Aircraft Accidents and Probable Cause

Having worked as an NTSB investigator, a process is followed when investigating a major aircraft accident. There are two main reports written by each specialty lead – a specialty is a subject, e.g. maintenance, flight crew, ATC, etc. These two reports are the Factual and the Analysis reports. They are fed into the final report, called the Blue Book, the culmination of all the different specialties. It is in the Blue Book that ALL the Probable Causes are presented.
Despite advances in aviation tracking, there is always unconfirmed information that is referred to in any final accident report. The Probable Cause means that with all the evidence collected and testing performed, the NTSB’s specialists’ best analyses leads to certain conclusions. But let me be clear: Probable Causes are based on analysis taken from the FACTS … period.
What we’ve witnessed in the wake of the March 24th tragic crash of Germanwings flight 9525 is the unleashing of the irresponsible. These myopic trips from the inexperienced are Sharpton-esque in their misdirection and boldfaced ignorance; it serves one purpose: creating turmoil. Even the fact that the cockpit voice recorder information, recklessly provided to the media, is a violation of the control of evidence in a professional investigation. By contrast, an NTSB investigation is a demonstration in professional actions and empathy; actions because they follow the rules; empathy because they care for the victims’ family members’ pain.
The media justifies their folly by employing ‘aviation specialists’ to push their conjectures. Many of these ‘specialists’ are not aviators; they are attention seeking bureaucrats whose only attachment to aviation is in title, one not generated from a knowledge of aviation but political affiliation.
I’ve followed social and news media since the accident. 99% of the ‘facts’ reported would NOT be included in an NTSB Factual report because they are not factual by definition. The media reports with words, e.g. ‘likely’, ‘could’ or ‘might’; ambiguous accusations with a buckshot effect: scattered and deadly.
Where are the truths, the moral convictions, and the supporting evidence? They don’t exist. The media provides speculation, not because it holds up, but because it stirs up. And those fascinated by the tragedy welcome this line of storytelling because they don’t know better.
Let’s re-examine the speculation, but take it a step further because these ‘facts’ would never end up in an NTSB Factual report as unquestionable information:
• The first officer did not open the cockpit door despite the Captain’s pounding on said door. What if Andreas Lubitz COULD NOT open the door? Did he verbally refuse to? Did he inform ATC he didn’t want to? Did he make an announcement? Did he yell to a deity? The problem with this scenario: no one can prove he wasn’t incapacitated. Only breathing was heard, which one can do following, e.g. a stroke, heart attack, etc.; alive, incapacitated, but still breathing.
• No suicide notes were found. Where’s the evidence? Depression in 2009? That was six years ago. What health care professional made the diagnosis? Did he actually open an artery or was he simply expressing regret at a decision or the loss of a loved one?
• He dismissed his sick leave note. What was the sick note for? A cold? Migraines? Sore ankle? Any and all these reasons would cause a pilot to request time off, unless they were feeling better on the day of flight.
• The plane descended steadily to the ground. Think about this one; if he was suicidal, why not just nose it over; why the drama? Why take the chance the captain would get in? Why not shut down the engines?
• After becoming incapacitated, could the autopilot have been disabled, like in Eastern Airlines flight 401? If the autopilot was accidentally turned off the A320 could perform a slow descent to the ground.
If this investigation turns a corner, the media will drag the victims’ families through it all over again; their suffering will be renewed, like salt in a wound, they will live through every … unnecessary … minute … again. And the media will sell more papers, burn more air time, flash photos of grief stricken people. And they will claim, Absence of Malice. As an investigator, I met and have spoken with many victims’ family members: parents, siblings, spouses. They want facts, not speculation; they want the right fixes that honor their loved ones, not band-aids; they want closure, not repetition.
P.T. Barnum supposedly said, “There’s a sucker born every minute.” Are we being played as suckers? This investigation has taken on the frantic speed of a luge race, where each turn is dictated by a paranoid media, intent on controlling the conversation and ignorant of the subject matter at hand. When do we step back? When is someone going to manage this investigation; someone who will not leak out every dubious morsel to the media? Is it beneficial that every passenger now stares suspiciously at a pilot, doubting his or her safety when the door to the cockpit is closed?
Let’s assume Lubitz did kill the passengers. What’s the fix every ‘aviation expert’ is touting? Increased psychological testing of every aviator. My thirty-plus years in the aviation industry and accident investigation tell me how it will play out. A therapist will be hired, one who the union and airline can agree on; one who sits in his office biting his nails while staring at his correspondence school diploma. One who questions a pilot because she hates her place in the seniority list. One who recommends unpaid leave for a mechanic who forgot his wedding anniversary. Or one who retests an air traffic controller who likes to play with model trains.
Now let’s assume Lubitz was incapacitated and the accident was just that … an accident. Now we have a bigger problem. We were so busy demonizing Lubitz, we missed the real cause; the real flaw escaped our notice. And it will only be a matter of time before it happens again.
It comes down to FACTS people. At this moment there are only two possible Probable Causes: Lubitz would not open the door, or Lubitz could not open the door.
Where will the facts point?

2 thoughts on “Aircraft Accidents and Probable Cause”

  1. Stephen,

    You had an interesting statement in your blog: “But let me be clear: Probable Causes are based on analysis taken from the FACTS … period.”

    The NTSB lacked facts wrt the fatal B737 rudder rolls and had to add “most likely.”

    If you got to NTSB in 2001, you know that was the era when the various B737 rudder fix effectivenesses became known.

    It wasn’t the sticking dual-concentric hydraulic valve after all, it was an EMI-induced fault mode of the old analog yaw damper coupler (on the B737/100-500 only, not on the NGs). Both were considered mechanical failures – your area of expertise.

    The 2nd U585 report was signed in early 2001, yet the board decided against stating the facts shown by working backward. Chairman Hart was one of the five signatories.

    Perhaps it was to prevent the feeding frenzy of the families all suing each other.

    Was that why Jim Hall resigned in late 2000?

    I’ll put your new book on my reading list.

    V/R, Doug Hughes ISASI MO4415

    1. Doug, you are right; I was unclear. I’ve tried to not let my emotions get the best of me with this Germanwings accident, but the media tests my resolve. I should have said the Probable Cause is taken from analysis from a Factual report that is straight facts; ‘analysis’ should have been explained better because, although the public does not read the Analysis report, they get the highlights of it in the Blue Cover. Technically I was correct, just ambiguous. Accidents like US Air 427 begged for analysis, just like MH370, because the facts were not available. What the NTSB did not do in accidents, like 9/11, was make assertions; the FBI ran those cases and we (the NTSB) were sworn to silence and followed their lead. As with Germanwings 9525, the unfounded accusations are despicable, especially since many are not supported with released evidence – just hearsay – and because they may hinder the safety findings of the final outcome.

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