Thursday, December 04, 2014

Celebrity plane crashes draw special scrutiny from the National Transportation Safety Board

Thomas Frank , USA TODAY

Flooding the zone

The small-airplane crash that killed a pilot in Owasso, Okla., last year seemed like a minor event that would require just one or two federal investigators.

But this crash killed the son of U.S. Sen. James Inhofe.

The National Transportation Safety Board assembled an unusually large team for a single-fatality crash: At least seven NTSB investigators, three Federal Aviation Administration inspectors and four manufacturing companies tested the airplane's engines, propellers, valves, switches and shafts; conducted a rare sound-spectrum study to determine the engines' condition in flight, and a radar study to calculate the airplane's position in its final minutes. They scrutinized Perry Inhofe's flight-training record, his communication with air-traffic controllers and interviewed at least 20 people, including his flight instructor and his widow, who detailed Inhofe's eating, sleeping, drinking and snoring habits.

The outsize investigation is typical of how the NTSB treats airplane crashes that kill prominent and politically connected people and celebrities — and a sharp contrast to how it investigates most crashes of private aircraft, a USA TODAY analysis shows.

The NTSB, considered the world's premier aviation investigator, has given special treatment to crashes that killed John F. Kennedy Jr., former senator Ted Stevens, singer John Denver, Missouri Gov. Mel Carnahan and lesser-known people with political ties, records and interviews show.

In at least 15 crashes since 1996 that killed prominent people, the NTSB took extensive steps to determine the cause of the crash, assigning teams of investigators to analyze numerous possible problems. The investigation of JFK Jr.'s crash involved at least 56 people: 16 from the NTSB, 11 from the FAA, and 29 from other agencies and companies, NTSB records show. The typical investigation of a fatal private-airplane crash involves four to five people, according to a USA TODAY review of 600 NTSB investigations since early 2011.

John DeLisi, head of the NTSB's Office of Aviation Safety, said a larger initial team goes to a high-profile crash to accelerate the investigation and get information to the public more quickly.

"The prominence of anyone involved plays a role in our initial response because it escalates the public interest," DeLisi said. He declined to say how this approach affects the NTSB's overall investigation, which typically takes a year or more.

But lawyers representing crash victims and survivors say the NTSB's treatment of high-profile crashes discredits the agency.

"The NTSB stumbles over themselves wanting to get press coverage in high-visibility crashes," said Jon Kettles, a Dallas aviation attorney. "I represent three families, they've gotten zero info from the NTSB. The disparity is deplorable."

After a glider accident in 1999 killed Donald Engen, the NTSB undertook its first "major investigation" of a fatal glider crash since at least 1983 and released a 42-page report, agency records show. Most reports on fatal glider crashes are two or three pages.

Engen is a former NTSB board member and FAA administrator.

"Obviously, there was a strong feeling in the board because most of the members of the board knew Mr. Engen personally," said Jim Hall, the NTSB chairman from 1994 to 2001.

The NTSB extensively investigated a 1998 crash that killed Lt. Gen. David McCloud, a military commander in Alaska whose death drew the attention of Ted Stevens, then Alaska's senior U.S. senator and Senate Appropriations Committee chairman.

"When the head of my appropriations committee had an interest in something, I had an interest in it as well," Hall said.

And Stevens' death in 2010, nearly two years after he lost a re-election bid, triggered a major investigation, with at least 31 investigators, company representatives, police and consultants. The crash killed five.

The detailed investigations contrast sharply with how the NTSB approaches most of the roughly 250 annual fatal crashes of private airplanes and helicopters. Four or five people — from the NTSB, FAA and manufacturers — typically review the flight history, aircraft wreckage, weather, pilot experience and pilot toxicological reports, and sometimes study an aircraft component for malfunction.

In detailed investigations, teams might scrutinize a pilot's background for health or emotional problems; possible missteps by air-traffic controllers; potential malfunctions of numerous components; factors affecting crash survival, including seat belts, emergency response and airport conditions; the aircraft's design and maintenance; and a wide range of atmospheric conditions gleaned from satellites, radar, pilot reports and advisories.

DeLisi said the NTSB does not set out to conduct an expansive investigation of a private-aircraft crash but lets investigators determine the scope as they look at possible causes.

"We need to make decisions based on the circumstances of the accident and our resources," DeLisi said.

Detailed investigations sometimes assuage pilots and their surviving families because they uncover factors that exonerate the pilots involved, USA TODAY found.

After legendary test pilot Scott Crossfield was killed flying his Cessna Centurion in 2006, an NTSB major investigation found that an air-traffic controller had failed to give him adverse weather assistance.

The depth of the Crossfield investigation, involving at least 12 people, and the findings were unusual for the NTSB, which has found pilots solely responsible for about 75% of fatal crashes of private aircraft since mid-2010, a USA TODAY analysis shows. The findings are usually succinct and blunt, citing a pilot's "failure," "improper decision" or "inadequate" maneuver.

The NTSB investigation of the 1997 home-built airplane crash that killed John Denver also was highly unusual for its depth, which included at least 30 interviews, and its finding of a design flaw in the location of a handle that controlled fuel flow.

Going by the book

The NTSB has privately encouraged giving priority to crashes involving prominent people.

An agency manual listing factors that determine the number of officials sent to a crash site says that one factor — deaths and injuries — "considers not only the numbers of people but their prominence."

The manual directs regional NTSB offices to notify NTSB headquarters in Washington, D.C., after major events such as crashes of commercial or commuter flights, deadly midair collisions — and crashes involving "public figures or officials of widespread recognition or prominence."

"The more public interest there is, the more it will drive the investigation," said Keith McGuire, an NTSB investigator from 1977 to 2006.

McGuire oversaw the investigation of a 1996 crash that killed 7-year-old pilot-trainee Jessica Dubroff and two others as she tried to become the youngest person to fly across the U.S. A team of at least nine people studied how the weather, airplane weight and flying angle affected the Cessna Cardinal's stall speed, what time pilot-in-command Joe Reid went to sleep and woke up for three days before the fatal flight and a hotel clerk's impressions of the three people the morning of the flight. The NTSB's 69-page final report is nearly nine times the average length of other reports on three-fatality crashes in 1996.

"We spent a lot of time on that because of the public interest," McGuire said. He said an extensive investigation does not "short-change another investigation. It might delay another investigation."

Several former NTSB board members say public interest and news media scrutiny justify extensive investigations.

A large NTSB team at celebrity crashes is vital to handle a media throng, make information public quickly and contain speculation and intrusiveness, said John Goglia, an NTSB board member from 1995 to 2004. The NTSB pulled John F. Kennedy Jr.'s Piper Saratoga out of 120 feet of water in 1999 in part to prevent amateur divers from getting hurt or killed trying to take photographs, Goglia said.

The NTSB took 1,067 photos of Kennedy's airplane and its parts.

The NTSB views high-profile crashes as rare and valuable opportunities to address a wide audience of pilots and the public. "Those are, to me, teaching moments and an opportunity to remind the pilot community as well as the general public of the risk in aviation and the importance of specific details," said Hall, the former NTSB chairman.

The NTSB used the Perry Inhofe crash on Nov. 10, 2013 to push for safety improvements in the aircraft model he was flying, a Mitsubishi MU-2B, which had been scrutinized previously by both the NTSB and the FAA because of its crash history.

"We had an opportunity in that accident," said DeLisi of the NTSB. "We knew that the prominence of the individual was going to lead to increased public interest. We take advantage of situations like that to help push our safety recommendations." The NTSB recently urged the FAA to provide better guidance to MU-2B pilots.

Sen. Inhofe, who is a leading congressional advocate for private pilots, declined to comment.

Former NTSB board member Steven Chealander, who served from 2007 to 2009, said that celebrity involvement does not drive investigations. "To say that this guy is a big celebrity so we're going to make a big deal out of this, that would be wrong, because you're going to taint the reputation of the NTSB as a fact-finding, science-based, investigative agency," he said.

Many probes are handed off

The NTSB has wide discretion in how it investigates airplane and helicopter crashes.

Federal law requires that the agency determine the "probable cause" of every aviation crash that kills or seriously injures someone or that substantially damages an aircraft. In non-fatal crashes, the NTSB often makes the determination based largely on pilot statements.

With 90 aviation investigators, the NTSB says it gives priority to crashes that will yield the most benefit in terms of safety improvements. "Our only objectives are to determine the probable cause of the accident and to extract lessons learned that will prevent similar accidents in the future," the NTSB said in a 2013 annual report.

Some celebrity crashes get extra NTSB scrutiny solely because of their circumstances, such as New York Yankees pitcher Cory Lidle and his flight instructor crashing Lidle's Cirrus into a Manhattan high-rise apartment building in 2006, five years after the 9/11 attacks. The death of golfer Payne Stewart and five others in 1999 drew national attention because their Learjet flew hundreds of miles on autopilot after the crew became incapacitated before crashing in South Dakota.

Some high-profile crashes have yielded NTSB safety recommendations urging improvements in an aircraft model, pilot training, flight operations, air-traffic control procedures or other factors. NTSB's non-binding recommendations are usually followed and have led to safety features such as crash-avoidance warning systems in aircraft.

But some extensive investigations of high-profile crashes yield little.

After the 2012 death of Steve Appleton, CEO of Micron Technology, an $8-billion-a-year company, four NTSB investigators worked with an FAA inspector and five company representatives to determine the cause.

The effort was exceptional considering that the crash killed only one person and involved a home-built airplane. The NTSB typically conducts "limited" investigations of home-built plane crashes and does not send its own investigator to the site.

The team investigating Appleton's death produced an 18-page final report — seven times the length of the average NTSB report on fatal home-built airplane crashes in 2012 — but struggled to find the cause.

Investigators found that Appleton failed to maintain adequate airspeed but that he lost engine power "for reasons that could not be determined."

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