“Independent Aircraft Accident Investigation Agencies”
Good morning. I applaud the efforts of the Air Accident Investigation Bureau of Singapore and the Singapore Aviation Academy for organizing this conference – one where in attendance we have key representatives from accident investigation authorities throughout the world.
This morning I will discuss the NTSB’s views of independent aircraft accident investigation agencies.
Let’s start by referring to ICAO Annex 13, paragraph 5.4, which says: “The accident investigation authority shall have independence in the conduct of the investigation and have unrestricted authority over its conduct.”
When I testified to the US Senate at my confirmation hearing, I highlighted that our transportation systems are vital to our national economy and well-being. And I said that although these transportation systems generally perform very well, w hen transportation accidents do occur, it is imperative that we be able to reassure the traveling public that the government is conducting honest, competent, timely, thorough, and unbiased investigations.
I believe the way we have achieved that in the United States is by having a truly independent accident investigation agency.
We have been investigating accidents for a long time in the US. We have likely made some mistakes over the years but we have learned from our mistakes to improve our processes. Let me give you a brief history of where we were, and how we got to where we are now.
I collect airmail from the 1920’s and early 30’s. What makes my collection unusual is that this airmail often didn’t make it to its destination because it was in a plane crash.
Here is one from 1926—notice that embossed on the letter are these words: “Mail delayed by accident at Mendota, Minnesota, in which pilot Elmer Lee Partridge was killed.” It is postmarked June 7, 1926.
The year 1926 is significant because it was that year that the US Congress passed the Air Commerce Act. This Act was in response to the high number of airmail and other plane crashes, and it charged the Department of Commerce with investigating the cause of accidents. One of the reasons this responsibility was given to the Department of Commerce was because many of these crashes involved airmail planes, and at the time, the Department of Commerce was charged with overseeing airmail.
In 1931 a Fokker F-10A operated by Transcontinental and Western Air (TWA) crashed in Kansas, killing all onboard including famed Notre Dame football coach, Knute Rockne. The nation was stunned. According to a paper presented to International Society of Air Safety Investigators (ISASI) in 2003 by Jeff Guzzetti and Brian Nicklas, “No attempt was made to secure the accident site, and souvenir hunters carted away anything that could be carried by hand, including the propellers and fuselage. [When investigators arrived the next day, all they found was two wings and three engines.] Three days later, the Aeronautics Branch of the Commerce Department in Washington, DC, issued a public statement that said the agency ‘assumed’ pieces of the propeller blade broke off and severed the wings. It also publicly speculated that a piece of ice had formed on one of the propeller hubs, broken lose, and struck the propeller blade.” A few days later, more inaccurate statements were released by government investigators and the investigation was overshadowed by the public perception of secrecy, incompetence and conspiracy.
In response, in 1934 the Air Commerce Act was amended to require that reports on probable causes of fatal aircraft crashes be made public.
The following year, a DC-2 crashed in Missouri, claiming five lives including a US Senator. Public debate and criticism over the cause of the crash demonstrated the need for an independent investigative body.
In 1940, the five member Civil Aeronautics Board (CAB) was organized and accident investigation duties were assumed by the newly formed CAB’s Bureau of Safety.
On June 30, 1956, a United Air Lines DC-7 and a TWA Lockheed Super Constellation collided over the Grand Canyon. At the time, it was the world’s largest aviation disaster. This accident brought tremendous pressure to bear to increase aviation safety and in 1958, the Federal Aviation Agency (now Federal Aviation Administration) was created to regulate aviation, control navigable airspace and develop and operate air navigation and air traffic control.
Although the FAA was charged with regulating aviation within the US, the accident investigation function was still performed by the CAB Bureau of Safety. This provided autonomy between the regulator and the investigator.
On April 1, 1967, the US Department of Transportation (DOT) was formed. Within DOT was the FAA and other transportation modes, such as the Federal Railroad Administration and the Federal Highway Administration. Also housed within DOT was the newly formed National Transportation Safety Board (NTSB). Our investigative authority had been expanded to include all modes of transportation.
Although the statute that formed the DOT stated that the NTSB would be an “independent government agency, located within the DOT, to promote transportation safety by conducting independent accident investigations,” some questioned how an agency could be truly independent if it was housed within another government agency. The mere perception that both the regulators and accident investigation authorities were within the same agency brought increased pressure to become totally independent.
Finally, in 1974, Congress passed the Independent Safety Board Act of 1974. The Act noted: “Proper conduct of the responsibilities assigned to this Board requires vigorous investigation of accidents involving transportation modes regulated by other agencies of government; demands continual review, appraisal, and assessment of the operating practices and regulations of all such agencies or its officials; and calls for the making of conclusions and recommendations that may be critical of or adverse to any such agency or its officials. No federal agency can perform such functions unless it is totally separate and independent from any other department, bureau, commission, or agency of the United States.” With that, the Safety Board became a truly independent agency, reporting directly to Congress.
In our 40 years, the NTSB has investigated over 128,000 accidents involving all modes of transportation, and over 118,0000 have involved aviation. We have issued over 12,500 safety recommendations, with an 82 percent acceptance rate.
Our independence is crucial. We call it the way we see it and we don’t pull any punches. We do not have regulatory authority. When we uncover a deficiency, we cannot enact a law or regulation to “fix’ the problem. We can only issue a safety recommendation to the appropriate organization and then see what happens. The big stick is that we track these recommendations and DOT agencies are required to report to Congress those recommendations that they haven’t implemented.
Here are just a few of the advantages of being independent.
- Top priority and focus remains exclusively on safety
- Not influenced by politics, media, self interest groups
- Public trust, integrity and credibility
- Acceptance by public
- Transparency – the ability to look inside and see what government is doing
- Investigations that actually accomplish their intended purpose – prevent future accidents
- A safer transportation system
How Independent are your Investigations?
- Is your investigation team able to release a report without the approval of another government official, body or agency?
- Is funding, staffing and operating authority for your investigations independent of political pressures and other influences?
- Are your investigations perceived by the public as being credible and impartial?
If you answered “no” to any of these questions, then perhaps you are not totally independent. If you did answer “no,” here is some guidance to provide a roadmap to achieving greater independence.
ICAO Doc 9756, Part 1 “Organizing and Planning,” Paragraph 2.1.2 says: “The accident investigation authority must be strictly objective and totally impartial and must also be perceived to be so. It should be established in such a way that it can withstand political or other interference or pressure. Many States have achieved this objective by setting up their accident investigation authority as an independent statutory body or by establishing an accident investigation organization that is separate from the civil aviation administration. In these States, the accident investigation authority reports direct to Congress, Parliament or a ministerial level of government.”
Regarding Legislation, ICAO 9756, Section 2.2 states: “Appropriate legislation should define rights and responsibilities of accident investigation authority. The investigative body should have immediate and unrestricted access to all relevant evidence without requiring prior consent from judicial bodies or other authorities. Accident investigation procedures should not be constrained by judicial processes, and national legislation and regulations should specify the procedures to keep these two functions independent. Legislation should clearly state that the sole purpose of the investigation is prevention, not to apportion blame or liability.”
Each country derives tremendous economic advantage from air commerce. So, when accidents occur within your country, you should have adequate funds to properly investigate them. This not just my opinion, but it is also the word of ICAO. “The accident investigation authority should have ready access to sufficient funds to enable it to properly investigate those accidents and incidents that fall within its area of responsibility,” (ICAO Document 9756, Section 2.3.)
The NTSB has relied on the above-mentioned ICAO guidance, and we have also relied heavily on our independence from the Independent Safety Board Act of 1974. Also important is the Freedom of Information Act, which, while not limited to accident investigation, says that many government documents must be available for release to the public. Also important is the Government in the Sunshine Act of 1976, which requires multi-member federal agencies such at the NTSB, to conduct much of our business “in the sunshine,” or in other words, in front of the public. All of our meetings are publicly announced in advance and they are open to the public.
We have a web site that provides public access to all aviation accidents since 1962, recent full accident reports and safety studies, annual summaries of aviation accident data, and a searchable database of NTSB opinions and orders. Live webcasts of Board meetings and public hearings are also available.
Each of our five Board Members are appointed by the President, with the advice and consent of the Senate. And to ensure that no political influence is exerted – real or perceived – no more than three members can be from the same political party.
And although not directly a function of independence, we utilize a party system, whereby we allow technically qualified industry, government and union representatives to participate in our investigations. We have gained tremendous advantage from this system and no doubt, the parties contribute greatly to our ability to successfully complete our investigations. And while the parties share our goal of finding what happened so that it can be prevented, they are also interested in ensuring that their represented interests are getting a fair shake. For example, in the process of the unions looking over the shoulder of the manufacturer and vice versa, and the manufacturer looking over the shoulder of the FAA and so forth, no stone is left unturned.
We all seek credibility, but how do we achieve it? Credibility is built with independence. The point I want you to take home with you is this: Low independence equals low credibility; High independence equals high credibility.
There are challenges to independence, including special interests groups, public and political pressures, Internet blogs and 24-hour news services. But, like other things in life, things worth achieving are worth working for.
An independent accident investigation builds trust, credibility – and most importantly – will serve to improve transportation safety within your country.
Do you have independent investigations?
The NTSB stands ready to provide you with additional information to assist you in establishing independent investigations.
Thank you very much.