When it Comes to Safety, Not All Flights are Created Equal

By Chairman Robert L. Sumwalt

Last week, we officially adopted our final report on the tragic May 15, 2017, crash of a Learjet 35A on a circling approach to Teterboro Airport in New Jersey. The crash took the lives of the two occupants—the aircraft’s pilots. The probable cause of the accident was the pilot‑in‑command’s (PIC’s) attempt to salvage an unstabilized visual approach, which resulted in an aerodynamic stall at low altitude.

The accident airplane’s operator offered on-demand flights under Part 135 of the Federal Aviation Regulations. (The air carriers that most people are more familiar with, which fly regularly scheduled routes, are regulated under Part 121.) The accident flight was a positioning flight subject to Part 91 rules; however, the procedures that the operator used, the pilots’ training, and the Federal Aviation Administration’s (FAA’s) ongoing oversight duties all pertained to Part 135 aviation.

Imagine knowing that some of what was happening on this accident flight was going on in your regularly scheduled air carrier flight. First, the PIC was not flying the airplane until just before the accident, when the second-in-command (SIC) relinquished control, despite the fact that, by the company’s own standard operating procedures (SOPs), the SIC was not experienced enough to be flying. This was only one of many instances during the flight of an SOP violation or the failure to use required SOPs.

Additionally, during initial training, the PIC and the SIC both had difficulty flying circling approaches in a simulator. This Part 135 carrier, however, did not have a program in place to follow up with pilots who had exhibited issues during training. What’s more, despite both pilots’ training problems flying a circling approach, they were teamed together for this flight.

This accident flight was also an example of poor crew resource management (CRM). CRM done well results in SOP adherence and effective communication and workload management. However, during this flight, the captain had to extensively coach the SIC while also fulfilling his pilot monitoring responsibilities. He did neither well. Both pilots lacked situational awareness.

Contributing to the accident was the PIC’s decision to allow an unapproved SIC to act as pilot flying, and the PIC’s inadequate and incomplete preflight planning. Also contributing to the accident was the carrier’s lack of any safety programs that could identify and correct patterns of poor performance and procedural noncompliance, and the FAA’s ineffective safety assurance system procedures, which failed to identify the company’s oversight deficiencies.

In response to this accident, among other things, we recommended that the FAA require Part 135 operators to establish programs to address and correct performance deficiencies, as well as to publish clear guidance for Part 135 operators to create and implement effective CRM training.

This accident illustrates that Part 135 flight crew members don’t always follow the same procedures or exhibit the same discipline as professionals in Part 121 operations. Before the accident at Teterboro, we found that pilot performance either caused or was a major contributing factor in seven major aviation accidents involving Part 135 on‑demand operators between 2000 and 2015. A total of 53 people were killed and 4 were seriously injured in these accidents. This year, we added “Improve the Safety of Part 135 Aircraft Flight Operations” to our Most Wanted List of transportation safety improvements to help draw attention to this problem.

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Many air carriers operating under Part 121 are required to continually seek and identify risks, and once the risk assessment is done, put measures in place to mitigate those risks through safety management systems (SMSs). Conversely, while some Part 135 operators have implemented SMS, most have not.  In response to the Teterboro accident, we reiterated a previous recommendation to the FAA to require that all Part 135 carriers in the United States have an SMS in place.  In Part 121 training, performance deficiencies are required to be followed up on; there’s no such requirement for Part 135 operators to monitor deficiencies in their pilots’ training.

Further, although Part 135 operators, like their Part 121 counterparts, are required to provide CRM training, they receive less thorough guidance on what constitutes effective CRM training. This shortcoming was evident in the Teterboro accident, where the crew did not display good CRM during the accident flight.

I’ve had two very interesting roles in life – being an airline pilot and serving as an NTSB Board Member. While serving as an airline pilot, I was also a member of a flight operational quality assurance (FOQA) team. In that role, I looked at minor procedural deviations in nonaccident flights with the purpose of learning where potential problems were. In this accident, we reiterated previous recommendations to the FAA to require flight data monitoring (FDM) programs to accomplish the same kind of oversight for Part 135 aviation, and that Part 135 operators install the necessary equipment to acquire FDM data.

In my role as an NTSB Board member, I have seen too many cases where accidents occur in part due to procedural noncompliance and lack of professionalism. A pilot might be born with certain aptitudes, but no one is a born professional; it takes work and constant discipline. Professionalism is a mindset that includes hallmarks such as precise checklist use, callouts, and compliance with SOPs and regulations. Those traits were conspicuously absent on this accident flight. And, now as my role as a frequent airline passenger, I’m glad that airlines are required to have SMS programs; I know they make my flights safer.

The NTSB believes that tools such as an effective SMS should be required and used in Part 135 aviation as well as by Part 121 carriers. We hope that including “Improve the Safety of Part 135 Aircraft Flight Operations” on our Most Wanted List for 2019–2020 will encourage action on this issue.

 

Why?

By Nicholas Worrell, Chief, NTSB Safety Advocacy Division

Earlier this month, I had the opportunity to address more than 150 driver educators at the Dori Saves Lives Driver Education Conference, a meeting at which I first spoke in 2015. The conference is named for Dori Slosberg, who died in a 1996 traffic crash along with four other teens. She was only 14.

2019 Dori Slosberg Foundatin Event
Nicholas Worrell, Chief, NTSB Safety Advocacy Division, addresses attendees at the 2019 Dori Saves Lives Driver Education Conference

Today, more than 20 years later, motor vehicle crashes remain the leading cause of death for young people ages 5­–24. That’s why the work of the Dori Slosberg Foundation and others around the nation is so important.

Compared with earlier generations, Millennials are quick to look at the world as they find it and ask why? This is a good habit; you can’t improve in any endeavor—from education, to manufacturing, to transportation safety—without looking at the status quo and asking why things are the way they are.

We know why young drivers are involved in crashes—most often because of inexperience, distraction, speed, and impairment. And we also know that those risky behaviors are often coupled with low seat belt use rates. So why are young drivers getting behind the wheel impaired or driving distracted? How can policy address risks like inexperience and speed in this age group? Some of the most important voices in traffic safety are young survivor advocates who have refined the raw why? of intolerable loss into the thoughtful and lifesaving why? of policy change.

At the conference, I welcomed the last of the millennials to the traffic safety fight in their new roles as young driver educators. I asked them to never stop asking “why,” just as the NTSB never stops asking that same question to determine probable causes of transportation accidents and crashes. And I challenged them to act on the proven solutions that will prevent traffic crashes—comprehensive laws, education, and enforcement.

Last month, we released our 2019­–2020 Most Wanted List, which includes some of these proven solutions.

For previous blogs about outreach to Dori Saves Lives and driver educators, visit:

 

Don’t Rely on the Luck of the Irish for a Safe Ride Home

By: Member Jennifer Homendy

St. Patrick’s Day is a big deal in our house. “Leprechauns” sneak in the night before to raid our kitchen cabinets. Sometimes they write things in green paint on our walls; other times they leave gold coins. And my daughter always tries to catch one in her latest handmade trap (spoiler alert: it’s never happened). This is also one of the busiest weekends of the year for us. My daughter is an Irish dancer, and over St. Patrick’s Day weekend, our schedule is jam packed with parades and multiple performances at local pubs where there’s lots of dancing, drinking, and good ole reveling in Irish culture. What always concerns me, though, is the number of people who walk out of those pubs right into their cars after an afternoon of drinking.

Did you know that nearly 29 people die each day in the United States in alcohol-impaired driving crashes? That’s one person every 50 minutes, or more than 10,000 people a year. Alcohol-impaired driving crashes are 100% preventable. It’s simple. Choose one: drink or drive. Don’t do both.

St. Patricks Day Impaired Driving Image

This Sunday, you may be tempted to think: well, it’s just one drink, or it’s just two. Although the current legal definition of alcohol impairment in 49 states is a blood alcohol concentration of 0.08% (0.05% in Utah, thanks to the efforts of the NTSB), research shows that impairment begins at much lower levels; even small amounts of alcohol affect the brain and human performance behind the wheel.

So, this St. Patrick’s Day, we want you to have fun. And the best way to do that is to have a plan in place before you start to celebrate. Leave the driving to someone who’s sober or take transit, call a cab or a rideshare service, but please don’t drink and drive.

Ethiopia Airlines Flight 302, Annex 13, and the NTSB’s International Mission

By Chairman Robert Sumwalt

Yesterday, the NTSB issued a press release about our ongoing assistance to the Ethiopian Aircraft Accident Investigation Bureau in its investigation into the crash of Ethiopian Airlines flight 302.

Under the provisions of Annex 13 to the Convention on International Civil Aviation—or simply, Annex 13—Ethiopian authorities are responsible for investigating the accident because it happened in Ethiopia; however, because the airplane was designed and manufactured in the United States, the U.S. is invited by the host country to participate in the investigation. That role is carried out by the NTSB.  The NTSB did designate an accredited representative to lead the U.S. team of investigators assisting the Ethiopian investigation.

The accredited representative and other NTSB team members are currently on the ground in Addis Ababa. Additional NTSB investigators were dispatched to France to assist the Ethiopian investigators and the French Bureau d’Enquêtes et d’Analyses (BEA) with downloading and analyzing the accident flight recorders. The NTSB accredited representative in Ethiopia will coordinate all US input into the investigation—not just that from NTSB investigators, but also from the Federal Aviation Administration (FAA), Boeing, and others. The FAA can bring to the table nuanced knowledge of how the aircraft type is regulated and certificated. The airplane and engine manufacturers have detailed engineering and operational knowledge. They, and any other entities that can render technical assistance, are designated technical advisors—the rough equivalent of parties to a domestic investigation.

Annex 13 rights and responsibilities go both ways. For instance, many readers remember the NTSB’s investigation of the crash-landing of Asiana flight 214 in San Francisco in 2013. The NTSB was responsible for the investigation because the accident happened in the United States, and the Boeing 777 aircraft was designed and manufactured here. However, the airplane was registered in the Republic of Korea, and Asiana Airlines was a Korean operator. So, during that investigation, the Korean Aviation and Railway Accident Investigation Board (KARAIB) provided an accredited representative to assist the NTSB investigation.

With so many aircraft manufactured in the United States and flown by US airlines, the NTSB represents the US in numerous accident investigations the world over via Annex 13. Annex 13 sets down the objective of the investigation, which is in concert with our objective at the NTSB.

The sole objective of the investigation of an accident or incident shall be the prevention of accidents and incidents. It is not the purpose of this activity to apportion blame or liability.

Although it is not unheard-of for investigators to approach investigations somewhat differently, there is a shared commitment among participants to determine the facts and findings. Under Annex 13, investigators are able to investigate, by and large, with future aviation safety as their only goal. And every time an accident doesn’t occur, it’s in some part due to safety lessons learned though the roles and relationships established by Annex 13.

Annex 13 ensures that every investigation has access to the technical expertise and resources needed to learn safety lessons and prevent recurrences.

For more information on NTSB participation in foreign investigations go to: https://go.usa.gov/xEswV.

Episode 24: Sleep Awareness Week

This week is Sleep Awareness Week. The theme this year, “Begin with Sleep,” highlights the importance of good sleep health for individuals to best achieve their personal, family, and professional goals.

In this episode of Behind-the-Scene @NTSB, we talk with Mary Pat McKay, MD, MPH, Chief Medical Officer; Jana Price, PhD, Senior Human Performance Investigator, Office of Research and Engineering; and Jeff Marcus, Acting Chief, Safety Recommendations Division, about our biological need for sleep, the importance of screening for and treating sleep disorders, such as obstructive sleep apnea, NTSB fatigue-related accident and crash investigations, and ways to address and mitigate fatigue risk across transportation modes.

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The NTSB has been long concerned with the issue of fatigue in transportation. We’ve issued more than 200 safety recommendations across the transportation modes directly related to fatigue. Several recommendations specifically address obstructive sleep apnea and other sleep disorders.

Reduce Fatigue-Related Accidents and Require Medical Fitness – Screen for and Treat Obstructive Sleep Apnea are issues on the 2019-2020 NTSB Most Wanted List. To learn more about the Most Wanted List and related safety recommendations, visit https://ntsb.gov/safety/mwl/Pages/default.aspx.

 

Get the latest episode on Apple Podcasts , on Google PlayStitcher, or your favorite podcast platform.

To catch up on past episodes and to find more ways to listen visit: https://www.blubrry.com/behind_the_scene_ntsb/

If you have questions about the podcast, or ideas for future topics, feel free to email us at SafetyAdvocacy@NTSB.gov

Most Highway Crashes Are Not Accidents

By Vice Chairman Bruce Landsberg

Traffic crashes that claim the lives of one, two, . . . maybe even five people don’t seem that severe. Would there be more urgency to address highway safety if per-crash fatalities were higher? Suppose a family member or a friend was the one killed or injured? Typically, it’s not until someone we love is hurt that we realize most highway crashes are not accidents at all, but are thoroughly preventable. “Accidents,” on the other hand, are unforeseen and unpredictable.

Fatal crashes can often be attributed to the all-too-human failings of trying to get somewhere just a bit quicker than traffic or road conditions will safely allow, not planning for alternative transportation after a few drinks, being distracted by a text message, or choosing to get behind the wheel after a night of too little sleep. We know how to stop this—the solutions aren’t new or complicated. The NTSB has been advocating for effective countermeasures for decades. Last month, we issued our 2019­–2020 Most Wanted List of transportation safety improvements, which highlights the actions needed to prevent transportation accidents and crashes. Guess what’s on the list? Distraction, fatigue, and medical fitness. Speed and impairment are also included.

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All drivers—private and commercial—are supposed to be medically fit to drive. Professional drivers who are prone to seizures, who may be suffering from undiagnosed diabetes, or who are at risk of another sudden-onset, incapacitating illness shouldn’t be operating big rigs or motor coaches until they’re treated and under a physician’s care. The Federal Motor Carrier Safety Administration (FMCSA) has made some progress in improving its medical oversight system, but too many drivers continue to obtain licenses despite medically disqualifying conditions. Is this acceptable?

Fatigue is another huge problem on our roads. According to the National Highway Traffic Safety Administration, in 2015, 90,000 police-reported crashes, which led to an estimated 41,000 people injured, involved drowsy drivers. In 2017, nearly 800 fatalities resulted from drowsy driving, and these numbers are certainly and significantly undercounted. Undiagnosed obstructive sleep apnea affects both professional drivers and the public at large. Drivers who aren’t sleeping well should see a physician about underlying causes of insomnia. Fatigue is proven to have the same deadly effects as alcohol consumption.

Finally, distraction! It’s been conclusively proven that humans are lousy multitaskers, and our ability to self-assess our skills to the contrary is likewise flawed. (I’m really good, and if you don’t believe it, just ask me!) Studies have consistently shown that mobile phone use also leads to about the same level of impairment as—you guessed it—too much alcohol (the NTSB has recommended that all states lower legal DUI levels to .05 percent blood alcohol concentration). Texting while driving can increase the crash risk up to 22 times. In 2016, more than 3,100 fatal crashes involving distraction occurred on US roadways (again, this number is likely much underreported). In this age of constant connection, it’s beyond time to ask ourselves, is it worth the cost?

And it’s not just portable devices that are causing distraction, either. Auto manufacturers want to sell the most fun-to-drive products with the best infotainment systems. But too much button pushing and menu navigation means too much heads-down time in complex traffic environments. Let’s use our technology and knowledge to stop the carnage.

A balance of regulation and common sense is needed on both sides of the regulatory divide. Ultimately, it comes down to the cost of human life versus the cost of doing business. It all depends on who’s doing the calculation, but the real cost of lives lost, and collateral damage go well beyond insurance settlements and lawsuits.  Is that phone call, text, minutes saved, or extra drink truly worth it? The upside is minimal, the downside horrendous—possibly life-ending or financially ruinous. But it won’t happen to you or anyone you know, right?

By midnight tonight, another 100 friends, neighbors, and family members will have died on our roads. In just one day, several thousand more will have been badly injured, many with no full recovery. This statistic will repeat every day this year, and the next, and the next. And not one person in those crashes, whether they were at fault or innocent victims, started out that day thinking it would be their last. So, what are you going to do about it?

 

 

 

Episode 23 – Vice Chairman Bruce Landsberg

In this episode of Behind-the-Scene @ NTSB, we have a conversation with Vice Chairman Bruce Landsberg. Vice Chairman Landsberg shares with us his passion for safety education and training, his past work to improve aviation safety and the path he has taken to become an NTSB Board Member.

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Get the latest episode on Apple Podcasts , on Google PlayStitcher, or your favorite podcast platform.

To catch up on past episodes and to find more ways to listen visit: https://www.blubrry.com/behind_the_scene_ntsb/

If you have questions about the podcast, or ideas for future topics, feel free to email us at SafetyAdvocacy@NTSB.gov

Keep up-to-date by connecting with NTSB on TwitterFacebookInstagram, and LinkedIn.

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