As the Wrench Turns - Rush to Judgment, Lessons Learned from John Goglia

For an accident investigator, the high pitched beep beep beep of the pager going off was never a welcome sound. That it was going off just before midnight East Coast time meant the accident was bad. Bad enough that the NTSB Command Center in Washington, D.C. couldn’t hold notification until morning.   It was February 16, 2000; the initial report to the Go Team was a cargo plane had crashed on take off from Mather Field in Sacramento, California. The words were scrawled across the alphanumeric pager that was the height of technology in those years. An update shortly thereafter, identified the aircraft as an Emery DC-8 cargo jet.
As an NTSB Board Member from 1995 to 2004, I was beeped on every significant transportation incident – planes, trains, buses, trucks and boats – whether I was on call or not. My role was to investigate accidents and determine probable cause. Determination of probable cause was of critical importance – if we got the probable cause wrong, our future fixes wouldn’t be right. And another accident could occur.
 A Board Member was designated as the on-scene spokesperson for every major accident. On this day, I was not the member on call but because of my aviation background, I was particularly interested in aircraft accidents. And here I had a personal interest, as well:   as an FBO operator years before, I had provided contract services to Emery and knew many of their crews.   I asked the Command Center to keep me posted.
Through the night, I was called as more information flowed in. The aircraft, en route to Dayton, Ohio, had crashed into an outdoor auto salvage yard and exploded on impact. Secondary fires ignited and hundreds of cars on the lot exploded. By morning, the sad news that all three crew members were confirmed dead. Miraculously, no one on the ground was hurt.
Within 24 hours, the air traffic control tapes were reviewed and indicated that the pilot had reported balance problems seconds after take off. Conjecture was that the cargo aircraft was improperly loaded and the focus of the investigation narrowed in that direction. Adding to the initial hypothesis was the knowledge of an earlier crash of a Fine Air DC-8 cargo aircraft moments after lift off from Miami International Airport. There the probable cause was determined to be an improperly secured load that shifted on take off causing an extreme tail heavy condition. The aircraft stalled and crashed just outside the airport perimeter.
For months after the Emery accident, investigators focused on how the aircraft was loaded and how the load might have shifted. The investigation was hampered by the location of the accident – burnt aircraft parts were intermingled with burnt automobile parts. But it was also hampered by the initial fixation on aircraft loading as a primary factor.   As investigatory leads failed to pan out, a flight data recorder (FDR) engineer on his own initiative decided to compare the FDR data from this accident with data from the earlier Fine Air accident. That comparison indicated that the crews’ actions, in their attempts to recover the aircraft, were not the same. Maybe the accidents weren’t all that similar. Investigators broadened their focus.   All the cargo loaders were re-interviewed. It became clear that it was extremely unlikely that the load on this aircraft could have shifted . Maintenance records were combed over in much greater detail. Mechanics who had worked on the aircraft were interviewed. Now the pieces started coming together and focus sharpened around maintenance work performed on the flight controls. Eventually the data revealed that maintenance was done on the elevators and a control rod was improperly attached. As the bolt loosened, the crews lost control of the elevators and the aircraft could not climb. This theory of the accident matched the FDR data and was ultimately determined to be the probable cause of the accident. As a result, the NTSB recommended inspection of the entire DC-8 fleet and similar problems were found on eleven aircraft.
Moral of the story: Whether troubleshooting an aircraft maintenance problem or investigating probable cause of an accident, it’s important to gather all available information first. A rush to judgment can lead to errors and waste time and money.