Aircraft Accidents, the NTSB and Industry

Last week I spoke about the NTSB’s investigators/engineers, how they lacked the general knowledge of industry, the subject of many major investigations. I received substantial pushback from many, including two guys I worked with at the Board, who I’ll call John (a Survival Factors engineer) and Paul (a Systems engineer). Paul is a very talented systems engineer who did work for the airlines, thus is quite adept at his job with a healthy understanding of how the industry operates. John has been handling accidents for many years; he also suffers from a condition identified in Scott Adams’s comic strip Dilbert as the Knack, an uncanny ability to see a bigger picture and know when the wool is being pulled.
Both men are the exception, not the rule. Both men also demonstrate a dislike for attention and bureaucracy. I’ll explain shortly.
The point I made about having a lack of industry experience is in relation to knowing more than the other people you lead. Every NTSB investigator leads a group, whether it is Systems, Air Traffic or Operations, they must lead people from the FAA, the air operator, representatives from the airframe and engine manufacturer as well as union reps. These people have an incredible advantage in that they know the equipment, the people, the environment and the players far better than the NTSB investigator in their group. It is here that the NTSB investigator who lacks industry experience loses control of the group; the reps will understandably protect their paycheck provider; if the NTSB investigator doesn’t know where he or she is being misled, so much the better. The NTSB group leader will be unable to control their group and, thus, the outcome of the investigation. That part of the investigation will be corrupted and consequently wrong.
Which leads us back to Paul and John who refuse to get caught up in the spotlighted world of Investigator-in-Charge, or IIC. These are the inexperienced engineers who ‘grow-up’ to be IICs. This is a position many investigators aspire to, it leads to management and the title of ‘expert’. This is why I made the point that “inexperienced-in-industry” engineers will eventually rise to the level of IIC; he/she will rub elbows with the Board Members. Board Members are the face of the NTSB, the camera icon and the one who enters into every Americans’ living room and smart phone. They repeat the analysis provided by, none other than, the IIC.
And what if the IIC has no idea what’s going on in the investigation due to their inexperience? The investigation is flawed. Furthermore, the peace of mind the families demand will be nothing; the learning from past accidents will be tarnished by the inexperienced IIC’s unfamiliarity with what happened beyond the obvious crash scene. If his/her group leading NTSB investigators are inexperienced, then who is there to rely on?
Inexperienced leaders, flawed analysis, and nothing to catch it; the accident investigation is doomed even before the smoke settles at the scene. As one IIC said during an all-hands meeting, “Flight deck … is that the cockpit?”

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