RV Accident Probable Cause Listings

[scrollF4]

Dan and JRS,
I concede that EAB NTSB investigations aren't as rigorous as they could be or ought to be. As Doug said, once the probable cause is published, PLEASE discuss it here.

[sailvi767]

In most cases there is little or no actual investigation. The FAA and NTSB are swamped while facing decreasing budgets. They have to clear the accidents and often latch on to the quickest and simplest probable cause to get it off their desk. The simply have no choice.
Unless a accident has a high public interest, VIP's or some unique aspect it is going to be cleared with a few phone calls.
George

[gyoung]

Originally Posted by sailvi767

In most cases there is little or no actual investigation. The FAA and NTSB are swamped while facing decreasing budgets. They have to clear the accidents and often latch on to the quickest and simplest probable cause to get it off their desk. The simply have no choice.
Unless a accident has a high public interest, VIP's or some unique aspect it is going to be cleared with a few phone calls.
George

That was my experience. After my RV accident I naively thought the investigators would inspect my engine and systems and run it in a test cell. Nope, I've been watching too many TV investigators. The local FAA guy showed at the scene and then the wreck was trucked off to the salvage yard and never viewed or touched until I bought it back. Probable cause - engine failure on approach for unknown reasons with a contributing factor of no suitable place to land.

Nobody other than me was hurt and there was minimal property damage other than the airplane. They're just not going to spend the time/money without fatalities, newsworthy damage or celebrities involved.

[ed. Greg, thank you for your post! Very informative, and stuff I didn’t know. I watch too much CSSI also <g>.
Kindest and best,
Doug]

[1001001]

In my engineering career, I have participated in and led many formal and informal root cause analyses. One of my morbid hobbies is reading accident reports from many industries, as I believe it can help my awareness of potential problems, technical, personal, and organizational in nature, in my own work as a chemical process engineer.

I have noticed that many NTSB reports tend to quote verbatim the pilot's own description of events (to the extent that bad editing on the investigator's part reveals this often when they fail to change first person pronouns to the second person in the report). The style of reports varies greatly, from excellent ones where the condition of various pieces of equipment and instruments is meticulously described to ones where it is clear the investigator never looked at the wreckage with anything like a critical eye.

It is often easy to tell into the first few words of a report what the probable cause will be, as the style of the report often signals it unwittingly.

I understand from experience that doing a good true root cause analysis can be a long and difficult process due to insufficient data, and sometimes outright deception on the part of the parties to the investigation who wish to preserve their reputations, jobs, and wallets (against liability suits).

I don't know how to fix it, but I strongly believe that more money for the NTSB or FAA is not necessarily the way to go. I would like to see an independent, nongovernmental agency that has no stake in reaching predetermined conclusions to support increased regulation, nor to protect pilots, maintenance staff, and manufacturers from liability, but to reach the true root causes of as many accidents as possible, in the interest of the safety of pilots and the passengers who trust them with their lives.

I understand that the NTSB was made an "independent" organization for this purpose but for every report they generate that does a good job getting to the bottom of an accident, there seem to be several that are quick to just parrot the easy solution: that the pilot in command, being responsible for the safety of the flight, somehow failed to accomplish that task. Some reports seem to be written in ways to support certain pet issues that the FAA or NTSB identifies as common problems that need fixing, with less than stellar backup for those conclusions in the facts contained in the report dockets.

I could ramble on about this for a long time but the fact remains that our analyses could be quite a bit better than they are, to the benefit of all. I respect DR's rule that we wait until the official probable cause is out to begin speculation, BUT I have little faith that those reports are complete in most cases.

[jrs14855]

Originally Posted by sailvi767

In most cases there is little or no actual investigation. The FAA and NTSB are swamped while facing decreasing budgets. They have to clear the accidents and often latch on to the quickest and simplest probable cause to get it off their desk. The simply have no choice.
Unless a accident has a high public interest, VIP's or some unique aspect it is going to be cleared with a few phone calls.
George

I know of one FAA FSDO office where the staffing has increased by a factor of six since around 1990. The main issue with FAA staff availability is that the FAA too frequently is focused on the wrong issues.

[glenn654]

Has there been an accident report released on Tony Kennedy's accident yet?

Glenn Wilkinson

[scrollF4]

Originally Posted by glenn654

Has there been an accident report released on Tony Kennedy's accident yet?

Glenn Wilkinson

Here's the NTSB query page: http://ntsb.gov/_layouts/ntsb.aviation/index.aspx

I don't know enough details about Tony Kennedy's accident to fill in the search windows, but if you do, you can find your answer here.

BTW, this link is included in DR's "RV Accident Probable Cause Listings" sticky.

[jtrusso]

Originally Posted by glenn654

Has there been an accident report released on Tony Kennedy's accident yet?

Glenn Wilkinson

No.


http://ntsb.gov/_layouts/ntsb.aviati...7-b18c1d7b17f6

[jrs14855]

I just reread an accident report from Apr 14, 2007. Information that I expected to find is no longer available. There is no mention of pilot ratings and experience.
The private information that I have gotten is that this was an attempted turn back maneuver following an engine failure on takeoff. There is no mention of the turn back in the report.
In the previously available information it was stated that the accident was investigated by a FAA FADO Inspector. That is no longer mentioned.
The cause is listed as engine failure for undetermined reasons. Everyone that I have talked to knows that the cause was fuel exhaustion.
This accident was widely discussed shortly after the event, including an article in Sport Aviation. Despite the limited information now available it is an excellent opportunity to study how badly things can turn out when a VERY experienced pilot basically ignores all protocols and even common sense and decides to turn a first flight into a three ring circus.
It pains me to say this but there were also some very qualified people present who should have put a stop to the flight. Unauthorized person on board for a first flight.

[rbibb]

I'll offer an example based on something that happened to someone 'close" to me.

Plane crashes on final. Pilot lives and is, luckily uninjured.

Result of "investigation": Pilot Error - ran out of fuel.

What actually happened: Pilot Error - pilot for got to switch tanks and ran one dry at just the wrong time.

The difference is critical in my mind in that the investigating body based their conclusion there was no gas in the tanks. Of course not because the tanks ruptured on impact and the gas ran out on the ground (no fire for some lucky reason).

Conclusion implied "careless and reckless" action implying poor pre-flight.

Pre-flight as fine as aircraft had sufficient fuel to not only meet FAR minimums but extended reserve for flight planned. Actual cause was distraction and inattention once in flight, not before it. Minor difference - maybe but critical one nonetheless.

The point is to agree with the Colonel to only comment once the report is out but to do so with the firm knowledge that the investigation will only be cursory at best in the case of civilian light planes - especially so if there are no fatalities.