Aircraft Accidents and Inheriting the Wind

He who troubles his own house will inherit the wind, …” Proverbs 11:29

The last two articles I wrote reference theology.  Although I do enjoy a good theological discussion, it is not my intention to wax dogmatic in my articles.  I find Scripture to be multi-interpretational, meaning that there is more than one meaning behind passages written in the Bible, Quran and the Torah.

To me, the above passage from Proverbs can be interpreted that, “He who troubles his own society, inherits nothing;” you can substitute family, house, industry, etc., for the word ‘society’.  It is part of a quote; I don’t normally sub-quote anything because I think it takes the author’s intent out of context.  However, I am going to take some liberties with this quote.

My students often ask me why I dislike the influence of the National Transportation Safety Board (NTSB) so much.  My answer is: I don’t hate the NTSB, but I disagree with a lot that they say.  In fact, I respect many of the technical people who conduct the investigations.  But, to be honest, I’m not so crazy about the track record of the Federal Aviation Administration (FAA) either.  Both organizations suggest a decision-making process, saturated with ignorance.  And here’s why …

Bureaucracy, plain and simple.  Trying to communicate safety concepts through any bureaucracy, whether industry, airline, manufacturing or within government is like falling through the ice on a Minnesota lake; you, the safety advocate, are under the ice and attempting to break upwards through the frozen layer.  This analogy may seem overly dramatic, yet it’s the impossibility of breaking through that speaks to my point.

Has anyone ever tracked the success rate of an NTSB recommendation?  Have aviation professionals taken the time to contest the findings of the NTSB or FAA, and thus the effectiveness of changing, eliminating or writing regulation?

My old friend, Bill O’Brien – a man who commanded sold-out houses for his seminars in which mechanics would sit on the rafters to hear him speak – once told me that to change a Federal Aviation Regulation (FAR) was a three-by-three investment.  What this means is that every change to an FAR, e.g. a word or punctuation, costs three million dollars and took three years to complete.  Bill told me this in 2004 (he passed away in 2009), so it is likely that the cost has risen considerably.  But he was correct, because I’ve taken part in FAR rulemaking; the $3,000,000 cost he quoted, it turns out, is on the low end of accurate; it is also a conservative estimate to say three years; it is usually more.

Look at the Colgan flight 3407 accident, Buffalo, NY, February 12, 2009; as with many accident investigations and resulting recommendations, the consequences of actions taken are not thought out.  Colgan 3407 was a Regional feeder to a larger air carrier, Continental Airlines.  Certain problems identified from Colgan 3407 stemmed from Regional pilot qualifications and Regional pilot domiciles; these were indigenous issues limited to certain Regional air carriers and not others.  To explain why ‘cookie-cutter’ solutions cause more problems than good would take way too much space than my website would allow.

Let me elaborate: FedEx and UPS both fly cargo overnight.  However, they are as different as apples and carrot sticks, in so many ways.  When one looks at Delta, American, United and Southwest together, they would notice that the differences far, far outweigh the similarities, even though their missions are similar (they all move passengers and freight).  Regional carriers flying for, e.g. American, are just as different from each other; they have to be, e.g. by the equipment they fly and the schedules they contract for.  With these facts, how does the FAA blanket-manage air carrier certificates so diverse from each other in the same way?  Answer: They don’t.  Furthermore, they can’t.

This week, an industry panel is recommending to the FAA to relax dozens of safety rules brought about from the Colgan 3407 accident.  Whether one agrees or disagrees with the proposals, they are indicative of the NTSB’s knee-jerk recommendation process; that the NTSB is either: (a) too inexperienced in how the commercial aviation industry has evolved to suggest sweeping aviation safety laws; or, (b) the NTSB never considers the consequences of such actions.  The NTSB just makes recommendations and then they move onto the next accident; their job is done.  The FAA, meanwhile, looks cowed; they have implemented, without reasonable consideration, rules that cripple the commercial air carrier industry without any thought to the NTSB’s ineffective recommendations.

It isn’t apparent to the Colgan 3407 victims’ families, who pushed for legislation spearheaded by the inexperienced NTSB’s recommendations, that the legislation isn’t working.  It would shock them to realize that what they push so hard for has a negative effect that negates their argument.  Worse, what they spent so much time fighting for has no effect at all.

Aircraft accidents are tragic opportunities; to suggest otherwise is both ignorant and cruel.  Ignorant because we have an opportunity to learn from mistakes and, what should be a one-time event, turn the tables, capture our errors and purge them with no chance for re-occurrence; one time, no repeats.  Cruel because if we don’t learn, if we shirk our responsibility as safety investigators, we condemn other innocent people to suffer the same fate as those lost in the original accident.

Let me give a good example: ValuJet 592 crashed on May 11, 1996; its tragic end brought to light a deficit of training in the Air Cargo Operations industry.  What should have occurred as a result?  Immediately, comprehensive training should have been designed and delivered in proper Air Cargo Operations, e.g. weight and balance, ramp personnel training, hazardous materials, contracting oversight, etc.  These training programs should have been built strictly by those who know Operations best: Air Carrier and FAA Operations experts.  The NTSB should have recommended that this happen right away; don’t wait for the report to come out, get it done.  If only this happened, we might have avoided tragic accidents and the loss of life in, e.g. FedEx 1406 – 9/5/1996; Fine Air 101 – 8/7/1997; Air Midwest 5481 – 1/8/2003; UPS 1307 – 2/7/2006; UPS 006 – 9/3/2010; and National Airlines 102 – 4/29/2013.

Aviation bureaucracies have troubled their own house.  As a result, we, the travelling public, have inherited nothing.

Aircraft Accidents and Writing

“Fiction reveals Truth that Reality obscures.”            Ralph Waldo Emerson

“I’m one of the most dangerous types of aviation professional: an aircraft technician with a word processor.”            Daniel Tenace, The Air Crash Files: Flameout

In 1977, I read a novel that altered the direction of my life; a novel is, by nature, Fiction.  It didn’t win any awards; the author wasn’t famous; yet it opened my eyes to writing and aircraft accident investigation.  Basil Jackson’s, Flameout, was about a fictional airliner that crashes during a routine flight.  The accident’s circumstances were unusual, almost fantastic, yet they were so believable … the operative word being: ‘believable’.

There are many books and reports on aircraft accident investigation, both fiction and non-fiction.  Some are enjoyable and/or instructive, while others border on ludicrous.  It’s not that the author doesn’t try to maintain a level of believability; in my opinion, they just don’t realize when they’ve crossed the line.  Others target persons or organizations; they forget the point of accident investigation is to reveal truth, not assign bias or blame; to avoid intentionally hurting someone out of conjecture, ignorance, spite or convenience.

Along these lines, the true heroes are those who research dangers to safety.  On November 24, 2016, I wrote about four gentlemen: Jon Loffi, Jamey Jacob, and Jared Dunlap, all of Oklahoma State University (OK); and Ryan Wallace of Polk State University (FL); they wrote a research paper: Seeing the Threat: Pilot Visual Detection of Small Unmanned Aircraft Systems in Visual Meteorological Conditions.  The paper analyzed the ability to physically see an Unmanned Aerial Vehicle (UAV) from a slow moving aircraft, under controlled conditions.  This is an unbiased report putting the UAV under the scope, without lobbying, to verify if they are a threat to aviation safety.  Their findings are accurate, irrefutable and chilling; taking a proactive look at UAVs and their effect on aviation.  I look forward to the next paper.

There are many non-fictional works analyzing accidents, e.g. Malaysia MH370 or Air France 447.  I don’t often read them because of their processing of facts; I’m spoiled by facts.  The reason for this is because the National Transportation Safety Board (NTSB) reports rely heavily on facts.  The first NTSB report for any accident is, in fact, called: the Factual report.  A Factual report tells the reader everything factual about: the aircraft, the pilot(s), the technician(s), the airport, the weather conditions, the air carrier, etc.  This information cannot be disputed or alleged – it is factual; it is first-hand from the source; it’s not second-hand.

When a non-fiction writer – not an investigator on site, but an ‘outside-the-accident-investigation’ source – gets into authoring about an accident, they rely heavily on second hand information, aka Hearsay.  In addition to the non-fiction book writer’s inexperience, the quality of the second-hand information determines the quality of the outcome.  The writer’s naiveté on an aircraft’s systems or a pilot’s training is only handicapped further by their prejudices, assertions and the final product’s quality.  The final non-fiction investigatory book’s reliability is questionable.

Think about a 1990’s investigation of the Titanic sinking.  No one living was there in the shipyard as the Titanic was being built or heard the decisions made in the White Star Line’s Board Room.  One hundred years later, we can only assume we have the story right.  Real problems suffered by Titanic’s construction aren’t technologically applicable today … or are they?  But the point is made: unless there is a first-hand knowledge of the topic, there is less chance of portraying the facts accurately.  A reader focuses on accuracy, not someone else’s opinion.

Which is why, I prefer to write fiction.  I don’t hurt anyone; I can apply my experience to the problems I see; and hopefully, people will sit up and listen.

Novels are fun to read; you get a lesson and a story for the price of one.  Even the greatest story-teller ever, Jesus, was into fiction; no, seriously, look it up.  No one thinks that The Good Samaritan was actually Jesus’s crazy Uncle Tonoose or that The Prodigal Son was a kid he knew from school.  They were Parables; stories that taught lessons at a dozen different levels.

My first aviation novel: The Air Crash Files: Jet Blast, gave the reader a seat up front into the machinations of Accident Investigation.  But it also came with a warning and a lesson; a chance for the aviation industry to step back and take stock of where we are going at light speed, perhaps to slow the ‘roller-coaster’ process down before it gets away from us.

My second novel came out on September 18, 2017.  The Air Crash Files: Thermal Runaway, takes the aviation industry into alien territory – its own day-to-day activities.  Introduce an unknown entity into the everyday and, if not respected, it plays like pure Sodium and Water; like mixing humans and dinosaurs in Jurassic Park; the ‘normal’ becomes ‘chaos’.  Something that is not considered when introducing a new product into the industry, is how that product cannot adapt to the everyday ways of the industry.

For example, it is interesting to see how a UAV is being assimilated into the National Aerospace System (NAS).  The UAV began as a hobby, until the military found a defense capability; it exploded onto the NAS in an unrestrained frenzy of amateurs and professionals dragging the UAV into controversies of safety versus utilization; it’s a long fight.

In a far less highlighted position is 3-D printing.  This evolving technology, although not as controversial, still needs to be proven safe, a fact hampered by cries for approval tempered by concerns for safety.

NOTE: I am proud of my novels because they can be read by someone as young as an eight-year old; there’s no profanity; no adult situations in Jet Blast or Thermal Runaway.  What would be the purpose or need?  I strived to create works that my Grandson could read then discuss with me later.  And isn’t that the point of writing: to reach the people best influenced by what they can learn?  Give them something to dream about doing?

Thanks to Basil Jackson, it worked for me.

Aircraft Accidents and HAZ

Did you ever watch an Arnold Schwarzenegger movie?  I swear airliners, trucks, cars, motorcycles, unicycles, skate boards, Big Wheels, roller skates … they all explode with such ferocity all from a fender-bender type impact.  I would find it believable if all the bad guys were driving Ford Pintos (I guess you younger folks will have to look that up), but they’re not.  My favorite is Bruce Willis’s character, John McClane, opening that engine valve on the B747’s #2 motor … you know, that secret valve that starts dumping fuel like Niagara Falls, so he can ignite it with a common lighter and explode the airliner on take-off.  I can’t tell you how many accident investigations I was on where THAT’s happened.

No, seriously, I really can’t … um, tell you.

It’s Hollywood; the brighter, louder, more fantastic the explosion, the more aviation people scratch their heads going, “Did he just open a valve on the … where did he find that valve?”  We recognize that movie makers are going for the Wow! Factor; it’s understandable.  After all, Hollywood is having such a hard time with believability these days.

Talking about things that go ‘PHOOM!’ in the flight, last week the Federal Aviation Administration (FAA) proposed a fine of $50,000 dollars (yes, that’s four zeroes) against a shipping company in France for violating United States (US) Federal Hazardous Materials (HAZ) Transport regulations.  The fine was set for shipping six plastic bottles of liquid disinfectant spray (think the French version of, e.g. Lysol) on two American Airlines flights from Blagnac, France through Dallas, Texas, then onto Nuevo Leon, Mexico.  The bottles were not labeled properly as hazardous materials, which they are.

Meanwhile, in Charlotte, NC, a shipping company violated US hazardous laws by shipping 142 lithium batteries in checked baggage; they are also being fined fifty thousand dollars for not notifying American Airlines of the batteries on two flights connecting Charlotte to San Francisco, via Dallas.  All-in-all, a busy week for American Airlines’ Dallas Operation.

Lithium batteries – charged or uncharged – are prohibited from being shipped as air cargo on US passenger airliners; only uninstalled spare batteries are allowed in check-in baggage; even so, there is a limit.  Lithium batteries are suspected to have been involved in the UPS flight 1307 inflight fire in Philadelphia, PA; the FedEx flight 1406 in Newburgh, NY; and the UPS flight 0006 fatal inflight fire in Dubai.  There is a legitimate safety concern with shipping lithium batteries in large quantity, especially in a cargo hold that has flammable bags, clothing and boxes that are inaccessible to the flight crew, as in ValuJet flight 592.  Luggage that is loose in the belly of a narrow body aircraft is a problem; having the luggage containerized in a wide-body airliner is more difficult to extinguish.

Where the French shipper erred was that they violated the International Civil Aviation Organization’s (ICAO) rules for transporting HAZ – Annex 18: The Safe Transportation of Dangerous Goods by Air – and ICAO’s Article One: The Contracting States Recognize that Every State has Complete and Exclusive Sovereignty Over the Airspace Above Its Territory.  Article One covers flights into, out of and over each member state, e.g. the US, France and Mexico.  These rules are different for each state; some are stricter than others.  ICAO, originally comprised of the Allied Nations of World War II in the 1944 Chicago Convention, before expanding to include 191 separate states, determines international agreements in relation to aviation.

But let’s be clear: HAZ is not to be taken lightly.  For instance, certain HAZ materials can become an aerosol on contact with atmosphere; if drawn into the air conditioning system they can blind or cause dizziness to the pilots … you know, those men and women flying the airliner.

How are Hazardous Materials classified?

  1. Class 1 – Explosives
  • These are divided into projectile, mass explosion capabilities or fire hazard.
  1. Class 2 – Gases
  • Divided into flammable, non-flammable and toxic gases
  1. Class 3 – Flammable Liquids
  2. Class 4 – Flammable Solids
  3. Class 5 – Oxidizing Substances
  • Divided into oxidizing substances and organic peroxides
  1. Class 6 – Toxic and Infectious Substances
  • Divided into toxic and infectious substances
  1. Class 7 – Radioactive Materials
  2. Class 8 – Corrosives
  3. Class 9 – Miscellaneous Dangerous Goods

In a cargo aircraft, HAZ is isolated and controlled.  While some can be loaded with other freight, e.g. magnetic materials, they still have to be kept a safe distance from aircraft wiring and electronics.  Other Restricted Materials, aka ORMs, e.g. dry ice, must be limited in quantity; they go directly from a solid to a gas; they give off ‘smoke’ as a byproduct.

How the HAZ is isolated is by containerizing it.  Unit Load Devices, aka Containers, designed to carry HAZ are completely metal, including the door.  This is because metals, e.g. aluminum, have a higher burn rate than plastic or collapsible Containers.  The metal doors form a better seal that keeps oxygen out and the smoke in.  The HAZ Containers often have a corrugated floor, not so much for strength, but to channel HAZ liquids away from other HAZ freight.

The bigger the aircraft, the broader the options for shipping HAZ.  A narrow body aircraft might contain a single position (or station) of HAZ, while a wide-body cargo jet can have up to three different HAZ Containers, all located behind the cockpit.  Each HAZ Container has netting to separate the HAZ freight from each other, since certain HAZ cannot be located next to, below or on top of other HAZ freight, e.g. Corrosives and Flammable Liquids.  If there’s a spill, the corrugated floor prevents the corrosive fluids from a leaking drum on one side of the HAZ Container, from coming in contact with a flammable liquid drum on the other side of the HAZ Container – it could happen.

The HAZ is separated, restrained and enclosed inside the HAZ Container.  There is one more safety measure to protect the crew and aircraft: the extinguisher system.  Quite simple, yet effective, each HAZ Container is assigned its own fire bottle/extinguisher.  Restrained against a bulkhead or the aircraft’s side wall, the fire extinguisher(s) connect to their own hose, which is routed into the separated cargo cabin; the pilot doesn’t go near the HAZ Container.  With one end of the hose attached to the bottle, the other end is attached to the HAZ Container by a quick-release adapter, located dead center, above the access door.  In case of fire, the pilot breaks the safety on the bottle and shoots the extinguishing agent directly into the HAZ Container.

The reason cargo airlines ship HAZ freight is simple: money; lots and lots of money.  If done right and according to the rules, shipping HAZ freight is as harmless as shipping a suitcase full of cotton pajamas.  Perhaps I shouldn’t use that analogy: I hear Hollywood is filming a remake of the Doris Day classic: The Pajama Game, starring Arnold Schwarzenegger; and I’ll bet cotton pajamas will be bursting into flames all over the screen.

“Que Sera, Sera … Baby.”

Aircraft Accidents and Lessons Unlearned V: N6142N

The earliest recommendation that a phenomenon called the Bermuda Triangle (aka The Devil’s Triangle) exists dates back to 1950; the points of the Triangle were set at Miami, Florida; San Juan, Puerto Rico; and the island of Bermuda.  This ‘mystery’ region was the cause of much inaccurate speculation for the disappearances of several aircraft and maritime ships, amounting more to ghost stories and not given credit as scientifically based research.

The attraction of the Bermuda Triangle was not in its actual existence, but in its tally of unsolved ships and aircraft.  The fascination of not being able to solve a mystery is why we read books, watch TV and engage in movies: a chance to outguess the unknown.  But what happens when the aircraft is within reach and the owner/operator will not have the accident investigated?

On July 28, 2017, a privately-owned Beech 19A Musketeer Sport, crashed in the Kunia Loa Ridge Farmlands, north-northeast of Makakilo, Oahu, Hawaii in the middle of a Nature Reserve; three passengers and the pilot were killed upon impact.  These victims join hundreds of other tragic events that resulted from aircraft impacting terrain, so no special note should be made about this particular flight or these particular victims.  However, this time the accident took place under what appear to be circumstances on the fast road to unsubstantiated conditions.

Unlike the missing aircraft of the Bermuda Triangle, the National Transportation Safety Board (NTSB) and the Federal Aviation Administration (FAA) have the wreckage in a place that, although inaccessible from the road, is able to be removed, if even piece by piece, by helicopter. For instance, the bodies were removed by helicopter.

According to the NTSB and the FAA, the owner has the last word on whether to recover the aircraft; Jahn Mueller, the owner of the aircraft has decided NOT to recover the wreckage.  In addition, the State Department of Land and Natural Resources has decided that the aircraft presents no threat to the environment, so they have no plans to push for removal.  Another issue, that technically has no bearing on this accident: another aircraft owned by Mister Mueller, a Piper PA-28, crashed a month earlier under questionable circumstances resulting in the injuries to the passengers and pilot.  That accident remains under investigation.

The story, as reported here, is largely dependent on newspaper input – because of the decision of Mister Mueller, the NTSB’s accident updates are delayed and incomplete.  These local news stories often result in a lot of emotional information tied in with the tragedy.  It is the responsibility of the seasoned investigator to take the emotion out of the tragedy and investigate on a tack unaffected by passionate reaction.

How this accident stands out so far from others of its kind is because the owner’s total lack of concern with cause.  What adds to the curiosity is the law, giving the owner complete control of the Probable Cause of the accident and not the NTSB or FAA.  So, let’s dismiss the emotions; instead let’s speak about the Lessons Unlearned from denying the analysis of the wreckage.

The point of accident investigation is to learn from the mistakes made and prevent them in the future; this point I have driven home consistently from article to article.  In November, I wrote about three professors from Oklahoma State University and one from Polk University writing a paper on the Pilot Detection of Small Unmanned Aircraft and the impact on the National Airspace System.  This is proactive investigating at its best; taking an emotional topic that gets obscured by the theatrics of lawyers and the tunnel-vision of lobbyists.  Instead, the group took the problem of unmanned aircraft front and center and answered the question of ‘Do they threaten other aircraft?’

So, let’s do the same and focus on the foolishness of not investigating this one accident fully.  For one, the possibility exists that the owner or repairer of the aircraft may have made a mistake in maintaining the aircraft.  Did this happen due to technician (human) error or was it due to some manufacturer’s error?  By not allowing the NTSB or FAA to put the wreckage through some post-accident testing under controllable conditions, the flying community will never benefit from the lessons unlearned.  Furthermore, people may yet die from the mistakes made by the pilot, the manufacturer or the owner.

It is that simple; the flying community will not benefit.  Those who doubt any manufacturer’s mistakes being gleaned from the wreckage, I ask them to consider TWA 800; the aircraft had been flying for over twenty years, yet a built-in error led to the explosion of the airliner at a great loss of life.  Colgan 9946 was a victim of a mistake made in the manufacturer’s maintenance manual; this on a model of airliner that had been maintained for over eighteen years.

As explained, the manufacturer of both the airframe and the engine(s) are in a position that it benefits them to not push the investigation; any mistakes made by them remain hidden as if the aircraft fell into a black hole.  This result could be exemplified by the National Airlines flight 102 accident, where a bungling investigation left more questions than answers.  Did Boeing benefit from those investigation mistakes made?

In the end, with the case of N6142N, the final decision for future recovery of the wreckage will likely be moved from the owner and placed in the jurisdiction of the insurance company who covered the aircraft; indeed, this could still be the case.  Am I suggesting that an insurance company can save the day in this instance?  Yes, in an accident, the decision on what to do with the wreckage, post-investigation, lies with the insurer.  After the owner/operator of an airliner accepts the check for the aircraft, the insurer becomes the sole owner with complete control of what is to be done with the wreckage.  In this case, the insurer should be curious as to why the aircraft crashed; it should cause concern about whether the owner/operator is a safety risk for coverage in the future.

The final outcome, months down the road, may be that this accident will no longer be a mystery.  In the meantime, as time plays out, the aviation community is less safe.  Pilots will be less confident when an aircraft like the Beech 19A Musketeer Sport is maintained; they will know that something unlearned may affect their next flight.  Until this accident is made right with a proper investigation, the four victims’ last moments will be just as mysterious as a triangle off the Florida coast.

Aircraft Accidents and Who’s On First

Did you ever see the original Vaudeville film clip of (Bud) Abbott and (Lou) Costello’s ‘Who’s On First’?  It’s truly a lost art form.  The two comedians go back and forth as Bud tries to teach Lou the basics of baseball using an imaginary team made up of players, e.g. Who, What, Why, Because, etc.  Although they share the same stage and are on the same topic, they never talk on the same plane.

A friend of mine recently asked me what roles do the Federal Aviation Administration (FAA) and the National Transportation Safety Board (NTSB) play in an accident investigation.  I asked him, “Did you ever see the original Vaudeville film clip of Abbott and Costello’s …”?

Look, accidents aren’t funny; I mean no disrespect when I write this, but the analogy has some validity; I’m not trying to be humorous, but ironic.  I’ve been trying to broach, what are to me, a couple of serious accident investigation subjects in my weekly articles.  The first is to look beyond the findings found in accident reports with my ‘Lessons Unlearned’ series; finding the lessons that were missed the first time the accident was investigated.

The second is that we, the flying public, will never benefit from accident investigations if the processes aren’t approached more seriously and the procedures revised to the year 2000 and beyond.  That means better training, investigators with experience in the field, hiring these experienced people and truly breaking the accident into the Provable and the Disprovable.  The National Airlines 102 accident, AAR 15/01, is just such an accident, missing so much that needed to be disproved as to leave more questions than answers; showing that the only thing proven was that the ambiguous video was all that mattered – that the report proved the video, instead of the other way around.  When the Blue Cover report is read with the Factual reports, the Findings become the poster children of how not to investigate an aircraft crash.

Here, in paragraph five, let’s look at the FAA’s and the NTSB’s interaction at an accident.  In aviation, there are two types: domestic and international.  In each of these there are defined roles: the FAA is the expert organization, while the NTSB, dependent on the FAA’s expertise, is unbiased and in control.  The FAA not only comes to the table with a deep knowledge of the operator, the industry they operate in and experience in the oversight of the operator, but they have the historical records for all domestic aircraft, from a Cessna 150 to a Boeing B787, from an airline to privately-owned aircraft.

An aircraft that is maintained by a manufacturer’s suggested program and Title 14 of the Code of Federal Regulations (CFR), Federal Aviation Regulation (FAR) Part 43: Maintenance, Preventive Maintenance, Rebuilding and Alteration, the FAA provides a Blue Ribbon package.  This includes pertinent information to the aircraft itself that is researched.  For Air Carriers (14 CFR Part 121) or Air Taxis (14 CFR Part 135) who maintain their aircraft under an approved Maintenance Program, the Operator has this information in their records.  This information is presented to the NTSB Investigator to include in his Factual report along with other important data that spells out what the aircraft facts are, weather conditions, flight rules and pilot information.

The Aerospace branch of the NTSB, as an impartial organization, heads the various investigatory groups, e.g. Operations (including Pilots), Aircraft Systems, Air Traffic (if necessary), Structures, Engines, Aircraft Maintenance and Airports (if necessary).  Assigned to each group are representatives of the major players in the accident: the FAA, the air carrier, aircraft manufacturer, engine manufacturer, Airports (if necessary), any Unions (if necessary).  The FAA will shadow the NTSB; the FAA is a major resource for the NTSB to tap during the investigation and provides any oversight information available.

As I found as an NTSB accident investigator during aircraft maintenance investigations, the FAA is invaluable; they understand the operators’ culture, and the industry; they are fluent in the regulations, guidance and policies.  Furthermore, they can be a technical foil to the manufacturers and the air carrier in that they have access to all pilot and technical training.

The NTSB is 90% dependent on the FAA during the original stages of the investigation.  During the classes I teach to inspectors, investigators and industry, I make sure they understand how this relationship works.  Not all participants in accident investigation are on the level; aside from finger-pointing, participants can go to great lengths to protect their companies.  It is the FAA’s experience that keeps the parties in line; the NTSB has little experience with industry cultures and no experience with the regulations, policies or day-to-day activities of an air carrier.  The NTSB is the coordinator of all activities; they schedule testing, conduct interviews, assure all parties participate and, of course, they write the reports.

The FAA does not assign any inspectors from the accident airline’s oversight office to the investigation; this prevents the hiding of any skeletons of its own.  As with all inspections, audits or investigations, the FAA utilizes inspectors from outside the airline’s region to avoid the appearance of bias.

As the testing phase, interview phase and, if necessary, the Hearing, take place, the NTSB takes front and center.  They run the testing, determining what simulations will be made and how the run-throughs will proceed.  The FAA takes an inactive part here, joining the other observers; their activities are minimal.  The FAA helps with the scheduling and offers advisory support, but that’s about all.  After testing is concluded the NTSB spends the remaining time fine-tuning their reports.

With interviews, the NTSB takes the lead.  During interviews, all parties – including the FAA – can be excluded, if the interviewee requests it; all but the NTSB.  Each party member, however, is supplied with a transcript of the interview afterwards.  It was my experience as an accident investigator, the interviewee had never cut the FAA from the interview; I, personally, always thought it would show bad mojo to cut the FAA out.  After all, it wouldn’t be a good optic and would probably raise suspicions.

With the Hearing, the FAA joined the other parties in the process of asking questions.  I’ve always found the Hearings to be a Gladiator match; a place where one person or entity is tied to a post; the hungry lions and tigers let loose on one occupant of the ‘Hot Seat’, who becomes lost under the barrage of starving cats.  This is an arena focused more on politics than safety; where ‘gotchas’ are the competition of choice; where each party to the accident is given a chance to stake a claim or be staked by someone else’s claim.

With an International accident, the NTSB is invited to consult; sometimes many NTSB investigators are represented.  This, however, does not mean the NTSB runs the show.  In this, the FAA has a more prominent role.  The FAA is more familiar with foreign aviation culture.  It is the FAA the foreign accident investigation group turns to for advice and guidance.  The NTSB only plays a consulting role; one that is very limited and always secondary to the FAA’s presence.

This is not to say the relationship is a close one between the FAA and the NTSB, in either the Domestic or International investigations.  The investigatory procedures used haven’t changed in decades; the dance the NTSB and FAA stumble through often end with the FAA being frustrated with the NTSB’s naiveté, while the NTSB often puts the blame squarely on the FAA.

As it stands, during the investigation, the NTSB and the FAA have their assigned jobs; they respond to their responsibilities.  The front-line professionals get along and move through the investigation, for the most part, in cooperation.  Unfortunately, it’s the upper echelons in both agencies that gum up the works; in other words, Management gets involved.  And that’s where the Abbott and Costello analogy comes in, that while the NTSB pushes their Recommendations based on unfamiliar objectivity, the FAA tries to fix problems based solely on their experience, often the same experience that allowed the aircraft to crash in the first place.  Just like Bud and Lou, they talk at each other; they say a lot, but then nothing at all.  They frustrate everyone involved, turning the investigation into a shadow of its former self; becoming lost in the minutiae of the blame game; opportunities are wasted; very little is solved.

Ironically, if everyone is able to get back to the point mentioned in paragraph five and slowly move forward, giving the investigation priority while showing the media the door, progress would be made.  The NTSB investigators and FAA inspectors would benefit from better cohesion.  Imagine the great leaps forward in safety, made from cultivating an improved symbiotic relationship between the FAA and the NTSB; how that would benefit the flying public.  We would be a safer industry, confident in the integrity of every mode of transportation.  So, why do the Powers-That-Be not create more coherent procedures for defining the changing roles of the FAA and the NTSB in accident investigations?  I don’t know.

But the answer has to be better than … Third Base!