Aviation Accidents and Lessons Unlearned LXXVII: EstoAir N525EG
On November 30, 2018, an EstoAir Cessna 525A Citation crashed after taking off from Clark Regional Airport (JVY), Jeffersonville, Indiana (IN). The aircraft impacted terrain near Memphis, IN, after colliding with trees at 10:28 local time. The flight was operated under the provisions of Title 14 code of federal regulations (CFR) Part 91, conducted as a business flight. The National Transportation Safety Board (NTSB) assigned this event accident number CEN19FA036.
In the original report published 11/1/2021, the NTSB determined the probable cause(s) of the accident to be: “The asymmetric deployment of the left-wing load alleviation system for undetermined reason, which resulted in an inflight upset from which the pilot was not able to recover.” The Defining Event was, “Flight control sys [system] malf [malfunction] /fail.” Finding #1 showed, “AIRCRAFT: Control surface (fitting on wing) – Malfunction;” Under History of Flight, Finding #2 showed, “INITIAL CLIMB: “Flight control system malfunction/fail (Defining event).”
Page 1 of the Modified CEN19FA036 report from the NTSB Archives
The wing extension and winglet systems by Tamarack Aerospace Group, the NTSB made the accident’s probable cause. Tamarack, an NTSB systems group member, disputed the decision because the NTSB’s analysis ignored key data. Tamarack then petitioned for reconsideration (PFR). The process took two years and three months (27 months), but on February 23, 2024, CEN19FA036 was rewritten to say: “The pilot’s inability to regain airplane control after a left roll that began for reasons that could not be determined based on the available evidence.” Finding #1 changed to “AIRCRAFT: Undetermined;” Finding #2 changed to, “INITIAL CLIMB: Loss of control in flight.”
Page 2 from the modified CEN19FA036 report from the NTSB Archives.
Unlike past aviation lessons unlearned dot com articles, it wasn’t clear how the NTSB arrived at the new probable cause, meaning this article couldn’t be written from clear revised evidence. But Tamarack’s PFR stands as a good ‘lesson unlearned’; it demonstrated how the PFR process is flawed. How long has it been since Title 49 CFR Part §845.32 was last revised? Are NTSB systems investigators qualified to explore these aviation technology advances so their ‘probable causes’ can stand up to scrutiny?
When engineering changes or major alterations, like a Supplemental Type Certificate, are presented by industry, Federal Aviation Administration (FAA) engineering does the math, the testing, and proofs before making a design approval. With FAA design reviews, the paperwork … never … goes to the bureaucracy for determinations. That negates safety. When Tamarack pursued reconsideration, their PFR request didn’t go to engineering for analysis, justification, and approval. Instead, their PFR went to NTSB Board Members, aka presidential appointees. With Tamarack’s PFR being a safety of flight issue – which all pilots and mechanics would take very seriously – why did bureaucrats make this decision?
NTSB Response letter from the NTSB Archives.
The NTSB’s response letter contained a concerning issue: “…the NTSB [systems group lead] did not consider information in Tamarack’s supplemental party submission, dated October 26, 2021;” the NTSB lead investigator didn’t add Tamarack’s supplemental part submission in the report. Was the NTSB investigator skilled in Tamarack’s technology? How could he be? Was anyone at the NTSB qualified to review Tamarack’s design data? Did the FAA systems group member suggest having FAA engineering examine the technical data?
Of the three board members who reviewed the PFR, two had long careers in management. The third had an impressive active pilot and flight instructor career, but a pilot isn’t a design engineer. What do these questions point to? Whether Tamarack’s PFR succeeded or not, the NTSB based this aviation safety decision … for a popular aircraft’s safety … on bureaucrats – not experience or knowledge. Management types who were not qualified were the final word on the PFR. With numerous technical safety issues to be analyzed, the NTSB left this decision to untrained and unqualified administrators.
What about the NTSB investigator, aka engineer, who refused Tamarack’s supplemental party submission in the first place? How did he decide on the original probable cause without examining the design information Tamarack submitted? As a result, any final cause resolution was dragged out to 63 months. The accident aircraft was totally accessible, not submerged in the ocean or on a mountain top.
Why did the NTSB systems group chairman omit (refused?) Tamarack’s supplemental party submission from the report? We’ve seen, through root cause analysis, NTSB investigators who’ve ignored important accident information before, like ValuJet 592’s ramp responsibilities or National Air Cargo 101’s Boeing report. But this was different. With ValuJet and National, it was a failure to understand. In this EstoAir report, it was a refusal to understand. This unqualified NTSB investigator’s error brought to light three safety issues the aviation industry should not sit for:
1. NTSB investigators got it wrong. They held Tamarack accountable, because … why?
2. The NTSB allowed the true cause to continue to exist, unaddressed, for years.
3. Tamarack employees had to appeal to bureaucrats with the authority – but not the experience, knowledge, and understanding – to correct the misjudgment against Tamarack.
Let’s tackle the 3rd point first. Title 49 CFR Part §845.32 Petitions for Reconsideration or Modification of Report, states under (a) (2), “Petitions must be in writing and addressed to the NTSB Chairman.” NTSB board members are administrators; management; they don’t rise through the ranks. They’re politically connected – presidential appointees. How many board members ever turned a wrench; directed air traffic; shot an approach with a passenger-filled airliner? How many board members worked for the FAA as inspectors or other transportation regulators? Have any board members worked inside the Rail, Highway, Pipeline, or Marine industry? Do they lead accident investigations or are they talking heads at press conferences reading from cue cards. Board members deal with budgets, travel vouchers, and make speeches; they post on social media; talk to the press about how they make travel safe; and how investigators would be lost without them. But they don’t do anything for safety.
Reconsiderations must be reviewed by professionals with subject matter expertise – not NTSB engineers. Title 49 CFR Part §845.33 Investigation to Remain Open, states, “The Board never officially closes an investigation, but provides for the submission of new pertinent evidence by any interested person.” That subpart makes no sense. “If the Board finds such evidence is relevant and probative … the Board will provide parties an opportunity to examine such evidence and to comment thereon.” After the fact?
Where’s the urgency? Where’s the pursuit of truth? “If the board finds …?” Is this the same Board that denied Tamarack’s evidence? Did this investigator reinvestigate his mistake, and resubmit a report to the board members a second time? How many PFRs has the NTSB denied so far? What does “The Board never officially closes an investigation” mean? Why not? The NTSB is supposed to provide quality investigations of accidents; to arrive at uncontestable conclusions; to write recommendations that improve transportation safety.
Title 49 CFR Part §845.33 is government doing what government does best: absolving itself of all blunders, even before they happen. It’s excusing bad behavior; the justification for performing substandard work. NTSB accident investigations aren’t like a docuseries portrays; instead, they’re organized chaos, with lots more chaos than organized. We’re also led to believe bureaucrats are incredibly perceptive, on-top-of-their game, like in spy thrillers, but they’re more self-involved than scheming; they’re not like the antagonists in those books and films.
Regulatory agencies can’t get away with excuses. The FAA’s Flight Standards Division must arrive at root cause; no ‘shooting from the hip’. Like I did, each experienced aviation safety inspector (ASI) must qualify their report’s evidence, testing, interviews, facts – no opinions. An ASI’s report is then reviewed by an experienced office manager before it’s forwarded to an experienced specialist, who also vets the report and evidence provided. If the report passes technical edits, it goes to FAA Legal for regulatory compliance. No certificate is revoked; no fine levied; no action taken; until this process is followed. I know because I was also one of the experienced specialists who sat down with FAA Legal. If an FAA ASI was William Tell, he’d hit the apple every time.
The FAA’s Flight Standards as William Tell successfully splitting the apple on his son’s head.
As a former NTSB major accident investigator my experience with the NTSB investigatory process is I, the experienced investigator, gathered all the evidence, facts, and interview statements. I submitted my report to my INexperienced lead, whose primary language was not English, who edited my report by removing facts he didn’t understand. The butchered report then went to the INexperienced management, who wrote the findings and recommendations – without my feedback. The report was then approved by INexperienced Board Members, most of whom had no idea what they were looking at. If an NTSB investigator were William Tell, the apple would remain unbruised, while his son (sons???) would be … well, it would get messy.
An NTSB Investigator as William Tell missing the target.
Of course, the FAA’s regulatory while the NTSB is investigatory. However, both agencies have the same goals: To further and improve aviation safety by analyzing facts and evidence; by leaving no stone unturned. The differences aren’t in their goals, but their approaches. The FAA determines root cause, while the NTSB settles for probable cause. But it’s time the aviation industry understands … there’s no such thing as ‘probable cause’. It’s not real; it’s an oxymoron. In aviation, it’s not even defined. Even the Supreme Court attempted to define the term ‘probable cause’ on several occasions, but “… they recognize that probable cause is a concept that is imprecise, fluid, and very dependent on context.”
The word ‘Probable’ is an adjective meaning: “supported by evidence strong enough to establish presumption but not proof.” In other words, a probable cause means ‘maybe’, ‘probably’, or ‘could be’ what happened. Is that what industry needs to know? The NTSB can’t tell you what happened, so settle for ‘it might be’. How does one correct a moving maybe?
While probable cause is ambiguous, root cause is definable. In researching for an article, I found a 2016 Civil Aviation Authority presentation with a Root Cause definition as: “The fundamental reason for an event which, if corrected, would prevent reoccurrence; the last cause in the chain of events.” Root cause, therefore, means uncontestable cause(s) for an event. To be clear, 100% of the time, the FAA closes their investigations with facts.
Isn’t that what NTSB is supposed to do? Give the transportation industry corrective actions to correct safety issues? Prevent reoccurrences? Aren’t Recommendations written to improve safety? Doesn’t the NTSB dictate to the regulatory agencies how they should do their jobs? But we are led to believe, “The Board never officially closes an investigation,” that NTSB reports are, per Title 49 Part CFR §845.33, a ‘maybe it is … maybe it isn’t’ event. Or maybe industry will figure it out itself. By deferring to §845.33, the NTSB demonstrates the NTSB only needs to apply as much effort (or lack of effort), knowledge, resources, experience, professionalism, or time as they want to an investigation, because the regulation says they’re not responsible for their errors.
Which brings us to issue number two: Did the NTSB, after granting Tamarack the reconsideration, properly reinvestigate? The aviation industry still may have a problem; there’s something wrong with either the Cessna 525A Citation … or EstoAir … or (fill in the blank) [pilot, mechanic, engineering] training. Is there an unsolved accident out there with … something wrong, that nothing’s been done to correct? How will we know what probably, maybe, sorta happened?
Which brings us to issue number one. Did Tamarack suffer financial harm from the NTSB’s mistake? Was their reputation hurt? As quick as Tamarack was in submitting the PFR, it’s hard to imagine their company didn’t receive – at a minimum – bad press in the aviation community. Question: How many other legitimate PFRs are out there? If my website’s root cause analyses are correct … a lot.
It’s my opinion that PFRs will – and should – increase. I’ve been analyzing NTSB report findings in my website: https://aviationlessonsunlearned.com each month for over six years. The NTSB causal mistakes are alarming for (1) incorrect probable causes and (2) overlooked safety issues. I’ve conducted root cause analysis for years at the FAA; taught it as an aviation safety instructor; and practiced it since 2007 as an ISO9001 Auditor and Lead Auditor. My company at acmx-safety-pros.com and this website both demonstrate how important root cause analysis is in industry, in assuring aviation professionals understand the importance of fundamental accident and incident prevention.
It's time to wake up industry. We’re broken! Government won’t save us because they’re lost! And that goes for Rail, Marine, Highway, and Pipeline as well. NTSB accident reports have been written under the conditions of Title 49 CFR §845.33 and that’s not being safety proactive.