The Role of the
in Aviation Safety
Principles of Transportation
The movement of millions of passengers over distances thought impossible decades ago is symbolic of the modern air transportation era that is characterized by speed, comfort and personal convenience. The commerce of aviation, both the operation of commercial aircraft for profit and the development of aeronautical systems, is also an important symbol of national prestige and a powerful economic force. Safety in air transportation is therefore a matter of significant national importance.
The National Transportation Safety Board (NTSB) plays a central role in the overall equation of aviation safety. The agency enjoys the reputation of being the foremost independent safety investigative authority in the world. The caliber of the agency s investigations and reports has become the international standard. The NTSB is considered to be the best in the business and has served as a model for independent investigative authorities in many countries. And although the NTSB investigates thousands of marine, rail, highway, pipeline and general aviation accidents each year, the public reputation and credibility of the Board substantially rests on its ability to determine the cause of major commercial aviation accidents (Lebow, et al. 18).
The NTSB was formed through the Department of Transportation Act of 1966 and the Independent Safety Board Act of 1974 ( Code of Federal Regulations Part 800 ). These two pieces of legislation placed the responsibility of investigating and determining the probable cause(s) of all civil aviation accidents with the NTSB ( 1996 Annual Report to Congress 28). The agency was later charged with the duties of investigating safety issues within the other modes of transportation marine, rail, highway and pipeline. While the agency commands no significant enforcement powers - that is, it is not a regulatory agency - it does exert enormous influence based on the accuracy of its investigations and the authority of its recommendations. The NTSB has its headquarters in L EnfantPlaza, downtown Washington, D.C.
The primary function of the Board is to promote safety in transportation. The Board is responsible for the investigation, determination of facts, conditions and circumstances and the cause or probable cause of all accidents involving civil and certain public aircraft. In addition, the Board investigates highway accidents, including railroad grade-crossing accidents; railroad accidents in which there is a fatality, substantial property damage, or which involve a passenger train; pipeline accidents in which there is a fatality, significant injury to the environment, or substantial property damage; and major marine casualties and marine accidents involving a public and a non-public vessel or involving Coast Guard functions ( Code of Federal Regulations Part 800 ). Simply stated, the Board s mission is to prevent accidents and save lives in transportation. And although the NTSB s mission is primarily a proactive one the prevention of transportation accidents the agency accomplishes this mission by being reactive in responding to catastrophic events. In reality, the Board uses the lessons learned from real-world accidents as catalysts to prevent future occurrences. The NTSB aims to improve quality through the analysis of failure.
The Board consists of five Members appointed by the President with the consent of the Senate ( Code of Federal Regulations Part 800 ). This allows the agency much more latitude when investigating accidents and making recommendations. With the absence of a separate agency to report to, such as the FAA or DOT, the board can exercise its full discretion without fear of retribution. The NTSB currently employs a workforce of 402, including office clerks, investigators, engineers, specialists and writers, making it the smallest federal agency within the United States government (Goglia). It is the primary responsibility of the team of crash investigators, engineers, lab technicians and specialists to examine and test all recovered evidence from an accident to determine the probable cause. This team then submits its findings to the Board Members for review and acceptance.
The Investigative Process
The Board uses selection criteria to apply its limited investigative resources to those accidents that will generate the most safety benefits. Not all aviation accidents are investigated by the Board, however all aviation accidents are required to be reported to the NTSB within 48 hours of discovery. Specific to aviation, the Board s investigative response is limited primarily to the following scenarios:
All accidents involving 49 CFR Parts 121 and 135 air carriers;
Accidents involving public (i.e., government) aircraft;
Foreign aircraft accidents involving U.S. airlines and/or U.S.-manufactured transport aircraft or major components of;
Accidents involving air traffic control, training, mid-air collisions, newly certified aircraft/engines, and in-flight fire or breakup;
General aviation accidents, some of which are delegated to the FAA for fact finding ( Strategic Plan ).
The Go Team
The Office of Aviation Safety has the primary responsibility for investigating aviation accidents and incidents, and proposing probable causes to the Board. When the Board is notified of a major aviation accident, it launches a Go Team, which varies in size depending on the severity of the accident (Lebow, et al. 14). The team, accompanied by a Board Member and led by an investigator in charge (IIC), can consist of experts in as many as 10 different specialties. Each expert manages a group of other specialists from government agencies and industry in establishing a factual record of the accident (Lebow, et al. 14). Go Teams are traditionally dispatched from headquarters within a couple of hours after notification of an accident ( 1996 Annual Report to Congress 33).
The Party Process
The party system allows the NTSB to leverage its limited resources and personnel by bringing into an investigation the technical expertise of the companies, entities and individuals that were involved in the accident or that might be able to provide specialized knowledge to assist in determining the probable cause of an accident. With the exception of the FAA, party participation is a privilege, not a right (Lebow, et al. 15). The investigator in charge has the authority to grant party status, and each party representative must work under the authority of the IIC or senior accident investigator. Media, lawyers, insurance personnel, claimants and litigants, victims and family members are prohibited from participating as a party (Lebow, et al. 15). In providing the Board with technical assistance and expertise, the participants are also afforded many opportunities to learn what happened and formulate theories as to the cause of an accident.
The Board often times holds public hearings as part of a major accident investigation. The purpose of the hearing is two-fold; first, to gather sworn testimony from subpoenaed witnesses, and, second, to allow the public to observe the progress of the investigation ( Strategic Plan ). The Safety Board is a public agency, and conducts its investigations in a public manner, often in the glare of intense media attention. Public hearings allow the Safety Board and industry to exercise their accountability and allow the Board to meet its mandate to conduct a full, fair, and unbiased investigation.
After the investigation is complete and all parties have had an opportunity to review the factual record, a technical review meeting of all parties is convened. That meeting is held to ensure that no errors exist in the investigation, and that there is agreement that all necessary steps have been completed. 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 ( 1997 Annual Report to Congress 31). The record of the investigation, including the transcript of the hearings and all exhibits entered into the record will become part of the Safety Board s public docket on the accident. The final report of the investigation is completed by the Safety Board staff and forwarded to the Safety Board for consideration. The five Board Members then deliberate over the final report in a public meeting, resulting in a ruling to adopt or reject the findings of the investigation. Recommendations resulting from the investigation are forwarded to the appropriate agency or industry where corrective action is suggested to take place. The NTSB and the addressee then typically engage in a series of exchanges, revisions, substitutions, and clarifications before a recommendation can be classified, Closed, Acceptable.
Accident Investigation Today
Under Annex 13 to the Chicago Convention, the international treaty that provides the structure for the governance of civil aviation throughout the world, the NTSB is the government agency charged with the responsibility for assuring compliance with U.S. obligations (Lebow, et al. 17). In the event of a civil aviation accident outside of U.S. territory, the NTSB appoints the accredited U.S. representatives to the investigation and oversees advisors from the U.S. aviation industry. It is critical to the mission of the Board that it be allowed to participate in accidents involving U.S.-made aircraft, systems, structures and registered air carriers. NTSB involvement enables U.S. authorities to take necessary measures to prevent future accidents based on the findings of the investigation. The agency also provides necessary technical support, such as the readout of cockpit voice recorders and flight data recorders, to foreign investigators.
Most Wanted List
The NTSB s Most Wanted list was created in 1990 to highlight recommendations the Board feels should be acted on as soon as possible (Donoghue 46). These recommendations, the agency feels, have the most potential to improve safety, save lives, and reduce accidents and injuries. Once a Most Wanted recommendation is classified, Closed, Acceptable, meaning suitable action has been taken to address the concern, it is taken off the list and replaced with a new one. The Board maintains a list of ten Most Wanted improvements, encompassing all modes of transportation, not just aviation. Since the program s inception, the list has had a positive impact on a variety of transportation safety issues.
The Board also has an outreach program designed to persuade others to act on specific safety issues. These outreach efforts include conducting industry symposia, workshops, and advocating safety initiatives at various governmental levels.
On a December evening in 1972, an Eastern Airlines L-1011 crashed into the Florida Everglades while on approach to Miami International airport. Almost two years later, a TWA 727 crashed into a mountain while on approach to Washington Dulles International Airport. The common thread in these two accidents was that not one mechanical malfunction contributed to either accident. The Safety Board concluded that these two accidents resulted from an anomaly termed controlled flight into terrain . Furthermore, the Board concluded that a terrain warning system in the cockpit could have prevented these accidents (We Are All Safer 6). The Board s recommendation called for all large passenger aircraft to be equipped with a ground proximity warning system that issues aural warnings when an aircraft is approaching terrain. The FAA adopted this recommendation and has since extended the requirement to commuter aircraft with 10 or more seats.
Since 1968, the Safety Board has issued over 60 recommendations addressing windshear and related weather issues. Major recommendations were first issued following the 1975 crash of an Eastern Air Lines 727 in New York. In early August 1985, a Delta Air Lines L-1011 crashed while trying to land at Dallas/Fort Worth International Airport during a thunderstorm. It was the seventh fatal airline accident since 1970 found to be attributable to the weather phenomenon called windshear (We Are All Safer 10). As a result of the Safety Board s recommendations, research efforts were launched that increased our knowledge and understanding of windshear. Safety improvements such as enhanced windshear training for pilots, low-level windshear alert systems and the installation of Terminal Doppler Weather Radar at major airports were developed as a result of the Board s findings.
On July 17, 1996, Trans World Airlines flight 800, a 747-100, suffered an in-flight breakup over the Atlantic Ocean shortly after takeoff from JFK International Airport. Investigators determined that the aircraft experienced a catastrophic explosion of the center wing fuel tank, which killed all 230 onboard (We Are All Safer 28). The extensive recovery effort and subsequent investigation resulted in recommendations and improvements made in coordination with the FAA and Boeing Aircraft. It has led to heightened awareness and understanding of the hazards posed by fuel vapor at elevated temperatures, the flammability of Jet A fuels, shortcomings in fuel tank electrostatic protection, deficiencies in electrical surge protection, failing fuel pump safety, and an understanding of aging wiring issues. With respect to the 747 fleet, the Board s recommendations have resulted in fuel system product improvements, service bulletins and airworthiness directives to correct issues uncovered by the investigation ( Final Report ).
The NTSB s strategic plan clearly states what it expects to accomplish for the taxpayer: 4 goals aimed at preventing or reducing the severity of future transportation accidents. Its mission is focused and its responsibility is great.
1. To prevent future accidents, save lives, and reduce injuries and property damage.
2. To ensure that survivors and families of victims of transportation accidents receive timely, compassionate assistance from the operator, other government agencies, and community service organizations.
3. To provide aviators and mariners with fair, timely, independent appellate review of certificate actions taken by the FAA and the US Coast Guard.
4. To be the best managed agency in government in order to facilitate the accomplishment of other goals ( Strategic Plan ).
The NTSB s vision is for the public to continue to have confidence in the nation s transportation systems, even when accidents do occur. Knowing that an independent body will determine the causes of accidents and recommend corrective actions be taken is a large part of the public s assurance. The NTSB has become a critical link in the chain that ensures the safety of the traveling public in the United States and throughout the world. Its investigative practices, determination, the passion that its employees possess, and most of all, the commitment to improving all aspects of safety in transportation under scrutiny and the most demanding of circumstances, are what makes the National Transportation Safety Board the worldwide standard. It is in the interest of all who travel, by whatever mode, to ensure that the NTSB continues to strive for excellence in independent accident investigation.
Donoghue, J.A. No Trespassing. Air Transport World. March 2000: 46-48.
Final Report. National Transportation Safety Board. http://www.ntsb.gov/events/TWA800/default.htm 11 November 2000.
Goglia, John. NTSB. Issues in Aviation Lecture Series. Daniel Webster College: Nashua. 28 November 2000.
Lebow, Cynthia C.; Liam P. Sarsfield; William L. Stanley; Emile Ettedgui; and Garth Henning. Safety in the Skies: Personnel and Parties in NTSB Accident Investigations. Santa Monica, CA: Institute for Civil Justice RAND, 1999.
Strategic Plan. National Transportation Safety Board. http://www.ntsb.gov/Abt_NTSB/strategic/plan.htm 11 November 2000.
United States. National Transportation Safety Board. 1996 Annual Report to Congress. Washington, D.C., 1996.
United States. National Transportation Safety Board. 1997 Annual Report to Congress. Washington, D.C., 1997.
United States. National Archives and Records Administration. Code of Federal Regulations, Part 800. Washington, D.C.: GPO, 2000.
We Are All Safer. 2nd ed. Washington, D.C.: National Transportation Safety Board, July 1998.