Meet the NTSB: Partners in Prevention

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“Oh my God, he crashed!” There is an immediate hush over the crowd of spectators, peppered with comments of disbelief.  From behind the trees, beyond the airport perimeter, the dark smoke rises into a crystal blue sky. The noise of the crowd is quickly drowned out by the sound of sirens on emergency vehicles as they race to the scene, hoping that they can get there in time to save the pilot.   

For the other air show pilots, doubt immediately takes hold.  They look at their airplanes and in their minds start to ask: “What kind of airplane was Joe flying? Was it the same model as mine? What if there is a defect with the flight controls or the engine?  When was my last annual inspection?  What about the weather up there?  Is there clear air turbulence that I didn’t catch in the weather briefing this morning?  Maybe he hit a bird.  Am I at risk?  Am I going to fly today?” 

The air show coordinators may be wondering if the show’s structure, schedule or venue had something to do with the accident. The air boss is wondering about the briefing they gave earlier that morning. “What if Joe missed some key element that I briefed?  What if I forgot to brief something that contributed to this?” And though these thoughts will be dealt with in greater detail later, city officials, the airport, the show promoters and show organizers are already thinking about what this does to the show.  Do we cancel the whole show or do we go on?  Can we go on with an accident site off the end of our runway?  What will the FAA say and do?  What about the people who are going to have to come in and investigate what happened?  Is that the NTSB that does that?

Who is the NTSB?

To the public at large, the NTSB is the group of people in Washington, D.C. who travel to the sight of a major airline crash. They go after the black boxes in the hopes that the voice recorder will have preserved critical information that might provide NTSB investigators with the clues necessary to determine what caused the accident.

In fact, the NTSB is the nation’s transportation guardian. They are the crash investigators for accidents involving trains, ships, commercial highway vehicles, pipelines, and aircraft. More importantly, the NTSB is the agency that recommends to industry and other government agencies the changes needed to make transportation safer.

The NTSB is actually a five-member council, each member a Presidential Appointee, confirmed by the U.S. Senate. One member is designated as the chairman; another member, the vice chairman. Board member appointments are for five years. The chairman’s term is for three years. These five members are, by law, the persons who determine the probable cause of transportation accidents. But before the Safety Board can get to that point, a staff of investigators, scientists, and engineers will investigate the facts and circumstances surrounding an accident. Those people will identify key safety deficiencies that set up the conditions in which the accident occurred. And, they will prepare a factual report and propose recommendations for the Safety Board to consider.

For all its importance to the nation’s transportation industry, the NTSB is one of the smallest in the Federal government.  At 385 members strong, the Office of Aviation Safety is the most visible and the most active NTSB division.  During the course of a year, the 70 investigators assigned will conduct over 1,500 accident investigations involving substantial damage to aircraft and serious or fatal injuries to people. Air Safety Investigators (ASIs) will travel the world in support of U.S. manufactured or operating aircraft involved in mishaps.  The cases can be major in scope, as in the crash of a passenger jet; or it can be local, as in the crash of a general aviation airplane.

But regardless of the size and scope of the accident, the mission of the NTSB is the same and is applied the same in each case: investigate the accident so as to determine the cause; identify the safety deficiencies that contributed to the accident; and then make recommendations for change, so that similar accidents don’t happen again.  There is a secondary and subtler mission performed by the NTSB through the investigative process; reassuring the public that transportation is — and will remain — safe.

The First People You’ll Meet

In the moments following an air show accident — someone, usually the FAA’s inspector on sight — notifies the NTSB investigator on-call.  The NTSB has investigators assigned to nine regional offices throughout the country.  The regional offices are responsible for responding to accidents that occur in the states within the regions.

For example, if an accident occurs at Santa Fe, New Mexico, the NTSB’s Central Mountain Region in Denver, Colorado, will be notified, as they have responsibility to respond to accidents occurring in Colorado, Wyoming, Utah, Kansas, and New Mexico.

Although they may be several hours away from the accident scene, NTSB Air Safety Investigators are already gathering and preserving vital information important to the investigation.  Even before they travel to the accident scene, ASIs will talk to airport officials and law enforcement to ensure that the accident site is secured so that key evidence is not disturbed.  They will request that the FAA inspectors at the scene talk with the air boss and air show officials and begin gathering statements, briefing notes and records pertaining to the pilot and his or her aircraft.

What Information Should be Gathered Right Away?

Your role with the accident or the victim will determine what you should gather and preserve for NTSB investigators.  If you are part of the pilot’s support team, gathering the aircraft maintenance records and all information you might have on the pilot or his aircraft is vital.

If you are the air boss or played a role in the briefings preceding the show, you will be asked to provide a statement and, if you have them, copies of materials you used during your briefing.

If you are a friend or a colleague of the pilot, you probably know something about the pilot’s activities during the hours or days preceding the crash.  Your information could be vital to the human factors study that the NTSB will do when assembling information on the pilot.  It is important that you identify yourself to the FAA or air show officials as soon as you can.

Air show coordinators and announcers can be key facilitators in gathering important evidence for the NTSB.  An announcement should be made, asking anyone who thinks they may have recorded or photographed the accident to meet air show officials at a designated location.  They could very well hold the key images that can help investigators determine what happened.  There is no law or requirement for anyone to give up these items and no official should coerce anyone into giving up his or her cameras or videotapes.  People who do this are providing a service to the public.  When receiving these items, it is important to get addresses and phone numbers from the people providing the discs, so that the NTSB can return them. Typically, once the investigator has copied the tape or downloaded the images to another device, the investigator will promptly return the items to their owners.

When an air show accident occurs, hundreds if not thousands of spectators will witness the accident.  Again, this is where air show coordinators and announcers can be of great help.  The NTSB does not have to interview each and every person who saw something and most likely won’t, and spectators are not obligated to provide witness statements.  But if people want to write out a statement and provide contact information to air show officials to be later turned over to the NTSB, an announcement to the crowd as to where to deliver those statements would be helpful.

It is important to act in the moments immediately following the accident.  The crowd goes home and those key people leave during the hour or two after the crash occurs.  Once they are gone, video evidence, and people’s impressions and observations will be difficult to gather, if not lost for good.

When the NTSB Arrives

Safety Board investigators in the regions can be on a commercial flight heading toward the accident scene within a few hours.  Prior to that, however, investigators pull together their team members.  They will request support from airframe and engine manufacturers.  If the aircraft is foreign manufactured, there are International Civil Aviation Organization considerations.  Investigators have to gather information about the environment in which the accident took place. Terrain, weather, time of arrival on scene, and city and state infrastructure all play into the investigator’s assessment of the risks he or she, and their team will face.

Once they do arrive on scene, NTSB investigators will meet with local law enforcement and the FAA to be briefed on what has been done up to that time. After that, the Air Safety Investigator-in-Charge (ASIIC) will determine the plan of events that the investigation will follow.

Where the accident scene is located is important and can drive the pace of the investigation.  If the crash happens in a neighborhood, an industrial park, or on a major road that is vital to the community, the ASIIC will expedite the on-scene work and get the aircraft moved as quickly as possible.  The same is true should the accident happen on the runway where the air show is staged.  As long as there is a crashed airplane on the runway or in the fields nearby, the runway will remain closed. A closed runway can mean passenger service interruption and loss of revenue for the airport and the community.  A crash on the runway also impacts the air show, especially if there are more days of aerial exhibitions scheduled.  Getting the site documented, the aircraft moved to another location, and getting the runway open will be the investigator’s first priority. Secondary to this is seeing that the air show gets the opportunity to put on the subsequent days of aerial demonstrations.

With accidents on the airport and not on the runway, but in view of the crowds, the last thing the NTSB, airport, or air show officials want is for spectators to watch investigators sift through the wreckage of a crashed aircraft.  In such cases, NTSB investigators may have the airport construct some type of barricade to mask the accident scene from the crowd.  The team might delay sifting through the wreckage until after the show is over for the day and the crowds have gone.  Positioning large fire trucks between the wreckage and the crowds is one method of blocking the spectators’ view of the crash site.  Once the accident site is secure and blocked off from the public, air show officials can resume the air show if they wish.

What the Investigators Do On Scene

The accident site holds clues to why the accident occurred.  If a site is spread out over a wide area, it’s possible that there was a lot of speed involved and that the aircraft’s attitude was mostly horizontal to the ground prior to impact.  If parts of the airplane, as a wing or an elevator, are located somewhere else, away from the main crash site, this could be evidence of an in-flight structural failure or a collision with another airplane, bird or object.

The wreckage itself holds clues as to what might have happened.  The angle formed by crushed metal on the wings, fuselage and cowlings, the direction of bending of propeller blades, landing gear, spars and stringers, and soot patterns from fire can tell investigators what attitude the airplane was in when it impacted the ground.  Investigators examine flight control surfaces and trace control cables from the control surfaces through pulleys and bell cranks to the control stick, to ensure that there was no binding or jamming that could have placed the airplane in an attitude from which the pilot could not recover.

Investigators will look at the engine for signs of internal failure that may have happened prior to the crash.  They will examine the torsional bending and rotational scratches on propeller blades to determine if the airplane’s engine was driving under power at impact.  They will determine the common heading along which the wreckage path is oriented and compare it to the show line and runway orientation.  Investigators will plot where parts came to rest on the ground in relation to the wreckage path.  They will photograph every ground scar and every piece of wreckage.  When this is done to the ASIIC’s satisfaction, the team will then prepare to gather and move the wreckage to an indoor facility.  Once relocated, the investigative team resumes examining the wreckage in greater detail.

NTSB investigators also contact the local coroner or medical examiner to gather preliminary information from the pilot’s autopsy.

While at the scene, the NTSB Investigator-in-Charge (ASIIC) will likely talk to the media.  The NTSB sees media briefings as an opportunity to reassure the public.  The ASIIC will coordinate with airport, law enforcement and air show officials for a time to hold a press briefing.  Information conveyed by the ASIIC will consist of those facts already gathered.  The ASIIC will not speculate as to the cause of the accident, but will assure the public that they are looking at all aspects that could have contributed to the accident.  The ASIIC will also stress that the investigative process takes time.  Investigations cannot be complete until all the science and engineering has been done and the autopsy and toxicology results are received.  It is not unusual for an investigation of an air show accident to take up to six months to a year to complete.

The ASIIC will field questions from the media.  Often times, the press will ask the ASIIC if he or she thinks the air show should go on.  NTSB investigators will not comment on areas that are the decision of the air show officials.  Those questions are always deferred to the air show’s spokesperson.

The on scene investigation of an air show accident can last a couple of days or a week, depending on what the team finds at the scene.  At the end of each day, the ASIIC will hold a progress meeting of all the team members.  The progress meeting is a closed meeting.  Following the meeting, the ASIIC will usually meet with air show, airport, and other key officials to bring them up to date as to the status of the investigation.

When the ASIIC is satisfied that he/she has all the information they can glean from the accident scene, the team will meet one final time to consolidate their field notes, ensure that everyone on the team is current with the information found thus far, and determine and plan any follow up testing that needs to be conducted.  The ASIIC will usually meet one last time with air show, community and airport officials to brief them on the team’s findings and to answer any questions.

In the Weeks and Months to Follow

Before leaving the scene, the ASIIC will determine what to do with the airplane wreckage. Investigators may re-visit the wreckage later to conduct further testing.  NTSB investigators will coordinate with the aircraft’s insurer to arrange for the wreckage removal, its storage, and the accident site clean up.

On his or her return to the regional office, the ASIIC will write a preliminary report of the accident.  The preliminary report is submitted — when practical — within five days of the accident.  After it is received at NTSB Headquarters, the preliminary narrative is placed on the NTSB’s Internet site at http://www.ntsb.gov/ntsb/query.asp.  The purpose of the preliminary report is to notify the public that an accident has occurred and is under investigation by the NTSB.  The preliminary report contains those facts known by the investigative team at that time.  As the investigation continues and additional facts are gathered, the information will change.

In the weeks and months following the accident, the ASIIC will continue to gather information about the accident.  Video and digital images obtained at the scene are sent to the NTSB Vehicle Performance Laboratory in Washington for enhancement and examination.  The ASIIC and aircraft performance engineers examine the products frame by frame, looking at control surface positions, aircraft attitude, propeller revolutions and other pertinent information at each stage of the maneuvers performed.  This information is compared to how the maneuvers are supposed to be performed to determine if there are anomalies with the maneuver execution.  Weather factors, such as wind conditions or density altitude and its impact on aircraft performance, are included.  NTSB investigators often draw on the experience of other air show performers who are intimately familiar with how the air show maneuvers are set up and executed in the particular aircraft.  Also during this time, medical experts will report their findings and toxicology results.

Finally, when practical, a 72-hour history of the pilot’s life is assembled to determine if any human performance issues might have played a role in the accident.  For instance, was the pilot under unusual stress?  Was the pilot well rested before the air show or was he or she seen out late the night before?  Was the pilot fighting off a head cold?  A severe head cold can affect inner ear equilibrium.  Family members who were with the pilot in the days preceding the accident may have more information.

When the ASIIC and the investigative team are satisfied that they have gathered all the evidence necessary to complete the case, the ASIIC and the staff write a factual report for submission to the Safety Board.  This report does not conclude as to the cause of the accident.  Once the report has been edited and any open questions resolved, the factual report is finalized and submitted to the Safety Board for its consideration. Also at this time, the factual narrative is placed on the web, replacing the case’s preliminary report.

While the factual report is being reviewed and edited, the ASIIC is also considering what recommendations for change need to be considered to prevent future accidents with similar circumstances from happening.  If mechanical deficiencies were found during the investigation that contributed to the crash, recommendations might be directed toward the manufacturers or the FAA. The FAA can in turn issue service bulletins or Airworthiness Directives.  If there were training deficiencies identified, recommendations might be directed toward FAA Flight Standards ensuring better oversight and demonstration of proficiency.  Issues surrounding the air show might be identified, as to where the crowd line was placed with respect to where the crash occurred, or with the sequence of show performers, possibly placing a propeller-driven airplane into the wake of a large jet that passed only moments before.  These recommendations can be formalized as proposals to the Safety Board for their approval and issuance.  There is also an informal process, where Safety Board investigators meet with air show organizers and aircraft manufacturers informally and discuss what they found during the investigation.  This method allows the people in the room to decide the best course of action to fix the problems.  This also allows for change to happen right away, where the formal recommendation proposal process, though important, may take longer.

Cases submitted to the Safety Board are usually considered within two to three months. When considering a case, the Board members can issue probable cause and accept the report as it is. They can place the report on notation; where each of the Board members must be briefed, and sign off on the report individually. Finally, the Safety Board can schedule the report to be discussed during a Sunshine Meeting.  Cases that go before the Safety Board are public meetings that are covered by the media. They result is formal and public adoption of the probable cause of the accident and any recommendations put forth by the staff.  The case report is published as a mini “Blue Cover” report.  The final report in its entirety is placed on the web.

Is That It?

Although a final report is issued and may contain recommendations for change, that is not the end of the story.  A report is just a document, and recommendations will not prevent future accidents if the industry does not embrace them.  NTSB reports are written to be read by persons with an interest in that area.  For air show performers, the report should allow them to reflect on their own skills and reassess if they are indeed planning, preparing and performing properly. Distractions, last second changes in schedules, an oil leak, a lapse in concentration, all these can contribute to the chain of events leading up to an accident.  Reading the NTSB report about the accident might provide you with some personal lessons learned.  After all, the best pilots are the ones who know that on any given day, they could be Joe, especially if they are not prepared and do not have their “game face” on when they take to the air.

For those who put on the air shows, oversee the events, and brief the performers, knowing what can lead to an accident is vital.  Air bosses might look around the room as they are giving their briefing and note, “Hey, that guy, Joe, he doesn’t look like he’s paying attention.  I better make sure he got it.”  Show officials and other pilots look around.  If you see a pilot preparing to fly and he’s dragging, or he looks pale, talk to him.  Ask him, “Are you okay?  Do you feel up to flying today?  It’s okay if you don’t.”  It could be nothing, or that gesture might be “the out” he’s looking for.  You may have just broken the chain of events leading to a fatal accident.

Finally, when you read these reports and there are things you don’t understand, have ICAS call the NTSB.  The NTSB will try to put the lead investigator in touch with you or your group to answer your questions.  The NTSB plans to present during the ICAS Convention, some of the details surrounding recent air show accidents and the lessons to be learned from those cases.

How You Can Help?

No one knows the air show industry better than the people who work at it each day.  The manufacturers and the mechanics that maintain the airplanes are the ones who know those airplanes and their associated systems best.  The instructors who teach and have performed the aerobatic maneuvers flown are the experts in how the maneuvers are set up, entered and executed.  Air bosses are the experts in orchestrating and conducting the shows.  FAA inspectors are the overseers.  The pilots who fly in the shows each week know the maneuver sequences and can readily recognize when things are not in sync.  All of you can help the Safety Board help you.  The better our investigators understand the events involved in a case, the better job they can do, and the better lessons they can put forth.  ICAS is working with the NTSB to make this happen; to link you, the experts, with investigators as they examine the evidence underlying the air show accidents they investigate.  The NTSB’s goal in working with ICAS is to help prevent the next accident from happening. The Safety Board wants to see air shows thrive and thrill spectators with exciting aerobatic flight. This can only happen with fewer accidents.  We are your partners in prevention.

Dr. David Bowling is the Regional Director for the National Transportation Safety Board’s Central Mountain Region, Office of Aviation Safety, in Denver, Colorado.  He is a Senior Air Safety Investigator having conducted over 450 aircraft accident investigations in 12 years with the agency.  Dr. Bowling holds an Airline Transport Pilot certificate and is an active CFII, MEI.  He is a former military pilot and a graduate of the National Test Pilot School.  He has flown more than 5,800 hours in over 50 different aircraft.  Dr. Bowling is the current NTSB liaison to the International Council of Air Shows.

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David Bowling
David Bowling is the regional director of the National Transportation Safety Board based in Parker, Colorado.