The Airline Accident Investigative Process

by nph | June 4th, 2010

Airplane Accident Investigation ProcessAll the Answers to Your Questions about Aviation Accident Investigations

All of the information found on this page comes directly from the NTSB website. For more information about this topic, click here.

After a plane crash or other aviation related accident, who is responsible for the investigation?
The National Transportation Safety Board (NTSB) was established in 1967 to conduct independent investigations of all civil aviation accidents in the United States and major accidents in the other modes of transportation. It is not part of the Department of Transportation (DOT), nor organizationally affiliated with any of DOT’s modal agencies, including the Federal Aviation Administration (FAA). The NTSB has no regulatory or enforcement powers.

How does the National Transportation Safety Board conduct an investigation?
At the core of NTSB investigations is the “Go Team.” The purpose of the Safety Board Go Team is simple and effective: Begin the investigation of a major accident at the accident scene as quickly as possible, assembling the broad spectrum of technical expertise that is needed to solve complex transportation safety problems.

Who’s on the Team?
The team can number from three or four to more than a dozen specialists from the Board’s headquarters staff in Washington, D.C., who are assigned on a rotational basis to respond as quickly as possible to the scene of the accident.

Who’s the Boss?
The Go Team’s immediate boss is the Investigator-in-Charge (IIC), a senior investigator with years of NTSB and industry experience.

What all does the NTSB investigate?
Each investigator is a specialist responsible for a clearly defined portion of the accident investigation. In aviation, these specialties and their responsibilities are:

  • OPERATIONS: The history of the accident flight and crewmembers’ duties for as many days prior to the crash as appears relevant.
  • STRUCTURES: Documentation of the airframe wreckage and the accident scene, including calculation of impact angles to help determine the plane’s pre-impact course and attitude.
  • POWERPLANTS: Examination of engines (and propellers) and engine accessories.
  • SYSTEMS: Study of components of the plane’s hydraulic, electrical, pneumatic, and associated systems, together with instruments and elements of the flight control system.
  • AIR TRAFFIC CONTROL (ATC): Reconstruction of the air traffic services given the plane, including acquisition of ATC radar data and transcripts of controller-pilot radio transmissions.
  • WEATHER: Gathering of all pertinent weather data from the National Weather Service, and sometimes from local TV stations, for a broad area around the accident scene.
  • HUMAN PERFORMANCE: Study of crew performance and all before-the-accident factors that might be involved in human error, including fatigue, medication, alcohol, drugs, medical histories, training, workload, equipment design, and work environment.
  • SURVIVAL FACTORS: Documentation of impact forces and injuries, evacuation, community emergency planning and all crash-fire-rescue efforts.

How do investigators report their findings?
At least once daily during the on-scene phase of an investigation, one of the five members of the Safety Board itself, who accompanies the team, briefs the media on the latest factual information developed by the team. While a career investigator runs the inquiry as Investigator-in-Charge, the Board Member is the primary spokesperson for the investigation. A public affairs officer also maintains contact with the media. Confirmed, factual information is released. There is no speculation over cause. Safety recommendations may be issued at any time during the course of an investigation.

How many investigations does the NTSB conduct each year?
The Board investigates about 2,000 aviation accidents and incidents a year, and about 500 accidents in the other modes of transportation—rail, highway, marine, and pipeline. With about 400 employees, the Board accomplishes this task by leveraging its resources. One way the Board does this is by designating other organizations or companies as parties to its investigations.

What is the Party System?
The NTSB designates other organizations or corporations as parties to the investigation. Other than the FAA, which by law is automatically designated a party, the NTSB has complete discretion over which organizations it designates as parties to the investigation. Only those organizations or corporations that can provide expertise to the investigation are granted party status and only those persons who can provide the Board with needed technical or specialized expertise are permitted to serve on the investigation; persons in legal or litigation positions are not allowed to be assigned to the investigation. All party members report to the NTSB.

How does the NTSB handle investigations that involve criminal activity?

In cases of suspected criminal activity, other agencies may participate in the investigation. The Safety Board does not investigate criminal activity; in the past, once it has been established that a transportation tragedy is, in fact, a criminal act, the FBI becomes the lead federal investigative body, with the NTSB providing any requested support.

What are Safety Recommendations?
Safety recommendations are the most important part of the Safety Board’s mandate. The Board must address safety deficiencies immediately, and therefore often issues recommendations before the completion of investigations. Recommendations are based on findings of the investigation, and may address deficiencies that do not pertain directly to what is ultimately determined to be the cause of the accident.

How does the NTSB issue a Final Report?
Months of tests and analysis eventually lead to the preparation of a draft final report by Safety Board staff. Parties do not participate in the analysis and report writing phase of NTSB investigations; however, they are invited to submit their proposed findings of cause and proposed safety recommendations, which are made part of the public docket. The Board then deliberates over the final report in a public Board meeting in Washington, D.C. Non-Safety Board personnel, including parties and family members, cannot interact with the Board during that meeting.

Once a major report is adopted at a Board Meeting, an abstract of that report—containing the Board’s conclusions, probable cause and safety recommendations—is placed on the Board’s website under “Publications.” The full report typically appears on the website several weeks later.

Source:

“The Investigative Process.” The National Transportation Safety Board. Sept. 2004. 02 June 2010.