In this episode of Behind-the-Scene @NTSB we talk with Tim LeBaron, Director; Kristi Dunks, Acting Deputy Director for Regional Operations; and Aaron Sauer, Senior Air Safety Investigator, in the Office of Aviation Safety, about their work to improve general aviation safety and the NTSB’s participation in the upcoming EAA AirVenture Oshkosh event. Hear more about our “Fly Like a Pro” presentation theme for this year, the safety messages being shared with the GA community, including our updated Safety Alert on fly-ins and other safety resources, and where you can find Member Mike Graham and NTSB staff throughout the event.
For more information about NTSB at the EAA Air Venture Oshkosh event, visit our webpage.
To learn more about NTSB aviation investigations, and to access investigative reports, visit our investigations webpage.
NTSB Safety Alerts are also available on our website.
By Lorenda Ward, Chief, NTSB Air Carrier and Space Investigations Division
When I read the Chair’s blog, “A Call to Action from Kennedy,” I asked myself, “Are we ready?” Not for commercial space exploration, but for the next commercial space accident investigation.
One of my responsibilities as the chief of the NTSB’s Air Carrier and Space Investigations Division is to ensure that our senior aviation investigators are prepared to respond to a commercial space accident. As the Chair outlined in her blog post, with the growth of commercial space launches and reentries, it is not a matter of “if,” but a matter of when.
What if we get the call today?
The NTSB has done a lot over the last several decades to prepare, including establishing the Quad-Agency Working Group with the Federal Aviation Administration (FAA), NASA, and the US Space Force, to build those important relationships between the agencies before a bad day happens. We meet regularly to discuss lessons learned and best practices from past investigations to ensure we are ready for the next investigation.
We also have a lot of training opportunities for our investigators that are above and beyond just attending industry conferences. Several years ago, I helped create a spacecraft design and systems engineering training course, as well as a commercial space externship program for our investigators to learn about the different space vehicles. We also take part in mishap tabletop exercises where we discuss the NTSB party process with both government and industry organizations. By far though, our best training opportunities have been the “on-the-job training” investigations that we’ve taken part in over the years. These investigations have provided us a great understanding of multiple launch vehicles and systems.
Responding to the Call
I remember leading the last fatal commercial space accident involving Scaled Composite SpaceShipTwo (SS2). I was actually at the site of another commercial space mishap, examining the recovered ordnance, when the SS2 accident occurred. Because of the possibility that cellphone signals could detonate unexploded munitions, our whole team had left our phones on the bus while we were at the storage location.
An FAA investigator who had stayed back came running into the bunker, saying we need to go now. I didn’t ask any questions and it wasn’t until I got back on the bus that I saw my boss had been repeatedly calling me for half an hour.
When I finally talked with my boss, he told me I would be the investigator-in-charge (IIC) of the go-team to investigate the first fatal commercial space launch accident. All the federal investigators (NTSB and FAA) had to work our way back from Wallops Island, Virginia, to DC. I had to keep pulling over to be patched into conference calls, so the commute took a lot longer than usual. At NTSB, we do not take calls while driving as distracted driving is a serious issue on our roadways. We have an agency-wide policy that prohibits staff from using a cell phone while driving. I remember at one point telling management I would never make it back to DC if I had to keep pulling over.
For the next 9 months, my focus was determining what happened to SpaceShipTwo. The accident occurred on October 31, 2014, when SS2 broke up during its fourth rocket-powered test flight and impacted terrain over a 5-mile area near Koehn Dry Lake, California. One test pilot (the co-pilot) was fatally injured, and the other test pilot was seriously injured. SS2, a reusable suborbital rocket, had released from WhiteKnightTwo, the carrier vehicle, about 13 seconds before the breakup. SS2 was destroyed, no one on the ground was injured by the falling debris, and WhiteKnightTwo made an uneventful landing.
SpaceShipTwo released from WhiteKnightTwo (Source: Virgin Galactic WK2)
Scaled Composites (“Scaled”) was operating SS2 under an experimental permit issued by the FAA Office of Commercial Space Transportation (AST) according to the provisions of 14 Code of Federal Regulations Part 437. The investigation identified several safety issues, to include the lack of human factors guidance for commercial space operators, missed opportunities during the FAA/AST’s evaluations of Scaled Composite’s hazard analyses, FAA/AST granting waivers from regulatory requirements, and an incomplete commercial space flight database for mishap lessons learned. The full report, safety recommendations and docket material, are available on the NTSB investigation page.
What Went Wrong?
The probable cause of the breakup was Scaled Composite’s failure to consider and protect against the possibility that a single human error could result in a catastrophic hazard to the SS2 vehicle. This failure set the stage for the copilot’s premature unlocking of the feather system which led to uncommanded feather extension and the subsequent overload and in-flight breakup of the vehicle. The accident vehicle had onboard video recording (cockpit image recorder) capability and the recording was obtained from a telemetry ground station located in Scaled’s control room at Mojave Airport, Mojave, California. This video was a key part of the investigation, showing cockpit displays and what actions the crew members took.
The Party System
All of our investigations use a party system, meaning that the operator and the regulator will be part of our investigation, at a minimum. For the SpaceShipTwo investigation, we invited Scaled, Virgin Galactic, Butler Parachute Systems, and the FAA to be parties. Scaled built and tested SS2 and had delivered WhiteKnightTwo to Virgin Galactic before the accident. Scaled had planned on transitioning SS2 to Virgin Galactic toward the end of 2014.
WhiteKnightTwo hangar visit during on scene phase of investigation, Nov. 2, 2014, Mojave, CA (Source: NTSB)
At the end of the investigation, a couple of the party members mentioned that when we first arrived on scene, wearing our blue jackets with giant yellow letters, they had no idea what to expect or what they were in for. They thought they were being invaded. For this reason, and others, we like to meet with commercial space operators before an accident, so we can explain the NTSB investigation process before we show up on their doorstep for an accident investigation. That initial reaction turned to one of trust as the investigation progressed. They said they were glad we led the investigation and had learned a lot from us. We, in turn, also learned a lot from all the parties.
Some party members also mentioned that they felt like full participants in the investigation, and that their voices were heard. To that point, the investigation would not have been completed in 9 months if we did not have the professionalism, openness, responsiveness, and willingness of the parties to trust our process.
To return to the question that I asked myself on reading the Chair’s blog: “Are we ready?”
Yes, we are ready. Nobody is more ready. This is what we do: Investigate. Communicate. Advocate.
By Jeff Marcus, Chief, NTSB Safety Recommendations Division
In many states, when using motorized recreational vessels, or engaging in activities like canoeing, kayaking, and standup paddleboarding, operators are not required to attend a boating safety course, obtain a license or certificate, be familiar with the navigation rules (commonly called the “Rules of the Road”), or even demonstrate proficiency in watercraft operation.
In 2016, the NTSB sought to better understand the scope of the issue and determine the safety impact on the nation’s waterways following:
our investigation of a collision between eight kayakers and a New York Waterways ferry,
feedback we received from marine industry representatives, and
concerns about the increase in encounters between commercial and recreational vessels.
We took what we learned and began to develop a safety recommendation report.
In 2017, we published Shared Waterways: Safety of Recreational and Commercial Vessels in the Marine Transportation System, providing our findings as well as recommendations to improve shared waterway safety. We found there is an increased safety risk, especially where confined waterways limit the ability of vessels to maneuver. This is exacerbated not only by the diversity of waterway users but also by differences in their experience, marine knowledge, and boat-handling skills. Moreover, state requirements varied considerably.
Chicago River. (Photo courtesy of Steve Dahlman)Cruise ship departing San Diego. (Photo courtesy of Port of San Diego)Kayaks pass commercial barge on Chicago River. (Photo courtesy of Larry Dostal)Photo of the Chicago River, taken from a commercial tour boat, with recreational vessels close by. (Photo courtesy of Larry Dostal)
At the time of our report, the US Coast Guard estimated that in 2015 only 28 percent of motorized recreational vessel operators were required by state laws to complete a boating safety course or pass an examination of boating safety knowledge. Could you imagine if that were the case when it came to obtaining a private pilot’s license? Clearly, recreational vessel operators need a minimum level of boating safety knowledge to mitigate the various risks associated with the type of vessel being operated.
So, we issued Safety Recommendation M-17-2, which asked the Coast Guard to seek statutory authority to require recreational boat operators to complete a national boating safety course. When we issued this recommendation, we were aware that the Coast Guard had previously sought statutory authority to require recreational boat operators to complete a national standard minimum boating safety education course. As our Shared Waterways report pointed out, at that time, over 70 percent of motorized vessel operators and most nonmotorized vessel operators were still not required to demonstrate minimum boating safety knowledge.
Today, we commend the US Coast Guard for its determined and sustained role in promoting recreational boating safety. Although the Coast Guard has not been granted authority to implement a minimum national standard for boating safety as we’d hoped, it has developed an alternative approach that addresses the safety issue. Instead of saying there was nothing they could do because they didn’t have statutory authority, the Coast Guard developed a solution to address the safety problem. Consistent with congressional direction, the Coast Guard focused on supporting state-led initiatives to develop educational programs and requirements for recreational boaters. Working in partnership with the National Association of State Boating Law Administrators, the states, and various recreational boating stakeholders, the Coast Guard helped develop and update boating education standards. With the Coast Guard’s active support, recreational boating education has greatly improved nationwide. In its latest update to the NTSB, the Coast Guard reported that currently all but five states have mandatory boating safety education.
Safety is a journey, not a destination. Although there is always more to be done, the Coast Guard’s alternative action led to significant improvements in recreational boating safety across the nation and satisfied the intent of our recommendation.
We issue safety recommendations to other federal agencies and transportation stakeholders engaged in all modes: air, highway, rail, marine, and pipeline. Although we may recommend a particular action, there are often alternative solutions that are equally effective in addressing a safety problem that we identify through our investigations. Like sailing into the wind, sometimes a direct path isn’t possible; sometimes you must tack back and forth to make the mark. We encourage our safety recommendation recipients not to give up if our recommended action proves unattainable, and to pursue alternate actions to satisfy the intent of the recommendation. Our goal is to improve transportation safety in any way possible.
We ask all our recommendation recipients to share updates with us on relevant actions they’ve taken to address our concerns. Hearing from them helps us evaluate progress and properly classify the status of recommendations.
Stay safe on the water. Let’s work together as we navigate our way to zero transportation deaths and serious injuries, and safer transportation for all.
NTSB Safety Compass Blog 