Robert L. Sumwalt, III
I’d like to ask a question that I’d like for you to think about – not just in the next few minutes – but over the next several weeks, as well. The question is: Are you prepared to interact with NTSB in the wake of an accident?
Generally speaking, an emergency response plan should have at least three elements. One is how the organization deals with the accident from an internal and public relations perspective. Another aspect of the plan pertains to dealing with families and victims. And, finally, the plan should address how to interact with the NTSB.
I suspect many companies are fairly well-equipped to deal with the first two of these components. But, based on my experience in going to accidents, is that many organizations don’t have a good idea of how to deal with the NTSB after an accident.
What I to do is stimulate some thinking along these lines so that you can be better prepared.
First, let me give you some background. If there is an accident involving fatalities, or if it otherwise a high-profile crash, we will likely send a board member.
I have been on about twelve accident launches as a Board Member and when I do, I often read in the paper that “Member Sumwalt is leading the investigation."
This is a misconception.
Board Members are not accident investigators. We do not lead the investigations; we have expert staff who handle that.
A Board Member's job on an accident is to serve as the public face of the investigation. We serve as a liaison between investigators, the family members, and news media.
Whenever there is a transportation accident in this country, the public needs to be assured that the government is conducting an honest, competent, transparent, thorough, and independent investigation. That is what the Board Member is there to do. We are responsible for doing press conferences, meeting with the family members, and being a public face for the accident investigation.
What many people find interesting is that when I leave an accident, I typically won't see that accident again until the investigators have completed their investigation, drafted the report, and are ready to present it to the Board Members. I make it a point not to get involved and go poking around in the day-to-day goings on of that investigation.
And, why? Because Board Members are here to provide oversight of the staff’s products. It is difficult to provide oversight of something that you’ve been involved with because you tend to lose your objectivity. So that’s why it is important for us to resist the temptation of staying involved in the active investigations.
About a month before the Board Meeting, staff provides the draft report to the Board Members.
During that four week period, I will read the report the first time, cover-to- cover. I’m just trying to take it all in and get a general understanding of the accident and the issues associated with it. I look for disconnects in logic and areas where I think the report can be strengthened. Then I will have a one-on-one meeting with the investigative staff to ask questions and discuss concerns. I may also suggest minor editorial changes at this time. If I have serious changes or concerns about the report, I will write a memo. These memos may address my suggested changes to findings, the probable cause, or recommendations. I will also copy my Board Member colleagues so they will know my areas of interest and concern. Once staff replies, they perhaps make changes to the report or explain why they did not. I then read the report again, up to three times, if needed. I review the public docket and read all party submissions.
As former Board Member John Lauber once told me, "I want to know everything I can to get ready for a Board Meeting. It's like getting ready for a type rating oral." As a pilot, I can relate to what it’s like to get ready for a checkride or an oral exam.
Many people are surprised to learn that Board Members don’t get together as a group and discuss accidents before Board Meetings. We can’t, due to the Government in the Sunshine Act, which states that Board Members cannot have a quorum and discuss agency business outside of a publically announced meeting. Our statutory quorum is three Board Members, so this means that no more than two Board Members can get together at the same time to discuss the upcoming Board Meeting.
To summarize, Board Members don't lead the investigation. We have technically qualified experts who do that, and they do it quite well.
The Board Members are there to provide a public face for the accident investigation and oversight of staff's product once it is presented to the Board for a Board Meeting. We can’t maintain impartiality if we are involved in the actual accident investigation process.
Now, I would like to discuss some “take home” points which relate to your accident preparedness.
First, the NTSB can designate party status to those organizations that can provide technical expertise to the investigation. Parties to an aviation accident would be FAA (by statute) and could include the operator; the airframe, engine, and major component manufacturers; pilot, air traffic controller, maintenance, and flight attendant unions; airport authorities; first responders; and anyone else the Investigator-in-Charge (IIC) deems can provide technical assistance to the investigation. I would encourage you to seek party status and you do this with a request to the IIC. Why would you want to be a party to the investigation? Well, from our perspective, you provide the NTSB with technical expertise that we may need. When piecing an airplane back together, who better can recognize the aircraft parts than those who designed and manufactured them? Who knows an company’s procedures better than the pilots who fly for that company? Who has better access to training records than the company that employed the pilots?
Another benefit is the ability to get immediate corrective action when problems are noted during the investigation. Two years ago today, I was in Yuma, Arizona, after a Southwest Airlines 737 had approximately six feet of the fuselage open up in-flight. While in Yuma, some anomalies were noted - anomalies that could be traced back to the manufacturing of the aircraft. Boeing was a party to the investigation. We all arrived in Yuma on a Saturday - the day after the event - and those manufacturing anomalies were noted that day. Boeing started immediately on determining a corrective action. The next day, Boeing issued a Service Bulletin, and the following day, FAA issued an Airworthiness Directive. If Boeing and FAA were not parties to the investigation, I dare say things could not have happened this quickly.
Finally, I think a party system ensures transparency. By having the manufacturer watching over the shoulders of the FAA, and the pilots' union watching over the manufacturer, and everyone watching the NTSB, it provides checks and balances that everything is being looked at - that no stone is being left unturned.
Party status is a privilege and not a right, and as such, it can be revoked. On rare occasions, we have removed party status. We may do this when a party doesn't follow our rules, the directions of the NTSB IIC, or otherwise takes actions that could be prejudicial to the investigation. Our rules aren't difficult, but they do require a clear understanding of them. So, my suggestion is learn our rules before an accident - it's obviously a lot easier to learn when you are not in the "heat of the battle," so to speak. And, once called into action, make sure you abide by our rules.
Second, as a party member, you are entitled to make a party submission to express your views on the facts, analysis, probable cause, and recommendations. Remember, my job is to provide oversight over our staff's product. I'm not there to defend the staff’s product. I'm there to ask tough questions so that when I do vote on the accident report, I feel comfortable that I know all of the pertinent issues.
I only learn what staff tells me, unless I get into the public docket and read your party submissions. Your submissions are a valuable part of a Board Member's information gathering process and it is your opportunity to provide your perspective of the facts, findings, probable cause, and recommendations.
Third, meet with the Board Members before the accident. Most people aren't even aware that they can do that. And, concerning the timing of these meetings, each Board Member has their own preference but for me, I prefer meeting close to the Board Meeting date.
Some parties want to come in months before the Board Meeting. For me, that doesn’t work as well as when the party comes in right before the Board Meeting. If we meet too early in the process, I likely am not that familiar with the accident. I’d prefer to have you come in just a few days before the Board Meeting because by then, I’ve read the draft report, I’ve met with staff, I’ve written my memo, and formed opinions on the issues. I have gone through the docket, read your party submission, and can therefore, ask questions about it.
So, in summary, become a party to the investigation, make a party submission, and do what most others don’t do - meet with Board Members.
The NTSB has a plaque outside its Training Center that states, "From tragedy we draw knowledge to improve the safety of us all."
That's what we do at the NTSB - we try to take something tragic and learn from it so that others don't have to suffer the same consequences.
The agency has been doing this for 46 years, and we generally do pretty well at it. Sometimes, in spite of trying to do our best, we miss something. And this leads to my fourth “take home” point; we have provisions for Petition for Reconsideration. The statute allows that if you have new information that may be relevant to the investigation or if there is erroneous information, a party may file a Petition for Reconsideration.
We do review those and in some cases, the petition is granted in whole or in part. Please keep this in mind.
Thank you and I hope this information is helpful in your preparing for an accident.
Good luck and I hope we don't have to meet professionally.