NTSB Accident Investigation Process
Member Earl Weener’s Explanation
The NTSB investigative process is not well understood and the media with their current news life cycle fights the Board’s deliberative processing of the information. There is a website which explains the staff’s discipline for all accidents, but Member Weener, PHD, has written an insightful explanation of how the team is constituted and how it conducts its examination of GA accidents. The full text is included below.
This is the first in a new series of posts about the NTSB’s general aviation investigative process. This series, written by NTSB staff, will explore how medical, mechanical, and general safety issues are examined in our investigations. I hope you take time to read these posts and, in doing so, come away with a greater understanding of the NTSB, our processes, and our people.
It has been my ongoing honor and privilege to serve as a Member of the NTSB over the past seven years, and I’ve been impressed by the diverse professionals who make up the NTSB staff. They work in different modes—rail, highway, pipeline, marine, and aviation—and specialize in engineering, human factors, medicine, safety outreach, and recorders, to name a few, but they all share a common goal: to protect the traveling public through recommendations aimed at improving transportation safety.
The NTSB is made up of approximately 430 dedicated employees who have a wide range of educational backgrounds and relevant experience. Our ranks include MDs, JDs, and Ph.Ds. Among our investigators, we count former members of law enforcement, industry professionals, and technical experts. When we investigate an accident, a multidisciplinary team is selected to fit the needs of the investigation.
I’m often asked how the NTSB—particularly our crash investigation process—works. The NTSB is required by law to investigate every aviation incident in the United States, and our aviation safety staff investigate more than 1,200 aviation events each year. Our investigative process looks at three factors—human, machine, and environment—to determine the probable cause of accidents and incidents. This process has evolved during our 50 years, leveraging the skills, talents, and professionalism of our people, who use the latest investigative techniques and tools to find facts, analyze those facts, and determine why and how an accident happened.
Investigators consider what may have caused or contributed to the events of every accident. They look for issues in areas such as mechanical failures, operations, and weather conditions. They doggedly work to recover all onboard recorders and other sources of data, even when those recorders may be severely damaged. They also consider pilot performance, collecting evidence regarding possible fatigue, medical fitness, prior training opportunities, and specific aircraft experience.
Evidence is gathered through cooperation with pilots, witnesses, law enforcement officials, the FAA, airport officials, industry, and other stakeholders; in extreme cases, our staff can also issue subpoenas to obtain needed evidence. Investigations cannot and do not try to answer every question of why and how, but focus on questions of what caused the accident, or made it worse. Probable cause is the factor—or factors—that, based on all available evidence, the Board concludes most likely resulted in the accident. It generally takes around a year to produce a final report, which includes a probable cause and contributing factors.
Based on our investigations and special studies, we issue safety recommendations to regulatory agencies, industry, and other parties to an investigation who are positioned to implement our suggestions and improve transportation safety. The NTSB isn’t a regulatory agency, so we cannot compel compliance with our recommendations; however, of the more than 14,500 safety recommendations issued in our 50-year history, more than 80 percent are acted upon favorably. This is testimony to the NTSB’s diligence, investigative acumen, and commitment to transportation safety.
Looking back over the years and contemplating the NTSB’s contributions, I am proud to see that transportation safety has, in fact, improved greatly—especially in commercial aviation. We have seen significant improvements in aircraft crashworthiness; the introduction of life-saving technologies, such as collision avoidance and ground proximity warning systems; implementation of safety policies and regulations aimed at preventing pilot impairment, distraction, and fatigue; and emphasis on safety management systems and enhanced flight crew procedures. NTSB investigations identified the need for these advancements and helped incentivize remarkable safety improvements. Modern commercial aviation is safer now than ever before.
I often quote author Douglas Adams, who tells us that people are almost unique in their ability to learn from others, but remarkable for their resistance to doing just that. You may have heard the old saying, “knowledge is power.” We believe “knowledge is safety.” I hope you take a moment to learn about the NTSB’s investigative process in the next several blog posts, and that you come away with a greater understanding of how we at the NTSB strive to turn our knowledge into safer transportation.
ntsbgov | August 14, 2017 at 10:00 am
Looking forward to future Compass articles on the Board’s execution of its mission.
In 2011, the NTSB Training Center developed and hosted a Volunteer Pilots Safety Stand-Down. The success of this safety seminar prompted the Training Center to develop and present seminars on a regular and continuing basis. The NTSB partners with the FAA and other interested groups to develop programs that cover the safety, regulatory, and training aspects of GA safety. The goal of the Training Center is to deliver at least two Safety Seminars each calendar year. These Safety Seminars are designed for pilots, flight instructors, and other members of the GA community. Pilots participating in the FAA’s WINGS program receive credit for attendance.
NTSB officials recently announced that they will hold a safety seminar in Ronkonkoma, NY next month following a series of crashes on Long Island referenced in the following article.
Sen. Chuck Schumer (D-N.Y.), who pressed for federal involvement, said the seminar would be the first of its kind on Long Island and would help local pilots learn about the causes of crashes and how to prevent them.
“These seminars are well attended, make the skies safer, and even allow pilots educational credits they can use to lower their insurance costs,” Schumer said.
The NTSB in March said that it examined 156 aviation accidents in the state over the past five years at Schumer’s request.
The review found that nothing set those accidents apart from those in general aviation, the agency said.
“For those accident investigations that have been completed, the causes have been similar to the cause of general aviation accidents that we investigated overall,” the agency said in a letter to Schumer on March 23.
About one-third of the crashes — including a cluster of seven early last year on Long Island — were caused by loss of pilot control, the agency said.
 Earl F. Weener, Ph.D. took the oath of office as the 41st Member of the National Transportation Safety Board on June 30, 2010. He brings to the Board his experience as an industry executive, long-time safety advocate, flight instructor, pilot, boat captain and aerospace engineer. He is a tireless safety advocate who works to promote collaborative efforts between government and industry believing that the partnership approach is often more effective, less burdensome and quicker than a regulatory solution.
During his 24 years with Boeing, he rose from engineer, integrally involved with cutting-edge commercial cockpit design, to executive. In D.C., he managed Boeing’s Engineering and Technical Government Affairs. Returning to headquarters in Seattle, he served as Chief Engineer of Airworthiness, Reliability Maintainability and Safety and then Chief of Systems Engineering. His responsibilities included the management of a staff of engineers and technical experts numbering more than 450 employees. After leaving Boeing, he served as Foundation Fellow for the Flight Safety Foundation. Within this role, he organized and executed multiple national and international collaborative government and industry programs. For his work, he was recognized with a 2005 Honeywell Bendix Trophy for Aviation Safety and was appointed to serve on the Flight Safety Foundation’s Icarus Committee and its Board of Governors.
As a Board Member, Dr. Weener has focused on safety improvements in business and general aviation for both fixed wing aircraft and helicopters. He represents the Board at meetings of the General Aviation Joint Steering Committee and the Commercial Aviation Safety Team, groups of industry, government, safety and other stakeholders working together to develop cooperative solutions to safety concerns. He also worked with commercial motor vehicle groups, cruise lines, and railroads to provide safety messaging to their members. He has represented the Board on the scene of major accident investigations, including the Metro North Railroad commuter train derailments in Connecticut and New York, 2013, and the collision between a duck boat and motorcoach carrying a group of exchange students in Seattle, Washington, 2015. He has participated in numerous Board meetings, often adding his own concurring or dissenting statements to Board opinions.
In addition to his education and career, Dr. Weener has first-hand transportation experience. He holds licenses as a flight instructor and charter pilot. He keeps his own plane, a Beechcraft Bonanza, and flies whenever possible. He is also a boating enthusiast. In 2000, he received his United States Coast Guard Master’s License. After commissioning a specially designed steel hull trawler, he lived aboard for several years. His travels included the East Coast Intracoastal Waterway, the Great Lakes, the waterways from Chicago to Mobile, Alabama, the West Coast, as well as the inside passage to Alaska. As a young man, he held a commercial driving privilege and drove a delivery truck.
Dr. Weener, a Michigan native, worked as flight instructor to put himself through college and graduate school, while attaining scholastic honors including membership in Tau Beta Pi, a National Engineering Honor Society, and Sigma Gamma Tau, a National Aerospace Engineering Honor Society. He earned his Bachelor’s, Master’s, and Doctorate degrees from the University of Michigan. He and his wife Linda currently reside in Northern Virginia.
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