The NTSB is well known for its crash investigations, and just about everyone you meet is familiar with the dark blue NTSB windbreakers with bold yellow lettering that seem to swarm over an accident site.
The Office of Aviation Safety, Major Investigations Division (AS-10) is home to seven Investigators-in-Charge (IICs) for major aviation accidents. They are the lead investigator for major aviation accidents and incidents. But, you might not be as familiar with the role they often play in accidents outside the US. On average about 75% of the accidents and incidents that AS-10 investigators work on are non-US events. In fact, one of our investigators does nothing BUT accidents throughout the continent of Africa!
A “day in the life” of a foreign accident launch and investigation is not something most people get a look at, so we thought we’d let Bill English, one of the AS-10 IICs, provide you a look behind the curtain of one of our recent major overseas accident investigations.
On September 3, 2010, following a reported cargo fire, a Boeing 747-400 freighter, operated by UPS as Flight 6, crashed after attempting to turn back to Dubai Airport, United Arab Emirates (UAE). The accident is still an open investigation by the UAE, so the probable cause and findings have not been determined. However, I can tell the story of how we worked with the UAE accident investigators to set up the investigation and all of the follow up activity.
The NTSB’s first notification of the accident was a call from the FBI located in UAE, who called our liaison in the Office of Transportation Disaster Assistance reporting they heard of a “plane down.” The initial word was that it was an MD-11 airplane. Interesting – I had just returned from another MD-11 accident in Saudi Arabia when I received the call. The initial information started to come in and we soon found the airplane was actually a 747. We knew right away that this would have a lot of NTSB and other US involvement, since the International Civil Aviation Organization (ICAO) Annex 13 procedures provide for participation by the State of the Operator and State of Manufacture in an investigation. UPS and Boeing are both US entities of course, so we immediately started assembling our team. As a point of clarification, in these foreign investigations, my role is not as the IIC but rather as the, "U.S. accredited representative," representing the U.S. Governments participation in the investigation and overseeing al U.S. entities that serve as technical advisors needed to support the investigation.
The image that probably comes to mind for many members of the public when they think of an accident launch is something like firemen sliding down a pole – directly into the FAA jet. Sorry, not even close. When travelling overseas, we often need to obtain visas to enter the host country, arrange transportation to sometimes out of the way places, and coordinate with the State Department and other agencies for security and notification. In this case, the notification was on a Friday afternoon of Labor Day weekend, when people had started to scatter to the “four winds,” for the long holiday weekend. To make matters even more complicated, Friday is the weekend in UAE, and a tropical storm was impacting their east coast!!
Thanks to an enormous amount of teamwork within NTSB headquarters, and our counterparts at the Department of State, the FBI, and all the parties involved, our team had visas in hand by Saturday afternoon, in enough time to board a plane headed for Dubai Saturday evening.
Our team consisted of an Accredited Representative, who in this case was me (The IIC for oversees accidents come from the State of occurrence), and four NTSB subject matter specialists – in operations, human factors, systems, and fire. Additionally, the launch team included an FAA representative and another dozen or so people from UPS, Boeing, and the Independent Pilot’s Association. We also sent an investigator to UPS’s headquarters in Louisville, Kentucky to examine the maintenance records. Of course, that was just the Go- Team. We had dozens of folks here at NTSB and advisors across the U.S. ready to assist over the holiday weekend.
We arrived in Dubai late at night and rose the next morning to see an incredibly destructive accident scene. The airplane had experienced a cargo fire that rapidly spread through the airplane, creating so much thick smoke that the crew could not see their instruments. The airplane impact area, on a small Army post, burned for 24 hours, almost completely destroying one of the world’s largest airplanes. By the time we arrived, the UAE investigators had located the airplane’s cockpit voice recorder (CVR), but had not yet found the flight data recorder (FDR). That’s always one of the first steps in “eating the elephant” so after some initial orientation, we started to systematically grid the accident site to document everything, and find that FDR!!
Did I mention that the accident site was about 120 degrees Fahrenheit, on blackened desert sand? It was also during the month of Ramadan, when Muslim observants don’t eat or drink between sunup and sundown, and it is considered somewhat rude for non-Muslims to eat or drink in front of observant. Such ideal conditions for an accident investigation!
During the next nine days, we performed intensive on-scene work, including wreckage documentation, ATC investigation, and examination of cargo loading. Oh, and we found the FDR. We were supported by technical groups back in the U.S. who provided us with information from the recorders that were downloaded in the NTSB lab in DC, cargo information from UPS in Louisville, and technical support information about the airplane from Boeing in Seattle.
The work hasn’t stopped there, though – in fact, it pretty much never stopped. Our U.S. team, in concert with the UAE, has been conducting numerous studies, test flights, interviews and aircraft examinations to try and understand what has come to be known as one of the worst cargo aircraft accidents in recent memory. When we finally get to the bottom of this accident, it will be due to the cooperation and teamwork of dozens, if not hundreds, of dedicated investigators stretching from Dubai to DC, to Seattle, to Louisville, to New Jersey, to China and Hong Kong. It is truly a worldwide effort by people committed to making aviation much safer everywhere in the world.