What Happens When The What Happens When The Phone Rings?Phone Rings?

Why do we investigate accidents?

How is it done?

Certified aircraft manufacturers are required to have trained

personnel ready to respond to their aircraft accidents 24/7

The recurring questions:The recurring questions:

Why did this accident occur?

What can we do to keep this kind of accident from occurring again?

The NTSBThe NTSBNational Transportation Safety BoardNational Transportation Safety Board

Investigates the accidentWrites the report

Responsible for accident site security / safety

Determines “Probable Cause”Makes recommendations

FAAFAA

Regulatory Agency

Administrative / Enforcement

FAA is “party” to ALL NTSB aviation accident investigations

Congressional Mandate:Congressional Mandate:

The aircraft manufacturer

The engine manufacturer

ALPA

May have NTSB investigation “party” status

How is the NTSB able to form an How is the NTSB able to form an effective team on short notice?effective team on short notice?

Professionalism

Dedication

Mutual respect

Reputation

Effective accident investigation Effective accident investigation is all aboutis all about

Relationships

ASI Skill Sets:ASI Skill Sets:Accident investigation is a craft which must be

developed:

Mentoring and trainingOn the job experience

Schools and workshops

Good communication, written and technical skillsCommon sense! (A “sixth sense”)Integrity DedicationFlexibility

Be able to “visualize” what happened

Be able to understand what happened, and why

Requires exceptional people skills

Challenges all investigators face Challenges all investigators face at the accident site:at the accident site:

A changing chain of command

The wreckage may be located at any number of places, terrain, or climates

Many pieces may be missing

Or may be in a condition that makes them impossible to recognize

ASI’s must be able to deal with:ASI’s must be able to deal with:

The pure horror of it all, sensory overload

Politics

The M E D I A

“Inconvenience”

A strong sense of humor helps!Must have compassion

The 4 Phases of an The 4 Phases of an Aircraft Accident:Aircraft Accident:

Rescue PhaseInvestigation Phase

Recovery PhaseLegal Phase

Rescue Phase

Investigation phase

What happens whenWhat happens when the phone rings?the phone rings?

““The Call”The Call” can come from anyone, any timecan come from anyone, any time

The manufacturer may be asked to provide a qualified ASI to assist the NTSB

The investigator on call has to Be prepared to go anywhere, any time

Medical, passport, “GO” Bag

Verify the OccurrenceVerify the Occurrence

Ask: what, where, when, etc.Request “Party Status” from the NTSB

Brief company internal teamThe Internal team works their contacts

THE ASI LAUNCHES TO THE SITE ASAP!

The well-dressed ASI

Is it an Accident or Incident or neither?

At The SiteAt The Site

Secure the site

Preserve evidence

Be aware of the hazards which may be present

First Day on Site

The NTSB IIC meets with the “parties”:

Provides most recent informationReviews rules, restrictions, expectations

Explains how the investigation will proceed Assignments are made

TIME IS SHORT!

Work the planWork the planWhat Are The Priorities?

Determine the condition of CAPS and AAIRWalk the site; note energy path, direction

Contingency photos Lay the wreckage out, if possible

Inventory the “four corners” of the aircraftDetailed notes

Sketches are good

Digital and / or videos are better

Line objects up with a prominent landmark

Use multiple angles

Many aircraft don’t have FDR’s or CVR’s

We have to figure it out the old fashioned way

US Aircraft registration number

Models can be helpful for interviews

End of Day Wrap up MeetingEnd of Day Wrap up Meeting

Review what we have learnedReview what is still missing

Work out plan for the next day

(can take several days)

Myths:Myths:

The plane always blows up or burns

The engine always sputters and quits before impact

The PIC was the best pilot, ever

One person always solves the mystery

“Black Boxes” aren’t black

Recovery Phase

Recovery PhaseRecovery Phase

The aircraft may have to be moved again

Component testing, measurements

Review of facts; summary from each ASI

You may have to build a road to get to it!

Or transport the wreckage to a STORAGE FACILITY

Wreckage Lay-out

When the ASI Returns from When the ASI Returns from the accident site:the accident site:

The company ASI briefs senior managementThe NTSB investigation continues

NTSB Investigation “Parties” share dataThe company ASI sends his

preliminary report to NTSB IICCompany Investigation / report writing

beginsMore travel for various inspections

Forensic ExaminationsForensic Examinations

INVESTIGATORS LOOK AT EVERYTHING!

Engine tear down inspection Auto Pilot

Fuel SystemMCU

StructureLanding gear

Avionicsetc

Engine Tear Down Inspection at TCM

Inspecting The Engine Case

Testing Spark Plugs / Magnetos

MCU Examination

Initial report schedule and Initial report schedule and sequence:sequence:

FAA Preliminary report on web: www.faa.gov

Within 1-3 days, removed in 10 days

NTSB Preliminary on web: www.ntsb.gov (Aviation)

Within 1-10 days

Final NTSB ReportsFinal NTSB Reportson the web and the public docketon the web and the public docket

NTSB Factual: +/- 6 monthsNTSB Final: ? days – 2 years +

Contains the NTSB’s “Probable Cause”

The NTSB may choose to conduct a public hearing

But always on the web:www.ntsb.gov – (Aviation)

The company will conduct an The company will conduct an InternalInternal review of specific review of specific

accidentsaccidents

Critical personnel attend

Each company has its own review process

Typical Company Accident Report

Legal PhaseLegal Phase

Requests for production of documents

Wreckage inspections Depositions

Component testing

Can take years……………..

Wreckage Inspection

Wreckage Layout (again)

Let’s keep the shinny side UP!