[Peetwo]

NTSB v Ethiopian Flight ET 302 FR: Part II

Courtesy Hessel W. van der Maten, via Linkedin: 

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Hessel W. van der Maten

Aside from everybody’s opinion on responsibility, liability and accountability for the accident, this communication from the NTSB provides some good insight into an important part of the investigative process: draft report review.

ICAO Annex 13 stipulates who may participate in the investigation. While the State of Occurrence (here: Ethiopia) is in charge of the investigation, many accredited representatives provide information that could find its way into the final report. A draft of the final report is normally sent to those involved to collect feedback on factual accuracy. To maximize transparency, the investigative authority sometimes publishes this feedback, with their commentary on why this was or was not incorporated into the final report. This way, the reader can determine the objectivity, veracity and thoroughness of the investigation.

The NTSB decided to publish their feedback and I have no doubt this decision was not taken lightly. Investigative authorities are not supposed to apportion blame and this release only aims to increase transparency so that we can improve our learning and attempt to prevent reoccurrence.

NTSB Releases Comments on Ethiopia’s Investigation of the Boeing 737 Max Accident

12/27/2022

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WASHINGTON (December 27, 2022) — The National Transportation Safety Board published Tuesday the comments it provided to the Ethiopian government on their draft accident investigation report into the 2019 crash in Ethiopia of a Boeing 737 Max airplane.

The NTSB took the unusual step of publishing the comments on its website after Ethiopia’s Aircraft Accident Investigation Bureau (EAIB) failed to include the NTSB’s comments in its final report on its investigation into the March 10, 2019, crash of Ethiopian Airlines flight 302, a Boeing 737-800 MAX. The NTSB received the EAIB final accident report on December 27.

In accordance with the provisions of the International Civil Aviation Organization Annex 13, countries participating in the investigation are provided the opportunity to review the draft report and provide comments to the investigative authority. If the investigating authority disagrees with the comments or declines to integrate them into the accident report, participating countries are entitled to request that their comments be appended to the final report.

The EAIB provided the NTSB with its first draft of the report last year. The NTSB reviewed the report and provided comments on several aspects of the accident the NTSB believed were insufficiently addressed in the draft report. The comments primarily were focused on areas related to human factors.

After the EAIB reviewed the comments, it provided the NTSB with a revised draft report for its review. The NTSB determined the revised report failed to sufficiently address its comments. As provided by the ICAO Annex 13 process, the NTSB provided the EAIB with more expansive and detailed comments.

Instead of incorporating the most recent and expanded comments into their report, or appending them as had been requested, the EAIB included a hyperlink in their final report to an earlier and now outdated version of the NTSB’s comments.

The NTSB also noted that the final report included significant changes from the last draft the EAIB provided the NTSB. As a result, the NTSB is in the process of carefully reviewing the EAIB final report to determine if there are any other comments that may be necessary.

The NTSB’s comments are available online.

MTF...P2