Change Of Watch At The NTSB

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With the Senate’s confirmation Monday of Jennifer Homendy as the Chairman of the NTSB, I’ll resist cliches about frying pans and fires and instead offer the observation that she has work to do. In my view, the NTSB was once the gold standard for efficient, competent government agencies, but of late, it has been less impressive. It hasn’t quite come asunder, but it could and should be doing better than it is.

Since our beat around here is general aviation, that’s what I’ll focus on. The airlines get more than their share of love from both the FAA and the NTSB while GA enjoys benign neglect. (That’s not all bad, by the way.) My beefs are several. First of all, the agency continues to drag its feet on closing accident investigations with no apparent accountability or improvement. Side note: The investigations appear to be uneven in quality and thoroughness.

Not so long ago, you could expect an investigation to close to a final report in about a year, give or take a few months. Now, I routinely see open investigations that are two years or older. That is, when I can find them. Which gets me to beef number two: To call the new online database system the NTSB launched last fall a hot mess is generous. It’s a difficult-to-use kludge that returns uneven results and, at least for me, vastly slows finding the kind of broad data-driven things I like to work on.

The NTSB hailed the so-called CAROL system as a step forward but I find it lacking. While it does offer direct access to the digital dockets, it lacks a quick-view utility that the previous system had. You could, for example, click on the HTML source and skim the material before digging further. Now you have to download a portion of the docket to see what’s there. It’s literally like fishing. I have a couple of projects on the back burner because I lack the time to grind through this problem.

And now beef number three: The NTSB is not doing this work, either. While I’m not convinced there are new and mysterious accident trends percolating in the world of GA, how would you know if you don’t look? I feel like I’m flying increasingly blind on accurate accident rates. Part of the NTSB’s imprimatur is enterprise research that determines accident cause trends and to make recommendations to address these. I care less about the recommendations—in fact, I care very little—than I do the underlying findings that make them necessary. If we in the industry know what the trends are, we can pretty well figure out how to address them in various ways, jollied along by the insurance companies.

We don’t need the NTSB, which is indifferent to GA, nor the FAA, which is sometimes hostile, to tell us how fix things. Is anyone arguing for more regulation to push down the GA overall and fatal accident rate? If so, do let me know. On the plus side, the board now has two GA-experienced members in vice-chairman Bruce Landsberg, formerly of Flight Safety and the old AOPA Air Safety Foundation, and Michael Graham, a naval aviator who did a stint on the GA/bizjet side of Textron. Both of these members have air safety bona fides and it shows in the board meetings.

As for Ms. Homendy, she is not a pilot so let me just dispense with that by noting that she is not a pipeline welder, a railroad bridge engineer or a licensed ship captain, either. The chairman’s job is still, as it has always been, leadership of what is a competent and well-resourced staff of investigators, to set the tone and determine the priorities. For all I know, the marine and pipeline industry have the same complaints we do in general aviation, but whether they do or they don’t, the hoped-for-solution is to reach down into the clanking machinery and blow the sand out of the gears. In other words, it’s a management challenge and don’t pretend it’s an easy one.

Let’s give it a year and see what improves.

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23 COMMENTS

  1. “Let’s give it a year and see what improves.”

    Or I suppose more precisely “Let’s give it a year and see what changes”. I’d like to think the changes will be an improvement, but that’s not a guarantee…

    Unrelated, it would be helpful if when I click on the “Log in to comment” link, it redirects me back to what I was trying to comment on instead of the user profile page, and forcing me to go back to the main page to re-select the article I was trying to comment on.

  2. Robert Sumwalt,

    Thank you for your years of service at the NTSB. You exerted a significant positive safety influence on me personally even in the years prior to your NTSB service. Your contributions to my sector of GA were significant particularly through your active contributions to us at Bombardier Safety Standdown. You redefined professionalism for many of us in that sector. Your influence will live on well past your service with the NTSB. Again, thank you.

    John Kliewer

  3. For aviation, at least, Sumwalt was the best chairman ever. But, neither he, nor his successor, can change the systemic problems at the NTSB that have developed the past 20 years, or so. Hiring practices and qualifications, for starters. Now, there are too many investigators, especially at the field offices, that are not well trained nor motivated. Too many avoid traveling to the accident site when they can, if for no other reason they have not been conditioned to carnage.

    And, so it goes.

    The Kobe Bryant investigation was good, because it was handled from headquarters with a go-team, and with a very capable IIC (he has been there long enough to be considered “old school.”)

    Had Sumwalt still been at the helm, a go-team sent to Truckee would have been more likely.

  4. All same Canada at times in the past several decades.

    I do say recent accident reports appear quite thorough recently.

    An engineer built a business on investigating crashes after investigators had finished. Often finding much more. Very detailed work, for insurance companies and other involved parties.

    The official report on PW314, B737 in Cranbrook in 1978, is weak, for example.

    And down under, it took a doctor querying Australia’s agency about the crash of a single engine seaplane flown by a very experienced pilot to get the cause out.
    The doctor asked if bodies had been tested for CO poisoning.
    Erps, no, we are rushing to do that now.
    Indeed, pilot and front seat passenger both had signs of CO poisoning.
    Leak in an exhaust manifold plus improperly reinstalled plate in firewall.

  5. If you have watched the NTSB board meetings on General Aviation over the last 2 years you will have seen that a rough road is opening up. Ms. Homendy has repeated bashed GA on the CT. B-17 crash, the Bryant S-76 crash, the Hudson River photo helicopter crash, and others. She has not taken a positive approach to fix issues but a snide attack on everyone. Member Landsberg has done little better even with his extensive aviation background. But that is only the tip of the iceberg. There are few solid investigations of any aviation accident. While the FAA does about 87 percent of the investigations they are only concerned with the 9 areas they regulate. The rift between the NTSB and the FAA continues to widen. Both are part of the DOT. Lets see if Secretary “Pete” can get some harmony between everyone. The General Aviation crowd who need guidance not bickering.

    • But the three ‘GA’ crashes you list were caused by deficiencies in piloting and/or maintenance and/or operator not paying attention to risks.

      Yes, as were many crashes in full airline operations.

      And more broadly, security authorities ignoring risks – as I detail regarding the attacks by terrorist warriors on September 11, 2001 in http://www.moralindividualism.com/prior.htm. And airlines were not on the ball.

      There will be a push to require video recorders.

    • RT, while FAA is part of DOT, the NTSB is a completely independent agency since the Independent Safety Board Act of 1974. While some positive action to address these noted issues would be welcome Congress separated NTSB from DOT to avoid potentials for conflict of interest as well as influence of results.

  6. I’m wondering if the use of NTSB results in court shouldn’t be reconsidered for GA. It would be different if there was anything new in GA, but there isn’t really. If the FAA would stop their innovation tax, it might make more sense, but as it is now, what’s the point?

  7. I believe the answer to the NTSB and FAA ineptness is clear:
    They need to follow their own advise… The Most Wanted List:
    https://www.ntsb.gov/safety/mwl/Pages/default.aspx

    The agencies needs a dose of their own sour medicine and swallow a big gulp of SMS (safety management system). Do a Tap Root on their weaknesses. They have a systemic bureaucratic problem that needs resolved by using the same techniques and programs they push down my throat. Maybe they can resolve their problem in “FOUR YEARS”??????? …and the Flight Instruction Rules too.

  8. All same Canada at times in the past several decades, but I do say recent accident reports appear quite thorough.

    An engineer built a business on investigating crashes after investigators had finished. Often finding much more. Very detailed work, for insurance companies and other involved parties.

    The official report on PW314, B737 in Cranbrook in 1978, is disappointing, for example.

    And down under, it took a doctor querying Australia’s agency about the crash of a single engine seaplane flown by a very experienced pilot to get the cause out.
    The doctor asked if bodies had been tested for CO poisoning.
    Erps, no, we are rushing to do that now.
    Indeed, pilot and front seat passenger both had signs of CO poisoning.
    Leak in an exhaust manifold plus improperly reinstalled plate on firewall.

    Problem I see with GA accidents is the resources to investigate them.

  9. The NTSB seems to be suffering from the typical mission creep of a large government agency. Asking one agency to oversee everything from pipelines to railroads to air travel at a time when the nation’s infrastructure is showing the strain of age is a tall order. The problem is that, even though they have people trained in different disciplines, the disparity between airplanes, pipelines and bridges is a tough chasm to bridge. And, the difference between airline disasters and GA accidents is equally disparate. Big disasters get big press coverage, so they get the lion’s share of the attention. GA, not so much. As Paul says, that’s not all bad. I suspect that the NTSB is finding it difficult to replace experienced investigators who are reaching retirement age with younger staff that have the same drive and experience level. Welcome to the modern world. Personally, I find it inexcusable that the FAA and NTSB have had their long-running cat fight without someone telling them to get along. Maybe “Mayor Pete” should take the agencies to the woodshed, but I’m not holding my breath. I predict in a year we will see little has changed.

  10. I’ll echo Paul’s comments on the NTSB’s new CAROL system for searching accident reports. It comes across as designed by someone trying to maximize the difficulty in accessing accident information. As part of my work, I read 100 NTSB aviation accident reports a month. The previous search system was fast and intuitive. The CAROL system is anything but intuitive and relies on has a multi-page instruction manual filled with arcane jargon that simply isn’t helpful. I’ve spent several hours working to figure out CAROL and can use it for most of what I need but am constantly frustrated by its shortcomings and the fact that it hides information a user needs to do a search (good luck figuring out how to find accidents between two dates – you can do it, but figuring out how is time-consuming).
    I’m also concerned that a number of accident reports for the time period near the end of that covered by the old system and the first year or so of CAROL have been lost or cannot be accessed. I’ve no data, but in 15 years of searching and reading accident reports monthly, I’ve gotten a feel for how many accidents will have occurred for a type of airplane during a year. When the system returns only a fraction of that number, I get concerned.
    What has made it worse is that when I’ve tried to reach out to the NTSB through the contact information in CAROL. I’ve never gotten a response to my questions.
    The NTSB had an excellent system for searching aviation accident reports – it screwed it up with CAROL. While it might be fun to assert that it was done on purpose, my experience with large bureaucratic organizations in the public or private sector is that it’s just the result of incompetence along with high-level supervisors insisting on having things done their way rather than in ways recommended by subordinates who actually know what they’re doing.

  11. My issue with NTSB is not with the process–it is with the conduct of GA investigations.

    We had a medical helicopter crash at the airport I manage. Five other witnesses viewed the crash, myself and another helicopter pilot. I sent all witnesses to a neutral corner to describe what they observed. When we heard from NTSB–they asked us to secure the site (already done)–“don’t let anyone in–INCLUDING THE FAA.”

    THE NTSB “investigator” took our notes–“You know what I don’t like about this? These notes are almost all the same.” I assured him that they were done independently. We noted that the helicopter approached the ramp–that there was a puff of smoke from the right side of the helicopter–the the blades coned as he tried to arrest the descent–that it was still coming down at a high rate–that he tried to skid it onto the grass, but the aircraft skid caught the edge of the pavement, causing it to roll over. The NTSB “investigator” was in the cockpit, and announced “I think I’ve found the cause–there were TWO flight nurses on board–the helicopter had an FM entertainment radio installed–I think the pilot was just trying to impress the nurses and boogeying to the music.” I pointed out that ALL of the switches on the audio panel were in the “speaker” position–(though everyone was wearing headsets”–and that it was highly unlikely that he was monitoring 2 comms, 2 VORs, ADF, marker beacons, ambulance frequency, and hospital frequency ALL at the same time. He continued to try to defend his position–I told him “The BIG thing you missed is the fact that this helicopter is flown from the RIGHT seat–not the left–where the switches were ALL selected!

    I pointed out to him that the right engine side of the helicopter was sooted and scorched–but not the left side. Firemen on the scene confirmed they extinguished a fire on the right engine. A subsequent teardown THREE MONTHS LATER confirmed the right engine failure.

    Yet we PAY these people for their incompetence! I have nice letters from the hospital, emergency helicopter provider, and the pilot–“I’m SO GLAD that we had experienced people that observed and documented the crash!” This is far from the ONLY instance of NTSB incompetence.