(Reprint of Aviation Week and Space Technology's
Editorial of May 15, 2000, page 66)

EDITORIAL

The mission of the independent U.S. National Transportation Safety Board is, first, to investigate an accident and determine the probable cause (or causes). Then, its job is to propose changes to aircraft design, maintenance or operational procedures, air traffic control, management oversight or other factors that led to the accident.

In essence, the goal of NTSB investigations is to identify problems so they won't happen again. Laying blame is not the point. It may, of course, be a by-product of any accident investigation, but that is not the board's objective.

NTSB Chairman James Hall has visited the U.S. Attorney General's Office in Washington many times to discourage prosecutors from attempting to find criminal fault while the board industry and pilot organizations are still trying to determine the cause of an accident. Hall and others contend that if blame or threat of litigation is allowed to move to the fore, people will be afraid to talk to accident investigators. And that will hinder the fact-finding that is aimed at preventing similar crashes. Hall is worried that the lawyers are getting out of hand. He cites the recent prosecutions of SabreTech employees in Miami following the 1996 crash of ValuJet Flight 592, saying the case may prove to be an impediment to accident investigations in the future.

However, I strongly believe the failure of SabreTech employees to put caps on oxygen generators constituted willful negligence that led to the killing of 110 passengers and crew. Prosecutors were right to bring charges. There has to be some fear that not doing one's job correctly could lead to prosecution. Aviation is not and should not be exempt from legal due process.

Who would suggest there is no wrongdoing when a mechanic signs a card indicating an inspection has been performed, when he knows it was not? How should we treat two pilots who make a very hard, three-bounce landing in a Boeing 757 and fail to write it up in the maintenance log? Do we shrug that off when structural damage is discovered two landings later? I would hope the airline took disciplinary action in the case of the two pilots, and conducted some walk-around inspection training for others.

There has to be a balance in aircraft crash investigations between safety requirements and needs, and justified criminal or disciplinary actions. After all, deterring illegal actions can forestall some types of repeat accidents, too. One prime example was the crash of a Pan American 707-321 C at Boston's Logan International Airport in November 1973. There was a fire on board the cargo aircraft, which crashed during an attempted emergency landing. It was found that 16,000 lb. of hazardous chemicals had been misidentified, incorrectly packed and improperly loaded onto the aircraft. The safety board identified the accident cause, and indictments were brought against the airline and the chemical and shipping companies. This accident was the foundation for many of the regulations in effect today to govern hazardous materials.

I believe Hall's intentions in approaching prosecutors are good, but any meeting of the minds between the NTSB and U.S. attorneys should not be codified into new laws and regulations. The current system of accident inquiries has functioned well, with investigators and lawyers working in parallel. It is often more difficult for NTSB investigators to ignore lawyers chasing potentially large claims as the result of an accident. And one would hope that attorneys representing the survivors of an accident would not get in the way of a safety investigation. But the an- is not to preclude prosecutors and civilian lawyers from bringing criminal charges or filing suits

At some point, the legal world may start to interfere with the overarching goal of improving safety. If the blame game does get out of hand, one solution might be for the safety board to follow the same procedures as used in U.S. military aircraft accidents. A military accident board investigates a crash, then comes up with the cause and says what should be done to prevent a recurrence. The military judicial system then follows up when blame is a factor and investigates the accident and human factors. But it does not use the information gathered by the accident board.

For now, though, the safety board should not overreact to the ValuJet criminal prosecutions and upset the balance of safety and blame. This would be unfortunate because the NTSB and judicial system have all of the necessary tools to help aviation safety, if they use them with wisdom.

David M. North
Editor-In-Chief

AVIATION WEEK & SPACE TECHNOLOGY
May 15, 2000 / page 66