NTSB session seeks to better document accident investigations

April 17, 2013

When the National Transportation Safety Board invited industry groups and government agencies to discuss areas the NTSB should better document in general aviation accident investigations, AOPA and the AOPA Foundation’s Air Safety Institute responded with suggestions based on years of research and experience producing safety-focused training materials for pilots.

After the April 3 NTSB “listening session,” AOPA President Craig Fuller called on NTSB Chairman Deborah A.P. Hersman to meet with the association to discuss ways that their organizations could work together to implement new safety initiatives.

NTSB holds ‘listening session’

AOPA Foundation Vice President of Education and Operations Kathleen Vasconcelos and AOPA Regulatory Affairs Manager David Oord attended the NTSB’s listening session. The NTSB outlined goals including pinpointing the elements of GA accidents that should be documented in its reports; identifying how that information can be documented; and demonstrating how the information, in the aggregate, can be used to improve aviation safety.

The discussions followed up on a 2012 forum that heard suggestions about information that could be added to NTSB accident reports such as more background on the pilot’s training, and descriptions of avionics and other equipment aboard an accident aircraft.

Oord noted that efforts to pinpoint and develop remedies for known accident causes are in progress through the work of the General Aviation Joint Steering Committee (GAJSC), which AOPA co-chairs along with the FAA. In March, AOPA reported on the committee’s release of its first report that focused on loss-of-control accidents in the landing phase of flight.

Oord described the panel’s method of collecting and analyzing accident data that was then used as the basis for coming to conclusions about studied accidents. A more data-driven emphasis would sharpen the NTSB’s goal of “obtaining a better understanding of the cause of accidents,” he said.

Since 1950, said Vasconcelos, the Air Safety Institute, a division of the AOPA Foundation, has provided general aviation safety education through seminars, courses, videos, publications, and flight instructor refresher clinics.

In 2012, the Air Safety Institute “reached the general aviation community nearly 1.8 million times,” she said.

Vasconcelos pointed to an Air Safety Institute-produced documentary-style video of an accident’s aftermath as an example of how valuable information can be obtained in an interview with the pilot after an accident. If the pilot involved in the accident depicted in the video had not been willing to share his story, the role played by human factors would not have been known, she said. Although the pilot survived the accident, his young son did not.

Since its launch in August 2012, the video had been viewed 55,508 times by Dec. 31, making it the institute’s “most viewed safety product of 2012,” she said.

Vasconcelos also told the NTSB that an erosion of timeliness of NTSB investigations being made available had affected the gathering of accident information for the Air Safety Institute’s Joseph T. Nall Report, which is considered the industry’s “go-to publication for analysis of GA trends.”

The report is used by the Air Safety Institute and AOPA “to understand which areas need focus for safety education,” she said. However, the “milestone” for when a sufficient percentage of fatal accidents have been assigned probable causes by the NTSB to allow their use in data analysis has been “progressively slower to arrive,” she said. The twenty-second Nall Report was published in 2012.

Vasconcelos also said the NTSB should include more information about the weather conditions that existed at the time of accidents in the reports.

More resources for investigations

In the wake of the NTSB having placed GA safety on its Most Wanted List of priorities for board advocacy, AOPA called on the NTSB to dedicate more resources to on-site accident investigations, which they said are now delegated to other parties 85 percent of the time.

Compared to investigations of air carrier and commercial aviation accidents, GA accident investigations are “significantly shorter, contain less detail, and can be inconsistent,” said Oord.

Oord agreed that investigators should gather more information about accidents through personal interviews.

“General aviation accident investigations often have very little information related to the pilot. To obtain that key component, investigators should interview family, friends, hangar mates, business acquaintances, and instructors to get a better understanding about pilot behavior, the decision-making process, and risk threshold,” he said.

“In order to develop better strategies to improve safety, the FAA and industry need a better understanding of the pilot’s decision making. Only through better investigations will that information be obtained,” he said.

Fuller, in his letter to Hersman, also raised the issue of scarce resources—pointing out that the new outreach effort exists in a budget climate that has already taken its toll with the scheduled June 15 closing of 149 contract airport control towers.

“NTSB’s voice on the negative implications of cuts such as these could be of critical importance in the months ahead,” he wrote.

Dan Namowitz

Dan Namowitz | Aviation Writer

Dan Namowitz is an aviation writer and flight instructor. He has been a pilot since 1985 and an instructor since 1990.