Aircraft Accidents and Passing the Buck

In my first novel: Jet Blast, a character spoke about the ‘hot potato’, a term given to a particular event or evidence that is used by one party of an accident investigation to throw suspicion on another party.
Fifteen years ago this week I was in Murfreesboro, TN, interviewing the inspector for the repair station that conducted heavy maintenance on an airliner – a cargo DC-8 – that crashed; he verified the safe installation of a part that caused the accident. Unfortunately, all he had was his word with little evidence.
The airline’s Director of Quality Assurance (DQA) piled on this inspector with his opinions and accusations, saying that the repair station was the only entity that could have incorrectly installed the part. He was adamant and the investigators, which included my fellow NTSB investigator, believed him without question.
Several weeks later – on the morning of September 11, 2001, to be exact – I was in Dayton, OH, conducting interviews with the airline’s management concerning the accident. The DQA was present and I had the chance to interview him. He restated to me that the aircraft had arrived on an overnight cargo sort and that the time the aircraft was on the ground – two hours – was not enough to remove the part and replace it before the aircraft’s scheduled departure. The night that this occurred was November 25, 1999.
Now I’ve commented many times that the NTSB lacks the required expertise to know when one party to an accident investigation, e.g. the airline, is lying to them. This accident was an example of the NTSB’s naiveté in maintenance. The DQA felt confident that we would miss an important point and was not in a rush to help out.
It turned out that November 25, 1999, was Thanksgiving. Usually air cargo airlines, like the one I worked for, use holiday layovers to clean up maintenance. So I asked the DQA, “Did you fleet in on holidays?” His demeanor changed, suddenly wishing to berate me for asking such a ‘foolish question’. I replied, “Humor me. Did you fleet in on holidays, like Thanksgiving?” He begrudgingly answered that they did. “So,” I continued, “the window for conducting maintenance on November 25, 1999, wasn’t limited to two hours as you stated, but instead to twenty-six hours. This was more than enough to remove the part and re-install it incorrectly.” The chance that the airline’s people caused the accident suddenly increased exponentially.
In accident investigation, as demonstrated in my novel: Jet Blast, show that asking the right question is important. What’s more important, however, is to keep everyone: FAA, airline, union, manufacturer, etc., honest. And when they can’t be honest? The investigator has to be smart enough and experienced enough to know when to ask the right question.

Leave a Reply

Your email address will not be published. Required fields are marked *