Accident Investigation

On May 20, 1926, the U.S. Congress passed the Air Commerce Act, a bill that had far-reaching implications. It gave the U.S. Department of Commerce, under William P. MacCracken, Jr., responsibility for testing and licensing pilots, issuing certificates for aircraft that were airworthy, establishing airways and aids to air navigation, and making and enforcing safety rules. The Department of Commerce created an Aeronautics Branch, also headed by MacCracken, to carry out these duties. MacCracken's staff was given responsibility for investigating air accidents. It was also to determine if any of the other Aeronautics Branch responsibilities needed changing or strengthening to prevent future accidents.

On March 31, 1931, a Fokker trimotor airplane flown by Transcontinental and Western Air lost a wing and crashed on a Kansas farm, killing all on board. One of those killed was the popular football coach from the University of Notre Dame, Knute Rockne. The intense public scrutiny generated by the crash forced the Aeronautics Branch to abandon its policy of secrecy concerning the results of accident investigations. The Branch eventually pinned the crash on an aircraft design flaw and banned the model from passenger service pending corrective action.

In 1935, a DC-2 also flown by Transcontinental and Western Air crashed and killed U.S. Senator Bronson M. Cutting from New Mexico. Many closely followed the investigations by the Bureau of Air Commerce (successor to the Aeronautics Branch) and by Congress. While the Bureau's report placed most of the blame on the airline, the congressional investigation highlighted problems with the Bureau's procedures and navigation aids. 

After the investigations, Congress concluded that the Department of Commerce and its Bureau of Air Commerce were reluctant to admit that the accidents may have been related to their own rules and procedures. Congress also stated that the Bureau worked too closely with the commercial airlines and aircraft manufacturers to be objective. The Bureau was supposed to promote commerce through aviation, but at the same time, it was to find the cause of accidents, even if that meant embarrassing itself or American companies. In 1938, the Civil Aeronautics Act established the new Civil Aeronautics Authority (CAA) and its three-member Air Safety Board to conduct accident investigations and recommend ways of preventing accidents entirely free from pressure by the aviation industry or government.

In 1940, President Franklin D. Roosevelt split the authority into two agencies: the Civil Aeronautics Administration (CAA) and the independent Civil Aeronautics Board (CAB). The CAA took responsibility for air traffic control, airman and aircraft certification, safety enforcement, and airway development. The CAB assumed safety rulemaking, economic regulation of the airlines, and accident investigation. It also was charged with determining if any other government functions relating to aviation contributed to air accidents because procedures were difficult to follow or because government requirements did not call for the proper equipment.

From World War II until 1958, the government focused on helping airports and the air traffic control system grow and on regulating the economics of air travel. Accident investigation remained very important, but no new legislation was passed. Then, in 1958, a series of midair collisions led to new interest in air traffic control. Investigations revealed that the crashes, at least in part, were caused by the two different air traffic control systems that existed—one military and the other civilian—in the same national airspace. The Federal Aviation Act that created the Federal Aviation Agency (FAA), led by its first administrator Elwood “Pete” Quesada, would consolidate the airspace system into a single system while assuring the Department of Defense that it would get control of the airspaces in wartime. Safety rulemaking would transfer from the CAB to the new FAA, as well as concentrate on building new technology. Accident investigation would remain with the CAB.

In 1966, Congress authorized a new Department of Transportation (DOT) to begin operations on April l, 1967. FAA was renamed the Federal Aviation Administration and placed within the new cabinet-level department. At the same time, the CAB transferred its accident investigation role to the new National Transportation Safety Board (NTSB), which was placed within DOT for support purposes but would act independently of it. The five NTSB members were appointed by the President for five-year terms and confirmed by the U.S. Senate. The NTSB would also make recommendations to government regulatory groups related to preventing future accidents. After passage of the Transportation Safety Act of 1974, the NTSB became completely independent from DOT.

In 1975, the FAA and the National Aeronautics and Space Administration (NASA) jointly established the Aviation Safety Reporting System (ASRS). This system encourages voluntary reporting of dangerous incidents in flying by granting certain protections to those making the reports. The ASRS provides information that is used to identify potential hazards in the national aviation system for possible action. Since its formation in 1975, more than 300,000 voluntary ASRS reports have been analyzed. The data has shown that more than two-thirds of all aviation accidents and incidents are caused by human performance, including improper actions by pilots, air traffic controllers, flight attendants, mechanics, and airline ground personnel, rather than by mechanical or weather problems.

In their search for the causes of accidents, investigators have continued to apply advanced technology. Examples include new flight data recorders able to provide more types of information about what happened to an aircraft before it crashed. In terms of organization, the role of the Federal Government in accident investigation has remained basically the same since 1975. As of August 2001, the NTSB employs about 400 staff members who investigate about 2,000 aviation accidents and incidents a year. An accident is associated with the operation of an aircraft that takes place between the time any person boards the aircraft intending to fly and the time all passengers have disembarked in which anyone dies or is seriously injured or in which the aircraft is substantially damaged. An incident is an event other than an accident that affects or could affect safe operations.

--Roger Mola

Selected Bibliography

Bilstein, Roger E. Flight in America, From the Wrights to the Astronauts. Revised Edition. Baltimore: Johns Hopkins University Press, 1994.

Burkhardt, Robert. The Federal Aviation Administration. New York: Frederick A. Praeger, 1967.

Komons, Nick A. Bonfires to Beacons: Federal Civil Aviation Policy Under the Air Commerce Act, 1926-1938. Washington, DOT/FAA, 1980.

Air Disasters 1920-2000. http://www.airdisasters.co.uk

Air Transport Association, Airline Handbook, Chapter 6: “Safety.” http://www.air-transport.org/public/Handbook/Default.htm.

FAA Historical Chronology. http://faa.gov/docs/A-INTRO.htm

NASA Aviation Safety Reporting System. http://asrs.arc.nasa.gov

National Transportation Safety Board, Aviation Accident Investigation. http://www.ntsb.gov/aviation/aviation.htm

Additional References:

Jones, Fred. Air Crash: The Clues in the Wreckage. London: Hale, 1985.

Krause, Shari Stamford. Aircraft Safety: Accident Investigations, Analyses, and Applications. New York: McGraw-Hill, 1996

Stewart, Stanley. Air Disasters. London: I. Allan, 1986.