Accident Investigation Guide: 2005 Edition

Chapter 9—Aviation Investigations

9.1 Introduction

Aviation resources operate under the concept of total interagency mobilization that moves across agency boundaries. Because of this mobility, information about specific accidents or incidents and the lessons learned from these situations must be disseminated quickly and thoroughly.

9.2 Scope and Purpose

The National Transportation Safely Board (NTSB) has the responsibility to investigate all Forest Service aviation accidents.

The investigation process and report should follow procedures already established in this guide. Specific differences that apply to aviation mishaps (accidents and incidents with potential) are identified in this chapter.

9.3 National Transportation Safety Board Investigations

Working with the NTSB creates unique interagency working relationships due to differences in policies and procedures.

The NTSB will conduct the investigation in one of the following ways.

1. The NTSB investigator in charge (IIC) conducts the onsite investigation.
   
   
   • When the IIC conducts the onsite investigation, the qualified technical investigator assists the IIC as requested in the collection of data to support the NTSB factual report.
     
     
2. The IIC delegates the onsite investigation to the Federal Aviation Administration (FAA).
   
   
   • When the FAA conducts the onsite investigation, they do so with the full authority of the NTSB. The QTI will be the liaison with the FAA onsite investigator.
     
     
3. The IIC delegates the onsite investigation to the Forest Service.
   
   
   • When neither the NTSB nor the FAA conduct the onsite investigation, the QTI will conduct the onsite investigation and provide all data collected to the IIC.

9.4 Forest Service Investigations

1. NTSB Led Investigations
   
   The NTSB will appoint an investigator in charge (IIC) to perform the NTSB factual investigation. The investigation process and direction is under the authority of the IIC.
   
   The Forest Service investigation team will conduct their investigation following the investigation guide procedures in this guide concurrent with the NTSB. The Forest Service QTI will be a member of the NTSB investigation and will be the liaison between the Forest Service and the NTSB.
   
   The NTSB IIC will lead the factual investigation. NTSB investigations, whether conducted by the NTSB or its agent, shall have precedence over all other activities.
   
   
2. FAA Lead Investigations
   
   All onsite investigations conducted by the FAA shall be accomplished in the same manner as the NTSB conducted investigations.
   
   
3. Forest Service Led Investigations
   
   Forest Service accident investigation teams shall follow the procedures outlined in this guide.

9.5 Composition of the Investigation Team

Refer to chapter 1.5 for composition of the investigation team.

9.6 Forest Service Accident Investigation Report

1. The NTSB IIC will produce an official NTSB Factual Report. Due to the Forest Service requirement for a report within 45 days, a preliminary accident investigation report is produced that includes a factual section and a management evaluation section. The QTI will coordinate closely with the NTSB IIC to produce the Forest Service preliminary report for agency use, following the procedures established in chapter 6. This Forest Service preliminary report must be reviewed and approved for release by the NTSB IIC before going to the Accident Review Board (exhibit 9–1). The Forest Service preliminary report will remain preliminary until release of the NTSB Factual Report.
   
   
2. The NTSB is responsible for the factual investigation of all Forest Service aircraft accidents. The NTSB report is prepared using NTSB forms and format and may take up to 12 months to complete. When the NTSB Factual Report is released, the National Aviation Safety Center will evaluate and determine whether any significant factual findings differ with the Forest Service preliminary report. If significant differences are found, the national aviation safety manager may request, through the appropriate authorities, to reconvene the Accident Review Board.
   
   
3. The Forest Service preliminary factual section is used for developing the management evaluation section (exhibit 9–3).

9.7 Aviation Investigation Sequence

1. The aviation investigation sequence will follow the format established in chapter 1.7. The aviation investigation sequence is unique in that the QTI must collaborate closely with the NTSB IIC and the Forest Service team leader to ensure information sharing and release of information.
   
   
2. The QTI will attend all NTSB meetings and will brief the
   Forest Service team leader.

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