International Society of Air Safety Investigators

Submission for the 2016 ISASI Seminar in Reykjavík, Iceland

Alliance or Rebellion: Linking Efforts of State Safety Oversight Agencies

By Jeff Guzzetti, AO3317

__________________________________________

Jeff Guzzetti is currently the Acting Deputy Director of the Office of Accident Investigation and

Prevention at the U.S. Federal Aviation Administration (FAA). He joined the FAA in May 2014 as the

manager of the Accident Investigation Division. Mr. Guzzetti also served as the Assistant Inspector

General for Aviation Audits at the U.S. Department of Transportation's Office of the Inspector General

for four years, where he led audits of FAA aviation safety programs. His prior experience also includes

18 years with the U.S. National Transportation Safety Board's (NTSB) Office of Aviation Safety, where

he served as a field investigator, major accident investigator, and the Deputy Director of Regional

Operations. Mr. Guzzetti has also worked as an air safety investigator with the Cessna Aircraft

Company, and as a safety engineer with the U.S. Naval Air Systems Command. He earned a Bachelor

of Science degree in Aeronautical Engineering from Embry-Riddle Aeronautical University, and he holds

a Commercial Pilot license with multiengine, instrument ratings, and Seaplane & Glider pilot ratings.

The views expressed in this paper do not necessarily represent the views of the United

States (U.S), the U.S. Department of Transportation (DOT), the Federal Aviation

Administration, or any other Federal agency.

_____________________________________________

Abstract

The United States (U.S.) and many other ICAO nations each have various agencies inside their

borders with overlapping yet differing roles in regulating, investigating, and evaluating the

aviation industry. These interrelationships often produce tension and “rebellion” under the false

premise that working together is an unacceptable “conflict of interest” or that the authorities of

their respective agencies are being usurped. This paper demonstrates that creating “alliances”

and linking the efforts between these agencies can actually accelerate improvements to aviation

safety by fueling enhanced awareness and support for implementing practical safety actions.

Suggested practices and behaviors for creating alliances and thwarting rebellion are presented.

Examples are also presented regarding the U.S. National Transportation Safety Board (NTSB) --

the lead investigative agency for civil aircraft accidents -- and its typical target for

recommendations -- the Federal Aviation Administration (FAA) which oversees every aspect of

the daily operations of aircraft in the U.S. Meanwhile, the FAA and NTSB are subject to scrutiny

by the Government Accountability Office (GAO) and the U.S. Department of Transportation’s

Office of the Inspector General (DOT OIG), who both employ exceptional methodologies to audit

and report on deficiencies within the FAA and NTSB. Specific examples of both collaborative and

conflicted efforts among all these agencies will be presented, including the identification and

mitigation of hazards associated with helicopter air ambulance operations and also with airline

pilot fatigue. Examples of overlapping responsibilities between internal safety agencies within

other states -- such as Germany, Russia, and Iceland -- are also presented.

Introduction

The United States (U.S.) and many other ICAO nations each have various agencies inside their

borders with overlapping yet differing roles in regulating, investigating, and evaluating the aviation

industry. These interrelationships often produce tension and “rebellion” under the false premise

that working together is an unacceptable “conflict of interest” or that the authorities of their

agency are being usurped. However, these relationships should be fostered, rather than be

allowed to wilt from ignorance, arrogance, or fear. Instead of being predisposed to rebel against

each other, these agencies should find ways to link their efforts in order to achieve their ultimate

objective of accelerating safety improvements in aviation. Enlightened managers and staff can

and should provide for a culture of enhanced awareness to support practical safety actions.

The NTSB and the FAA

In the U.S., the lead agency for all civil aviation accidents is the National Transportation Safety

Board (NTSB) -- an independent and highly credible organization with less than 120 air safety

investigators out of a total of about 400 people. The small size of this elite agency is at once its

strength and its weakness. Its small size allows it to be nimble, quick, and focused. However, its

size is also a challenge, because, by statute, the NTSB must assign an investigator-in-charge (IIC)

and determine the cause for every one of the nearly 1,300 civil aviation accidents that occur each

year in the U.S.[1] If one does the math, one would find that it is impossible for an NTSB IIC to

travel to each accident site, let alone conduct research, write reports, and live a normal life.

Throw in a half-dozen significant and complex aviation accidents and airline incidents, and the

math becomes more troublesome. In fact, NTSB travels to less than 15 percent of these accidents,

and therefore must rely on the voluntary support and expertise from the FAA – a massive

bureaucracy of 40,000 people charged with regulating and controlling every facet of aviation in

the U.S. [2] It would not serve either agency to refrain from a high level of collaboration with each

other as they develop ideas to improve safety in the wake of an accident or incident.

The U.S. Congress intended to prevent duplication between investigations conducted by the FAA

and NTSB, and therefore established that the NTSB shall always take the lead role. However,

Congress also recognized that the FAA must participate as a party in all NTSB aviation accident and

incident investigations, thus enabling it to obtain safety-critical information in a timely manner –

to meet its safety oversight needs -- during the NTSB's fact-gathering activities.[3] As long as

longstanding federal ethics and agency policies are followed, and with a healthy dose of

transparency, the NTSB’s independence would not be compromised if it needs to utilize some of

the 40,000 FAA employees as force multipliers to perform on-scene investigations.

Looking beyond the “macro” view of an agency’s investigative practices, one must focus on the

personal relationships between the individuals and personalities within the state agencies that are

actually conducting the daily grind of investigative work. If these individuals do not play well in

the investigation sandbox, potential life-saving safety improvements may be delayed. Aviation

and accident investigation teams tend to be populated with accomplished experts that may have

oversized egos, assertive personalities, or a narrow focus of their mission. In most cases, the

individual relationships and work efforts of FAA and NTSB investigators are productive, but

miscommunications, grudges held from previous investigations, arrogance, and ignorance can

sometimes cause problems. It is the responsibility of the managers and leaders of these agencies

to instill an appropriate culture and develop guidance that serve to eliminate useless “rebellion.”

The “Ashburn Accord”

During the communication chaos that typically occurs after any significant airline accident or

serious incident, the NTSB and FAA can be spring-loaded to “rebel” against each other when

attempting to obtain critical evidence for each of their needs. For example, in the wake of a fatal

accident overseas of a cargo jet operated by a U.S. airline in 2010, the FAA immediately wanted

access to the maintenance records of the accident airline. However, the airline demurred and

initially refused to allow the FAA – the regulatory agency responsible of its oversight – to gain

access to this information. The reason given was that “the NTSB is in charge” and that “FAA will

have to go through the NTSB.” This did not please the FAA inspectors assigned to oversee the

airline. However, the NTSB was also not pleased that the FAA attempted to gain access to

“evidence” that the NTSB’s authority clearly indicates the agency’s “priority” to obtain. Was the

FAA trying to pull a fast one? Was the airline trying to “hide” evidence behind the guise of an

NTSB investigation? Was the NTSB blocking FAA efforts to ensure the FAA’s requirement for

“continuing operational safety (COS)” ? Should the investigators from NTSB and the inspectors

from the FAA have pulled out their badges to see which one was bigger in order to settle this

rebellion? Of course, in hindsight, the answer to all of these questions is NO !

Although the NTSB and the FAA have different roles, both share the need for timely, unimpeded

access to operational safety information. After this incident, and also prompted by previous

concerns regarding engine failure investigations, the NTSB, FAA, aircraft manufacturers, engine

builders, and airline representatives got together in an attempt to forge an “alliance” of

understanding. During a two-day meeting in early 2014 at the NTSB Training Center in Ashburn,

Virginia, the FAA and NTSB hammered out the basics for a “joint policy letter” which was later

formalized and signed on June 4, 2014. The policy was informally dubbed the “Ashburn Accord”

and was distributed to the U.S. aviation industry to clarify the roles and responsibilities of the

NTSB and the FAA during an incident or accident investigation. [4]

The Ashburn Accord states that the NTSB and FAA “both perform critical roles in maintaining

aviation safety,” but asserts that the NTSB has “priority” over any other investigation. However,

the letter also makes clear that the FAA has the authority to investigate aviation safety-related

matters as necessary to ensure “continuous operational safety” and will do so as needed after a

significant accident or incident. The FAA depends on the cooperation of the manufacturers and

airlines that they certify to ensure collection of timely and relevant data in these investigations,

and the Ashburn Accord stresses that the FAA may require information in addition to that

required by the NTSB. Or, the FAA may require information more expeditiously than the NTSB to

address urgent unsafe conditions. In these situations, the FAA is clearly authorized to obtain such

information directly from the parties. The Ashburn Accord provides important guidance to help

ensure that the appropriate priority is placed on the collection of investigative information that

the FAA needs. If “rebellion” arises, the policy states that the NTSB, the FAA, and the operator or

manufacturer (or both, as appropriate) will conduct an “Interagency Communication Call” at the

start of an investigation to identify and coordinate information requests. Following that call, any

information that is provided to the FAA must be shared with the NTSB. Also, if there are any

questions regarding an information request, the assigned NTSB IIC should be contacted

immediately via the NTSB 24-hour Response Operations Center.

With regard to conducting interviews, the Ashburn Accord stipulates that the NTSB will lead

interviews of operator and manufacturer personnel, and will conduct them “as soon as practical.”

An FAA party representative, along with other party representatives, will be invited to participate

in the NTSB interviews. The FAA may conduct its own follow-up interviews if additional

information is needed, and FAA will share the results of these interviews with the NTSB as per

their obligations as a party. If the NTSB is unable to conduct interviews for its purposes within a

reasonable time, the policy allows the FAA to coordinate with the NTSB to conduct its own

interviews to ensure continuous operational safety and to provide the results to the NTSB.

Now that a written policy exists, potential rebellious parties can reference the policy during the

chaotic hours following a major accident. Alliances are formed, rebellion is crushed, and safety

issues are identified and mitigated more quickly.

An “Alliance” for Information Sharing

Another example of collaboration between similar and competing safety oversight agencies is

information sharing. A specific example involves the use and benefits of FAA’s Aviation Safety

Information Analysis and Sharing (ASIAS) system. Implemented in 2007 by the FAA, ASIAS collects

and analyzes data from multiple databases to proactively identify and address risks that may lead

to accidents. It is a collaborative industry-government information sharing and analysis system

that combines, analyzes, and disseminates aviation safety data and report products. [5] The

system is fed by a wide variety of data sources from both public and protected proprietary

aviation data. Publicly available data includes information from many sources such as the NTSB

Accident and Incident Reports database. Proprietary and/or confidential sources include data

from aircraft operators, including Flight Operations Quality Assurance (FOQA) extracted from

aircraft recorders, and voluntary safety reports submitted by flight crews. Interactions between

the FAA and the aviation industry range from analyzing ASIAS data to identifying and

recommending risk mitigations. While NTSB will never have access to the protected proprietary

ASIAS data, a written agreement was struck in November 2012 that allows the NTSB to initiate

written requests for de-identified and aggregated ASIAS data related to aircraft accidents

involving U.S. airlines that occur in the U.S. [6] The NTSB has agreed it will not publicly disclose

ASIAS information it receives via this process unless the ASIAS Executive Board agrees.

The FAA can be a rich source of information for NTSB investigators. For example, On August 14,

2013, an Airbus A300, crashed short of the runway during a localizer-only nonprecision approach to

an airport in Birmingham, Alabama. The NTSB determined that the primary cause of this accident

was the flight crew’s continuation of an unstabilized approach and their failure to monitor the

aircraft’s altitude during the approach, which led to an inadvertent descent below the minimum

approach altitude and subsequently into terrain. During the NTSB-led investigation, recorded data

from the FAA’s air traffic system was used to not only assist with characterizing the accident

approach, but also to analyze other approaches flown by many other unidentified airlines to similar

runways during a 3-year-period. An analysis was applied to 1.4 million approaches at a subset of 31

U.S. airports that had at least one runway with only a nonprecision approach, a situation similar to

that of the accident flight. Approaches to runways with and without precision approaches at the

31 airports were compared with respect to vertical speed metrics. The vertical speed of flights on

approach to runways with a precision approach at these airports exceeded a vertical speed of 1,450

feet per minute at one-third of the rate of approaches to runways without precision approaches.

Based on these data, NTSB issued recommendations to the FAA, and awareness was raised in the

airline industry about these types of non-precision approaches. [7]

The GAO, OIG, and the “Yellow Book”

Meanwhile, both the FAA and NTSB are subject to scrutiny by two other oversight agencies -- the

U.S. Government Accountability Office (GAO) and the U.S. Department of Transportation’s Office of

the Inspector General (OIG). These agencies work at the behest of the U.S. Congress and conduct

formal, in-depth “performance audits” that provide essential accountability and transparency over

government programs, including FAA’s safety oversight efforts and the NTSB’s investigation

operations. The rigorous standards for audits conducted by the GAO and the OIG are cited in a

GAO publication known as “The Yellow Book”. Its actual title is

“Government Auditing Standards.” The standards contained in the

Yellow Book are commonly referred to as “generally accepted

government auditing standards” or “GAGAS.” GAGAS provides a

framework for conducting high quality audits with competence,

integrity, objectivity, and independence. GAGAS also contains

requirements and guidance dealing with ethics, auditors’

professional judgment, quality control, performance of the audit,

and reporting. [8] Portions of the Yellow Book provide an

outstanding template for any aircraft accident investigators to

utilize. It is an extremely well-written, succinct, and useful

reference that can and should be applied to our trade.

Figure 1:

The GAO “Yellow Book”

For example, listed below are a few key Yellow Book definitions that auditors must adhere to as

they conduct their audits and document their findings.

_______________________________________________________

 Professional skepticism - an attitude for a questioning mind and a critical assessment of

evidence. An assumption that management is not dishonest nor of unquestioned honesty.

 Threats to independence - Circumstances that could impair independence. Whether

independence is impaired depends on the nature of the threat, whether the threat is of such

significance that it would compromise an auditor’s professional judgment or create the

appearance that it may be compromised, and on the mitigations applied to reduce threat.

 Condition: A situation that exists. The condition is determined and documented during the audit.

 Criteria: The required or desired state

 Cause: The reason for the difference between condition and the criteria, which may also serve

as a basis for recommendations for corrective actions.

 Effect: A clear, logical link to establish the impact of the difference between the condition and

the required criteria. The effect identifies the outcomes or consequences of the condition

 Effective recommendations: Recommendations that encourage improvements in the conduct of

government programs and operations. They are addressed to parties that have the authority to act

and when the recommended actions are specific, practical, cost effective, and measurable.

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Another useful example can be found in Chapter 6 of the Yellow Book, which contains standards

for the “field work” involved in performance audits conducted in accordance with GAGAS. [9]

This chapter provides requirements to establish an overall approach for auditors to apply in

obtaining “reasonable assurance that the evidence is sufficient and appropriate to support the

auditors’ findings and conclusions.” Specifically, the field work requirements for performance

audits address: planning the audit; supervising staff; obtaining sufficient and appropriate

evidence; and preparing documentation.

Perhaps the most rigorous and powerful GAGAS tenant is the requirement for the audit

organization to establish and maintain a “system of quality control” that is designed to provide

“reasonable assurance” that the organization and its personnel comply with professional

standards and applicable legal and regulatory requirements. In order to provide this assurance,

GAO and OIG must have an external peer review performed by an independent reviewer of the

audit organization at least once every three years, and the organization should make its most

recent peer review report publicly available. [10] Typically, this is done by posting the peer review

report on a web site for public transparency of peer review results. If the organization fails the

peer review, the report serves as a scarlet letter to all that the agency is not credible – a powerful

incentive for audit agencies to always strive for competence and pass their peer review!

The DOT Office of Inspector General

The FAA and NTSB are also subject to audits and investigations by the DOT OIG. The Inspector

General Act of 1978 gives the OIG authority to conduct performance audits (and separate

criminal investigations) to provide recommendations that lead to program improvements that

directly enhance the safety, efficiency, and effectiveness of the U.S. transportation

infrastructure. [11] The Act also prevents officials in the scrutinized agency from interfering with

audits or investigations, and it requires the IG to keep the U.S. Secretary of the DOT and the

Congress informed of its findings. Perhaps the most powerful authority granted by the Act is for

the IG to “…have access to all records, reports, audits, reviews, documents, papers,

recommendations, or other material available to the Department relating to its programs and

operations.” That means that virtually any document that the DOT OIG wants to obtain from the

FAA is fair game, including draft reports, open departmental enforcement investigations, etc.

The NTSB and GAO do not have this authority.

Additionally, the OIG has the ear of the Congress and the DOT Secretary should any of the DOT

agencies—such as the FAA--- attempt to obstruct their audit efforts. Unlike the NTSB and GAO,

the OIG is also authorized by Congress to report any "serious or flagrant problems" to an agency

head under the IG Act. The agency chief, in turn, must pass on that OIG report to Congress

within seven days -- thus earning the document its moniker of "seven-day letter" and

guaranteeing a maelstrom of media coverage and Congressional attention for the agency

audited. But doing so is considered the “nuclear option” because it could ends the collaborative

relationship between the IG and his or her secretary. Still, the 7-day letter is a powerful tool in

the OIG arsenal, and the mere threat to use it can prompt closed-door negotiations between an

IG and management in order to quell rebellion.

Finally, the audit reports that are issued by the DOT OIG are extremely well-written, and the

professionals in our trade should readily refer to them as an excellent reference on relevant

aviation safety topics. For example, the report’s “Background” section provides a useful primer

of the audit topic, and the “Results in Brief” section – or the “RIB” -- summarizes the main

findings of the audit with one succinct paragraph per major finding. And, as previously

mentioned, the support and documentation of each “finding” section is unassailable due to the

adherence to the Yellow Book standards. Perhaps the only criticism of an OIG or a GAO audit

report is that the findings and recommendations can sometimes lack a practicality about them,

since they are written by “auditors”, rather than aviation accident investigators and industry

users. However, the OIG allows FAA and NTSB to provide comments on the draft audit report,

and the OIG will append those comments in their final report. The OIG continues to monitor FAA

and/or NTSB’s actions taken to address any recommendations made in its final report, and the

progress on these recommendations are routinely reported to Congress. [12]

Investigating the Investigators

Why are the roles of the GAO and DOT OIG important for aviation safety and accident investigation?

The answer should be obvious. As shown in Figure 2 below, the primary agency to conduct all U.S.

civil aviation accidents (i.e. NTSB), and the agency that regulates and oversees all aspects of U.S. civil

aviation (i.e. FAA), are held to the standards that the public expects of them by the frequent audits

conducted by the GAO and DOT OIG. Additionally, the recommendations resulting from

Figure 2.

Diagram of Roles & Relationships Between NTSB, FAA, GAO and the DOT OIG

Recommendations

Accidents

NTSB

FAA

GAO

Inspector

General

Safety

Action

the work of the NTSB, GAO, and DOT OIG regarding various aviation safety topics can be force

multipliers to bring pressure to bear (or in many cases to support), FAA and Congressional safety

actions. With respect to the NTSB, Figure 3 below provides a sampling of independent

performance audits that it undergoes from the GAO and the DOT OIG.

Figure 3:

Examples of GAO and OIG Audit Reports targeting NTSB Budget and Operations

Characteristics for Creating Alliances and Accelerating Corrective Safety Actions

The ICAO Manual of Aircraft Accident and Incident Investigation cites that the “Ideal Investigator”

is “… trained personnel possessing many qualities, not the least important of which are an

inquisitive nature, dedication… diligence and patience. The definition continues with:

“…Technical skill, perseverance and logic are the tools the profession; humility, integrity, and

respect for human dignity the guiding rules.“ [13] When it comes to building alliances and

thwarting useless rebellion, the key words in this definition are the ones that describe the

characteristics of human relationships: Patience, Humility, Respect for Human Dignity.

Other guidance can be found in a list of principals recently agreed upon by all of the executives

within the FAA. Named after the location of the FAA Executive strategic planning meeting for

agency operations, these “Shepherdstown Principles” [14] could readily be applied during the

rise in tensions between investigators and auditors in the heat of an inquiry, as shown here:

GAO and DOT OIG Audits of NTSB

 Assume Positive Intent and Set the Tone – Consider that everyone working on the

investigation or audit is trying to improve safety. Resist negativity and assumptions.

 Collaborate and Build Connections – Keep attuned to the needs and issues of others

involved in the investigations and audits. Foster relationships. Find common ground.

 Explain the “Why” and Be Transparent – Ensure others fully understand your concerns and

solutions. Ask them to ask “Why”. Lean into conflict and resolve issues with boldness and

creativity. Don’t just send demanding emails, or “project” what you think the other is

thinking. Pick up the phone. Talk it out. Better yet, get a cup of coffee together.

 Always Model Cooperation – Make decisions that communicate your willingness to

cooperate. Collaboration and engagement starts at the top.

Perhaps the most useful behavior to apply is one of empathy. When one attempts to fully

understand the other’s argument or perception – to the point of being able to actually argue

their side better than they can – a true understanding of the other’s challenges and authority

and concerns is attained. In other words, try to “Walk a mile in the Other Guy’s shoes.”

Rebellion – Barriers to Forming Successful Alliances

On the opposite side of the ledger, the characteristics and behaviors that fuel the fire of useless

rebellion are:

 Arrogance – No one wants to try to educate someone who thinks they “know everything “

about this issue at hand. There is no room for empathy and alliance when arrogance exists.

 Badge Envy – The “my badge is bigger than your badge” attitude only serves to alienate and

infuriate those who are trying to get their job done.

 Competition – Some investigators or auditors want to be the first one to “solve the accident.”

But preventing accidents is a race against time, not each other. Investigation is a team sport.

 Projection – Projection occurs when clear and frequent communications between two parties

does not exist. The communication void allows one to “project” their own guess about how

the other feels or thinks, without actually verifying this, and talking it out.

Case Study 1: U.S. Airline Pilot Commuting and Fatigue

On February 12, 2009, a Bombardier DHC-8-400 was on an instrument approach to Buffalo-

Niagara International Airport, Buffalo, New York, when it crashed into a residence about 5

nautical miles northeast of the airport. The 2 pilots, 2 flight attendants, and 45 passengers

aboard the airplane were killed, along with, one person on the ground. [13] The NTSB’s

investigation found that both pilots had not been adequately rested because they had chosen to

“commute” from their residences that were far away from their pilot base in Newark, New

Jersey. As a result, the NTSB recommended

that the FAA “require airlines to address

fatigue risks associated with commuting,

including identifying pilots who commute;

establishing policy and guidance to mitigate

fatigue risks for commuting pilots; using

scheduling practices to minimize

opportunities for fatigue in commuting

pilots; and developing or identifying rest

Figure 4.

DHC-8-400 accident site in New York – February 2009

facilities for commuting pilots. [15]. Later, in September 2010, the DOT OIG issued an audit report

entitled “FAA and Industry Are Taking Action To Address Pilot Fatigue, But More Information On Pilot

Commuting Is Needed.” The report independently supported similar findings by the NTSB, and

cited two similar recommendations to the FAA.[16] In part, the first recommendation was for FAA

to “ensure the collection and analysis of data regarding domicile and commuting length for all Part

121 flight crews,” and the second was for FAA to “review and analyze the Part 121 domicile and

commuting data collected to determine if further changes to flight duty and domicile regulations are

needed, or if airlines need to take further mitigating actions in their fatigue management systems.”

The FAA initially opposed the recommendations, citing that it had just issued substantial rules

that revised and enhanced crew rest that addresses fatigue in general, regardless of the cause.

The FAA also stressed their philosophy that pilots should take personal responsibility to be “fit

for duty” before each flight. However, the OIG reiterated its view that these data were

necessary to determine how prevalent fatigue existed due to airline pilot commuting, and they

cited their recommendations as a “high priority” in response letters to Congress.[17]

Additionally, the DOT OIG indicated that its views on the topic were consistent with similar

recommendations made by NTSB, giving them more clout. Yet the FAA continued to rebel.

Through several written responses and meetings that occurred over the course of about two

years, managers at the FAA and the OIG attempted to overcome the impasse regarding the OIG

recommendations. Building an alliance can sometimes take a while. The FAA stipulated that

commuting can definitely contribute to pilot fatigue, and that many pilots commute, but they

indicated that a “study” was not needed and would waste precious resources. They also indicated

that each airline must have a Fatigue Risk Management Plan (FRMP) in place, accepted by the FAA

principle inspector for the airline annually. The DOT OIG appreciated the FAA’s view that

commuting is widespread in the industry and can contribute to fatigue, and they gave serious

consideration regarding the role that FRMPs could play in meeting the intent of this

recommendation. After much discussion, FAA indicated a willingness to develop and publish

guidance to their inspectors and/or the airlines that would essentially compel the airlines to

specifically address commuting in their annually-updated FRMPs in order to lay out a process by

which the airline could intervene should the commutes of their pilots become problematic. The

OIG felt that the FAA’s proposal was viable and met the intent of their recommendations.

Case Study 2: U.S. Helicopter Air Ambulance Safety

Calendar year 2008 was the deadliest year on record for the helicopter air ambulance industry in

the U.S., with 8 fatal accidents and 29 fatalities, prompting the NTSB to hold a 4-day public

hearing in February 2009. [18] One month later, the GAO issued an audit report on entitled

“Potential Strategies to Address Air Ambulance Safety Concerns.” [19] In the report, the GAO

identified several potential strategies for improving air ambulance safety that were similar to

what the NTSB had identified. In September 2009, the NTSB issued ten recommendations to the

FAA regarding improved pilot training; collection and analysis of flight, weather, and safety

data; and the use of dual pilots, autopilots, and night vision systems. [20]

Figure 5:

Reports Addressing Helicopter EMS Safety from (left to right) OIG, GAO, and NTSB

The FAA did not rebel against the findings and proposals, because they also immediately

recognized that something needed to be done. The NTSB and GAO reports and recommendations

served to elevate the issue in the eyes of Congress, who supported the FAA’s issuance of a final

helicopter air ambulance rule in February 2014. But this case study does not stop there. Congress

asked the DOT OIG to review FAA’s progress in improving air ambulance safety. One year later, the

OIG issued an audit report that found that while FAA’s recently issued helicopter air ambulance

rule was a good first step toward improving safety, continued delays in finalizing all of the safety

efforts that Congress wanted was affecting FAA’s ability to focus its accident reduction efforts and

limiting the effectiveness of safety initiatives. The OIG also stated that the FAA would need to be

better positioned to effectively oversee a rapidly expanding industry and would need to obtain

meaningful safety data to analyze for trends. The OIG made five recommendations to strengthen

FAA's oversight of the industry, and the FAA concurred with all of them. [21] This case study shows

how all four safety oversight agencies (see Figure 5 above) came together to improve safety.

Numerous other case studies could be presented regarding the interrelationships between the

FAA, NTSB, GAO and DOT OIG, and how they can support each other to accellerate safety action.

The chart shown in Figure 6 below provides a partial listing of recent aviation safety issues and the

reports/recommendations that were issued for each.

SAFETY ISSUE

NTSB

Reports

GAO

Audits

DOT IG

Audits

EMS Helicopter Safety

Unmanned Aircraft

Pilot Fatigue

Bird Strikes

Runway Incursions

ATC Near Misses

Lithium Battery Fires

Figure 6:

Table Showing Common Safety Issues Addressed in Reports by FAA, NTSB, GAO, and OIG

(Source: FAA, NTSB, GAO, and DOT OIG main web sites)

Case Study 3: Germany’s BFU, BMVI, EASA, and a Midair Collision

At last year’s 2015 ISASI Seminar in Munich, Johann Reuss, the deputy director of the German

Federal Bureau of Aircraft Accidents Investigation (BFU), effectively laid out yet another example

of the benefits of “alliances” between safety oversight agencies – this time in Germany. In his

paper entitled "Independence does not mean isolation: A practical Approach,” Reuss explained

that the BFU is the responsible safety investigation authority in Germany for the accidents and

serious incidents in civil aviation. [22] The BFU adheres to European and national requirements ,

and is subordinated to the Federal Ministry of Transport and Digital Infrastructure (BMVI).

German law stipulates the professional independence of the BFU and permits the director of the

BFU to initiate an investigation and appoint and IIC in order to identify safety deficiencies and

make recommendations. In his paper, Reuss cited the BFU’s investigation into the tragic midair

collision in July 2002 between a Tupolev Tu-154 passenger jet and a Boeing 757 cargo jet over the

southern German town of Überlingen. The official investigation by the German BFU identified the

main cause of the collision to be a number of shortcomings on the part of the Swiss air traffic

control service in charge of the sector involved, and also ambiguities in the procedures regarding

the use of the on-board aircraft collision avoidance system. Reuss clearly articulated that a major

investigation in Germany is effective only if the investigation process is transparent, safety

recommendations are comprehensible, the safety investigation authority give and receive sound

facts about the ongoing investigation, and licensing and regulating authorities are involved in

accordance with their nation’s regulations. [23]

Case Study 4: Russia’s Aviation Investigation Structure and a Boeing 737 Accident

Another ICAO-member state that has a similar “check and balance” aviation safety structure is

Russia. The Interstate Aviation Committee (IAC/MAK) was established in Russia in 1991 pursuant

to the interstate Agreement on Civil Aviation and Airspace Use. The principal aim of the IAC is to

ensure safe and orderly development of civil aviation of Russia’s member states, specifically to

include certifying aircraft, engines, and hardware. Interestingly, the IAC has a separate group that

conducts independent investigations of all civil aircraft accidents that involve the aircraft of the

member states. Additionally, the work related to aircraft accident investigation is overseen by the

Aircraft Accident Investigation Commission (AAIC) and the Aircraft Accident Investigation Scientific

and Technical Support Commission (AAI STSC). Because of these “alliances,” the IAC Investigators

have at their disposal a modern laboratory which provides capabilities for flight recorders data

recovery, readout and analysis, flight dynamics analysis, aircraft and fracture analysis. [24]

Additionally, Russia’s Federal Air Transport Agency (FATA) – which is the equivalent of the FAA in

the U.S. – conducts the government oversight of day-to-day Russian aviation operations. All of

these aforementioned Russian agencies had a stake in an accident that occurred on November 17,

2013, when a Boeing 737-500, operated by a Russian airline, crashed during a missed approach at

night at the airport in Kazan, Russia. The IAC determined that the cause of the crash was related to

flight crew’s failure to maintain control of the airplane, due to spatial disorientation, inadequate

flight crew training, and other systemic weaknesses in safety to include a lack of adequate

oversight by FATA. There were many controversies and some dissention related to the

investigation, as non-investigative members of the IAC sought to indict the design of the aircraft,

rather than follow the obvious facts that led to the official cause. However, in the end, rebellion

was put down, and alliances between IAC, FATA, and others led to a comprehensive and impactful

final accident report with recommendations that will enhance aviation safety in Russia. [25]

Case Study 5: Iceland and the ITSB, ICAA, EASA, and a Russian jet

Finally, three years ago, right here in our host country, Iceland’s Parliament passed Act no.

18.2013, which combined three transportation committees in a single commission of inquiry for

transportation accidents under the Minister of the Interior. The Act stipulates that investigations

should only aim to reveal the causes of transport accidents and incidents, not to apportion

blame or liability, with the aim to prevent similar accidents. The Icelandic Transportation

Investigation Board (ITSB) was born. Meanwhile, The Flight Safety Division of the Icelandic Civil

Aviation Administration (ICAA), which is also under the auspices of the Ministry of the Interior,

acts as Iceland’s regulator. Additionally, Iceland is a party to EASA, and the Flight Safety Division

participates in its operations. EASA provides oversight and development and coordination

regarding requirements in flight operations and license issues. [26]

Shortly after the passage of Act no. 18.2013, a prototype Sukhoi RRJ-95B

Superjet 100 airliner impacted the runway with its landing gear retracted

during a go-around at Keflavik International Airport in July 2013. The

purpose of the flight was to expand the airplane’s capabilities for CAT IIIA

automatic approaches. After seven approaches and go-arounds, the

objective of the last approach to was to assess the automatic flight control

system performance during go-around at a radio altitude of 3 feet above the runway, with the

right engine shut down and in a crosswind exceeding 20 knots. During this last go-around, the

airplane climbed to 27 feet altitude after the landing gear had been selected to the up position,

followed by a loss of altitude. The airplane hit the runway with the landing gear retracted and

skidded down and off the runway. The crew evacuated the airplane one crew member suffered

minor injuries during the evacuation.[27]

The ITSB determined the most probable cause of the accident to be flight crew fatigue, and they

issued nine safety recommendations and one safety action. The ITSB recommended to EASA to

ensure that necessary changes were made to the emergency escape slide design of RRJ-95B

aircraft that are EASA-certified to meet the maximum wind requirements specified by EASA. The

investigation also determined that the use of green color code during activation of the airport

emergency plan was prone to causing confusion, prompting the ITSB to issue a “safety action” to

the Iceland Ministry of Transport to revise the regulation and change the green color code to

another color to avoid confusion. The alliances built between the ITSB, EASA, the Flight Safety

Division of the ICAA, and the Icelandic Ministry of Transport demonstrated once again that

creating alliances among a state’s safety oversight agencies can lead to enhanced safety.

Conclusion

The five cases cited above demonstrate that creating alliances among state safety oversight

agencies can lead to improvements in aviation safety. Instead of being predisposed to rebel

against each other, agencies should do what is necessary to create a culture of respect and

understanding, and to find ways to link their efforts in order to achieve their ultimate objective of

accelerating safety improvements in aviation.

References:

1. 49 U.S. Code of Federal Regulation Part 830. National Transportation Safety Board Authorities

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Continued Operational Safety (COS) Information During a NTSB Investigation”. June 4, 2014.

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10/01. Adopted February 2, 2010.

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Commuting Is Needed”. Report No. AV-2011-176. Washington, DC. September 12, 2011.

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Testimony Before the House of Representatives. April 22, 2009. No. GAO-09-627T.

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Concerning Helicopter Emergency Medical Services.

21. DOT OIG. “Delays in Meeting Statutory Requirements and Oversight Challenges Reduce FAA’s Opportunities

To Enhance HEMS Safety”. Report Number AV-2015-039. Washington, DC. April 8, 2015.

22. Reuss, Johann. "Independence does not mean isolation: A practical Approach” Paper presented to the

delegates of the ISASI 2015 on Aug. 28, 2015, in Munich, Germany.

23. German Federal Bureau of Aircraft Accidents Investigation. Investigation Report No. AX-001-1-2/02. Midair

Collision Between Boeing 757-200 and Tupolev TU154M. May 2004.

24. Zayko, Sergey. “Russia’s Interstate Aviation Committee: A description of the Russian Interstate Aviation

Committee makeup and operation.” ISASI Forum Magazine. March 2013

25. Zemlianichenko. Associated Press. “Russian agencies in dispute over decree to ground nation’s Boeing

737s” Seattle Times. November 5, 2015.

26. Icelandic Transport Authority . “About the ICT”. http://rnsa/is

27. Icelandic Transport Authority . “Report on Plane Crash Sukhoi RRJ-95B,July 21, 2013 at BIKF”. Aug. 1, 2013.