Presented by : Sianturi, MBA Avi Mgt

NAME RANK

: B. R. PARDOMUAN SIANTURI, MBA AVI MGT : MAYOR TEK / 520232

DOB
UNIT PHONE MOBILE

: BANDUNG / 21 JUNI 1973

: DISLAMBANGJAAU : 8709254 / FAX 8714523 : 081319132662/083850900538

POSITION : KASIBINPALLAMBANGJA

ADDRESS : GEDUNG B-1 LT. 3 MABESAU

E-MAIL

: okkiesianturi95@yahoo.com

MILITARY COURSES AA U Sesarcabpa Teknik XI Susfam F27 dan C-130 Remotely Piloted Vehicle Operator Course, France Dikkualsus JMU F27 37th Qualified Aero Engineering Instructor Course, India SF260 Marchetti Mechanic Course, Singapore Sekkau 76 Targadik 49th Flight Safety and Accident Investigation Course, India Peace Support Operations Instructor Course Indonesian Military Landworthiness Inspector Course FORMAL EDUCATIONS SD 012 Tarakan SMPN I Tarakan SMAN 4 Medan Post Graduate (S2) RMIT Australia

1995 1996 1997 2000

2001 2001 2002 2004 2005

2008 2009 2009 1985 1988

1991 2007

Employment History
Skadron Teknik 021 Lanud Halim PK 1996 - 2000

Skadron Udara 2
Skadron Udara 17 Skadron Udara 2 Skadron Pendidikan 303 Wingdiktekkal Dislambangjaau

2000 - 2002
2002 - 2003 2004 - 2005 2005 - 2007 2008 - NOW

SCOPE
1. INTRODUCTION 2. PURPOSE OF INVESTIGATION AND INVESTIGATION 3. INITIAL FIELD INVESTIGATION 4. GATHERING EVIDENCE 5. PRESERVATION OF EVIDENCE

6. DETERMINATION OF ACCIDENT RECONSTRUCTION OF FLIGHT PATH

7. SAFETY PRECAUTIONS

SITE

AND

INTRODUCTION

CRASH SITE INVESTIGATION

The remains of a crashed aircraft are not necessarily mute, and may have a story to tell, if properly investigated.

INVESTIGATION
A PROCESS CONDUCTED FOR THE PURPOSE OF ACCIDENT PREVENTION WHICH INCLUDES THE GATHERING AND ANALYSIS OF INFORMATION, THE DRAWING OF CONCLUSIONS, INCLUDING THE DETERMINATION OF CAUSES AND, WHEN APPROPRIATE, THE MAKING OF SAFETY RECOMMENDATIONS.

DEFINITIONS

AIRCRAFT ACCIDENT An occurrence associated with the operation of an aircraft which takes place between the time any person boards the aircraft with the intention of flight until such time as all such persons have disembarked, in which:

A person is fatally or seriously injured as a result of direct contact with the aircraft or its jet blast. The aircraft sustains substantial damage, the aircraft is missing or completely inaccessible.

DEFINITIONS

Contd...

AIRCRAFT INCIDENT An occurrence other than associated with the operation which affects or could affect operations. FATAL INJURY Any injury that results in death of the accident.

an accident, of an aircraft, the safety of

within 30 days

DEFINITIONS

Contd...

SERIOUS INJURY An injury which is sustained by a person in an accident and which:

Hospitalization for more that 48 hrs, commencing within seven days from the date the injury was received. Fracture of any bone (except simple fractures). Lacerations which cause severe hemorrhage, nerve, muscle, or tendon damage. Injury to any internal organ. Second or third degree burns, or an burns affecting more than 5% of the body surface. Verified exposure to infectious substances or injurious radiation.

DEFINITIONS

Contd...

SUBSTANTIAL DAMAGE Damage or failure which adversely affects the structural strength, performance, or flight characteristics of the aircraft, and which would normally require major repair or replacement of the affected component.

TYPE OF INVESTIGATION

STATE / DOMESTIC INVESTIGATION

Done by country (NTSC, ATSB, etc)

IN-HOUSE INVESTIGATION

Done by special agency (PPKPU)

INTERNATIONAL INVESTIGATION

SCOPE OF INVESTIGATION

The extent of the investigation depends on the actual or potential consequences of the occurrence or hazard. The depth of investigation should be that which is required to clearly identify and validate the underlying hazards. Line between relevance and irrelevance is often blurred, so it needs better understanding.

INVESTIGATION METHOD
Used to identify and validate perceived safety hazards. Competent analysis. Effective communication. All above: INTEGRATED APPROACH.

INTEGRATED SAFETY INVESTIGATION METHODOLOGY

Hazard or occurrence notification and assessment Data collection process
Assess notification and decide to investigate or not

Identify events and underlying factors Reconstruct logical progression of occurrence events Analyze facts and determine findings regarding underlying factors and hazards

Sequence of events

Integrated investigation
Estimate risk and determine acceptability for each hazard Identify defenses that are missing or inadequate

Risk assessment process Defense analysis Risk control analysis Safety communication process

Identify and evaluate risk control options

Communicate safety message to stakeholders

INVESTIGATION TECHNIQUE
GOOD Investigators:
They are not afraid to be wrong. They will accept facts that are contrary to their present theory. They readily admit that they dont know everything. When they need help, they seek help. They listen to the other investigators. They dont necessarily believe them, but they listen to them.

QUALIFIED PEOPLE PROMPTNESS RESPONSIBILITY ORGANISATION THOROUGH ACCURATE OBJECTIVE COMPREHENSIVE REPORTING

INVESTIGATIVE ORGANISATIONS

The National Transportation Safety Board (NTSB). The Federal Aviation Administration (FAA). International Civil Aviation Organization (ICAO). The National Transport Safety Committee (NTSC). Panitia Penyelidik Kecelakaan Pesawat Udara (PPKPU).

PURPOSE OF INVESTIGATION AND INVESTIGATOR

PURPOSES
INITIAL TEAM TO ARRIVE AT THE CRASH SITE INITIAL COORDINATION AND ACTION PRESERVE PERISHABLE EVIDENCES SECURING THE CRASH SITE MAPPING & PHOTOGRAPHS THE CRASH SITE DETERMINE FACTS, CONDITIONS AND CIRCUMSTANCES OF THE ACCIDENT SITE LIAISON OF DISLAMBANGJAAU

INITIAL INVESTIGATION PROCESS

PREPARATION BEFOREHAND INITIAL FIELD INVESTIGATION REPORTING

PREPARATION
INITIAL COORDINATION INVESTIGATION EQUIPMENTS PERSONAL SURVIVAL ITEMS DIAGRAM & PLOTTING EQUIPMENTS WITNESS INTERVIEWING EQUIPMENTS EVIDENCE COLLECTION EQUIPMENTS PHOTOGRAPHIC EQUIPMENTS REPORT WRITING EQUIPMENTS TECHNICAL DATAS PERSONAL ITEMS

INITIAL ON-SITE ACTIONS

ESTABLISH A BASE OF OPERATIONS ESTABLISH LIAISON WITH AUTHORITIES SECURE AND PROTECT CRASH SITE DETERMINE WHAT HAS HAPPEN SO FAR CONDUCT AN ORGANISATIONAL MEETING ESTABLISH SAFETY RULES INITIAL WALKTHROUGH TAKE INITIAL PHOTOGRAPHS COLLECT PERISHABLE EVIDENCE INVENTORY WRECKAGE DIAGRAMING AND PLOTTING

INITIAL FIELD INVESTIGATION

ESTABLISH SAFETY RULES

CHEMICAL HAZARDS PRESSURE VESSELS MECHANICAL HAZARDS PYROTECHNIC HAZARDS HYGIENE HAZARDS MISCELLANEOUS HAZARDS

GATHERING EVIDENCE

GATHERING EVIDENCE
INITIAL SITE SURVEY INITIAL WALKTHROUGH PHOTOGRAPHIC & DIAGRAMMING RECORD ALL OBSERVATIONS COLLECT EVIDENCE

GATHERING EVIDENCE
Initial Site Survey
Use helicopter to orbit site at various altitudes. Aerial photography. Make a pass down the flight path vector to impact point. Conduct walk through inspection starting from impact point.

GATHERING EVIDENCE
Initial Walkthrough
Locate all major components (TESTED) Tag and identify all possible parts. DO NOT move wreckage unless necessary. Advice supplementary personnel. Make thorough attempt to locate FDR. Record objects that are not a part of aircraft.

GATHERING EVIDENCE
Record all observations in a Tape Recorder & Video Camera. Questioning witnesses.

GATHERING EVIDENCE
Fluid samples (Fuel, Oil, Hydraulic, etc). Loose papers, maps and charts. Evidence of icing. Runway condition. Switch positions and instrument readings. Control surface and trim tab positions. FDRs and CVRs. Ground scars.

TYPES OF EVIDENCE
CRITICAL TIME EVIDENCE:
SAMPLES.

FIRE PATTERN.
LIGHT BULBS.

WITNESSES.

RETRIEVABLE DATA:
CSFDR. AC LOADING RECORDERS. HEAD-UP DISPLAY VIDEOS.

AC VIDEO TAPE RECORDER.

PERSONAL RECORDERS.

FLUID SAMPLING
Use appropriate containers
Fluid container compatibility

Aircraft
Fuel Oil (Each engine) Hydraulic fluid (Each system)

Servicing Equipment
Impound until samples taken Take atleast two samples
One for investigation team One for immediate analysis

WITNESSES
VARIES WITH THE ACCIDENTS. VITAL IN SOME CASES.

DEFERENTIATE BETWEEN WHAT THE WITNESS SAY AND THE FACT.

INTERVIEW NOT INTEROGATION.

WITNESSES
COMMON ERRORS
LACK GOOD INTERVIEWING SKILLS.

TEND TO INTERROGATE THAN INTERVIEW.

INTERRUPT. DONT LISTEN TO THE ANSWERS.

HUMILIATION.
INHIBITIVE. NOT EASILY ESTABLISH RAPPORT PEOPLE WE DONT KNOW WELL. WITH

IDEAL INTERVIEW
PLANNING THE INTERVIEW
Set priorities Obtain contacts Select location Prepare for the interview

CONDUCTING THE INTERVIEW

Make the witness feel at ease (tell the right and purpose) Qualify the witness Encourage to tell a story Repeat the story to ensure the facts Thank the witness / reward

FACTORS AFFECTING WITNESS REPORTING

WITNESS BACKGROUND IN AVIATION / IQ PERCEPTION OF WITNESS EMOTION / EXCITEMENTS INTERPRETATION OF THE AMBIGUOUS AGREEMENT WITH OTHER WITNESS ENVIRONMENTAL PHYSIOLOGICAL PSYCOLOGICAL

RETRIEVABLE DATA
Crash survivable Flt data recorder AC loading recorder HUD video AC video tape recorder Personal recorder

DETAILED ON-SITE EXAMINATION

COCKPIT. AIRFRAME. POWER PLANTS. SYSTEMS:
FUEL SYS HYDRAULIC SYS ELECT SYS INSTRUMENTATION EJECTION SYS

FIRE. WRECKAGE PATTERN.

DANGERS TO EVIDENCE
Traces disappear by evaporation
Precipitation

Carelessness
Nature

Souvenir hunters
Site Clearance

GATHERING EVIDENCE
All efforts to preserve evidence should be understood. Evidence gathering exercise must be controlled. Deliberate plan to be made to examine site. Formulate story with out drawing conclusions.

MEASURES TO SAVE EVIDENCE

Cordon off. Photograph. Identification/questioning of witnesses. Samples. Preservation of ground traces. Completeness of wreckage.

PRESERVATION OF EVIDENCE

PRESERVING EVIDENCE
Bodies to be photographed and examined by doctor before moving. Physical evidence must be protected from further damage:
Edges of broken surfaces contamination. Do not wash, clean, brush off parts. Do not mate together broken pieces.

PRESERVING EVIDENCE
Gather all evidence from cockpit:
Check all controls, selectors, switches & handles. Note readings of all instruments. Photograph all items.

PRESERVING EVIDENCE
Wreckage documentation:
Accurate wreckage distribution diagram. Full photographic record.

Record damage during wreckage movement .

Record and protect evidence likely to disappear or change (Critical time evidence):
Samples of all POL and gases. Fire pattern. Fragile items like bulbs.

PRESERVING EVIDENCE
All recording devices like FDR, AFTR, CVR, DVR etc. Impounding of documents (All records pertaining to

Man, Machine & Flight)

Pilot Blue Books & Log Books Training records of pilot

FDR data of previous ten sorties

Engine Log books

ATC records

DETERMINATION OF ACCIDENT SITE & RECONSTRUCTION OF FLIGHT PATH

SCOPE
Recording of Accident Site.
Photograph. Impact Sketch.

Reconstruction of Flight Path.

Flight Path Chart Contact Sketch.

RECORDING OF SITE

Accident Photograph. Impact sketch.

AERIAL PHOTOGRAPH
Forethought brief SAR crew & photographer. Request. Overlay giving:
Approach direction. Point of first contact. Direction and elevation.

AERIAL PHOTOGRAPH
SUGGESTIONS Fly in something that has an open window or door. Dont touch the camera to any part of the aircraft or helicopter. Arrange for something of known dimension to be visible in the wreckage scene Get at least one picture as close to vertical as possible. Always take two shots in rapid succession for each picture. Note the altitude for each picture taken.

PHOTOGRAPHIC PRIORITIES
PERISHABLE EVIDENCE AERIAL OVERVIEWS OVERVIEWS OF THE SCENE SIGNIFICANT SCENE ELEMENTS WRECKAGE INVENTORY CLOSE-UPS DOCUMENTS WITNESS VIEWS EXEMPLARS

IMPACT SKETCH
In addition to accident photograph. Starts with point of first impact. Types:
Grid System Polar System Single Point System Straight Line System

IMPACT SKETCH
Have details of:
Crater depth. Ground markings. Traces of skidding and sliding. All essential parts. Compass direction. Obstacles. Wind direction and velocity.

Inspite of this, should not be cluttered.

Tenerife 747s Collision

GRID TYPE

POLAR TYPE

RECONSTRUCTION OF FINAL FLIGHT PATH

SAFETY PRECAUTIONS

AVOID COMMON ERRORS

Visiting site in a hurry without preparation. Ignoring safe investigating practices and common safety precautions. Arriving at conclusions before starting investigation. Disturbing the wreckage before collecting evidences/ documentation.

SITE SECURITY & SAFETY

Cordon area Security arrangements Make cartridges safe Identify Crash site hazards
Bioenvironmental hazards Toxic substances Mechanical hazards Pressure vessels Radioactive hazards Fire/Explosive hazards

PERSONNEL SAFETY
Hazard control Scene control Neutralisation of known hazards Safety awareness brief all personnel Personnel Protective Equipment
Surgical gloves Leather gloves Exposure suits, etc.

CONCLUSION
The accuracy and thoroughness of investigation determines the adequacy of ultimate action taken to remove or eliminate factors that cause or contribute to mishaps

PENYELIDIKAN PPKPU
BIDANG MISI PROGRAM OPERASI/LATIHAN. SYLABUS LATIHAN. PROGRAM SIMULATOR. BIDANG MANUSIA KESEHATAN (MEDICAL/ILA). PSIKOLOGI. BIDANG MATERIIL TINGKAT/MACAM KERUSAKAN YANG DIAKIBATKAN DARI BENTURAN/IMPACT. PENGUJIAN MATERIIL/FUEL/OLI MESIN/HIDROLIK. KERUSAKAN BENDA LAIN (DILUAR PESAWAT/ALUTSISTA). KONDISI DARI SYSTEM PESAWAT/ALUTSISTA PASCA ACCIDENT.

PENYELIDIKAN PPKPU
BIDANG MEDIA LINGKUNGAN KERJA/KANTOR.

LINGKUNGAN KELUARGA.
BIDANG MANAJEMEN ORGANISASI SATUAN/LANUD/KOTAMA/MABESAU/MEBES TNI. PENGADAAN SUKU CADANG.

PEMELIHARAAN SUKU CADANG.