Safety in the skies : personnel and parties in NTSB aviation accident investigations : master volume

CONTENTS THE INSTITUTE FOR CIVIL JUSTICE ............................... iii BOARD OF OVERSEERS ............................................. iv CONTENTS ........................................................ v FIGURES ........................................................ ix TABLES ......................................................... xi PREFACE ...................................................... xiii ACKNOWLEDGMENTS .............................................. xvii ABBREVIATIONS ................................................. xxi SUMMARY ....................................................... xxv CHAPTER 1: INTRODUCTION ......................................... 1 A NATIONAL FOCUS ON AIR SAFETY ............................... 2 THE ROLE OF THE NTSB IN AVIATION SAFETY ...................... 4 OBJECTIVES OF THE STUDY ...................................... 6 RESEARCH APPROACH ............................................ 9 CHAPTER 2: THE NTSB’S ROLE IN AVIATION ACCIDENT INVESTIGATION AND NTSB’S OPERATIONAL BASELINE ................................ 13 INVESTIGATING A MAJOR COMMERCIAL AVIATION ACCIDENT .......... 13 The Party Process ........................................ 16 The Team Approach ........................................ 18 PUBLIC HEARINGS AND ACCIDENT REPORT PREPARATION ............. 19 Follow-Up Activities ..................................... 20 Notation Draft and Board Meeting ......................... 22 INTERNATIONAL ACCIDENT INVESTIGATIONS ....................... 23 NTSB OPERATIONAL BASELINE ................................... 25 Operating Budget ......................................... 26 Staff Overview ........................................... 28 Accident History ......................................... 29 CHAPTER 3: EMERGING AVIATION TRENDS: POTENTIAL IMPACT ON AIRCRAFT ACCIDENT INVESTIGATIONS ............................ 37 IMPROVING THE SAFETY AND EFFICIENCY OF AVIATION ............. 37 National Aviation Safety Goals ........................... 39 The Safety Research Agenda ............................... 42 Accelerated Introduction of New Safety Technology ........ 43 GROWING COMPLEXITY IN AVIATION: IMPLICATIONS FOR THE NTSB ... 49 Increasing Reliability of Aircraft and Ground Systems .... 50 Design-Related Accidents: A Growing Danger ............... 51 NTSB Will Need New Investigative Methods ................. 55 THE CHANGING COMPOSITION OF THE TRANSPORT FLEET ............. 61 Diversity of Aircraft Types and Systems .................. 62 Larger Aircraft with Higher Passenger Densities .......... 63 The Aging Fleet .......................................... 65 - vi - TRENDS IN GENERAL AVIATION .................................. 73 NEW USERS OF THE NATIONAL AIRSPACE SYSTEM ................... 78 CHAPTER 4: AIRCRASH LITIGATION: THE LIABILITY ENVIRONMENT IN WHICH THE NTSB OPERATES ..................................... 81 CHARACTERISTICS OF AIR CRASH LITIGATION ..................... 82 THE CHANGING FACE OF AVIATION LITIGATION .................... 85 Fewer Early Settlements .................................. 86 Fact-Finding Through Litigation .......................... 87 Contested Liability ...................................... 88 Escalating Jury Awards and Insurance Settlements ......... 88 The Use of NTSB Materials in Civil Litigation ............ 89 NTSB Reports Are “Roadmaps to Liability” ................. 97 EVALUATING THE PARTY PROCESS ................................ 99 The Role of Parties ...................................... 99 The Role of Parties in Fact-Finding ..................... 103 Family Representation in Investigations ................. 105 Proposals to Extend the Parties’ Role to the Analysis Phase of the Investigation .............................. 109 Enhancing the Party Process ............................. 111 DETERMINING PROBABLE CAUSE ................................. 113 The Primacy of the Probable Cause Finding ............... 120 Restructuring the Probable Cause Finding ................ 126 CHAPTER 5: STAFFING, WORKLOAD, AND TRAINING AT THE NTSB ....... 131 STAFFING ................................................... 132 Characteristics of the Workforce ........................ 133 Salary Comparisons with Industry ........................ 142 WORKLOAD ................................................... 146 Aggregate Workloads ..................................... 146 Trends in Overtime Payments ............................. 151 Headquarters Investigative Activities ................... 152 Regional Investigative Activities ....................... 155 How NTSB Personnel Spend Their Work Time ................ 158 TRAINING ................................................... 161 Rationale for Training .................................. 163 Amount of Training ...................................... 167 Sources of Training ..................................... 173 Administration of the Training Process .................. 177 Training Content ........................................ 179 CHAPTER 6: IMPROVING NTSB INVESTIGATIVE AND OPERATIONAL PROCESSES ..................................................... 185 INSUFFICIENT ATTENTION TO AIRCRAFT INCIDENTS ............... 188 MANAGING INFORMATION AT THE NTSB ........................... 196 Control and Management of Information Is Decentralized .. 196 More Attention to Database Management Is Needed ......... 200 Insularity Inhibits Exploration of Alternatives ......... 203 Rapid Access to Outside Knowledge Would Assist Investigations .......................................... 205 ACCIDENT INVESTIGATION AND REPORTING PROCESSES ............. 209 Final Report Preparation Process Should Be Streamlined .. 209 - vii - Tension over NTSB Findings and Recommendations Will Likely Increase ................................................ 217 Future Accidents May Challenge NTSB Investigative Methods 221 Inadequate Testing Facilities Undermine NTSB Independence ............................................ 229 LACK OF COST ACCOUNTING DATA INHIBITS MANAGEMENT OF INVESTIGATIVE RESOURCES .................................... 233 CHAPTER 7: CONCLUSIONS AND RECOMMENDATIONS .................... 237 CONCLUSIONS ................................................ 237 RECOMMENDATIONS ............................................ 239 Strengthen the Party Process ............................ 240 Create a More Expansive Statement of Causation .......... 241 Modernize Investigative Procedures ...................... 241 Streamline Internal Operating Procedures ................ 243 Better Manage Resources ................................. 245 Maintain a Strategic View of Staffing ................... 245 Streamline Training Practices ........................... 246 Improve Facilities for Engineering and Training ......... 248 APPENDIX A: HISTORY AND STRUCTURE OF THE NTSB ................. 251 NTSB HISTORY AND STATUTORY AUTHORITY ....................... 251 ORGANIZATION OF THE NTSB ................................... 257 FAMILY ASSISTANCE AND THE OFFICE OF FAMILY AFFAIRS ......... 263 APPENDIX B: DATA ANOMALIES AND BASELINE ACCIDENT DATA ......... 265 APPENDIX C: NTSB “PARTY PLEDGE” ............................... 269 APPENDIX D: RESULTS FROM RAND SKILLS AND EXPERIENCE QUESTIONNAIRE ...................................... 271 SAMPLE ..................................................... 271 ADMINISTRATION ............................................. 271 RESPONSE RATES ............................................. 272 APPLICABILITY OF THE RESPONSES ............................. 273 DESCRIPTION OF THE SURVEY .................................. 274 ACCURACY OF SELF-REPORTED WORKWEEKS ........................ 275 STATISTICAL COMPARISONS OF SUBSETS OF RESPONDENTS .......... 277 STAFFING AND WORKWEEK RESULTS .............................. 277 Total Professional Experience of OAS Members and Other Respondents ............................................. 277 Ages of NTSB Technical Staff Members .................... 277 Workweeks of NTSB Technical Staff Members ............... 277 Differences in Workweeks by Experience Level ............ 279 Percentage of Time Spent Answering Public Inquiries ..... 279 TRAINING AT NTSB ........................................... 280 Percentage of Time Spent Training ....................... 280 Years of Experience at the NTSB in Relation to Training . 280 Effect of Workload on Training .......................... 281 APPENDIX E: RAND SKILLS AND EXPERIENCE QUESTIONNAIRE .......... 283 APPENDIX F: CASE STUDY ABSTRACTS .............................. 295 COMAIR FLIGHT 3272 ......................................... 295 DELTA FLIGHT 554 ........................................... 296 - viii - SIMMONS FLIGHT 4184 ........................................ 296 TWA FLIGHT 800 ............................................. 296 USAIR FLIGHT 427 ........................................... 297 VALUJET FLIGHT 592 ......................................... 297 BIBLIOGRAPHY .................................................. 299