What are the chances?

ISSN 2369-873X

7 March 2013
Posted by: Brad Vardy

The phrase “What are the chances of that happening?” is a common one, often heard when random events produce astonishing outcomes. It is not a phrase that I use much, if at all. In my 30+ years in aviation, I had come to the point where nothing really surprised me anymore. That was until the evening of May 28, 2012, when I received a call from the TSB’s Director of Air Investigations, Mark Clitsome.

“There’s been a mid-air collision in the United States, near Warrenton, Virginia, involving two general aviation aircraft: one flown by an NTSB employee, and the other by an FAA inspector. There are fatalities. They’ve asked us to do the investigation.”

In the aviation world, the National Transportation Safety Board (NTSB) is the TSB’s counterpart in the United States; in other words, they are the independent agency responsible for investigating transportation accidents. The U.S. Federal Aviation Administration (FAA) is the aviation regulator, equivalent to Transport Canada in this country. An accident involving both the regulator and the safety board was certainly unprecedented anywhere, and investigating an occurrence in which one of their own employees was involved put the NTSB in a potential conflict of interest. So they turned to their northern neighbour for help.

One of the aircraft involved, a Piper PA-28
Image of one of the aircraft involved, a Piper PA-28

The International Civil Aviation Organization (ICAO) is a specialized agency of the United Nations, created in 1944 to promote the safe and orderly development of international civil aviation. Through the Convention on International Civil Aviation (also known as Chicago Convention), it sets standards and regulations necessary for aviation safety, security, efficiency and regularity between the 191 member states. Annex 13 to this document stipulates how member states interact with respect to accident investigation, and it was under Section 5.1 of this annex that the investigation was delegated to Canada.

One of my responsibilities as Manager, Head Office Operations, is to oversee the TSB’s international activities and obligations in aviation, so this occurrence fell under my purview. I called the NTSB Director of Aviation Safety in Washington, offered our sympathies, and asked how we could help. He indicated to me that when they became aware of the specifics of the situation, they ceased all investigation activities and called the TSB.

Would we be able to come down to Virginia and conduct the investigation? Absolutely.
The rest of the evening was spent building the team that would deploy for the field phase of the investigation. Western Regional Manager Jon Lee was appointed Investigator in Charge, accompanied by Randy Vitt, Senior Technical Investigator from the Central regional office in Winnipeg. They were to travel the next day, arriving in the evening. I caught the 6 am flight from Ottawa to the Washington Dulles Airport to start figuring out exactly how we would proceed, what the team would be facing when they arrived, and to sort out the details of conducting a TSB investigation on U.S. soil under the Canadian Transportation Accident Investigation and Safety Board Act (CTAISB).

The TSB has conducted investigations in foreign jurisdictions in the past, but these were usually in countries that did not have an accident investigation board of their own, or whose board lacked the resources or experience required. The scenario facing us was unprecedented and complex.

I stepped off the plane in Dulles and was met by Paul Cox, the NTSB investigator who was originally assigned to the occurrence, and the manager for the region. They briefed me on what they had done and learned so far, and confirmed that both sites were secured by police. We then went to the FAA Washington (Dulles) Flight Standards District Office (FSDO), office to speak with FAA officials and NTSB senior management.

The NTSB confirmed that the investigation had been delegated to Canada, and offered full access to all of their investigative resources and facilities. To ensure independence of the investigation, we discussed the limitations to their involvement. Paul was appointed as the U.S. Accredited Representative to the investigation under ICAO Annex 13. With initial ground rules in place, Paul and I left for the accident area.

Jon and Randy examining the wreckage
Image of Jon and Randy examining the wreckage

I spent the rest of the day working the two main accident sites, taking notes and photographs, and gathering as much data as I could before Jon and Randy arrived. During that time, Paul and I discussed potential challenges, especially with respect to investigating on U.S. soil. This would require a special Memorandum of Understanding between the TSB and the NTSB specific to this investigation. That document was negotiated and signed by the Chairs of both organisations within two days. Under the Memorandum and the provisions in ICAO Annex 13, the authority and independence of the investigation was assured.

When Jon and Randy arrived that evening I briefed them on what I’d learned so far. Jon took the reins, and we developed a plan for the next day. We decided that Lothar Hopp, a Senior Air Traffic Services Investigator from my group at Head Office should join us to help with air traffic, airspace and communications aspects of the investigation. With the full team in place, the field phase of the investigation was completed in four days.

The outstanding cooperation of the NTSB and FAA continued through the examination and analysis phase, and the report into this tragic occurrence should be released to the public later this year.

Along the way there have been many challenges, but the professionalism and dedication of all involved—at all levels, on both sides of the border—has turned this investigation into a shining example of international cooperation. It is a testament to the integrity of those who choose to serve in this way, those for whom advancing safety for the industry and the travelling public is in their DNA.

We all wait for that next phone call, when the skills and expertise of our organization will again be called upon to reduce the number of times we ask: “What are the chances of that happening?”


Image of Brad Vardy

Brad Vardy began his aviation career in 1981, flying helicopters throughout most of Canada, including the high Arctic, and for United Nations missions in Asia and Africa. After his commercial career, he worked as a Senior Test Pilot for Bell Helicopter Textron and held various positions at Transport Canada, before joining the TSB in 2010 as Manager, Head Office Air Operations. Brad is the father of two, enjoys long-distance motorcycle touring, photography, and thinks he’s an awesome chef.

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