washingtonpost.com
Correction to This Article
A Feb. 8 article about aircraft accident investigations incorrectly said that a June 2002 crash in Meridian, Miss., was caused by a faulty crankshaft bolt made of zinc rather than harder cadmium. The bolt failed because it had been improperly heat-treated.
NTSB Goes to Fewer Crashes
Backlogged Investigators Pass on Small-Plane Accident Sites

By Sara Kehaulani Goo
Washington Post Staff Writer
Wednesday, February 8, 2006

Strapped with a backlog of cases and a tight budget, the National Transportation Safety Board is sending investigators to fewer and fewer fatal airplane crashes -- particularly those involving small planes. And that has safety experts worried.

Last year, the agency's accident investigators showed up at 62 percent of all fatal plane crashes, compared with 75 percent of all fatal crashes in 2001, according to NTSB numbers. But data from the Federal Aviation Administration -- which is required to send an investigator to every accident and take note of whether the NTSB is on the scene -- indicate that NTSB investigators showed up less than half the time last year.

The NTSB chafed at the FAA numbers, calling them inaccurate. After a back-and-forth between the agencies, the FAA backed down, acknowledging that its numbers may be unreliable.

Whether the NTSB showed up at 62 percent or less than half of all fatal crashes last year, the downward trend since 2001 has alarmed former accident investigators.

Most of the nation's 1,700 crashes last year involved small planes, such as turboprops owned by individuals. About 350 of those accidents caused at least one fatality.

"The consequences are, you're going to miss some things," said Gene Doub, a former NTSB accident investigator who teaches at University of Southern California. "Every one of these are not just dumb pilots. Some are airspace-system or training issues or airworthiness issues."

Acting NTSB Chairman Mark V. Rosenker said the agency wants "more safety payback" for the accidents where it spends its time. Beginning in 2004, investigators stopped going to small crashes in which the cause seemed to be obvious, such as an inexperienced pilot who flew into trees or a crop-duster that struck a utility pole.

Under the current process, he said, investigators can focus on crashes where a new safety lesson is likely to be gained. Investigators have been encouraged to whittle away at the agency's backlog of 944 accident investigations, each of which is more than six months old. (In 2001, the backlog was 2,400 cases.) "Investigators were showing up to a scene, writing down facts and sticking it in a pile," Rosenker said. "There is a greater payback in doing it the way it is currently being done."

If an NTSB investigator does not arrive on the scene, the agency relies on the FAA to handle much of the field work and eventually an NTSB investigator writes up a probable cause. The NTSB has about 70 accident investigators, and the FAA has several hundred inspectors who also serve as investigators.

Seasoned investigators worry that showing up at fewer accidents means the NTSB could miss an opportunity to improve safety.

The NTSB did not send an accident investigator to a June 2002 crash in Meridian, Miss., after a pilot flying a Piper aircraft reported engine trouble, declared an emergency and crashed in a field short of the airport. The pilot, who was flying alone, was seriously injured.

At first glance, the accident appeared to be caused by an engine failure, which is not unusual to investigators. After examining the engine, FAA investigators learned that a crankshaft gear bolt had failed because it had been improperly made of zinc rather than harder cadmium. The engine's manufacturer, Lycoming, had made a similar part for helicopters, which had also failed and caused several accidents.

Three months later, in Byram Township, N.J., another pilot flying a Piper with the same model of Lycoming engine crashed after the engine quit at 3,500 feet. Two people were killed, and two others on board were seriously injured. The NTSB sent an investigator to that accident, which was caused by a failure of the same crankshaft gear bolt.

Safety experts and makers of small aircraft said the incident highlights the consequences of the NTSB's picking and choosing certain kinds of accidents to investigate on-site.

"While the FAA is very competent, what they do in their primary mission is not accident investigation," said Gregg Feith, a former NTSB accident investigator who works as a safety consultant. Feith said the FAA serves as a regulatory agency whereas the NTSB is an independent agency whose sole mission is to find the cause of accidents. "If you don't go on-scene and examine it, you're never going to find out the root cause . . . you're going to find the obvious cause," he said.

The NTSB said it is "unfair" to blame the second Piper accident on the NTSB's decision not to send an investigator to the other accident. Jeff Guzzetti, the NTSB's director for regional operations, blamed the FAA for not alerting the aviation community to the problems with the crankshaft bolt sooner.

The FAA disagreed, saying that it was aware of the Lycoming problem with helicopters but was not aware that the problem existed on planes.

Brian Riley, lobbyist for a group representing small-plane manufacturers such as Cessna and Piper, said he has urged Congress to give the NTSB more money so it could hire more investigators.

The 2007 budget plan gives the agency a boost, from $76 million to $80 million, after a flat budget from 2005 to 2006. But it is unclear if Congress will approve the administration's request -- and if it does, how the NTSB would spend it.

Riley said he does not see much hope for more investigators.

"In an ideal world, I'd like them to do all accidents, but I know that will never happen," said Riley, of the General Aviation Manufacturers Association. "We feel the NTSB is the unqualified organization who can come out and do an investigation. They are rarely challenged. It's like a stamp of approval."

View all comments that have been posted about this article.

© 2006 The Washington Post Company