AOPA’s unusual critique of the NTSB might be addressed by SMS

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AOPA Criticizes NTSB’s Approach to GA Accident Investigation

Quantitative Safety Management Systems (SMS) Might be the Answer

jim coon AOPA Criticizes NTSB“AOPA is calling on the National Transportation Safety Board to conduct an internal review to examine why the independent safety agency has approved ‘speculative probable cause reports related to general aviation accidents’ despite little evidence to support the conclusions.”

The above is a direct copy of a headline from the AOPA’s website. Aside from its length, it is quite remarkable that the GA pilots’ association Senior Vice President of Government Affairs Jim Coon, a highly regarded advocate in the aviation safety space, to be so critical of the NTSB.

The tone of March 24, 2017 letter appears to grow out of long festering frustration with the “dialogue” with the Board. AOPA Air Safety Institute, in an August 31, 2016 letter, questioned a probable cause determination in a case in which a medical report found no evidence of recent or old infarction. Then Chairman Hart responded in a November 2016 letter, that a “hyperacute infarction” might occur over a few minutes, yet leave no evidence, if a victim died traumatically. That correspondence focused on two specific incidents in which acute cardiac events were found to be the probable cause for each. The Board’s response reiterated its justification; AOPA attributed the finding to a personal agenda within the NTSB’s technical staff.


→  Curiously, pilot health has been a point of disagreement between these two aviation safety powerhouses. The association has asserted that the 3rd Class medical for pilots is unnecessary, while the Board has opposed the relaxation. Is that the “personal” agenda?

ntsb most wanted listMr. Coon, in his most recent letter, seems to have elevated the debate. His criticism has moved from the individual cases to the NTSB’s approach to GA accident investigation. He mentions the Board’s Most Wanted List as a possible contributor towards this tendency to find evidence in specific accidents which tend to support a pre-existing thesis.

Here are some of the major points of the Coon letter:

  • AOPA is “perplexed” that the NTSB has kept GA on its 10 Most Wanted List for safety improvements despite traffic fatalities being 7,500 percent higher; boating resulting in 150 percent more deaths; and even bicycling having a death rate twice that of GA.
  • Absent definitive evidence, “it should be acceptable to make a ‘no determination of cause’ finding.”
  • Personally, after having worked with the NTSB for decades, it is disheartening that the Board is now allowing someone at the staff level to approve these academic probable cause determinations. Moreover, I am dismayed that the Board’s Chief Medical Examiner allows this speculative practice to continue.
  • “We hope the Board would work towards a more data driven approach similar to that which the FAA has embraced, and more specifically the Flight Safety Standards Division. Together, we have invested significant time and effort to move to a data driven approach under the Commercial Aviation Safety Team (CAST) and the General Aviation Joint Steering Committee (GAJSC),” he wrote.
  • An internal review could correct the problem of speculative probable cause determinations, he said, and ensure that “personal agendas in the medical office are not being incorporated into the Board’s reports.”

One way of examining the AOPA complaint is that the Board’s traditional process is to find “probable cause” based on historic factsBy transiting to MWL and other prospective assessments, the Board may be creating subconscious reasons for the staff to justify these future safety pronouncements.

That is not to say that there is any malice inferred in this hypothesis, but that it is a human predilection to find facts which supports past professional judgments. If an individual has devoted considerable thought and thorough research to support a hypothesis, it is not surprising that the investigator MIGHT, unintentionally, find facts which support that prior articulated premise.

AOPA Criticizes ntsb general aviation accident investigationThe AOPA letter suggests that the Board could benefit from a more data-driven approach to its work to avoid the subjectivity which it avers occurred in this pattern of findings. One remedy to the concern that the MWL influences future NTSB investigations and findings of probable cause would be to involve that quantitative regimen of SMS to all of its predictive statements. In that the NTSB was one of the original apostles of this approach, it would be proper for the Board to employ this analytical discipline.

The answer to AOPA’s complaint may be to involve the SMS quantitative approach to its prospective finding.


AOPA is calling on the National Transportation Safety Board to conduct an internal review to examine why the independent safety agency has approved “speculative probable cause reports related to general aviation accidents” despite little evidence to support the conclusions.
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