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INTRODUCTION TO SET

Welcome

I don't know whether to post this here or in the editorial section of the site, so I put it both places. The views expressed are mine and mine alone..

Ludwig Benner

This set of documents compares an NTSB investigation with a subsequent investigation by others related to litigation. The NTSB reported that the crew became disoriented during a training maneuver, and essentially said that crew behavior and lack of management oversight of its trainng program caused the accident. The Petition for Reconsideration, on the other hand, argues that the aircraft engine broke off the aircraft in flight, making it unflyable.

Who is right? Read the reports and try to decide for yourself.

view NTSB Report
view ALPA Petition for Reconsideration
view Stearman paper

 (View other sets).


POINTS TO PONDER

After reading the reports, here are some points to ponder and comment on, but please, from an investigation process research perspectiveNo ad hominum attacks.. Click on the FORUM in the menu bar to submit your comments.

  The NTSB had posted the following at http://www.ntsb.gov/Aviation/NYC/92A053.htm

THE PURPOSE OF THE FLIGHT WAS TO PREPARE TWO FIRST OFFICERS FOR A CAPTAIN UPGRADE FLIGHT. THE INSTRUCTOR PILOT DISABLED THE STUDENT'S ATTITUDE INDICATOR DURING FLIGHT, AND THE STUDENT HAD DIFFICULTY MAINTAINING AIRPLANE CONTROL. DURING A SIMULATED INSTRUMENT APPROACH, WHILE IN THE PROCEDURE TURN, THE INSTRUCTOR SIMULATED AN ENGINE FAILURE IN ADDITION TO THE ATTITUDE INDICATOR FAILURE. THE STUDENT ASKED THE INSTRUCTOR TO TAKE CONTROL OF THE AIRPLANE BECAUSE HE BECAME DISORIENTED, HOWEVER, THE INSTRUCTOR REFUSED. THE INVESTIGATION REVEALED THAT THE INSTRUCTOR WOULD TURN HIS OWN FLIGHT INSTRUMENT LIGHTS TO THE "DIM" POSITION WHEN THE STUDENT WAS FLYING SO THAT HE COULD NOT "PEEK" AT THE OPERABLE ATTITUDE INDICATOR. EXAMINATION OF THE WRECKAGE REVEALED THAT THE INSTRUCTOR'S LIGHT RHEOSTAT WAS IN THE DIM POSITION. THE ACCIDENT OCCURRED OVER THE OCEAN, ON A MOONLESS NIGHT. NEITHER THE OPERATOR, NOR THE FAA WERE AWARE THAT THIS INSTRUCTOR WAS USING BLOCK ISLAND FOR TRAINING, OR WHAT TRAINING METHODS HE WAS EMPLOYING.

Probable Cause

THE INSTRUCTOR PILOT'S LOSS OF ALTITUDE AWARENESS AND POSSIBLE SPATIAL DISORIENTATION, WHICH RESULTED IN THE LOSS OF CONTROL OF THE AIRPLANE AT AN ALTITUDE TOO LOW FOR RECOVERY; AND COMPANY MANAGEMENT'S LACK OF INVOLVEMENT IN AND OVERSIGHT OF ITS BEECHCRAFT 1900 FLIGHT TRAINING PROGRAM. CONTRIBUTING TO THE ACCIDENT WAS THE INSTRUCTOR PILOT'S EXERCISE OF POOR JUDGMENT IN ESTABLISHING A FLIGHT SITUATION AND AIRPLANE CONFIGURATION CONDUCIVE TO SPATIAL DISORIENTATION THAT AFFORDED THE PILOTS LITTLE OR NO MARGIN FOR ERROR.

The NTSB findings have been disseminated for 7 years as the truth. For example, doing a quick search for N811BE on the Internet, I found the NTSB version repeated by well meaning folks at

http://aviation-safety.net/database/1991/911228-0.htm

During that time, the focus of public prevention efforts has been crew behavior, pilot training and management oversight of training..

Has anyone ever pondered the consequences of whose investigation produced the truth when investigation results conflict? Some consequences are suggested by Safety's Hidden Defect: Accident Investigation, the hazardous iceberg displayed at www.iprr.org/Editorials/edpage.html

Injustices.
Since the NTSB report, for example, the family of the pilot whose behavior the NTSB cited have had to live the stigma associated with the probable cause assigned by the NTSB. If the NTSB report is wrong, the relatives of the crew have had been though at least 7 years of unnecessary torment thus far. How can they get the error reversed after it has been disseminated? If the NTSB is right, why did it not respond for over 3 years?

Litigation.
The NTSB report apparently left sufficient uncertainties that parties had to resort to litigation to resolve the differences. How could this be preempted by the NTSB reports? Isn't litigation a signal of investigation problems?

Misdirected investigations
The findings in this case add to investigators' experience base in future accidents. If it is wrong, how with that affect future investigations? As one reads the NTSB report, for example, one can see the centralized control management philosophies in the NTSB report. With this perspective at the top, NTSB investigators will seek and find what they think they should be looking for in future investigations and reports.

Wrong policies
If investigators find what they think they should look for, NTSB will tend to impose strong centralized management concepts on the aviation community (similar to that which pervades Government) which may or may not be warranted in aviation systems where every contingency can not reasonably be foreseen. Should these philosophies and policies be challenged? If so by whom? Or should NTSB be focusing on defining problems, rather than proposing solutions like it recommended in this case, possibly based on flawed underlying investigation work? If NTSB was right, should litigation policies be reexamined?

Distrust
If the NTSB report is wrong in this case, how many more investigations are suspect? How does the NTSB handle issuance of a correction, if that is necessary, without undermining public confidence as is happening with exposures of police misconduct. If it is right, why does it take so long to establish that fact? Does the NTSB report reflect biases at the investigator or Board level favoring the cause de jour?

Flawed data
For accident analysts interested in prevention, it will make a difference whether the NTSB or the Petitioners are right, because they will trust the NTSB data reported for their analysis. If NTSB is wrong, does that mean analysts using the data need to figure out how to validate NTSB data before they utilize it in their statistical operations? If so, how could this be done?

Flawed research
If the NTSB is right, analysis would conclude prevention efforts should directed at crew actions and training oversight. On the other hand if the Petitioners are right, prevention would be aimed at aircraft design and maintenance. For statistical analyses, if NTSB is wrong this may undermine any research findings for prevention efforts when using the data.

Delays
The delays in closure of the accident investigation project is demonstrated by this case, with impacts already discussed. The delays cost money. Petitions for reconsideration take time and money. Responding to Petitions poses demands on NTSB staff. What ways might be available to reduce the delays in closure for all concerned, and produce outputs that are not contentious?

Missed opportunities
If the Petitioners are right, consider lost opportunities to improve safety. As nearly as I can tell, there were no subsequent accidents involving the claimed engine mount problem on this aircraft. But if there had been, and the problem continued to be defined as poor judgment, the missed opportunity because of flawed investigations is obvious - unnecessary losses. What can be done to get consistent, complete and trustworthy investigations the first time.

Another aspect of this issue is the missed opportunity to improve investigation processes. The NTSB has its traditional investigation processes and experience base, which have been challenged in the recent Rand study.. If it turns out that the NTSB was wrong, one may wonder, also, whether the entry of the NTSB into this accident investigation may have delayed the introduction of new thinking about investigating what actually happened and why it happened, as with the work with the data recorders. Maybe competition could be productive.


Another aspect of this discussion is the role of the internet in exposing and accelerating discussion of the differences such as those encountered here. But that's for another day.

Comments are invited. The cost of errors is real. There is a problem.

Ludwig Benner, Jr.
April 17, 2000

PS In case it is not apparent, I am inclined to view the Petitioners report as more persuasive because the amount of value-free data and logic presented.


While searching the internet, I also found the following (http://www.ntsb.gov/Aviation/NYC/87A117.htmhttp://www.ntsb.gov/Aviation/NYC/87A117.htm)
NTSB Identification: NYC87LA117
For details, refer to NTSB microfiche number 34646A
Scheduled 14 CFR 135 operation of BUSINESS EXPRESS
Accident occurred APR-06-87 at BOSTON, MA
Aircraft: BEECH 1900, registration: N811BE
Injuries: 1 Serious, 10 Uninjured.
DURING TAXI OPERATIONS IN PREPARATION FOR A TAKEOFF FROM BOSTON LOGAN AIRPORT, THE BEECH AIRCRAFT WAS STRUCK BY A GROUND VEHICLE AND SUBSTANTIALLY DAMAGED.
Probable Cause Visual lookout..Inadequate..
Driver of vehicle Clearance..Not maintained..
Driver of vehicle