Paying Passengers Deserve Safety on All Flights

By Member Michael Graham

In 2015, the Federal Aviation Administration (FAA) required commercial airlines to develop a comprehensive safety management system (SMS) to improve safety for the flying public. An SMS is an organization-wide system that ensures operators are properly identifying, assessing, and mitigating the conditions that exist for an accident to occur.

The FAA, however, has not required the same for revenue passenger-carrying operations under Title 14 Code of Federal Regulations Parts 91 and 135, leaving passengers on these flights at unnecessary risk. Similar to passengers of commercial airlines, those passengers who pay for a charter flight, skydiving experience, or hot air balloon ride exercise no control and bear no responsibility over the airworthiness or operation of which they are being flown. Therefore, paying passengers of Part 91 and Part 135 flights deserve a similar level of safety as those who fly on a commercial airline. That is why Require and Verify the Effectiveness of Safety Management Systems in all Revenue Passenger-Carrying Aviation Operations is on the NTSB’s 2021–2022 Most Wanted List of Transportation Safety Improvements.

The Problem

Togiak, AK – Separated section of empennage with vertical and horizontal stabilizers and rudder attached.

Since the airlines were required to develop an SMS in 2015, the NTSB continues to investigate Part 91 and Part 135 accidents that could have been prevented by an effective SMS—all involving paying passengers—including the following:

  • On October 2, 2016, Ravn Connect flight 3153, a turbine-powered Cessna 208B Grand Caravan airplane operated under Part 135, collided with steep, mountainous terrain northwest of Togiak Airport in Alaska, killing both commercial pilots and their passenger. The operator did not have an SMS, and we found that after experiencing two previous controlled flight into terrain (CFIT) accidents in the preceding three years the company had missed opportunities to adequately assess this CFIT-related risks and implement more effective strategies for preventing such accidents.
  • On May 15, 2017, a Learjet 35A departed controlled flight while on a circling approach to runway 1 at Teterboro Airport in New Jersey, and impacted a commercial building and parking lot. The pilot-in-command (PIC) and the second-in-command (SIC) died. The operator lacked both an SMS and a flight data monitoring program, and the company did not identify or mitigate hazards that contributed to this accident, including the pairing of pilots who had exhibited difficulties in training, the informal practice of some captains who allowed unapproved copilots to serve as pilot flying, and other patterns of flight crew procedural noncompliance.
  • On March 11, 2018, an Airbus Helicopters AS350 B2 lost engine power during an aerial photography flight and ditched on the East River in New York City. The pilot sustained minor injuries and his five passengers drowned. Again, the operator lacked an SMS and, although the operator’s employees were aware of the potential hazards that led to the accident, the operator did not have a robust safety program that could adequately prioritize and address hazards that played a role in this accident, including the potential for entanglement of a passenger harness/tether system with floor-mounted engine controls, the inability of passengers to evacuate without assistance, and the possibility the emergency flotation system might only partially inflate due to difficulties with the float activation mechanism.
  • On June 21, 2019, a Beech King Air 65-A90 airplane, N256TA, impacted terrain after takeoff from Dillingham Airfield, Mokuleia, Hawaii. The pilot and 10 passengers were fatally injured, and the airplane was destroyed by impact forces and a postcrash fire. In this accident, the operator failed to address numerous safety issues that a formal SMS would likely have identified as significant risks and prevented the accident. These included allowing passengers to be transported in a poorly maintained airplane, not implementing any standard operating procedures (SOPs) or written guidance for the company’s parachute operations, providing no structured initial or recurrent training for company pilots, using flawed methods in calculating the weight and balance of its flights, and allowing its pilot to routinely violate numerous Federal Aviation Regulations. In April 2021, the NTSB issued Safety Recommendation A-21-13, which asked the FAA to require SMS for the revenue passenger-carrying operations discussed in the Part 91 aviation investigation report; these operations included parachute jump flights.

These accidents seemingly had little in common, yet, in each case, an effective SMS might have helped the operator identify hazards or better mitigate those that were already known.

An Effective SMS

Any operator can print out the four pillars of an SMS, put up a poster, and add an anonymous comment box to the breakroom. However, implementing an effective SMS that changes safety behavior in an organization is not a box-checking exercise. An effective SMS is a management system that brings safety conscious behaviors to the forefront of an organization, which aids in identifying and mitigating risks inherent in flight operations and other activities. Every day, every task.

An effective SMS must fully address the following four pillars:

  • Safety policy
    • Sets objectives, assigns responsibilities, and develops standards
    • Clearly defines roles and responsibilities
    • Engages accountable executive
  • Safety risk management
    • Systematic processes for identifying hazards and mitigating risks
  • Safety assurance
    • Monitors, measures, audits, and assesses the performance of SMS
  • Safety promotion
    • Ensures a positive and just safety culture
    • Circulates and incorporates safety lessons
    • Advocates, communicates, and trains the principles of SMS

By establishing an effective SMS and creating a safety culture that fosters the free flow of safety-related information and organizational learning about the nature of operational risks, operators will reduce the likelihood of an accident and improve the safety of their flight operations.

What Can Be Done

Oversight is necessary to ensure operators adhere to the principles and processes of an effective SMS to provide sufficient safety to paying passengers. The NTSB has investigated numerous accidents involving operators whose deficient SMS failed to identify and mitigate the conditions that contributed to the accident. Therefore, the NTSB calls on the FAA to require SMS for all revenue passenger-carrying Part 91 and Part 135 operations and provide ongoing oversight.

To operators, the NTSB’s investigations repeatedly demonstrate that an effective SMS could have identified the hazards and mitigated the risks that led to the accidents. Do not wait for an accident to occur or a FAA mandate to invest in the safety of your passengers, pilots, and other personnel, voluntarily implement an effective SMS today.

World Day of Remembrance for Road Traffic Victims

By Chair Jennifer Homendy

November 21 is the World Day of Remembrance for Road Traffic Victims. It is a day to honor the 1.3 million lives lost each year around the world in motor vehicle crashes.

Today, I urge everyone to take a moment to remember all those who have lost loved ones in crashes, as millions have done around the world since 1995. Here in the United States, traffic deaths are up 18 percent over the first half of 2020. We are on pace to lose 40,000 Americans this year alone.

My thoughts are with all who have lost loved ones, but especially those I’ve met who lost loved ones in crashes that the NTSB has investigated, and the survivor advocates I’ve gotten to know over the years.

We need to remember these numbers are people from our communities. They are lives lost: mothers, fathers, or children suddenly, permanently gone; brothers and sisters absent from holiday gatherings; friends missing from a baby shower. We record our losses in data tables, but we feel them at the dinner table, and in the graduations, weddings, and birthdays never celebrated.

At a November 10 virtual roundtable on the need for our nation to transition to a Safe System approach, I called for a moment of silence in advance of the World Day of Remembrance. I said then that, for the NTSB, the toughest part of our job is facing family members after a tragedy, explaining that their loved one’s death was 100 percent preventable and that we’ve issued recommendations which, if acted upon, would have prevented the crash and the loss of their loved one.

Then I said that we need a paradigm shift in how we address this ever-growing public health crisis.

For 26 years now, the world has memorialized the victims of motor vehicle crashes, and we have been right to remember them. No loss should be forgotten. But these are unnecessary losses. They must not be remembered only in words.

They deserve and demand action now.

They demand to be remembered with road treatments, traffic calming measures, engineering speed assessments, road safety laws, and other investments that will result in safe roads and safe speeds on those roads.

They demand to be remembered with the manufacture of safe vehicles that should come standard with better technology for avoiding collisions, including collisions with pedestrians, bicyclists, and motorcyclists.

They must be remembered with vehicle sizes and shapes that are less likely to result in the pedestrian and bicyclist deaths that we have seen so often.

They demand to be remembered with ignition interlocks for all impaired drivers, in the development of in-vehicle alcohol detection technology, and in fair and just traffic law enforcement.

They demand to be memorialized with increased investments in alternative modes of transportation, like public transit, which will reduce crashes on our roads, in newly changed laws to improve road safety, and in the enforcement of existing laws.

But most of all, these victims should be remembered as what they were: flesh and blood. Human. Vulnerable.

Put that image at the center of all the other aspects of our roads, and you’ll see the road as we must in order to finally make it safe. Don’t think of numbers, think of people. Put them at the center of every decision about our road system. That’s the paradigm shift that we need—to make our many layers of traffic hazards into layers of traffic protection, so that when crashes happen, nobody pays for it with their life.

This Day of Remembrance, let’s remember that the candle we light to remember victims is more than just a memorial; it’s a light showing the way to a safer tomorrow.


In this episode of Behind-the-Scene @ NTSB, we talk with Mike Fox and Steve Prouty, Highway Crash Investigators, Nathan Doble, Transportation Research Analyst and Brittany Rawlinson, Statistician about the 2021-2022 Most Wanted List safety items Implement a Comprehensive Strategy to Eliminate Speeding-Related Crashes and Protect Vulnerable Road Users through a Safe System Approach.

For more information about the NTSB Most Wanted List visit our website.

The NTSB safety research reports mentioned in this episode are available on our website.

The previously released podcast episodes featuring Mike Fox are available on our website.

The previously released podcast episode featuring Nathan Doble is available on our website.

Get the latest episode on Apple PodcastsStitcher or your favorite podcast platform.

And find more ways to listen here:

Improve Pipeline Leak Detection and Mitigation

By Member Michael Graham

Every day more than 2.6 million miles of pipelines across the United States transport enormous volumes of natural gas and liquid petroleum that provide for the nation’s energy needs. These pipelines crisscross the country under our neighborhoods, homes, and businesses. While, statistically, pipelines are the safest method for energy transportation, the NTSB has investigated some accidents that demonstrate the need for improved pipeline leak detection and mitigation:

  • ​On February 23, 2018, a natural gas-fueled explosion at a house in Dallas, Texas, injured all five occupants, one of whom died. The house sustained major structural damage. Investigators located a through-wall crack in the 71-year-old natural gas main that served the residence and positive gas measurements leading from this crack to the residence. Investigators believe the pipeline was likely cracked in 1995 by accidental damage from mechanical excavation equipment. Leaked gas accumulated and eventually ignited from the gas main, which was damaged during a sewer replacement project 23 years earlier. Atmos Energy Corporation failed to detect the leak during an earlier investigation of two related natural gas incidents just two days before the February 23rd explosion.
  • On August 10, 2016, a 14-unit apartment building in Silver Spring, Maryland, partially collapsed due to a natural gas-fueled explosion and fire, which also heavily damaged an adjacent apartment building. Seven residents died and 65 were transported to the hospital, along with three firefighters, who were treated and released. The probable cause was the failure of an indoor mercury service regulator with an unconnected vent line, which allowed natural gas into the meter room where it accumulated and ignited.
  • On September 9, 2010, a 30-inch-diameter segment of an intrastate natural gas transmission pipeline, owned and operated by the Pacific Gas and Electric Company (PG&E), ruptured in a residential area in San Bruno, California. The rupture produced a crater about 72 feet long by 26 feet wide. The section of pipe that ruptured, which was about 28 feet long and weighed about 3,000 pounds, was found 100 feet south of the crater. PG&E estimated that 47.6 million standard cubic feet of natural gas was released, ignited, and resulted in a fire that destroyed 38 homes and damaged 70, killing eight people and injuring many more. Several people were evacuated from the area.

High Consequence Area Leaks

According to the Pipeline and Hazardous Materials Safety Administration (PHMSA), in the last five years, an estimated 1.05 million leaks have been repaired on gas distribution systems. While most pipeline leaks are minor, during the same time, there have been 827 leaks in high-consequence areas – segments of pipeline systems within more populated areas that pose the greatest threat to human life and property – on gas transmission systems, and an estimated 167 accidents on gas distribution and transmission systems.

Leak Detection and Mitigation

Pipelines reliably and efficiently transport the energy that provides heat and electricity for countless Americans. Ensuring the safe distribution and transmission is paramount. Pipeline leak-detection and mitigation tools are essential and can make the difference between a minor leak and a deadly explosion. The NTSB first identified the need for leak-detection and mitigation methods in natural gas transmission and distribution pipelines nearly 50 years ago, but PHMSA, the federal pipeline regulator, has yet to require operators to use these life-saving measures, and many operators have yet to act on their own.

Pipeline systems equipped with leak-detection systems and automatic shutoff valves, or remote‑control valves, can warn operators of an imminent accident and allow for quick mitigation. Also, placing gas service regulators outside buildings can prevent a gas-leak incident; yet, many older homes and multifamily structures still have regulators inside, which can trap accumulating gas and lead to an explosion. And finally, methane detection devices help mitigate the consequences of a natural gas leak by alerting the public, thereby minimizing exposure.

I encourage PHMSA, industry groups, pipeline operators, and the public to work together to ensure the continued safe transportation of our important energy resources.

What is the Solution?

The Role of The Regulator

PHMSA is trusted to act on behalf of citizens to enhance pipeline safety. To better protect public safety, the NTSB has called on PHMSA to:

  • Require all operators of natural-gas transmission and distribution pipelines to equip their supervisory control and data-acquisition systems with tools to help recognize leaks and pinpoint their location.
  • Require automatic shutoff valves or remote-control valves to be installed in high‑consequence areas and in class 3 and 4 locations.
  • Require that all new service regulators be installed outside occupied structures and that existing interior service regulators be relocated whenever the gas service line, meter, or regulator is replaced. Multifamily structures should be prioritized over single-family dwellings.
  • Require methane-detection systems in residential occupancies with gas service.

The Role of Industry Groups

Gas industry groups can also play a critical role in improving public safety. The NTSB urges industry groups to:

  • Revise the National Fuel Gas Code, National Fire Protection Association 54 to require methane-detection systems for all types of residential occupancies with gas service.
  • Develop additional guidance for gas distribution operators so they can safely respond to leaks, fires, explosions, and emergency calls.

Operators Can Enhance Safety Directly

Regardless of when—or if—PHMSA makes the NTSB’s recommended changes, pipeline operators can take steps now to mitigate gas pipeline risks. The NTSB recommends operators take the following action:

  • Review and update, as needed, their incident-reporting practices; policies and procedures for responding to leaks, fires, explosions, and emergency calls; and integrity management programs.
  • Equip supervisory control and data-acquisition systems with tools to assist in leak detection.
  • Install remote-closure and automatic-shutoff valves in high-consequence areas and class 3 and 4 locations.

These steps taken by the regulator, industry groups, and operators can reduce gas pipeline risks.

What You Can Do

The public also has an important role in preventing pipeline leaks and incidents.

The most common cause of a pipeline leak is accidental damage. If you are planting a tree, installing a fence, or digging on your property for any other reason, call 8-1-1 before you dig. The NTSB has investigated numerous accidents in which accidental damage played a role.

You can also greatly decrease the possibility of an undetected gas buildup by purchasing and properly installing a methane detector in your home. Early detection is critical.

As a reminder, if you ever smell gas, please evacuate the area, and contact 9-1-1 and the gas company.

Improve Pipeline Leak Detection and Mitigation is a safety item highlighted on the 2021-2022 Most Wanted List of Transportation Safety Improvements.

Learn more on

In this video, NTSB Member Michael Graham and HAZMAT Investigator Rachel Gunaratnam, talk about why leak-detection and mitigation tools are essential and can make the difference between a minor incident and a deadly explosion.

Atmos Energy Corporation Natural Gas-Fueled Explosion
Dallas, TX | February 2018

Building Explosion and Fire
Silver Spring, MD | August 2016

Pacific Gas and Electric Company Natural Gas Pipeline Rupture and Fire
San Bruno, CA | September 2010

A Look Back on Teen Driver Safety Week 2021

By Bryan Delaney, NTSB Safety Advocate

Last month, as part of Teen Driver Safety Week the NTSB held two virtual roundtables to discuss the state of teen driver safety and graduated driver license laws (GDLs). While the dialogue was robust and yielded many critical insights, these events reminded us that one week isn’t enough to highlight the dangers associated with teen driving; to keep teen drivers safe on the roads, our focus must persist long into the future.

As advocates for teen driver safety, peers, parents, guardians, and mentors must continue to set a positive example, instill good driving behaviors during this learning stage, and work toward effective programming and policy that promotes teen driving safety.

We wanted to share some of the key takeaways from experts who participated in our two roundtables. If we heed their words, teen drivers will be safer on our roadways today and into the future.

Tara Gill, Senior Director, Advocacy, Advocates for Highway and Auto Safety

“Crashes are a leading cause of death for teens. And it shouldn’t be acceptable that thousands of teens are killed each year in crashes involving a teen driver. Traffic safety laws, vehicle safety technology, along with requirements and standards and road safety upgrades—this is the package we should be looking at. We must urge all states to give their GDL program a second look and prioritize changes to improve the programs.”

Haley Reid, National Vice President of Membership, Family, Career, and Community Leaders of America (FCCLA)

“Encourage students, and encourage parents, and encourage peers to take advantage of the opportunities provided for students who are part of FCCLA and other similar organizations.

Teens and parents should be part of the solution together.”

Shaina Finkel, National President, Students Against Destructive Decisions (SADD) National

“Make yourself and your safety the first priority. You should always do what you know is right on the road and off the road.”

Kelly Browning, Executive Director, Impact Teen Drivers

“To parents, the number one influencer: be the driver you want your child to be.”

Rick Birt, President & CEO, SADD

“The power of peer-to-peer prevention is one thing I am going to walk away with today. We need to rely on them (teens leaders) to really be the mobilizer to reach all the other students in the hallways of our schools and streets in our communities. We need to invest in the peer-to-peer approach with adult allies to support them, cheer them on from the sidelines, and give them resources.”

Sandy Spavone, Executive Director, FCCLA

“We need to prioritize teen driver safety education and making it equitable and fair for all youth. We must invest in our next generation. Teen driver safety education needs to be a priority in the United States.”

Charlie Klauer, Research Scientist and Training Systems Lead, Division of Vehicle, Driver, and Safety Systems, Virginia Tech Transportation Institute

“To teens and all drivers, keep your eyes on the road. Be patient and take things slow. There is no reason to go fast, no reason to look away and mess with other things. It is critical to pay attention and drive safe.”

William Van Tassel, Manager, Driver Training Programs, AAA National

“It’s all about vehicle choice. We need to make sure that our new drivers use the vehicle technology (collision avoidance technology) safely and effectively. It’s one thing to get it in their hands, but we have to take it another step as well. They have to be trained to use that. We know that most of these drivers are operating vehicles without a fully developed brain so there is a great temptation to consume vehicle technologies for a performance benefit rather than for a safety benefit, at least among younger drivers. To be able to counter that, they need to use them safely and effectively. In training drivers, that’s probably going to be perhaps our biggest issue over the next 20 years.

Pam Fischer, Senior Director of External Engagement, Governors Highway Safety Association (GHSA)

“We can’t diminish the important role of parents. Graduated driver license laws are really parent programs that are designed to give them the minimum standards to shoot for. We have to make sure parents understand that and leverage GDL for all its worth, because it is a proven tool.”

Kenny Bragg, Senior Highway Investigator, NTSB

“For parents, become as involved as you can in your child’s transition to motoring. Give them the education, have conversations, and give guidelines. Do everything you can to ensure your child’s success.”

Rebecca Weast, Research Scientist, Insurance Institute for Highway Safety (IIHS)

“I want to plug vehicle choice. There are lots of points of contact for parents and teens as they are going through the process of teens becoming a licensed driver. Vehicles should be a slightly larger vehicle, slightly heavier vehicle with a lower horsepower and it will limit their ability to do things that are risky. If it’s possible to put them into a vehicle with advanced safety features, parents and teens need to know how these features work.”

All our roundtable participants discussed the importance of education—educating parents, states, policymakers, and lawmakers—about the importance of a relentless focus on teen driver safety. After all, education plus action equals positive change.

Watch video of the roundtables here:

NTSB Roundtable on the State of Teen Driver Safety

NTSB Roundtable on the State of Graduate Driver License Laws