1. What Happens When The Phone Rings? What Happens When The Phone Rings? Why do we investigate accidents? How is it done?

2. Certified aircraft manufacturers are required to have trained personnel ready to respond to their aircraft accidents 24/7

3. The recurring questions: Why did this accident occur? What can we do to keep this kind of accident from occurring again?

4. The NTSB National Transportation Safety Board Investigates the accident Writes the report Responsible for accident site security / safety Determines “Probable Cause” Makes recommendations

5. FAA Regulatory Agency Administrative / Enforcement FAA is “party” to ALL NTSB aviation accident investigations

6. Congressional Mandate: The aircraft manufacturer The engine manufacturer ALPA May have NTSB investigation “party” status

7. How is the NTSB able to form an effective team on short notice? Professionalism Dedication Mutual respect Reputation

8. Effective accident investigation is all about Relationships

9. ASI Skill Sets: Accident investigation is a craft which must be developed: Mentoring and training On the job experience Schools and workshops Good communication, written and technical skills Common sense! (A “sixth sense”) Integrity Dedication Flexibility Be able to “visualize” what happened Be able to understand what happened, and why Requires exceptional people skills

10. Challenges all investigators face at the accident site: A changing chain of command The wreckage may be located at any number of places, terrain, or climates Many pieces may be missing Or may be in a condition that makes them impossible to recognize

11. ASI’s must be able to deal with: The pure horror of it all, sensory overload Politics The M E D I A “Inconvenience” A strong sense of humor helps! Must have compassion

12. The 4 Phases of an Aircraft Accident: Rescue Phase Investigation Phase Recovery Phase Legal Phase

13. Rescue Phase

14. Investigation phase

15. What happens when the phone rings? “The Call” can come from anyone, any time The manufacturer may be asked to provide a qualified ASI to assist the NTSB The investigator on call has to Be prepared to go anywhere, any time Medical, passport, “GO” Bag

16. Verify the Occurrence Ask: what, where, when, etc. Request “Party Status” from the NTSB Brief company internal team The Internal team works their contacts THE ASI LAUNCHES TO THE SITE ASAP!

17. The well-dressed ASI

18. Is it an Accident or Incident or neither?

19. At The Site Secure the site Preserve evidence Be aware of the hazards which may be present

23. First Day on Site The NTSB IIC meets with the “parties”: Provides most recent information Reviews rules, restrictions, expectations Explains how the investigation will proceed Assignments are made TIME IS SHORT!

24. Work the plan What Are The Priorities? Determine the condition of CAPS and AAIR Walk the site; note energy path, direction Contingency photos Lay the wreckage out, if possible Inventory the “four corners” of the aircraft Detailed notes

27. Document the wreckage before moving it Sketches are good Digital and / or videos are better Line objects up with a prominent landmark Use multiple angles

28. Many aircraft don’t have FDR’s or CVR’s We have to figure it out the old fashioned way

30. US Aircraft registration number

32. Models can be helpful for interviews

33. End of Day Wrap up Meeting Review what we have learned Review what is still missing Work out plan for the next day (can take several days)

35. Myths: The plane always blows up or burns The engine always sputters and quits before impact The PIC was the best pilot, ever One person always solves the mystery

36. “Black Boxes” aren’t black

37. Recovery Phase

38. The aircraft may have to be moved again Component testing, measurements Review of facts; summary from each ASI

39. You may have to build a road to get to it!

40. Or transport the wreckage to a STORAGE FACILITY

41. Wreckage Lay-out

42. When the ASI Returns from the accident site: The company ASI briefs senior management The NTSB investigation continues NTSB Investigation “Parties” share data The company ASI sends his preliminary report to NTSB IIC Company Investigation / report writing begins More travel for various inspections

43. Forensic Examinations INVESTIGATORS LOOK AT EVERYTHING! Engine tear down inspection Auto Pilot Fuel System MCU Structure Landing gear Avionics etc

44. Engine Tear Down Inspection at TCM

46. Inspecting The Engine Case

47. Testing Spark Plugs / Magnetos

48. MCU Examination

49. Initial report schedule and sequence: FAA Preliminary report on web: www.faa.gov Within 1-3 days, removed in 10 days NTSB Preliminary on web: www.ntsb.govwww.ntsb.gov (Aviation) Within 1-10 days

50. Final NTSB Reports on the web and the public docket NTSB Factual: +/- 6 months NTSB Final: ? days – 2 years + Contains the NTSB’s “Probable Cause” The NTSB may choose to conduct a public hearing But always on the web: www.ntsb.govwww.ntsb.gov – (Aviation)

51. The company will conduct an Internal review of specific accidents Critical personnel attend Each company has its own review process

52. Typical Company Accident Report

53. Legal Phase Requests for production of documents Wreckage inspections Depositions Component testing Can take years……………..

54. Wreckage Inspection

55. Wreckage Layout (again)

56. Let’s keep the shinny side UP!

57. Mike Busch Buschaeroworks@gmail.com (218) 390 0318 3/31/09 Buschaeroworks@gmail.com