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NTSB criticized for 'speculative' accident cause findings

AOPA calls for immediate internal review to test for bias

AOPA is calling on the National Transportation Safety Board to conduct an internal review to examine why the independent safety agency has approved “speculative probable cause reports related to general aviation accidents” despite little evidence to support the conclusions.

Photo by Mike Fizer.

AOPA Senior Vice President of Government Affairs Jim Coon criticized speculative practices that seem to be finding their way “into the culture of NTSB.” He objected to probable cause findings of medical incapacitation that have appeared in accident investigations, “contrary to other compelling evidence,” in a letter to Bella Dinh-Zarr, the NTSB’s acting chairman. Dinh-Zarr assumed the NTSB’s leadership post on the expiration of Christopher Hart’s term as chairman March 15.

AOPA is concerned that in some cases the NTSB is relying less on facts and more on speculation. Several recent probable cause findings raise concern about an erosion of data-driven, facts-based standards that have long given NTSB accident analyses credibility, Coon wrote.

The problem has persisted despite a meeting on the issue between then-NTSB Chairman Hart and AOPA President Mark Baker in 2016, he wrote.

A case in point was Hart’s response to a November 2016 letter from the AOPA Air Safety Institute that questioned a probable cause determination in a case in which a medical report found no evidence of recent or old infarction. Hart responded that a “hyperacute infarction” might occur over a few minutes, yet leave no evidence, if a victim died traumatically.

Hart’s response “clearly suggests the probable cause of the accident in question was and is purely speculative,” the letter said.

In two cases, accidents CEN15LA195 and CEN15FA281, death was attributed by medical examiners to blunt force injuries. However, the accidents occurred in airport traffic patterns in scenarios typically associated with loss of control—a scenario consistent, in one case, with an eyewitness account.

Absent definitive evidence, “it should be acceptable to make a ‘no determination of cause’ finding,” Coon wrote.

“Personally, after having worked with the NTSB for decades, it is disheartening that the Board is now allowing someone at the staff level to approve these academic probable cause determinations. Moreover, I am dismayed that the Board’s Chief Medical Examiner allows this speculative practice to continue.

“We hope the Board would work towards a more data driven approach similar to that which the FAA has embraced, and more specifically the Flight Safety Standards Division. Together, we have invested significant time and effort to move to a data driven approach under the Commercial Aviation Safety Team (CAST) and the General Aviation Joint Steering Committee (GAJSC),” he wrote.

An internal review could correct the problem of speculative probable cause determinations, he said, and ensure that “personal agendas in the medical office are not being incorporated into the Board’s reports.”

Furthermore, AOPA is “perplexed” that the NTSB has kept GA on its 10 Most Wanted List for safety improvements despite traffic fatalities being 7,500 percent higher; boating resulting in 150 percent more deaths; and even bicycling having a death rate twice that of GA, Coon said.

The NTSB’s new acting chairman, Dinh-Zarr, is a public health scientist specializing in injury prevention, who had served as the NTSB’s vice chairman since March 31, 2015. She has been an NTSB board member since March 23, 2015.

Before her appointment, she was director of the U.S. Office of the FIA Foundation, an international philanthropy dedicated to promoting safe and sustainable transportation, and as the North American director of Make Roads Safe—The Campaign for Global Road Safety, the NTSB said.

Previous positions included service with The American Automobile Association (AAA), the National Highway Traffic Safety Administration, the U.S. Centers for Disease Control and Prevention, and the Texas Transportation Institute.

Hart, a pilot, attorney, and aerospace engineer, served as the NTSB’s thirteenth chairman for two years, and as acting chairman for a year before that. An NTSB board member since 2009, Hart will continue as one of the agency’s five board members, the agency said in a news release. His term on the board expires in December.

The NTSB is an independent agency “charged with determining the probable cause of transportation accidents and promoting transportation safety, and assisting victims of transportation accidents and their families.” Each NTSB board member is nominated by the president and confirmed by the Senate for five-year terms. Separate Senate confirmation is required for the board’s chairmanship.

Dan Namowitz
Dan Namowitz
Dan Namowitz has been writing for AOPA in a variety of capacities since 1991. He has been a flight instructor since 1990 and is a 35-year AOPA member.

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