By Cat Hofacker|May 2021
Even after the pandemic winds down, full-time telework might be the norm for many aerospace professionals. Not so for the U.S. National Transportation Safety Board, says Dana Schulze. The 84 investigators she oversees in the Office of Aviation Safety will “always need that in-person ability to touch, gather, look” at the wreckage of all U.S. civil aircraft crashes to determine the probable cause. NTSB has found creative ways to get investigators this crucial hands-on access while minimizing their risk of covid-19 exposure. Schulze is confident the agency will employ that same creativity in ensuring its investigators are versed in the technology of emerging markets, including in-development urban air mobility vehicles, which would likely require different investigation techniques than those for today’s aircraft. I called Schulze at her home office in Maryland to hear what it’s like to be one of NTSB’s crash detectives. Our conversation has been compressed and lightly edited.
Q: Why have an independent agency, distinct from FAA, carry out investigations of plane crashes and make safety recommendations?
A: That’s a foundational question for this agency, because the United States is in many ways unique in its approach to accident investigation. Not a lot of other countries have independent agencies like we are. Often, they are like NTSB was when it was first born: They’re part of the department of transportation or the civil aviation authority. We report directly to Congress, and the importance there is that we don’t have skin in the game, so we’re objectively, credibly going to convince the public that we’ve done a comprehensive, thorough job, and in doing that really move safety change. In particular, if the public has a sense that — for example, if we were part of the FAA — that they weren’t looking at themselves objectively, that would be a confidence issue for the public and the FAA. Credibility is all we really have to push safety change because NTSB does not have the authority to enforce its recommendations. We really need to convince our audience — which are the stakeholders in the aviation community: the manufacturers of aircraft and systems, the operators, the airlines, all the way down to the general aviation pilot and the regulator — that change needs to happen. Having that independent, no-skin-in-the-game third party really helps formulate that credibility.
Q: We often hear about government employees leaving for the commercial sector, but your experience was the opposite. What drew you to NTSB and government service?
A: I came from the manufacturing world, from the aircraft side of things. My education is engineering, but my craft was always safety and reliability. I always wanted to do something that felt novel, that felt like a deeper mission; I wanted more than either building something, designing something or ensuring its safety on that side. And I always was fascinated with the forensic side of accident investigation and the safety opportunities. What drove me to NTSB was that dedication to some greater cause. I’m not unusual in the sense that probably almost all folks that come to the NTSB come in that regard. The interesting thing about what we do is when we launch to the scene of an accident as a team, it’s a very clear mission. That’s our best work, as an agency and as an individual, when we’re in the middle of responding to an accident and trying to get in there to make sure we get what we need to find out what caused the accident and how to prevent it in the future.
Q: Along with that higher vision you described, what were some other changes in transitioning from the private sector to government work?
A: When I came from industry, I was a manager, so I oversaw reliability and safety professionals. We had a lot of projects that I was responsible for providing technical expertise to in the private sector. When I came to the government, I came as an investigator. One of the leaps I took was, in a sense, going backward. I went from a leadership position to a rank-and-file employee. What I took away from it is that when you want to go outside your comfort zone, so to speak, and you want to expand your horizons, you might have to seemingly take a step backward to take a step forward. To be a more effective leader where I am now, I don’t know how I could have done it if I didn’t learn from the grassroots how we do our job, what challenges I would face day to day. It was scary a little bit because I wasn’t as in control of my own fate because I wasn’t a manager anymore, but it was a great experience. I still reflect on it being the right decision.
Q: With 400 total employees spread across the country, how do you maintain a unified sense of purpose?
A: I frankly would like to see us be a little bit bigger, but our investigation work units are small by design. It’s very difficult to be agile and nimble and get what you need quickly during investigations if you have a cast of thousands, right? Our very distributed team of experts is a strength of ours because it allows us to respond quickly when accidents happen anywhere in the country. In some cases, it’s easier to attract and retain the best talent if they can live somewhere that’s more effective for their home life as well. That culture is a big part of our strength, but it’s also something that has to be nurtured through that effective, useful communication, meaningful communication.
Q: How did the pandemic impact you?
A: We had migrated to the Microsoft Teams platform in the fall of 2019, and we were doing all-hands meetings for all aviation employees on a periodic basis. Once March 2020 came around and we hit the pandemic, all of those technology solutions — Teams, SharePoint sites where employees can provide input, a portal site or employee site to convey information — became critical. That’s how we’ve tried to maintain the culture.
Q: How has the agency adapted its investigative work in light of covid-19 travel restrictions, when so much of NTSB’s role involves traveling to the scene of these crashes?
A: As soon as the pandemic hit and travel was stopped, we really began thinking through, “How can we do the mission, but do it in a way that keeps people safe?” We fortunately have a number of medical doctors on staff who help support our investigative work, so we were able to consult with them, and we stood up a small working group to develop a focused covid management protocol. When we got notified of an accident, we had this checklist that we could go through and figure out if we could safely travel someone to the scene. For example, could they use their own car instead of having to go on a plane? What about staying at hotels? We led that effort in the Office of Aviation Safety because we are obligated to investigate every civil aviation accident. We did a pilot program of the use of this risk assessment form in the summer of 2020, and the agency rolled out a more general version for all divisions in September. We developed something called a covid positivity tracker. It’s a dashboard you can pull up on your phone that if you have an accident happen in Allegheny County, Pennsylvania, for instance, you can go in your tracker and it’ll tell you what the positivity rate is at that time for covid in that area. This allowed us to evaluate the covid situation where the investigators are coming from, where they’re going and their exposure risk. We rolled this process out and although unfortunately we really were not able to launch on a lot of accidents, it did enable us to get back out there in some cases. On the other side of that, we relied on our party system — accident stakeholders who assist in our investigations, such as the airplane manufacturer. The FAA is always a party to our investigations by statute, and they have inspectors that are located across the country as well. Often when we couldn’t travel, our investigators in charge were in direct contact with those local FAA inspectors, who would travel to the scene to the extent they could and help us photo document the scene, collect any other pieces of evidence that might be needed. The other process that we would employ is working through Teams or through phone calls, the investigator in charge would actually coordinate with the insurance adjuster. They would collect the wreckage and send it to a salvage yard or someplace where it can be locked down, that we could get to later once the covid numbers are acceptable, so that we can go do our inspection of the wreckage at that point with parties.
Q: While many of us have learned that our jobs can be done remotely, it sounds like NTSB has learned the opposite: In-person investigation can’t be replaced. Why can’t technologies like 3D scanning or drone imagery fill that gap?
A: At the end of the day, you still always need that in-person ability to touch, gather, look, but we have enabled some of those technologies. We have a fleet of drones, and we stood up a drone accident site documentation program in 2016. We have some very experienced, certified pilots who can go out and fly the drones above crash sites, but we still have to get the pilot to the scene to be able to actually launch the drone. These are small unmanned operating systems that don’t have the range for beyond-line-of-sight operations. Another technology is when we had accidents in proximity to surveillance cameras, those could be used to photo document the wreckage or take video. One of the things that we commonly do outside of a pandemic is a tear-down examination, where we’ll have representatives there from the aircraft manufacturer, someone from the operator and obviously the FAA gather while NTSB specialists examine the wreckage. Well, we didn’t want to do that under covid because now we’re bringing maybe four or five people in from all areas of the country, in some cases internationally. So we said, “OK, how about if we do this?” How about if we send our investigator to oversee or conduct the tear down at a salvage facility. That’s a controlled environment, it’s not publicly accessible and we know the ventilation is adequate. We would set up a camera somewhere so that the investigator could actually conduct the work and the parties could watch and maybe provide some guidance along the way. Because at the end of the day, the personal touch and firsthand evidence gathering is really critical to what we do.
Q: Crashes are rare, so what do the day-to-day, less visible parts of the job comprise?
A: When investigators are not running out the door to the accident site, they’re doing follow-up work. Early in the investigation, it might be in the form of traveling to a manufacturer’s facility to examine a piece of wreckage, or it could be bringing the wreckage to our labs in Washington, D.C., and being able to examine them in our lab with the parties. There’s a fair amount of follow-up work that involves examinations. They may travel to do interviews, or they may do interviews through Teams or on the phone. To conduct interviews and document findings, they may also be reading up, researching on different topic areas that become pertinent in an investigation.
The other thing that they’re often doing that some people don’t like is writing. The first step in an investigation is to collect evidence and facts, but at some point you have to document them in a way that can be meaningful to the industries that need that data, to be able to understand whether it’s pertinent to their operations but also to the public so that the public understands what happened, how did it happen and why? The other thing that investigators do in non-covid times is something we call advocacy, which is going out and meeting with the district groups, doing presentations to help get our safety recommendations adopted either voluntarily by industry organizations who can do something about it or through the FAA. That often can involve travel; it can involve being part of roundtables and workshops at our training center where we have the ability to set up roundtable events and things like that; it could be flying to an industry conference where we’re going to present.
Q: How is NTSB preparing for the new range of technical experts it will need for emerging markets like advanced air mobility?
A: One of the things that we do a lot of is outreach, which is where we go out to the industries that are doing those things. We ask them to come in and talk with us, for a couple of reasons. First is just what you’re talking about, to really become more technically adept at what skill sets are going to be needed. The second is to learn what evidence is going to be available in those systems. In the aviation world, we’ve honed that craft of knowing what data we can go capture and credibly know what happened during these crashes, but how do we do it in these new segments of the industry? For urban air mobility, one of the first things we started talking with some of our other government partners like NASA about was, “What does a black box on these vehicles look like? How do we capture the data that is managing the bigger system?” Because that’s not a black box on one vehicle, it’s some centralized data network. How do we capture that? We do outreach because we want companies to know who we are and what we do. Unfortunately, someday when that technology gets monetized and becomes an industry segment, they may have to work with us. We always have the saying, “We don’t want to meet people in the middle of chaos.” We want to meet you before chaos. We want to have that relationship. We want you to know very clearly what our role is versus what the FAA’s role is, and how you can best enable the accident investigation process.
Q: How do NTSB employees become more versed in the technology of these emerging markets?
A: We might also bring in training opportunities for our staff, but those are a little more difficult to do in our world because what we do is so unique. I can’t really go buy an off-the-shelf product from even AIAA on accident investigation of urban air mobility vehicles, for instance. Sometimes we will develop tailored training. We’ll ask people to come in on specialized topic areas; that might be the control systems for these autonomous vehicles, for example. We might have somebody coming from a university or from a manufacturing industry to give us that training too. But I would say the outreach becomes one of the most important parts. The last thing that we have done are what we call externships. We ask these industry leaders, “Hey, can we embed some staff in your organization for two weeks, just to get them immersed in the technology?” That starts seeding that thinking about all these areas we need to worry about, our processes for investigating the data, evidence. That’s been really effective. For the aviation and aerospace industries, hopefully it’s valuable to them too, because again, they get to build that relationship with us. They’ll know more about what to expect if their products were ever involved in an investigation.
Q: NTSB safety recommendations often prompt changes, from aircraft design to certification, but what’s an example of investigations that prompted changes to your own protocol or methods?
A: In 2006, we investigated our first unmanned aircraft system accident. It was a U.S. Customs and Border Protection Predator drone accident that happened down by the southwest border of the United States in Nogales, Arizona. That’s a pretty good size drone: about 10,000 pounds [4,536 kilograms] with a wingspan almost as long as a Boeing 737.
A Predator B drone has a wingspan of 20 meters compared to 38 meters for a Next-Generation 737 aircraft. — CH
The interesting thing about this crash was that’s a very sparsely populated area. There’s nobody that lives out there, and yet this drone crashed and came down about a hundred yards from a private home. So when NTSB got notified in the event, the first question we had was, “Is this even within our authority to investigate? Is that an aircraft?” We made a decision at that time that this is an aircraft, and we are going to investigate this. It falls under our authority to investigate all civil aircraft, civil aviation accidents and certain public-use aircraft that are operated by government agencies. What we learned, No. 1, is we need to amend our definition of an aircraft accident — at that time, it only included situations where a person gets onboard the aircraft, and they’re not going to get on a drone, at least not yet. We ended up expanding our regulations to include unmanned aircraft accidents in 2010. The other thing that investigation taught us is boy, we need to have more published procedures on how we’re going to investigate accidents. In piloted aircraft, you have a control system that the pilot sits at to manage the flight path, so how are we going to investigate these UAS accidents and capture these flight logs? It was very eye-opening, and it really formulated our thinking going forward on keeping ahead of emerging technologies.
Q: There’s some mysteries or crashes that never get solved, for instance the Malaysia 370 flight that disappeared and was never found. How are you able to turn those cases into teachable moments?
A: That was an accident that we did not lead an investigation on, but we supported because it was a U.S.-manufactured airplane. There is an international protocol that the United States works under for that. At the end of the day, our contribution was to provide technical expertise to the Malaysian government to be able to identify recommendations so that in the future, if an airplane goes missing, there’s more reliable data to know where its last location was before it crashed. That was the big problem with that accident; we just don’t have viable data. Better satellite data tracking systems since then have been emerging, as well as deployable recorders where if an airplane is in a flight condition that clearly indicates some level of duress, the recorders automatically deploy. They float if it’s in a water environment. If it’s overland, they’re crash-hardened and protected so that we at least know where the aircraft is, where the wreckage most likely is. If we had a circumstance in the U.S. where that was a U.S. airplane, we would absolutely be looking for ways to ensure we could find that aircraft better in the future. It wasn’t something we could do for that investigation.