The Importance of Accident Investigation

This semester I am taking a class that is required for my major called "Aviation Safety Programs." I did not know much about this class before the first day, besides that we would be learning how to be safer and more cautious pilots in our flight operations. Now that the first week of classes has come and gone, I am looking forward to this class more than most of my others. The basic setup of this class is that we will be reading and watching videos about aircraft accidents and analyzing what went wrong. We then write 250-500 words a week about a factor of the accident that stuck out to us. A large percentage of our final grade is calculated from a presentation that we each give about an accident that is randomly assigned to us.

This may sound grim, but it is so important to sit down and work through exactly what caused a deadly accident to happen so that you can avoid the same mistakes in the future. Whether it is pilot error, instrument malfunction, or an accident caused by ATC, knowing how to understand and avoid the same fate is paramount to creating safer skies.

For example, the first accident that we investigated was Colgan Air flight 3407. As 40+ aviation students anxiously watched the projector screen, we were shown a video that recreated the accident with a 3D model of the aircraft and instruments visualizing what the black box had recorded. Additionally, this video had real audio from ATC communicating with the copilot shortly before the accident. It was disturbing to hear, as it made the accident seem so much more real.

After watching the video, we opened discussion to what we believed went wrong. Was it icing? Was it the captain who had previously failed stall awareness training? Was it the first officer who had been working so much between flying and being a waitress that she was deliriously tired? It is important to consider all of these factors and logically work through why this was a bad decision/scenario. We then read the NTSB report and discussed how they came to their conclusions.

This is the infamous accident that lead to the House Transportation and Infrastructure Committee introducing the "Airline Safety and Pilot Training Improvement Act of 2009." Many things changed in the world of professional aviation after this law was passed. Regulations governing pilot training became much more strict. Additionally, the hour requirements for a pilot to earn their ATP rating changed from 250 to 1500. Although both pilots had several thousands of hours of training, the distraught families of the victims who pushed for these updates to regulations simply wanted to try and ensure something like this never happened again.

As you can see, the aftermath of this accident was colossal. It had a huge impact on the aviation industry as a whole, the effects of which aviation students will witness firsthand for years to come. Had the NTSB reported that the cause of the accident was icing with minimal other factors, perhaps the outcome would have been different. However, we cannot be sure of this. The important thing to gather from this is that the entire accident could have been avoided if the pilots had stopped the sequence of bad events from early on.

The "Decide" model is often used to evaluate in-flight emergencies. Having a prior knowledge of events that have lead to accidents can assist with logical thinking when evaluating impeding danger.

Each accident starts as a chain of events. Imagine dominos in a line. When you knock down one, others start following after quite quickly. One of the things we will be doing in my class is identifying which moments leading up to the accidents are dominos. We will analyze where it starts, what makes it worse, and what the ultimate result is. I think that this is fascinating, and it is extremely important for all pilots to examine aircraft accident reports to become better informed and prepared in case they recognize something that could be a domino.

I want to encourage every pilot out there, whether it is their profession or they fly for fun, to begin paying attention to accident reports. It can be difficult, as most pilots have an "it won’t happen to me," attitude, but doing so will help make flying safer for yourself and everyone around you.