These papers were presented at past ANZSASI conferences. Information from these papers that is used in other publications must be attributed, as they remain the property of the authors.

The papers can be downloaded as PDF documents (by "Right" clicking on the link and choosing "Save Target As"). A number of the early papers were scanned from paper copies, hence minor typographic errors may have occurred during the scanning process. Some of the early PDF papers have been zipped to reduce their file size.


1997 1999 2000 2001 2002
2003 2004 2005 2006 2007
2008 2009 2010 2011 2012
2013 2014 2015 2016

Papers not presented at ANZSASI Seminars

Safety Culture and its measurement in aviation, presented by John A. Flannery

The paper was written as part of course requirements for the Master of Aviation Management at the University of Newcastle, NSW; and the paper was presented in a modified form at a HESSD University workshop.


1997 Regional Seminar - Brisbane, Australia

Opening address presented by Allan Hawke
... and on the eighth day, God created pilots presented by Dr Graham Braithwaite
Culture, CRM and aviation safety presented by Brent Hayward


1999 Regional Seminar - Gold Coast, Australia

Opening address presented by Air Marshal Errol McCormack
Shaken but not stirring? - The 'need to know' basis of aviation safety presented by Dr Graham Braithwaite
TAAATS Implementation presented by Geoffrey Dickie
A program for monitoring fatigue in long-haul commercial operations presented by Dr David Powell
The media are not the enemy presented by Martyn Gosling
Violations of Controlled Airspace project presented by Ian Dix
A systemic investigation - Where do you start? presented by Chris Sullivan


2000 Regional Seminar - Christchurch, NZ

Flight Safety Foundation: CFIT/ALAR action group status report presented by Captain Stu Julian
Garrett TPE 331 engine turbine failure presented by Vlas Otevrel
Aviation Recorders--Their use by safety investigators in the 21 st Century presented by James Donnelly
Rapid decompression and hypoxia in aircraft accident and incident investigation presented by Robin Griffiths
The investigator, the media, and the rights of the public presented by Martyn Gosling
Safety and security in aviation – The dividing line is blurred presented by Mark Everitt
Reducing bird hazards: Double or nothing? presented by Peter Reardon
The use of flight recorders in the RNZAF presented by Wing Commander Jim Rankin
Scientific methods for accident investigation presented by Dmitri Zotov
The ATSB: What does it mean for aviation safety? presented by Carol Boughton
The jigsaw of time in an ATS investigation presented by Christopher Sullivan
B747 VH-EBS – Podstrike Perth 2 September 1999 presented by Phil Robertson/Barry Sargeant


2001 Regional Seminar - Cairns, Australia

Aircraft Avionics presented by Mal Gordon
Analysing an Accident with a WB Graph presented by Dmitri Zotov
Court of Inquiry presented by Sqn Ldr Russell Kennedy
Enhancing Safety presented by Neville Blyth
Four Unrelated Accidents presented by James Donnelly
Kalkara Investigation presented by Robert Pell and Graham Clark
Main Rotor Blade Analysis presented by Sam Webb
Metro III Gear Failure presented by Ken Mathews
Oxygen Fire in an EMS helicopter presented by Ron Heitmann
Promoting Safety presented by Al Bridges
Investigating the Causes of 'VFR' into 'IMC' presented David O'Hare & Douglas Owen
Who Cares About CAIR presented by Chris Sullivan


2002 Regional Seminar - Auckland, NZ

Personnel Licensing for Investigators presented by Richard MacFarlane
Outline  Powerpoint
The ADF Safety Occurrence Reporting System presented by Peter Wood DFS
Boeing 767 Erroneous Glideslope Incident at Apia presented by
Chris Kriechbaum and Dave Stobie
Air Safety Investigator Training presented by Graham Braithwaite
Benefits of Incident Investigation presented by Philip Naughton
Crisis Management presented by Lindsay Naylor
Fatigue as a Contributing Factor presented by Michelle Millar
Flight Deck Communication presented by Jim Donnelly
Bell Iroquois Accident, Wellington, NZ presented by Alister Buckingham
Medical Hazards for Investigators presented by Rob Griffiths
Military Aircraft Accident Investigation in Australia presented by
Shane Thompson
Promoting Safety with Minimum Resources presented by Alastair Bridges
Preventing Operations on Closed Runways presented by John Duske
Outline of Piper Chieftain Accident, Whyalla, South Australia presented by Rod Fearon
Uncommanded Engine Shutdown-B717-200 presented by Sam Webb

2003 Regional Seminar - Maroochydore, Australia

A380 Airport Considerations presented by Cam Spencer
A380 Operator Considerations presented by Rob Sharp
ADF Aviation Safety Occurrences presented by Peter Wood
Dead Men Do Tell Tales presented by Rob Griffiths
Flight Data Analysis - An Airline Perspective presented by Neil Campbell
IL 76 accident Timor Leste presented by Geoff Kimmins
Inflight Wing Panel Separation presented by John Shepherd
NZ Aerospace FU24-950 Report presented by Alister Buckingham
Reasoning with the Reason Model presented by Mike Walker
Safety Climate presented by John Flannery
The Obvious Cause presented by Ian McClelland


2004 ISASI Seminar - Gold Coast, Australia (there was no ANZSASI seminar in 2004)

Accident Involving an Ilyushin IL-76 Transport Aircraft in East Timor Presented by S. Barter, L. Molent, P. Robertson, S. Thompson, G. Fox & G. Kimmins
New Opportunities and New Boundaries:  Presented by Michael Bartron & Mike Gamlin
Re-inventing (with wheels, wings and sails) - A New Look at Transport Accident Investigator Training Presented by Dr Graham Braithwaite
The ATSB Ansett Class A Investigation Presented by L. Brown, R. Batt, S. Garniss, M. Watson, and J. Walsh
The Protection of the Sources of Safety Information Presented by James Burin
Flight Data Analysis Using Limited Data Sets Presented by Neil Campbell
Investigation of Fatal Double Engine Flame-out to Shorts SD 360 Turboprop Presented by Peter Coombs
Air Safety Investigation in the Information Age Presented by Dr Robert Crispin
Managing Fatigue as an Integral Part of a Fatigue Risk Management System Presented by Professor Drew Dawson & Kirsty McCullough
Underwater Recovery Operations off Sharm el-Sheikh Presented by Olivier Ferrante & Jean-Claude Vital
Latent Failures in the Hangar: Uncovering Organizational Deficiencies in Maintenance Operations Presented by Dr Alan Hobbs
Investigate, Communicate and Educate: Are We Doing All Three with the Same Energy? Presented by Réal Levasseur
A300B4 Loss of All Hydraulics, Baghdad: A Remarkable Example of Airmanship Presented by Yannick Malinge
Past, Current and Future Accident Rates: Achieving the Next Breakthrough in Accident Rates Presented by Dr Robert Mathews
Human Factors in Stressful Team Situations: A View from an Operational and Training Perspective Presented by Werner Naef
Juridicial and Technical Aspects in the Investigation of Aviation Accidents and Incidents in Argentina and Latin America Presented by Com Luis Oritz & Dr Griselda Capaldo
Airborne Collision Avoidance System: ACAS/TCAS from the Accident Investigation’s Point of View Presented by Johan Reuss
Analysis of Aircraft Propulsion System Failure Presented by Dr Arjen Romeyn
HFACS Analysis of Military and Civilian Aviation Accidents: A North American Comparison Presented by Dr Scott Shappell and Dr Doug Wiegmann
WYSIWYG – Or is it? The Need for a Standard for Secure Digital Photography in Accident Investigation Presented by Corey Stephens & Chris Baum
The Use of Full Flight Simulators for Accident Investigation Presented by Robin Tydeman
Equipment Damage and Human Injury on the Apron Is it a cost of doing business? Presented by Bob Vandel
Using Physical Evidence from More Complex Mid-air Collisions Presented by Gijsbert Vogelaar & Keith McGuire
The Size of the Aircraft Doesn’t Matter Presented by Lorenda Ward
The Role of Lessons Learned in the Investigate, Communicate, Educate-Cycle for Commercial Aviation Presented by Dr Paul Werner & Richard Perry
When an Aircraft Crash is not an Accident: Experiences of an Air Safety Investigator at Ground Zero Presented by Eric West
The Myth of the Unstable Approach Presented by Dr Ed Wischmeyer
Maintaining an Aircraft Accident Investigation Capability in a Small Military Aviation Organisation Presented by Wing Commander Peter Wood
Who moved my (Swiss) cheese? The (r)evolution of human factors in transport safety investigation Presented by M. Young, S. Shorrock, J. Faulkner & G. Braithwaite


2005 Regional Seminar - Queenstown, NZ

Airspace Incident Investigation Presented by Richard White
Analysing the Dash 8 Accident with the Theory of Constraints Presented by Dmitri Zotov
Aviation Research Presented by Mike Watson
Analysis of Bell 407 Night VFR Accident Presented by Sam Webb and Richard Batt
Aging Aircrew Presented by Dr Robin Griffiths
Emergency Locator Transmitters Presented by Lloyd Klee
Near Collision in Japan Presented by Hiroaki Tomita
Strategic Approach to Fire Safety Presented by Tim Holey
UH-1H Main Rotor Blade Fatigue Presented by Patrick Conor, Alan James, Michael Hollis
The Use of Enhanced Ground Proximity Warning System (EGPWS) Data for Aviation Safety Investigation Presented by Neil A. H. Campbell

2006 Regional Seminar - Melbourne, Australia 

Cabin Safety Culture  Presented by Kai-Hui Lee
Challenges of Multi-Modal Investigations  Presented by Cpt John Mockett
Human Factors Training  Presented by Werner Naef
Improving Quality Analysis  Presented by Dr Michael Walker
NZ Safety Management System  Presented by Richard White
Order Better Than Chaos  Presented by Geoff Dell
Payne Stewart Learjet Investigation Paper   Powerpoint  Presented by Joanne De Landre, Gerry Gibb and Nicole Walters
Risk Management as a Tool for Safety Management  Presented by Geraint Bermingham
Developments in Flight Recorder Equipment and Analysis  Presented by Neil Campbell
Dangerous Goods in Passenger and Crew Baggage Paper   Powerpoint  Presented by Chris Reed
Spurious TCAS Warnings  Presented by Cpt John Martin
Bird Strikes - Is the risk increasing? Presented by Alan Moffat
Double Blackhawk De-Fuelling Incident Presented by Marcus Bromet

2007 Regional Seminar - Wellington, NZ 

Aviation Safety Successes and Challenges  Powerpoint  Presented by Jim Burin
Communication in Aviation Safety  Presented by Paul Krivonos
Data Recovery From GA Engine Monitors  Powerpoint  Presented by Eric Blankenstein
Investigations; What Business Is This?  Presented by Lois Hutchinson
Managing A Major Investigation  Air France  Presented by Mark Clitsome
Moving From SMS to Safety Case  Powerpoint  Presented by Dmitri Zotov
Safety Investigator Training  Presented by Colin McNamara
The Evolution of Flight Data Analysis  Presented by Neil Campbell
The Role of the Coroner  Presented by Judge Neil MacLean
Threat and Error Management  Presented by Dave Carbaugh
Workload and RNAV Approaches  Presented by Stuart Godley

2008 Regional Seminar - Adelaide, Australia 

Accident Data and the Helicopter Offshore Safety Case Presented by Steve Walters
Adaptation of Line Operations Safety Audit (LOSA) to single pilot operations (LOSASP) Presented by Laurie Earl, et al
Cabin Safety Presented by David Lattimore
Challenges for TAIC Presented by Cpt Tim Burfoot
Challenges in Material Repair Presented by Neville Blyth
Challenges in Regulation Presented by Mick Quinn
Decoding Onset of Stressful Behaviour Presented by Werner Naef
Level Crossing Safety and Rail Investigation Presented by Mark Stallbaum
Making Safety a Priority Presented by Greg Russell
Managing Safety in a Start-Up Low Cost Carrier Presented by Mike Innes
Opening address - Challenges for Safety Investigations Presented by Julian Walsh
Risk Approach to Night Offshore Operations Presented by Gerry Gibb & Cameron Ross
Role of the Pilot Investigator Presented by Gary Parata
Runway Incursions Presented by Peter Williams
The Concept of Risk in Air Transport Operations Presented by Dr Dimitri Zatov
Three Principles of Human System Integration Presented by Dr Alan Hobbs, et al

2009 Regional Seminar - Rotorua, NZ 

A Police View of Investigations Presented by Steve Wood
Annex 13 and the Joint Investigation Presented by Tim Burfoot
Evaluating Computer Graphics Animations of Aircraft Accidents and Incidents Presented by Neil Campbell
Field Equipment and Computer Simulation Presented by Dan Foley
New Challenges in Aviation Safety Investigation Presented by Neville Blyth
QF30 Depressurisation Presented by Neville Blyth
QF72 Learmonth A330 Pitch Events Presented by Mike Walker
Significant Strike Investigations Presented by Phil Shaw
SMS and the Emporers New Clothes Presented by Grant Brophy
Torsional Vibration Presented by Justin Williams

2010 Regional Seminar - Canberra, Australia

A practical Human Factors Approach to Managing Error in Aviation Maintenance Presented by CMDR Rick Sellers
Assessing Adhesive Bond Failures Presented by Maxwell Davis and Andrew McGregor
Birdstrike - Perched Out on a Limb Presented by Jeff McKee, Kylie Patrick, and Phil Shaw
Cultural Considerations for Investigators Presented by Peter R Williams
Fibre Composite Aircraft – Capability, Safety & Accident Response Presented by Russell Taylor
Predicting Pilots’ Risk-Taking Behaviour Presented Brettt Molesworth & Betty Chang
Safety Investigations & Education in an Airline Presented by Nathan McGraw
Safety Management Systems: Pitfalls and Lessons Presented by Dr Geoff Dell
The Application of HFACS in an OH&S Reporting System Presented by Michael Flannery

2011 Regional Seminar - Wellington, NZ

AAIB Singapore Presented by David Lim
Aging Aircraft Presented by Pieter van Dijk
Applying Numbers to the Cheese (Merged) Presented by Mike Watson
Data Recovery Presented by Alex Talberg
Grieving Families and Media Grief Presented by Peter Northcote
Investigating Without Systemic Issues Presented by Rob Chopin
MES Analysis Presented by Dmitri Zotov
Performance Based Navigation Approaches Presented by Obrad Puskarica
Practical Application of HF in Maintenance Presented by Rick Sellers
Respirable Effects and Carbon Fibre Presented by Sam Watson
Scientific Investigations: Logic or Rhetoric Presented by Stuart Birks
The Direction of Aviation Safety (Merged) Presented by Ian Brown
The Forensics of Fatal Transportation Accidents Presented by Christine Negroni

2012 Regional Seminar - Sydney, Australia

A340 Tailstrike Melbourne Airport Presented by Paul Ballard
Aircraft fires & lithium batteries Presented by Chris Reed
Basic aviation risk standard Presented by Greg Marshall
Breakdown of separation (Merged) Presented by Samantha Moran
DSTO Support to Accident & Incident Investigations Presented by Simon Barter
Evidence Based Training For Airline Pilots Presented by Patrick Murray
The Effects of Noise Cancelling Headphones on Performance Presented by Brett Molesworth
The Use of Recorded FDR Wind Data in Investigations Presented by Neil Campbell
'Reason' and 'Risk' Presented by Rick Sellers

2013 Regional Seminar - Christchurch, NZ

Amateur-built Aircraft Accidents Presented by D. Wilson

DHC-8 Propellor Overspeeds Presented by E. Blankenstein and D. McNair

Event Risk Classification Presented by R. Taylor

Q300 Nose Gear Incidents Presented by P. Williams

2014 ISASI Seminar - Adelaide, Australia (there was no ANZSASI seminar in 2014)

Seminar Program - 2014
Dutch Safety Board - Reversing the False Glideslope Myth Presented by K. Beumkes and M. Schuurman
Cranfield – Working with the Newsmedia Presented by G. Braithwaite
GE Aviation - SMS Framework and Investigation Lessons Learned Presented by D. Chapel
ATSB - VFR into dark night Presented by R. Chopin and M. Walker
NTSB - Safety cultures and accident investigation Presented by B. Czech, L. Groff and B. Strauch
Boeing and NTSB - UAS for aircraft accident investigations Presented by B.English, J. Kraus and P. Pillar
NTSB - Asiana 214 Presented by B. English and T. LeBaron
JTSB - Flight training school accident investigation Presented by K. Fukuda
Cranfield - Towards the Next Generation of HUMS Sensor Presented by M. Greaves
Irish Aviation Authority - Just Culture Presented by K. Humphreys
Boeing - In Service Safety at Boeing Presented by S. Lie
HKCAD - Fuel Contamination Presented by V. Liu
BEA - Touchdown Too Long Presented by P. Mauviot and R. Bevillard
CASA - A Review of SMS elements and the Identification of Organisational Factors Presented by H. Meyer
DSTO - 75 years of Scientific Accident Investigation Support at the Bend Presented by L. Molent and N. Athiniotis
Embraer - Change Point Analysis Applied to SMS Presented by P. Razaboni
The Influence, Measurement and Development of Organisational Safety Culture Presented by R. Sellers
United Airlines - Challenges of Large Airline Safety Investigation Organisations and their SMS Presented by J. Tsujimoto

2015 ANZSASI Seminar - Auckland, NZ

Seminar Program - 2015
406MHz Antenna Performance Presented by Lloyd Klee
Application of Coroners Act Presented by Judge Deborah Marshall
Cabin Evacuations after Unprepared Emergencies Presented by Enrique Argento
Directorate of Defence Aviation and Air Force Safety (DDAAFS) Presented by Marc Rhodes and Brendon Blank
Effective Use of SMS in Flight Training Presented by Andrew Bennett and Rocky Rua
Flight Data Monitoring Presented by Clint Barnes
High Altitude Loss of Control in Automated Aircraft and Pilot Competence Presented by Ashok Poduval
Isolation Does Not Mean Autonomy - APCSWG Presented by Susan Rice
Propulsion System Health Monitoring Presented by Adrian Weller
Safety Communication in an Era of Information Overload Presented by Margo Marchbank and Robert Wilson

2016 ANZSASI Seminar - Brisbane, Australia

Seminar Program - 2016
Runway Misalignments - Take Another Look Presented by Barry Stephenson and Peter Williams
The Process of a Recent Skydiver Fatality Investigation Presented by Richard McCooey
The Fatiguing Effects of In-Cabin Aircraft Noise on Cognitive Performance Presented by Brett Molesworth
Runway Incursion Risk in the Resource Sector Presented by Geoff Roberts
Go Around Human Factors Issues Presented by Wayne Martin
Tiger Moth In-flight Break-up Presented by Eric Blankenstein
Recent ATSB Experience in Underwater Recovery Presented by Simon Grummett
Towards a Next-generation Airline Flight Operations System (AFOS) Presented by Dan Handlin and Lindsay Fenwick
Preparing for a Global Aeronautical Distress and Safety System Presented by Brian O'Flynn
Aviation Safety Through a Voyage of Discovery Presented by Pierre Blais
Human Factors of Remotely Piloted Aircraft Systems: Lessons from Incident Reports Presented by Alan Hobbs