Category Archives: Inside NTSB

Inside the NTSB’s General Aviation Investigative Process

Addressing Medical Issues

By Dr. Nicholas Webster, NTSB Medical Officer

This is the second blog in a new series of posts about the NTSB’s general aviation investigative process. This series, written by NTSB staff, explores how medical, mechanical, and general safety issues are examined in our investigations.

The NTSB investigates every aviation accident in the United States. In each investigation, we look at the roles of the human, the machine, and the environment. By learning about the factors that cause an accident, we can make recommendations to prevent similar accidents in the future.

I am one of two medical officers (physicians) at the NTSB who work closely with investigators in all modal offices. When an investigator-in-charge (IIC) is concerned that operator medical issues, drugs, or toxins may have affected performance, he or she coordinates with us to study the medical aspects of the event. The medical officers review medical documents, toxicological testing results, and sometimes autopsy reports of those involved in accidents. In conjunction with the investigative team, we help determine if operator impairment or incapacitation contributed to the cause of the accident, then we help craft language to explain to the public the nature and significance of the medical issues and how they affected the operator and contributed to the accident’s cause. We also work closely with the Board’s biodynamics and survival factors experts to help evaluate accident-caused injuries and determine what changes could be made to prevent future injuries.

The resulting information is presented in a medical factual report, which documents all pertinent medical issues and any potential hazards that the medical issues posed. To ensure accuracy, these fact-based scientific reports are peer reviewed by the investigative staff before they are published as part of the public docket. The medical, factual, and operational details of each event are then analyzed by the investigatory team, which determines probable cause by consensus, peer review concurrence, and Board authority. The probable cause represents the most likely explanation for the event given all available evidence.

Two recent cases have garnered some attention in the general aviation (GA) community, both involving fully functional airplanes operating in manageable weather. In these cases, both pilot action (error or impairment) and pilot inaction (incapacitation) can lead to an accident. In these cases, we found that the pilots were operating in a relatively low-workload environment and had the skill and experience necessary to safely complete the flights. On the other hand, medical data showed that both pilots had severe heart issues that could cause sudden incapacitation without leaving a trace.

The first accident occurred on April 11, 2015, when an experimental Quad City Challenger II airplane crashed into terrain near Chippewa Falls, Wisconsin. The 77-year-old pilot died and the airplane was substantially damaged. The pilot had the skill and experience to operate the airplane in visual conditions. According to witnesses, while the airplane was on the downwind leg of the traffic pattern at the pilot’s home airport, it entered a steep dive that continued until it struck the ground in an open field. Investigators found no evidence of preexisting mechanical concerns and, based on the propeller damage, determined that the engine was producing power at impact. Operational evidence also strongly supported pilot incapacitation.

The pilot had a history of coronary artery disease, which was treated by multivessel bypass surgery. He also had high blood pressure, elevated cholesterol, and hypothyroidism, which were controlled with medications. The autopsy showed that the pilot had an enlarged heart; severe multivessel coronary artery disease (greater than 80-percent occlusion of all vessels), with coronary artery bypass grafts and complete occlusion of two bypass vessels; scarring of the ventricular septum, indicating he had had a previous heart attack; and active inflammation of the anterolateral wall of the left ventricle of his heart. These findings, particularly the large scar and active inflammation of the heart muscle, placed the pilot at high risk for an irregular heart rhythm, which can easily cause decreased blood to the brain and result in fainting without leaving further evidence at autopsy.

Additionally, according to the Chippewa County Coroner Death Report, the cause of death was blunt force trauma. However, the examining pathologist further stated, “the most likely scenario to explain [the pilot’s] death is that he suffered an arrhythmia secondary to myocarditis.” These findings are discussed in detail in the medical factual report. Based on the available evidence, we determined the probable cause of the accident to be the pilot’s incapacitation due to a cardiovascular event, which resulted in a loss of control and subsequent impact with terrain.

The second accident of note was the crash into terrain of a homebuilt Europa XL airplane on June 26, 2015. As in the previous case, the pilot died and the airplane was substantially damaged. In this accident, the 72-year-old pilot also had the skill and experience needed to successfully complete the flight, especially given that it was a clear day and he was operating under visual flight rules.

The airplane crashed under power in a steep, nose-down, slightly inverted attitude in an open field about a half mile from the end of the runway, slightly to the right of an extended centerline. According to the IIC, there was no evidence of preexisting mechanical concerns, the engine was operating at impact, and the operational evidence suggested pilot incapacitation.

The pilot had a history of severe coronary artery disease, which was treated with multivessel bypass surgery, stents, and medication. Additionally, he had elevated cholesterol and high blood pressure, which were treated with medications. Since his last medical certification examination, an exercise stress test showed no significant changes, but a cardiac catheterization report documented that his coronary artery disease had progressed, resulting in 90‑percent occlusion of the left anterior descending coronary artery and impaired blood flow to a part of the heart muscle. Additionally, the autopsy identified multivessel coronary artery disease treated with patent coronary artery bypass grafts, and documented up to 70-percent occlusion of the left anterior descending coronary artery.

These findings are discussed in detail in the medical factual report. The pilot’s severe progressive coronary artery disease and the impaired blood flow to an area of his heart muscle placed the pilot at high risk for an acute cardiovascular event such as a heart attack, anginal attack, or acute arrhythmia. Any such event would likely cause a sudden onset of symptoms such as chest pain, severe shortness of breath, palpitations, or fainting, and would leave no evidence visible on autopsy if death occurred in the first few minutes.

The Mahoning County Coroner Autopsy Report cited multiple blunt force injuries as the cause of death, with coronary artery disease and chronic hypertension contributing to the cause of death. Again, although the pilot died of blunt force injuries, the evidence supports our finding that the accident sequence was likely initiated by his incapacitation due to a cardiovascular event.

These cases illustrate how we integrate medical findings into our investigations. We also provide interested parties with links to publicly available, detailed information that supports our findings. In both of the cases described here, the medical factual reports document significant medical issues in pilots who were operating under sport pilot rules; however, we only determined the medically related probable causes after thorough, scientific, peer-reviewed analysis of all the available facts concerning the human, the machine, and the environment.

Our goal is to identify medically related hazards that may be causal to or resultant from the accidents we investigate, and then work with the experts on the investigative team to develop mitigation strategies, which take the form of safety recommendations, that target and eliminate these hazards and improve transportation safety.

Inside the NTSB’s General Aviation Investigative Process

By Member Earl F. Weener

This is the first in a new series of posts about the NTSB’s general aviation investigative process. This series, written by NTSB staff, will explore how medical, mechanical, and general safety issues are examined in our investigations. I hope you take time to read these posts and, in doing so, come away with a greater understanding of the NTSB, our processes, and our people.

It has been my ongoing honor and privilege to serve as a Member of the NTSB over the past seven years, and I’ve been impressed by the diverse professionals who make up the NTSB staff. They work in different modes—rail, highway, pipeline, marine, and aviation—and specialize in engineering, human factors, medicine, safety outreach, and recorders, to name a few, but they all share a common goal: to protect the traveling public through recommendations aimed at improving transportation safety.

The NTSB is made up of approximately 430 dedicated employees who have a wide range of educational backgrounds and relevant experience. Our ranks include MDs, JDs, and Ph.Ds. Among our investigators, we count former members of law enforcement, industry professionals, and technical experts. When we investigate an accident, a multidisciplinary team is selected to fit the needs of the investigation.

Member Weener and investigators at the scene of the July 2013, crash of a de Havilland Otter Air Taxi, in Soldotna, Alaska

I’m often asked how the NTSB—particularly our crash investigation process—works. The NTSB is required by law to investigate every aviation incident in the United States, and our aviation safety staff investigate more than 1,200 aviation events each year. Our investigative process looks at three factors—human, machine, and environment—to determine the probable cause of accidents and incidents. This process has evolved during our 50 years, leveraging the skills, talents, and professionalism of our people, who use the latest investigative techniques and tools to find facts, analyze those facts, and determine why and how an accident happened.

Investigators consider what may have caused or contributed to the events of every accident. They look for issues in areas such as mechanical failures, operations, and weather conditions. They doggedly work to recover all onboard recorders and other sources of data, even when those recorders may be severely damaged. They also consider pilot performance, collecting evidence regarding possible fatigue, medical fitness, prior training opportunities, and specific aircraft experience.

Evidence is gathered through cooperation with pilots, witnesses, law enforcement officials, the FAA, airport officials, industry, and other stakeholders; in extreme cases, our staff can also issue subpoenas to obtain needed evidence. Investigations cannot and do not try to answer every question of why and how, but focus on questions of what caused the accident, or made it worse. Probable cause is the factor—or factors—that, based on all available evidence, the Board concludes most likely resulted in the accident. It generally takes around a year to produce a final report, which includes a probable cause and contributing factors.

Based on our investigations and special studies, we issue safety recommendations to regulatory agencies, industry, and other parties to an investigation who are positioned to implement our suggestions and improve transportation safety. The NTSB isn’t a regulatory agency, so we cannot compel compliance with our recommendations; however, of the more than 14,500 safety recommendations issued in our 50-year history, more than 80 percent are acted upon favorably. This is testimony to the NTSB’s diligence, investigative acumen, and commitment to transportation safety.

Looking back over the years and contemplating the NTSB’s contributions, I am proud to see that transportation safety has, in fact, improved greatly—especially in commercial aviation. We have seen significant improvements in aircraft crashworthiness; the introduction of life-saving technologies, such as collision avoidance and ground proximity warning systems; implementation of safety policies and regulations aimed at preventing pilot impairment, distraction, and fatigue; and emphasis on safety management systems and enhanced flight crew procedures. NTSB investigations identified the need for these advancements and helped incentivize remarkable safety improvements. Modern commercial aviation is safer now than ever before.

I often quote author Douglas Adams, who tells us that people are almost unique in their ability to learn from others, but remarkable for their resistance to doing just that. You may have heard the old saying, “knowledge is power.” We believe “knowledge is safety.” I hope you take a moment to learn about the NTSB’s investigative process in the next several blog posts, and that you come away with a greater understanding of how we at the NTSB strive to turn our knowledge into safer transportation.

‘Ride Your Own Ride’ – Even in Groups

By Chris O’Neil

The vast majority of the miles I’ve logged as a motorcyclist have been as a solo rider, where I alone plan the route, set the pace, and determine when and where to take breaks. Riding alone, to me, reinforces the independence, mental solitude, and freedom I feel every time I saddle up. Riding alone allows me to easily ride at my comfort and skill level.

I also enjoy large group rides from time to time, where someone else is responsible for the trip planning, and execution—and where I can just follow along a route with a bunch of folks who love riding as much as I do. However, riding close to so many others can lull you into a false sense of security or can create a sense of performance pressure—or both. Riding within your limits, or “riding your ride,” when in a group is one way to avoid these dangerous mental states and ensure a safe and fun ride.

Just because you’re not leading the group ride, doesn’t mean you don’t have a role in planning the ride. The group leader should provide a pre-ride briefing that covers the route, planned stops, hand signals, and procedures to follow if the group gets separated or if a rider has an emergency. Actively listening and participating in the pre-ride briefing helps get your mind in the ride.

(Photo by Larry G. Carmon)

Group riding is generally done in a staggered column of two within a single travel lane, requiring riders to maintain an interval with the biker ahead of them and the rider in the staggered position. It’s easy to get fixated on the mechanics of maintaining these intervals and to forget to continue your own scanning of the roadway. Seeing and evaluating potential risks and planning how to avoid or mitigate them is a continuous process for motorcyclists that doesn’t stop whether you’re in the lead, the middle, or at the tail of your group. The visibility that comes with riding in a group does not replace the need for you to identify your escape routes should an emergency – like an animal darting out into your path or a car encroaching your lane – arise.

It’s also easy to feel a little pressured when in a group ride – the sense of a need to keep up, to take turns and curves at the group’s speed, to not get separated at a traffic signal, or to proceed through an intersection before you’re really ready. I have felt this pressure a couple times while riding in groups and I took a few twisties a bit faster than I would have if I were on my own.

And now I know better. I learned to overcome that mindset by recognizing I’m riding with a group of friends – no one is judging me. These folks want me to enjoy the ride as much as they do, and they want to help me become an even more accomplished rider. I remind myself, in every group ride, that I’m going to ride my ride and that’s not only okay, it’s expected by the folks with whom I’m riding. If I’m riding my ride, I’m in my comfort zone. If I’m in my comfort zone, I’m more relaxed and less likely to panic or overcorrect in an emergency, and less likely to crash or cause a crash because I’m confident that my abilities match my environment.

Motorcycle Safety Month is wrapping up just as the motorcycle riding season is shifting into high gear. Getting out with friends in group rides is a big part of the season and ensuring you’re riding your ride, every ride, is one way to make every ride a safe ride.

For tips on riding in groups or the SEE (search, evaluate and execute) process, visit the Motorcycle Safety Foundation’s website at https://www.msf-usa.org/Default.aspx.

 

Chris O’Neil is the NTSB Chief of Media Relations.

Today’s Actions, Tomorrow’s Consequences

By Nicholas Worrell

In the past 2 months, several occasions have raised awareness about the dangers we face in highway safety:

  • National Distracted Driving Awareness Month
  • Public Health Awareness Week
  • Impaired Driving Awareness Month
  • Click It or Ticket National Enforcement Mobilization
  • Global Youth Traffic Safety Month
  • Bicycle Safety Month
  • Global Road Safety Week
  • Motorcycle Awareness Month

Naturally, the NTSB has played a role in many of these initiatives in support of our highway safety recommendations; but it is often the work of advocates and brave legislators around the country that move states toward action on our recommendations.

Unfortunately, despite these national and global initiatives, the numbers are trending in the wrong direction. After years of decline and plateau, the number of traffic deaths per year spiked in 2015 and 2016. When the 2016 numbers are tallied, it’s reasonable to assume that they will be the highest in a decade.

The cultural shift we need to stop this trend will take greater education, legislative, and enforcement efforts. In our April 26 roundtable, “Act 2 End Deadly Distractions,” we brought together advocacy groups, insurance companies, survivor advocates, and law enforcement representatives to discuss the problem and identify specific solutions. Survivor advocates went away with new tools and contacts, as well as with information on how to take more effective action to move the public, state and local governments, employers, and law enforcement. The assembled advocacy groups announced an alliance, the National Alliance for Distraction Free Driving.

NTSB Highway Investigator Kenny Bragg talks with students at the Prince George’s County (MD) Global Youth Traffic Safety Month event

Earlier this month, the NTSB’s Advocacy Division collaborated with Prince George’s County (MD) Police Department, the National Organizations for Youth Safety (NOYS), and Freedom High School in Virginia to educate youth about driving hazards. Together, we kicked off our Global Youth Traffic Safety Month social media campaign, #1goodchoice, to promote teen driver safety.

Last week, I represented the NTSB at the International Road Federation’s 6th Caribbean Regional Congress. At the meeting, I emphasized the “service” part of civil service and shared what NTSB Advocacy has learned in promoting action for safer driving and safer roads.

Nicholas Worrell talks with attendees at the International Road Foundation’s 6th Caribbean Regional Conference

Even as safety features become more and more common, our driving behavior has not become safer. We must change behavior to make a real difference, and that change in behavior starts with ourselves. The first step to making this change is realizing that those who die in highway crashes are not some “other people”—they’re somebody’s loved ones. They were somebody, themselves. They could have been us. You can take action to increase awareness—your own as well as that of those around you. Turn away from messages about how much we can drink before driving, for example, and think instead about separating the two behaviors. Realize that, whether you’re speeding to make a red light or glancing at your phone while driving, it can wait. Get enough sleep before driving. Wear a helmet when you’re on a motorcycle. Be alert to pedestrians and bicycles, and be alert as a pedestrian and a bicyclist. Reach out to people you know, either through social and traditional media or by simply having a face-to-face conversation with your loved ones and friends about the behaviors they need to change when they’re on the road.

Act to end distractions by joining the conversation at #Act2EndDD. You can talk about your one good choice (#1goodchoice). If you’re a survivor advocate, you can get in touch with the National Alliance for Distraction Free Driving for tools and ideas on how to put an end to distracted driving.

If each of us changes our own behavior, we will create a safer world. We must all take responsibility and act to keep drivers, passengers, pedestrians, bicyclists, and motorcyclists alive.

The Legacy of a Judge

By Christopher A. Hart

NTSB Administrative Law Judge Patrick G. Geraghty giving a presentation during AirVenture 2012.
Judge Geraghty giving a presentation during AirVenture 2012.

When people think of the NTSB, they most often think of our investigators working diligently at the scene of accidents in transportation. Many are also familiar with the safety recommendations that we issue to help make transportation safer.

What is less well known is that the NTSB serves as a “court of appeal” for airmen, mechanics or mariners who are contesting an FAA or USCG certificate action.  Our administrative law judges hear, consider, and issue initial decisions on such appeals.

On February 6, 2016, the NTSB suffered the sudden loss of Administrative Law Judge Patrick G. Geraghty. On behalf of the entire agency, I would like to express my condolences to Judge Geraghty’s family, friends, and colleagues.

Judge Geraghty served this nation as a naval aviator in the U.S. Marine Corps where he flew F-4 Phantom jets during the Vietnam War.  After his military service, he served as a senior trial attorney with the Federal Aviation Administration before becoming an Administrative Law Judge.  He was first appointed to hear cases with the U.S. Department of Labor. Judge Geraghty joined the NTSB as an administrative law judge in 1975.  During his more than 41 years of distinguished service with the NTSB, he heard and decided hundreds of medical and aviation enforcement cases.  He was a respected jurist who was always generous in sharing his expertise and advice with his fellow judges and with staff.

Judge Geraghty sometimes upheld FAA orders to suspend or revoke a pilot’s license, but he was also an instructor who helped many pilots learn how to comply with the regulations — and fly more safely — as they began or advanced their aviation careers. He held an airline transport pilot certificate and was a certified flight instructor. He also earned the prestigious title of PADI course instructor in scuba diving, and trained hundreds of scuba divers and instructors.

Judge Geraghty balanced scholarship and professionalism with a zest for everything else that life had to offer. He was a voracious reader and a lifelong learner, and he passionately pursued skiing, scuba diving, martial arts, and flying. In recent years, he learned to play the bagpipes, and traveled to Italy to take an immersion course in Italian. At the time of his passing, he was working toward a black belt in Kung Fu.

In addition to many colleagues and friends, Judge Geraghty is survived by his wife, Donna; his sons, Michael and Matthew, and his grandsons Matt and Jack.

Judge Geraghty will be greatly missed, but his legacy lives on in the many lives he enriched, both through his service to others and through the example that he set.

Our Thanks to Safety Communicators

By Sharon Bryson

CompBreakfastYesterday, I had the pleasure of hosting a meeting of transportation safety communications professionals. They came from many organizations, each with their own unique missions and capabilities. I began the meeting by saying that our attendees had one thing in common: they all worked for safety, something that really matters.

But as the conversation unfolded, I realized that in saying that, I had overlooked the obvious. They had something else in common: they were all passionate, dedicated communications professionals.

Our guests openly shared information both about their upcoming initiatives and about the challenges that they faced. They recounted some of their experiences in overcoming the challenges of an ever-shifting media landscape and shared knowledge with one another about getting the safety message out to their audiences.

Their spirit of collaboration was inspirational to me, as the director of an office tasked with developing messages based on NTSB safety recommendations and sharing those messages with the public.

Just as importantly, their knowledge of today’s communications landscape confirmed once again what I had already seen on countless occasions: in getting transportation safety messages out, we have powerful, committed, and smart allies among safety advocacy organizations.

While attendees differed in their missions and agendas, all of us came away committed to working in closer collaboration in the future.

It’s my daily honor to work for an agency with an unyielding focus on transportation safety.

But yesterday it was a special honor to host the professionals who share the NTSB’s safety mission. This is the type of needed collaboration that will help us prevent crashes, deaths, and injuries in all modes of transportation. 

To all of yesterday’s attendees, thank you.

Sharon Bryson is Director of the NTSB Office of Safety Recommendations and Communications

Honoring a Distinguished Gentleman and Jurist

By Chairman Christopher A. Hart

Judge_William_FowlerA commitment to aviation safety and fairness for all parties, with a passion for justice. That describes Judge William Fowler, a long-time NTSB Chief Administrative Law Judge whose career in service to the American public was nothing short of extraordinary.

On Sunday, August 9, 2015, the judicial and aviation community, along with the NTSB, bid farewell to Judge William Fowler, who passed away at the age of 93. He left a long legacy and storied career of public service.

I have known Judge Fowler for several decades, even before I first came to the NTSB in 1990. Judge Fowler, though not tall in stature, was most certainly a giant among men. He was humble, kind, dignified, helpful, and a gentleman, with superb judicial instincts.

Judge Fowler knew Supreme Court Justice Thurgood Marshall, who served as an inspiration to many who have become lawyers, judges, and even chief judges. As Justice Marshall was an inspiration for so many, Judge Fowler served as an inspiration for me from the day we first met.

More than a half century ago, Judge Fowler came to Washington, DC, to work for Attorney General Robert F. Kennedy as a special assistant on the Department of Justice’s organized crime task force that investigated Mafia activity.

Prior to answering the call to serve for the U.S. Attorney General, Judge Fowler had already distinguished himself as the city prosecutor in his hometown, Akron, Ohio, then as Ohio’s Assistant Attorney General, and then as Chief of the Highway Division of the Ohio Attorney General’s Office.

After coordinating federal efforts against organized crime, which played an instrumental role in securing 11 convictions in New York and Pennsylvania, Judge Fowler’s next career move was to federal administrative law. That included positions with the U.S. Department of Labor, Social Security Administration, and U.S. Civil Service Commission (now the Office of Personnel Management). He began at the NTSB in 1969, when he was appointed as a Hearing Examiner. He was named the NTSB Chief Administrative Law Judge (ALJ) in 1977, and he continued serving in that position, not only managing the entire ALJ office, but also presiding over thousands of cases, until he retired in May 2012, after 53 years of distinguished service to the NTSB and to the American public.

In 2009, Judge Fowler was awarded the Mary C. Lawton Outstanding Government Service Award for his lifetime of excellence in administrative law. He was best known in the courtroom for his dignity and calm judicial temperament. He was not only a wonderful, caring, and thoughtful person, but he was such a great jurist that he won the respect of even those who lost their cases before him.

We at the NTSB thank Judge Fowler for his humanity, justice, and service to the NTSB and to the entire aviation community. He was always, and will always be, an inspiration to me, and he set a wonderful example for the entire federal service. He will be greatly missed, but his legacy will remain forever.