Four years ago, the NTSB questioned whether manufactures like Boeing should be allowed to self-certify that their aircraft designs meet FAA requirements.  The NTSB suggested that “self-certification” may have contributed to the battery fires that were being experienced on Boeing’s 787s.  After all, it’s the FAA’s job to make an independent determination that an aircraft design is safe.  It makes little sense to pass that job to the manufacturer, who is hardly independent.

The FAA’s response was to delegate even more authority to manufacturers.  In fact, the GAO reports that 90% of all aircraft certification work is now outsourced to the manufacturers themselves. 

How is that working out?  Not surprisingly, not so well.  According to documents obtained by the Seattle Times,  through 2015, Boeing was fined $13 million to settle FAA proceedings arising from falsification of certification and repair work.  The Seattle Times noted that one Boeing mechanic told FAA investigators that he had been entering false data into aircraft inspection records for at least seven years.

The NTSB allows aviation manufacturers to participate in its crash investigations.  But it excludes from the investigation the crash victims, the victims’ lawyers, and their experts.  That’s how the NTSB has gone about investigating aviation accidents for years.  It’s little wonder, then, that the NTSB’s final reports are frequently biased in favor of the manufacturers and against the pilots or the passengers.  The conflict of interest inherent in the NTSB’s investigations is one reason why the NTSB most often concludes that a crash is due to pilot error rather than, for example, a mechanicalChairman of Wilson Elser's Helicopter Defense Practice defect.

Lawyers for crash victims have long complained that the manufacturers and their lawyers are too cozy with the NTSB.  When the manufactures aren’t trying to influence the NTSB’s conclusions in their favor, they are using their status as a “party” to the NTSB investigation to gather information they can later use to defend themselves in lawsuits the victims might bring.

Lawyers for manufacturers used to deny that they were too chummy with the NTSB.  Now, not only do they concede that its true, but they have started touting their relationship with the NTSB as a way of attracting more manufacturers as clients.

Wilson Elser is one of the country’s largest aviation lawyer firms representing manufacturers and other industry interests.  Today the firm announced that it is launching a “national helicopter defense practice.”  Why should a helicopter manufacturer hire Wilson Elser after a crash?  Well, because Wilson Elser is in tight with the NTSB:

Our team consists of accomplished litigators and trial attorneys, which are key to any defense team, as well as collective experience in aviation and aerospace with a distinct focus on rotorcraft. Together with our strong relationships with the National Transportation Safety Board and Federal Aviation Administration, we are able to gather the information necessary to create strong defense theories.”

It hardly seems fair that defense law firms are allowed to use their cozy relationship with the NTSB and their status as a “party participant” in the NTSB investigations to gain an advantage in litigation against the crash victims.  Yet, that is the way it is.

Robinson Helicopters began installing crash-resistant fuel tanks in 2010.  Robinson Helicopters with fuel tanks installed before then tend to catch fire during accidents that, but for the fire, would have been survivable.

The Australian authorities thought that the safer tanks were a good idea.  Enough Robinsons had caught fire after minor accidents that in 2013 the Australian government grounded all RobinsonAustralian R44 Post Crash Fire R44 helicopters operating in Australia until their owners installed the new-style fuel systems.

The NTSB asked the FAA to follow suit and issue a similar order grounding R44 helicopters in this country.  But the FAA refused.  Even assuming the old-style Robinson fuel tanks were needlessly dangerous, the FAA thought they really weren’t all that different from the fuel tanks installed in many other older helicopters.  If the FAA grounded Robinsons until they were fixed, they’d have to ground a lot of helicopters produced by other manufacturers as well.

But the FAA has known about the trouble with old-style fuel systems for a very long time. In fact, since 1991, FAA regulations have required manufacturers to install in their helicopters fuel systems that are proven "crash resistant."  Trouble is, those regulations apply only to helicopters designed after 1994.  They do not apply to helicopters that are manufactured today, but were designed (or certified) before 1994.  

Unfortunately, the majority of light helicopters manufactured in the US today were designed before 1994, and so in practice the regulations seldom apply.  The NTSB thinks its time for that to change.  The NTSB’s latest safety recommendation asks the FAA to:

Require, for all newly manufactured rotorcraft regardless of the design’s original certification date, that the fuel systems meet the crashworthiness requirements of 14 Code of Federal Regulations 27.952 or 29.952, “Fuel System Crash Resistance.”

What will the FAA do in response to the NTSB’s recommendation?  If history is a guide, unfortunately, the FAA will do nothing.

Families of those involved in five different general aviation crashes and their lawyer are suing the NTSB, charging it with obstruction of justice.  The suit claims that the NTSB withheld from the families information concerning each of the crashes in violation of the Freedom of Information Act.

I’ve commented before about how the NTSB’s “party system” creates a conflict of interest that skews the results of its investigations in favor of the manufacturers.  But this lawsuit goes further than that.  It alleges not just a conflict of interest, but collusion between the NTSB and the manufactures:

Upon information and belief, investigators and others employed by the NTSB collude with manufacturers and, upon their departure from government, most often accept employment defending the aircraft and component manufacturers whom they are previously tasked to investigate.

As a result of that collusion, the lawsuit alleges, the NTSB withholds and even destroys evidence for the express purpose of preventing the victims and their families from finding out what really caused the crash and holding those responsible accountable.

The NTSB, through its officers, employees and/or its agents, including party participants, acted and continues to act with the intent to avoid, evade, prevent and/or obstruct the timely investigation of airplane crashes.

Does the NTSB really destroy evidence? Every aviation lawyer knows that it does exactly that, at least to some extent.  For example, an NTSB investigator may take many photos of an accident scene or wreckage.  Yet, he will make part only certain of those photographs part of the “Public Docket.”  The investigator may simply discard the rest before the NTSB releases its final report and opens the docket to public review.  The lawsuit seems to suggest that at least some investigators discard material purposely and selectively so that evidence that would incriminate the manufactures or other “party participants” never sees the light of day.

Explosive stuff.

 

Obstruction of Justice against the NTSB

A few hours ago, USA Today published a lengthy investigative report devoted to small aircraft crashes. The conclusion:  aviation manufacturers have long concealed the fact that their defectively designed products cause aircraft crashes and injures. And the investigating agencies, including the NTSB and FAA, let them get away with it.

The report covers many of the issues we’ve touched upon before on this blog, from defective carburetors, to defective pilot seats, to faulty ice-protection systems. The report also covered a subject we’ve covered on this blog extensively – post crash helicopter fires in otherwise survivable accidents:

One of the most gruesome and long-standing problems has caused scores of people to be burned alive or asphyxiated in fires that erupt after helicopter crashes. Such deaths are notorious because they can occur after minor crashes, hard landings and rollovers that themselves don’t kill or even injure helicopter occupants. The impact can rupture helicopter fuel tanks, sending fuel gushing out, where it ignites into a lethal inferno.

Using autopsy reports and crash records, USA TODAY identified 79 people killed and 28 injured since 1992 by helicopter fires following low-impact crashes. In 36 non-fatal crashes, fire destroyed or substantially damaged helicopters after minor incidents such as rollovers, crash reports show.

The report didn’t mention the most recent Robinson fire that killed the R44’s pilot at Birchwood Airport in Alaska just two weeks ago.

Pilot error?

I’ve been saying for years that many crashes that the NTSB attributes to "pilot error" simply aren’t. The USA Today report backs that up.  The report discussed the fatal crash of a single engine Piper following engine failure.  The NTSB chalked up the engine failure to pilot error.  But, as it turns out, the crash was caused by a defective carburetor float. The judge handling the case noted that the carburetor manufacturer had received more than 100 warranty claims for similar problems before the crash. Yet none of that product history made it into the NSTB report.

Ruling against Lycoming  [the engine manufacturer] and Precision [the carburetor manufacturer], Philadelphia Judge Matthew Carrafiello found evidence both might be culpable. Precision received more than 100 warranty claims concerning carburetor defects, the judge said, and Lycoming continued to use the carburetors even though it "knew of ongoing problems" with the carburetors "and of numerous plane crashes resulting from such problems.

None of that information was included in the NTSB investigation, which was aided by Lycoming and Precision and blamed Andy Bryan, the pilot, for "failure to abort the takeoff" and "failure to maintain adequate airspeed during takeoff."

According to the report, many of the crashes that the NTSB concludes are due to pilot error are actually due to defectively designed aircraft.

Federal accident investigators repeatedly overlooked defects and other dangers of private aviation as they blamed individual pilots for the overwhelming number of crashes of small airplanes and helicopters . . . The failure of crash investigators to find defective parts, dangerous aircraft designs, inadequate safety features and weak government oversight helped allow hidden hazards to persist for decades, killing or injuring thousands of pilots and passengers . . .

Manufacturers mislead the FAA

Part of the problem is that the NTSB does not travel to the site of many small airplane crashes, leaving the on-scene investigation to the FAA. Unfortunately, according to a former NTSB investigator, the FAA personnel don’t have the same investigative experience as the NTSB investigators and are easily duped by the manufacturers.

Many times what happens now is that when the accident occurs, the technical rep of the (manufacturing) company will call the NTSB and say we’ll be party (to the investigation), we’ll go out there and let you know what we see … the only people on scene would be perhaps an FAA guy and the field rep of the manufacturer," said Douglas Herlihy, a former NTSB investigator who now reconstructs crashes, often for plaintiffs in lawsuits against manufacturers.

"If you (the NTSB) are not there, you’ve got the representative from the company at the scene. His job is to skew the facts, to ignore the product difficulties and to remove the question of liability," Herlihy said.

No conclusion yet as to exactly what caused the Galloping Ghost to crash last September at the Reno Air Races. But the interim report the NTSB issued today disclosed that the Galloping Ghost experienced an “upset” 6 seconds before it lost its left elevator trim tab. That, in turn, caused the aircraft to go out of control.  None of that  information is really new, and was discussed shortly after the accident in this post and in the post’s many thoughtful comments.Galloping Ghost vs. Unmodified P-51D

The NTSB also issued safety recommendations that specifically questioned whether the Galloping Ghost had been properly tested at race speeds or otherwise evaluated for resistance to “flutter;” an aerodynamic phenomenon that can destroy an aircraft in seconds. But that’s not news either — flutter and its possible role in this crash was discussed the day after the crash here.

There is one fact, however, that we didn’t know before. Race officials inspected the aircraft just before the race and determined that the aircraft’s trim tab’s screws were too short. But the NTSB could find no documentation that the screws had been replaced and the discrepancy resolved before the race started. Though the race inspector stated that he verified that all the aircraft’s discrepancies had been resolved, the NTSB recommended that, in the future, race organizers develop a system that tracks discrepancies found during pre-race technical inspections and ensures that they have been resolved before an aircraft is allowed to race As the NSTB put it:Trim Tab - Reno NTSB

without a method to track discrepancies to resolution, conducting pre-race inspections is of limited value.

The NTSB’s interim report doesn’t say whether the screws were, in fact, replaced. For that, we’ll have to wait for the NTSB to issue its factual report. But even without a system for race officials to track discrepancies, whenever a mechanic performs any work on an aircraft, he is supposed to record that work in the aircraft’s maintenance logs.  If there’s no entry in the Galloping Ghost’s logbooks showing that the screws were changed, that’s evidence that the work wasn’t done, or at least wasn’t done properly.

Besides recommending that race officials establish a better system of ensuring that aircraft discrepancies are repaired before race time, it issued recommendations that would, among other things:  

  • Require race pilots to be trained to tolerate or avoid high g-loadings;
  • Revise the mathematical formulas used to lay out the race courses;
  • Require aircraft to be tested at race speeds before they be allowed to compete; and
  • Require pilots to practice on the actual race course before being allowed to compete.

 

Related Content:

 

The NTSB blamed the helicopter crash that killed 9 firefighters on the the helicopter’s operator.  Basically, the NTSB concluded that the helicopter crashed because it was overloaded.  But today a jury disagreed, deciding that the Sikorsky helicopter crashed because one of its two engines failed.  The jury handed down a $70 million verdict against GE, the engine’s manufacturer.

Why is a jury allowed to come to a conclusion totally opposite to that reached by the NTSB?  In short, because the NTSB’s findings are inadmissible in a court of law.  And there’s good reason for that.  For starters, a victim’s family is not allowed to participate in the NTSB investigation, while the manufacturers who may be to blame for the accident are.  As a result, the NTCarson Helicopter Iron 44 CrashSB’s findings frequently favor the manufacturers

Is that what happened here? Did the NTSB unfairly favor GE?  It seems that it may have. 

I spoke today with one of the participants in the trial held in Portland.  He explained that, originally, the NTSB had determined that one of the helicopter’s engines did, in fact, fail in flight.  That report mysteriously "disappeared," however, shortly after it was published.  As did the engine’s fuel control unit.

The NTSB ultimately took the position that losing the fuel control unit was no big deal, because it believed the engine hadn’t failed.  But plaintiffs introduced at trial substantial evidence that it had, including an audio recording made during the crash sequence which helped proved that one of the engines "rolled back," or shut down, just before the impact.

In December, 2010, the helicopter’s operator issued a press release complaining that the NTSB proceedings were unfair.  Given today’s verdict, it makes for particularly interesting reading.

 . .  the facts clearly show that the primary cause of this accident was a loss of power to the #2 engine of the aircraft. There is a strong chain of physical evidence in the [NTSB’s evidence] that indicates a high probability that a malfunctioning fuel control unit (FCU) caused a sudden loss of power as the aircraft transitioned to forward flight. Extensive independent real-world flight testing has confirmed that even [if overweight, the helicopter should] have had enough power to fly away from . .  with two properly operating engines. The co-pilot has confirmed much of this evidence with his recent testimony.  . . The NTSB has ignored his testimony in favor of supposition. . .

Unfortunately, early in this investigation the NTSB lost custody of several fuel control parts, and conducted a filter inspection incorrectly, which they have acknowledged. Since that time, the NTSB has chosen to ignore the physical evidence and flight parameters that indicate a possible blockage in the FCU. They repeatedly refused to participate in independent flight testing, and they have not given proper consideration to the copilot’s direct testimony of conditions and available power just prior to the crash.

The NTSB says that during tomorrow’s hearing, it will be looking to industry leaders to give it a “deeper understanding of regulations” bearing on the operation of the nation’s air shows. Of course, the only regulatory body that has the authority to control air shows is the FAA. But what the Board will find — if it asks the right questions — is that for the most part, the industry regulates itself. According to one veteran air racer, Howie Keefe, the FAA is more or less “hands off” when it comes to air show safety. From Martha Bellisle’s article in the Reno Gazette-Journal:

Keefe said the industry is largely self-regulated because the pilots and engineers are the most qualified to determine whether another pilot can handle a certain race or course or whether a certain design can handle the stress of a trick or race. ‘The classes themselves can say yes or no to a person who wants to race — if they can’t do a roll, they can’t race,’ Keefe said. ‘The FAA can’t do that. We rely on the expertise of the people in the industry to make the decisions.’

Perhaps a “hands off” policy is fine for the participants. But not so much for the spectators, who expect that if the FAA approves an event, it is overseeing the event’s safety in some meaningful fashion, and not merely turning the reins over to the event sponsors.

This Board says that the purpose of tomorrow’s public hearing is to help it investigate future air show accidents. But this Board is more assertive than past boards. There’s little doubt that it will find the FAA’s oversight lacking. The question is whether it will do anything about it.

The NTSB is underfunded and understaffed. So it investigates accidents using the "party system."  That means the NTSB relies on those who may have caused the accident for help in investigating the accident’s cause. Unfortunately, the "party participants" seldom point the NTSB towards evidence in their files that would tend to incriminate them. As a result, NTSB reports go easy on the industry players.

From time to time, I’ve offered examples of cases (like the ones here and here) where the real cause of the accident was found by plaintiffs lawyers — sometimes well after the NTSB report is published.

Here’s yet another example, this time arising out of the crash of the Continental (Colgan) Flight 3407. According to a recent CBS News report, lawyers for the families uncovered emails showing that Colgan Air knew the captain was not qualified to fly the Q400, but put him in the left seat anyway.   

According to an ABC report, in one of the emails a Colgan Vice President states that the captain

had a problem upgrading” and, taking that into consideration, “anyone that does not meet the [minimums] and had problems in training before is not ready to tackle the Q.”

The “Q” is a reference to the Bombardier Q400. Despite Colgan’s concerns about the captain’s ability to fly the Q400, they promoted him anyway.  Just five months after that, the new Q pilot crashed his aircraft in Buffalo, killing 50.

This wasn’t merely a case of "pilot error," it was the result of an airline that didn’t take safety seriously enough. The newly released emails are critical to understanding why the accident happened, and how similar accidents can be avoided in the future. Yet, an NTSB spokesman confirmed that Continental did not provide these emails to the NTSB at any time during its year long investigation of the crash.

It looks like the company’s emails tell the story of why Continental Flight 3407 crashed.  And it was the plaintiffs’ lawyers, not the NTSB, who found them.