Swissair probe suffered a lack of resources, report reveals

Canadian Press

Ottawa � The massive investigation into the 1998 crash of Swissair flight 111 suffered from a chronic shortage of people and technology, says a newly released document.

"Human resources available and assigned to the (Swissair) team were inadequate to sustain a prolonged complex investigation, which resulted in an insufficient number of qualified personnel available for certain tasks," says a July 4 report from the Transportation Safety Board.

There was an "excessive workload for those assigned to the team, and an inordinate amount of overtime over a very long period."

The scathing report, obtained under the Access to Information Act, raises basic questions about training, noting that "some investigation team members were not sufficiently knowledgeable about international investigation standards, protocols and procedures."

The final report into the Sept. 2, 1998, crash, which killed all 229 people aboard, took more than 4-and-a-half years to produce � and the so-called lessons-learned analysis suggests a lack of resources was a significant factor in the delay.

Administrative support to the $56.8-million probe was inadequate, the level of technical help required for the investigation was underestimated, and consulting contracts for outside assistance were beset by delays and difficulties.

The overtime bills alone speak to how the investigation team, led by veteran Vic Gerden, was badly overworked. The total paid to date is $7.4 million, much of it occurring in the first year.

Even the writing of the final report, which was delivered March 27, suffered delays because the editorial staff hired to produce it were unfamiliar with the technical aspects of a crash investigation.

"The technical accuracy of the report . . . was at times inadvertently changed during the editing, thereby requiring that TSB investigators invariably reverify, re-edit and redraft text."

Twice in the last three years the board has come under criticism in transportation industry surveys for the excessively long time it takes to report on major accidents. As of August, 74 of 154 active investigations were more than a year old, even though the agency aims to complete the majority of its probes within a year.

The lessons-learned report, which was produced by the board's air branch, is only the first of many arising out of the Swissair investigation, the most expensive and complex since the TSB was founded in 1990.

The board's executive director, David Kinsman, has ordered an agency-wide post-mortem on the Swissair experience, to be completed by next March 31.

"Swissair, because of the size of it, has a lot of impacts that go across all the boundaries within the organization," Mr. Kinsman said in an interview.

He acknowledged that the investigation stretched the agency to its limits, forcing it to "come up with a couple of hybrid solutions for Swissair . . . it wasn't an easy process."

Mr. Kinsman declined to comment on whether the lack of resources delayed production of the final report.

"I personally haven't reached any conclusions in that regard," he said.

The agency was forced to go to Treasury Board for $60 million in extra funding to cover the cost of the Swissair investigation, which involved months of retrieving shattered debris from the ocean floor off Peggy's Cove, N.S., and the reconstruction of parts of the airframe in a Halifax hangar.

Mr. Kinsman said Treasury Board provided all the money that was requested.

One change already arising out of the Swissair experience is the development of a new computer system that will better manage technical information in an accident probe, he added.

http://www.globeandmail.ca/servlet/story/RTGAM.20031108.wswiss1108/BNStory/Front/

This sounds similar to what they say about the NTSB here in the U.S. I don't find any of the problems mentioned here at all surprising, particularly that they were underfunded or had to supervise the writing in the final report. Glad to hear that they did! Furthermore, I hope nobody will take the words stated in this article out of context. It doesn't imply that the report was inaccurate only that they needed to correct the way it was written in some cases which they clearly did. Let's just hope that individuals don't use this information to further their own agenda. I trust that the final report is accurate. I don't agree with everything written in the report (the pilots' ability to land) but for the most part I am satisfied with their conclusions except in some cases I don't think they went far enough. This was a very complex investigation and I think they did the best they could with what they had. I'll be interested to see that report in March if it is available to the public and what they do to remedy the problems they encountered.

Just look at what the Rand Report says about the NTSB here in the U.S. This is from Air Safety Week:

Review of Accident Investigation Procedures Eschews Sweeping Reform
Dec 13, 1999
RAND Report Finds Safety Board Spread Thin
"Status quo plus" may best describe the recommendations resulting from a major review of accident investigation procedures.

After more than a year's effort at a cost of some $400,000, the results of the first independent review of the National Transportation Safety Board's (NTSB) workload and the "party system" of accident investigations were announced last week. The RAND Corporation's Institute for Civil Justice performed the review at the request of NTSB Chairman Jim Hall.

The report described the NTSB as insular, overworked, underfunded, understaffed, and undertrained for the growing complexity of accident investigations involving new technology aircraft. Chairman Hall said simply that he initiated the study "with no misunderstanding when you ask for a report in Washington, DC that it comes back saying everything is rosy."

Regarding the parlous state of fiscal and human resources for the NTSB's burdensome mission, Hall said bluntly, "I have repeatedly gone to Congress asking for more money and personnel, and every year OMB (the Office of Management and Budget) has zeroed it out."

Hall hastened to add, "I'm not interested in building a large bureaucracy."

While recognizing the potential conflict of interest in the "party system," whereby manufacturers, airlines, unions, and other organizations participate in accident investigations, the RAND study stopped short of recommending any significant change to the arrangement. For example, one of the issues was whether or not the parties' role should be expanded from their involvement in fact-finding to include the analysis phase of the investigation, and perhaps even their involvement in the writing of the report.

Cynthia Lebow, who led the RAND study, said, "We came out recommending that the party process should stay where it is." By that she meant the current membership should be maintained and the parties "should stick to fact-finding, not analysis."

While endorsing the current system, Lebow said the limitations of the party system need to be addressed. For example, the NTSB could augment its in-house resources by retaining the services of outside laboratories. The Safety Board, Lebow urged, needs a "network of sources and expertise so they can supplement their own knowledge."

Among its recommendations, the RAND study suggested a whole new mission for the NTSB: evaluation of aviation security. "This is an area where we have no expertise," Hall confessed. In addition, the RAND study recommended that the NTSB assume a more pro-active stance, investigating incidents as well as accidents to better identify safety deficiencies before they result in lost aircraft and lost lives. Reducing the NTSB's role in investigating general aviation (GA) accidents might offset the added workload. For the full report, see the RAND website http://www.rand.org and click on "hot topics."

Selected Recommendations from the RAND Review
The NTSB should not...augment the party system by including family representatives, plaintiff experts, insurers or other individuals or organizations that have no direct involvement in identifying the technical cause of an accident.

The NTSB should move away from simplistic, one-line probable cause statements and instead...causal factors should be ranked in terms of their contribution to the event...

The NTSB should perform a nationwide assessment of federal laboratories, universities and independent corporate resources to identify tools, facilities, and experts capable of augmenting NTSB resources.

The NTSB should consider...training state and local investigative authorities to conduct more routine general aviation accident investigations.
Source: RAND

If you really think about it, many of these problems regarding crash investigations would go away if video cameras were allowed in the aircraft.

Nov. 10, 2003. 01:00 AM



Analysis slams Swissair probe
Inquiry lacked resources, it says

Cites excessive workload, overtime

OTTAWA�The massive investigation into the 1998 crash of Swissair Flight 111 suffered from a chronic shortage of people and technology, says a newly released document.

"Human resources available and assigned to the (Swissair) team were inadequate to sustain a prolonged complex investigation, which resulted in an insufficient number of qualified personnel available for certain tasks," says a July 4 report from the Transportation Safety Board. There was an "excessive workload for those assigned to the team, and an inordinate amount of overtime over a very long period."

The scathing report, obtained under the Access to Information Act, raises basic questions about training, noting "some investigation team members were not sufficiently knowledgeable about international investigation standards, protocols and procedures." The final report into the Sept. 2, 1998, crash, which killed all 229 people aboard, took more than 4 1/2 years to produce. The analysis suggests a lack of resources was a significant factor in the delay.

Administrative support to the $56.8 million probe was inadequate, the level of technical help required for the investigation was underestimated, and consulting contracts for outside assistance were beset by delays and difficulties.

The overtime bills alone speak to how the investigation team, led by veteran Vic Gerden, was badly overworked. The total paid to date is $7.4 million, much of it occurring in the first year.

Even the writing of the final report, which was delivered last March 27, suffered delays because staff hired to produce it were unfamiliar with the technical aspects of a crash investigation.

"The technical accuracy of the report ... was at times inadvertently changed during the editing, thereby requiring that TSB investigators invariably re-verify, re-edit and redraft text."

Twice in the last three years, the board has come under criticism in transportation industry surveys for the excessively long time it takes to report on major accidents.

As of August, 74 of 154 active investigations were more than a year old, even though the agency aims to complete the majority of its probes within a year.

The lessons-learned report, which was produced by the board's air branch, is only the first of many arising out of the Swissair investigation, the most expensive and complex since the TSB was founded in 1990.

The board's executive director, David Kinsman, has ordered an agency-wide post-mortem on the Swissair experience, to be completed by next March 31.

He acknowledged the investigation stretched the agency to its limits, but declined to comment on whether the lack of resources delayed production of the final report.

Canadian Press

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