The textbook accident investigation is a slow, deliberative examination of the facts and equally thoughtful assessment of the probable cause. The above referenced case is in some ways not a standard process; for the collision was between aircraft operated by individuals associated with the FAA and the NTSB. Thus, the Canadian Transportation Safety Board (TSB) was asked to perform the duties of its US counterpart on American soil. The extraterritorial jurisdiction is the only unusual aspect of the handling of this matter.
TSB Investigator-in-Charge, Jon Lee, has conducted his work by the book. He has completed the 1st or field phase, in which his team inventories available evidence. The TSB has accumulated photographs and documents and has examined the wreckage. Critical to their analysis will be the information garnered through their interviews of the surviving pilot and eye-witness statements. Objective data will be developed from AT data and the comments of air traffic controllers. Because the Cherokee GPS was recovered, its memory includes the very useful flight path information.
Now the TSB team will deliberate, assessing alternative scenarios as to how this accident came to pass and in good time, at the end of Phase 2, the accident investigator will issue his report including what happened, why it occurred and what lessons might be gleaned to avoid a reoccurrence.
This description of what is happening in this Warrenton, VA accident demonstrates how the NTSB, and its sister agency the TSB, reaches a decision in this case as well it should be in all cases. The team has been allowed to do its job and the likelihood that the result will be well reasoned is high.
Unfortunately such a meticulous thought process does not always occur. In many high profile cases, such as the tragic 1996 TWA 800 crash, the press insists that the investigation must be resolved at the 24/7/365 pace which it works. In such instances, a reporter finds an “expert” who postulates his/her hypothesis of what caused the accident to occur. [NOTE: it is rare that any aviation safety professional is willing to engage in such guessing early in an investigation.] That speculation then becomes a QUESTION, which a member of the press poses to an NTSB representative, an FAA official, an airline executive or someone else involved in the investigation.
All too often, the theory behind this QUESTION requires that the investigators assign scarce NTSB resources to prove or disprove this speculative theory. It is quite possible that the work to disprove the press QUESTION will be done to the detriment of factors considered by the team to be more likely cause of the accident. Why? Because of the power of the press. Even worse, there have been instances, again the TWA 800 case is a good example of such a false step, where actual regulatory actions were adopted in response of such a “false positive.”
Good job TSB and hopefully the press will learn from this case the value of careful deliberations in accident investigations.Share this article: