Refusing to Take “No” for an Answer

By Chairman Robert L. Sumwalt

On July 17, 1996, about 12 minutes after takeoff from John F. Kennedy International Airport, New York, Trans World Airlines (TWA) flight 800 (TWA-800), a Boeing 747-131, crashed in the Atlantic Ocean near East Moriches, New York. The accident killed all 230 people on board, and the airplane was destroyed. The NTSB’s investigation of this accident was the most extensive, complex, and costly air disaster investigation in US history, and was the subject of high public interest and front-page headlines for years.

On August 23, 2000, a little more than 4 years after the crash, the NTSB determined the probable cause to be an explosion of the center wing fuel tank (CWT), resulting from ignition of the flammable fuel/air mixture in the tank. Because multiple potential sources were identified, the singular source of ignition for the explosion could not be determined with certainty, but the likely source was a short circuit outside of the CWT that allowed excessive voltage to enter the vapor-laden fuel tank through the fuel-quantity–indicating system in the CWT.

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On December 13, 1996, while the investigation was still ongoing, the NTSB issued the first of three sets of safety recommendations to the FAA. We based these initial recommendations on early findings of the investigation to address the threat of a fuel tank exploding on an airliner. Two recommendations included the development of design or operational changes to prevent explosive fuel-air mixtures in the fuel tanks—including the development of nitrogen-inerting systems. A nitrogen-inerting system replaces the air in an empty fuel tank with nitrogen, creating an environment in which neither a fire nor an explosion can occur. A total revision to FAA regulations for wiring and maintenance, including those of fuel-quantity–indicating systems, also resulted from our findings in this accident investigation.

The FAA’s initial response to our inerting recommendations was to convene a group of industry experts, who found that the costs of implementing the recommendations was too high to be practical. We disagreed and urged the FAA to consider other options. The FAA tried again, tinkering around the edges of the problem, focusing on the wiring and electrical systems in aging aircraft. We welcomed these improvements but reiterated that the agency was ignoring the core issue—the hazard posed by potentially explosive aircraft fuel tanks. To its credit, the FAA chose to apply some “out of the box” thinking, and, together with Boeing, developed a system on the airplane to address the threat.

That innovative technology, called a molecular sieve, separates air into nitrogen and oxygen, the two primary gases. The oxygen is vented overboard while the nitrogen is used to inert the fuel tank. The FAA performed in-depth analysis of the technology, and Boeing produced several prototype systems for testing and evaluation. These tests showed the system to be effective, have minimal operational challenges, and to be reasonably priced. Boeing began installing these systems on some of the new airplanes it was producing.

On November 23, 2005, the FAA proposed a new regulation that required newly manufactured and in-service airliners to reduce the chances of a catastrophic fuel-tank explosion. A final rule was enacted by in 2008, and 100 percent compliance with the rule became mandatory on December 26th of 2017—21 years after the NTSB first recommended fuel-tank inerting to the FAA.

The enactment of the fuel-tank flammability rule is a major safety improvement, addressing a critical safety problem at the heart of many aviation accidents over 45 years. However, its enactment was clearly far from easy; it took the persistent advocacy of the NTSB and the efforts of FAA and Boeing staff unsatisfied with cursory cost-benefit analyses. It took the commitment of senior management at the FAA and DOT—including the Director of the Certification Service, Associate Administrator of Safety, the FAA Administrator, and the Secretary of Transportation—to implement this needed safety regulation.

The traveling public is safer today because these organizations, working together, refused to take “no” for an answer.

Most Wanted List Progress Report: Rail Safety

By: Chairman Robert L. Sumwalt

 The NTSB is releasing a series of blogs highlighting the progress the transportation community is making in each mode to advance issues on our 2017–2018 Most Wanted List. This series sheds light on the progress made and what needs to be done going forward to improve transportation safety. This is the fourth and final blog of the series.

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Chairman Sumwalt and Robert Hall, Director, NTSB Office of Railroad, Pipeline and Hazardous Materials Investigations talk with attendees at the Most Wanted List midpoint meeting

On November 14, 2017, the day before our Most Wanted List (MWL) progress meeting, we concluded our investigation into the April 2016 Amtrak train derailment in Chester, Pennsylvania. As I offer the closing words of this blog series highlighting the progress made  to address issues on our list, the NTSB is presently investigating the December 2017 Amtrak train derailment in DuPont, Washington, and the February 2018 Amtrak train and CSX freight train collision near Cayce, South Carolina. And, on February 15, I testified before the US Congress regarding the urgency for the industry to fully implement positive train control (PTC) by year’s end. That same day, we also issued three urgent safety recommendations to address findings from our investigations into the Cayce accident and the June 2017 Long Island Rail Road accident in Queens Village, New York.

At our midpoint meeting, I joined members from our Office of Rail, Pipeline, and Hazardous Materials Investigations to lead a discussion on rail safety. While there has been progress with implementing some of the NTSB’s recommendations, the Chester and DuPont derailments and the Cayce collision tragically illustrate that more needs to be done – and quickly!

A deficient safety management system and impairment were factors in the fatal Chester accident. And, like many accidents we’ve investigated, distraction played a role. When the accident occurred, the dispatcher was speaking to his spouse on a landline. We’ve recommended that Amtrak prohibit such calls while dispatchers are on duty and responsible for safe train operations.

The Chester accident also illustrated the fact that drug use by rail workers has been on the rise in recent years, playing a part in seven accidents in the last 3 years and nine accidents in the last decade, compared to only one accident in the prior decade. In the Chester accident, a backhoe operator who was killed had cocaine in his system, and two different opioids were discovered in the track supervisor’s system. During our investigation, the Federal Railroad Administration (FRA) moved quickly to require random urine drug screening for maintenance‑of‑way workers, effective April 2018. Additionally, the Amtrak locomotive engineer tested positive for marijuana, although there was no operational evidence that his prior drug use impaired his performance on the morning of the accident. What it did show, however, is that despite DOT random drug testing requirements for locomotive engineers, such a program did not deter his use of an illicit drug.

Fatigue and medical fitness are other significant MWL issues for rail, and we’re disappointed that the FRA and the Federal Motor Carrier Safety Administration have withdrawn an advanced notice of proposed rulemaking that would’ve supported sleep apnea screening for railroads and for commercial highway carriers. Clearly, there’s still important work to do on these issues.

Regarding another significant MWL issue for rail, strengthen occupant protection, the FRA has made progress toward developing a performance standard for keeping window glazing in place during an accident. Unfortunately, meaningful improvements related to the safety of corner posts, door designs, restraint systems, and locomotive cab crashworthiness have been slow.

The MWL’s safe transport of hazardous materials issue area focuses on transporting energy products in safer tank cars, built to the DOT-117 rather than DOT-111 and CPC 1232 standards. We are pleased to see that the more robust DOT-117 standard is being used for transport of crude oil. Ethanol transport, however, still widely relies on the DOT-111 and CPC 1232 standards. We urge stakeholders to move to using the DOT-117 standard when carrying ethanol as soon as possible, ahead of the mandated deadlines.

There has been little, if any, progress to improve transit safety oversight since we released the current MWL. To exercise effective oversight, the Federal Transit Administration (FTA) must continue to use the authority it gained with the Fixing America’s Surface Transportation Act and Moving Ahead for Progress in the 21st Century Act to promulgate safety rules.

Finally, on the issue of expanding recorder use, the industry is moving forward with installing inward-facing video cameras on passenger trains, which is a step in the right direction. However, we would like to see the FRA move forward on requiring the installation and that the requirement be expanded to include audio recording, and we believe that the freight rule should follow suit. The FTA still has no such requirements for transit rail.

As I offer the last thoughts on our MWL midpoint meeting blog series, I want to thank all those who attended for taking the time to offer suggestions and share their perspectives on the issues affecting the safety of our nation’s transportation system. As we move into the second year of this MWL cycle, I challenge our stakeholders to target one or more recommendations on which they can make measurable progress before this year is over. We all want to have the safest transportation in the world, and it will take us working together to accomplish it.

 

Recognizing Important Women Leaders at NTSB—From Yesterday and Today

By Chairman Robert Sumwalt

March is Women’s History Month, so it’s only appropriate to look at some of the American women who have helped influence and shape today’s transportation system, including those working at the NTSB today.

We have witnessed the extraordinary accomplishments of women like Bessica Raiche, the first female pilot in the United States to make a planned flight, and our very own Member Bella Dinh-Zarr, the first Asian American to become a Board Member at the NTSB. Member Dinh-Zarr has spent years advocating for and promoting safe and sustainable transportation. These women have reached great heights in their careers and are renowned nationwide for their successes.

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Shannon Bennett (left), Sharon Bryson and Dana Schulze

Yet, there are many more women—perhaps not as nationally known but just as important to the NTSB’s critical mission—that we would like to recognize. In celebration of Women’s History Month, we recently sat down with some of the exceptional women who have emerged from the NTSB’s ranks to become leaders in management and safety. They inspire staff every day to work hard to improve transportation safety, sharing NTSB safety messages and encouraging us all to remember our mission to save lives. They are role models for many at the agency—men and women. We asked them to share their thoughts on leadership with staff last week at a special briefing, and we think their lessons are beneficial to all, even those outside our organization. Here’s what they had to say.

Dana Schulze is the deputy director of the NTSB’s Aviation Safety (AS) Office. As second-in-command of AS, she oversees all aviation accident and incident investigations in the United States and those involving US products or operations overseas. More than 50 air safety investigators and supporting staff within AS report directly to her. She approves information AS releases and routinely briefs Congressional staff and industry stakeholders on behalf of our agency. She began her career in the aircraft manufacturing industry as a mechanical engineer and has experience developing, manufacturing, and conducting failure investigations involving aircraft systems. From there, she rose through the NTSB ranks to her current position. She attributes her success to a continuous learning approach and her interest in improving aviation safety. Because of her critical-thinking skills and ability to lead others, she quickly rose to a leadership position at the agency.

According to Schulze, she did not initially set out to join management, but when the opportunity was offered, she recognized that she could add value and be a good fit. She believes a leader should be able to inspire and motivate others. Through integrity, consistency, and transparency, a leader “can instill a balance of vision and practicality,” she says. She says she has been inspired by thought leaders such as Steven Covey. Transportation has long been a male-dominated industry, and Schulze encourages women to get involved with transportation-related STEM programs that interest them, even those outside their comfort zones.

Sharon Bryson is the NTSB’s deputy managing director. She joined the agency more than 20 years ago after a career providing services to military families at Dover Air Force Base. When she arrived at the NTSB, the agency had just been given the responsibility for family assistance by Congress. Bryson took a lead role in setting up the NTSB’s first family assistance program. This program, now called Transportation Disaster Assistance, is still in place today and has served thousands of families over the years. Later, after serving as director of the Office of Safety Recommendations and Communications, Bryson became the agency’s deputy managing director, a position that involves assisting the Managing Director with managing the day-to-day activities of the agency.

According to Bryson, having the opportunity to mentor others and share what she has learned about leadership is very important to her.  She strives daily to engage with staff members and actively highlights their individual abilities, with the goal of seeing them thrive. “A leader is supposed to support and guide,” she says. By recognizing the strengths and weaknesses of the people around her, she puts value in their diverse opinions; there is no room for judgement or negativity. “When all of these are combined, it creates an environment where people feel engaged and encouraged,” she says.

Shannon Bennett came to the NTSB’s Office of General Counsel in June 2010 before becoming an advisory and special assistant to Board Member Dinh-Zarr in June 2015. She comes from a long military history, having enlisted in 1993 as an Air Force ROTC cadet during college, then serving 11 years on active duty as a judge advocate. She continued to serve in the Air Force Reserve and was assigned as a judge advocate in the Office of The Judge Advocate General at the Pentagon. According to Bennett, when she separated from active duty in 2010, she wanted to find a job where, as in the Air Force, she felt that she was serving her country and making a difference in people’s lives. That’s how she wound up at NTSB.

Leadership is “the art of influencing and directing people to accomplish the mission,” Bennett says, quoting the Air Force Pamphlet on Leadership she received as an ROTC cadet. She tries to live by the adage “saw the log in front of you,” meaning, do your very best in every job that’s given to you no matter how big or small, rather than seek the glory of a job you don’t have. Mentoring is also very important to her, and she encourages all leaders to guide others.

As we celebrate Women’s History Month, let’s all take the time to look around us and celebrate the unique and powerful women in our own lives. We are so grateful to have Dana, Sharon, and Shannon as members of our “Women Dream Team,” as well as all the other female employees at the agency who work daily to improve transportation safety and inspire those around them.

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Don’t Turn A Blind Eye on Risky Pilot Behavior

By Leah Read

This is the seventh blog in a new series of posts about the NTSB’s general aviation investigative process. This series, written by NTSB staff, explores how medical, mechanical, and general safety issues are examined in our investigations.

 

“Turning a blind eye, makes nothing disappear.”  Anonymous

Leah Read
Leah Read, Senior Air Safety Investigator

When air safety investigators arrive at the scene of a fatal aircraft accident, we meet with law enforcement officers, witnesses, friends of the pilot, and family. During these critical interviews, we start to get a bigger picture of the circumstances surrounding the accident and those involved. It’s very common to hear almost immediately that the pilot was very “conscientious,” “thorough,” and an “excellent pilot.”

But there are also times when no one seems to be saying anything much at all about the pilot…until we dig deeper. That’s when we hear things such as, “The pilot never maintained his airplane right.” or “Everybody knew he was going to crash eventually.”

There are also times when the investigator will get a call via our communications center that a witness must talk to someone “right away.” The witness then tells us that the pilot had a LONG history of “maverick-like” behavior, was known to “buzz” a friend’s house, or used illegal drugs—as just some examples. In these situations, we will ask the witness if they had talked to the pilot about this behavior or contacted the Federal Aviation Administration (FAA). They sometimes tell us, “I tried to talk to him, but he wouldn’t listen. He was too prideful.”

But more often, they tell us that they didn’t say anything to the pilot or FAA. Sometimes, the pilot was a friend whom they didn’t want to embarrass or cause any trouble. Personally, as a fellow pilot, I can understand the concerns.

But what if you see something, and don’t step up and say something? The reality is that nonreporting can put people at risk.

Many don’t realize that there are actions the FAA can take if risky pilot behavior is reported. The FAA has established a hotline for confidential and anonymous reporting. As noted on the FAA website, “The FAA Hotline accepts reports concerning the safety of the National Airspace System, violation of a Federal Aviation Regulation (Title 14 CFR), aviation safety issues…. The FAA Hotline provides a single venue for…the aviation community and the public to file their reports.”

As one FAA inspector told me, “We can’t investigate what we don’t know.” If a complaint was made via the FAA Hotline, the FAA would be obligated to investigate. Remember, you may not only save the life of another pilot but also an innocent passenger or bystander.

The NTSB, unfortunately, has seen the tragic consequences of turning a blind eye to a known hazard. I have seen accidents that have occurred in someone’s front yard, skimmed the roof of an apartment building, or crashed near a school. If the airplane had impacted just a few yards in either direction, the damage and loss of life could have been so much worse. This was the case in an accident I investigated where the pilot lost control of the airplane, crashing into a front yard just feet from an occupied house. Thankfully, there was no fire, and no kids were playing in that front yard.

Within moments of arriving on scene and being debriefed by law enforcement, I was handed a witness statement. Very quickly, I realized the witness was quite credible—and what he had to say about the pilot was alarming. The pilot had a known history of reckless behavior. Further investigation revealed that people knew of the pilot’s behavior but didn’t want to report him for several of the reasons I mentioned above. Not surprisingly, the FAA had no negative history on the pilot. He had a clean record and was never on their radar.

Sadly, in this accident, the pilot and his innocent passenger died. But what if he had other passengers onboard? What would have happened if he had crashed into the house, or, worse, a crowd?

A colleague of mine investigated an accident where a pilot was flying an airplane he was not rated to fly, in instrument conditions without holding an instrument rating. The pilot had recorded numerous notes in his logbook that provided compelling evidence of his own unsafe flying, by his own admission. The pilot noted landing on a major highway and flying low over a crowd during parades. He was also known for unsafe low-level flights over airshows and having a general disregard for proper communication procedures. Yet nothing was done about his behavior; people turned a blind eye to it. Tragically, the pilot and three occupants died in the accident when the airplane encountered instrument meteorological conditions and impacted terrain.

In the big scheme of things, we need to ask ourselves, who are we really protecting by keeping quiet?  As active pilots, mechanics, airport personnel, friends, and family members, you are the eyes and ears to what’s going on out there. You know your airport and the people who use it. You know when your friend or family member seems risky or unsafe. If you identify a hazard, then speak up. Or, file a report with the FAA Hotline. Just remember, we all share the same airspace or may be nearby if their plane crashes.

Stay safe and don’t turn a blind eye!

For more information on submitting a report of a risky pilot via the FAA Hotline, visit: https://hotline.faa.gov/

Leah Read is a senior air safety investigator in the NTSB Office of Aviation Safety.

Episode 13- Jana Price

In this episode of Behind-the-Scene @NTSB, we get to chat with Senior Human Performance Investigator, Dr. Jana Price.  March is Sleep Awareness Month and Dr. Price is an expert in the field of fatigue….so we were lucky to have the chance to chat with her.

We all know what sleep is important, but it shouldn’t be an afterthought. Dr. Price tells us why and even shares the reason we feel groggy after a nap (spoiler alert, sleep inertia).

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

And find more ways to listen here: https://www.blubrry.com/behind_the_scene_ntsb/

Episode 12- Leslie McClam

In this episode of Behind-the-Scene @NTSB, we get to chat with Career Development Advisor Leslie McClam. She shares with us how she got started at the Agency and the creative programs she has been involved with to support staff development.

We learn that every Agency needs a Leslie! She discusses how lifelong career development is important, and key, to employee engagement. And the more the staff is engaged, the more they enjoy the work they do. Leslie reminds us that everyone at the Agency contributes to the mission to support the improvement of safety in all modes of transportation.

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

And find more ways to listen here: https://www.blubrry.com/behind_the_scene_ntsb/

Most Wanted List Progress Report: Aviation Safety

By Member Earl F. Weener

The NTSB is releasing a series of blogs highlighting the progress the transportation community is making in each mode to advance issues on our 2017-2018 Most Wanted List. This series sheds light on the progress made and what needs to be done going forward to improve transportation safety. This is the third blog of the series.  

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Member Earl Weener and John DeLisi, Director, NTSB Office of Aviation Safety, talk with attendees during the aviation session of the Most Wanted List midpoint meeting

Aviation is one of the safest forms of transportation—largely due to government-industry collaboration efforts such as the Commercial Aviation Safety Team and the General Aviation Joint Steering Committee. We have seen no passenger fatality in the domestic operation of a U.S. airline (Part 121) since 2009, and the accident rate is trending slightly downward in General Aviation-GA (Part 91 and Part 125). While we celebrate the safety gains made across the commercial aviation industry, there is still work to be done across all sectors, especially in GA.

On November 15, the NTSB brought together government, industry, and advocacy representatives from the transportation safety community to get a progress report on our Most Wanted List (MWL) of transportation safety improvements. Aviation Safety Director John DeLisi and I led the aviation portion of the discussion.

 

 

We learned that industry is taking the lead to improve safety, and, while some Federal Aviation Administration initiatives have been helpful, more may be needed. Yet the best path to getting NTSB recommendations adopted, most agreed, was encouraging a more aggressive voluntary, collaborative approach to safety.

Our focus on preventing Loss of Control (LOC) In Flight in General Aviation (GA)—the only aviation-specific issue on the MWL—was the primary focus of our conversations. Successfully resolving this problem requires continuing collaboration, which, so far, appears to be occurring widely and effectively. The GAJSC is one organization helping to facilitate this collaborative approach. At the mid-point meeting, we also announced that the NTSB will be collaborating with the FAA, industry associations, flight schools, technology manufacturers, and others in an upcoming April 24, 2018, roundtable on LOC solutions. The number of LOC and fatal LOC accidents are both trending down as of 2016, our last complete year of data. We won’t call that progress yet, but we might look back one day and say that it was.

The changes to Part 23 of the Federal Aviation Regulations reforming small aircraft certification standards have enabled streamlined adoption and installation of new technologies, such as AOA indicators that would prevent LOC, without a lengthy and costly supplemental FAA flight certification. Private industry can now do what it does best: innovate.

We also discussed another MWL issue, Expand Recorder Use to Enhance Safety. In particular, the NTSB would like to see more cockpit cameras, which aid in accident investigations and provide useful data for developing policies/procedures to prevent accidents. However, privacy issues, data protection challenges, and fears of punitive actions by companies appear to still hinder progress in this area.

Just as we have seen tremendous benefits in crash survivability on our highways with the use of seat belts and air bags, the aviation community so too must also recognize the significant safety benefits of enhanced occupant protection systems, such as five-point shoulder harnesses. While helicopter pilots appear to be buckling up, others in GA are not—including passengers. Child restraint systems (“car seats”) should also be used in planes; yet, they widely are not. The NTSB reported at this meeting that we are collecting more data on if/how seat belts are used in our accident investigations.

Progress is being made on the carriage of lithium-ion (LI) batteries. Heat from one battery can propagate to nearby batteries before a fire breaks out, introducing a challenge for fire detection and suppression. However, we expect the FAA to complete testing related to this risk within this MWL cycle. We also await the Pipeline and Hazardous Materials Safety Administration actions to harmonize its regulations with the International Civil Aviation Organization’s technical instructions regarding segregating lithium batteries carried as air cargo from other flammable cargo.

Just before the beginning of this MWL cycle, in 2016, the new flight and duty regulation went into effect, a huge win for managing fatigue in commercial aviation. We continue to fight for the small wins. We still need to apply the same level of safety to cargo flights, but we have seen progress toward applying it to maintenance personnel.

And, in 2017, the FAA communicated that they’ll research the prevalence of impairing drug use – OTC, illicit, and prescription – throughout aviation. Previously, we had studied their presence in pilots in fatal accidents, which revealed an alarming rate of OTC use in fatal accidents. It may be too early to discuss any changes to medical fitness in aviation due to BasicMed. However, one of the related concerns is the loss of flight time data that we previously gathered as part of the medical certification process.

After our progress report meeting, I felt optimistic that the improvements being made, especially by industry, will serve to make aviation even safer. I encourage all stakeholders and the general flying public to consider areas where we still need to make progress. Everyone has a role to play in improving aviation safety—whether you are a pilot, an operator, or sitting in the seats.