Reviewing accident reports provides an opportunity for self-assessment.
May 6, 2019
Many business aircraft pilots react to news of an aircraft accident by focusing on the lessons they may take away from it, in hopes they may avoid a similar unfortunate outcome.
Among the most frequently reviewed sources of accident information are the NTSB’s preliminary, factual and probable-cause accident reports. These reports – published in sequence throughout the investigation, which for fatal accidents typically takes approximately one year – provide increasingly detailed information about the accident sequence and such factors as equipment, environment and human factors, including crew experience and performance.
Often, such reports also reveal scenarios in which pilots may either imagine themselves or are ones that they’ve already encountered.
“When reading through a report, I change the pronouns to ‘I’ as in, ‘there I was,’” said Dr. Dan Boedigheimer, a member of the NBAA Safety Committee and CEO of Advanced Aircrew Academy. “From there, I try to identify the points where I might have made a different decision.”
Tom Huff frequently reviews accident reports in his role as chair of the NBAA Safety Committee, as well as in his position as aviation safety officer for Gulfstream Aerospace.
“It is critically important that we look at accident findings as learning opportunities,” he said. “That said, how we consume the information presented is also key.”
Noting that many pilots lack the time to regularly parse through the NTSB website, Huff suggested it may be more effective for pilots to engage with their organization’s safety officer on accident investigation findings pertinent to their company’s operations.
Webinars addressing accident scenarios are another valuable tool, added Huff, as are the detailed accident reviews published in several aviation periodicals and safety-focused industry gatherings that focus on one or more accidents sharing a common cause or chain of events.
“I believe it’s most useful when safety practitioners dissect and analyze content in the docket, or in the initial or final reporting, and then provide some level of commentary in a forum such as NBAA’s own safety conferences,” Huff said. “There are lots of rich sources available to help pilots derive the key takeaways from accident investigations to ‘re-cage their gyros,’ so to speak.”
THREE RECENT ACCIDENTS
A Cessna Caravan impacts mountainous terrain in Alaska during deteriorating weather conditions.
Probable Cause: Controlled flight into terrain
(CFIT) resulting from continued VFR flight into instrument meteorological conditions, with the company’s routine use of an inhibiting switch to silence terrain warnings a contributing factor
An owner-flown Citation CJ4 crashes shortly after a nighttime takeoff over a large lake.
Probable Cause: CFIT due to pilot spatial disorientation, with pilot fatigue and confusion over systems differences and autopilot mode as contributing factors.
A chartered Hawker 125 impacts an apartment complex while approaching to land in Akron, OH, in instrument meteorological conditions.
Probable Cause: An aerodynamic stall due to the crew’s mismanagement of the approach and multiple deviations from company standard operating procedures.
Dan Ramirez, NBAA Safety Committee member and safety director at XOJET, recommends that such processes should also be a part of a flight department’s safety culture.
“Your training program should identify sources for safety information and methods by which your operation puts that information to use,” said Ramirez. “That may actually be easier to implement from an owner/operator perspective, but it applies to the Part 135 world as well. We must take ownership of that process as professionals, regardless of our ratings.”
Naturally, pilots want answers to why such accidents occurred and often formulate possible explanations in their immediate aftermath, well before all the facts are known. While such thinking may help pilots in examining potential links in the accident chain, Boedigheimer emphasized the important distinction between forming informed hypotheses based on early information and drawing conclusions without all relevant data.
“Speculation becomes harmful when you externalize it and start playing Monday morning quarterback, especially in public forums,” he said. “What we’re talking about is internalizing information to promote a thought process within yourself about the factors that may have been involved.”
It’s also important that pilots recognize that even statements of probable cause are an opportunity for critical thinking that may also lead pilots to different conclusions than the official determination of cause.
“The NTSB investigation process understandably takes time, and not all recommendations require regulatory change,” Huff said, adding this is where
a multidisciplinary team, such as the NBAA Safety Committee, can help.
“Several NTSB recommendations have been directed at NBAA, including a study of compliance with mandatory pre-takeoff flight control checks,” he continued. “We have technical experts from all facets of business aviation who can research and develop effective solutions, as well as aid the implementation of corrective actions.”
“A probable cause report is a statement from a party system; it’s what everyone involved in the investigation came to agreement on as the most likely scenario leading to the accident,” Ramirez added. “At my company, I encourage my team to also review the factual report and, in particular, the investigation docket for possible contributing factors that you may miss if you only focus on probable cause.”
Ramirez also emphasized the benefits of looking at reports from outside the business aviation industry, citing two uncontained turbine failures over the past two and a half years involving a popular jet operated by the same commercial airline.
“Such events should prompt your operation to review their own systems,” he said. “What are your engine check procedures? Are you conducting proper blade analyses? None of those questions are raised if we only look within our industry.”
Above all, reviewing NTSB reports and their findings is not about passing judgment.
“You must enter into reading accident reports with the mentality that you are not trying to second-guess the crew’s actions or intentions,” Boedigheimer said.
“I believe the more you read through a report and internalize the factors that may have been involved, the more it helps your own scenario data gathering for identifying potential hazards.”
That may also lead to revelations even for experienced pilots, as Boedigheimer recalled after reading the probable cause report about a 2012 runway excursion that highlighted his own lack of understanding about the effects of different runway surfaces in wet conditions.
“I’d flown the same type [of aircraft] for 20 years and didn’t think I had anything new to learn about it,” he explained. “After reading the report, I realized that I also wouldn’t have thought to consider if the runway surface was grooved or not. Put me on the same trip on the same day, and I would have gone off the runway, too.”
THE SEQUENCE OF ACCIDENT REPORTING
The NTSB issues a series of accident reports it categorizes as “preliminary,” “factual” and “probable cause.” Here are the steps that the Safety Board takes as it investigates aviation accidents and publishes its findings:
- Local or regional FAA personnel are often the first aviation-focused respondents to an accident scene. Their preliminary findings are published within 24-48 hours of the event through the Aviation Safety Information Analysis and Sharing (ASIAS) program.
- The NTSB then takes over the investigation and forms a dedicated “Go Team” representing a spectrum of technical expertise from across the industry. This team publishes its Preliminary Report within approximately two weeks. That report may include potential accident factors, but always with the important caveat that all such data is subject to change as the investigation progresses.
- As the NTSB draws closer to convening a hearing to determine the probable cause of an accident, the Safety Board may publish a detailed Factual Report outlining findings from throughout the investigation pertaining to the accident. This report may be accompanied by the complete accident docket, which includes detailed information on multiple aspects addressed throughout the investigation, including supporting data, photographs and reports from team members and related personnel.
- The Probable Cause Report is often the last official posting from the NTSB and includes the investigators’ official statement(s) of proven or likely final and contributing causes of the accident based on the available data. While this is considered the Board’s final statement of cause, an accident docket may be reopened if additional information is discovered following issuance of the Probable Cause Report.