Accident investigations are not courts of law, but they should strive for the ideal of complete objectivity that judicial systems espouse
It is inevitable that national culture affects the way accidents are investigated, but investigators should struggle from beginning to end to ensure that it does not affect the outcome. If it does, not only is the truth obscured, avoided or perverted, but the very process of accident investigation loses its credibility.
The diametrically opposed judgements of the Egyptian and US investigators as to the cause of the EgyptAir Boeing 767 crash leaves the reader of both carefully argued reports struggling with the simple fact that the respective outcomes happen to reflect what, on national grounds, the countries concerned would hope they might be, just as they would have backed their own soccer teams in a game between the two. In the end, readers of the reports are strongly tempted to agree with the report that reflects the cultural thinking closest to their own background.
There have been several examples in recent years of cultural clashes over accident investigation. The recently published Aerospatiale/BAe Concorde investigation (Flight International, 22-28 January) produced cultural sparring between the French and UK investigators, but no fundamental differences over the outcome. The fiercest point of conflict was not cultural but legal and procedural - in France the judiciary control the technical investigation, which the UK maintains does nothing but slow down the determination of the causes. The cultural difference concerned the preferred means of establishing certain facts: the UK would have examined certain phenomena by pure physical testing, whereas the French team preferred to use test results projected by engineering calculation. That boils down to a choice of methodology that happens to be culturally related. However strongly each side may feel about their own approach, at least the reader of the reports can recognise that they both have their validity because neither system is perfect.
A more vicious cultural clash was seen in the now-infamous investigation by the US National Transportation Safety Board (NTSB) of an ATR 72 crash near Roselawn, Indiana, in 1994, in which all 68 people on board were killed. The aircraft iced up and became uncontrollable. The French certification authorities and manufacturer pointed out that the pilots were flying the aircraft for an extended period in known icing conditions that were well outside the aircraft's design limitations, and that their limitations were clearly described in the pilots' operating manual. The NTSB decided that the aircraft's design was fundamentally flawed. Clashes between the NTSB team and the French parties became vitriolic and eventually pointless, entailing verbal exchanges that owed more to the culture of the soccer pitch than air accident investigation. The US Federal Aviation Administration, while it demanded anti-icing system improvements to the ATR, was at odds with the NTSB's basic reasoning, and set up an extensive test programme which established that any of the current turboprop commuter types would have been at risk of going out of control in the same circumstances.
The 1997 Silk Air Boeing 737-300 crash in Indonesia brought a difference of conclusions. The Indonesian accident investigators said that they could reach no conclusion at all. The NTSB argued that there was such a massive weight of circumstantial evidence in events that occurred just before the aircraft entered a far more dramatic dive than the one that led to the EgyptAir 767 crash - being almost vertical with the engines developing power at impact - that the crash was deliberately caused by the captain. The different conclusions resulted from the Indonesian investigator's decision to demand the equivalent of judicial proof of cause, while the NTSB's mandate is to determine a "probable cause".
In the EgyptAir investigation things got off to the worst possible start when, leaked to the press from the NTSB/Federal Bureau of Investigation camp even before the aircraft's flight data recorder had been recovered, came the "information" that the crash was the result of the relief co-pilot's intent to commit suicide, deduced mainly because he had started praying in Arabic just before the aircraft nosed over into a dive.
From that point onwards the Egyptian and US investigators, quite apart from the Egyptian and US public and media, were involuntarily tipped into polarised approaches. The NTSB has done much in its investigation to repair the damage done, but complete objectivity had been rendered almost impossible. This mistake must never happen again.
Source: Flight International
