by John Goglia – January 1, 2021
I have been to the scene of many fatal aircraft accidents, far too many. Major airline disasters, commuter crashes, and even some general aviation (GA) accidents as a member of the National Transportation Safety Board (NTSB). Before serving on the NTSB, I went to the scene of a number of airline crashes as a union safety representative. It is never easy to conduct an on-scene investigation, especially in the immediate aftermath of a crash. The things you see are not ones you ever want to describe but they haunt you for a lifetime. No matter how bad the crash scenes are, the truly hardest thing to do is address grieving family members who need and deserve answers to their most pressing questions. And, yet, as much as families want and need answers, rarely are accident investigations quick, and often getting to the bottom of what happened can take years.
I have briefed grieving family members on NTSB accident investigations, sat with them as they wept, and tried to comfort them as best I could by providing them the factual information we were able to gather to try to help them make sense of what happened. One thing I learned early on meeting with the surviving family members is that they usually have three questions uppermost in their minds: what happened? Could the accident have been prevented? And, most importantly, did their loved ones suffer? In addition, after major crashes, it’s also not unusual to see family members come together to lobby for changes that would prevent similar future crashes, at least in part so that their loved ones did not die in vain.
While the NTSB has a worldwide reputation for conducting meticulous, thorough investigations into airline disasters, its worldwide reputation does not extend to conducting typical GA accident investigations. Unless a major public figure is killed—as in the death of John F. Kennedy, Jr. in July 1999 when his Piper PA-32R disappeared en route to Martha’s Vineyard—the accident investigations are usually handed off to the FAA and the probable causes are most commonly ascribed to pilot error, even at times when the investigations are, in my opinion, inconclusive, at best.
I understand as well as anyone the reasons for this lack of in-depth attention to GA accidents—the NTSB staff is miniscule (approximately 400 people total) as is its budget (less than $100 million). However, a recent documentary that was scheduled to premiere in December raises important questions about how the NTSB handles GA accident investigations and whether it can’t do better. Although the accident that is the focus of the film occurred more than a decade ago, the questions it raises about the NTSB’s commitment to GA accident investigations are particularly relevant during this pandemic time.
The NTSB—for reasons inexplicable to me—has refused to conduct GA accident investigations, citing the dangers to its personnel from the pandemic. This reasoning makes no sense to me at all. NTSB investigators are required to take blood-borne pathogen training specifically designed for the unique environment of an accident site. Blood-borne pathogens are clearly not the same as airborne ones that are reportedly the cause of the spread of Covid, but it seems that appropriate training for investigators could have been designed and provided, which mitigate the risk of catching the virus without sacrificing the importance of GA accident investigations. Investigators are already familiar with strict protocols for wearing personal protective equipment and have successfully demonstrated their abilities over the many years that blood-borne pathogen training has been required.
But back to the documentary and the reason for this article. Hopefully, by the time you read this, the film Invisible Sky will be widely available for streaming at www.invisibleskyfilm.com. I think it’s an important film for everyone in the GA community to see, as well as anyone who is interested in aviation safety. In brief, the film documents the tragic 2006 crash of a Cessna 206 piloted by a young, aspiring opera singer and carrying four graduate students at Indiana University’s music school. The airplane crashed on approach to Monroe County Airport near Bloomington, Indiana in night IFR weather conditions. The pilot, 24-year old Georgina Toshi, was instrument rated and legal to fly the flight. All five persons aboard the aircraft that night died in the crash.
The NTSB delegated the accident investigation to the FAA—as is fairly routine in GA accidents—which sent two investigators to collect evidence. The NTSB ultimately determined that the probable cause of the accident was pilot error caused by the pilot’s continued descent below decision height and not maintaining adequate altitude above the trees while on approach. The NTSB’s conclusions did not make sense to Ms. Toshi’s father, also a pilot, and he engaged his own accident investigators to reconstruct the accident, interview witnesses, and determine an alternative scenario for what may have caused the accident. His investigation revealed information that had either not been discovered by government investigators or was ignored by them for reasons that are not altogether clear.
I won’t give away any more of the storyline but the film makes for riveting watching for those of us who have spent much of our careers in accident investigations. It pains me to say that the film does not show the NTSB in its finest hour. Regardless of why the NTSB made the decisions it made in this case, the film raises important questions of the accuracy of GA accident investigations and their probable cause determinations. If the probable cause conclusions are not reasonably defensible, actions taken to prevent future GA accidents are also suspect. How do we know that current recommendations for preventing GA accidents are reasonable if they weren’t predicated on rigorous accident investigations? This may be just one accident but it raises questions that all of us should want to know the answers to.