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STEPHEN CARBONE is an avid writer of aviation fiction; his first novel Jet Blast has appealed to mechanics, pilots, air traffic controllers, etc. by giving accurate depictions of the accident investigation process. A former airline mechanic, he has been involved in many aspects of commercial aviation and went on to investigate major aviation accidents for the NTSB. A member of ISASI, Stephen holds a Master's degree in systems safety from ERAU. His weekly blog can be found at: http:// jetblast.tateauthor.com SAFET Y MATTERS www.AviationPros.com 55 IN 2003, I ASSISTED THE AVIATION SAFETY Council (ASC) — the Taiwanese version of the NTSB's Aeronautical division — during the China Air 611 accident. Taiwan is an incredible place, very beautiful and full of history. I grew to respect the professionals at the ASC as we shared inves- tigatory techniques. Unfortunately Report ASC- AOR-16-06-001, the TransAsia Airways ATR72, flight GE235, has lost something in the translation from Mandarin (Chinese) to English. I find the world today relies heavily on written interactions, e.g. texting, emails, etc. Verbal com- munications are almost nonexistent; we're losing the ability to translate our thoughts into understandable intentions. If I capitalize all letters, I'm yelling; if I write something sarcastically witty, it's viewed as patronizing or insulting. The [digital] pen is more powerful than the sword. My experience with report writing dictates that there is a 'method' to the flow of information 'mad- ness'. Take the ongoing Malaysian Air MH370 disap- pearance/spectacle: how much opinion and theory were (and still is) flung against the wall in the hopes of something sticking? It was like watching a confused Durga, unsure of which path to point to. Now, how much fact came to the surface and was followed up on? Not so much. There are two reasons for that: one — way too many experts, and, two — one must follow the facts to analyze, not the other way around. I'm often critical of the NTSB. However, one thing they do right is the blue cover (aviation) report, the final collection of information for an aviation accident report; the blue cover report lays out the facts before engaging in any type of supposition or analysis; it's like Hercules Poirot explaining the crime to the suspects. It provides that flow of information without the contamination of opinion, allowing the reader to make the connection. Terms like 'may have' or 'probably' have no place here; more definitive verbs and adverbs are used. This is even true with the Blue Cover's Executive Summary; this is the down-and-dirty about the acci- dent, recapping for the Board Members so they can go right to the probable cause(s) and recommen- dations; Board Members review accidents taking place in five different modes, so it makes sense. It takes up less than one page and no more than four paragraphs. Report ASC-AOR-16-06-001, by comparison, com- mits nine pages to the Executive Summary; this is the equivalent of explaining the entire plot of a book on the jacket. TransAsia Airways, flight 235 lost control, crashing into the Keelung River after striking the Huan-Dong overpass. It lost power shortly after take-off, maneuvered through several downtown buildings before rolling over to port and plunging into the river. It was miraculous anyone onboard survived and multiple building occupants weren't lost on the way to the accident. In the Executive Summary, report ASC- AOR-16-06-001 contains numerous assumptions on the part of the investigator, e.g. 'Had the crew prioritized their actions to stabilize the aircraft …' or 'the pilots did not respond to stall warnings in a timely manner'. This takes the report out of context. Many allegations are presumptuous unless evidence is provided to lead the reader there, e.g. following the cockpit voice recorder transcript (CVR-T) later in the report I was unsure as to how these conclusions were made — the factual section starts 16 pages after, while the analysis comes in at 140 pages in. One unsettling assumption in the report states, 'the pilot reduces power and then shuts down the wrong engine.' I read the attached CVR-T several times; unless the conversations were incorrectly An accident report is supposed to flow from fact to fact to fact, building upon the narrative; the writer is meant to lay out the events By Stephen Carbone