NTSB Safety Compass

Why We Care When Things Go Right

By Lorenda Ward, Sr. Investigator-In-Charge, NTSB Office of Aviation Safety

As an investigator-in-charge (IIC) at the National Transportation Safety Board (NTSB), part of my job is to launch to aviation accident scenes. When my team and I arrive at the scene of an accident, we come prepared to uncover the sequence of events that led to the accident—whether it was weather, human factors, or a problem with the plane’s structure, systems, or engines. It’s the NTSB’s responsibility to find out what occurred and provide recommendations to prevent future accidents.

When we investigate an accident, we don’t only look for the things that went wrong, but we also look for those that went right. Sometimes these “rights” ensure the accident didn’t become an even greater tragedy, and sharing them can help crewmembers and operators in the future ensure the safest flight possible. A good example of this is a recent accident we investigated in Michigan.

On March 8, 2017, an Ameristar Charters Boeing MD-83 ran off the end of the runway during a high-speed rejected takeoff at Ypsilanti Airport in Michigan. The plane was scheduled to carry 6 crewmembers and 110 passengers to Washington, DC—among them, the University of Michigan men’s basketball team, cheerleaders, band, coaches, and some parents. Fortunately, no one was killed, though some passengers sustained minor injuries.

Rear view of accident scene

I led the small team that was launched to the accident site. On scene, we found that the right geared tab of the elevator flight control system had become jammed. Our investigation showed that this occurred during a strong windstorm that struck the area while the aircraft was parked at Ypsilanti Airport prior to the flight.

Seconds after the captain tried to “pitch,” or rotate, the airplane’s nose up, he quickly realized that the airplane was not going to get airborne. At that time, the airplane was traveling at a speed of 158 mph and was about 5,000 feet down the 7,500-foot runway. Because the elevator was jammed in the airplane nose-down position, no matter how far back the captain pulled the yoke, the nose refused to pitch up. The captain quickly called to abort the takeoff, but the plane was traveling too fast to be stopped on the remaining runway. It departed the end of the runway at about 115 mph, traveled 950 feet across a runway safety area, struck an airport fence, and came to rest after crossing a paved road.

Our investigation determined that the flight crew had completed all preflight checks appropriately, including a flight control test, and found no anomalies before initiating the takeoff. Furthermore, we determined that there was no way the pilot checks could have detected the flight control jam.

It’s important to note that, not only did the captain appropriately reject the takeoff once he felt the airplane was not able to fly, but the check airman did not try to countermand the rejected takeoff. And after the plane came to a rest, the cabin crew also followed procedures to coordinate a careful, safe passenger evacuation.

Also essential to the safe outcome was the fact that the passengers followed the crew’s instructions, so everyone got off quickly without any serious injuries. Unfortunately, too many times, we see passengers delay an evacuation by ignoring crew instructions to, say, retrieve their luggage.

Although the accident airplane crashed through a perimeter fence and crossed a road before coming to a stop, an extended runway safety area that was added to Ypsilanti airport between 2006 and 2009 allowed the airplane plenty of room and time to come to rest safely. This expansion was part of a national program started by the Federal Aviation Administration in 1999 in response to an NTSB recommendation to add runway safety areas to many commercial airports.

Our investigative team learned that three critical factors—things done “right”— helped prevent this accident from becoming a tragedy, in which numerous lives could have been lost:

1) The captain’s quick response

2) The crew’s adherence to procedures, which resulted in a quick and efficient evacuation

3) The addition of a compliant runway safety area

After 20-plus years of investigating accidents, it’s refreshing to me to see an accident in which more things went right than wrong, and where people lived to tell the tale because of good decision making. These cases don’t normally get a lot of attention, but it’s important for us to understand and report out all our findings—even the good—because we see lessons there, too.

I encourage everyone to read the full Ypsilanti report. A link to the accident docket and related news releases are also available at https://www.ntsb.gov/investigations/pages/2017-ypsilanti-mi.aspx.