An Aircraft Accident Prize

In Ashburn, Virginia, the National Transportation Safety Board Academy sits just north and east of the George Washington University Virginia campus. The Academy is a state-of-the-art learning center that presents lessons of accident investigation, mostly aimed at Aviation. There are impressive classrooms and conference rooms that enable students from every country to learn the techniques of accident investigation from the professionals themselves that sort and sift through wreckage regularly.
Before I left the NTSB, I taught at this facility twice. It really was impressive and allowed me to teach to a large audience. The labs allow lessons in structural testing, systems detail, and proper on-site procedures in the correct ways to handle wreckage. Outside you can ‘reconstruct’ an accident from the boneyard. But most notably is the TWA800 reconstruction inside the hangar. It is … disturbing.
When you first see it, you are in awe of the tragedy that still lingers like a shroud. The structure is a near complete rebuild of 93 feet of the fuselage, including wing roots. The website advertises that it has ‘been used to train hundreds of investigators’, focusing on the fuel tanks in the center of the aircraft because it was there – and only there – that things went horribly wrong. What is the other seventy feet of the aircraft there for?
I understand the fascination seeing this icon of air disasters; it’s as if viewing the Hindenburg or the Titanic up close. It’s a reminder of the lives lost. But now it’s just morbid. The excess fuselage doesn’t teach us anything. It sits in the hangar as a testament to misplaced arrogance; a shining example of just because we could do a thing, doesn’t mean we should do a thing.
Does the NTSB think the victims’ families are glad that their loved ones died in a vehicle on display for all to see, their loss naked, grief disregarded, feelings ignored? After all isn’t one of the reasons that the NTSB does what it does is to allow closure; allow the dead to be buried?
It’s time to take the structure down.

Aircraft Accident Associations

The search for truth is best expressed in President Kennedy’s words, “… not because they are easy, but because they are hard.” The truth is always hard. Blame is made easy by pounding a table or shouting louder.

On February 2nd, a TransAsia ATR 72 crashed into the Keelung River after taking off. At the time a local reporter wanted to blame the aircraft for the accident, analysis that lacked substance, credibility, and traction. Misleading allegations irreversibly damage those harmed by speculation.

In May 1979, an American Airlines DC-10 crashed, its separated left engine found on the runway. Reports fueled speculation of unsafe DC-10 designs. Airlines were ordered to ground their DC-10s until a definitive cause could be determined. Result: air carriers reliant on the DC-10 fleet suffered heavy financial losses. With limited evidence, the decision to ground was a good one, though devastating.

The TransAsia brand itself will take big hits. On July 23, 2014, TransAsia flight 222 crashed killing forty-eight; two TransAsia accidents within seven months. The determinations are still months away and TransAsia will not escape the effects.

Disinformation confuses the flying public, who rely on the media’s and investigating officials’ words to explain what happened. The Malaysia Airlines flight MH370 accident is indicative of how not to investigate. The investigation changed direction often with no logical pattern. It put the victims’ families through an emotional roller coaster; the public’s trust was shaken. The priority became: calm the public with false hopes; satisfy an impatient media. Theory was afforded credibility while opinion became fact.

Disinformation is a distraction. In accident investigations every lead must be disproved, not the other way around. Distortions exhaust necessary resources on fools’ errands, drawing critical attention away from the trail.

Accident investigation is not about assigning blame; culpability is shared by more than one entity and intent is never a factor. Accident investigation is about cause, followed by recommendations. Investigators are not trained litigators; they deal in federal regulations, not in criminal or civil law. Investigations are driven by facts of the accident and analysis of cause; the approach isn’t quick; it’s unattractive and data intensive.

The facts are at least a year away; there remain months of testing followed by months of analysis. Ultimately there will be no speculation. In the end accident investigators will be reporting all the facts. The truth won’t come easy; it will be very hard.

The Future of Tracking Aircraft Accidents

Aviation leaders were invited by ICAO to meet last week to discuss improving airliner tracking. These conferences are mostly bureaucratic think-tanks. If you’ve ever had the pleasure, there’s a lot of podium pounding theatrics, with an expected outcome. While nobody would oppose such ideas, the bureaucrats make promises that cannot be kept.

Improved satellite tracking is a doable option. In today’s aircraft, maintenance and flight reports are transmitted regularly. A software rewriting could up the time between updates; FAA’s and aircraft manufacturer’s standards should be met; that reprogramming doesn’t interfere with normal onboard systems.

Detachable recorders are impracticable at this time for numerous reasons, e.g. the use of explosive squibs and how to deploy; a gee-whiz idea that can’t be implemented … yet.

Tamper-proof transponders are unacceptable; bureaucrats need to understand this promise is naïve. Federal Regulations dictate every piece of equipment on board the aircraft MUST be capable of being deactivated from the cockpit, no matter how small the amperage. This is a safety issue and non-negotiable at this time. It would be a safety of flight risk.

Video of the cockpit will never happen. The cockpit is the pilots’ ‘office’. To put a recorder in the flight deck poses more danger than not. Mistakes will be made when concerns of legal culpability play into a pilot’s decision making; they’ll worry that all video of their decisions will be kept on file, that any innocent choice or comment will be used by management against them – and they would be right. During the NPRM process, the pilots’ unions, aircraft manufacturers, and even some airlines would never agree.

To make idle promises doesn’t move the ball forward. If aviation organizations are serious then make suggestions that are achievable – no blank check promises. Put the people who can design real solutions at work and apply common sense. Aircraft can be made even safer, but reality must prevail.

Aircraft Accidents that Disappear

On December 18, 2003, an LAS DC-9 crashed near Mitu, Colombia. Foreign soil accidents aren’t always listed in the NTSB archives.
However, the NTSB participated in the investigation; they invested taxpayer money, investigator time, analyzed the recorders; it has to be listed. Furthermore, an NTSB investigator/liaison spearheaded the investigation with Colombian officials.
That investigator was me.
Why’s this important? Two air crash websites showed the aircraft was missing, the crew ‘believed’ dead and the recorders unrecovered. A third said it crashed, aircraft located – not recovered – and the cause: Undetermined. One surmised: controlled flight into a mountain, aka, pilot error.
There was no mountain and no pilot error.
This is what happened: the aircraft suffered a catastrophic structural failure due to a poor engineering design. I heard the CVR recording; sound analysis pinpointed a loud bang somewhere around the wing box. I read the FDR readout; all flight and engine controls were locked during the plummet from cruise altitude to the ground. The crew didn’t fly into a mountain; they yelled all the way to impact, unable to move the controls.
How does this Colombian aircraft accident affect the US? The cause was defined, but ignored by the NTSB. The victims were wrongly blamed. Most importantly, the DC-9 was leased to LAS by a U.S. operator; the poor engineering design could still be on a US-flown narrow-body passenger or cargo aircraft. Where did the findings go?