The US Naval Safety Center describes an accident as “a failure of an organization’s overall safety program” . The underlying premise of this definition is the hazards that caused an accident were not discovered in time – and therefore, there was a failure in the organisation for not trapping or preventing those hazards. Attempting to overcome this failure, the International Civil Aviation Organization (ICAO) has defined the objective of any accident investigation as “being for the prevention of accidents and incidents…not the purpose to apportion blame” (ICAO, 2001). By investigating accidents, the ICAO’s objective uses the outcome of those investigations as a means to identify and prevent potential hazards that may later surface, or be the causal factor, in future accidents.
The above definition and objective relate to current investigation techniques. From a historical perspective though, the very first aircraft accident report was released in February 1909 and relates to an accident that occurred during a preparational flight conducted prior to an official demonstration event for the US War Department in September 1908. Being a military inquiry, the investigation was conducted by 1st Lieutenant Frank Lahm (from the US Signal Corps) and the findings, and subsequent report was presented to the Office of The Chief Signal Officer.
This article will analyse the tabled report from this first investigation. By first presenting a brief outline of the accident and then assessing both the content and the structure of this report, this article will present a critical view of this historical report using current day techniques and definitions.
Accident Outline
On 17th September 1908, Orville Wright was undertaking preparations for a demonstration flight of a new aircraft that his company had built. He had arranged for the installation of new and longer propellers with the view to increasing the speed of the aircraft. The existing propellers were 8 feet 6 inches in diameter, and it was estimated the new propellers were approximately 9 foot in diameter. It was anticipated that the new propellers would assist the aircraft with the official speed trials that formed part of the forthcoming demonstration.
Wright wanted to take the aircraft for a test flight with the new propellers and it was suggested by a third party that Lt. Selfridge accompany him on this unofficial flight. The aircraft took off at 5:14pm and circled the field 4.5 times. A northeasterly wind of 4mph was recorded on the day of the accident.
Multiple witnesses on the ground reported that a section of a propeller fell apart and broke-off. The aircraft initially glided down from approximately 150 feet to an estimated 75 feet high and then “dropped straight to the ground the remaining 75 feet”.
A broken portion of the right propeller was located approximately 200 feet away from the impact point.
The two occupants of the aircraft were still seated when assistance arrived on the scene. Both were held in place by wire braces that crossed the front of the seats. Wright was laying across these wire braces and appeared to be dazed but still conscious and was able to speak. Lt. Selfridge was unconscious when found in a face downward position laying across the wire brace. He was transferred to the base hospital where he died of a fractured skull at 8:10pm that evening. He never regained consciousness.
The investigator opined that “excessive vibration” from the aircraft caused the right propeller to come in contact with a guy wire. Repetitive striking of this guy wire caused the propeller to both loosen and break apart. The rear rudder fell to a horizontal position which ultimately lifted the rear of the aircraft in an upward position – therefore causing the aircraft to pitch forward in the final moments of the flight.
The aircraft was moved to a local shed that evening and was later shipped to Ohio by order of Orville Wright.
Report Analysis
Section 1.1.1 of the ICAO Manual of Aircraft Accident and Incident Investigation specifies that:
“The Final Report of an aircraft accident investigation is the foundation for initiating the safety actions which are necessary to prevent further accidents from similar causes”.
This essentially means that the final report must include details on what, how and why and conclude with findings that lead to recommendations – that when actioned, may prevent similar accidents from occurring again.
The Final Report for the 1908 accident does contain a record of the relevant facts (details on what happened), and it also contains analysis of those facts (in the form of comparing witness statements, mapping the physical locations of the various witnesses, the taking of measurements and seeking environmental and locational information). Reference is also made in the report to accompanying photographs which detail the final positioning of aircraft flight surfaces however these photographs were not viewable in the reviewed version of this report. This use of photographs (and also diagrams and charts) in a Final Report satisfies the requirements in paragraph in 1.12 in ICAO’s Annex 13 Aircraft Accident and Incident Investigation.
The investigator spoke to the pilot and took that statement into account in reference to the various witness statements and located material evidence (propeller debris on field etc). These statements and material evidence are then drawn upon to compile an explanation as to how the accident occurred.
The report concludes with the investigator’s opinion as to why the accident occurred however it does not include any recommendations that may prevent similar accidents from occurring again – nor does it detail any safety issues that need to be addressed. Both these deficiencies are required as per paragraph 1.1.2 of ICAO’s Manual of Aircraft Accident and Incident Investigation.
Paragraph 1.4.1 ICAO’s Annex 13 – Aircraft Accident and Incident Investigation – 9th Edition specifies that the Final Report must be distributed to the manufacturer – namely Orville Wright (who was the pilot and the manufacturer). It is not clear from this report that this requirement occurred. Relatedly, paragraph 1.5.2 of the same document details that Final Reports for any accident investigations should also be distributed to the Aircraft Registry authority. This current requirement does not have any impact on the reviewed investigation due to aircraft in the United States of America were not required to be registered until March 1927 (Federal Aviation Authority, 2017) – approximately 20 years after the reviewed accident.
Paragraph 2.4.1 ICAO’s Annex 13 – Aircraft Accident and Incident Investigation – 9th Edition also specifies that a basic and factual report (titled a Preliminary Report) should be compiled and distributed within the first two to four weeks of an investigation. This did not happen for the reviewed accident per se, however the first page of the Final Report does include a brief one-page summary of a meeting that occurred on September 18th, 1908 – one day after the accident.
This one-page meeting summary includes very basic factual information about the accident including a description of what occurred and the identification of the deceased. Mention is also made that the Board (attending this meeting), were unable to consult or question Orville Wright (at the time of the meeting) about the accident due to his “condition being of such to prohibit consulting or questioning”. This may imply that the pilot (and manufacturer) of the aircraft may not have had the opportunity to provide factual input into the minutes of the initial meeting (which can be considered the equivalent of the currently required Preliminary Report).
It is unknown whether this one-page meeting summary was distributed to any other party prior to being included in the Final Report – which was sent to the Office of the Chief Signal Officer in February 1909 (5 months after the accident). It is also unknown if the actual Final Report was distributed to any other party – including the aircraft manufacturer.
Final Thoughts
It could be argued that the compilation of the Final Report for the 1908 accident did meet the majority of current requirements as defined in both Annex 13 – Aircraft Accident and Incident Investigation and Doc 9756 – Manual of Aircraft Accident and Incident Investigation. The relevant facts were documented as was an analysis on provided information (witness accounts coupled with environmental details and material evidence). Details on how the accident occurred was also included and the report concluded explaining why the accident took place.
However, the lack of a set of recommendations coupled with no details on various safety issues that need to be addressed is a major concern – especially when compared to reporting requirements for current accident investigations. Essentially, there is no potential or documented means to use factual evidence from this investigation to prevent future accidents from occurring.
This major deficiency means that the respective report does not meet the current requirements as defined in both Annex 13 – Aircraft Accident and Incident Investigation and Doc 9756 – Manual of Aircraft Accident and Incident Investigation.
There is uncertainty though on the distribution of both the minutes (which may form the required Preliminary Report) and the Final Report. Current requirements have these reports being sent to the aircraft manufacturer but there is no evidence that this occurred for this investigation. Nor is there evidence that the manufacturer had any comment into the minutes of the initial meeting.
Arthur Conan Doyle is quoted as saying “It is easy to be wise after the event”. The review of the report for the very first aircraft accident in September 1908 does highlight a major deficiency when compared against current requirements and techniques. It is easy to be critical of such deficiencies when viewing historical documents – however, with current techniques and documents now requiring the inclusion of recommendations and details of safety issues, then the objective in using the findings from previous accidents to prevent future accidents can hopefully be met.
