Accident Investigations (Hijack of WRSD thread)

Hi, Ramy (and others),

I don't want to hijack the "Wide-Ranging Safety Discussion" thread, so I'm
starting a new one.

In the other thread, Ramy mentioned "rather than the all so lame reaction
of 'waiting for the NTSB report'".

I'm going to ask if you've ever been party to an NTSB investigation
before? In case you're not familiar with this term "party to" in this
context has a specific meaning whereby the NTSB invites various technical
experts to be involved with an investigation. These people are not NTSB
employees and must consent to keep confidential the information that they
learn until the NTSB completes its investigation.

Thanks to the "Texas tragedy" I and a few others in our club are parties
to this investigation. I take strong issue with the assertion that
abiding by our agreement with the NTSB is "lame." It is in fact a
pre-condition for being allowed to lend our insight to the investigation,
and I think and hope that this insight will produce a more informed
conclusion than might be the case with an investigation conducted without
the benefit of people who actually know about soaring. For this reason I
think it is in the best interests of all of us to allow some of our fellow
pilots to be parties to these investigations, but in order to do this we
have to agree to confidentiality.

I assume that you're not familiar with this process (I wasn't either,
until Sunday, June 17), so that's why I bring it up. You can gripe all
you want about whether this process is to your liking, but once we agreed
to abide by the NTSB's terms, it is not "lame" to honor this agreement.

On another level, however, I must say that before this investigation I
tended to agree with what I believe to be the opinion of many in this
forum. I used to think that if only I knew all the information that the
investigators know, with my stunningly deep knowledge of all things
aviation, I surely could accurately determine the true cause of an
accident in minutes, much faster than these government bureaucrats who
haven't flown anything besides a desk in decades.

Being involved with this investigation has changed my opinion. I will
grant you that some accidents are probably more "cut and dried" than
others, and some causes probably can be determined rather quickly.

However, not all can. With the confusion and raw emotion that was present
in the immediate aftermath of the accident, I heard a number of
conflicting eyewitness reports, saw seemingly inconsistent physical
evidence from the crash scene, and experienced other factors that made
drawing any concrete conclusions very unlikely to be correct.

And it's precisely the accidents that don't have an obvious cause that
hold the most potential for learning. After all, how much more will we
learn from a "low energy, attempting to stretch the glide, stall-spin
accident" or a "hit a fence during off-field landing" type accident.
We've all heard of these before, and I think we've already learned these
lessons (at least to the extent that you can learn from other's
misfortunes). But accidents that have unique aspects hold more potential
for learning, but also have more potential for mis-interpretation, and
therefore require even more reticence in our speculation.

I have strong respect for the NTSB investigator in charge. Although I've
only met him on June 17, he strikes me as a sharp guy, and a
professional. Maybe not an expert in soaring, but he immediately asked
for help from some of us in order to improve his ability to analyze the
facts. I sure hope nobody on this forum has to meet one of these guys "in
action" (since this would mean someone close to you has probably died),
but if you ever do have to get to know them, I suspect you will have a
better opinion of them than you might just reading the year-old (or more)
accident reports.

Until ALL the evidence has been collected, analyzed, and double-checked it
is not possible to determine a true cause for an accident. It is not
"lame" to allow this process to run its course.

I have no problem with members of the forum speculating about the possible
accident causes. Dreaming up possible scenarios and running through how
we might deal with them is a good training exercise. So, by all means,
continue the discussion, but please avoid characterizing waiting for all
the facts to be in before drawing a conclusion about any particular
accident as "lame."

--
Stefan Murry

On Tuesday, June 26, 2012 3:03:57 PM UTC-7, S. Murry wrote:
Hi, Ramy (and others),

I don't want to hijack the "Wide-Ranging Safety Discussion" thread, so I'm
starting a new one.

In the other thread, Ramy mentioned "rather than the all so lame reaction
of 'waiting for the NTSB report'".

I'm going to ask if you've ever been party to an NTSB investigation
before? In case you're not familiar with this term "party to" in this
context has a specific meaning whereby the NTSB invites various technical
experts to be involved with an investigation. These people are not NTSB
employees and must consent to keep confidential the information that they
learn until the NTSB completes its investigation.

Thanks to the "Texas tragedy" I and a few others in our club are parties
to this investigation. I take strong issue with the assertion that
abiding by our agreement with the NTSB is "lame." It is in fact a
pre-condition for being allowed to lend our insight to the investigation,
and I think and hope that this insight will produce a more informed
conclusion than might be the case with an investigation conducted without
the benefit of people who actually know about soaring. For this reason I
think it is in the best interests of all of us to allow some of our fellow
pilots to be parties to these investigations, but in order to do this we
have to agree to confidentiality.

I assume that you're not familiar with this process (I wasn't either,
until Sunday, June 17), so that's why I bring it up. You can gripe all
you want about whether this process is to your liking, but once we agreed
to abide by the NTSB's terms, it is not "lame" to honor this agreement.

On another level, however, I must say that before this investigation I
tended to agree with what I believe to be the opinion of many in this
forum. I used to think that if only I knew all the information that the
investigators know, with my stunningly deep knowledge of all things
aviation, I surely could accurately determine the true cause of an
accident in minutes, much faster than these government bureaucrats who
haven't flown anything besides a desk in decades.

Being involved with this investigation has changed my opinion. I will
grant you that some accidents are probably more "cut and dried" than
others, and some causes probably can be determined rather quickly.

However, not all can. With the confusion and raw emotion that was present
in the immediate aftermath of the accident, I heard a number of
conflicting eyewitness reports, saw seemingly inconsistent physical
evidence from the crash scene, and experienced other factors that made
drawing any concrete conclusions very unlikely to be correct.

And it's precisely the accidents that don't have an obvious cause that
hold the most potential for learning. After all, how much more will we
learn from a "low energy, attempting to stretch the glide, stall-spin
accident" or a "hit a fence during off-field landing" type accident.
We've all heard of these before, and I think we've already learned these
lessons (at least to the extent that you can learn from other's
misfortunes). But accidents that have unique aspects hold more potential
for learning, but also have more potential for mis-interpretation, and
therefore require even more reticence in our speculation.

I have strong respect for the NTSB investigator in charge. Although I've
only met him on June 17, he strikes me as a sharp guy, and a
professional. Maybe not an expert in soaring, but he immediately asked
for help from some of us in order to improve his ability to analyze the
facts. I sure hope nobody on this forum has to meet one of these guys "in
action" (since this would mean someone close to you has probably died),
but if you ever do have to get to know them, I suspect you will have a
better opinion of them than you might just reading the year-old (or more)
accident reports.

Until ALL the evidence has been collected, analyzed, and double-checked it
is not possible to determine a true cause for an accident. It is not
"lame" to allow this process to run its course.

I have no problem with members of the forum speculating about the possible
accident causes. Dreaming up possible scenarios and running through how
we might deal with them is a good training exercise. So, by all means,
continue the discussion, but please avoid characterizing waiting for all
the facts to be in before drawing a conclusion about any particular
accident as "lame."

--
Stefan Murry

Stephen, points well taken. My comment about it being "lame" was not directed specificaly to you. In the majority of cases I am aware of, those who claim we need to wait for the NTSB report has nothing to do with the investigation. In many investigations, the NTSB does not bother to solicit input from those who can help, and can't even get the facts right. It really all depends on the profile of the accident. This one is a high profile so it gets the right attention. I very much appreciate you share this with us so we understand the reasons for keeping it quiet for now. I can only imagine the difficult job you have in hand and the emotional magnitude of this tragedy and my heart goes to you and all those impacted.

Ramy

From the current issue of NTSB Reporter:
Close-up: Mid-Air Collision ( March 2010)
History of the Flight
(No witnesses) so used radar tracting data
Pilot Information
Airplane Information
Meterological Information
Airport Information
Wreckage and Impact Information
Medical and Pathological Information
Tests and Research
Airplane Contact Information
Collison and Convergence Information
Radar Data and Calculated Collison and Convergence Angles
Measured Collision and Convergence Angles
Probable Cause

I've been reading this newletter for more than 15 years and the above is a typical outline of the reported NTSB investigation process.

I've never gotten the impression the NTSB would "not bother to solict input from those who can help" and the newletter has not reported the NTSB "can't even get the facts right."

As each issue contains 4 of these "Close-UP" reports: 4/month x 12 issuse/year x 15 years = approximately 720 reports.

Over more than 20 years as a medical expert witness, including cases involving auto, truck, motorcycle, bicycle, boat, train, and aircraft accidents, I've rarely had to request additional data; however, when I have it is promptly provided if available.

Ramy, I am curious as you imply your experience has been different. Can you share and cite from any of the "many" investigations you mention in which the NTSB did not solicit information from those who could help or got the facts wrong?

On 6/26/12 8:10 PM, Roy Clark, "B6" wrote:
I've never gotten the impression the NTSB would "not bother to solict input
from those who can help" and the newletter has not reported the NTSB "can't even get the facts right."

A good friend was killed in a thunderstorm / downburst scenario no more
than 2 miles from my home. He didn't return at the end of the day, and
we found out about it from the early evening news. We were unable to
get through to anyone that evening to find out where exactly the crash
occurred.

The next morning, I started calling at first light, but was unable to
get a hold of the investigator, or anyone who could tell me anything
about the accident location. They just sent me to voicemail. By 0930
or so, I decided to drive to the local town newspaper office to find out
if someone there could tell me about the accident. I reached the scene
at around 11, but nearly all evidence of the crash had already been
hauled away. The landowner was gracious enough to let me in so I could
try to get an idea of what may have happened.

I finally got in touch with the investigator in the early afternoon, and
several days later was able to help with downloading and analyzing the
flight recorder trace. At that time, I also showed them an identical
sailplane as involved in the crash. But other than that, the NTSB folks
were (appeared) not at all interested in my input.

I was terribly upset and disappointed that they had no interest in
having an experienced sailplane pilot help with the accident scene and
perhaps provide insight into my friend's decisions and actions that day.
When I spoke with the investigators several days later during the FR
download, I found they really had no clue about sailplane operations,
and soaring in general.

I was also saddened to learn that instead of a normal disassembly of the
wreckage, the salvage company used a chain saw to cut the wings and tail
boom to put them on a flat bed trailer. As I said, my home at that time
was less than five minutes drive from the crash site, and 20 minutes
from the glider port and access to this plane's trailer.

Overall, this left a very bad taste regarding bureaucracy and the lack
of interest in obtaining TIMELY expert advice.

Tom,
I don't think they can solicit input from a "good friend". If they seek help, I think they'll want to make sure it's from an impartial individual. Otherwise they won't know what they have.
Mike

On 6/26/12 10:40 PM, Mike Koerner wrote:
I don't think they can solicit input from a "good friend". If they seek help, I think they'll want to make sure it's from an impartial individual. Otherwise they won't know what they have.

See Frank's response for a partial answer.

What bothered me was that they didn't seek immediate feedback from an
expert witness, whether me or some other glider pilot. I was calling
everyone I could think of and all I got was dead ends.

-Tom

On Tuesday, June 26, 2012 10:26:44 PM UTC-6, Tom S wrote:
On 6/26/12 8:10 PM, Roy Clark, "B6" wrote:
I've never gotten the impression the NTSB would "not bother to solict input
from those who can help" and the newletter has not reported the NTSB "can't even get the facts right."

A good friend was killed in a thunderstorm / downburst scenario no more
than 2 miles from my home. He didn't return at the end of the day, and
we found out about it from the early evening news. We were unable to
get through to anyone that evening to find out where exactly the crash
occurred.

The next morning, I started calling at first light, but was unable to
get a hold of the investigator, or anyone who could tell me anything
about the accident location. They just sent me to voicemail. By 0930
or so, I decided to drive to the local town newspaper office to find out
if someone there could tell me about the accident. I reached the scene
at around 11, but nearly all evidence of the crash had already been
hauled away. The landowner was gracious enough to let me in so I could
try to get an idea of what may have happened.

I finally got in touch with the investigator in the early afternoon, and
several days later was able to help with downloading and analyzing the
flight recorder trace. At that time, I also showed them an identical
sailplane as involved in the crash. But other than that, the NTSB folks
were (appeared) not at all interested in my input.

I was terribly upset and disappointed that they had no interest in
having an experienced sailplane pilot help with the accident scene and
perhaps provide insight into my friend's decisions and actions that day.
When I spoke with the investigators several days later during the FR
download, I found they really had no clue about sailplane operations,
and soaring in general.

I was also saddened to learn that instead of a normal disassembly of the
wreckage, the salvage company used a chain saw to cut the wings and tail
boom to put them on a flat bed trailer. As I said, my home at that time
was less than five minutes drive from the crash site, and 20 minutes
from the glider port and access to this plane's trailer.

Overall, this left a very bad taste regarding bureaucracy and the lack
of interest in obtaining TIMELY expert advice.

I assisted the NTSB and FAA investigators with digging through this wreckage looking for a logger. This wreckage was recovered, in part, with a chainsaw, which I thought unnecessary and certainly reduced a lot of salvage potential (which impacts us when you factor the total mode of the insurance underwriting business). Both the FAA and NTSB investigators displayed a sort of gallows humor, which I suppose comes with the territory. I did not know the pilot personally as Tom S did, but involving at least someone from the club or a soaring operation in recovery would seem prudent. We had another fatal in the state. A friend of the pilot had to become confrontational with the CAP to approach the crash site. BTW, it was Tom S and his search crew that found the wreckage, in a difficult area. But eyes skilled in what glider shapes are made it possilbe. Had there been any delays, looming winter snows would have hidden it for months at least. Now, as to the cause in this case, I don't the FAA nor NTSB bothered to seek the real answer. (NTSB.gov appears unreachable at the moment). That said, in other cases, the FAA is persistent if they feel local findings are not accurate.

Frank Whiteley

On Jun 26, 11:24*pm, Frank Whiteley wrote:
On Tuesday, June 26, 2012 10:26:44 PM UTC-6, Tom S wrote:
On 6/26/12 8:10 PM, Roy Clark, "B6" wrote:
I've never gotten the impression the NTSB would "not bother to solict input
from those who can help" and the newletter has not reported the NTSB "can't even get the facts right."

A good friend was killed in a thunderstorm / downburst scenario no more
than 2 miles from my home. *He didn't return at the end of the day, and
we found out about it from the early evening news. *We were unable to
get through to anyone that evening to find out where exactly the crash
occurred.

The next morning, I started calling at first light, but was unable to
get a hold of the investigator, or anyone who could tell me anything
about the accident location. *They just sent me to voicemail. *By 0930
or so, I decided to drive to the local town newspaper office to find out
if someone there could tell me about the accident. *I reached the scene
at around 11, but nearly all evidence of the crash had already been
hauled away. *The landowner was gracious enough to let me in so I could
try to get an idea of what may have happened.

I finally got in touch with the investigator in the early afternoon, and
several days later was able to help with downloading and analyzing the
flight recorder trace. *At that time, I also showed them an identical
sailplane as involved in the crash. *But other than that, the NTSB folks
were (appeared) not at all interested in my input.

I was terribly upset and disappointed that they had no interest in
having an experienced sailplane pilot help with the accident scene and
perhaps provide insight into my friend's decisions and actions that day..
* When I spoke with the investigators several days later during the FR
download, I found they really had no clue about sailplane operations,
and soaring in general.

I was also saddened to learn that instead of a normal disassembly of the
wreckage, the salvage company used a chain saw to cut the wings and tail
boom to put them on a flat bed trailer. *As I said, my home at that time
was less than five minutes drive from the crash site, and 20 minutes
from the glider port and access to this plane's trailer.

Overall, this left a very bad taste regarding bureaucracy and the lack
of interest in obtaining TIMELY expert advice.

I assisted the NTSB and FAA investigators with digging through this wreckage looking for a logger. *This wreckage was recovered, in part, with a chainsaw, which I thought unnecessary and certainly reduced a lot of salvage potential (which impacts us when you factor the total mode of the insurance underwriting business). *Both the FAA and NTSB investigators displayed a sort of gallows humor, which I suppose comes with the territory. *I did not know the pilot personally as Tom S did, but involving at least someone from the club or a soaring operation in recovery would seem prudent. *We had another fatal in the state. *A friend of the pilot had to become confrontational with the CAP to approach the crash site. *BTW, it was Tom S and his search crew that found the wreckage, in a difficult area. *But eyes skilled in what glider shapes are made it possilbe. *Had there been any delays, looming winter snows would have hidden it for months at least. *Now, as to the cause in this case, I don't the FAA nor NTSB bothered to seek the real answer. (NTSB.gov appears unreachable at the moment). *That said, in other cases, the FAA is persistent if they feel local findings are not accurate.

Frank Whiteley

NTSB investigators are primarily "airplane people" and as such are not
as conversant with soaring issues as we would like. Nonetheless,
some are glider pilots. I've put a few through their PP-Glider
ratings. I have been surprised several times at the depth of
knowledge shown by FAA inspectors. I've trained a few of them too.
Both groups have a tough job and tend, by the nature of their work, to
see the worst of the aviation world.

Perhaps one reason we feel unsatisfied is we expect a more nuanced
investigation which ranks several probable causes. Investigators,
OTOH, are trained to seek the simplest explanation using "Occam's
Razor" as a guide. In this case, the pilot was dealing with a Level 5
thunderstorm and probably crashed in blinding rain, fog and mist. To
the NTSB investigator, that says it all. Light aircraft, particularly
gliders, must give CB's a wide berth.

To me it was highly informative that of all the pilots facing the same
storm, Tom S with the greatest experience chose to run away from it
and land at Boulder 70 or so miles from home. In my estimation, that
decision put him at the top of my list of good pilots.

Tom,

Just like any profession, I'm sure there are "better" and "worse" NTSB
investigators. And even the best undoubtedly have bad days.

Sounds like your experience was either with a "worse" investigator or a
good one on a bad day. Or something in between.

I only wanted to give my personal point of view that not all the
investigators are mindless bureaucrats. Some may be, but it's not a
given. This, actually, was something of a revelation to me which is why I
shared it.

--Stefan

On Tue, 26 Jun 2012 23:26:44 -0500, Tom S wrote:

On 6/26/12 8:10 PM, Roy Clark, "B6" wrote:

Overall, this left a very bad taste regarding bureaucracy and the lack
of interest in obtaining TIMELY expert advice.


--
Stefan Murry

On Jun 26, 8:10*pm, "Roy Clark, \"B6\"" wrote:
From the current issue of NTSB Reporter:
Close-up: Mid-Air Collision ( March 2010)
History of the Flight
* (No witnesses) so used radar tracting data
Pilot Information
Airplane Information
Meterological Information
Airport Information
Wreckage and Impact Information
Medical and Pathological Information
Tests and Research
* * Airplane Contact Information
* * Collison and Convergence Information
* * Radar Data and Calculated Collison and Convergence Angles
* * Measured Collision and Convergence Angles
Probable Cause

I've been reading this newletter for more than 15 years and the above is a typical outline of the reported NTSB investigation process.

I've never gotten the impression the NTSB would "not bother to solict input from those who can help" and the newletter has not reported the NTSB "can't even get the facts right."

As each issue contains 4 of these "Close-UP" reports: 4/month x 12 issuse/year x 15 years = approximately 720 reports.

Over more than 20 years as a medical expert witness, including cases involving auto, truck, motorcycle, bicycle, boat, train, and aircraft accidents, I've rarely had to request additional data; however, when I have it is promptly provided if available.

Ramy, I am curious as you imply your experience has been different. *Can you share and cite from any of the "many" investigations you mention in which the NTSB did not solicit information from those who could help or got the facts wrong?

Roy,

as an MD and expert witness, perhaps that is why you have not
encountered resistance to your request for information.

Brad