2 OverviewThe relationship between regulatory oversight and GA accident investigationInvestigating in the absence of CVR or FDR dataNew tools and techniques for investigating GA accidentsThe challenges of change in GA
3 National Transportation Safety Board Investigates and determines the facts, conditions, and circumstances of aviation accidentsDetermines the probable causeMakes recommendationsConducts special safety studiesDoes not have regulatory authority over civil aviationLET ME BEGIN BY STRESSING A FEW VERY IMPORTANT DIFFERENCES BETWEEN THE FAA AND THE NTSB.THE NTSB IS A SMALL ORGANIZATION - ABOUT 350 EMPLOYEES WHO INVESTIGATE SAFETY ISSUES IN ALL MODES OF TRANSPORTATION.THE FAA IS LARGE - ALMOST 50,000 EMPLOYEES WHOSE RESPONSIBILITIES COVER ALL PHASES OF AVIATION.(REFER TO SLIDE) THE NTSB IS AN INDEPENDENT AGENCY THAT ANSWERS ONLY TO OUR CONGRESS, NOT TO THE DEP’T OF TRANSPORTATION.THE FIVE NTSB BOARD MEMBERS ARE APPOINTED BY THE PRESIDENT . THE BOARD’S INVESTIGATIVE WORK IS DONE BY A STAFF OF PILOTS, ENGINEERS, AND OTHER EXPERTS IN SUCH FIELDS AS FLIGHT OPERATIONS, AIR TRAFFIC CONTROL, METALLURGY, METEOROLOGY, AND HUMAN PERFORMANCE.NEXT SLIDE
4 Federal Aviation Administration FAA has the responsibility to ensure the safety and efficiency of the United States National Airspace System (NAS)Participates in NTSB investigations, but not in the determination of probable causeDetermines if any of FAA’s nine responsibilities were involvedInitiates corrective actionTHIS IS AN IMPORTANT POINT, SO I WANT TO EMPHASIZE IT - EVEN THOUGH WE PARTICIPATE IN THE NTSB INVESTIGATIONS, WE NEVER TAKE ANY PART IN THE SAFETY BOARD’S DETERMINATION OF THE PROBABLE CAUSE.WE DO, HOWEVER, DETERMINE WHETHER ANY OF THE FAA’S NINE RESPONSIBILITIES WERE INVOLVED IN THE CIRCUMSTANCES OF THE ACCIDENT. IF ANY OF THEM WERE INVOLVED, WE IMMEDIATELY BEGIN THE PROCESS OF TAKING WHATEVER CORRECTIVE ACTION IS APPROPRIATE.NEXT SLIDE
5 The Nine FAA Responsibilities Performance of FAA facilitiesPerformance of Non-FAA facilitiesAirworthiness of aircraftCompetency of airmen, air carriersAdequacy of FAR’sAirport certification standardsSecurity standardsAirman medical qualificationsViolation of FARsTHESE ARE THE NINE FAA RESPONSIBILITIES, AND I THINK THEY DON’T NEED MUCH EXPLANATION.
6 FEBRUARY 8, 2001GATES LEAR JET 35AREPUBLIC OF GERMANYI-MOCO
11 Reality Check Significant GA Accidents Common GA Accidents Regional NTSB investigatorLocal FAA Flight Standards Inspector(s)FAA “Go Team” from Washington, D.C.Common GA AccidentsNTSB conducts a “desk investigation”Washington NTSB participation only in limited cases
12 Reality Check What this means… Other parties, such as manufacturers, often provide the majority of technical support.Both NTSB and FAA investigations are often not extensive.A tendency to put the accident in somewhat simple “buckets”A risk of missing an opportunity to learn something new.This needs to change as we see more complex new aircraft types and operations, and gain access to more data
13 The relationship between regulatory oversight and GA accident investigation Major case – Normally, the principal inspector does not serve as FAA IIC (FAA Coordinator)In many GA cases, the exact opposite is trueCertificate holder principal inspector is often the FAA IIC/FAA CoordinatorIntegrity of the NTSB investigationIntegrity of the FAA investigationNo operating certificateNo principal inspectorNo regular oversightLimited corrective actions
14 The relationship between regulatory oversight and GA accident investigation Problems-Integrity of the NTSB investigationOperator or pilot will be reluctant to share information because the FAA is asking the questionsIntegrity of the FAA investigationOperator may claim they were responding to an NTSB investigationThe NTSB is the initial avenue of appeal in cases of suspected violation of the regulationsSolutions-FAA Inspectors: Represent the FAA, forward factual information to the NTSB for their use.Ensure the operator/pilot know who the Inspector is representing
15 Other problems when only FAA assets are on-scene Access-Seldom a problem in the pastEven less so now with the Aviation Safety Inspector badgeParticipation by Non-governmental Parties-Some Inspectors have refused or delayed access to the scene by manufacturer's representativesLack of familiarity with the Party SystemLack of coordination with NTSB IIC
16 Difficulty in determining what happened where no CVR or FDR data is available How did it get here?
17 When no CVR or FDR data is available Much greater emphasis on traditional investigative techniquesInterviewsForensicsWreckage examinationGround scarsNavigation/Fuel AccountingWeatherRadio comm recordingsEngine tear-downComponent tear-downMedical History/Autopsy/Drug-Alcohol ScreeningReach out for more data!
18 New tools and techniques for investigating GA accidents DataNon-Volatile MemoryGPS, even hand-held unitsDisplay systemsEngine controls and instrumentsRecording devices (Not FDR or CVR)Data LoggersVideo recordersBetter visualization of flight trackData analysis and correlation to topographic dataSimulation capabilities to support follow-up actions
19 FAA Flight Data LabThe lab assists in accident investigation by analyzing flight data in order to create graphical plots as well as accident recreation animationsData can be obtained from numerous devices with non-volatile memory chipsThese include, but are not limited to, GPS’s units (panel mount and handheld), multi function displays and primary flight displaysThe products generated by the lab are used by investigators as well as upper level management to develop a better understanding of the sequence of an accident event
43 SummationThe investigative body and the regulator share information, but have different responsibilities.The volume of accidents and incidents requires discipline to maintain the integrity of each investigation.Changes in aircraft and on-board equipment, types of operations, and the evolving GA marketplace will continue to challenge the GA accident investigator.These changes will also allow greater access to data in investigations.Better investigations, with more effective corrective actions, will result.