Aircraft accident investigative techniques continue to advance, but the new tools employed are not so new. Robert W. Moorman explains.
The aircraft accident investigation process has not changed significantly in several years. Changes that have occurred are subtle, linked to aircraft design advances and modifications as well as the incorporation of new technologies outside of aviation. The end game has always been to advance safety. Communication tools devised for other uses are becoming an integral part of aircraft accident investigation, and these developments are requiring a corresponding augmentation in accident investigator training.
Composite Materials “The increased use of composite materials in transport and general aviation aircraft has expanded the investigative process,” said Dr. Paul Schuda, director of the National Transportation Safety Board Training Center.
The NTSB Training Center, which was profiled by CAT in issue 1/2012, continues to enhance its course on composite materials. The strengths and limits of composites and what to look for at crash sites are discussed at a three-day course at the Center.
Several university-affiliated and independent training academies provide a familiarization course on composites as part of aircraft accident investigator training. But what is needed, some investigators say, is a series of courses on advanced composites, which cover in detail the science of composites and how to determine if there was internal damage to the composite structures, and whether that damage could have been a factor in an accident.
Improvements “The development of composite materials has gone ahead of the ability to figure out how these materials break,” said Bob Benzon, retired NTSB investigator, now part-time instructor at the NTSB’s Training Center. “The composites are no longer minor components.” Benzon said it was “imperative that government investigators keep up with this type of progress.”
Enhancements to accident investigation and related training are needed in other areas. The widespread installation of advanced glass cockpits in various classes of commercial and general aviation aircraft has prompted NTSB to enhance its investigative process and beef up training. Investigators are looking to the avionics manufacturers to learn more about advanced avionics systems. The NTSB is sending seven investigators to Cessna in Wichita for a one-week course on aircraft with advanced avionics, primarily the Garmin G1000 integrated avionics flight deck system.
“A lot of the investigators here, like me, learned to fly on analogue systems,” said Schuda. With this course, “we will find out what the general aviation population is experiencing,” he said.
In addition to working with industry, NTSB is developing a training course on advanced avionics systems. “Some of our engineers are seeing a lot more systems coming into the lab for download of data that they used to not have to work with,” said Jill Demko, NTSB Technical Training Officer, responsible for developing technical training for domestic and international accident investigators.
The lack of training and understanding of sophisticated avionics systems were causal factors in the July 6, 2013 crash landing of an Asiana Airlines Boeing 777 on approach into San Francisco International Airport, said Bob Francis, member of the Flight Safety Foundation Board and former NTSB board member. That lack of understanding of onboard systems was also a factor, he said, in the August 14, 2013 crash of UPS Airlines Flight 1354. The cargo aircraft crashed short of the runway at Birmingham-Shuttlesworth International Airport in Alabama, killing both pilots onboard.
New Courses NTSB will soon offer a course on Digital Forensics, which will include how to analyze still photographs or video footage shot in the cabin or on the ground of an accident or incident.
“Some of the best shots we got from the US Airways [Miracle on the Hudson, Flight 1541, Jan. 15, 2009] landing on the water were from a security camera at a warehouse that recorded the landing,” said Schuda. NTSB worked on that investigation with the FBI, which uses digital forensics extensively in their investigations.
A UAS training module for NTSB investigators is also in development. The course will be open to outside investigators eventually. “UAS could potentially end up in accidents someday,” said Demko. “So we are training our investigators on the operation of UAS and later on the accident investigation of UAS.”
A module on commercial space launch vehicles is also planned.
Schuda said the Center is “getting up to speed” on light sport aircraft. The Sport Pilot Rule requires NTSB to investigate accidents involving ultra-light aircraft. NTSB did not investigate accidents involving ultra-light aircraft prior to the rule. Another area of concern for NTSB accident investigators is the growing popularity of the experimental amateur-built aircraft. These aircraft are not certificated, instead, they are built to a standard. Investigating accidents involving ultra-light and amateur-built aircraft will at some point require additional training for NTSB accident investigators, said Schuda.
Schuda said there is “increasing awareness” about how fatigue, cockpit communications and medications might have contributed to aircraft accidents.
“The whys of accidents have also become very important,” said Frank S. Del Gandio, President of the International Society of Accident Investigators. Del Gandio is a former program manager for the FAA’s accident investigation training school at the Transportation Safety Institute in Oklahoma City. Say, pilot error was a major factor in an accident. “Why did the pilot screw up,” asked Del Gandio. “Was there a cultural problem at the airline?”
Del Gandio referred to an airline crash years ago, where investigators found that the pilots didn’t get paid unless they flew. The decision to fly the aircraft was not based on safety, but economics. In this instance, that decision proved deadly.
Aircraft accident investigators are looking closer at texting as a possible factor in aircraft accidents. In one recent helicopter accident, said Demko, the pilot was found to have texted a lot prior to the flight. Investigators determined texting was a factor why the pilot didn’t appropriately fuel the helicopter.
NTSB now offers a two-day course on fatigue and medication. A recent NTSB report found an upward trend in the use of both potentially impairing medications and illicit drugs of pilots who died in crashes. Almost all of the crashes - 96 percent - were in general aviation, the report found.
The NTSB also offers a once-per-year systems safety course that was customized by NASA. Investigators learn what a safety management system needs and how to analyze it. A root cause analysis course, which provides a systematic way of finding probable causes to an aircraft accident, also is offered. This is an area that the Center will focus more on in the future, said Schuda.
Not-so-new Tools Neither aircraft accident agencies nor accident investigator schools appear to have acquired next-generation technology, hardware and software, to enhance accident investigations or as tool for instruction.
What investigators are doing is utilizing tools that are readily available to everyone. One tool becoming increasingly valuable to accident investigators is the smart phone, as investigators can get over 3,000 photographs on some higher end smartphones.
“What you have is an 85% solution on your hip,” said Steve Preteska, Director of Aircraft Accident Investigation Programs, Southern California Safety Institute. [See sidebar] Investigators are availing themselves to the latest in off-the-shelf technology, such as smartphones, iPads/tablets and software that can help make their job easier.
“Most smartphones today have the ability to do a great deal of documenting an aircraft accident,” he said. “Before we dragged in a cameraman and equipment, separate GPS units and surveyors. Nowadays, that capability can be found on a smartphone, iPad or similar device.”
NTSB offers a three-day photography course to teach investigators how to use their personal camera - typically a smartphone - for an accident investigation. On the second day, students learn how to photograph subjects in normal and reduced light, and the third day of instruction involves software enhancement of photos - what is possible, what isn’t.
Accident investigators are also receiving help from the public. Not to provide eyewitness accounts of accidents - which are often inaccurate - but to retrieve still photos or video footage from their smartphones or similar devices.
Don Enns, regional manager of the Toronto Air Branch for the Transportation Safety Board (TSB) of Canada recalled one incident where a member of the public was helpful to an accident investigation. This air traveler was experimenting with the camera on his new tablet, which could record still photos or video. Inadvertently, he recorded the takeoff of a nearby aircraft that crashed. That video was valuable evidence in TSB’s investigation.
The TSB and other accident investigation agencies are retrieving valuable flight data information from advanced avionics. This too has a training component.
“Some of the newer avionics have recording capability,” said Enns. “Others are not designed specifically to record flight data, but inadvertently have it [memory capability].” Valuable accident related information could be retrieved from these systems, he said.
TSB became interested in the value of retrieving “non-volatile memory” from avionics systems when it was investigating the September 12, 1998 Swissair Flight 111 crash off the coast of Nova Scotia.
Like the NTSB and other agencies, TSB is considering using small drones equipped with a camera as an investigative tool. The drones could be used to follow the flight path of the aircraft from approach to impact. The drones also give investigators on site a wide overview of the debris field.
The use of smartphones and related devices are only one component of something larger that has worked into aircraft accident investigations and the training of investigators. One of the bigger factors in the change in aircraft accident investigations “is the rise of social media,” said Dr. Matthew Greaves, senior lecturer and head, Safety and Accident Investigation Center, Cranfield University. “Aircraft accidents are under the spotlight. The constant clamor for news is being met by different agencies in different ways,” said Greaves.
The NTSB has been very forthcoming with details, while other agencies worldwide are more reserved in their public comments regarding ongoing aircraft investigations, said Greaves. Providing more details early on in an investigation poses a “real risk,” he added. “Accident investigators risk losing their credibility with the traveling public and among industry groups by releasing information too soon. We have to be very careful about pre-judging anything.”
The Cranfield Safety and Accident Center offers a six-week ab initio Aircraft Accident Investigation Course. A three-week advanced aircraft accident investigation program follows that course. Students learn about accident investigation related legislation and regulations; hot to handle aircraft wreckage; interviewing witnesses to an accident; how to photograph a site; laser scanning; and how data recorders work. Students also learn how to deal with the news media, what information can be disseminated and how not to speculate on the probable cause of an accident.
Cranfield sits on a 1940s-era Royal Air Force base with a useable airport and runway facility. Students deal with real wreckage on the airfield and are required to write a full “Annex 13” aircraft accident investigation report replete with recommendations. Cranfield instructors evaluate the report. [The International Civil Aviation Organization’s Annex 13 is the recommended international standards and recommendations for aircraft accidents and incidents investigations.]
Cranfield students obtain a Master of Science certificate at the end of the six-week course. They can go on to take one-week modules that range from flight data monitoring, to human factors to honing legal skills. Students will be required to write a thesis at the end of the course.
Accident investigation technologies and techniques may not have changed dramatically in the last few years, but advances in aircraft technology, everyday communications tools and more emphasis on human and ancillary factors have helped advance the science and enhance safety. Sometimes small steps can be just as significant as a giant leap for mankind.
SIDEBAR (342 words)
From Aviation to Healthcare Southern California Safety Institute (SCSI), known mainly for its aviation safety and investigator training, is moving into health care. “We are taking the investigation and prevention methodologies from aviation into the health care business,” said Steve Preteska, director of Aircraft Accident Investigation, who expects a major client on board “by the end of this year.”
Preteska said there is significant synergy between the high-risk industries of aviation and healthcare. Crew Resource Management (CRM), Safety Management Systems (SMS), aviation mishap investigation processes and techniques could aptly apply to the doctor and nurses working in an operating room, he said.
A recent SCSI White Paper drove home the point of a need for a CRM-like practices in healthcare: “In the U.S. healthcare system, the best available data conservatively estimates that deaths due to medical error causes the equivalent of a Tenerife-like loss every three weeks, yet no parallel public, media or political outrage exists to mirror that which occurred following that dreadful day in 1977.
On March 27, 1977, two fully loaded Boeing 747s collided on the runway of Los Rodeos Airport on the island of Tenerife. 583 of the 644 passengers perished on board the two jumbo jets. The accident remains the largest single-loss of life event in commercial aviation history.
Interviews with nurses and other healthcare professionals revealed a “startling readiness” to embrace these aviation safety related tools, the paper stated. However, doctors give a mixed reaction to a CRM like program for their profession, said Preteska. Younger doctors are willing to consider a team approach to their segment of health care, while older doctors worry that such a change could undermine their authority, he added.
As of now, SCSI has not developed a full curriculum for health care professionals. If a major client signs on, it is likely that they will favor an “a la carte” approach initially rather than committing to a full range of courses.
SCSI is also exploring the possibility of adding a parachute accident investigation course and one on commercial spacecraft to the curriculum. Robert W. Moorman