VAI Spotlight on Safety: If you could see what I’ve seen—An investigator’s perspective on accident prevention How to improve the odds your flight crew makes it home safely tonight. By Seth D. Buttner The First Fatal Aviation Accident I was young when I read the story of the first known fatal aviation accident, the Sep. 17, 1908, crash of a Wright Model A piloted by none other than Orville Wright. The aircraft crashed during a demonstration flight in Fort Myer, Virginia. Wright’s passenger, US Army Lt. Thomas Selfridge, was killed in the event. An investigation was set into motion, led by 1st Lt. Frank Lahm. Lahm was chosen for the investigation because he had the appropriate technical acumen as well as personal experience with the Wright Brothers, having flown in a Model A demonstration just days before. Lahm’s report was issued five months after the accident, which he attributed to a failure in the airplane’s propulsion system. The propeller broke mechanically and struck a bracing wire on the tail, causing the tail to fail in flight. There’s a famous photo of the aftermath of the accident; I have it hanging in my office as a reminder of the details one needs to be aware of in pursuing this passion for aviation science and flight. It’s interesting, isn’t it? Orville, who is synonymous with sparking the dream of aviation, was involved with the first fatal crash and, as a result, the first accident investigation. And Lahm, who had just flown with Wright days prior—who had actually helped pull Wright from the wreckage on that September day in 1908—investigated it. Had events played out differently, Lahm very well could have been flying with Wright at the time of the crash. It’s hard to find a more personal stake in safety than this. As a young man, when I first began learning to fly, I had worked as a helper at my local FBO, where I remember being tasked to disassemble a crashed-up Cessna. I don’t remember the details about its circumstances, but it had been involved in a fatal accident right near my hometown of Crystal Lake, Illinois. There I was, in the apprenticeship stage of my aviation career. I recall working at the FBO thinking about the “how and why” of aviation as I pulled parts and components off the aircraft. And so, the dream of aviation, which I love so much, for me has been viscerally tied to investigations from the start. The Primary Causal Factors of Accidents In the history of accident investigation, we’ve always looked back on the event, trying to puzzle out what went wrong, so we can learn from our mistakes. Of course, today accident investigations work much the same. We follow in Lahm’s footsteps, making engineering changes, safety recommendations, or improvements to aviation practices—whatever it takes. But this can only be done after we’ve fully analyzed the evidence and the circumstances surrounding the crash. In over 30 years of investigations, I can tell you aircraft accidents and crashes have happened for a wide variety of reasons. I’ve seen many! Simply put, accident causes can be broken down into three categories of factors: environmental factors, mechanical factors, and human factors. In my presentations, I often use a logarithmic graph showing two opposite exponential curves with a changing relationship between two of the categories listed above, mechanical factors and human factors (above). This graph shows us that early aviation industry accidents were largely caused by mechanical error. But, as technology has advanced, the portion of accidents caused by pure mechanical flaws has fallen drastically. Today, human factors are almost regularly a primary cause, if not a contributing element in the cause, of aviation accidents. The line on the graph has flipped. So, if we’ve mitigated mechanical error by improving technology, what do we need to do to mitigate human errors? Mitigating Human Error Recently, I was part of a webcast with some other investigators in which we discussed real-life stories and what might tie them together. The conclusion we reached was focus. If pilots and technicians could see and understand firsthand the devastation that resulted from their choices and actions due to unwarranted risk, we’d be able to flatten the curve if not nearly eliminate fatal accidents altogether in aviation. I believe it would intertwine a new thread of safety into your passion for aviation. I’ve investigated over 600 accidents in my career. I’ve seen too many smoking holes, too many broken bodies. If you could see what I’ve seen, you would: • Slow down • Pay attention • Just say no. The most human thing we can do as pilots and maintenance technicians is practice professional techniques. Maintaining respect for the science of aviation, humility in your actions on the job, and patience in your work will take you a long way. In addition, I am certainly a proponent of staying proficient in your training and holding to personal limitations as a key to being a safe, successful aviator. So, back to that initial question: why accident investigation? It’s simple. I want to help us look back, and therein do better in the future. Each accident we investigate gives us another opportunity to learn, to make better, and to keep the dream of aviation soaring. Seth D. Buttner is senior manager, accident investigations, for Airbus Helicopters North America.
