Accident Investigation - Essay Example

Accident Investigation Introduction Accidents in the road, sea, and air are becoming common occurrences, and more so with increasing population and technological advancements in the past decade or so. These accidents have been investigated by the National Transportation Safety Board (NTSB) in order to assess and evaluate their causes in the hope of consequently improving safety in the travel industry. This paper shall discuss National Transportation Safety Board accident investigations in the United States. This discussion shall be carried out using a domestic accident in the United States in the last five years, evaluating how it was investigated – the procedures, and the final results. Accident: Facts of the Case For this paper, the incident of a Beech 200, N266EB which was flying for the Weekend Air Charter Services, Inc., operating as a personal flight on its final approach to runway 23 at the Grand Strand Airport, North Myrtle Beach, South Carolina will be discussed. According to the NTSB (2007), the plane took off from the Trenton Mercer Airport, Trenton, New Jersey on the 3rd of February, 2006 at 1900 hours. Witnesses narrate that they saw the plane taking two approaches to the runway. On its first approach they observed that the plane was ‘fish tailing’ while it was about 30 feet over the runway (NTSB, 2007). They saw that the plane was able to regain control and it then flew over the runway until it passed the air traffic control tower. They then saw the plane do a climbing left turn. Witnesses also account that they heard the pilot tell the air traffic controller that he was doing a go around (NTSB, 2007). The air traffic controller then asked the pilot if the sea fog was troubling him; the pilot replied in the negative, but that his “left engine kept power up a little too much and would not come back” (NTSB, 2007). The witnesses next accounted that the plane circled the airport to the left and then they watched it attempting to land on the runway for a second time. A witness accounts that as the plane approached the runway, it “climbed and rolled left, went inverted and nosed down into the grass to the left of the runway and burst into flames” (NTSB, 2007). Someone hollered for the fire department to be called in. The fire department tried to offer assistance, but the plane was already engulfed in flames. As a result of the accident, “the airline transport-rated pilot, and five passengers received fatal injuries and the airplane was destroyed” (NTSB, 2007). Procedure of the NTSB The NTSB is “an independent agency that determines the probable cause of transportation accidents and promotes safety through the recommendation process” (Wells and Rodrigues, 2004, p. 52). It is tasked with investigating accidents and making a rational and appropriate determination of these incidents in the interest of establishing cause and consequently preventing similar incidents from recurring. 1. The Go-team (Wensveen, 2007). First and foremost, as soon as an incident or an accident is reported, an NTSB-go team, under the leadership of an investigator-in-charge (IIC), is immediately sent to the accident site (Wells and Rodrigues, 2004). This IIC will now undertake the field part of the investigation by gathering as much information as he can from the witnesses and from possible survivors of the crash. The Federal Aviation Administration (FAA) is usually the first who would be informed of the accident, and then the Director of the NTSB field office involved is informed next. This office would then inform the go-team on duty, the board member on duty, the NTSB chair, and the public affairs office (Wells and Rodrigues, 2004). Usually within two hours, the go-team is on its way to the accident site. 2. At the Site (Wensveen, 2007). The IIC, together with the go-team, is tasked with conducting an inspection of the wreckage and uncovering all other possible information pertinent to the incident. The go-team of the NTSB will also handle the gathering of information based on their areas of expertise. There are usually five or more expert members of the team who will conduct the process of investigation. This includes an air traffic control specialist, a meteorologist, a human-performance expert, an expert trained in witness interrogation, an engine specialist, and experts on hydraulics, electrical systems, and maintenance records (Wells and Rodrigues, 2004). The first two days of the accident are crucial to the investigation because the scene is still fresh and an accurate investigation of the scene is made possible. The investigation and information gathered at this stage is also crucial because these field notes are “the only official representation of conditions immediately following an accident. They are very important because a witness’s memory of events can change with time and the wreckage itself can be altered shortly after the on-scene phase of the investigation is completed” (Rand Corporation, n.d., p. 19). Before the go-team would arrive, the scene is kept secure by an investigator from the nearest field office assisted by local authorities. Representatives of the aircraft manufacturer, airline, the engine manufacturer, and the FAA are usually also called in. In instances of major accidents, a member of the NTSB usually accompanies the team. The IIC would then assign each of these individuals to a section of the go-team (Wells and Rodrigues, 2004). The go-team usually stays and investigates the crash site in about 10-14 days, depending on the need. In instances where there are fatalities, a local coroner is often called in to perform autopsies of the flight crew. This will help determine if the accident is caused by any incapacity or medical problems on the part of the flight crew. It will also determine where the crew is seated and who was flying the plane (Well and Rodrigues, 2004). The go-team is then divided into groups of experts and each expert now focuses on his area of expertise. Coordination is accomplished by the chairpersons in each team. Through their expertise and their existing knowledge about aviation, the team members now compare and evaluate what they were able to uncover from the wreckage (Wells and Rodrigues, 2004). Wells and Rodrigues, 2004) explain that there are three aspects or disciplines which are assessed in the process of the investigation. This includes air traffic control, operations, and weather. Firstly, the ATC experts would assess the ATC facilities, the procedures and flight handling, and would then develop a flight history. Secondly, the other experts would assess the flight operations including the flight training and experience of the crew. And lastly, the weather experts would assess the meteorological conditions that may have precipitated the accident (Wells and Rodrigues, 2004). Other experts also assess different aspects of the crash in order to further evaluate the causes of the accident. 3. In the Laboratory (Wensveen, 2007). Laboratory experts in the NTSB office in Washington also conduct their tests in order to decipher data from the voice recorders and data flight encoders (Wells and Rodrigues, 2004). Metallurgy is also one of the aspects of the laboratory testing which is undertaken on the airplane. This is usually conducted on different parts of the wreckage recovered. When the on-scene investigation is finished, each team leader or NTSB chair would now complete his report on his area of expertise. Such report is placed in a public docket available for every one’s viewing. The investigators will still continue to gather information about the case; to conduct more interviews, public hearings, and analysis on the factual information gathered (Wells and Rodrigues, 2004). 4. The Safety Recommendation (Wensveen, 2007). The investigation is capped by the NTSB’s safety recommendation submitted to the FAA. As the factual phase of the investigation is concluded, a thorough analysis of the facts gathered will now be conducted at the NTSB’s headquarters in Washington, D.C. The IIC and the NTSB senior staff would also draft the final report for presentation to the members of the Board (Wells and Rodrigues, 2004). Such report would now contain the probable cause of the accident and the recommendations of the members of the investigating team. 5. The Public Hearing (Wensveen, 2007). A public meeting of the Board will next be held in Washington. The members of the investigating team usually attend such meetings (Wells and Rodrigues, 2004). 6. The Final Report (Wensveen, 2007). The NTSB would later either adapt the report of the investigating team or it may require further investigations on the incident. The report will always stay open in order to allow members of the investigating team to possibly revise or reconsider their statements or findings on the accident (Wells and Rodrigues, 2004). Procedure as applied to accident cited in this case 1. The Go-team. First and foremost, the report made by the NTSB does not make mention of circumstances indicating when they were called in to investigate the plane crash. Such details are already implied from their official report. The factual circumstances that they now narrate indicate different groups of experts investigating the incident. 2. At the site. According to the NTSB (2007), the report of the human performance expert reveals that the pilot was issued the necessary certificates to fly the plane. The pilot’s most recent medical test revealed that he must wear corrective lenses. The investigation also revealed that his total civilian flight hours stood at 3400 hours. His logbook was not found and was believed to have been in the airplane during the accident (NTSB, 2007). Investigation from other experts reveals that the plane was issued an airworthiness certificate on April, 1998. Records also reveal that the plane was inspected under the current manufacturer’s phase program. Records also indicate that the plane underwent other inspections, and that the plane complied with the necessary requirements for safety (NTSB, 2007). However, records also reveal that the plane underwent several repairs, and it underwent only limited maintenance after it was overhauled in 1997. From the time it was overhauled, it went through several shop repairs for a variety of problems (NTSB, 2007). Only its propellers were overhauled in 2002, however, no other records of maintenance were recorded on the propellers since the overhaul (NTSB, 2007). Meteorological experts report that skies were: “clear of clouds, no ceiling, visibility 7 statute miles, temperature 13-degrees Celsius, dew point temperature 13-degree Celsius, wind 150 degrees at 6 knots, and altimeter 29.84” (NTSB, 2007). From the wreckage, the experts were able to piece together the damage to the plane. The Forensic Pathologist from the local coroner’s office established that the cause of death of the pilot was multiple trauma and burns sustained from the plane crash (NTSB, 2007). Toxicology reports reveal no carbon monoxide, cyanide, ethanol, and drugs in the pilot’s system. 3. In the Laboratory. After field investigations, the laboratory testing on the air traffic control transmissions were done at the headquarters in Washington. Background sound signatures associated with the aircraft were checked and analyzed. No recorded data capturing the plane’s attempted landings were retrieved (NTSB, 2007). 4. The Safety Recommendation. There were no safety recommendations indicated in the NTSB report. 5. Public Hearing. Implied from the NTSB report. 6. The Final report. The final report as finalized by the NTSB (2007) based on the reports submitted by the members of the go-team and the experts who conducted the investigation on the plane reveal no abnormal pre-impact conditions which would have interfered with the normal flight of the plane. Information contained in the Operating Handbook and FAA approved Flight Manual indicate stalled speed with gear extended, 40 degrees flaps, and zero bank angle as 84 knots indicate air speed. The NTSB concluded that: “the pilots failure to maintain control during landing approach for undetermined reasons” (NTSB, 2007). The NTSB’s function, in this instance, ends with its establishment of probable cause. It cannot actually be expected to conduct its investigations with absolute certainty. Nevertheless, it is tasked with the determination of probable cause based on competent evidence in order to help establish possible civil liability (Kolczynski, 1997). Works Cited Chapter 2: The NTSB’s Role in Aviation Accident Investigation and NTSB’s Operational Baseline. (n.d) Rand Corporation. Retrieved 09 October 2009 from the World Wide Web: http://www.rand.org/pubs/monograph_reports/MR1122.1/MR1122.1.ch2.pdf Kolczynski, P. (1997) NTSB Investigation Guide. Aviation Law. Retrieved 09 October 2009 from the World Wide Web: http://www.aviationlawcorp.com/content/ntsbinvest.html#Heading1  NTSB Identification: ATL06FA044. (27 June 2007). National Transportation Safety Board. Retrieved 09 October 2009 from the World Wide Web: http://www.ntsb.gov/ntsb/brief2.asp?ev_id=20060208X00173&ntsbno=ATL06FA044&akey=1 Wells, A. and Rodrigues, C. (2004) Commercial Aviation Safety. USA: McGraw-Hill Publications Wensveen, J. (2007) Air Transportation: A Management Perspective. Victoria: Burlington Publishing Company. Read More