Thursday, March 26, 2009

The Colgan Air accident: Don't draw conclusions from incomplete information

Colgan Air logoYesterday the U.S. National Transportation Safety Board (NTSB) issued a factual update about last month's Colgan Air Dash 8-Q400 accident near Buffalo. The NTSB update provided fodder for a new round of speculation by the news media regarding what may have caused Flight 3407 to crash on February 12, 2009. Last month those stories focused on icing; now the media spotlight has shifted to actions by the crew.

But hey, folks: we still have only bits and pieces of the story. The investigation is still underway, and -- more to the point -- it is only in its early stages. The NTSB is still collecting and collating a massive amount of data - about the aircraft and its systems; about the crew, their actions during the accident flight, their backgrounds and training; about operations, maintenance procedures and training practices of the carrier; and about environmental conditions aloft on the night of the crash. The latest update gives us a peek at a few more data points among the thousands that will be considered, but does not draw conclusions. Neither should the press.

I think this is the underlying message in a statement issued yesterday by Colgan Air in response to the latest NTSB update. Here is that statement:
We welcome the update from the NTSB on the progress of this investigation. As the report clearly indicates, there is still no definitive conclusion as to what caused this accident. It remains an active investigation and one with which we are cooperating thoroughly.

It’s important not to jump to conclusions, and instead focus on what is factual and released by the investigating team at the NTSB. Nothing in today’s announcement pinpoints a cause nor does it offer theories on a cause, as was suggested in some news reports. Again, the only absolute fact is that we do not know the cause of this accident.

We look forward to discussing recommendations the NTSB may have that could make our industry even safer. We stand by our FAA-certified crew training programs which meet or exceed the regulatory requirements for all major airlines and include training on emergency situations. When our crews fly our aircraft, we believe, and the FAA has certified, that our crews are prepared to handle emergency situations they might face.
It is tempting to infer probable cause from isolated facts in NTSB updates, but all of us would do well to remember that we do not yet know all the facts. We were not on the flight deck of the accident aircraft; we have not heard the contents of the cockpit voice recorder; we have not seen all the data from the flight data recorder; we have not examined all the debris from the aircraft - and even if we had heard and seen all of the above, we -- like the NTSB, at this point -- still would not be able to conclusively state the cause for this accident.

Once the NTSB assembles and models all of the data and information they have collected, they will issue a comprehensive final report that will make public their conclusions regarding probable cause. In addition, they will likely make one or more safety recommendations intended to correct a flaw, refine a procedure, or supplement crew training so that a similar accident can be avoided in the future.

Armchair accident investigators -- in the media and elsewhere -- would do well to learn and acknowledge that there is very rarely a single item than can be isolated as a causal event. Instead, accidents result from the interaction of a host of conditions, decisions, actions, and reactions, known colloquially as the Swiss Cheese Model. It is the job of the NTSB to figure out how it was that the holes in the Swiss Cheese slices lined up, allowing the accident to happen. This can't be discerned by examining one slice at a time.

We all can guess what might have caused an accident, and in the end, some of us will have guessed correctly.  But until all of the details and data are known, we cannot -- and should not -- present our guesses about probable cause as if they were facts.

RELATED: Click here to view all posts about Colgan Air Flt 3407 on Aircrew Buzz.