1. General Aviation Accident Investigation

2. 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

3. 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

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 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

5. 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.

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

11. 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

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 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

14. 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

15. 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

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 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!

18. 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

19. 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

20. THIS IS NOT AN ACTUAL ACCIDENT

21. THIS IS NOT AN ACTUAL ACCIDENT

22. JULY 30, 2001
PIPER PA
GLACIER BAY
NEAR HANES, ALASKA
N39586

31. Enhanced Flight Vision Systems (EFVS)
Gulfstream G450

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

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

43. 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.

45. 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
(202)