Investigators Are On The Scene

Oct. 1, 2001
Good advice and safety tips for aircraft technicians from accident investigators

For those of us who make a living in aviation, the words, "NTSB and FAA Investigators are on the scene," are somehow a comfort. Even the raw edge of the flying public’s fears is softened because the public, like us, have come to understand that these Investigators will find the cause of the accident and the FAA and the aviation industry will take measures to prevent a similar accident from happening again.
But have you ever wondered why there are two Federal Investigation teams, why not just one? The reason is both the NTSB and the FAA have different areas of responsibilities at the accident site. The NTSB has only two areas of responsibilities. They have to determine probable cause and make safety recommendations. While the FAA assists the NTSB investigator to find the probable cause, the FAA investigator is also there to see if the FAA was at fault or deficient in the performance of its assigned responsibilities.

Many different roles
Nine areas of responsibility the FAA investigator must examine
1. Performance of FAA’s facilities or functions
2. Performance on non-FAA owned and operator ATC facilities and Navaids
3. Airworthiness of FAA-certificated Aircraft
4. Competency of FAA-certified Airmen, Air Agencies, or Air Carriers
5. Adequacy of the Federal Aviation regulations
6. Adequacy of the FAA’s airport certification safety standards or operations
7. Adequacy of FAA’s Air Carrier and Airport Security
8. Medical qualification of Airmen
9. Violation of the Federal Aviation Regulations

To do the job, the FAA accident investigator must be an actor and play many roles. One minute the investigator plays the detective on the scene. The next minute, he or she plays the diplomat, the resource manager, and media target. They play all these roles while dressed in an environmental suit breathing through a face mask, smeared with Noxzema® to fool their sense of smell from the impossible to describe, but never forgotten, smell of dried blood mixed with burnt aluminum. Then they finish their job they go back to their desk in Washington, fill out their reports and wait for the next phone call. A phone call, that in my mind, is a personal invitation to take another walk through Hell.
What kind of a background does a person need to do this kind of job in which you must make sense out of chaos? Most of us figured the accident investigators profession demands rock solid steady individuals, with superior IQs, keen insight, and blessed with iron nerves, strong character, and even stronger stomachs. But, is this perception true? Curiosity aroused, I took the opportunity to take a short walk down the hall to the Office of Accident Investigation Division.

Manager Bud Donner
The FAA Accident Investigation division is run by Bud Donner, a man about my age, whose other lives before hiring on to the FAA in 1988 were spent as an Air Force pilot, Continental Airlines pilot, an NTSB Investigator and an FAA Investigator. I invited myself into his office unannounced, offered a brief introduction, and watched his eyes focus on mine. I told him I wanted to do an article on his division. His eyes narrowed even further. I told him I wanted to ask him and his Investigators a few questions about the job they do.
Since I do not have the face of an angel, I had to promise that they would see the article first and buy off on it. His argument for this little concession of mine was that he read some of my previous articles, which included references to elephants, gorillas, and dead cats, and he was taking no chances. After my blood dried on the promissory note, I asked my questions and he answered them. First off, I asked the typical bureaucratic questions and I found out that the Accident Investigation Division had two goals. The first is to provide 100 percent participation in all domestic accidents investigated by the NTSB. The second goal is to participate in 80 percent of major foreign accidents. He has to meet these goals with 7 investigators. Right now two of the Investigator positions are open. Anyone interested in being an investigator can check out job bid at on the Internet.
I then segued into my next series of questions by asking Bud what attributes would the perfect investigator have. He surprised me by saying he would look for broad aviation experience in an applicant and the ability to manage FAA resources like air traffic control. The applicant should have the inherent ability to get along with people in high stress situations. This was not my perception of what an investigator should have and seeing my bewildered look, he laughed, and said that the ideal candidate would be all of the above plus be 30 years of age, have an aeronautical engineering degree, an ATP, and an A&P with an IA. He added that some time spent as a newscaster and an air traffic controller would be nice, but he said these people are hard to come by.
I next asked Bud what training would he put the new investigator through before he or she went out on their own.
He rattled off the following, "Two accident investigation courses, one airplane the other rotorcraft; Human Factors training; Cabin Safety training; and courses on specific make and model aircraft like Boeing and Airbus. OJT is also important."
He continued, "During breaks in the training, the new investigator goes on accidents and shadows a more experience investigator and learns things about the job that is not written in textbooks or on PowerPoint presentations. On the average, a new investigator is on their own in about 10 months. This moment of truth happens when their names are put on two rotating accident call-up lists. The first list is for domestic accident the other is for the foreign."
I then asked Bud what lessons he has learned in this job. Bud came forward in his chair and shared the following lessons that he learned as a manager:
• No matter how much pressure there is, do not release false or unsubstantiated information.
• Be careful with how you use the English language.
• Hire the best and train them well because they will represent the FAA and the United States of America.
• Don’t interfere or second-guess the investigator’s work.
I closed by asking him, "What is the best thing and the worst thing about his job?"
Bud smiled and said, "The best thing is the people I work with — there is no worst thing, I love my job — but don’t tell the higher ups."

Branch Manager Lyle Streeter
Lyle started his aviation career as a line boy, then spent six years in the Navy, an FBO operator, A&P, Commercial Pilot, Multi-engine, Instrument, Flight Instructor. He joined the FAA in 1977 as an air traffic controller and has been an Accident Investigator since 89. In response to my question what was the worst accident, he said any accident in South America that was drug related is bad news. He has been on several. Besides the jungle, which is bad enough, there is the constant threat that the drug dealers want their cargo back and life there is very cheap. What was your most memorable? Lyle said it had to be the Lauda Air 767 that had a thrust reverser deployment in flight on May 26, 1991. As a result of that investigation, a lot of AD and engineering changes were made.
"Lessons learned?" I asked.
"This is what I learned," he said. "Both the weakest and strongest link in the aviation safety chain is the human being. That is both the cause of accidents and the answer to preventing them."

Investigator Bob Henley
Henley has been an investigator for the past 7 years. Bob’s a tough guy who smiles less than I do, and I don’t smile at all. He is professional down to his toes. I know these things because I worked with him for three years when he was in the Aircraft Maintenance Division. Anyway, since I knew him, I decided to get a little personal and ask him what made him apply for the job as an accident investigator. He told me that he did not plan it. During his 39 years in aviation, Bob went from the Air Force as a crew chief, got his A&P mechanic certificate, worked industry as a government inspector, became FAA Manufacturing Inspector, then an FAA Airworthiness Inspector, and then became an Accident Investigator. He said there was no plan to be in accident investigation; it was kind of pre-ordained for him decades ago.
In my response to what was the best accident he was on, he looked at me kind of funny. Then, I clarified it by saying, "What was the accident that you got the most satisfaction or good that came out of it?"
Bob said, without a doubt, it was the Swiss Air MD-11 accident in September of 1998. The Canadians have not issued the probable cause yet, but over 100 Airworthiness Directives on wiring came out because of that accident. The ADs should save some lives. Since Bob is retiring, I asked him what would he share with mechanics in lessons learned as an accident investigator. Bob simply said: "Make sure that you always know what you are doing, and do it in a precise and professional way."

Investigator Victoria Anderson
Ms. Anderson is a Cabin Safety Specialist whose aviation career began working as a Flight Attendant at Branniff International Airlines. She later taught in Branniff’s training department. Anderson joined the FAA at the Dulles FSDO as a Cabin Safety Inspector in 1990 and for the past 8 years has been an Accident Investigator.
I asked her what was the worst accident she worked. Her eyes looked away and then back to mine and said that it was the USAir 427 outside of Pittsburgh. It killed 131 people. In response to my question about what was her most notable accident, she answered that it was the Air Force 737 that Secretary Ron Brown was killed on. Victoria said as a new investigator, she got valuable experience sitting on the board and see how the military, aircraft, and engine manufacturers did business. She smiled when she told me that she got a little respect from the old timers when she pulled some strings and got a hold of the only FAA expert that was familiar with coastal bending of Non-Directional Beacons and got him to participate in the accident investigation.
I asked her what were some of the lessons learned. She said, "Never stop learning, you might need it. Anything can happen."

Investigator Tony James
Tony is both a GA and Air Carrier rated pilot with over 40 years of experience. He is a quiet man, who takes comfort in his own thoughts. He seemed generally surprised that I wanted to interview him. My first question to Tony was, "Why did he become an Accident Investigator?
He smiled and simply said, "I like to figure out problems — you know, like the TV detective, Columbo."
Okay, Columbo, what was the worst accident you ever worked? Tony thought for a moment and said from the terms of pressure, the worst accident was the one that killed John F. Kennedy, Jr. near Martha’s Vineyard. Everything was made more difficult by the intense media attention. Tony smiled again and said, "But you know, we got every piece of that airplane, every piece. We know exactly what caused the accident."
I then asked him what was his most unusual accident. He answered, "Getting myself rescued by helicopter off a glacier near Juneau, Alaska when the weather closed in."
"Any lessons learned?" I asked.
"Yes," the quiet man replied. "Most of the accidents that I investigated were caused by errors in judgment." Looking at no one in particular, Tony said, "They should know better."

Investigator T.R. Proven
T.R. is an ex-Navy A-4 driver, with 12 type ratings including DC-8 and B 737. T.R. joined the FAA in 1975 and has been a full-time Accident Investigator for the past three years.
I asked what was his worst accident that he worked. He said, "All accidents are the same, but despite being in aviation 40 years, they always teach me something new."
In reply to my question about what was the most notable, he said from the notoriety and attention from the press, it was the last one he worked — the Cessna 402B in which the pop singer Aaliyah died.
Any words on lessons learned?
He looked at me straight on and said, "Every time you are faced with a safety issue and there is no one there but you, take extra time to make the right decision."

Investigator Eric West
Six-foot-four, A&P mechanic with IA, private pilot with instrument rating, crew member on SH2D helicopters in the Navy, and former aviation insurance investigator, Eric has been an Accident Investigator for 2 years.
He told me his worst accident was the A-STAR helicopter accident in the Grand Canyon in August of this year. Beside the location of the accident, he said the aircraft burned and it was bad.
In response to my question about what was the most unusual accident, he said it was the Egypt Air 767. Eric was on the cockpit voice recorder committee. He said it was unusual due to the deep political implications — FBI and State department participation complete with Arabic translators. The CVR committee work lasted 10 days when the norm is two.
"Unbelievable experience," he said shaking his head.
"Words of wisdom?" I asked.
Eric smiled and said, "CYA-R!"
Before I could translate he said, "Cover Your Areas of Responsibility with research and training."

Investigator Duncan Monaco
Duncan is the new guy on the block. He has been an Investigator for a year and has been out on five accidents — the last three on his own. He has a ATP, Flight Instructor, single and multi-engine with 5,000 hours in his logbook. Duncan joined the FAA in 1990 with our Office of Information Analysis, and then transferred to Accident Investigation in 2000.
In response to my questions of what was the worst accident, he said the crash in Denver last year of the King Air with members of the University of Oklahoma basketball team on board. The accident was made more personal because he has a son the same age as several of those on board.
His best accident he was involved with in terms of working with different cultures and nationalities was the Thai Air B 737 accident in March of this year. Duncan said the CAA of Thailand could not have been more helpful.
"It was a great experience working across national boundaries trying to make aviation safer," he explained.
"Words of wisdom?" I asked.
"Do not be influenced by the opinions of others until you make up your own mind," he warns. "Learn to listen."
Well, I hope you got a little insight into the people who do the accident investigation for the FAA. Take my word for it, the investigators are not gifted or special. They are just good people doing a tough job.

Editor’s Note:
All of us at AMT wish to express our condolences to the family and friends of those who lost their loved ones in the tragic events of September 11, 2001.
This article was written and submitted before those events occurred and is intended to offer insight into this important, and unfortunately necessary, facet of aviation.

About the Author

Bill O'Brien