AIRCRAFT ACCIDENT INVESTIGATION MOOC LEGISLATION, REGULATION, ROLES AND RESPONSIBILITIES

Course Introduction – Course Description This course covers essential aspects of the aircraft accident investigation process starting with preparation for investigation through report writing. Particular emphasis is placed on the human factors and survival factors investigation techniques. The course provides participants with knowledge of the process of investigating accidents and incidents in an aviation organization. A critical analysis of selected aircraft accidents and an evaluation of casual factors are covered.

Course Introduction – Additional Information Students will have access all features of Canvas and Virtual Crash Lab Badges and Certificates of Completion are awarded upon successful completion of: Discussion participation in all four Modules, Viewing Lectures in all four Modules, and Passing four Module Quizzes

OVERVIEW History of aircraft accident investigation Roles and Responsibilities NTSB accident investigation terminology Regulations governing civil investigation

HISTORY OF AVIATION ACCIDENT INVESTIGATION In the early days, aviation was a private enterprise and was seen as “inherently dangerous” There was little government involvement or control Accidents were expected since the technology was new, unproven, and risky. Pilots and aircraft designers were considered to be daredevils. Accident investigation was limited to non-existent

HISTORY Early 20 th Century increased emphasis on all facets of aviation safety.  First fatal airplane crash 17 Sept. 1908, killing Lt Thomas Selfridge and injuring Orville Wright  First formal US investigation Air Commerce Act of 1926 began US federal involvement in aviation safety by the Department of Commerce UK’s Public Safety and Accidents Investigation Committee investigated first accident in 1912

US HISTORY (CONT) Later legislation changed the names and responsibilities of investigative agencies  1938 – Civil Aeronautics Act (Civil Aeronautics Authority)  1940 – Civil Aeronautics Administration  1940 – Civil Aeronautics Board  1958 – Federal Aviation Act (Federal Aviation Agency)  1966 – Department of Transportation Act  Established DOT and NTSB (took over CAB responsibilities)  FAAgency became FAAdmin  1974 – Independent Safety Board Act – Separated NTSB from DOT

EARLY INVESTIGATIONS Aviation was considered “inherently dangerous” until the mid 1950s. If you participated in aviation and had an accident, it was assumed you knew and accepted the risks involved. Most accidents written off as “pilot error”. Scientific investigation and analysis of accident causes and corrective actions slow in developing.

US INVESTIGATION AGENCIES National Transportation Safety Board – all civil aircraft accidents in the U.S., territories, and possessions, certain public-use aircraft accidents. International accidents when invited. Federal Aviation Administration – accidents delegated to it by the NTSB: fender benders, agricultural accidents, and balloon accidents Military services – investigates own accidents Private organizations – Airline Pilots’ Assn and aircraft manufacturers

INTERNATIONAL INVESTIGATION AGENCIES International Civil Aviation Organization International Civil Aviation Organization – sets requirements for international investigation. European Accident Investigation Agencies – Links European Aviation Safety Agency Transportation Safety Board of Canada Air Accident Investigation Bureau of Singapore MODULE 2

WHY WE INVESTIGATE Depending on the agency: Corrective Action – best reason to investigate is to prevent future accidents. Punishment – survivors, family members, and the media like to assign blame. Not a good reason to investigate. May reduce the likelihood of getting factual participation. Compensation – in this litigious world, everyone is looking for a way to sue someone else. May hamper the investigation.

NTSB DEFINITIONS ACCIDENT: An occurrence associated with the operation of an aircraft, which takes place between the time any person boards the aircraft 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 received SUBSTANTIAL DAMAGE. Includes UAS as defined at 49 CFR 830.2

SUBSTANTIAL DAMAGE Damage or failure, which adversely affects the structural strength, performance or flight characteristics of the aircraft, and which would normally require major repair or replacement of the affected component. MODULE 2

INJURY DEFINED Fatal Injury means any injury that results in death within 30 days of the incident. Serious injury means any injury that (1) requires hospitalization for more than 48 hours, commencing within 7 days from the date the injury was received; (2) results in a fracture of any bone (except simple fracture of fingers, toes, or nose); (3) causes severe hemorrhages, nerve, muscle, or tendon damage; (4) involves injury to any internal organ; or (5) involves second- or third-degree burns, or any burns affecting more than 5 percent of the body surface. MODULE 2

INCIDENT (NTSB) & (ICAO) DEFINITION An occurrence, other than an accident, associated with the operation of an aircraft, which affects or could affect the safety of operations. Note: NTSB will investigate some high interest incidents.

NTSB U.S. & Worldwide accident investigation Small Organization  Five member board  around 400 full time employees  Investigators, Administrators, Law Judges  Since its inception, the NTSB has investigated more than 132,000 aviation accidents and thousands of surface transportation accidents  Investigates about 2,500 transportation accidents per year-2,000 are aviation related

NTSB BOARD MEMBERS President nominates/Senate confirms Five year terms – offset to provide continuity Three members from party in White House Three members with technical expertise Chairman & Vice Chairman - Appointed for two year terms

NTSB MANDATE “The NTSB shall investigate or have investigated (in the detail the board prescribes) and establish facts, circumstances, and cause or probable cause of aircraft accidents, etc” – 49 USC § 1131 Important Note: Only the NTSB determines probable cause of US civil aircraft accidents.

NTSB INVESTIGATION (CONT) Public Hearings  Not required for all accidents  Open to the public  Board Member presides over meetings  Testimony given under oath. Final Reports  Usually presented within one year of the accident  Contains analysis of the facts discovered in the investigation  Board Members discuss and approve final report in the Washington, D.C. headquarters  Released to the public

NTSB INVESTIGATION (CONT) Safety Recommendations  Most important part of the investigative process  If something critical is discovered during the investigation, the Board Members may release recommendations before the investigation is complete  Recommendations are designed to prevent future accidents  Recommendations are not mandatory, they are only recommendations

FAA RESPONSIBILITIES Review all NTSB recommendations Decide which, if any, to implement Issue directives to airlines, manufacturers, airports, ATC facilities, etc. to implement all or part of the NTSB recommendation Monitor industry compliance with directives

FAA Evaluates Whether or Not … Violations of FARs were a factor The Federal Aviation Regulations (FARs) were adequate Performance of FAA facilities and functions was a factor Airworthiness of FAA certificated aircraft was a factor The competency of FAA-Certificated airmen, air agencies, commercial operators, air carrier, or airports was involved

FAA Evaluates Whether or Not … (Cont) The airport certification safety standards or operations were involved The air carrier/airport security standards or operations were involved Airmen medical qualifications were involved The performance of non-FAA owned and operated ATC facilities and NAVAIDS was a factor

LEGAL FOUNDATION OF INVESTIGATION “Accident and incident investigations are conducted by the Board to determine the facts, conditions, and circumstances relating to an accident or incident and the probable cause(s) thereof. These results are then used to ascertain measures that would best tend to prevent similar accidents or incidents in the future. … Accident/incident investigations are fact-finding proceedings with no formal issues and no adverse parties. They are not subject to the provisions of the Administrative Procedure Act (5 U.S.C. 504 et seq.), and are not conducted for the purpose of determining the rights or liabilities of any person.” 49 CFR 831.4

ACCIDENT NOTIFICATION 49 CFR covers NTSB notification procedures Requires operators of any civil aircraft and some public aircraft who have an accident to immediately notify the closest NTSB regional office Also requires immediate notification when some incidents occur (830.5(a)) FAA Order B outlines FAA notification procedures and reports

NTSB NOTIFICATION INFORMATION Type, nationality, registration marks of aircraft Name of owner and operator Name of pilot-in-command Date and time of accident Last point of departure and point of intended landing

NTSB NOTIFICATION INFORMATION (CONT) Position of the aircraft Persons on board, number killed, number seriously injured Nature of the accident, weather, and extent of aircraft damage Description of explosives, radioactive materials, or other dangerous articles on board

LEVELS OF INVESTIGATION Major investigation – Go Team response. Usually reserved for major airline accident or other serious accidents. Headed by NTSB Board member Major field investigation – Headed by Investigator In Charge (IIC). Specialists and technical assistants as needed with support from regional headquarters. Field investigation – Usually single IIC from regional office investigates. Limited investigation – Operator reports to NTSB for review. May be handled by FAA.

SAFETY RECOMMENDATIONS This was why the accident was investigated in the first place. If this is not right, the investigation time and money were wasted. Recommendations must be based on accident cause(s) and must provide a way to prevent them in order to prevent future accidents. NTSB investigations may release proposed recommendations on immediate hazards as soon as they are determined. Do not have to wait until the final report is issued.

RECOMMENDATIONS (CONT) NTSB recommendations are not mandatory. They go to other agencies such as the FAA for implementation. These agencies analyze the recommendations, do cost-benefit studies, and decide to implement or not implement the recommendations depending on the results of their analyses. Status of NTSB recommendations can be seen at the FAA’s Aviation Safety Information and Sharing (ASIAS) website at

INTERNATIONAL INVESTIGATIONS International Civil Aviation Organization (ICAO) Treaty and Annex 13 covers accident investigation. Who investigates?  Nation where the accident occurs has primary responsibility for investigations within its territory. May delegate this to nation of registry or operator.  In international waters, responsibility goes to nation of registry

INTERNATIONAL INVESTIGATIONS (CONT) Other Representatives  Nation of Registry and Operator must furnish information on aircraft and aircrew. May appoint representatives to the investigation  Nation of Manufacture and Design may appoint representatives to the investigation.  Nations providing information, facilities, or experts to the investigation may have a representative.  Nations suffering fatalities or serious injuries to its citizens may appoint representatives.

INTERNATIONAL COMPLICATIONS ICAO Annex 13: Investigation is to prevent future accidents not assess blame or liability. Some nations levy civil or criminal penalties against airlines, aircrew, or others shown to have caused an accident. NTSB frequently invited to investigate or support foreign accident investigations because of knowledge, expertise, technical capabilities, and laboratory facilities. When one nation’s investigators investigate another nation’s accident, national pride can get in the way of fact finding and objective analysis. Often result in separate reports with different findings and are never finalized.

SUMMARY Every accident is different, but federal regulations and NTSB procedures provide structure for notification, investigation, and reporting aircraft accidents. NTSB Go Team is heart of initial response to any US civil accident. Provides the ability to scale an investigation team to meet the circumstances of a particular accident.

SUMMARY (CONT) Major NTSB investigations can last one year between accident and formal report. This allows sufficient data collection, laboratory analyses, data analyses, and contemplation to ensure thorough, thoughtful investigations. Conclusions lead to causes that lead to recommendations designed to prevent future accidents International investigations pose additional challenges, but ICAO Annex 13 helps standardize international investigations.