bill english, ntsb
TRANSCRIPT
NTSB Accident and Incident Investigations
From Triple-sevens to Quad-copters
Bill English
NTSB Investigator in Charge
SUSB Expo, April 28, 2015
San Francisco Last time I was here… The drone will fly
in from right over there…
Introduction
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• Participants in pending commercial segment
• Professionals, aviation industry
• Must deal with accidents/incidents/events
What is the NTSB?
• Investigative agency
• “Determine Probable Cause, and make recommendations to prevent recurrence.”
• Independent – not FAA, DoT etc.
• Board – 5 Presidential Appointees
• Modes and Support
• Aviation, Rail/Pipeline/Hazmat, Marine, Highway
• Laboratory: Recorders, Materials, Vehicle Perf.
• Safety Rec’s, Family Assist, Public Affairs, Legal
• Wait, isn’t there another function of the Board?
Board also hears appeals
• FAA certificate/civil penalty
• Also Coast Guard penalties
• Administrative Law Judge
• First level
• Full Board
• Pirker case
• Did NOT redefine the term aircraft:
• “49 USC 40102(a)(6) [and] 14 CFR 1.1…are clear on their face.”
• Decided a narrow issue:
• “the prohibition on careless and reckless operation in 14 CFR §91.13(a)”
• Mooted by PL 112-95
• No applicability to commercial operation
How does NTSB work?
• Investigate accidents and incidents, by statute
• History of UAS involvement
• Not isolation – party system
• International treaties/protocols
• Scope
• Incidents (Events) – 830.5 notifications, options. Hobby? Sightings? “Safety issues”
• Thorough - appropriate
• Limits - Pt103, Enforcement, Security, Privacy (White House guy)
• Media relations
What defines a UAS accident?
• Civil aircraft
• Or non-military Public (Fed/State/Local)
• Sec 333, COAs, Exp, Part 107 (pending)
• Substantial Damage and/or Serious Injury or Fatality
• “from the time the system is activated”
• Excludes <300 lbs if no injuries
• Required Notifications
• In-flight fire, flight control malfunction (define?), crew member
incapacitation, midair collision, $25000 ground damage, rotor
blade damage (!!) etc.
• Other Significant Safety Events
Sightings
• FAA developing a
taxonomy/procedure for
handling – multiple
functions
• Safety, Enforcement,
Security, Privacy
• Possibly like Runway
Incursion index,and/or
Laser events.
• LEA guidance
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sUAS stakeholder roles
• Party system
• Direct role in investigation
• Safety/Technical participants
• Work under NTSB
investigator/groups
• Provide all relevant info
• Access to all factual info
sUAS stakeholder roles
• Operator
• Commercial company
• Public Agency
• Individual (General Aviation)
• Manufacturer
• Assembler?
• Software?
• Regulator
• FAA, by law
• Public Agency – if PAO
• Foreign entities - ICAO Annex 13
• Others - as appropriate
Preparation for events
• Staff for safety
• Company response structure
• Checklists – what to lock down
• Response – what to bring along
• Know your hardware/software/documentation
• Safety/SMS
• Your internal assessment
• Operational and Airworthiness records
• What to report
• NTSB form 6120
• FAA
• Others (AAIB-UK)
Investigations in practice
• A major civil UAS accident
• No way to predict scenario
• Avoid the “Three Mile Island Event”
• Safety investigation principles
• Causes and recommendations• Not enforcement
For illustration only – not an actual event
Press and Pressures
Investigator
Board
Member
Investigations in practice
• Determine safety issues in context
• Man/Machine/Environment
• (Management, Method)
• Sequence of Events – “What”
• Empirical, documented
• Active Failures/Factors
• “How” did each event occur
• Root Cause(s) – “Why”
Investigations in practice
• Move from Direct/Proximate Causes…
• Sequence of events
• Identify gaps
• Iterate sequence
• To Root Causes/Latent Conditions
• Often organizational/cultural
Investigations in practice
MAN-MACHINE
INTERFACEPROCEDURES
TRAINING
MANUFACTURING /
INSTALLATIONMAINTENANCE DESIGNMISUSE
SUPERVISION &
STAFFING
PERSONAL
CONDITIONCOMMUNICATION
PLANNING &
RECORDS
VERIFICATION /
VALIDATION
REQUIREMENTS
SPECIFICATION
SAFETY /
RELIABILITY
ASSESSMENT
QUALITY & SAFETY
ASSURANCE
HUMAN ERROR
(OPERATIONAL)
KEY EVENT
EQUIPMENT
FAILURE
FAILED/MISSING
SAFETY
CONTROL
REQUIREMENTS
IMPLEMENTATION
Regulator
RO
OT
CA
US
E
Manufacturer
Operator
Direct Causes
Investigations and Issues
• Real life lessons learned
• “How drones crash” – common scenarios
• Military history
• Factors/Causes:
• Carb ice
• Mission Pressure
• Ditching
• No divert capability
• Loss of Control
• No battery monitoring
• Mode Confusion
• New function test engaged
• Case Studies – Police Helo, Multi-rotor battery
Investigations and Issues
• Similarities and difference to manned?
• Commonality with technically advanced aircraft
– large and small
• Mode Confusion: “What’s it doing now?”
• Common features to investigating ATC
• Recorded data – no standards
• Frequency spectrum aspect
• Plan your flight, fly your plan
Four Principles of Drone Safety(inspired by Jeff Cooper and Isaac Asimov)
• Treat all drones as if they are always powered up
• Ground injuries, hazardous materials or components
• Never fly over anything or into airspace you have
not considered
• Your specifc mission and capabilities – 107? LE?
• Crowds? Controlled Airspace? Terrain and weather!
• Ensure your drone is ready for and capable of your
planned mission
• Right platform for this job? Modifications? Mission pressure,
Terrain and weather!!
• Be sure of your flight mode and what it will do next.
• “Ahead of the aircraft”
Case Study
• Mishap scenario - Lake Conroe
• Police Dep’t received grant
• Local manufacturer – “military grade”
• Aircraft lost after main rotor blade delamination
• Blade manufacture of hobby-grade
• Previous maintenance/mishap events
• Inappropriate platform for mission
• Lack of awareness of airworthiness responsibility
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Case Study
• Mishap scenario - Lake Conroe
• Police Dep’t received grant
• Local manufacturer – “military grade”
• Aircraft lost after main rotor blade delamination
• Blade manufacture of hobby-grade
• Previous maintenance/mishap events
• Inappropriate platform for mission
• Lack of awareness of airworthiness responsibility
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Determine Cause - event redacted for discussion
• Mishap scenario – Individual Videographer • Prep flight for filming job, COTS multi-rotor
• Flew mission, low battery, lost aircraft
• Pilot statement – had flown length before, was “sure” battery was fully charged
• Telemetry data:• Long period powered on ground
• Took off with low voltage
• Failsafe returned to launch
• Pilot switched modes, returned to mission
• Failsafe again triggered – too late
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FCC Critical Set
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Sequence of Events – Gaps?
Takes off with low
voltage
Battery failsafe –
RTL overridden
Executes moderate
length mission
Top Level Event
Low voltage,
motors fail
Pilot: Battery fully charged
Ground delay
Pilot switches modes
Mission continues over
residential area
What is history
of battery -
cycles?
Does pilot understand
GCS battery monitor?
Documentation?
Pilot monitor
battery voltage
at GCS? Pressure to
complete?
Significance of mode
switching – training,
documentation?
NPRM/Part 107
• NTSB has commented
• [TBD when notation finalized]
• Expands the universe of civil aircraft operations
• Some unknown territory
• Operational – Test or Flight Training vendors and prep?
• Airworthiness/Maintenance – Manufacturer/vendor
support?
• Part 830 will apply – scoped appropriately
• Will we modify 830?
Summary
• Events will happen, robust investigations, you are part of this – before/during/after
Bill English
202-297-8875
NTSB Comm Center
202-314-6290
Questions and War Stories
“There I was…flat on my back at 20,000 feet...”
