Two weeks after crashing his Piper Saratoga plane, Mark Williams left the hospital in a wheelchair and met with federal crash investigators for an interview that felt like an interrogation.
"They kept on berating me, 'How much fuel was in (the plane)? What was your fuel burn that day?' Their questions seemed so accusatory," recalled Williams, an amateur pilot and a dentist from Meridian, Miss.
Williams tried to describe how his six-seater had lost power 1,100 feet in the air. But the investigators had their own ideas. Because there was no fire after the crash, they suspected Williams had burned up his fuel and wanted him to take the blame.
Williams, who suffered a broken pelvis, broken shoulder and a severed ear, insisted there was no fire because the fuel drained out when a tree limb sheared off a wing.
Days later, Williams' statement was confirmed by a third federal investigator, who found that a failed engine component — not pilot error — caused the June 7, 2002, crash, Williams said. Federal investigators would blame the same component for a New Jersey crash three months later that killed a Canadian couple and critically injured their two sons, ages 8 and 5.
Williams wonders to this day what investigators would have concluded had he not been alive to speak to them.
"Had I not survived, this accident would have been wrapped up as pilot error, fuel exhaustion, and nobody ever would know the difference," Williams said.
Federal accident investigators repeatedly overlooked defects and other dangers of private aviation as they blamed individual pilots for the overwhelming number of crashes of small airplanes and helicopters, a USA TODAY investigation has found. The failure of crash investigators to find defective parts, dangerous aircraft designs, inadequate safety features and weak government oversight helped allow hidden hazards to persist for decades, killing or injuring thousands of pilots and passengers, the investigation found.
The National Transportation Safety Board, which investigates accidents and urges safety improvements, has an international reputation for exhaustive investigations of commercial jet crashes. But its probes of "general aviation," which covers private planes and helicopters, are much more brief, often done by telephone and frequently reliant on manufacturers to find problems with their own aircraft parts.
NTSB investigators visited a crash scene or did "a significant amount of investigative work" in only 15% of the 64,000 general-aviation crashes from 1982 through 2013, according to a USA TODAY analysis. They did significant investigations of 32% of airline accidents, which are often incidents involving damage on a tarmac or injuries caused by turbulence. In the Williams case, the NTSB had Federal Aviation Administration safety inspectors conduct the initial interview with Williams.
"The NTSB could do more" to investigate general-aviation crashes, former NTSB chairwoman Deborah Hersman said in a recent interview, "but I think it's a question of asking what does the public want and what are they willing to pay for." The NTSB has given top priority to commercial airline crashes, which it has helped to virtually eliminate. There hasn't been a major airline crash since early 2009.
But the shortcomings in general-aviation investigations have compounded a death toll of nearly 45,000 since 1964 — roughly nine times more than were killed in passenger airlines.
An in-depth review of federal records shows:
At least 214 air-ambulance helicopters have crashed since 1982, killing 272 patients, pilots and medical personnel and injuring 175. The NTSB blamed 72% of the crashes on pilots, but a 2006 board study found that many of the crashes were caused by flight dispatchers failing to tell pilots about dangerous weather and hazardous landing conditions, or could have been prevented by safety systems that warn when an aircraft is too close to terrain.
Isolated, minor incidents also show the danger of shallow investigations . After a Cessna 172F landed at Pilot Country Airport near Tampa in 1998 and plowed into a dirt mound at the end of the runway, the NTSB blamed the pilot and said nothing about the mound being so close to the runway.
- $48 million against British parts maker Doncasters, including $28 million in punitive damages, for a 2006 crash that killed six in a deHavilland airplane.A jury blamed defective turbine blades that caused one of two engines to fail. The NTSB could not determine why the turbine blades broke and blamed the pilot for "failure to maintain airspeed" after the engine failure. Doncasters paid the $48 million.
"Why would you not disclose that when the NTSB is relying on you and you know the (NTSB) field-office guy doesn't have a specialized knowledge of carburetors?" said Portland attorney Matthew Clarke, who filed the lawsuit.
The NTSB blamed the pilot's "improper decision" to fly into low-visibility conditions.
Pilots also were blamed — and later exonerated — in numerous cases involving air-traffic controllers. Since 1997, the U.S. government has paid $60 million to settle 41 claims over crashes that the NTSB blamed on pilots but which claimants said were caused by air-traffic controllers, federal records show.
Former Marine Gavin Heyworth was blamed by the NTSB for a 2003 midair helicopter collision that killed two others because of his "failure to comply" with air-traffic-controller instructions. But after a week-long bench trial, a federal judge ruled that FAA controllers failed to keep the two helicopters apart and had acted "negligently and carelessly." The Justice Department settled claims against the FAA over the crash for $10.1 million.
The NTSB finding "was one of the worst things that ever happened to him," said Heyworth's attorney James Pocrass. "He felt responsible for the death of those two people. The vindication he had from the judge was bigger than winning the case."
Chapter 4: Trying to fix a deadly problem
The NTSB has become increasingly concerned about general-aviation as crash and fatalities rates have remained stagnant for 15 years while commercial crashes have practically ceased. In 2012, the NTSB elevated general-aviation safety to its annual list of "most wanted" improvements in transportation safety.
"That was a breakthrough," the NTSB's DeLisi said.
The NTSB, run by five presidential appointees with a staff of 400, has focused since its creation in 1967 on hazards to the greatest number of people in aviation, rail transit, pipelines, waterways and roadways. The NTSB helps investigate 19 foreign airline crashes a year on average, including the recent disappearance of Malaysia Airlines Flight 370. Foreign investigations are "a particular challenge" because of the board's domestic obligations, the NTSB wrote in a recent annual report.
In 2012, the NTSB said that in many general-aviation crashes "pilots did not have the adequate knowledge, skills or recurrent training to fly safely." At the opening of the 2012 forum, Hersman, then the NTSB chairwoman, said, "GA pilots are not learning from the deadly mistakes of their brethren."
The emphasis on pilots and pilot problems has steered the NTSB away from mechanical problems or ways to increase the chances of surviving a crash, some experts say.
"There is essentially no requirement that specific injury data be collected. They don't even collect impact data, like angle (of the crash) or velocity," said retired Army colonel Dennis Shanahan, former commander of the U.S. Army Aeromedical Research Laboratory who has consulted for the NTSB.
"This has severely impeded researchers' ability to find out what's going on from an injury basis," Shanahan added. "If you're interested in a particular aircraft and you want to know what the injuries are, it can't be done."
Harry Robertson, an aviation-safety pioneer who developed stronger helicopter fuel tanks in the 1960s and is in the National Aviation Hall of Fame, said general-aviation deaths cannot be substantially reduced until the NTSB understands their cause.
"The most important thing they can do first is improve the quality of their investigations as to what it was that caused the injury and the death," Robertson said.
And once causes are known, "engineers can step in and figure out the ways to assure an improvement in crashworthy capabilities …Trying to improve crashworthiness is very hard if you don't know what broke."
The NTSB and its predecessor agencies have recognized for decades that general-aviation crashes are often mild enough for occupants to survive.
In 1980, the NTSB said, "General-aviation aircraft are unnecessarily lethal in crash situations which should be survivable."
To reduce automotive deaths, the National Highway Traffic Safety Administration gathers data on what kills or injures people in crashes. The findings have led NHTSA to mandate a wide range of safety equipment that has reduced the number of deaths in motor-vehicles to 21,667 in 2012 from 35,025 in 1988, even as the amount of driving increased 50%.
A 2002 report written for the Department of Transportation by Sue Baker, the Johns Hopkins expert, urged the NTSB to follow NHTSA's approach and collect detailed information on a random sample of general-aviation crashes. That hasn't been done.
Shanahan said the NTSB was interested when he was consulting there in 1989, but money was not available.
The NTSB has instead conducted in-depth studies on specific general-aviation aircraft and flying conditions that are causing extensive crashes, such as home-built airplanes and medical helicopters. The studies have found causes and patterns that were not found during individual crash investigations, and have led to safety recommendations and improvements.
But the NTSB safety recommendations come years or decades after a problem arises.
In May, an NTSB report noted problems with agricultural pilots and urged better pilot training, fatigue management and aircraft inspection.
The report did not note that since 1982, 4,200 agricultural airplanes and helicopters had crashed, killing 394 people and injuring 1,224.
In two-thirds of the crashes, the NTSB blamed the pilot.