I have been to the scene of many fatal aircraft accidents, far too many. Major airline disasters, commuter crashes, and even some general aviation (GA) accidents as a Member of the National Transportation Safety Board (NTSB). Before serving on the NTSB, I went to the scene of a number airline crashes as a union safety representative. It is never easy to conduct an on-scene investigation, especially in the immediate aftermath of a crash. The things you see are not ones you ever want to describe but they haunt you for a lifetime. No matter how bad the crash scenes are, the truly hardest thing to do is addressing grieving family members who need and deserve answers to their most pressing questions. And, yet, as much as families want and need answers, rarely are accident investigations quick, and often getting to the bottom of what happened can take years.
I have briefed grieving family members on NTSB accident investigations, sat with them as they wept, and tried to comfort them as best I could by providing them the factual information we were able to gather to try to help them make sense of what happened. One thing I learned very early on meeting with the surviving family members is that they usually have three questions uppermost in their minds: what happened? Could the accident have been prevented? And, most importantly, did their loved ones suffer? In addition, after major crashes, it’s also not unusual to see family members come together to lobby for changes that would prevent similar future crashes, at least in part so that their loved ones did not die in vain.
While the NTSB has a worldwide reputation for conducting meticulous, thorough investigations into airline disasters, I don’t believe this extends to conducting GA accident investigations, in part because of its frequent delegation of the on-scene portion. Unless a major public figure is killed as in the death of John F. Kennedy, Jr. in July 1999 when his Piper PA-32R disappeared en route to Martha’s Vineyard after takeoff from Essex County Airport in New Jersey—the on-scene investigations are often handed off to the FAA to collect the facts and circumstances and forward this information to the NTSB so it can accomplish the analysis and determine the probable cause. In situations like this, the probable causes are most commonly ascribed to pilot error, even at times when the investigations are, in my opinion, inconclusive, at best.
But back to the documentary and the reason for this blog. Hopefully, by the time you read this, the film Invisible Sky will be widely available for streaming. https://www.invisibleskyfilm.com/ I think it’s an important film for everyone in the GA community to see, as well as anyone who is interested in aviation safety. In brief, the film documents the tragic 2006 crash of a single-engine Cessna 206 piloted by a young, aspiring opera singer and carrying four graduate students at Indiana University’s music school. The plane crashed on approach to Monroe County Airport near Bloomington, Indiana in night IFR weather conditions. The pilot, 24-year old Georgina Joshi, was instrument rated and legal to fly the flight. All five persons aboard the aircraft that night died in the crash.
The NTSB delegated the on-scene accident investigation to the FAA—as is fairly routine in GA accidents—which sent two investigators to collect evidence. The NTSB ultimately determined that the probable cause of the accident was pilot error caused by the pilot’s continued descent below decision height and not maintaining adequate altitude above the trees while on approach. The NTSB’s conclusions did not make sense to Ms. Toshi’s father, also a pilot, and he engaged his own accident investigators to reconstruct the accident, interview witnesses, and determine an alternative scenario for what may have caused the accident. His investigation revealed information that had either not been discovered by government investigators or was ignored by them for reasons that are not altogether clear.
I won’t give away any more of the storyline but the film makes for riveting watching for those of us who have spent much of our careers in accident investigations. It pains me to say that the film does not show the NTSB in its finest hour. Regardless of why the NTSB made the decisions it made in this case, the film raises important questions of the accuracy of general aviation accident investigations and their probable cause determinations. If the probable cause conclusions are not reasonably defensible, actions taken to prevent future general aviation actions are also suspect. How do we know that current recommendations for preventing GA accidents are reasonable if they weren’t predicated on rigorous accident investigations? This may be just one accident but it raises questions that all of us should want to know the answers to.