General Aviation: Up Close, Exciting, and Committed to Safety

By Deborah Hersman

Member Hersman with Paul Poberezny (Founder, EAA) and Rod Hightower (President, EAA)

What a week this has been! I have literally been across the country and across our nation’s transportation landscape. On Monday, I rode the train from DC to New Jersey to meet with members of the boards of transit authorities to talk about their role in safety oversight. On Tuesday, we conducted a board meeting to determine the probable cause of an October 2009 cargo tank truck rollover accident near Indianapolis. Then, on Wednesday, NTSB Board Member Earl Weener and I departed for Wisconsin on his Bonanza (a single-engine general aviation airplane manufactured by Beech).

In the aviation world, flying to Oshkosh, WI, can mean only one thing — EAA AirVenture. For nearly 60 years, the Experimental Aircraft Association, or EAA, has hosted what has turned into the world’s biggest aviation celebration at its annual “fly-in” jamboree.

At the NTSB, my usual interaction with the general aviation (GA) community is through tragedy — at the scene of an accident, reading a report, or participating in a board meeting following an often-fatal accident. In this line of work, I usually see what goes wrong rather than what goes right. I am pleased to report at AirVenture this week, I got to see the right stuff!

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Teaming Up To Improve Safety

By Earl Weener

RV-10 (Photo credit: Greg Hale)

Homebuilt aircraft, known in the United States as Experimental Amateur-Built Aircraft, or E-AB, have existed as long as powered flight. As the Experimental Aircraft Association (EAA) explains, “you could say that the Wright brothers were the first homebuilders, since they never relied on a factory to construct their airplanes.” Like today’s homebuilders, they used their own craftsmanship to build a flying machine.

About 33,000 of the 224,000 U.S. general aviation aircraft are E-AB and include a wide variety of aircraft built from prefabricated kits, existing plans, or a builder’s unique design. While the enthusiastic community that builds these aircraft has long been a force for innovation, unfortunately, we are seeing higher accident rates among this group of aircraft than in other general aviation segments.

The NTSB and EAA are collaborating to identify how to improve that record. The NTSB launched a study of accidents involving E-AB aircraft. The study is looking at a range of areas, including builder assistance programs, transition training for E-AB pilot-builders, flight test and certification requirements, and maintenance.

EAA is supporting the study by hosting a web-based survey this summer. Operators, builders, and owners of E-AB aircraft who are interested in participating in the survey should go to www.EAA.org/AB-Survey.

This week, Chairman Deborah Hersman and I are traveling to EAA AirVenture Oshkosh, the nation’s largest aviation event, which attracts homebuilders from across the country and around the world. This will be a great opportunity to see firsthand the range of homebuilt aircraft and talk directly with builders and pilots. I’m looking forward to it.

We expect to publish the completed safety study by fall 2012.


Honorable Earl F. WeenerEarl F. Weener, Ph.D., took the oath of office as a Member of the National Transportation Safety Board on June 30, 2010. Dr. Weener is a licensed pilot and flight instructor who has dedicated his entire career to the field of aviation safety.

He Was Working on the Railroad…

By James Southworth

Today, the railroad industry marks a 197th anniversary. On July 25, 1814, English engineer George Stephenson demonstrated the first steam locomotive. Stephenson did not invent the steam engine, but he developed the technology to move steam engines from hauling coalmining carts to powering the first form of commercial rapid transportation. Previously, the horse-drawn carriage was the fastest means of land travel. Now, two centuries later, railroads are essential to our lives.

Stephenson may have revolutionized land travel, but he also unwittingly introduced a new kind of transportation danger. On the maiden voyage of Stephenson’s rail line from Liverpool to Manchester, a Member of Parliament and one of several dignitaries on the train, William Huskisson, climbed onto the tracks to talk with the Prime Minister during a refueling stop. Another train pulling into the station on the same rail struck Huskisson. It may seem incredible today, but those early locomotives had no brakes. Stephenson unhooked the passenger cars from one of his trains and personally rushed Huskisson to medical attention. Without the extra weight of the passenger cars, the unburdened train was able to reach an astonishing 40 mph, then a world speed record. Unfortunately, that speed was not enough to save Huskisson, who later died of his injuries.

The Huskisson accident was the first of many. As Chairman Hersman pointed out in a speech at the U.S. railroad industry’s annual Harriman Awards, by the early 20th century, 48 percent of all deaths in the United States happened on railroads. At the turn of that century, lack of safety was an accepted cost of innovation. Today, safety is a goal of innovation. Railroads are investing in new safety technologies, such as positive train control, which gathers data about the positions of trains relative to each other, and automatically stops a train if another train is approaching on the same rail. What is good is that there are many 21st century innovators like George Stephenson, who are working to make trains better and safer.


James Southworth is the Railroad Division Chief in NTSB’s Office of Railroad, Pipeline and Hazardous Materials Investigations.

Training to Make General Aviation Safer

By Earl Weener

Next week, I’m flying my Bonanza to Oshkosh Wisconsin to attend EAA AirVenture, possibly the world’s largest aviation celebration and a big event for people in the general aviation (GA) community. Before heading out, being a flight instructor, I will be doing everything I taught my students — checking out the weather conditions, planning my route, checking NOTAMs (for non-pilot readers, those are the FAA’s Notices to Airmen, important reading before every flight), making sure my Bonanza is ready for the trip, among many other detailed preparations.

While at AirVenture, I hope to take advantage of the seminars and workshops. Although I’ve been flying for many years, there is always more to know and ways to improve. There is clearly room for improvement across GA. Last year in the United States, there were 1,435 GA accidents and 450 fatal injuries. Last month alone, there were 25 fatal GA crashes; this month there have already been more than 20 fatal GA crashes.

With my background in instruction, it is especially discouraging to learn that some of the causes or contributing factors to GA crashes are the same errors that have been made numerous times before by other pilots in similar circumstances. We should all be able to learn, and benefit, from the mistakes of others. Here’s an idea: if you are going to AirVenture, come by the Federal Pavilion and attend one of the NTSB workshops on accident investigation case studies. These investigations show us that all too often pilot decision making and proficiency are at the center of GA accidents.

This frequency raises the question: are GA pilots obtaining adequate training? Flying, regardless of aircraft type, requires proficiency in the same fundamental knowledge and skills. But flying, by its very nature, is varied and often unpredictable. My point is that just because a pilot holds a current certificate does not necessarily mean he or she is proficient and adept at dealing with adverse situations.

In the commercial world, pilots are paid to train and to fly in a variety of environments, thereby building invaluable flying experience. Alternatively, in the GA world, the burden is on the pilot to find both the time and financial resources for additional training and flying experience. In addition, the quality of flight instruction available to the GA community varies widely.

My message to GA pilots: Seek to improve your proficiency through training and experience. A good place to start is at EAA AirVenture [[add link: http://www.airventure.org/attractions/activities.html%5D%5D and its many workshops and forums. The bottom line is GA pilots do not need to be professional pilots to fly like pros!


Honorable Earl F. WeenerEarl F. Weener, Ph.D., took the oath of office as a Member of the National Transportation Safety Board on June 30, 2010. Dr. Weener is a licensed pilot and flight instructor who has dedicated his entire career to the field of aviation safety.

Accident Investigation at Its Finest

By John DeLisi

Pilatus PC-12
Pilatus PC-12

On March 22, 2009, a Pilatus PC-12 bound for Bozeman, Montana, diverted to Butte’s Bert Mooney Airport and crashed short of the runway. The pilot and all 13 passengers were killed and the airplane was almost entirely damaged from the impact and post-crash fire.

Last week, the NTSB Board met and determined the probable cause of this accident was a series of operational errors made by the pilot, notably the failure to add fuel system icing inhibitor to the fuel prior to the accident flight.

Uncovering the cause of this tragic accident was a major challenge for our investigative team. There were no survivors, no flight data recorders, no documented distress calls, and completely destroyed airplane wreckage. There was little to go on. For months, our team was uncertain whether they would be able to solve this puzzle.

There’s an expression “leave no stone unturned.” That is exactly what Dennis Diaz, this investigation’s systems group chairman, did. He methodically sifted through the wreckage to find a small circuit board because he believed one of its tiny computer chips could provide investigators much-needed information. He was right.

Finding the small computer chip that could rest on Dennis’s fingertip among the airplane wreckage was truly like finding a needle in a haystack.

That was just the first step. The circuit board was badly damaged and there were doubts the chip could be read. Dennis learned that even the company that manufactured the board would have difficulty with one so badly damaged. Undeterred, he worked with the Swiss Aircraft Accident Investigation Bureau and Germany’s Federal Bureau of Aircraft Accident Investigation. With a bit of luck and lots of ingenuity, intelligence, and talent, crucial data was extracted to illuminate a path to determine the accident’s cause.

The tiny computer chip provided huge pieces of information about the functioning of the fuel system onboard the airplane. Dennis Diaz’s investigative work was among the best I’ve seen in my 20-plus years of investigating aviation accidents.

Thanks to the extraordinary efforts of Dennis and the entire investigative team, the NTSB was able to determine the probable cause of the accident. This led to issuing important safety recommendations to help prevent future accidents and, just as importantly, to providing an answer to the family and friends of those who lost their lives in this tragic accident.


John DeLisi is Deputy Director of the Office of Aviation Safety.

Challenging Assumptions and Making Aviation Safer

By Tom Haueter

Fifteen years ago today, on a warm summer evening, a Boeing 747 took off from New York’s Kennedy airport. Within minutes, the airplane exploded and plunged into the Atlantic Ocean. All 230 people onboard perished.

What happened? TWA Flight 800 led to the NTSB’s biggest, longest, and most complicated investigation. After four years and many theories played out in the press about missile attacks and government cover-ups, the NTSB determined that the probable cause of the TWA flight 800 accident was the center wing fuel tank’s explosion due to tank’s flammable fuel/air mixture igniting. The ignition source remains a mystery. Our investigators determined that the most likely source was a short circuit outside of tank that allowed excessive voltage to enter it through electrical wiring associated with the fuel quantity indication system.

After this deadly crash, the NTSB issued a host of recommendations. Included among them was recommending the development of nitrogen fuel-inerting systems. Initially, the response from the aviation community was negative. Industry believed that the solution lay in reducing ignition sources, not inerting. All the models and the research, we were told, showed that inerting was too complicated, heavy, and expensive.

Over the years, fuel tank safety remained on the NTSB’s Most Wanted list. The FAA issued 70 advisory circulars and more than 100 airworthiness directives aimed at mitigating risks, but most of them addressed reducing sources of ignition. It did not release a proposed rule on fuel inerting until 2005.

What led up to that rule — the final rule was issued in 2008 — is a fascinating story. At the NTSB’s December 1997 public hearing on the accident, Ivor Thomas, Boeing’s chief engineer of fuel systems, testified. He said it was a “given” that fuel tank contents are flammable. It was up to engineers to reduce ignition sources.

The next year, Ivor Thomas retired from Boeing and went to work for the FAA on the science of fuel systems. It was time, he decided, to explore the chemistry and flammability of fuel — in other words, inerting. He questioned industry assumptions that inerting systems were too expensive, heavy, and unreliable. Years went by, but Thomas and an FAA team persevered.

Finally, along with FAA’s Dick Hill and the help of test engineers at FAA’s Technical Center in New Jersey, there was a breakthrough. The team figured out a way to reliably and economically use an onboard inerting system.

That, in turn, led to FAA’s final rule requiring fuel inerting for center wing fuel tanks, which are now making air travel safer thanks to persistent engineers who challenged assumptions.


Tom Haueter is Director of the Office of Aviation Safety.

Advancing Transportation Safety

By: Deborah Hersman

Every year, the NTSB, like many other federal agencies, prepares an annual report to Congress about our activities during the previous year. We submitted our 2010 report on June 24, detailing our many significant accomplishments across all transportation modes.  During 2010, we:

  • launched to over 200 accidents, including launches to six major accidents;
  • issued 227 safety recommendations (170 in aviation, 18 in highway, 25 in railroad, 7 in marine, and 7 in pipeline);
  • closed 132 safety recommendations in an acceptable status;
  • held 5 public forums on fishing vessel safety, aging drivers, child passenger safety in the air and in automobiles, professionalism in aviation and aviation code sharing arrangements.    

The accomplishments outlined in the report were realized in no small part due to our employees’ dedication to the goals of accountability, integrity, and transparency. We’re a small agency, but what we lack in numbers, we more than make up for in teamwork and a desire to leave no stone unturned in arriving at the correct probable cause of an accident or incident. Of equal importance are our safety recommendations, which stem from our investigations of accidents and incidents. Every recommendation we issue is based on our desire to prevent similar accidents or incidents from occurring in the future. I am very proud to serve as the Chairman of this remarkable agency, and I am equally proud of our mission and of the dedicated and professional employees who work to make transportation safer for all. The 2010 Annual Report may be viewed at the following link:  http://www.ntsb.gov/doclib/agency_reports/2010AnnualReport.pdf.