A glimpse at how NTSB conducts investigations
Less than 10 percent of an aircraft accident investigation takes place at the scene. After an initial seven to 20 days on-site, the process moves to file cabinets and back offices; parts, maintenance and service suppliers; and government and industry laboratories. On average, six months of post-accident meetings are coordinated from a local command center; most often the ballroom of the nearest hotel. One investigation lasted four-and-a-half years. If you become a “party” to an investigation by the National Transportation Safety Board (NTSB), you have committed your time for the duration.
The NTSB investigates aviation accidents involving U.S. aircraft other than those operated by the armed forces or intelligence agencies. As an independent federal agency, the NTSB is charged with determining the probable cause(s) of accidents falling within Department of Transportation oversight, which boils down to “barges, buses, planes and pipelines.” The NTSB conducts studies and makes recommendations to help prevent the recurrence of accidents and coordinates resources to assist accident victims and their families.
Ideally, the NTSB staff will never have reason to meet your staff “on the job.” But tragedy does happen, so the agency has tried to educate the industry in advance, hoping to ease the blow should an “event” occur. Several years ago a former chairman of the NTSB developed a PowerPoint presentation addressing what it means to be a “party” to an accident investigation, what it may cost, and how you can help yourself when the government arrives to help you.
The course has since evolved to become the NTSB Academy, where 300 industry participants pay $100 for a one-and-a-half-day Aviation Industry Training Program that includes a hard copy of the PowerPoint; a certificate of attendance; and icewater. As a condition of attendance, AIN agreed to NTSB requirements to omit names of attendees, presenters and specific investigations in this report.
The program ran April 30 to May 1, and the roster of 70 attendees included representatives of major airlines, Part 91 and Part 135 chief pilots, directors of safety, aviation schools, alphabet staff, a fractional services provider, maintenance technicians and military personnel. All told, one-third of attendees were corporate operators, but they generated two-thirds of questions because the content focused on the airline side.
The NTSB can act only on a narrow definition of “accident,” meaning an occurrence associated with operation that takes place between the time any person boards with the intention of flight and all such persons have disembarked, and in which any person suffers death or serious injury, or in which the aircraft receives substantial damage. A fatal injury is defined as an injury that results in death within 30 days.
A “party” or participant is as carefully defined. At the beginning of an investigation the NTSB invites organizations (such as the operator, manufacturer and affiliate unions) to contribute technical support. Only company employees are eligible to be parties and attend the organizational and progress meetings; no technical advisers, lawyers, company media relations or insurance personnel are allowed, though the company can hire such resources at its own expense on company time and property. If you are designated as a party, all costs are your own responsibility.
Parties typically meet for the first time at an organizational meeting established at a hotel, school or conference center near the accident site, chosen within the first several hours. If you think you are a party, the best procedure is to call the 24-hour NTSB communication center to make the determination and, if so, learn when and where to report. By law, the FAA is a party to all investigations. The organizational meeting is closed to all but the parties as narrowly defined, though may include official observers such as the ATF, the Postal Service or congressional staff.
Only after the initial organizational meeting do parties visit the actual accident site, which is a dangerous place from its “blue water” carrying biological hazard, metal shards and pressurized items. The NTSB Go-Team is dispatched to a site within two hours, but by intention no earlier; the NTSB philosophy is to let the emergency crews handle immediate needs but then arrive early enough to preserve evidence. Parties are expected to supply and pay for their own hazardous material protection, and the NTSB recommends that smaller operators use one of the companies specializing in standard hazmat packages; the suits and support items can be shipped to meet one’s staff at the site.
A full Go-Team is dispatched to major accidents–those involving a major carrier or regional airline having substantial damage, multiple injuries or deaths. A partial Go-Team may be dispatched to non-fatal accidents or incidents that involve safety issues or circumstances that warrant investigation, such as for newly certified aircraft, air traffic control issues and accidents generating a significant public interest, for example those involving a celebrity.
If there were hazmat materials on board the aircraft, tell the NTSB immediately. Corporate operators are advised to instantly tie down their dispatch package, maintenance package–“the whole load,” as one NTSB staffer said. Ask yourself: what can the Safety Board use that is in my office? Are there computer records and, if so, do we have access, for example if the function is contracted? If you’re a small operator and your maintenance is outsourced, can you retrieve the records in a complete and timely way? All of these materials are eventually due at the command post.
For most Part 91 and Part 135 accidents, the Go-Team is likely to consist of a single person from one of the 10 regional offices rather than from D.C. headquarters. The NTSB may provide on-site disaster assistance if there are six or more fatalities, and telephone assistance if there are fewer. The NTSB has found that, as a rule, half of the people designated by a small operator to act as its party cannot keep to the schedule. In some cases the people walk away once they have absorbed the realities of an accident scene–both emotional and economic.
If your party leaves or is asked to leave an investigation, substitutions are usually not allowed. Larger companies or those likely to be a frequent party, such as a manufacturer, facilitate their immediate response by keeping support items, such as personal clothing, ready to ship on the party’s behalf, and by keeping contact in a variety of formats and at all hours.
Though parties must cooperate, an interviewee has the right to representation, the right to protection from self-incrimination and the right to exclude the FAA from his interview, though he cannot exclude any other parties. Later on, the FAA gets all the paperwork anyway, and the reports become public information. The NTSB cannot grant immunity from prosecution or ensure confidentiality.
Local law enforcement usually wants nothing to do with aviation accidents, so the NTSB is eased into its role, commanding all functions including that of press spokesperson. The NTSB asks media to concentrate on its board member or inspector in charge (IIC) as a single source. Though reporters are often aggressive, they can be helpful in bringing witnesses to the NTSB’s attention, and in some cases even helping NTSB or emergency responders to pinpoint the location of the crash and related materials.
The NTSB advises that the safest response to media or customers is always, “It’s under investigation by the NTSB.” Honesty is your best friend, and you can always say you don’t know; in fact, parties can be removed for saying anything more. Another set of magic words the NTSB offers is, “It appears there are no survivors.” Though a CEO of a Part 91 company is not legally required to say anything, commonly accepted practice is that he or she should at least offer condolences. The NTSB can coach on sensitivity and composition.
Operators sometimes overlook the fact that flight attendants are part of the crew and that an accident involving their serious injury must be reported, though that doesn’t mean it will be investigated. Part 91 and 135 operators asked about hypotheticals; for example, would an attendant who is on the crew manifest but not on active duty need to report a scalding burn from a coffeepot? Generally, it’s best to report, even if the NTSB does nothing more than file it.
When the flight data recorder and cockpit voice recorder–the so-called black boxes that are, of course, orange–are found and delivered to the NTSB, the occasion is frequently a media photo opportunity. The boxes are usually cracked open within an hour of receipt and the tape heard within a half hour later. These items are the highest-density material mounted in the tail section and are typically ejected in an accident. Commonly, someone finds the flight data recorder and mistakes it for the cockpit voice recorder, removing it from the crash site before the real CVR is found and unknowingly destroying important clues to finding the rest.
Though the bulk of course content and examples apply to the major airlines, smaller operators did glean some tips. For example, the NTSB applauds the policy of airlines that have a “no-fault go-around policy,” saying that corporate operators should adopt the same. The NTSB also asks operators to report all birdstrikes, regardless of seriousness, for inclusion in the FAA’s database, warning that a major bird-related disaster is overdue and the reports may help in prevention.
More than 80 percent of NTSB safety recommendations are accepted by the FAA. The remainder are judged to be too contentious, costly or technically infeasible. Several attendees remarked that the NTSB has a long memory with regard to recommendations that are not adopted but which later lead to crashes, and dramatizes its “most wanted” list of recommendations on its Web site. Some 80,000 searchable NTSB accident reports are available online.
Few pilots or small operators know that the NTSB is also the final, non-court outlet for relief from certain regulatory actions, beyond which the matter moves to federal court. The NTSB acts as the appeals court for airmen, air carriers and mariners on the suspension, amendment, modification, revocation or denial of any operating certificate or license or assessment of civil penalty issued by the FAA.
The next cycle of the Aviation Industry Training Program will be held in October at the Safety Board’s new NTSB Academy on the Ashburn, Va. campus of George Washington University.