REFLECTIONS ON AVIATION ACCIDENT
PREVENTION
(with apologies to Cervantes)
I have just received the Proceedings of the Twenty-Sixth International Seminar of ISASI which was held in Seattle, Washington in September of 1995. I note with some satisfaction that most of the speakers concentrated on state-of-the-art and future technology to solve the problems of aircraft accident causation. Progress in these fields is encouraging and every effort to increase the chances of early and accurate determination of cause should be applauded.
However, there are some current basic problems that should receive some attention. Jim Hall, Chairman of the NTSB, outlined some of these needs in his four points which he called "First, Second, Third and Finally". His third point emphasized "a high level of competence in both state-of-the-art technology an in the BASICS of accident investigation", (caps added). He later adds that investigators must "develop accident prevention measures to prevent similar accidents". Wonderful in theory, but lacking in the understanding of reality and historical perspective. Today's investigators view their influence in attaining correction of defects in aircraft as a result of their investigation as likely as being able to throw Niagara Falls back with a soup ladle…… and for good reason.
The thought as expressed by one field investigator in particular was, "Why should I break my back to tell the board something that I have told them many times before. They don't and won't do anything about it anyway".
Despite the attitudes of some individuals, accident investigation is not a game to be won or lost as viewed in the courts, nor is it a search to fulfill the political, financial or career ambitions of the controlling participants. Ideally it is an attempt to seek out the true basic cause or causes of a mishap so that remedies may be applied to prevent such accidents in the future.
The first part of this procedure is the responsibility of the investigator…..determination of cause. The second part, i.e. the application of remedies to prevent recurrence, is a function beyond the authority of the investigator.…at least in the NTSB. This is where the system most frequently fails. Such failure to implement corrective action becomes a thorn in the side of all investigators and eventually leads to hasty and incomplete performance.
The statements of the heads of responsible governmental departments may be well intentioned. But, as my sainted mother used to say, "The road to hell is paved with good intentions". These appointees must publicly acclaim politically correct and timely philosophies or lose their jobs. The administrator of the FAA recently stated on a television interview that no aircraft in the United States would be allowed to fly with a known defect. Politically correct ? Yes. Factual ? Not by a long shot.
For example: Dr. Calabro and his wife Ruth were killed in an aircraft accident in1991 by a design defect which had been identified and reported to the FAA in 1985.The FAA confirmed that the defect in fact did exist and was indeed a hazard. However, as of the beginning of 1996 the defect has not been corrected. Hence, the public statement of the Administrator is patently false. Almost eleven years of stumbling, bumbling and stalling by the FAA and people are still being killed by a defect that the FAA admits does exist. This is just one example of defects that exist in the general aviation fleet that is still flying and causing accidents.
The excuse that the FAA uses for inaction in some of these cases is that fatalities caused by these defects are "statistically insignificant". Whose death is "statistically insignificant"? Yours, mine, your aunt Mable or your next door neighbor ? Maybe, in the eyes of the FAA, but let one U.S. Senator or other high profile person die in just such an accident as the one that killed Dr. Calabro and his wife and the FAA immediately goes into overdrive to make cosmetic corrections which may or may not be pertinent. The FAA uses statistics like a drunken man uses a lamp post…..more for support than illumination.
The deterioration of competent field investigation of general aviation accidents in the past few years is obvious and scandalous. The situation has gotten so bad that the aviation community should not "take it any longer". There are more deaths in general aviation every year than in the scheduled airlines. Yet, look at the difference in the investigations and the lack of effort to prevent general aviation accidents. The FAA seemed to think it was more important to ground Bob Hoover than to correct a design deficiency in an aircraft that has killed many people and will kill more if the FAA does not act in a reasonable fashion to correct the deficiency.
Talks and correspondence with retired NTSB personnel reveal that creeping political influence has overtaken the NTSB. The published reports of general aviation accidents tend to support this view. Many accidents re-investigated after the NTSB has returned the wreckage to the owner of record reveal that the original investigation was hurried, incomplete, slipshod and based primarily on the advice of the manufacturers representative who was a party to the investigation and "advised" the NTSB investigator in charge on scene…i.e. if the investigator in charge was actually "on scene". Sometimes the affair is conducted by telephone. Such investigation are recorded and tabulated and make up the statistics that are quoted, ad nauseam, and believed to be accurate by the public and often by the courts. Garbage in, garbage out. When the situation comes to this, the NTSB and the FAA are compounding a simple fracture.
Further, these wrong conclusions, once entered into the system, might as well be cast in stone over the entrance to the Supreme Court building. It is almost impossible to convince the NTSB or the FAA to correct the record. Organizational inertia, the " not invented here" syndrome and a natural reluctance to publicly admit failure makes changing an accident cause a difficult, expensive and time consuming procedure which is rarely successful in spite of obvious evidence presented. After many years in such attempts, one begins to assume the role of Don Quixote.
What is wrong, and how could it get fixed ? First, read the March 1, 1986 Aviation Consumer article on page nine of that issue entitled "What's Wrong With the NTSB?". At that time neither the Vice Chairman of the Board nor the Chairman of the Board had any aviation safety background before being appointed to the Board. One was the wife of a former Senator and the other was a small town judge from Arkansas who was active in the party in power. Has the situation improved since then? Read the Keynote Speech in the 1995 ISASI Proceedings. The current Chairman of the Board is new to the business of aviation safety. The first five paragraphs of his printed speech are revealing. What's wrong with the NTSB? Read the interview with Chuck Miller in the same issue of Aviation Consumer.(March 1, 1986). These articles were written in 1986 and the same problems are rampant today.
Where does ISASI as an organization fit into this situation? What can or should the organization do about this sad state of affairs? Who can best attempt to improve the investigations and the end product thereof ? If not ISASI then who ? Some organization with clout must take the bull by the horns and with the use of old fashioned truth and logic take action to cure this self serving political virus before it kills both the patient and the doctor.
After more than thirty years in the business of investigating accidents and more than sixty years in aviation I am discouraged by current trends. The politicians in power can't even balance the government checkbook. How can one expect them to come to grips with the problems of accidents in aviation. Quien sabe ? As it now stands it seems that prayer is the only answer and with the separation of church and state not even the Pope could influence this problem.
Hope springs eternal…..so someone once said. Damn the torpedoes, full speed ahead, some one else once supposedly said. I am out of torpedoes and almost out of hope. The little hope I have left is that I will live long enough to see improvement.
Norman L. Horton
