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Conducting An Accident Investigation

Paul Cox Senior Air Safety Investigator

Eastern Region

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Additional Purposes of this Presentation

• To note that just because the NTSB, BEA, AAIB, TSB, etc. does something a certain way, it might not be your way.

• However, it should be noted that there ARE common practices, which then used by most States to enhance communications.

• To give you ideas.

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• Man, Machine, Environment

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What is an Accident?

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What is an Accident?

An occurrence associated with the operation of an aircraft which:

• Takes place between the time any person boards

the aircraft with the intention of flight and all such persons have disembarked, and in which

• Any person suffers death or serious injury, or in which

• The aircraft receives substantial damage

• Missing aircraft?

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Unmanned Aircraft

An occurrence associated with the operation of any public or civil unmanned aircraft system that takes place between the time that the system is activated with the purpose of flight and the time that the system is deactivated at the conclusion of its mission, in which: 1. Any person suffers death or serious injury; or 2. The aircraft has a maximum gross takeoff weight of 300 pounds or greater and sustains substantial damage.

Serious Injury Any injury which: Requires hospitalization for more than 48 hours, commencing within 7 days of the date that the injury was received; Results in a fracture of any bone (except simple fractures of fingers, toes, or nose); Causes severe hemorrhages, nerve, muscle, or tendon damage; Involves any internal organ or; Involves 2nd or 3rd degree burns, or burns affecting more than 5% of the body surface

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Substantial Damage

Substantial Damage is… Damage or failure which: • Adversely affects the structural

strength, performance, or flight characteristics of the aircraft, and which

• Would normally require major repair or replacement of the affected component

Substantial Damage is not… • Engine failure or damage limited to

an engine if only one engine fails or is damaged,

• Bent fairings or cowling • Dented skin • Small punctured holes in the skin

or fabric • Ground damage to rotor or

propeller blades • Damage to landing gear, wheels,

tires, flaps, engine accessories, brakes, or wingtips are not considered “substantial damage” for the purpose of this part.

Incident Investigation • U.S. - “An incident is an occurrence

other than an accident, associated with the operation of an aircraft, which affects or could affect the safety of operations.”

• ICAO – Same, except a “Serious Incident” involved circumstances indicating a high probability of an accident . Attachment C of Annex 13 lists examples.

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Special Notification and Reporting

The operator of an aircraft shall immediately and by the most expeditious means available notify the nearest NTSB Field Office when an aircraft accident or any of the following incidents occur:

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• Flight control system malfunction

• Inability of any crew member to perform normal flight duties as a result of injury or illness

• Uncontained engine failure (turbine) • Release of propeller blade • Failure of 50% of EFIS, PFD, etc. • TCAS resolution advisory with risk of

collision

Important to Adequately Assess Level of Effort for Each Case •

Public Visibility

Complexity Injury Severity

Public Trust

Fleet Issues

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Accident?

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Accident?

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Accident?

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Accident or Incident?

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Accident or Incident?

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Accident?

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Accident?

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Accident or Incident?

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Accident?

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Break

• So, you got yourself an accident…

• Let’s start with the big picture…

Questions for the “Big Picture” • What?

• When?

• Where?

• Who?

• Challenges/Dangers?

Where can I get more information?

• First responders/local law enforcement/on-scene commander?

• Press?

• Internet?

• Other government agencies?

Who do I need to contact? • On-scene commander?

• Other government agencies?

• State of manufacture/design/etc.?

• Boss?

When can I get there? • Where is it?

– Distance? – Busy area/must be moved?

• What means of transport?

• What are the barriers to a quick response?

• When do I have to be there?

– Degree of interest? – Political interest?

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Response Time

What do I need to take with me? • Environment?

• Type of accident?

• Luggage limits?

• Paperwork?

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Go-Bag Equipment

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Credentials

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Mode of Transportation

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Jump seat

• Official business only

• “Must Ride” only to the site

• Dress & act appropriately

Jump seat

What about the victims? • When can they be moved?

– Is it safe to move them? – How will it affect your investigation? – Is removal needed quickly?

• Local concerns? • Religious concerns?

• Where will they go? • Autopsy/toxicology? • Family concerns?

What about the wreckage? • Dangers?

• Burnt?

• Location?

• Need to move?

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On-Scene Management

• Large vs. Small

• Residential vs. Remote

• Assistance vs. No Assistance

• Wreckage Examination

• Time & People Management

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Major “Stake Down”

• Make your presence known

• Wreckage preservation

• Initial photo documentation

• Extract & secure FDR/CVR

• Press may be optional

• Brief the additional investigation team members

On-Scene Management - People • Bringing order out of chaos….

• Investigative Team

– NTSB • Specialists • Group Chairmen

– Parties – Accredited Representatives

• Advisors

• Other Participants/Responders

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Other Responders

• Local authorities/politicians

• Insurance adjusters

• Recovery personnel

• News media

• Families of the victims

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Local Authorities

• The incident commander

• On-site safety

• On-site security

• Attitude and cooperation

• All politics are local

• Witness statements

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Insurance Adjusters

What information do they want… • Information

What they can provide… • Financial resources • Assistance with wreckage

that is difficult to access • Pilot background information

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Dealing With Insurance Adjusters

Do… • Allow them to establish that

this is their claim (let them see the logbooks)

• Tell them your plans • Release wreckage to them

with the approval of owner (if possible)

• Provide them the same factual information as the family and the press

• Allow them to quickly photograph the site under your supervision

Do Not… • Allow them to participate in

the investigation (no observers)

• Discuss possible cause • Provide them with

photographs or let them see your photographs

Recovery Personnel • Normally selected by insurance adjuster

• Normally has secure storage facility

• What the options if insurance can not be

determined? – Recovery personnel willing to take risk – Local/police recovery – Leave it

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News Media • Not your enemy, not your friend; they also have job to do • Take control • Coordinate briefing times (might ask when they need it) • Discuss processes • Could prepare/read a statement • Facts only • Could involve headquarters Public Affairs • State preliminary report will be available in 10 days • Practice beforehand!

Parties to the Investigation – Why?

• Force multipliers • Possess unique knowledge/technical expertise • Participant specific • Can effect positive change within their organization • Cannot withhold information • Full time employees • Responsive to NTSB personnel

Parties to the Investigation • May work for IIC or Group Chairman • Must work under direction of IIC/Group Chairman • Release of factual information to outside by

appropriate NTSB personnel only • Opportunity to review factual information and can

submit proposed conclusions and safety recommendations

• Cannot be litigants, must be full time • FAA always a party; others (manufacturers,

unions, etc.) determined by IIC.

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Coordination of Parties/Specialists

Organizational Chart: Regional Investigation

NTSB IIC

NTSB Specialists

FAA

Engine

Airframe

Component

Manufacture Operator AccRep/Other Government

Agency

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Coordination of Parties/Specialists

Organizational Chart: Major Investigation

Board Member

PA/TDA

NTSB IIC

NTSB Group Chairman

Systems

Structures

Maintenance

Powerplant

Operations

ATC

Weather

Human Performance

Human Factors

Recorders

Party Coordinators/AccRep

FAA

Airframe

Powerplant

Operator

Unions

Other Government

Agency

Deputy IIC

On-Scene Goal

• Collect Perishable Information – Environment – Wreckage Path (Direction & Angle)

• Tree Strikes/De-foliage – Four Corners – Flight Control Continuity – Evidence of Engine Power – Recorders; GPS/NVM; Video – Witness Interviews – Forensics

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A Documentation Procedure

• Aerial photographs

• Out to In

• Aircraft four corners

• Compass Rose • Four cardinal points • 15 Degree segments

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Aerial Photos

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Wreckage Documentation

Glasgow, Montana (-35 degrees F), Cessna 182G

• Flags

• Measuring tape

• GPS

• Pacing off

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Wreckage Documentation

Wreckage Diagramming Grid • Straight-line • Most Common

Polar • Compact accident sites • “Smoking hole” accident sites

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ATM/Security Cameras

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Wreckage Documentation/Photos

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Wreckage Documentation/Photos

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Wreckage Documentation/Photos

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Wreckage Documentation/Photos

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Wreckage Documentation/Photos

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Wreckage Documentation/Photos

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Wreckage Documentation/Photos

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Cut Branches

Clean, 45-degree cut usually means power

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Ground Scars

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Wreckage Distribution Pattern - Wide

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Wreckage Distribution Pattern - Localized

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Wreckage Dristribution

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Wreckage Distribution – In-Flight Breakups

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Wreckage Distribution – Mid-Air Collisions

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Helicopters

• Many of the same principles apply

• Rotating parts can give qualitative assessment if engine(s) were running or not at impact

• Other evidence may be contradictory

Helicopters

Check for witness marks on airframe structure from rotating engine and drive train components

Helicopters

Rub mark on skin from coupling

Helicopters

Scoring marks from coupling on adjacent structure

Helicopters/Rotorcraft • Main rotor blade coning indicates

low rotor rpm. • Possible loss of power • Possible loss of airspeed

(gyroplanes)

Semi-Rigid - Teetering Rotors

• During low g maneuvering, the rotor system does not control the fuselage.

• The fuselage can assume a position controlled by momentum and tail rotor thrust.

• This can result in the blade roots contacting the main rotor mast (Mast bumping) or the blade tips contacting the tail rotor boom.

Taking Good Photos

• Be systematic

• Establish a flow (out-in, circle, left-right, etc.) • Framing the subject

• Capture orientation of subject with respect to wreckage/terrain

• Take LOTS of photos from different

perspectives

• A rough diagram will help you remember what is what

• Check the quality of your photos before departing

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Photo Orientation

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Photo Orientation

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Cockpit Examination

• Instrument Panels • Needle Slap Marks

• Throttle Quadrant

• Avionics

• Non-volatile memory

• Annunciators • Light bulb analysis

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Cabin Examination

• Seats & Cargo Restraint System

• Survivability Concerns

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Seats and Restraints

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Seat Tracks

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Flight Control Continuity

• Control Cable Continuity

• Trim Tab Actuators

• Flap Drive Mechanism

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Flight Control Continuity

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Flight Control Continuity

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Landing Gear

• Drive Mechanisms

• Up Locks & Down Locks

• Tires • Brakes

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Fuel System • Vegetation browning

• Fuel type & quality

• Fuel gages

• Tanks

• Fuel caps and venting

• Pumps

• Engine driven • Boost

• Selector valves

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Electrical System

• Circuit Breakers

• Switches

• Wiring

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Wreckage Examination

• Instrument Gyros

• Pitot Tube

• Static Port

• Vacuum Port

Pitot-Static System

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Gyros

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Other Systems

• De-ice

• Pressurization

• Hydraulic

• Autopilot

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On-scene Duties

Move & Examen Wreckage

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On-scene Duties

Wreckage Recovery – Perhaps

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On-scene Duties

Wreckage Recovery

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On-scene Duties

Interviewing witnesses

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Interviewing

Interviewing

“Any person interviewed by an authorized representative of the Board during the investigation, regardless of the form of the interview has the right to be accompanied, represented, or advised by an attorney or non-attorney representative.” (49 CFR Part 831.7)

Rights of Interviewees

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Interviewing

• Grant Immunity from Prosecution

• Assure Confidentiality

Investigators Cannot…

Interviewing

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Interviewing

• Locating witnesses

• Types of witnesses

• Participants • Eyewitnesses • Background witnesses

• Characteristics

• Age • Professional background

Interviewing

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Interviewing

• Problems to expect

• Reprisal • Intimidation/Embarrassment • Expectations/Perceptions

• Interview settings

• People • Location • Preparation

Interviewing

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Interviewing

• Interview details

• Time • Establish rapport • Written statement

• Interview questions

• Non-questions • Leading, Directed, General

Interviewing

Post On-Scene Aids • Radar, GPS/NVM Processing • Radio Tapes/Transcripts/ATC Studies • FAA Documents • Pilot Records/Pilot Operator Report • Maintenance Records • Medical Records • Pilot/Maintenance Manuals • Toxicology • Component Teardowns/Testing • Human Factors/Fatigue Studies • Performance Studies

Investigation Process • On Scene Investigative Duties • Press/Family • Insurance Coordination • Wreckage Disposition • Internal Admin Functions • Preliminary Report • Follow-up Exams/Testing/Studies • Factual Report • Proposed Brief/Analysis, PC • Public Docket (Includes Redaction of Personal Data) • Peer Review • Party Review • Supervisor Approval • HQ Approval

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On-scene

Investigation Organizational

Meeting Groups and

Parties Progress meetings

Family Briefings Media Briefings

Preliminary report Factual

information

Investigative Hearings Fact finding Depositions Witnesses

Docket

Board Meeting

Docket Findings

Conclusions Probable Cause

Safety Recommendations

Final Report

Government in the Sunshine Act

Investigative Process - Majors

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On-scene

Investigation Organizational

Meeting Groups and

Parties Documentation

Progress meetings Family Briefings Media Briefings

Preliminary report Factual

information

Follow-up Duties

Fact finding Examinations

Testing Additional Witnesses Wreckage Disposal

Factual Report

Docket

Proposed Analysis Proposed

Probable Cause Safety Initiatives

Final Report

Government in the Sunshine Act

Investigative Process - Regionals

Investigator Tool Kit

• Includes…

• Checklists that may be of some help