Unusual Attitudes: Calamity Jane Crash Commentary

An insider's perspective on accident investigations.

Attitudes

Attitudes

(September 2011) With so much commentary on aircraft accidents from analysts, victims, witnesses, psychologists, perpetrators, investigators, manufacturers and Lord knows what other experts (real and self-proclaimed), why two cents' worth from me? I guess because my commentary is from the perspective of somebody trained and experienced in the investigation side of the business, who's witnessed more than her share of mishaps (during or shortly after the fact), lived through several and been personally responsible for a few — somebody who thinks she understands pilots, loves all things aeronautical, hates mediocrity as much as bureaucracy and wants flying to be as joyful and "sacred" to every other pilot as it is to her.

When you learn about a smash-up you generally seize on a likely scenario (fuel or stall/spins are generally safe bets), assign blame, murmur “How careless (stupid, criminal, juvenile ... ); I’m glad I’d never do something like that” and get on with life. But the easy and likely explanation isn’t always the truth and never tells the whole story. Early on I heard an NTSB investigator tell reporters at a rather grizzly site that he didn’t allow himself the luxury of judgment even when all signs pointed to the obvious. After 28 years and a fistful of certificates from accident schools, I’ve learned Mr. Santangelo was right. I’ve also come to accept that sometimes the causes — there’s never just one — will forever remain a mystery.

Relax. I’m not going to pontificate about how to “fly right” and be legal, but maybe I can shed a little light on the mechanics of accident investigations and the pecking order — like who’s in charge and what and how things happen.

Unless somebody prangs during an airshow or in front of an FSDO (the latter unlikely since FAA offices have mostly moved off airports), FAA inspectors are rarely on the scene, and by the time they arrive the site’s been pretty well sanitized: the injured or deceased removed by first responders, the fire department cleaning up or gone and the area secured by cops with miles of yellow tape. And the truth is that, if somebody important isn’t involved or the accident doesn’t rate coverage beyond the local news, FAA’s in no big hurry to get there. In the three field offices where I worked, if a call came at night or near the end of normal work hours, inspectors usually waited until the following day, saving the agency overtime and comp time.

Not that anybody ever asked for my opinion, but I believed FAA should be visible, at the scene as soon as possible. But accidents “belong” to the NTSB, so there really isn’t a whole lot FAA inspectors can do on their own. Part of the board’s raison d’être is that “fox guarding the henhouse” thing; the FAA itself might well be part (or all) of the cause. Field office inspectors are trained to investigate the sacred “Nine FAA Responsibilities,” which include the performance, airworthiness or adequacy of FAA facilities or functions, non-FAA-owned and -operated air traffic control facilities, navaids and the FAA itself — certified craft, airmen, air agencies, commercial operators or carriers. They assess if the regulations, airport certification safety standards and security standards were adequate. And finally they determine if the airman had proper medical certification and if there were any violations of the FARs.

So the focus of FAA inspectors isn’t so much on what happened or how but on who or what was at fault (with loud bells sounding if the agency itself might be implicated) and on making certain that everything about the flight was squeaky-clean legal. Then they secure the site and wait for the NTSB investigator, who arrives the next day with an air of superior knowledge and a more generous budget for conducting the investigation. Not surprisingly, his top dog status often bruises a few egos among the FAA troops, and grumbling resentment isn’t uncommon.

Nearly all engine, airframe, propeller and major component manufacturers have “go teams” that respond to accidents whenever their companies’ products might be involved. Early in my career, FAA policy was to keep industry representatives away from an accident site, but these days both the FAA and NTSB take advantage of their expertise. These guys are good — often ex-military, usually well trained and certainly more knowledgeable about a specific product than their government counterparts. Still, they have a pony in the race, so those findings and opinions are always validated by objective sources. Occasionally, with small accidents in which the government won’t pay for, say, an engine teardown, the manufacturer will offer the service free of charge, which may or may not be a good idea. It’s hard to imagine that XYZ Gizmo Co. would take its widget back to the factory and then report to investigators and the widow’s insurance company that it was a piece of crap.

Another difference these days is that NTSB doesn’t actively participate in as many investigations; its offices are understaffed (ever heard of a government office that wasn’t?) and widely scattered around the country. So when a crash involves a small airplane with nobody “important” on board (and especially when there are no fatalities) the accident is usually delegated to the local FSDO for investigation.

Anyhow, whoever ends up running the show, it’s important to secure or protect the site, and that usually means finding somebody to guard the wreckage overnight. You wouldn’t believe how quickly sightseers, souvenir collectors and, yeah, looters appear no matter how remote and inaccessible the site. Local cops won’t spend all night in a soybean field baby-sitting a small wrecked airplane, and, unlike their NTSB counterparts, FAA inspectors rarely have the budget to pay for private surveillance. There was a time when the CAP was eager to participate and cadets would set up a camp that would do the Army Rangers proud in no time. Not so anymore, at least the last couple of times I asked for help. Major Compasserror would need to liaise with Colonel Gumpscheck, who, when located, would advise (in stentorian tones) that he’d conference with the wing commander, General Rudderlock, concerning policy, liability and parental permission issues. Since all this liaising would go well into the following week, we just asked the cops to drive by and let the pieces sit unguarded.

By scheduling a bunch of check rides and holding a bunch of safety programs (sneaking the paperwork in on Sundays when nobody was around), I managed to steer clear of the office and was often out flying the 180 for fun when off duty. Whatever the reason, I achieved some fame for coincidentally being around when something happened — everything from fender-bender crosswind landings to serious accidents with multiple fatalities and destroyed aircraft. Plus I usually tagged along when anybody else in the office responded to a call; mostly the guys welcomed the help. I’d been at it for a long time, had the training and, most helpful, knew how to talk to the press without saying anything. When FAA Public Affairs mandated that all media be directed to the Chicago regional office, I could only shrug at questions from reporters I’d known and worked with for years. It was distressing to see and read the rumors and speculations offered by local “experts.” Like the nonpilot FBO who explained to reporters that a pilot struck cars head-on when he touched down (without fuel) on a divided highway “because pilots are trained to land against traffic ... you know, so they can see what’s coming at them.” Worse, the CFI — thrilled to be on TV — who was quick to explain how the pilot screwed up. Publicly airing a snap judgment within hours of an event that would take months to sort out didn’t sit well, and I had some unofficial, unauthorized and probably inappropriate phone conversations with these media stars about their performances.

Accident scenes aren’t pretty, but I didn’t suffer from any “post-you-name-it syndromes” so common these days, even when acquaintances or friends were involved. I once told a lecturing grief counselor at an accident course that, as a “woman of faith” (OK, so that’s a stretch), I strongly disagreed that professional counseling was needed by anybody exposed to death or mayhem. Maybe it’s different for investigators dealing with large accidents and multiple fatalities ... I don’t know. But I’d make the sign of the cross, say a quick prayer, maybe sprinkle a little holy water around and get on with the job. Maybe I’m just too tough a broad, but hysterical reactions struck me as being as phony as pilots who quit flying because somebody they knew had an airplane accident. (Yeah, I know that’ll generate a few letters). There’s always sadness, a deep sorrow that people suffered, that families would grieve and that a perfectly good airplane was reduced to junk. And sometimes frustration and anger because what happened was so careless, so unnecessary and avoidable.

What does keep me awake sometimes at night are the “why’s.” Yeah, too often the pilot did something wrong, stupid and/or illegal. But why did he get so slow on that base to final turn? Why did she try to stretch four hours of fuel into five? Why that punch into known violent weather? Why the show-off roll that close to the ground? Why the descent far below minimums in dense ground fog? Why the impossible attempt to land in pitch blackness on an unlit private strip? When you find a magneto that came apart, a broken master rod or a pilot who very probably died of heart failure in flight, it’s almost a relief. But these are rare; in 28 years I could count the true “mechanicals” or physical incapacitations on the fingers of one hand. Engines and pilots’ hearts are incredibly reliable.

Are the answers to the “why’s” found in lack of knowledge or skill, unfamiliarity with equipment, inexperience, bravado, fear or just rotten judgment? And I can’t help but ask “But didn’t somebody see it coming?”