AIRCRAFT ACCIDENT INVESTIGATION MOOC THE INVESTIGATIVE PROCESS ACCIDENT REPORTS

NTSB MOST WANTED NTSB Most Wanted Press conference to announce 2014 Most Wanted MODULE 2

NTSB “GO TEAM” 24/365 Alert Designated Investigator-in-Charge – trained investigator who leads the team Specialists – subject matter experts trained in accident investigation - see chart on next slide One NTSB Board Member Public Affairs Specialist

NTSB “GO TEAM” STRUCTURE

NTSB INVESTIGATION On-site  Time on-site varies with the complexity of the accident and the accessibility of the site  Generally 7-10 days – collect data, interview witnesses, gather evidence  Press briefings on site, particularly for high profile accidents

PARTIES (CONT) Parties who do not respond to the direction of the IIC may be removed. (831.11(a)(2)) Helps prevent conflict of interest. May include aircraft manufacturers, aircraft systems manufacturers, national representatives from each country with people involved in the accident, airline representative, and other involved parties. Supposed to be impartial and work toward discovering facts that will prevent future accidents.

PARTIES (CONT) Also provide specific technical manufacturer’s information and expertise that may not be otherwise available to the safety board. Most work well with the safety board, but there have been problems in the past with parties who tried to protect their company rather than discover the cause of the accidents.

GO TEAM COMPOSITION NTSB Board Member – Supervises the investigation. Is the public face of the investigation. Investigator-in-Charge (IIC) – Responsible for supervision and coordination of investigation team. Authorizes “parties” to the investigation. Prepares reports and news releases for NTSB Board Member. Leads investigation through completion.

GO TEAM SPECIALISTS Operations Specialist – Investigates airline operation and procedures; aircrew training, qualification and currency; aircrew actions and performance; aircrew records; and other operationally related items. Human Factors Specialist – Investigates human related aspects of the accident including fatigue, training, psychology, medical aspects, human- machine interface, ergonomics, and other human factors issues that may be related to the accident.

GO TEAM SPECIALISTS (CONT) Maintenance Specialist – Investigates airline maintenance actions, procedures, training, qualifications, recent maintenance on the accident aircraft, organizational maintenance practices, outsourced maintenance, aircraft records, and other maintenance related items. Aircraft Systems Specialist – Works with the Maintenance Specialist to determine aircraft system related factors that may have contributed to the accident.

GO TEAM SPECIALISTS (CONT) Structures Specialist – Works with Maintenance Specialist to determine aircraft structural related factors that may have contributed to the accident. Engines Specialist – Works with Maintenance Specialist to determine aircraft engine related factors that may have contributed to the accident.

GO TEAM SPECIALISTS (CONT) Air Traffic Control Specialist – Investigates sufficiency of ATC services to include communications, instructions, compliance, violations, procedures, training, and other ATC issues that may be related to the accident. Weather Specialist – Analyzes actual and forecast weather for accuracy, adequacy, and timeliness of information provided to the aircrew. Analyzes weather to determine whether or not it was related to the accident.

GO TEAM SPECIALISTS (CONT) Survival Specialist – Analyzes crash survivability: who survived and why; who should have survived and did not; who should not have survived and did. Incorporates crash dynamics, aircraft structures, fire information, and other factors into the analysis. Go Team members deployed as required. Accident factors determine which members deploy and when they deploy.

NTSB INVESTIGATION (CONT) Off-site  Intensive data and evidence analysis  Extensive laboratories and databases available for comparative analyses Reporting  Factual report issues 3-6 months after the crash  Reports available on the public docket  NTSB makes information available through the Public Inquiries Branch

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

ACCIDENT REPORT FORMAT

Factual Information  History of flight  Injuries to persons  Damage to airplane  Other damage  Personnel information  Aircraft information  Meteorological information  Aids to navigation  Communications  Airport information  Flight recorders Factual Information (Cont)  Wreckage and impact information  Medical and pathological information  Fire  Survival aspects  Tests and research  Organizational and management information  Additional information ACCIDENT REPORT FORMAT (CONT)

Analysis – Safety board deliberations, information supplied by parties, evidence analyses, etc. Conclusions – Findings decided by the safety board and the NTSB based on evidence analysis Recommendations – Changes recommended by the NTSB to prevent future accidents Appendices – Additional information required to support findings

CONCLUSIONS Declaration of what the safety board has determined based on the facts analyzed. Each point analyzed in the Blue Book must logically lead to a conclusion that summarizes the safety board’s position on that issue. Points analyzed that were determined not to be factors should still have a conclusion defending why it was not a factor. Conclusions summarize the investigation and identify the cause(s) of the accident.

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