraction, 3,4-dimethyl-5-phenyl-1,3-oxazolidine was synthesized by using (+)-pseudoephedrine HCl and formaldehyde. The analytical findings of the synthesized compound were consistent with those of the unknown interfering substance, confirming that it was the oxazolidine. Aldehyde contaminants in solvents or specimens can transform drugs of interest and may result in misidentification of a compound originally present in specimens. Therefore, chemicals used in analyses should be of the highest available purity, and a multi-analytical approach should be adopted to maintain a high degree of quality assurance.

Effects of Modality on Interrupted Flight Deck Performance: Implications for Data Link

Externally-imposed tasks frequently interrupt ongoing task performance in the commercial flight deck. While normally managed without consequence, basic research as well as aviation accident and incident investigations show that interruptions can negatively affect performance and safety. This research investigates the influence of interruption and interrupted task modality on pilot performance in a simulated commercial flight deck. Fourteen current commercial airline pilots performed approach scenarios in a fixed-base flight simulator. Air traffic control instructions, conveyed either aurally or visually ( via a data link system) interrupted a visual task (obtaining information from the Flight Management System) and an auditory task (listening to the automated terminal information service recording). Some results confirm the hypothesized performance advantage of cross-modality conditions, more compelling nature of auditory interruptions, and interruption-resistance of auditory ongoing tasks. However, taken together, results suggest the four interaction conditions had different effects on pilot performance. These results have implications for the design of data link systems, and for facilitating interruption management through interface design, aiding, and training programs.

Improving aviation accident research through the use of video

The investigation and analysis of aviation accidents is a critical aspect of aviation safety and a major tool for aviation system improvement. The National Transportation Safety Board is charged with the responsibility of determining the probable cause of aviation accidents, identifying contributing factors, and making recommendations for changes to equipment or procedures as a result of their investigations. The intent is to identify what went wrong and prevent its recurrence -- to learn from the errors of others and, thus, save lives and property.

The National Transportation Safety Board and the investigation of civil aviation and transportation accidents.

This article is a lucid account of the mission and activities of the National Transportation Safety Board. The concept of the Go-Team or ready team of specialists available on a 3-hour basis to accident scenes is described, as is the Human Factors Investigation. General aviation accident investigations are also discussed.