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Launched Aug 26 1996.
I don't know whether to post this here or in the editorial section of the site, so I put it both places.
INTRODUCTION TO SET
This set of documents compares an NTSB investigation with a subsequent investigation by others related to litigation. The NTSB reported that the crew became disoriented during a training maneuver, and essentially said that crew behavior and lack of management oversight of its training program caused the accident. The Petition for Reconsideration, on the other hand, argues that the aircraft engine broke off the aircraft in flight, making it unflyable.
Who is right? Read the reports and try to decide for yourself.
POINTS TO PONDER
After reading the reports, here are some points to ponder and comment on, but please, from an investigation process research perspective - No ad hominum attacks. Click on the FORUMS in the menu bar to submit your comments.
The NTSB had posted the following information about NYC/92A053 at its web site:
THE PURPOSE OF THE FLIGHT WAS TO PREPARE TWO FIRST OFFICERS FOR A CAPTAIN UPGRADE FLIGHT. THE INSTRUCTOR PILOT DISABLED THE STUDENT'S ATTITUDE INDICATOR DURING FLIGHT, AND THE STUDENT HAD DIFFICULTY MAINTAINING AIRPLANE CONTROL. DURING A SIMULATED INSTRUMENT APPROACH, WHILE IN THE PROCEDURE TURN, THE INSTRUCTOR SIMULATED AN ENGINE FAILURE IN ADDITION TO THE ATTITUDE INDICATOR FAILURE. THE STUDENT ASKED THE INSTRUCTOR TO TAKE CONTROL OF THE AIRPLANE BECAUSE HE BECAME DISORIENTED, HOWEVER, THE INSTRUCTOR REFUSED. THE INVESTIGATION REVEALED THAT THE INSTRUCTOR WOULD TURN HIS OWN FLIGHT INSTRUMENT LIGHTS TO THE "DIM" POSITION WHEN THE STUDENT WAS FLYING SO THAT HE COULD NOT "PEEK" AT THE OPERABLE ATTITUDE INDICATOR. EXAMINATION OF THE WRECKAGE REVEALED THAT THE INSTRUCTOR'S LIGHT RHEOSTAT WAS IN THE DIM POSITION. THE ACCIDENT OCCURRED OVER THE OCEAN, ON A MOONLESS NIGHT. NEITHER THE OPERATOR, NOR THE FAA WERE AWARE THAT THIS INSTRUCTOR WAS USING BLOCK ISLAND FOR TRAINING, OR WHAT TRAINING METHODS HE WAS EMPLOYING.
THE INSTRUCTOR PILOT'S LOSS OF ALTITUDE AWARENESS AND POSSIBLE SPATIAL DISORIENTATION, WHICH RESULTED IN THE LOSS OF CONTROL OF THE AIRPLANE AT AN ALTITUDE TOO LOW FOR RECOVERY; AND COMPANY MANAGEMENT'S LACK OF INVOLVEMENT IN AND OVERSIGHT OF ITS BEECHCRAFT 1900 FLIGHT TRAINING PROGRAM. CONTRIBUTING TO THE ACCIDENT WAS THE INSTRUCTOR PILOT'S EXERCISE OF POOR JUDGMENT IN ESTABLISHING A FLIGHT SITUATION AND AIRPLANE CONFIGURATION CONDUCIVE TO SPATIAL DISORIENTATION THAT AFFORDED THE PILOTS LITTLE OR NO MARGIN FOR ERROR.
The NTSB findings have been disseminated for 7 years as the truth. For example, doing a quick search for N811BE on the Internet, I found the NTSB version repeated by well meaning people at
During that time, the focus of public prevention efforts has been crew behavior, pilot training and management oversight of training..
Has anyone ever pondered the consequences of whose investigation produced the truth when investigation results conflict?Some consequences are suggested in the hazardous iceberg displayed at www.iprr.org/Editorials/Editorial.html
The delays in closure of the accident investigation project is demonstrated by this case, with impacts already discussed. The delays cost money. Petitions for reconsideration take time and money. Responding to Petitions poses demands on NTSB staff. What ways might be available to reduce the delays in closure for all concerned, and produce outputs that are not contentious?
Another aspect of this issue is the missed opportunity to improve investigation processes. The NTSB has its traditional investigation processes and experience base, which have been challenged in the recent Rand study.. If it turns out that the NTSB was wrong, one may wonder, also, whether the entry of the NTSB into this accident investigation may have delayed the introduction of new thinking about investigating what actually happened and why it happened, as with the work with the data recorders. Maybe competition could be productive.
Another aspect of this discussion is the role of the internet in exposing and accelerating discussion of the differences such as those encountered here. But that's for another day.
Comments are invited. The cost of errors is real. There is a problem.
Ludwig Benner, Jr.
PS In case it is not apparent, I am inclined to view the Petitioners report as more persuasive because the amount of value-free data and logic presented.
While searching the internet, I also found the following: