NTSB Needs to Re-Admit NATCA to Investigation
By Robert Mark on August 19th, 2009In life, everyone makes mistakes.
Most of the time, that’s really a good thing though because it offers us a unique path to become better at what we do. Being human though, admitting we screwed something up is not always easy, it’s downright embarrassing in fact. In government, admitting someone said or did something wrong is not viewed as an opportunity to learn or even as a simple mistake. It is – and always has been – seen as a sign of weakness, a philosophy that seems even more contradictory in our nation today now that transparency is the new goal.
In the case of the NTSB update report on the midair collision over the Hudson River last week, the safety board simply screwed up by including four little words in their initial report that didn’t belong there … “including the accident helicopter.” Those words were simply not correct.
The inference was that the Teterboro Tower controller should have noticed the helicopter on radar and pointed him out to the PA-32 pilot. 
As it turns out, the helicopter did not appear on the tower controller’s scope until after he had already turned the aircraft over to Newark approach. On Friday, the controller’s union – NATCA – took the unprecedented action of calling a news conference to clarify this error, something the NTSB was not at all happy about. The safety board said Monday that since NATCA had violated confidentiality rules and that they were being removed from the investigation.
Things Become Curiouser and Curiouser
In the NTSB news release that removed the union as a party to the investigation, the safety board confirmed the controller did not have the helicopter on radar before he switched him to Newark. Although the wording of the title of the release appears to focus only on the union’s removal, the words are there, buried in the sixth paragraph, “The accident helicopter was not visible on the Teterboro controller’s radar scope at 1152:20; it did appear on radar 7 seconds later – at approximately 400 feet.” The board should be applauded for that, especially because these kinds of admissions from the feds are rare, even if it is pretty tough to find. It was, of course, the right thing to do because it took everyone’s eyes off the ball, the real cause of the accident.
Doug Church, NATCA’s Director of Communication, told me today that the union did not take the move of going public with their concerns lightly and that they tried on numerous occasions to work with the safety board behind the scenes before going public again on Monday. “We needed to correct the misinterpretation of the facts that evolved from the NTSB’s original release last Friday.” Church said the union had received an e-mail from an NTSB representative admitting the error, but also making it quite clear the board had no intention of changing anything it had said previously.
Although the NTSB’s news releases have caused a media feeding frenzy and despite that fact that NTSB has admitted they got it wrong, the board has not considered readmitting the controller’s union back into the investigation process. That’s just plain silly at this point. Enough. The NTSB needs to finish the job. Yes NATCA violated a precious NTSB rule this time around, but you – the NTSB – got it wrong too. How about if we just call it a draw. Both groups need to learn to play nicer together.
The Crucial Point
NATCA has a perspective on this accident that is critical to understanding the cause. Arguably, there will be quite a bit of discussion about the Teterboro controller’s telephone conversation when he should have been attending to work, but to me that is even more a reason the union needs to be a part of the investigation.
Bob Richards, a former O’Hare controller and union activist for many years and author of Secrets From the Tower, said, “The NTSB did the right thing by correcting the mistake and retracting the error but not letting the union back into the investigation is unforgivable. They did the right thing and they need to do one more right thing.”
NTSB, finish the job. Bring the union back into the investigation and let’s all get back to the work at hand, preventing another midair collision.
Rob Mark, editor
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August 19th, 2009 at 2:52 pm
This incident has changed my view of the NTSB. In the past I have admired their meticulous attention to the process of finding the cause of accidents. Their ability to look at a mob of reporters, who are asking for the cause of an accident while the wreckage still smolders, and say that they would not jump to conclusions until the investigation is complete. I respected their recommendations, knowing that safety was the overriding intent, and shake my head when the FAA ignores the findings.
That being said, how the heck do they release a statement indicting the TEB controller, when their own timeline of events does not support the statement? They just don’t make irresponsible public announcements such as this. Not even when that hack Marion Blakey was running the NTSB.
The correction statement was less than genuine. Buried under a huge headline that NATCA was kicked off the investigation, and 7 paragraphs attempting to justify this action, came the admission of error. To their credit, most news sources saw through the smoke screen and reported the NTSB admission and the correction as the newsworthy item. The exception was the WSJ which took the predictable ant-union slant and led off with NATCA getting publicly spanked.
I agree with you that both parties need to work through this and NATCA inclusion is vital to the integrity of the investigation.
August 19th, 2009 at 3:33 pm
I disagree. NATCA should have withdrawn from the investigation BEFORE going public with their complaints. Whether NTSB behaved badly is totally irrelevant. NATCA’s party status must not be restored — the precedent would be disastrous in its effect on the integrity of future investigations.
August 19th, 2009 at 4:04 pm
So rules are rules and must never be disagreed with, right Frank?
Didn’t NTSB going public with a statement of fact they could not support violate the agreement as well?
How would the union having pulled out of the investigation prior to going public have changed anything?
August 19th, 2009 at 9:15 pm
“Whether NTSB behaved badly is totally irrelevant”
Frank, really! The NTSB didn’t behave badly. They released incorrect information. Not just insignificant BS, but non-facts that had a direct bearing on the investigation and the controllers reputation. Is it to much to ask of the NTSB to get their facts straight before crucifying the controller via news released?
What happened to the good old days where the NTSB didn’t give out info until they knew (or thought they knew) what actually happened?
August 20th, 2009 at 2:11 pm
How is it right that the NTSB can issue a press release with erroneous information, and punish NATCA for calling them out on it after NATCA gave them the opportunity to correct it?
It would be interesting to find out if the new head of NTSB is close with Marion. You have to wonder if there are other personal, behind the scenes things going on.
August 24th, 2009 at 1:38 pm
Unfortunately, NATCA has a history of “blaming the pilot” in most small plane crashes. The NTSB also has a similar history. This was especially true when M. Blakey was involved with NTSB and FAA.
This history of blaming the pilot (usually dead) has been a successful strategy for these organizations. They’ve been able to deflect any scrutiny of their own errors and incompetencies. Again, this stems from the current culture of government agencies. This history has been seen in Dallas, New York, and the DOT indicates the problem is system-wide.
In the final report, on this case, I certainly expect to see the standard “pilot error” shown as the cause. Due to the history of the agencies, it’ll be difficult to determine if this is the true cause or just another cover-up.
Some upcoming court cases are attempting to take on this “culture of cover-up” at the FAA. Looks like one has a good shot at exposing the ruse of “it’s always pilot error” (the pilot is alive). Multiple issues exist in the Excel-Jet case: controller error, cover-up, gov. attorneys directing their witnesses to disregard critical pieces of physical evidence (thereby leading to false opinions), etc. Unfortunately, in this case the gov. has to smear and try to destroy the career of a very distinguished (military) black pilot in order to make their case. Totally unfair. I think this case will generate media attention and shine some light on the SOP at the FAA.
These issues are critical to GA. The only way to advance safety in aviation is to admit mistakes and learn from them. When this isn’t done lives continue to be lost. I hope Babbitt can change the culture at the FAA/NATCA.
August 24th, 2009 at 2:14 pm
Interesting points Barry. In a VFR See-and -Be-Seen world, I don’t think there is any doubt at all this will be labeled primarily as pilot error.
As you point out though, there are ALWAYS extenuating circumstances.
Was the controller being on the phone the cause here though. Probably not. Sure doesn’t look like he was ready to be much help though.
It is interesting how organizations hide behind the “rules say” when it is convenient. We’ve watched FAA do that for years.
In this case, “the rules” said NATCA is out. Anyone who is a party to an accident needs to add their two cents.
I’m not familiar with the Excel-Jet story you mentioned. What’s that about?
Rob
August 24th, 2009 at 8:03 pm
Rob,
I’ll keep the Excel-Jet story brief here.
In 2006 the Sport-Jet (a VLJ entry by Excel-Jet) crashed/cartwheeled at the Colo. Springs airport. The company sued the gov. related to a controller error. And yes, the gov. claims pilot error. The pilot on board was a very experienced, ex-military, test pilot.
The “PilotMag.com” (july/aug 09) issue has a short piece on this “The Sport-Jet Story.” Seems this is just the beginning of the story. Rumor has it the premier wake vortex research institute in Europe will support/testify on behalf of Excel-Jet.
The best news…the two people in the plane walked away from the crash. The plane has a carbon fiber roll cage (like race cars) to protect occupants. Now that’s the real story!
Some very interesting info is starting to come out of this one. If you’d like a little more detail, I’ll e-mail it to you at jetwhine. Let me know.
Barry
August 24th, 2009 at 8:27 pm
Please do Barry. rob@jetwhine.com
August 25th, 2009 at 8:10 am
[…] NTSB Needs to Re-Admit NATCA to Investigation […]
August 25th, 2009 at 9:54 am
The NTSB has always looked to apportion blame rather than adopt a systems approach to safety and human error. Read this:
Recently, I attended a lecture by Sydney Dekker, pilot, aircraft mishap researcher and a university professor in Sweden. Dekker is an advocate for alternative ways to conduct the human factors portion of a mishap investigation. Some investigators may find his views quite radical (I witnessed this from an NTSB investigator during the lecture) while others will immediately identify with his ideas. I believe everyone who may be called upon to perform human error investigations will benefit from Dekker?s thoughts on the subject.
Taken from: http://www.safetyfromknowledge.com/pdf/FOCUS%20Paper%20on%20Human%20Error.pdf
August 25th, 2009 at 10:03 am
Thanks for that link Dave.
Some might say that the NTSB only apportions blame, but let’s be honest. Their mandate is to decide what happened. That means pointing the finger.
The problem – at least to me – always seemed to focus on the simplicity of the answers … “Pilot failed to maintain control,” … “Pilot flew into IFR weather … ” etc.
The questions they never answer is why the pilot or the controller did what they did. Why did the controller at LEX show up for work with only two hours of sleep that day?
We never hear any more about it.