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!

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