Board Launched Seven Major Accident Investigations In 2008

The NTSB delivered its 178-page report to Congress this week, detailing all of the activity across each of its disciplines in the past year.

The Aviation section of the report notes 213 accident investigation launches last year, of which 7 were major investigations. There were also 18 requests for international assistance.  The board issues 86 aviation-related recommendations, and closed 27 investigations.

Among the completed investigations was a February 18, 2007 incident in which an Embraer ERJ-170 regional jet, operated by Shuttle America, as Delta Connection flight 6448, was substantially damaged when it overran the end of runway 28 while landing at Cleveland Hopkins International Airport, Cleveland, Ohio, during a snowstorm. The aircraft received substantial damage, but the 74 people onboard were not injured. The Board determined that the probable cause of the accident was the failure of the flight crew to execute a missed approach when visual cues for the runway were not distinct and identifiable.

Ongoing investigations include a June 4, 2007 accident in which a Cessna 550 (Citation II), operating as a 14 Code of Federal Regulations (CFR) Part 135 medical transport flight crashed into the waters of Lake Michigan shortly after takeoff from General Mitchell International Airport, Milwaukee, Wisconsin. All six people onboard were fatally injured.

There is also a July 31, 2008, accident involving a Hawker Beechcraft BAE 125-800A, which was destroyed when it impacted terrain during an attempted go-around at Owatonna Degner Regional Airport, Owatonna, Minnesota. The nonscheduled domestic passenger  flight was operating under the provisions of 14 CFR Part 135. All eight people onboard sustained fatal injuries.

We know, cheery thoughts for your holiday weekend.

Regional accident and serious incident investigations are handled much like major investigations; but, since they are typically smaller in scope, a single regional investigator usually conducts these investigation as investigator-in-charge.

This investigator, working with representatives from other parties, ensures the investigation includes all the relevant facts, conditions, and circumstances needed to determine the cause of the accident and identify any safety issues. The factual reports of the accidents/serious incidents conducted by the regional investigators are published on the NTSB’s website. A brief report, including the probable cause of the accident, is also available once the probable cause has been determined. A map in the report shows the most regional accident investigations started in Florida and California, with more than 12 in each state.

The report also lists some of what the NTSB consider its significant achievements, among them that on July 16, 2008, the FAA issued its final rule on fuel tank inerting. This rule was the result of an NTSB recommendation aimed at eliminating fuel tank explosions in transport-category aircraft and had been on the NTSB’s Most Wanted List of Transportation Safety Improvements since 2002, and two important NTSB Safety Alerts issued in 2008. One addressing how pilots can prevent controlled flight into terrain when flying at night and the other reminding pilots of the importance of activating leading edge deice boots at the first sign of icing. These alerts provided pilots with information from recent investigations that they can use to prevent accidents.

FMI: http://www.ntsb.gov/publictn/2009/SPC0901.pdf