National Transportation Safety Board and Forensics

DATE: Established on April 1, 1967

IDENTIFICATION: US government agency responsible for investigating major transportation accidents involving motor vehicles, trains, airplanes, and ships.

SIGNIFICANCE: Investigators for the National Transportation Safety Board use forensic science techniques to examine the causes of transportation accidents and make recommendations aimed at improving safety based on their findings.

The National Transportation Safety Board (NTSB) was created within the US Department of Transportation in 1967 by President Lyndon B. Johnson . Initially, the NTSB was a political organization and thus susceptible to political manipulation, but in 1974 it was granted independent agency status. This meant that board members could not be removed by the president and that both the Republican and Democratic parties could nominate members to ensure partisan balance on the board.

One of the smallest agencies within the federal government, the NTSB is responsible for investigating accidents and incidents involving most major forms of transportation. Although the work of the NTSB is perhaps most strongly associated with airplane crashes, the board is also responsible for the investigation of pipeline, railroad, and ship accidents as well as some accidents involving motor vehicles. Pipeline ruptures and accidents involving vehicles carrying hazardous waste fall under NTSB control, as do train derailments and collisions and any incidents causing injury or death to railroad employees. Marine accidents (such as ships running aground or sinking) and other incidents (such as fires) involving commercial cargo ships or passenger cruise ships also come under NTSB scrutiny. The highway accidents investigated by the NTSB are usually those involving multiple vehicles or large passenger vehicles, such as interstate buses. The board also examines accidents caused by failures in road construction and engineering.

Making Air Flight Safer

The NTSB focuses on finding the causes of the accidents it investigates and making recommendations to prevent future accidents. The NTSB categorizes the causes of accidents as resulting from mechanical failure, human error, or a mix of both. When NTSB investigators find mechanical failure as a cause of an airplane crash, this prompts NTSB recommendations to manufacturers that are intended to solve the problem and prevent future accidents.

Carrying out NTSB recommendations following a finding of human error in an airplane crash can require coordination among the NTSB, the airline, and the Federal Aviation Administration (FAA). For example, the crash of ValuJet Flight 592 in the Florida Everglades in 1996 was attributed to a fire in the plane’s cargo hold caused by chemical oxygen generators. Following the NTSB investigation, the NTSB and FAA created new guidelines for airline cargo, including a requirement for active fire suppression devices, to prevent any other occurrence of the same kind of disaster.

NTSB and

Unlike most law-enforcement investigators, NTSB investigators have access to “eyewitness” in almost every air crash. The flight data recorder, popularly known as the black box, provides evidence of a plane’s mechanical functions before and during a crash, including any malfunctioning. The voice data recorder allows investigators to hear all conversations among the flight crew and between the crew and airport tower personnel. Both recorders are designed to survive crashes. The information provided by the recorders provides NTSB investigators with clues as to where they should look to explain the disaster. From there, they can examine parts of the plane that malfunctioned or interview members of the crew or tower personnel to find out what went wrong.

The ability of NTSB investigators to piece together what occurred immediately before and during an air disaster has put the NTSB in the forefront of forensic science. In the case of the explosion and crash of Trans World Airline (TWA) Flight 800 in the Atlantic Ocean in 1996, for example, NTSB investigators literally rebuilt the plane from recovered pieces and traced back what may have malfunctioned and led to the explosion. This effort required minute examination of every part of the plane, but the investigators eventually determined that the likely cause of the explosion and resulting crash was faulty wiring near a center fuel tank.

Another crash, that of Air Midwest Flight 5481 soon after takeoff from Charlotte, North Carolina, in 2003, was attributed by the NTSB to plane maintenance problems but also to FAA regulations concerning passengers and their luggage. By not updating these regulations, the FAA had allowed the plane to fly with excessive weight that was unbalanced as the plane took off, leading to the crash. In this case, the NTSB conducted a more conventional forensic investigation, using simulations and eyewitness reports to determine how the weight had shifted within the plane during takeoff.

In investigating airplane manufacturing or design problems, the NTSB works with aircraft companies and examines how particular airplanes are constructed. Investigators also seek out information on any mechanical problems that have been noted with particular types of airplanes and records on the maintenance of the aircraft in question. After Alaska Airlines Flight 261 crashed into the Pacific Ocean in January 2000, the NTSB investigated the possibility of both human and mechanical errors. Investigators concluded from their examination of mechanical aspects of the plane as well as maintenance records that the airline and the FAA were lax in their procedures and allowed some routine maintenance to be delayed beyond recommended times.

The NTSB uncovered additional maintenance problems in January 2024. The door of a Boeing 737 Max 9 operated by Alaska Airlines blew off the plane as it flew full of passengers, leaving a gaping hole in the side of the fuselage when it was about 16,000 feet in the air. The NTSB concluded that bolts had been missing in the door. The plane was scheduled for maintenance because airline engineers were concerned about warning lights. After the incident, all Max 9 aircraft, operated by Alaska Airlines and United Airlines, were grounded for inspections.

Bibliography

Adair, Bill. The Mystery of Flight 427: Inside a Crash Investigation. Washington, D.C.: Smithsonian Institution Press, 2002.

Bibel, George. Beyond the Black Box: The Forensics of Airline Crashes. Baltimore: The Johns Hopkins University Press, 2007.

Cobb, Roger W., and David M. Primo. The Plane Truth: Airline Crashes, the Media, and Transportation Policy. Washington, D.C.: Brookings Institution, 2003.

Faith, Nicholas. Black Box: The Air-Crash Detectives—Why Air Safety Is No Accident. Osceola, Wis.: Motorbooks International, 1997.

"Flight Control System Leads to Fatal Floatplane Crash." National Transportation Safety Board, 5 Oct. 2023, www.ntsb.gov/news/press-releases/Pages/NR20231005.aspx. Accessed 15 Aug. 2024.

Josephs, Leslie. "Bolts Appeared to Be Missing from Boeing 737 Max Door Plug That Blew Off Midflight, NTSB Says. CNBC, 6 Feb. 2024, www.cnbc.com/2024/02/06/ntsb-boeing-737-max-9-report-bolts-appeared-missing-from-alaska-air-plane.html. Accessed 15 Aug. 2024.

Krause, Shari Stamford. Aircraft Safety: Accident Investigations, Analyses, and Applications. 2d ed. New York: McGraw-Hill, 2003.

Lebow, Cynthia C., et al. Safety in the Skies: Personnel and Parties in NTSB Aviation Accident Investigations. Santa Monica, Calif.: RAND, 1999.

Schiavo, Mary, with Sabra Chartrand. Flying Blind, Flying Safe. New York: Avon Books, 1997.