NTSB Go Team: Expert Accident Investigation for Transportation Safety

1. NTSB

2. NTSB • Established in 1967 • Conduct independent investigations of • All civil aviation accidents in the U.S. • Major accidents in other modes of transportation • Not part of DOT, or organizationally affiliated with any of DOT’s modal agencies • Safety Board has no regulatory or enforcement powers • To ensure investigations focus only on improving transportation safety • Cannot be entered as evidence in court of law

3. NTSB • Accident response • Only on U.S. territory or in international waters • Elsewhere, a U.S. “accredited representative” from NTSB’s staff of IICs will assist government where accident occurs

4. NTSB “Go Team” • Purpose • Begin investigation at accident scene as quickly as possible • Assemble broad spectrum of technical expertise needed to solve complex transportation safety problems • Vary from 3 or 4 to more than a dozen specialists • Duty rotation • Must be reachable 24 hours a day by telephone • Usually do not have suitcase pre-packed but have • Carefully selected wrenches, screwdrivers, and devices peculiar to their specialty • All carry flashlights, tape recorders, cameras, and lots of extra tape and film

5. NTSB “Go Team” • Boss • Investigator-in-charge (IIC) • Senior investigator with years of NTSB and industry experience • Other specialties (aviation) • Operations • History of accident flight and crewmembers’ duties • Structures • Documentation of airframe wreckage and accident scene • Includes impact angles to help determine plane’s impact course and attitude • Powerplants • Examination of engines (propellers) and engine accessories

6. NTSB “Go Team” • Systems • Study components of plane • Hydraulic • Electrical • Pneumatic and associated systems • Instruments and elements of flight control system • Air Traffic Control • Reconstruction of ATC services given including • Acquisition of ATC radar data and • Transcripts of controller-pilot radio transmissions • Weather • Gather all pertinent weather data from NWS

7. NTSB “Go Team” • Human performance • Study of crew performance and all before-the-accident factors that could be involved • Fatigue • Medication • Alcohol • Drugs • Medical histories • Training • Workload • Equipment design • Work environment • Survival factors • Document impact forces and injuries, evacuation, community emergency planning and all crash-fire-rescue efforts • Other groups may be formed at accident scene

8. NTSB “Go Team” • Investigators lead • Working groups in one area of expertise • Groups staffed by representatives of “parties” • NTSB has complete discretion to “parties” • Parties to investigations • Organizations or corporations that can provide expertise to investigation are granted party status • Only persons with technical or specialized expertise are permitted to serve • Persons in legal or litigation positions are not allowed

9. NTSB “Go Team” • Members of Safety Board • One member briefs media daily on latest factual information developed by team during on-scene investigation phase • Usually not IIC • Public affairs officer maintains contact with media • Releases confirmed, factual information, no speculation • Parties to investigations • Organizations or corporations that can provide expertise to investigation are granted party status • Only persons with technical or specialized expertise are permitted to serve • Persons in legal or litigation positions are not allowed

10. NTSB “Go Team” • Accident Scene • Members remain at scene as long as necessary • Few days to several weeks • Continuation work • Washington headquarters • Specialization areas • Overhaul facilities • Teardown facilities • Any other required areas • Report • Form analysis, draft proposed report • Goes to Safety Board • Safety recommendations may be issued at any time during course of investigation

11. Criminal Activity • Safety Board does not investigate criminal activity • Other agencies may participate • FBI becomes lead federal investigative body • NTSB provides any requested support • Surrender of lead status • Only if Attorney General notifies Board • Criminal act may have caused act

12. Safety Recommendations • Board must address safety deficiencies immediately • Issue recommendations before completion of investigation • Based on findings • May address deficiencies that do not pertain directly to what is ultimately determined to be cause of accident

13. Public Hearing • Board may hold public hearing • Gather sworn testimony from subpoenaed witnesses on issues identified by board • Allow public to observe progress of investigation • Usually held within 6 months of accident

14. Final Report • “Parties” do not participate in analysis and report writing phase of draft final report • Are invited to submit proposed findings of cause and proposed safety recommendations • Board deliberates over final report in public Board meeting • Includes parties and family members • Cannot interact with Board during this meeting • Adoption of final report • Abstract written with conclusions, probable cause, and safety recommendations placed on web site • Full report typically appears on web site several weeks later

15. NTSB Part 830 Subpart A General

16. 830.1 Applicability • Contains rules pertaining to • Initial notification and later reporting of aircraft incidents and accidents • Preservation of aircraft wreckage, mail, cargo, and records involving all civil and certain public aircraft accidents

17. 830.2 Definitions • Aircraft accident • Occurrence associated with operation of an aircraft which takes place between time any person boards the aircraft and all such persons have disembarked • Any person suffers death or serious injury, or aircraft receives substantial damage • Civil aircraft • Any aircraft other than public aircraft • Fatal injury • Injury which results in death within 30 days of the accident

18. 830.2 Definitions • Incident • Occurrence other than an accident, associated with the operation of an aircraft, which affects or could affect the safety of operations • Operator • Any person who causes or authorizes the operation of an aircraft (owner, lessee, or bailee of an aircraft) • Public aircraft

19. 830.2 Definitions • Serious injury • Requires hospitalization for more than 48 hours, commencing within 7 days for the date of injury was received • Results in fracture of any bone (except simple fractures of fingers, toes, or nose) • Causes severe hemorrhages, nerve, muscle, or tendon damage • Involves any internal organ • Involves second- or third-degree burns, or any burns affecting more than 5 percent of body surface

20. 830.2 Definitions • Substantial damage • Damage or failure which adversely affects structural strength, performance, or flight characteristics of aircraft, and • Normally required major repair or replacement of affected component

21. 830.5 Initial Notification • Notify nearest NTSB field office when • Flight control system malfunction or failure • Inability of any required crewmember to perform normal flight duties as result of injury or illness • Failure of structural components of turbine engine excluding compressor and turbine blades/vanes • In-flight fire • Aircraft collide in flight • Damage to property, other than aircraft, estimated to exceed $25,000 for repair

22. 830.5 Initial Notification • Large multi-engine (more than 12,500 lbs) • In-flight failure of electrical systems which require sustained use of emergency bus powered • In-flight failure of hydraulic systems resulting in sustained reliance on sole remaining hydraulic or mechanical system for movement of flight control surfaces • Sustained loss of power or thrust produced by 2 or more engines • Evacuation of aircraft where an emergency egress system is utilized • Aircraft is overdue and is believed to have been involved in an accident

23. 830.6 Information Required • Type, nationality, and registration marks of aircraft • Owner name and operator • PIC Name • Date and time of accident • Last point of departure and intended landing point • Position of aircraft with geographical references • Number of persons aboard, number killed, and number seriously injured

24. 830.6 Information Required • Passenger info: • Number of Persons aboard • Number killed, and • Number seriously injured • Nature of accident, weather, and damage to aircraft • Description of any • Explosives • Radioactive materials • Other dangerous articles carried

25. 830.10 Preservation of Wreckage • Operator of aircraft involved responsible for • Preserving any aircraft wreckage, cargo, and mail aboard except to • Remove persons injured or trapped • Protect wreckage from further damage • Protect public from injury • All records • Recording mediums of flight • Maintenance • Voice recorders • If required to move wreckage, make sketches, descriptive notes, and photographs • Maintain all records until Board authorizes to the contrary

26. 830.15 Reports and Statements • Operator shall file a report • Within 10 days after an accident, or • After 7 days if an overdue aircraft is still missing • Only person trained in use of medical oxygen equipment may connect or disconnect • Each crewmember, if physically able, shall attach a statement with facts, conditions, and circumstances relating to the accident • If unable, crewmember submits as soon as physically able • Report filed with field office nearest accident or incident