Wednesday, July 03, 2002


A few days ago I wrote about how airline crashes have “causes” much more complex than what you read about in the paper, and how the NTSB looks always at the whole system, not just the proximate cause of a particular accident. I promised you information about those investigations in the hopes of generating ideas for an appropriate response to the Church Situation. Herewith, my follow-up.

The National Transportation Safety Board is an independent agency of the federal government, and though it is best known for handling investigations of airline disasters, it also investigates private plane crashes, the railway system, highways, marine incidents, and pipelines and other hazardous material delivery systems. Board members are political appointees, nominated by the President to serve a five-year term. They are not subject to removal except for cause, and, unlike other appointees in many agencies, invariably bring a background in government and industry that makes them highly expert from the day they start on the job. The five-year term helps ensure that appointees will vary from administration to administration. THE NTSB is not an arm of the Transportation department, cannot make regulatory changes, and has no enforcement powers (with slight, irrelevant exceptions).

When an airplane suffers “major damage” in an accident, the NTSB sends an investigative team to the site right away, to determine the causes. The “go-team” varies in size and configuration depending on many factors, but it generally includes the same types of people. First, the team is headed by an NTSB employee, a highly trained expert in accident investigation and managing a team of people with competing interests. Other, more junior experts from the NTSB are also assigned as cases demand. Generally speaking, the more visible the incident—i.e., the more deaths—the more likely the team will get a lot of resources.

Other members of the team usually include representatives of the airframe and engine manufacturers, the involved airline, law enforcement (at least until criminal causes have been ruled out), and other government agencies as necessary (for instance, the FAA, air traffic controllers, forensic pathologists, explosives specialists, etc.). Of late, the FAA and NTSB and airlines have also been making staff available to families of victims, though to the best of my knowledge there is no formal role for families in the investigation.

It may seem a conflict of interest to include the airline and manufacturers in the investigation. After all, each of them has a vested interest in blaming one of the others, in order to avoid potential civil liability. But their expertise is absolutely critical: no one knows the systems like the people who built it, and no one can explain the procedures better than the airline that wrote them. And the competing interests of the three parties generally have the effect of keeping everyone honest. Attempts at concealment by one are sure to be revealed by the others if discovered.

The investigation itself involves recovering every possible speck of the wreckage, every possible body and piece of luggage, first and foremost. Then interviews with everyone who had anything to do with the flight: surviving crew and passengers, ATC personnel, the maintenance crew that last worked on the plane, even gate attendants and catering staff can be interviewed in some cases. The last flight crew to use the plane before the crash also gets interviewed. Witnesses on the ground, surviving videotape, etc. etc. The data collected is massive and exhaustive. (Look here for the report on TWA 800, but be warned: it is a very large PDF file.)

At the end of the gathering, public hearings are held to examine the data and make the best possible judgments about what went wrong, both immediately, and systemically, to allow the crash to happen. Because the NTSB has no enforcement powers, and cannot even mandate but only recommend safety changes, the people involved are able to be more honest. And, with only very narrow exceptions, the data in an NTSB report cannot be used as evidence in a civil or criminal proceeding.

There are many possible pitfalls to attempting to create an NTSB-like investigation of the current Scandal. But only an honest assessment of the many complex factors that led to it, interwoven and horrifically tangled as they are, can lead us back out of it. Prayer, living the Gospel, practicing what we teach: these are all essential prerequisites, without which any attempt at repairing the damage will surely fail. But they are not sufficient, because by themselves they do not root out the problems any more than Air Florida could fix its icing procedures and be sure of not having another accident. The old cliché about “an accident waiting to happen” inspires the NTSB to exhaustive work. But writing a policy on sexual abuse, or kicking gay men out of the seminaries, or any other solution mooted right now addresses only a single aspect of the problem, which guarantees that something bad will happen again, sooner rather than later.


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