NATIONAL TRANSPORTATION SAFETY BOARD
AVIATION INVESTIGATION MANUAL
MAJOR TEAM INVESTIGATIONS
November 2002
RECORD OF REVISIONS
This manual and its appendixes have been revised significantly, and any previous
versions of these documents should be replaced in their entirety. Future revisions will be logged
using the table below.
REVISION
NUMBER
DATE OF
REVISION
AFFECTED
PAGES
REMARKS/PURPOSE
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FOREWORD
NOTE: This manual is a National Transportation Safety Board (NTSB) staff product
and is intended to provide information and guidance to NTSB employees who are involved in
organizing and conducting investigations. This manual has not been adopted by the NTSB Board
Members, is not regulatory in nature, is not a binding statement of policy, and is not all-inclusive.
The recommended procedures are not intended to become obligations of the NTSB or to create any
rights in any of the parties to an NTSB investigation. Deviation from the guidance offered in this
manual will at times be necessary to meet the specific needs of an investigation. However, such
deviations from the guidance offered in this manual shall be within the sole discretion of the
appropriate NTSB employees and shall not be the prerogative of parties to the investigation or other
individuals not employed by the NTSB.
The procedures in this NTSB Aviation Investigation Manual—Major Team
Investigations apply to “Go Team” investigations of major aviation accidents. An investigation of
this type could involve more than 100 technical specialists, representing as many as a dozen parties
and multiple Federal and local government agencies.
This manual provides general information to assist the investigator-in-charge (IIC),
group chairmen, and others who may participate in a major aviation accident investigation. It is
intended to provide guidance on the process of conducting a major investigation, from initial
notification to the adoption of the final report, probable cause, and recommendations by the
Members of the Safety Board.
Although this publication includes some technical information related to
investigative activities in major aviation accidents, it is primarily intended to provide guidance of a
procedural or administrative nature. Investigators should refer to Annex 13 of the International Civil
Aviation Organization (ICAO) for procedural references and to the ICAO Manual of Aircraft
Accident Investigation for technical information and examples of investigative techniques. Other
sources, such as military investigation manuals, can also be used to supplement information in the
NTSB’s Aviation Investigation Manual.
The Major Investigations Division (AS-10) will be responsible for keeping this
manual updated. The “Record of Revisions” on the preceding page should be used to acknowledge
receipt of new or amended pages. The manual’s original printing date will be indicated in the lower
left corner of the cover page. The effective date of any page change will be indicated by the entry on
the revision sheet. All recipients of this manual are encouraged to submit information to be
considered for inclusion.
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CONTENTS
Page
1. Pre-Investigation Preparation ………………………………………………………………………………1
1.1 The Go Team ………………………………………………………………………………………….1
1.2 The Go Team Roster………………………………………………………………………………..1
2. Notification And Initial Response ………………………………………………………………………..2
2.1 Headquarters Responsibilities and Procedures …………………………………………….2
2.1.1 Domestic Investigations………………………………………………………2
2.1.2 International Investigations………………………………………………….3
2.1.3 Role of the Safety Board Communications Center………………….3
2.2 Regional Office Responsibilities and Procedures…………………………………………3
2.2.1 Regional Office Responsibilities Related to a Go Team
Launch………………………………………………………………………………4
2.2.2 Stakedown Guidelines ………………………………………………………..4
2.3 Notification and Assignment of Go Team Specialists…………………………………..4
2.4 Party Notification…………………………………………………………………………………….5
2.4.1 Domestic Participants …………………………………………………………5
2.4.2 International Participants …………………………………………………….6
2.5 Travel Arrangements ……………………………………………………………………………….6
2.5.1 FAA Aircraft……………………………………………………………………..6
2.5.2 Commercial Aircraft …………………………………………………………..7
2.5.3 Rental Cars………………………………………………………………………..8
2.5.4 Hotels……………………………………………………………………………….8
2.5.5 Backup IIC Duties ……………………………………………………………..8
3. On-Scene Activities ……………………………………………………………………………………………9
3.1 Command Post/Meeting Room………………………………………………………………….9
3.1.1 Press Briefing Room…………………………………………………………..9
3.1.2 Telephones and Communications …………………………………………10
3.1.3 Equipment/Supplies ……………………………………………………………10
3.1.4 Administrative Support……………………………………………………….11
3.1.5 Contracting for Services or Supplies …………………………………….11
3.1.6 AS-10 Support Equipment…………………………………………………..12
3.2 Organizational Meeting ……………………………………………………………………………12
3.2.1 Identification and Assignment of Personnel…………………………..14
3.2.2 Forms and Badges………………………………………………………………15
3.3 Accident Site Safety Precautions ……………………………………………………………….16
3.4 Observers ……………………………………………………………………………………………….17
3.5 Lines of Authority……………………………………………………………………………………17
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3.6 Group Chairmen Responsibilities………………………………………………………………18
3.6.1 Field Notes………………………………………………………………………..18
3.6.2 Followup Activities…………………………………………………………….19
3.7 Progress Meetings……………………………………………………………………………………20
3.8 Initial Notification and Status Reports………………………………………………………..21
3.9 Press Briefing………………………………………………………………………………………….21
3.9.1 Board Member Present ……………………………………………………….22
3.9.2 Board Member Not Present …………………………………………………22
3.9.3 Transportation Disaster Assistance Briefings…………………………23
3.10 Daily Activities of the IIC ………………………………………………………………………..23
3.10.1 Headquarters Briefing…………………………………………………………23
3.10.2 Safety Board Staff Meeting …………………………………………………24
3.10.3 Party Coordinator Meeting ………………………………………………….24
3.10.4 IIC Site Visit ……………………………………………………………………..24
3.11 Final Progress Meeting …………………………………………………………………………….25
3.12 Release of Wreckage………………………………………………………………………………..25
3.13 Materials Laboratory Examinations……………………………………………………………26
3.14 Closing the Command Post……………………………………………………………………….26
4. Post-On-Scene Activities…………………………………………………………………………………….26
4.1 Administrative Tasks Upon Return to Headquarters…………………………………….26
4.2 IIC Duties for Work Planning……………………………………………………………………27
4.3 Public Hearing Action Memo ……………………………………………………………………28
4.4 Group Chairman Factual, Studies, and Analysis Reports………………………………28
4.5 FOIA Requests………………………………………………………………………………………..30
4.6 The Public Docket …………………………………………………………………………………..30
4.6.1 No Public Hearing ……………………………………………………………..31
4.6.2 Public Hearing …………………………………………………………………..32
4.7 Conducting Public Hearings ……………………………………………………………………..32
4.7.1 Preparation………………………………………………………………………..32
4.7.2 Prehearing Conference………………………………………………………..36
4.7.3 The Public Hearing …………………………………………………………….37
4.7.4 Techniques for Questioning Witnesses………………………………….37
4.8 Subpoenas/Sworn Testimony…………………………………………………………………….38
4.9 Technical Review ……………………………………………………………………………………40
4.10 Party Submissions……………………………………………………………………………………41
4.11 Report Planning Meeting ………………………………………………………………………….41
4.12 Preparation of the Final Report………………………………………………………………….42
4.12.1 Drafting the Report …………………………………………………………….42
4.12.2 Report Drafts……………………………………………………………………..42
4.12.3 OAS Protocol for Major “Blue Cover” Reports and Safety
Recommendation Letters …………………………………………………….44
4.13 Board Meeting ………………………………………………………………………………………..45
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4.14 Document Preservation/Archiving …………………………………………………………….46
4.15 Petition for Reconsideration ……………………………………………………………………..47
5. Other Investigations……………………………………………………………………………………………47
5.1 International Investigations……………………………………………………………………….47
5.1.1 Domestic Accident……………………………………………………………..48
5.1.2 Foreign Accident………………………………………………………………..48
5.2 Accidents Involving Known or Suspected Criminal Acts ……………………………..50
5.3 Commercial Space Launch Accidents ………………………………………………………..50
5.4 Underwater Recovery of Wreckage……………………………………………………………51
6. Role of the Office of Transportation Disaster Assistance ………………………………………..52
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APPENDIXES
A. IIC Checklist
B. Cockpit Voice Recorder Handbook
C. Stakedown Duties of Field Investigators
D. On-Scene Organizational Chart
E. IIC’s Opening Statement at Organizational Meeting
F. Guidance for Accredited Representatives, Advisors, Party Coordinators, and Other
Participants in the Investigation of Aircraft Accident Reports by the Safety Board
G. On-Site Safety
H. Group Chairmen Checklists
I. Sample Group Chairman Progress Meeting Brief
J. Materials Laboratory Examinations
K. Group Chairman Factual/Analysis Report Outlines
L. Hearing Officer’s Checklist for Preparing a Public Hearing
M. Exhibit Cover Sheet and Identification Numbers
N. Prehearing Conference Proceedings
O. Public Hearing Proceedings
P. IIC’s Opening Statement to Board Meeting
Q. Petition for Reconsideration Procedures
R. Policy on Freedom of Information Act
S. Excerpt From ICAO’s Manual Of Aircraft Accident Investigation
T. Occupational Safety and Health Information
U. Foreign Travel Information
V. Office of Transportation Disaster Assistance Task List
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1. Pre-Investigation Preparation
1.1 The Go Team
The Go Team is a group of investigators who are on-call for immediate assignment
to major accident investigations. The Major Investigations Division (AS-10) provides the IIC for
the Go Team. Divisions of the Office of Aviation Safety (OAS) and the Office of Research and
Engineering (RE) provide specialists and laboratory support. Regional investigators may be used on
the Go Team when headquarters investigators are unavailable and as the needs of the investigation
dictate. On some investigations, an investigator from a regional office might be assigned as the IIC.
A full Go Team may consist of the following specialists: air traffic control,
operations, meteorology, human performance, structures, systems, powerplants, maintenance
records, survival factors, aircraft performance, cockpit voice recorder (CVR), flight data recorder
(FDR), and metallurgy. Additional groups may be formed to interview witnesses, examine the
response of aircraft rescue and firefighting (ARFF) personnel, or other duties, as required, to support
the investigation. Each of the NTSB specialists will be the chairman of an investigative group.
NTSB specialists who are in training will be assigned as members of investigative groups, under the
supervision of another NTSB employee, usually a group chairman or IIC.
1.2 The Go Team Roster
The Go Team roster is a spreadsheet of names and telephone and pager numbers of
all Board personnel assigned current standby duty for major accident investigations and their
Division Chiefs. The Go Team list also identifies the names and numbers of all Board Members, the
Public Affairs (PA) Officer, the Executive and Managing Directors, the Directors of the Offices of
Government Affairs (GA), PA and Transportation Disaster Assistance (TDA), and the Directors of
the Regional Offices. A new list is prepared once each week or when necessary after a change of
duty officers or the launch of a prior group of Go Team members.
The current Go-Team roster is available on the intranet to authorized personnel.
Copies are distributed to all Board Members; the Offices of the Managing Director (MD), Aviation
Safety (OAS), Research and Engineering (RE), General Counsel (GC), Safety Recommendations
and Accomplishments (SR), GA, PA, and TDA; and each Division Chief and investigator in the
OAS headquarters office. Copies are also transmitted to each OAS Regional Office, the Federal
Aviation Administration’s (FAA) command center and accident investigation office, the Safety
Board’s Communications Center and the Department of State’s Office of Aviation Policy
(EB/TRA/AVP).
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All personnel on call should arrange their personal affairs such that they are able to
depart for the scene of an accident with a minimum of delay. Regardless of when they are notified
about an accident, Go Team members should be able to arrive at the airport within approximately
2 hours of being notified. For launches that occur during duty hours, Go Team members who live
too far to travel home and return to the airport within this timeframe should bring clothing and other
launch essentials to the office. Go Team members and their Division Chiefs should always ensure
that the information listed on the Go Team sheet concerning their phone/pager numbers is correct.
In addition, personnel should always ensure that they can be reached when on call. This includes
“testing” the pager for proper operation, forwarding alternate phone numbers to the Communication
Center, IIC, and supervisors in advance of expected travel, and maintaining contact with the NTSB
communication centers at the Safety Board. When changes to Go Team assignments are made, the
persons involved shall ensure that the IIC/duty officer, the Chief of the Major Investigations
Division, the OAS Director, and the Safety Board’s Communications Center are notified and
provided updated phone and pager numbers.
2. Notification And Initial Response
Early notification is essential to initiate and organize the investigation. Initial
information concerning the facts and circumstances of the occurrence will often be incomplete and
erroneous. For this reason, early factual information transmitted for alerting purposes must be
handled with considerable discretion. Parties notified are to be cautioned about the preliminary
nature of the data.
2.1 Headquarters Responsibilities and Procedures
2.1.1 Domestic Investigations
Initial notification of a major aviation accident will usually be received by the Safety
Board’s Communications Center. The Communications Center will advise the IIC on duty and
the Chief or Deputy Chief of the Major Investigations Division, who will inform the Director of
OAS or, in his absence, the Deputy Director. The OAS Director or Deputy Director, with input
from OAS Division Chiefs, will decide whether to launch a Go Team in consultation with the
Safety Board’s Chairman and/or the Executive or Managing Director.
Following a decision to dispatch the Go Team, the Chief of the Major Investigations
Division, the OAS Director, or the Deputy Director, will:
(1) notify the Chairman, the Executive or Managing Director, and the on-call Go
Team Board Member of the preliminary circumstances of the accident;
(2) obtain the Go Team Board Member’s decision regarding travel; ascertain if
he/she will accompany the team, and notify the IIC accordingly;
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(3) notify GA, PA, and TDA;
(4) notify the other Board Members (this can be done by pager);
(5) notify the NTSB Communications Center and the involved Regional Office(s) of
plans (e.g., travel, arrival, number of personnel, etc.)
2.1.2 International Investigations
The Chief of the Major Investigations Division, the OAS Director, or the Deputy
Director of Technical/Investigative Operations will advise the Chairman and Executive Director
of any major accidents outside the United States or its territories involving a U.S.-manufactured,
operated, or registered aircraft. If the Board is sending a U.S. Accredited Representative, GA,
PA, and TDA will also be notified. Section 5 contains NTSB policies and procedures for
international accidents. The Chief of the Major Investigations Division (or his designee) will
notify the FAA, interested parties, and the Department of State of an intended NTSB launch to a
foreign country.
2.1.3 Role of the Safety Board Communications Center
The Safety Board’s Communications Center was established to provide a centralized
operation to support all modes of transportation at critical periods during the accident investigative
process. Before a Go Team launch, the Communications Center can provide important initial
accident information through alphanumeric pagers and logistical support through arrangements for
air travel and rental car and hotel accommodations. After the launch, it can assist the IIC with
setting up the on-scene command post, configuring cellular telephones, laptop computers, and
pagers, and providing satellite telephone capabilities and language translation services. The IIC is
responsible for coordinating with the Communications Center on logistics.
2.2 Regional Office Responsibilities and Procedures
During duty hours, Regional Offices will notify headquarters via the
Communications Center whenever an accident (or incident with serious implications) occurs that
involves the following:
• air carrier, commuter, or air taxi operations,
• public figures or officials with widespread recognition or prominence,
• fatal midair collisions or collisions involving ATC, or
• matters of potentially high public interest.
During nonduty hours, the designated Regional Office duty officer shall notify the
Communications Center duty officer by the most expeditious means if receiving notification of a
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major accident or incident of the type described above. Travel to the accident scene will be initiated
without delay.
2.2.1 Regional Office Responsibilities Related to a Go Team Launch
NTSB Regional Offices are responsible for implementing notification procedures in
their geographic areas of jurisdiction. These offices will ensure that specific personnel are
designated to be on-call. The Regional Office with geographic jurisdiction for the accident will
typically provide at least one investigator to travel immediately to the site and perform initial public
affairs and “stakedown” coordination duties of the IIC. The regional investigator will continue to
function in this role until relieved by the IIC. After briefing the on-scene Board Member, IIC, and
Go Team, the regional investigator may be assigned as a chairman of one of the working groups,
provide support as necessary, or be released from the investigation. NTSB Regional Office
personnel who travel to a major investigation site will be considered part of the investigation team
until the IIC releases them from their duties.
2.2.2 Stakedown Guidelines
Regional Office personnel assigned to the initial stakedown of a major accident have
important duties that contribute to the overall success of the investigation. Those personnel include
investigators dispatched to the scene, as well as those handling administrative affairs (see
Appendix C). Personnel assigned to respond to the accident scene are obligated to reach the scene
as quickly and as safely as possible and to remain at the scene until properly relieved. NTSB
representation at this time is essential to convey to the news media, local authorities, and the public
that the investigation is under NTSB jurisdiction. The only information released to the media should
be that the Go Team is en route, name of the Board member on scene, name of the IIC, name of the
media contact, and when the team is expected to arrive. Initial activities, in addition to those listed
herein, should be aimed at gathering as much pertinent information as possible to brief the Board
Member and Go Team upon their arrival.
Remoteness of the crash site or difficult accessibility does not diminish the need to
establish NTSB jurisdiction. Every effort should be made to get to the crash site, even if
environmental conditions preclude remaining at the site for any appreciable length of time.
2.3 Notification and Assignment of Go Team Specialists
Once the initial notification of an accident has been received and the decision to
launch Go Team members has been made, the composition of the Go Team must be determined.
This decision will be based on the probable scope of the investigation and the magnitude of the tasks
but will also include the following factors: the number of injuries/fatalities, type of aircraft, previous
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accidents of this type, location of the accident, extent of aircraft or ground damage, weather, public
interest, and specialist workloads.
Because information about the nature of the accident is often incomplete and
frequently erroneous at the time of the launch, there may not be sufficient information with which to
make a final decision about the composition of the Go Team. If questions persist about requesting a
particular specialty, the specialist should be requested to accompany the Go Team. If his or her
expertise is later considered to be unnecessary, he or she should be released by the IIC at that time.
Regardless of the circumstances, accidents involving large air transport or “new generation” aircraft
will normally be staffed with a large Go Team.
The Office of Aviation Safety may determine that some accidents do not require full
Go Teams. For example, under most circumstances, a runway collision would require that air traffic
control (ATC) and operations specialists participate in the investigations, with possibly a human
performance specialist assisting in examining human performance factors. If an accident occurred
during potentially restricted visual conditions, icing conditions, or convective activity, the
participation of a weather specialist would be required. If evidence in an accident indicates a
probable aircraft malfunction, the participation of structures, systems, powerplants, and maintenance
records specialists would be required.
For partial Go Team launches, the participating specialists (and maybe even the IIC)
might be responsible for multiple areas of the investigation. Such a launch might result in the
assignment of an airworthiness group chairman responsible for any of the structures, systems,
powerplants, and maintenance records investigative areas. Likewise, an operations group chairman
might be assigned to cover any of the operations, air traffic control, meteorology, or human
performance areas.
2.4 Party Notification
2.4.1 Domestic Participants
The Safety Board typically extends party status to those organizations that can
provide the necessary technical assistance to the investigation. The IIC typically confers party status
to the operator, aircraft, systems, and powerplant manufacturers, and labor organizations involved
because of the accident circumstances. Most aviation-related organizations that the NTSB might
work with are familiar with NTSB procedures and will have their own sources to notify them of an
accident. However, this may not be the case with some parties. With the assistance of the Safety
Board’s Communications Center, the IIC should ensure that the appropriate parties are informed of
the accident, the location of the command post, and the time and location of the organizational
meeting.
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By statute, the FAA is automatically a participant in Safety Board investigations.
Many FAA personnel have worked closely with Board investigators over the years and are familiar
with major investigation procedures. The role of the FAA representatives is to support the Safety
Board’s investigation and determine if immediate regulatory action is necessary to prevent another
accident. FAA representatives are not to use their participation to develop information for punitive
actions or issuing violations.
Police, firefighters, National Guard, Department of Defense (DoD), Federal Bureau
of Investigation (FBI), Federal Emergency Management Agency (FEMA), National Disaster
Mortuary Team (D-MORT), Red Cross, Salvation Army, and other agencies can provide assistance
at the scene and attend on scene meetings but are not made parties to the investigation.
2.4.2 International Participants
International standards (Annex 13 to the Convention on International Aviation)
provide for the participation of an Accredited Representatives and their advisors. With the
assistance of the Safety Board’s Communications Center, the IIC will ensure that the appropriate
state accident investigation authorities and technical advisors (usually foreign manufacturers and
foreign certification authorities) are informed of the accident, the location of the command post, and
the time and place for the organization meeting.
2.5 Travel Arrangements
Typically, the IIC will have sufficient support from the Safety Board’s
Communications Center and other personnel for much of the initial coordination effort necessary to
make arrangements for the Go Team launch. During off-duty hours, the IIC should expect
assistance from the Safety Board’s Communications Center, back-up duty officer, other IICs, and
management personnel to help with such important items as travel arrangements, hotels, rental cars,
and on-site administrative support.
Whenever possible, the entire Go Team will travel together to the accident site. It is
important that all Go Team members begin the investigative process as soon as possible and with the
most current and accurate information. Investigators who travel separately should report to the onscene
command post promptly upon their arrival.
2.5.1 FAA Aircraft
An FAA airplane can be the most efficient and convenient way to get to or near the
accident site. The Chief or Deputy Chief of the Major Investigations Division, the OAS Director, or
the Deputy Director should submit the request for an FAA airplane to the FAA’s Accident
Investigation Division (AAI-100) at (202) 267-8190. After hours, the AAI-100 duty officer can be
reached through the FAA’s communication center at (202) 267-3333 or (202) 863-5100.
7
If an FAA airplane is available, the FAA representative will require a complete list of
the names of the Safety Board individuals who will comprise the team. At a minimum, seating on
the airplane should be provided for the IIC, the Board Member on duty, group chairman, and the
GA, PA, and TDA representatives. The FAA uses a Cessna Citation; a Lear Jet, and a Gulfstream
IV (G-IV) for transporting accident investigators to an accident site. The Cessna and Lear Jet can
hold 5 to 6 passengers, and the G-IV can hold 16 passengers. The G-IV has intercontinental range,
but passenger capacity may have to be reduced to obtain long-range capability.
If space on an FAA airplane is limited, team members should be selected according
to the importance of accomplishing their duties during the first few hours of the investigation. Give
priority to group chairmen whose initial presence on site with the IIC is critical. Typically, the
structures and systems group chairmen is needed to ensure oversight of on-site activities and the
operations group chairman is needed to interact with air carrier and pilot labor association personnel
on site. Other team members should be given priority on FAA aircraft according to the
circumstances of the accident. In all cases, if space is limited, Safety Board personnel who are in
on-the-job-training status should not be transported on the FAA airplane. Ensure that all intended
passengers on the FAA airplane understand the proper reporting time to appear at Hangar 6 at
Reagan Washington National Airport (DCA). The reporting time is generally 30 minutes before
departure time.
Those who will not be transported on the FAA airplane may be required to make
their own transportation arrangements, with the understanding that they should arrive at the site as
soon as practical, either by first available commercial flight, rental car or train. Team members who
are traveling separately should notify the Communications Center of their travel plans. The
Communications Center will relay this information to the IIC. All Go Team members not traveling
on the FAA airplane must be informed of the location of the command post and the approximate
time of the organizational meeting. If the location and time of the organizational meeting are not yet
known, Go Team members arriving after the rest of the team should contact the Safety Board’s
Communications Center to obtain this information. All Go Team members will be expected to
report to the command post in sufficient time to participate in the organizational meeting. A late
arrival or an unexplained absence from the organizational meeting or other official on-site duties
may result in disciplinary action.
2.5.2 Commercial Aircraft
If an FAA aircraft is unavailable and the distance to the site is beyond reasonable
driving distance, commercial aircraft will be used to transport the team. The Safety Board’s
Communications Center can arrange airline tickets and rental cars through the travel agency used by
the Safety Board. Because return times may vary among the team members, open returns should be
requested for travel back to Washington, DC. Normally, prepaid or electronic tickets should be
requested for team members to pick up at the airport. This will allow everyone to obtain his or her
tickets, particularly during off hours, with relative ease. Investigators traveling to the scene via
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airline jumpseat should check “Must Fly” on their jumpseat authorization forms (NTSB Form
7000-5) and ensure that the carrier understands the urgency of their travel. Investigators returning
from an accident via jumpseat should not check “Must Fly” on the form.
2.5.3 Rental Cars
Rental cars should be reserved for NTSB personnel when initial travel arrangements
are made. The number of required rental cars may vary, but a good rule of thumb is to initially
reserve one car for the IIC, one for the Board Member, and one for each group chairman. Because
additional cars can be rented and returned if they are not needed, reserve more rather than fewer cars
if in doubt. In some cases, SUVs or vans will provide greater comfort for personnel and more
capacity for parts, equipment, etc.
2.5.4 Hotels
The Chief of the Major Investigations Division or his/her designee will coordinate
arrangements for accommodation and meeting rooms for the Go Team with the Safety Board’s
Communications Center. NTSB Regional Office personnel, FAA FSDO staff, the NTSB’s travel
agency, or local law enforcement or military officials can also be used to assist in obtaining hotel
accommodations and facilities for the command post. The following factors should be considered
when selecting a hotel:
• Proximity to the accident site,
• Availability and adequacy of guest rooms for Safety Board personnel,
• Availability of two meeting rooms of sufficient size for a) a Command Post, and b) a press
briefing room,
• Cost of accommodations and meeting room, and
• Compliance with government hotel/motel requirements.
• Separate from the hotel where TDA staff are staying
If at all possible, major hotel chains are preferable to smaller, individual
establishments. When communicating with hotel personnel, NTSB personnel should identify
themselves and the purpose of the visit. A sufficient number of rooms to accommodate the entire
team should be requested, with people assigned the following priority: 1) the Safety Board, 2) other
Federal agencies, 3) International participants and 4) other organizations. The Safety Board cannot
“guarantee” rooms for other agencies or organizations.
2.5.5 Backup IIC Duties
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The backup IIC or another AS-10 staff member will log the accident information
into the AS-10 accident record (green) book, the Board’s Accident Data Management System
(ADMS), and NTSBKeys, and will draft the initial notification memo.
3. On-Scene Activities
3.1 Command Post/Meeting Room
The number of people expected to participate in the investigation will dictate the size
of the meeting room. This will depend on the expected number of groups established, parties
designated, and personnel from each party. In general, regardless of how small the team dispatched,
the meeting room should accommodate at least 30 people. On major air transport accident
investigations, the room should accommodate 100 to 150 people. Remember to account for the
space required by support personnel, furniture, phone lines, fax machines, copiers and the like when
considering whether the meeting room will be large enough to accommodate the number of people
anticipated.
For large investigations, instruct the hotel personnel to set up the room theater style,
with tables and chairs set up in rows. If possible, an aisle should bisect the room, with aisles on
either side of the rows of tables and chairs. The hotel should set up a head table at the front of the
room to accommodate the IIC, the Board Member, and his/her assistant, and Accredited
Representatives. The hotel should be requested to provide a chalkboard and/or whiteboard. A table
should be placed at the rear of the room where reports, documents, and other material to be
distributed to the parties can be placed. If possible, a separate room or area should be made
available for PA use. If this is not possible, a table for PA should be set up in the Command Post and
located away from the head table. It is important to note that the Safety Board is not authorized to
pay for any food or beverages for accident investigation participants. If the hotel provides coffee or
other amenities, ensure that the Safety Board is not billed for such items.
3.1.1 Press Briefing Room
The hotel containing the Command Post should also have an available room for press
briefings. The size of the room depends on the magnitude of the accident and the amount of media
present. GA, PA, and TDA are responsible for the setup of this room, which should include a
lectern with a pull-out shelf, if possible; 6 to 10 rows of seats with 8 to 10 seats per row, arranged
theater style; and risers behind the seats for cameras. Two entrances are preferred, one allowing the
Safety Board briefer to enter and exit without having to pass through a phalanx of reporters and
camera persons. It is also preferred that the press briefing room not be adjacent to the Command
Post.
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3.1.2 Telephones and Communications
The Safety Board’s Communications Center will make arrangements with the hotel
and the local telephone company for the installation, on an emergency basis, of outside telephone
lines in the meeting room. For a full Go Team investigation, the IIC should instruct the
Communications Center to request 10 outside lines or more, as required; for a partial Go Team
launch, the Communications Center should request four outside lines. The telephones are for
investigative team members to communicate with their home offices. All calls will be billed to the
Safety Board. Instruct team members that the phones are for official use only.
The IIC should reserve at least one outside line for exclusive use by the PA officer
and for incoming media calls. Because this line will likely receive extensive use, it should be placed
away from the other lines so that it will not disturb the work of others in the Command Post. In
addition, the IIC should reserve one line for his or her exclusive use to receive calls from
headquarters; this phone number should not be given to team members. This line will facilitate
communications between headquarters and investigative personnel on site. A list of all onsite phone
numbers should be sent to the Communications Center for distribution.
All Go Team members have cell phones, which should always be turned on when on
scene (team members should ensure that their cell phone batteries are charged and should carry a
spare set.) In remote locations where cell phone coverage is inadequate or in situations where secure
communications are necessary, the IIC can request the FAA coordinator to provide on-site
communications support. Also, unique communications requirements should be directed to the
FEMA representative who can access major national resources.
3.1.3 Equipment/Supplies
The Command Post/Meeting Room should be equipped with many of the tools of the
modern office, including the following:
• two photocopy machines (with sorters, toner, and paper),
• IBM compatible portable computers, if issued laptop computers are unavailable,
• printers and printer paper (two printers are available from AS-10),
• facsimile machine,
• a telephone message board and telephone message pads, and
• mailboxes and a table to place mail and materials for each of the parties.(the top of a large
box can be used for this purpose)
Because it may be unreasonable to ask the hotel to acquire this equipment on short
notice, the IIC should be prepared to arrange with local vendors to rent the equipment and the
needed supplies. Find potential vendors in the Yellow Pages or through recommendations or
suggestions of the hotel. If possible, survey several sources to determine prevailing rates and
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confirm that the rental costs are in accordance with prevailing rates. The Safety Board’s
Communications Center can assist with efforts to secure the appropriate equipment and supplies.
The IIC should ensure that the following items are available in the Command Post:
• NTSB laptop computer with Accident Data Management System (ADMS) program and
supplements (as required) installed
• Pilot/operator accident report form (NTSB form 6120.1)
• Attendance rosters
• Subpoena forms
• Witness Statements
• Wreckage Release forms
• Party Coordinator Signature form,
• Guidance to Party pamphlet (See Appendix F)
• On-Scene Organizational chart (see Appendix D)
• NTSB telephone directory
• Annex 13 (if appropriate)
Many of these items are available from the Safety Board’s intranet site or on the IIC
Checklist CD available from AS-10.
3.1.4 Administrative Support
Depending on the size of the team, the scope of the investigation, and the availability
of administrative support personnel from the Board, temporary clerical/secretarial assistance may be
hired for the Command Post. The IIC may request on-scene support from the NTSB administrative
staff. On a major investigation, a Command Post secretarial assistant will be needed to answer the
multitude of phone calls and to take and distribute telephone messages. Secretarial services will also
usually be needed toward the end of the on-scene phase when field notes will be prepared,
photocopied, and distributed. When arranging for secretarial services, be sure to inform the
temporary agency that the services will be needed at the NTSB Command Post and that the
secretarial assistant should expect to work unusual and long hours.
3.1.5 Contracting for Services or Supplies
The IIC will enter into any necessary agreement with vendors and will be
responsible for ensuring payment after the Command Post is closed. Where possible, purchases
should be made using the government purchase card. When using the government purchase card
to acquire goods or services, form SF44 may be used to document the terms of agreement with
vendors. If this form is used, it should be attached to the purchase card statement as supporting
documentation for the charge. Where purchases cannot be accomplished using the government
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purchase card, form SF44 should be used to document the terms of the agreement and provide
billing instructions to the vendor. Accordingly, the IIC must fully understand the details of the
agreement made to obtain services or supplies and obtain accurate estimates of the charges
incurred for those services or supplies. Before leaving the site, arrangements should be made to
settle vendor accounts (i.e., the charges are billed to the government purchase card, or the SF44
has been issued to the vendor indicating the services that were provided and the address to which
to send their invoice). Board Orders regarding financial matters must be followed.
If translation services are required, the Department of State’s Operations Center (listed on
the Go Team roster) should be contacted for the appropriate personnel. The memorandum of
understanding (MOU) developed by the Office of Transportation Disaster Assistance and the
Department of State will be used.
3.1.6 AS-10 Support Equipment
AS-10 has two «flyaway» suitcases available for use during the investigation. The
two kits contain such things as a video camera and tape, laptop computer, printer, various charging
devices, film, administrative supplies, and copies of the investigator’s manual. Mailing labels
attached to the kits allow them to be mailed quickly to an accident scene upon direction by the IIC.
The kits are intended for use with large accident investigations, where a considerable amount of
supplies or equipment might be needed. The IIC is responsible for the equipment in the kits and for
mailing them back to Washington after the on-scene phase of the investigation has been completed.
The kits, or at least the electronic equipment, should be secured each evening.
Each suitcase is equipped with a programmable combination lock that should be set
by the IIC prior to departure, if possible. Otherwise, AS-10 will set the combinations and inform the
IIC of the combinations while the kits are en route.
Additionally, two computer printers in the AS-10 area are boxed and can be shipped
to the command post.
3.2 Organizational Meeting
The manner in which the IIC conducts the organizational meeting will establish the
tone of the investigation. Therefore, the importance of being organized, articulate, assertive,
composed, and understanding cannot be overstated.
As the formal opening of the investigation into an aviation accident, the
organizational meeting serves several purposes. It will:
• Provide the opportunity to share preliminary information on the accident;
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• Introduce the participants of the investigation to each other and identify those eligible to
participate;
• Organize participants into investigative groups;
• Establish rules of conduct for the investigation; and
• Reiterate safety and health considerations for all participants.
All on scene activities should be shut down pending the organizational meeting. If
search and recovery operations are still in progress, the IIC should designate an NTSB representative
to remain at the site during the organizational meeting. The organizational meeting should be held
as soon as practicable upon arrival of the Go Team at the accident site according to the time of day
and the number of parties that have arrived. For example, if the Go Team members arrived at the
site during the night, key personnel from the parties may not arrive until the next morning.
Therefore, the meeting should not be held until after the key parties have arrived. If the team has
arrived in midafternoon and most of the parties will be expected to arrive in late afternoon, the
meeting should be in the early evening.
The IIC will prepare an outline of the issues to be covered in the organizational
meeting. The IIC will identify himself/herself and, after calling the meeting to order, ask reporters,
attorneys, and others not technically qualified or needed for the investigation (e.g., an accountant
with the airline) to leave the room. The IIC should then distribute the attendance roster for each
person to sign and make sure that business cards (or equivalent information) have been collected.
Photocopying the cards and distributing copies to investigation participants will allow participants to
maintain contact with each other after the on-scene phase has been completed. Then, depending on
which of the following are present, the IIC will introduce the Board Member, the Board Member’s
assistant, the GA, PA, and TDA representatives and all other Safety Board employees. Following
the introductions, other personnel in the room should identify themselves, their organizations, and
their positions within their particular organizations. Potential parties or individuals should
understand that, with the exception of the FAA, participation in the Board’s investigation is a
privilege, not a right. All party-group members are to be employees, not contractors, and are there to
contribute to the investigation or otherwise be helpful to the investigation.
After introductions, the IIC should state that the primary purposes of the meeting are
to explain operating procedures and to assign specialists to the investigative groups. The facts of the
accident will be reviewed and should include the following:
• Operator;
• Aircraft type and registration number;
• Type of flight, origin and intended destination;
• Number of fatalities (or best information presently known);
• Condition and location of crewmembers;
• Extent of aircraft damage; and
• Other information considered relevant (e.g., hazardous material (HAZMAT) and site
considerations)
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After preliminary information about the accident has been given, the IIC will discuss
the information contained in the «IIC’s Opening Statement at Organizational Meeting» (see
Appendix E). This statement advises the participants of Board policies relevant to the investigation.
The opening statement will include the following points:
• Safety Board authority to conduct the investigation
• Role of the Board member
• Role of PA, TDA, and GA;
• Role of parties to the investigation;
• Role of international participants in investigation (accredited representatives and technical
advisors)
• Organization of the team into groups of specialists;
• Qualifications of personnel to participate in the investigation;
• Expected participation of participants for the duration of on-site activities and follow-up
activities;
• Dissemination of information among investigation participants;
• Public release of information about the investigation;
• Site safety and security;
• Roles of party coordinators, group chairmen, accredited representative and advisors;
• Identification of the appointed Safety Board group chairmen;
• Who will be allowed at the progress meetings;
• CVR and FDR group participation; and
• On site commander
Following the IIC’s opening remarks, the Board Member present should be offered
an opportunity to speak to the group. After the Board Member’s remarks, the IIC will begin
assigning party participants to individual investigative groups in consultation with the group
chairmen. The IIC should bring handouts that explain such things as the NTSB’s authority and
investigation process and the role of parties in the investigation (see Appendix F). These handouts
should be distributed to the parties after the organizational meeting. The IIC should adjourn the
organizational meeting (and all progress meetings) by stating the time of the next meeting.
3.2.1 Identification and Assignment of Personnel
The IIC determines who will be parties to the investigation and should be selective
when making these designations. During the party designation process, party coordinators are also
identified. A party coordinator is the main spokesperson/representative for a party and is the IIC’s
main point of contact within a party during the investigation. This individual should have sufficient
authority within the party’s organization to be able to make decisions without a great deal of
consultation with his/her supervisors. Additionally, he or she should be available to the IIC at all
times during the investigation. Only party coordinators and participants will be allowed to attend
future meetings.
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As the investigative groups are formed, the party coordinators will be given the
opportunity to propose personnel from their organizations for assignment to one or more of the
groups. Only technically qualified individuals with the necessary expertise will be permitted to
participate in the investigation. Specialists typically include representatives of the operator,
manufacturers of the aircraft, powerplant, and accessories, labor associations, and other parties who
can contribute knowledge and expertise. The group chairmen and the IIC will assess the
qualifications of proposed group members when assigning them to the working groups. The group
should be limited to those personnel having the expertise to contribute to the investigation by
studying, evaluating, and documenting a particular discipline. The final decision regarding the
assignment of specialists will be made by the IIC in coordination with the respective group
chairmen.
For investigations involving international participation, Accredited Representatives may
have technical advisors under their supervision. The IIC and Accredited Representatives may assign
technical advisors to groups based on their technical qualifications.
For parties that are unfamiliar with Board procedures, such as small airlines, it is
advisable that the IIC fully explain the methods used to conduct the investigation, outline the major
tasks that will be expected to be accomplished during the subsequent days onsite, and explain that a
progress meeting will be held at the end of each day. It may be necessary for the group chairmen to
discuss the areas that their particular group will be focusing on and the type of expertise needed by
members of that particular group. The parties must be informed that all participants are expected to
be available for the duration of the investigation and that substituting personnel is not allowed except
in extreme situations.
Participants will be asked to report to their respective group chairmen after the
organizational meeting for further instructions.
3.2.2 Forms and Badges
As the investigative groups are being formed and party personnel are being assigned, the IIC
should use an “On Scene Organizational Chart” to assist in registering the investigative members,
their group assignments, and party affiliation. The IIC should also distribute the form «Statement of
Party Representatives to NTSB Investigation» to each party coordinator and obtain their signatures
(see Appendix D). This form contains pertinent excerpts from 49 Code of Federal Regulations
(CFR) Part 831 and explains that, by signing the form, the coordinators are obligating and indicating
the organizations they represent and all personnel assigned to the investigative groups that they
understand the rules and that they are willing to abide by them. It should be noted that the FAA
coordinator, Accredited Representatives and Technical Advisors to Accredited Representatives are
not required to sign this form. In subsequent phases of the investigation (CVR and FDR analysis,
component testing, etc.), all participants may be required to sign the form or a similar nondisclosure
form as a condition of their participation.
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The IIC has the option of distributing identification badges to the group chairmen for
investigation participants. The badges provide a method of restricting access to the accident site and
Command Post to only those individuals approved by the group chairmen or the IIC. Other
arrangements may be made with local authorities depending on the level of security desired and the
location of the accident site. If identification badges are used, the group chairmen will be responsible
for keeping track of their group members’ badges.
3.3 Accident Site Safety Precautions
Aircraft wreckage sites may expose investigators to certain risks, including
biohazards, airborne hazards, adverse terrain and adverse climatic conditions. The NTSB safety
officer will coordinate with the local Incident Commander (local police, National Guard, or fire and
rescue), if present, to determine hazards at the accident site and safety resources available to the
investigative staff. Personnel involved in the recovery, examination, and documentation of wreckage
may be exposed to physical hazards from such things as hazardous cargo, flammable or toxic
materials and vapors, sharp or heavy objects, pressurized equipment, and disease. The IIC and/or a
designated NTSB safety officer will be responsible for conducting a risk assessment of the accident
site, which will identify possible hazards, and determine the level of risk (high, medium, low) at the
work site. An environmental risk assessment can be conducted while en route and a more detailed
assessment accomplished following the initial visit to the accident site. The safety officer will then
develop countermeasures to identified risks and ensure that the appropriate countermeasures are
applied at the accident site (see Appendix G). The safety officer or the on-scene commander will
conduct daily safety briefings with all individuals who are working at the accident site. Throughout
the on-scene phase of the investigation, the IIC and the group chairmen will monitor everyone to
exercise good judgment, use necessary protective devices and clothing, and use extreme caution
when working in and around the wreckage.
It is the job of the Incident Commander to ensure that hazardous material is
identified at the accident site, and decisions to either remove the material or reduce the risk of
contamination or injury must be made before the investigative team is permitted to enter the site.
Once such actions have been taken, work at the site will be permitted. All team members should be
advised to be on the alert for any undeclared hazardous material and, if such material is found,
should immediately notify a group chairman or the IIC so that appropriate measures can be taken.
During the IIC’s opening statement, the IIC will state that the Safety Board will not
assume responsibility for any personal injuries incurred during the course of an investigation by
representatives of organizations participating in the investigation as a party or by an authorized
observer nor will the Board provide protective equipment to party participants. Safety Board
investigators shall remind all participants to use extreme care and to provide for their own needs on
site. Any safety concerns should be promptly expressed to the group chairmen or the IIC. Parties not
properly protected will not be allowed on site.
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All Safety Board personnel traveling to an area with certain known public health
risks or suspected diseases will be cleared by their supervisor before departure. The supervisor will
ensure that adequate personal protective equipment (PPE) is provided and the employee is medically
qualified for the work to be done. The Safety Board’s physician and the Department of State health
clinic can be excellent sources of information on the risks associated with certain countries or areas.
Inoculations can typically be arranged through an individual’s personal medical care facility or
through government agencies with which the NTSB has agreements.
The scene of an airplane accident may contain bloodborne pathogens. Bloodborne
pathogens are viruses, bacteria, and parasites that are present in the blood, tissue, or other body
fluids of infected persons. They could include, but are not limited to, hepatitis B and C virus (HBV)
and the human immunodeficiency virus (HIV), which causes AIDS. Some of these viruses do not
die upon contact with oxygen or when the fluids dry out. Studies, in fact, show that certain climatic
conditions may prolong the infectiousness of HIV. Those who work in or around the wreckage must
use extreme caution to minimize direct contact with bloodborne viruses. At a minimum, heavy
leather work gloves over nonpermeable rubber gloves should be used and in some case will be
required when touching the wreckage. Under certain conditions, such as within the wreckage where
investigators may come into contact with blood or human remains, full face masks, protective
goggles, and disposable overalls and booties shall be worn. Protective biohazard suits are also
available in Hangar 6 at Washington’s Reagan National Airport. Occupational Safety and Health
Administration (OSHA) requirements concerning training and on-scene protection procedures and
equipment are included in the Safety Board’s Exposure Control Plan, a copy of which is included in
Appendix T. The Safety Board’s Occupational Safety and Health Coordinator is responsible for
maintaining the plan and ensuring that it is updated annually; copies of the plan may be obtained
from the intranet. Each investigator who will be working on-scene will have two packages of
biohazard equipment as part of his or her go-team equipment.
3.4 Observers
The IIC may allow properly accredited members of Congressional oversight,
designated military personnel, representatives of other Federal agencies, or representatives of foreign
governments to be observers to the investigation. Training and familiarization with the Safety
Board’s investigative process is the sole purpose of the observer status. Observers should not have
any self-interest in the investigation, and they will be permitted access to only those portions of the
investigation deemed appropriate by the IIC. Observer status must be coordinated and approved in
advance. Although observers will sometimes work with one of the investigative groups, they will be
under the overall authority of the IIC and will be given factual information on a «need to know
basis.» The restrictions concerning public dissemination of accident information apply to all
observers.
3.5 Lines of Authority
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The IIC is the senior person on-scene and all investigative activity at the site is under
his/her control. The IIC has the overall authority and responsibility to resolve any difficulties that
may arise on scene.
Group members will first attempt to resolve problems directly with their respective
group chairmen if any difficulties arise among the team members during the on-scene investigation.
If a resolution is not reached, the group members should alert their respective party coordinators.
Concurrently, the group chairman will notify the IIC. The IIC and the party coordinator will discuss
the problem and attempt to resolve it, informing the group member and group chairman of the
decision.
If the IIC and party coordinator cannot reach resolution of a problem, they will then
discuss it with the Chief of the Major Investigations Division. If the issue cannot be resolved at that
level, it will be elevated to the OAS Director or other senior NTSB management levels for final
resolution (see the investigation organization chart in Appendix D for a detailed delineation of the
lines of authority).
3.6 Group Chairmen Responsibilities
Immediately following the organizational meeting, each group chairman should meet
with his/her group members. Since some group members will be unfamiliar with the procedures of
an NTSB accident investigation, several things should be discussed with the group, including the
scope of the group’s investigation, assignment of duties, and NTSB protocol concerning field notes.
It should be explained that for all matters related to the accident and the investigation, the team
members’ primary responsibility is to their working group and respective group chairman—not to
their respective organization. They must arrange their personal schedules to conform to the schedule
determined by the respective group chairman and commit to staying with the group until released by
the IIC and their respective group chairman.
3.6.1 Field Notes
Each group chairman is required to compile field notes documenting the on-site
activities of his/her group. Field notes represent the summation of factual material gathered and
information obtained by each investigative group participating in the investigation. Each group will
have one official set of field notes. The field notes will contain applicable information outlined in a
set of checklists (see Appendix H), as well as other information collected or documented by the
group. Appendix H also contains information on the responsibilities of each working group.
At the end of each day of the on-site investigation, each group should discuss its
efforts and review the progress of its field notes. This is most conveniently accomplished before the
daily progress meeting (see section 3.7). At the end of the on-scene investigation, every member of
each working group must sign the group’s field notes. These signatures indicate and clearly convey
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that each member of the group has read all of the field notes and either agrees with the information
included in the notes or has indicated, in writing, specific areas of disagreement and the reasons for
that disagreement. If group members do no
