General Aviation Accident Investigation

Overview The relationship between regulatory oversight and GA accident investigation Investigating in the absence of CVR or FDR data New tools and techniques for investigating GA accidents The challenges of change in GA

National Transportation Safety Board Investigates and determines the facts, conditions, and circumstances of aviation accidents Determines the probable cause Makes recommendations Conducts special safety studies Does not have regulatory authority over civil aviation LET 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

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 cause Determines if any of FAA’s nine responsibilities were involved Initiates corrective action THIS 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

The Nine FAA Responsibilities Performance of FAA facilities Performance of Non-FAA facilities Airworthiness of aircraft Competency of airmen, air carriers Adequacy of FAR’s Airport certification standards Security standards Airman medical qualifications Violation of FARs THESE ARE THE NINE FAA RESPONSIBILITIES, AND I THINK THEY DON’T NEED MUCH EXPLANATION.

FEBRUARY 8, 2001 GATES LEAR JET 35A REPUBLIC OF GERMANY I-MOCO

Reality Check Significant GA Accidents Common GA Accidents Regional NTSB investigator Local FAA Flight Standards Inspector(s) FAA “Go Team” from Washington, D.C. Common GA Accidents NTSB conducts a “desk investigation” Washington NTSB participation only in limited cases

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

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 true Certificate holder principal inspector is often the FAA IIC/FAA Coordinator Integrity of the NTSB investigation Integrity of the FAA investigation No operating certificate No principal inspector No regular oversight Limited corrective actions

The relationship between regulatory oversight and GA accident investigation Problems- Integrity of the NTSB investigation Operator or pilot will be reluctant to share information because the FAA is asking the questions Integrity of the FAA investigation Operator may claim they were responding to an NTSB investigation The NTSB is the initial avenue of appeal in cases of suspected violation of the regulations Solutions- FAA Inspectors: Represent the FAA, forward factual information to the NTSB for their use. Ensure the operator/pilot know who the Inspector is representing

Other problems when only FAA assets are on-scene Access- Seldom a problem in the past Even less so now with the Aviation Safety Inspector badge Participation by Non-governmental Parties- Some Inspectors have refused or delayed access to the scene by manufacturer's representatives Lack of familiarity with the Party System Lack of coordination with NTSB IIC

Difficulty in determining what happened where no CVR or FDR data is available How did it get here?

When no CVR or FDR data is available Much greater emphasis on traditional investigative techniques Interviews Forensics Wreckage examination Ground scars Navigation/Fuel Accounting Weather Radio comm recordings Engine tear-down Component tear-down Medical History/Autopsy/Drug-Alcohol Screening Reach out for more data!

New tools and techniques for investigating GA accidents Data Non-Volatile Memory GPS, even hand-held units Display systems Engine controls and instruments Recording devices (Not FDR or CVR) Data Loggers Video recorders Better visualization of flight track Data analysis and correlation to topographic data Simulation capabilities to support follow-up actions

FAA Flight Data Lab The lab assists in accident investigation by analyzing flight data in order to create graphical plots as well as accident recreation animations Data can be obtained from numerous devices with non-volatile memory chips These include, but are not limited to, GPS’s units (panel mount and handheld), multi function displays and primary flight displays The 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

THIS IS NOT AN ACTUAL ACCIDENT

THIS IS NOT AN ACTUAL ACCIDENT

JULY 30, 2001 PIPER PA-32-300 GLACIER BAY NEAR HANES, ALASKA N39586

Enhanced Flight Vision Systems (EFVS) Gulfstream G450

Automatic Dependent Surveillance – Broadcast (ADS-B) de Havilland DHC-2

JULY 16, 1999 PIPER PA-32R MARTHA’S VINEYARD, MA N9253N

Summation The 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.

Contact Information TONY JAMES Air Safety Investigator US Department of Transportation Federal Aviation Administration Accident Investigation Division, AVP-100 800 Independence Ave., SW Washington, DC 20591 (202) 267-7619 tony.f.james@faa.gov