Aircraft Accidents and Unfortunate Responses

A Greek, a Hindu and an Egyptian meet in the desert … No, that’s not the lead-in to a joke. It is the first chapter in the complete and unabridged novel by Lew Wallace, Ben-Hur: A Tale of the Christ. In the story, Judah Ben-Hur becomes consumed by vengeance against the Roman government; the thought of retaliation occupies his mind. It is only in his second meeting with the Christ that he understands his self-destructive ways and forgives those who wronged him. Judah learned to understand before he acted and let fall the sword from his hand. He learned to think … before he spoke.

Recently, the National Transportation Safety Board (NTSB) announced online that the July 14, 2020, Atlas flight 3591 NTSB accident Hearing “a success”. All the NTSB findings and recommendations would make the final report. At last, the NTSB would inform Industry what went wrong. This news generated talk and … some unfortunate responses.

Atlas 3591 crashed into Trinity Bay on February 23, 2019. The NTSB first updated the investigation on their website: on March 5, 2019, ten days after the accident, where they announced an initial Cockpit Voice Recorder review. Then – NOTHING. For 289 Days – Forty-One Weeks – Nine Months – nothing but chirping crickets. A review of the NTSB website showed that there were no other major aviation accidents in work. Then on December 19, 2019, the NTSB posted Atlas 3591’s Hearing would be on July 14, 2020, which was still another Seven Months later. The docket was finally open. Important updates? Go look in the docket.

This needs to be clear: the B767 (accident aircraft) is one of the most popular Widebody passenger airliners in the world, certified to fly 3 to 4 hours away from land on one engine. As per the Boeing website, One thousand and ninety-one B767s of all versions have been sold to air operators and the military around the world – 1255 with those ordered. Some major airlines brag upwards of 70 to 90 B767s in their fleet. The B767 can carry upwards of 269 passengers (not counting crew) onboard. Yet, it took 497 days to learn anything substantial about this popular airliner. It was unthinkable to have a 497-day information blackout, to leave industry in suspense for 1.5 years. It was a disservice to safety.

In response to the July 14th Hearing announcement, I commented online, “I find it troubling that an accident involving one of the industry’s most popular airliners, the B767, took almost ten months before the Public Docket opened … that seventeen months passed before the hearing was conducted.” A widebody airliner pilot responded to my comment, “Amazing how the Kobe Bryant crash investigation has been expedited, but this [Atlas 3591] took 1.5 years?” The airliner pilot’s observation was accurate. The Kobe Bryant (KB) helicopter accident investigation’s docket opened in 143 days – two times faster than Atlas 3591’s.

However, the airliner pilot’s response challenged the mindset of today, that no one should question government agencies, like the NTSB, even when they put public safety at risk. An NTSB manager responded to the airliner pilot, “Not a bad idea to get your facts straight before posting ridiculous accusations. The accident which claimed the life of Kobe Bryant and 8 others has not been completed. And furthermore, the NTSB didn’t have to spend 8 weeks digging through muck to recover parts on the Kobe Bryant crash.” This … was an unfortunate response. The manager’s statement was condescending. It was indicative of an NTSB that treats public reaction with indifference.

This is a problem. To dismiss a derisive comment is understandable, but to show disdain over a factual statement, albeit with some cynicism, is another. The airliner pilot’s skepticism was the result of his frustration at the NTSB’s ‘slow-to-action’ attitude towards Atlas 3591’s investigation. The purpose of safety recommendations and reports is to generate conversations among those in industry, to encourage research and development. Dismissing an aviation professional’s voice discourages this vital dialogue.  

No person should believe that government agencies are always right; to suggest that they can never be wrong, would be absurd. “Not a bad idea to get your facts straight before posting ridiculous accusations”? How unnecessary. An accusation? It was not. Furthermore, the manager’s response was sarcastic and unprofessional. The NTSB is a government organization, funded by taxpayers. The general public’s comments are expected and welcome, especially when based in fact.

It is true that government does not create jobs or prosperity; government also does not improve safety. Only government believes otherwise. Government is a referee, an umpire, a neutral outsider whose job is to assure everyone follows the rules. What rules? The regulations industry helps to write. NTSB labs do not create safe products; NTSB recommendations do not generate aviation safety. Manufacturers, air operators, repair stations, pilots, mechanics, flight attendants, aviation schools, air traffic controllers and the flying public; these folks make aviation safety possible. They are the check and balance. Because of their safety contributions, we are assured industry will survive with integrity.

Look at the timelines: the KB helicopter accident docket opened in only 143 days. The Ethiopian Air 302 B737-MAX accident investigators presented their FINAL report in twelve months (March 10, 2019 to March 9, 2020). The NTSB provided findings and recommendations for Ethiopian 302 and Lion Air 610 within that timeframe. Why? Neither 737-MAX accident was an NTSB investigation. Where was the urgency to improve safety with Atlas 3591? Why did it take 289 days to open Atlas 3591’s docket? Aviation professionals should have asked why.

In May 2002, as an NTSB investigator, I assisted Taiwan’s Aviation Safety Council (ASC) with the China Airlines 611 investigation, a B747 that was in pieces on the China Sea floor. An NTSB Structures investigator quickly discovered the root cause, relayed the information to the ASC. By August 2002, the ASC told industry and safety fixes were expedited. Information was delivered in a timely manner.

What about the next part of the NTSB manager’s unfortunate response? “The accident which claimed the life of Kobe Bryant and 8 others has not been completed” is odd. Not for using Mister Bryant’s name. Often accidents refer to their celebrity victims, e.g. JFK Jr or Payne Stewart. It was the, “… and 8 others …” that was odd. What do accident fatality numbers have to do with fact-based analysis?

Since my days working NTSB major accidents, I have found it strange that accidents involving cargo or with low profiles, e.g. low victim count, receive insufficient attention. For example, in 2001, Emery 17 (three pilots) took almost two years to reach a limited Hearing. Colgan 9446 (two pilots) was not given a full Go-team or Hearing. National 102 had an investigator-in-charge with zero previous major accident investigation experience. Fine Air 101 (four crewmembers) had unqualified investigators. Why?

By exploiting the death count, the NTSB manager assumed (incorrectly) that emotional disputes are relevant. Were the “8 others” helicopter victims more important than the three in Atlas’s B767? What about the unnecessary risk to the thousands who flew on B767s with possible unknown problems for 1.5 years? Emotional disputes had nothing to do with either accident. To use the “8 others” to somehow justify the Atlas 3591 delay was absurd. Emotions have no investigatory substance; they are devoid of facts. Did pontificating about victim numbers help find root cause or were they just a distraction? 

Take a look at the emotional arguments for destroying history by removing statues of our Nation’s Founders. Why? Will it erase the sin of slavery? Won’t the memory of former slaves and abolitionists be erased as well? Should the Pope push to have the Roman Colosseum leveled for the Christians that were slaughtered there? Should Jewish leaders raze Auschwitz or other Nazi labor camps; remove Passover from its calendar, just because they are reminders of suffering?

The NTSB manager then dug in his heels: “And furthermore, the NTSB didn’t have to spend 8 weeks digging through muck to recover parts on the Kobe Bryant crash.” Was this defensive slap because the NTSB’s authority was questioned? “… digging through muck?” Another unfortunate response.

I make no secret of my criticisms of NTSB investigations. But the NTSB investigators I worked with, those investigators on-site, whether qualified by industry standards or not, chose to ‘dig through muck’ because that is what accident investigation is. Whether on a mountainside or in a field in Kansas, all accident investigations, by the NTSB or any other organization, are the pursuit of facts and truth; the pursuit of root cause; the pursuit of aviation safety, no matter the effort or conditions.

For every emotion, there is an equal and opposite counter emotion (apologies to Sir Isaac Newton). The NTSB manager demonstrated that emotional overtones are not welcome in professional discourse. His unfortunate responses devalued those NTSB investigators’ efforts who put forth some good work.

The government is not the answer to safety. Aviation safety’s only hope in this everchanging technological world will come from timely facts, entrepreneurship and those who make safety improvements each day. Aviation safety does not pivot on government intervention. That point being made, it is our obligation to question all government analysis, especially when it comes to safety. In addition, free and open dialogue among influential aviation professionals should never be discouraged by government bureaucrats who spout … unfortunate responses.

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