Aviation Accident Investigation Research Articles

ШЛЯХИ ІНТЕГРАЦІЇ ЛЬОТНОЇ ПРИДАТНОСТІ В СТРУКТУРУ УПРАВЛІННЯ БЕЗПЕКОЮ ПОЛЬОТІВ ЦИВІЛЬНИХ ПОВІТРЯНИХ СУДЕН

Based on the analysis of the legal framework in force inUkraine, the fact of creating conditions for resolving most problems in the aviation industry is stated. It has been established that the effectiveness of their solution directly determines the state of affairs in the field of ensuring flight safety, therefore, the improvement of the current system for maintaining the airworthiness of Ukrainian aircraft is a priority for all participants in the aviation market. The actual level of flight safety in operation is determined by the functioning and interaction of the elements of the aviation transport system, is laid down during the development, certification, production and is implemented during the operation of aircraft. Therefore, this task can be successfully solved only at the state level. The state lays down the legal regulatory framework in the field of aviation, creates a system for managing the safety of civil aircraft flights, determines the authorities and rules for control and supervision, investigation of aviation accidents and incidents. Flight safety is defined as the state in which the risks associated with aviation activities related to the operation of aircraft or directly supporting such operation are reduced to an acceptable level and controlled. Ensuring flight safety requires certain management decisions, such as the inclusion of the necessary units in the structure of the airline, training and training of personnel, maintaining the airworthiness of aircraft, monitoring and analyzing the state of flight safety, etc. Decision-making in the context of safety actions is a compromise between the desire to achieve a certain result in obtaining a useful product, taking into account savings and ensuring the safety of the airline. The introduction of the concept of an acceptable (acceptable) level of risk reflects the goals and expected results of the oversight authority in the civil aviation industry, the operator or other performer in the flight support system, which must be achieved in the field of safety. An important factor in ensuring the high efficiency of modern aircraft airworthiness systems is the availability of such important elements as airworthiness monitoring systems and programs for monitoring the level of aviation equipment reliability. The connection between the process of assessing and monitoring the reliability of aviation equipment and the processes of flight safety management has been established. It is shown that by improving such elements of the aircraft airworthiness maintenance system as: the airworthiness monitoring system and the program for monitoring the level of reliability of aviation equipment, we solve a number of problems and obtain additional information about the reliability of aviation equipment, which plays an important role in the implementation of management processes. flight safety.

Major aviation accident investigation methodologies used by ITSA members

The International Civil Aviation Organization (ICAO) Annex 13 framework for aviation investigation is longstanding and well developed but does not require or audit use of methodologies for investigation analysis, including research literature safety/accident models (SAMs). Government Safety Investigation Authority (SIA) websites rarely mention methodologies. Limited published research engages directly with SIAs. A research/practice gap has been suggested.To address ICAO, SIA and research gaps, this qualitative multi-case study examines SIA use and documentation of methodologies for accident analysis. Nine of seventeen SIA members of the International Transportation Safety Association (ITSA) that investigate aviation accidents agreed to participate and provided written answers to our research questions, relevant internal documentation, and exemplar investigation reports.Our key findings are that participant SIAs have augmented ICAO requirements internally by their use of methodologies but that this usage was generally not obvious in published investigation reports and other SIA website material. It also varied significantly among the participants. All participant SIAs reported use of multiple methodologies, sometimes in the same investigation. Explicitly reported SIA methodology usage included: six Reason-based, six Rasmussen-based, three ‘recent systemic’, five ‘BowTie’, five ‘bespoke’, and seven using various other methodologies like ‘SHELL’.The industry impact of this qualitative research is hoped to be significant by being shared with participant SIAs unaware of each other’s practice, enabling consideration of different options. It can inform additional aviation SIAs, ICAO, air safety investigators, and other high-risk industry regulators and investigators. Safety researchers may be better placed to develop SAMs with greater practical industry relevance.

Key Safety Rules During Safety Investigation – On The Example of Two International Organisations

The aim of the work is to look at the most important safety principles during the investigation of aviation accidents. Two international organisations dealing with civil aviation were selected to present the topic. The most important legal acts in the field of investigation of aviation occurrences issued by these organizations were analyzed. The most important safety principles were selected from these acts and then compared.

FORENSIC SCIENCE POSIBILITIES WITHIN THE FRAMEWORK OF CRIMINAL PROCEEDINGS WHILE AVIATION ACCIDENTS

The article analyzes conceptual framework for specific expertise use while conducting forensic examinations related to aviation accidents. Foundations of such activities have been developed. In particular, it is stressed that effective implementation of criminal proceedings depends to a greater extent on the results of expert researches, especially if it is a complex process of aviation accident investigation. Similarly, the quality of expert researches depends on organization of research institutes activity regarding creation of effective methodologies for the analysis of different physical evidence obtained at the aviation accident scene. By using specific expertise, employees of forensic institutions independently or jointly with employees of other specialized institutions, law enforcement agencies, specialists-doctors can advance methods of expert research and, consequently, combat criminal offenses or ensure timely detection of the offender whereabouts.
 The possibility of expanding the compulsory appointment of forensic examinations in aviation accident criminal proceedings is being considered. Factual and legal grounds for the appointment and conduct of a forensic examination in this case are outlined.
 Scientifically substantiated recommendations on directions of counteraction to attacks on the aviation industry facilities are suggested, as well as the algorithm for developing innovations for the needs of law enforcement agencies is proposed.
 It is emphasized that the use of forensic science possibilities within the framework of a criminal proceeding related to aviation accidents is quite influential, since it helps to perform a multidisciplinary professional analysis of evidence, facilitate organization of forensic experts’ work, protect the rights of citizens and contribute to fulfillment of justice tasks in general.

Control and Monitoring Vehicle using Arduino and GSM Module

The Black Box control and monitoring system for vehicles concept is derived from the aviation industry, a flight recorder, colloquially known as a black box; although it is now orange-colored for easy search, is an electronic recording device placed in an aircraft for the purpose of facilitating the investigation of aviation accidents and incidents. With the advancement in technology and cost coming down, in our project we attempt to build similar device for our cars, not only this device will help us in post-crash analysis but also it will help us in quicker emergency rescue operation. Our research has been targeted towards building an integrated system for emergency rescue services in the event of a road accident. The purpose of the project is to find the accident location using GPS module and to send this location by means of sending a message using GSM module to the pre-coded number. This system is usually placed inside the vehicle. It reduces the time it takes for emergency rescue to arrive at the crash location.

Profesiini stresory v diialnosti pilotiv tsyvilnoi aviatsii [Professional stressors of civil aviation pilots’ activity

Background: Analysis of aviation accident investigations indicates that one of the main causes of accidents is a decrease in the level of stress resistance of the crew during extreme flight situations, which in turn can lead to a crash. The study of the problem of the negative impact of stressors on the effective operation of the flight crew, indicates that there is a need to form stress resistance in future pilots of civil aviation in the training process. This quality will reduce the threat to flight safety due to human error. Purpose: To characterize publications that actualize the issues of professional stressors in the activities of civil aviation pilots, because their activities are constantly accompanied by many specific stressors, most of which are long-term. Materials and Methods: In the process of research general scientific methods were used – abstract-logical, theoretical generalization, comparison, analysis and synthesis, system analysis. Results: The problem of the impact of stress on the professional activities of pilots is considered, which in modern conditions becomes especially relevant, because the number of air traffic is growing every year. The main four types of general stress that occur in professional flying, as well as the consequences it leads to, are analyzed. Groups of stressors acting on pilots during professional activity are considered and analyzed. An explanation of the psychological mechanisms (aggression, irritability, dogmatism and frustration) that may be involved in trying to cope with a stressful situation. Conclusions: The practical importance for further research in improving the training of future pilots of civil aviation to reduce the impact of the human factor on flight safety was substantiated, as evidenced by the direct impact of stressors on flight safety and the number of extreme flight situations.

Spatial Disorientation Impact on the Precise Approach in Simulated Flight.

BACKGROUND: The risks posed by flight illusions impacting pilot spatial orientation have been determined as a safety concern from numerous past aviation accident investigations. Early demonstration of the adverse effects of flight illusions on spatial orientation would be desirable for all pilots, especially at the early training stages to deeply embed good practices for onset detection, flight correction, and response mitigation.METHOD: Simulated flights on a disorientation demonstrator were performed by 19 pilots for 3 conditions: no illusion, somatogyral illusion, and Coriolis illusion. An objective approach for assessing pilot performance degradation due to flight illusions can be done by using a defined flight profile: instrument landing system (ILS) flight trajectory during final instrument approach. Deviations to the standard ILS profile were recorded to measure and evaluate the influence of the demonstrated flight illusion on pilot performance.RESULTS: The results show the expectation that the smallest deviations from the ideal trajectory are caused by pilot tracking error (no illusion), and the greatest deviations are caused by the Coriolis illusion. Results demonstrated a statistically significant effect of illusions on performance. According to statements from pilots, training for flight illusion response is essential to complement training in aircraft regulations and aerodynamics.DISCUSSION: Measuring the influence of vestibular illusions on flight profile with a simulator allows assessment of individual differences and improvement of pilot performance under the conditions of no illusion, the somatogyral illusion, and the Coriolis illusion.Boril J, Smrz V, Blasch E, Lone M. Spatial disorientation impact on the precise approach in simulated flight. Aerosp Med Hum Perform. 2020; 91(10):767775.

A Study on Strengthening the Independence of the Aviation and Railway Accident Investigation Board in South Korea

항공기의 사고 발생률은 타 교통수단과 비교하면 매우 낮은 편이지만, 항공기는 공중으로 비행하므로 비행 도중에 사고가 발생하면 추락할 위험이 크다. 또한 많은 부품으로 구성되어 있어서 사고발생 원인을 입증하기는 매우 어려운 실정이다. 따라서 항공사고조사는 위험요인을 판별, 위험정도를 평가, 안전권고의 근거를 제공하고, 사고와 관련 종사자들에게 안전에 대한 메시지를 전달하기 위해서는 객관성있고 공정성이 뒷받침 되어야 한다. 항공사고조사기관은 항공안전 조직 및 기능측면에서 전문성 강화를 위한 독립성을 국제적 관점에서 모색하였다. 항공조사 기관이 행정부처에 소속되어 있지만 구성 및 기능측면의 독립성에 대해 분석하였다. 따라서 항공·철도사고조사위원회의 독립을 제고하기 위하여 대통령 직속기관의 ‘국가항공·철도안전위원회’를 설립하여 법적으로나 예산, 인사 등 구성상 및 기능적 측면에서 독립적으로 조사할 수 있도록 개선해야 한다.The accident rate for aircraft is very low compared to other transportation modes, but in the event of an accident during the flight, there is a high risk of falling. In addition, it is very difficult to prove the cause of the accident because it consists of many parts. Therefore, aviation accident investigation should be objective and fair in order to identify risk factors, evaluate risk levels, and offer a safety message to those involved in the accidents. The organization of aviation accident investigation sought independence from an international perspective to enhance its professionalism in terms of organization and function for aviation safety. Therefore, the Presidential Committee for National Aviation and Railway Safety needs to be established to strengthen the independence of the Aviation and Railway Accident Investigation Board in South Korea so that it can perform independent investigation in terms of composition and function, such as budget, personnel, and so on.

A Novel Underwater Location Beacon Signal Detection Method Based on Mixing and Normalizing Stochastic Resonance.

A flight data recorder (FDR) is an electronic recording device placed in an aircraft for the purpose of facilitating the investigation of aviation accidents. If an aircraft crashes into water, an underwater locator beacon (ULB), which is installed on the FDR, is triggered by water immersion, and emits an ultrasonic 10 ms pulse signal once per second at 37.5 kHz. This pulse signal can be detected by sonar equipment. However, the ULB signal only can be detectable 1–2 kilometers from the surface in normal conditions. Stochastic resonance (SR) is a rising theory in the field of weak signal detection. The classical stochastic resonance limits state that the input must be small-parameter and the sampling frequency must be 50 times higher than the signal frequency. It cannot be applied to the ULB signal detection. To resolve this problem, this paper presents a novel approach named mixing and normalizing stochastic resonance (MNSR). By mixing the ULB signal and normalizing SR system parameters, MNSR provides a new way to detect weak ULB signal. Meanwhile, we propose the parameters adjustment method of MNSR. We prove the effectiveness through numerical simulation. An experiment in a tank is employed to verify the practicability of this method.

Мethod of automated development of solutions for special cases in flight

The article develops a method of automated decision making in the framework of the creation of DSS air traffic controller. The method of automated decision-making for special cases in flight is being developed as one of the stages of information technology for the creation of decision support system for air traffic controllers. This is necessary to help decide on the option of terminating the flight in the event of a special case in flight on the example of engine failure on the aircraft. The developed method involves the use of probabilistic programming technology. It includes: construction of a probabilistic hierarchical model of emergency based on the Bayesian network taking into account the factors influencing the decision-making process, creating a sample of examples for learning the model to improve future situations models on examples using the Bayesian learning paradigm, the choice of inference algorithm to obtain a probabilistic conclusion. The proposed method is implemented in the probabilistic programming system Figaro, which is free and available under an open source license. The program code is written in Scala. The set of training data was formed based on the results of the investigation of aviation accidents and catastrophes and contained fifty-two cases of forced landing at the aerodrome and on the site with different consequences. The learning process was learning the parameters of the model on the data and was performed on thirty- six examples. Other cases (sixteen) were used to test the prediction quality of the created model. The Bayesian learning paradigm is used to teach the model, which does not require a special learning algorithm and is performed using the inference algorithm. The Metropolis-Hastings approximation algorithm is used as the derivation algorithm. The developed method showed high accuracy of forecasting. The error between the actual result and the estimate obtained using the Bayesian network was 10%. Further research will be aimed at developing information technology for the creation of DSS air traffic controller for special cases in flight.

At the origins of the native medical aviation accidents study (to the 110th anniversary of the birth of A.G. Shishov)

The life and scientific path of Shishov Anatoly Grigoryevich - the founder of aviation medical avariology, the first chief of the Department of Aviation Medicine of the Military Medical Academy named after S.M. Kirov (1958-1965). A.G. Shishov is known for his work in the field of the study of causes, investigation and prevention of aviation accidents, professional selection of flight crew, medical and flight expertise, flight training simulators. A.G. Shishov justified the leading role of the «personal factor» in the development of aviation accidents. He introduced the practice of studying the psychophysiological state and individual characteristics of the personality of the pilot and increased the role of the aviation doctor in the investigation of aviation accidents to the status of a mandatory expert. A.G. Shishov developed an algorithm for the medical study of aviation accidents, incidents and erroneous actions of the flight crew, as well as a complex of medical measures for the prevention of accidents.

Pilot Posttraumatic Stress Disorder and Fatal Aviation Accidents

Abstract. The National Transportation Safety Board (NTSB) database was searched to identify fatal accidents in aviation related to trauma and stressor-related disorders in the United States and the medical requirements of aviation authorities were assessed. Between 2000 and 2015, eight pilots with a diagnosis of posttraumatic stress disorder (PTSD; of which two were aviation-related PTSDs) died in aviation accidents. These results indicate a minimum frequency of history of diagnosed PTSD in aviation fatalities to be 8 out of 4,862 fatal accidents (0.16%) in the United States. The guidance from aviation regulatory authorities is to medically assess pilots with a prior history of PTSD based on individual functional impairment and treatment response. The assessment of individual impairment would be significantly improved by the systematic data collection following aviation- and work-related traumatic events. It is also important for investigators to recognize the traumatization that occurs in aviation accident and incident investigations.

ORGANIZATIONAL AND LEGAL PRINCIPLES OF INVESTIGATION OF AVIATION DISASTERS

Objective: to determine the legal models for aviation accident investigation. To propose effective mechanisms of observing the rights and freedoms of a citizen and the interests of the state and legal entities in the investigation of aviation disasters. To offer author’s models of organizational support for the investigation of aviation disasters. Methods: the study was conducted using classical methods of scientific knowledge. With the help of the analysis method, the system elements of the legal mechanism for ensuring the rule of law in the investigation of aviation disasters are disclosed. With the help of the method of synthesis, variants of occurrence of situations of threats and dangers of a civilian aircraft during the flight task are considered. Results: according to the results of the study, mechanisms for effective law enforcement of aviation accident investigation were proposed. Identified and disclosed components of organizational support for the process of investigation of aviation disasters.

Two Aviation Accident Investigation Questionnaires for Passenger and Crew Survival Factors and Injuries.

Review of injuries resulting from aircraft accidents and analysis of their mechanisms have proved helpful in generating and implementing survival-related improvements. Ideally, such information should be correlated with seat belt type and use, as well as any brace position adopted. This information should be recorded and made publicly available to future researchers. Members of IBRACE have developed two questionnaires to assist accident / cabin-safety investigators to record this information in an integrated consistent manner. One questionnaire relates to the survivors and one to the deceased. IBRACE members hope that these questionnaires will assist the investigation of future aircraft accidents.Davies JM, Wallace WA, Colton CL, Yoo KI, Maurino M. Two aviation accident investigation questionnaires for passenger and crew survival factors and injuries. Aerosp Med Hum Perform. 2018; 89(5):483-486.

Transferring Aviation Practices into Clinical Medicine for the Promotion of High Reliability.

Aviation is a classic example of a high reliability organization (HRO)-an organization in which catastrophic events are expected to occur without control measures. As health care systems transition toward high reliability, aviation practices are increasingly transferred for clinical implementation. A PubMed search using the terms aviation, crew resource management, and patient safety was undertaken. Manuscripts authored by physician pilots and accident investigation regulations were analyzed. Subject matter experts involved in adoption of aviation practices into the medical field were interviewed. A PubMed search yielded 621 results with 22 relevant for inclusion. Improved clinical outcomes were noted in five research trials in which aviation practices were adopted, particularly with regard to checklist usage and crew resource-management training. Effectiveness of interventions was influenced by intensity of application, leadership involvement, and provision of staff training. The usefulness of incorporating mishap investigation techniques has not been established. Whereas aviation accident investigation is highly standardized, the investigation of medical error is characterized by variation. The adoption of aviation practices into clinical medicine facilitates an evolution toward high reliability. Evidence for the efficacy of the checklist and crew resource-management training is robust. Transference of aviation accident investigation practices is preliminary. A standardized, independent investigation process could facilitate the development of a safety culture commensurate with that achieved in the aviation industry.Powell-Dunford N, McPherson MK, Pina JS, Gaydos SJ. Transferring aviation practices into clinical medicine for the promotion of high reliability. Aerosp Med Hum Perform. 2017; 88(5):487-491.

Disastrous air crash and two investigations with different results

This case study is to analyse the catastrophe of Polish Air Force One, TU-154M aircraft on 10th of April 2010, near Smolensk North airfield, Russia. The catastrophe ended up in total destruction of the aircraft and death of all the passengers and crew on board. The results of the official investigations of the Russian Federation executed by the Interstate Aviation Committee and Poland executed by the Committee for Investigation of State Aviation Accidents are recalled, which found that the crash resulted due to pilot's errors. The evidence is presented showing faults in official examination proceedings and thus existence of grounds for possibility of drawing false conclusions. An academic investigation effort is undertaken to reconstruct the course of events during the last few seconds of flight of the TU-154M aircraft. The publicly available data, photographic evidence and circumstantial information have been analysed, which allowed pointing out a number of observations, which were not reliably explained by official reports scenarios. In view of that, execution of a new fully fledged repair investigation is recommended.

Disastrous air crash and two investigations with different results

This case study is to analyse the catastrophe of Polish Air Force One, TU-154M aircraft on 10th of April 2010, near Smolensk North airfield, Russia. The catastrophe ended up in total destruction of the aircraft and death of all the passengers and crew on board. The results of the official investigations of the Russian Federation executed by the Interstate Aviation Committee and Poland executed by the Committee for Investigation of State Aviation Accidents are recalled, which found that the crash resulted due to pilot's errors. The evidence is presented showing faults in official examination proceedings and thus existence of grounds for possibility of drawing false conclusions. An academic investigation effort is undertaken to reconstruct the course of events during the last few seconds of flight of the TU-154M aircraft. The publicly available data, photographic evidence and circumstantial information have been analysed, which allowed pointing out a number of observations, which were not reliably explained by official reports scenarios. In view of that, execution of a new fully fledged repair investigation is recommended.

비정밀접근절차 체크리스트 개발연구

After a thorough investigation of aviation accidents involving Korean national carriers both inside and outside of Korea and also after reviewing catastrophic events involving foreign carriers in Korea, we found numerous accidents that caused fatalities and serious personal injuries. Although the aircrafts involved were found to have no specific defects, many of the accidents were caused by the pilot's misjudgement according to previous studies. Our research is to find an new procedure to help the prevention of similar accidents by focusing particularly on CFIT accidents during the procedural operations of Non Precision Approach, Circling Approach and Visual Approach. Therefore, we emphasize the significance of this research on the development of the new checklist that will help achieve a safe and effective procedural operation for non precision approaches.

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.