Analyzing Fatals
The NTSB (or FAA when delegated by NTSB) investigates fatal accidents and the Board issues reports on the probable cause of the accident. The reports also list contributing factors to the accident. Typically, the final reports are peppered with words such as loss of control, controlled flight into terrain (CFIT) and other language describing the final event in the accident sequence and attributing it to one or more other events. But rarely does the report explain the “why” of the accident or the “how” of the pilot’s or other participants’ actions relating to the “why.” For example, in a loss-of-control accident, why did the pilot lose control of the aircraft and how did he or she place themselves in that predicament?