As I write, many long-time aviation accident investigators like myself are reeling from the events of the last few days and weeks. Two tragic airline crashes with significant loss of life just a few months apart in brand-new aircraft are, of course, tremendously concerning. Usually, aviation experts quickly and methodically tackle the investigations of the accidents to determine what occurred and how to prevent it from occurring in the future.
That did not happen after the crash of Ethiopian Airlines Flight ET302 that followed five months after the Lion Air Flight 610. A breakdown in the normally orderly process of accident crash investigation was taking place before our eyes, along with an apparent dismantling of the usual cooperation among those crash investigators from around the world. Not only did China and other countries ground the Boeing 737 Max with seemingly little or no coordination with the U.S.—the country that issued the aircraft its type certificate—but it also did so with little analysis, or at least transparency, of the reasons for its grounding.
Other norms—such as securing the accident site—also seemed to have fallen by the wayside with reports of extensive looting before crash investigators could arrive. The importance of the on-scene investigation cannot be overstated since important clues can oftentimes be found in the wreckage itself or even in the wreckage pattern.
It was also troubling to see how long it took for the black boxes—once they were retrieved—to be sent for analysis. Although I understand the hesitancy in sending them to the U.S. because of its relationship to Boeing, it is disturbing nonetheless that it took so long to find a country willing and able to do the analysis. And that it still took several days for the recorders to actually be sent. Of course, after the aircraft were grounded, the concerns from a safety perspective may be less critical…if the crash was the result of an aircraft design or manufacturing flaw. But if it was something else, then time remains important. If the black box data, for example, highlights a flaw in pilot training that’s applicable across aircraft models, then reading the flight data recorders as soon as possible remains a priority.
Over the years, aircraft accident investigations, even when in the glare of the media, have generally proceeded in a deliberate manner to gather facts, analyze them, and reach conclusions about what occurred. Sure, there have been hiccups and behind-the-scenes disagreements, but for the most part decisions have been fact-based and meticulously analyzed. That’s why complex investigations can seem excruciatingly long sometimes. The NTSB and its counterparts around the world have issued recommendations based on meticulous analyses and conclusions.
Uniformity of Approach
International aviation cooperation has a long and noble history. The process for international cooperation in aviation was hammered out in a groundbreaking agreement in 1944, known as the Convention on International Civil Aviation, more commonly referred to as the Chicago Convention because that is where the representatives from the original signatories met. Today, there are 192 signatories to the Chicago Convention who all agree to comply with the standards established by the International Civil Aviation Organization. Those standards cover aircraft, personnel, and air navigation and also include an entire section, or Annex, on accident investigations. The goal was to ensure the safety and efficiency of air transportation across international boundaries by setting up a framework for uniformity and standardization. While individual countries, or States as they are referred to by ICAO, retain their sovereign right to disagree with any ICAO standard, they are required to file their disagreements or differences with ICAO so that other member States are aware of them.
Annex 13, the section applicable to international accident investigations, has been the framework for working with other countries for as long as I have been an accident investigator, first as an airline employee, later as a member of the NTSB and most recently as an independent air safety consultant. The objective of accident investigations under ICAO is clearly stated and critical to bear in mind: “The sole objective of the investigation of an accident or incident shall be the prevention of accidents and incidents. It is not the purpose of this activity to apportion blame or liability.” It is very important to emphasize that the only objective is to determine what occurred, and why, in order to prevent future accidents or incidents. When I was at the NTSB, that was always the code under which we operated: to determine what happened to prevent the same or similar accidents from happening again. It was so well-known that that was how we conducted our investigations that I’m not even aware of any attempts by Congress or the Executive office to influence or change our accident reports.
I concur with the statement issued by the Flight Safety Foundation, and I believe it bears repeating in full: “This globally haphazard approach to an important airworthiness issue was most unfortunate, but we understand the need to reassure the traveling public. We continue to believe, however, that global aviation safety is best served by timely, harmonized decisions based on facts and evidence, not conjecture, politics, or media pressure. Moving forward, we must allow aviation safety professionals—investigators, regulators, engineers, and pilots—to calmly and objectively analyze the data, collaborate, and implement permanent, corrective fixes to ensure a tragedy like this can never happen again.“
Ultimately, the data may reveal that the Boeing 737 Max should have been grounded. But the process to arrive at that decision bears scrutiny for the future of aviation accident investigations. We have reached such a safe period in aviation travel that aircraft accidents—especially airline accidents with significant loss of life—garner 24/7 media and political attention. Those are often not the best circumstances for deliberative and thoughtful evidence-gathering and decision-making.