How Tragedy Led to Trust: National Aviation History Month

By Jeff Marcus, Chief, NTSB Safety Recommendations Division

From the Wright brothers’ first flight on December 17, 1903, to today, aviation has made remarkable progress. The affordability, speed, capacity, comfort, and, most importantly, safety of flight have all improved to the point that flying is one of the safest modes of transportation.

But that safety has been hard won. In honor of National Aviation History Month, let’s reflect on how the  aviation industry and Congressional action have evolved to further transportation safety.

The Early Days of Flying

Although most people are familiar with the Wright brothers, who did the research and development that produced the first airplane, many are unfamiliar with other important visionaries, such as Otto Lilienthal and Samuel Langley.

Otto Lilienthal with glider, 1895
Photo credit: Library of Congress

Karl Wilhelm “Otto” Lilienthal was a German pioneer of aviation who made the first successful flights with gliders, making the idea of a heavier-than-air machine a reality. His flight attempts in 1891 are seen as the beginning of human flight. Lilienthal made over 2,000 flights in self-designed gliders until his death on August 9, 1896, when he was unable to regain control after his glider stalled. Falling from about 50 ft, he broke his neck and died the next day. At the time of his death, Lilienthal’s total lifetime flying time was about 5 hours. The Wright brothers later cited Lilienthal’s death as the point when their serious interest in flight research began.

Samuel Langley’s Experimental Tandem Biplane on the Potomac River, 1896
Photo credit: Library of Congress

Another early aviation pioneer was Samuel Langley. In addition to being an American aviation innovator, Langley was the third secretary of the Smithsonian Institution. His first aviation success came on May 6, 1896, when his unpiloted, steam-powered, fixed-wing aircraft, weighing 25 pounds, made two flights—one 2,300 ft and the other 3,300 ft—after a catapult launch from a boat on the Potomac River. He followed that on November 11, 1896, with an improved aircraft model that flew more than 5,000 feet. In 1898, based on the success of his models, Langley received grants of $50,000 from the War Department and $20,000 from the Smithsonian to develop a piloted airplane.

Langley gave up on the project after two crashes on take-off on October 7 and December 8, 1903 (just a few days before the Wright brothers’ successful flight). The Smithsonian displayed Langley’s device as the first human-carrying airplane in the world capable of sustained free flight, triggering a decades-long feud with Orville Wright.

The first aviation fatality in a powered aircraft crash came on September 17, 1908, when, during a demonstration flight for the War Department in hopes of getting a military contract for their invention, Orville Wright crashed his aircraft, injured himself, and killed his passenger, Signal Corp Lieutenant Thomas Selfridge.

Lt. Selfridge & Mr. Wright stepping into the Wright airplane at Ft. Myer, 9/17/1908
Photo credit: Library of Congress

The Wright Flyer flew four circles around Fort Myer at an altitude of 150 feet. Halfway through the fifth, the right propeller broke, creating a vibration. The damaged propeller hit a guy-wire bracing the rear vertical rudder. The wire tore out of its fastening allowing the rudder to swivel to the horizontal sending the Flyer into a nosedive.

Wright cut the engine and glided to about 75 feet, but then the aircraft descended nose-down into the ground. Wright and Selfridge were thrown forward, and Selfridge struck one of the wooden uprights of the framework, fracturing the base of his skull. He died 3 hours later without regaining consciousness. Wright suffered severe injuries and was hospitalized for 7 weeks.

Despite the setback, aviation continued to develop worldwide, and on January 1, 1914, the St. Petersburg-Tampa Airboat Line became the world’s first scheduled airline. The airline provided service between St. Petersburg, Florida, and neighboring Tampa—a distance of about 23 miles with a travel time of 23 minutes (compared to 2 hours by boat). A one-way fare was $5.00 (approximately $130 in 2020 dollars), and flights rarely exceeded an altitude of 5 feet. The service terminated on May 5, 1914.

The Birth of Commercial Aviation

During the 1920s, airlines began to offer regular commercial air service. The were 24 fatal commercial airline crashes over 1926 and 1927, 16 in 1928. In 1929, which remains the worst year on record, there were 51 fatal crashes, about 1 for every 1,000,000 miles flown. In today’s world, this rate would result in 7,000 fatal airline accidents per year, or about 20 every day.

Partly in reaction to this accident rate, Congress passed the Air Commerce Act, which President Calvin Coolidge signed into law on May 20, 1926. The act established federal control over civil aviation by making the secretary of commerce responsible for improving air commerce by designating and establishing airways; establishing, operating, and maintaining aids to air navigation (but not airports); sponsoring and conducting research and development to improve such aids; licensing pilots; issuing airworthiness certificates for aircraft and major aircraft components; and investigating accidents.

On March 31, 1931, a Fokker F-10A operated by Transcontinental and Western Air (which evolved to become TWA) crashed near Bazaar, Kansas, after the wooden structure of one wing failed in flight. The crash killed eight people, including Notre Dame football coach Knute Rockne. The investigation found that the wooden wing became moist over time, causing the glue connecting the wing to the body to weaken, allowing the wing to separate. At the time, the investigation was publicly criticized for its secret nature. This crash brought about significant changes in the airplane industry, and was of cultural significance, given the death of Rockne and the public perception of aircraft safety. This accident, which killed a well-known public figure and the secretive nature of the investigation brought public attention to learning from accident investigations to prevent such disasters in the future. The intense public interest forced the Department of Commerce to make the results of aircraft accident investigations more transparent.

The investigation of the Bazaar, Kansas, crash resulted in a public expectation that the US government would objectively investigate crashes and publicly release its findings. In 1934, the Air Commerce Act was amended to require that reports on probable causes of fatal aircraft crashes be made public and banned the use of such reports and related evidence in court proceedings.

On May 6, 1935, a Douglas DC-2 operated by TWA crashed near Atlanta, Missouri. Its pilots were trying to make an emergency landing before their fuel ran out. The crash killed five, including Senator Bronson M. Cutting of New Mexico. Public debate and criticism over the cause of the accident showed the need for an independent investigative body.

Investigators from the Bureau of Air Commerce concluded that several factors led to the crash, including communications malfunctions, darkness, inaccurate weather forecasts, worsening weather at the destination airport, and errors in judgment, both from the airline dispatchers and the flight crew. They also found TWA in violation of several aviation regulations. Senator Cutting’s death drove Congress to investigate the Bureau of Air Commerce’s management of civil aviation. Senator Royal S. Copeland established a special subcommittee that harshly criticized the bureau in a report. Partly as a result, in 1938, President Franklin Roosevelt signed the Civil Aeronautics Act of 1938, which transferred federal responsibilities for nonmilitary aviation from the Bureau of Air Commerce to a new, independent agency: the Civil Aeronautics Authority.

Focus on Safety

On June 30, 1940, the Civil Aeronautic Authority was split into the Civil Aeronautics Administration (CAA) and the Civil Aeronautics Board (CAB). The CAA area of responsibility was air traffic control, safety programs, and airway development. The CAB focused on safety rulemaking, accident investigation, and economic regulation of the airlines.

During the 1950s, airline travel expanded. A midair collision on June 30, 1956, between a TWA Super Constellation and a United Air Lines DC-7 over the Grand Canyon killed all 128 occupants of the two airplanes. The collision occurred while the airliners were flying under visual flight rules in uncongested airspace. The accident showed that, even though US air traffic had more than doubled since the end of World War II, little had been done to expand the air traffic control system or to increase safeguards against midair collisions. This accident led directly to the Federal Aviation Act of 1958, which President Dwight Eisenhower signed on August 23, 1958. The law created the Federal Aviation Agency and led to the creation of the air traffic control system as we know it today.

Air traffic control booth with staff at Washington National Airport, Arlington, Virginia, 1958
Photo credit: Library of Congress

On October 15, 1966, President Lyndon Johnson signed the Department of Transportation (DOT) Act, which created the new cabinet-level department with five major agencies, including the Federal Aviation Administration. The DOT Act also created, within the DOT, an independent National Transportation Safety Board (NTSB) with authority to investigate accidents in all modes of transportation. The new DOT began operations on April 1, 1967.

President Lyndon Johnson signs the Department of Transportation Act
that created the NTSB, 1966
Source: NTSB.gov

In 1974, Congress made the NTSB completely independent of the DOT with the Independent Safety Board Act of 1974, which also prohibits the use of any portion of an NTSB report as evidence in a lawsuit related to matters discussed in the report and, with few restrictive exceptions, bars discovery, admittance into evidence, and public release of transcripts or recordings of a “cockpit or surface vehicle . . . voice or video recorder,” if not made public by the NTSB. In 1996, the Aviation Disaster Family Assistance Act expanded the role of the NTSB to include coordinating victim and family assistance following a major aviation accident.

The history of aviation, and the remarkable safety enjoyed today, are the result of the detailed aviation accident investigations throughout the years. And that work continues at the NTSB today, because we know that, from tragedy, we draw knowledge to improve the safety of us all.

Jeff Marcus, Chief of the Safety Recommendations Division, is retiring from federal service on December 29 after 43 years.

Marking World Day of Remembrance for Road Traffic Victims

By Nicholas Worrell, Chief, NTSB Safety Advocacy Division

Sunday, November 19, is the World Day of Remembrance for Road Traffic Victims. Every year on this day, people around the world honor the memories of crash victims. All of us at the NTSB want to express our condolences to those who have lost loved ones to motor vehicle crashes.

The NTSB works tirelessly to discover the cause of a crash and issue recommendations to prevent future crashes. From tragedy, we identify and advocate for improvements that move us toward a safer transportation system.

It can be said that much of the NTSB’s function is to remember, as we fight for the implementation of our safety recommendations even long after a crash. We remember crashes. We remember the recommendations that stemmed from them. And we never forget recommendations just because they have not yet been acted upon or because too much time has passed.

Similarly, victim advocates–those who have lost loved ones to senseless crashes–are often at the forefront of safety improvements, driven on by the memory of those they lost.

One of the better known and longest-tenured advocacy organizations, Mothers Against Drunk Driving, grew from a mother who lost her daughter to a national movement of victim advocates who support one another and work tirelessly to prevent future impaired-driving tragedies.

The In One Instant Teen Safe Driving Program was founded after a mother escorted her daughter to the funerals of three friends who were killed in car crashes. In One Instant has been implemented in more than 4,000 schools in all 50 states and educates young drivers on the risks associated with distracted, impaired, and reckless driving.

In 2017, the NTSB hosted the Act2End Distracted Driving Roundtable, which gave a voice to victim advocates impacted by distracted driving. Advocates spoke about turning their personal tragedies into effective advocacy efforts to prevent others from going through what they have endured.

It is not unusual for the NTSB to find itself supported by victim advocates in our quest for action on our safety recommendations. This goes beyond NTSB-hosted roundtables and webinars to our testimony in state legislatures about changes to the rules of the road. Why? Because, like the NTSB, these advocates remember, and they will not stop fighting for change until the highway deaths stop.

You don’t have to be personally affected by a crash to mark the World Day of Remembrance in your thoughts and in your actions. This World Day of Remembrance, commit to redoubling your attention to safe driving. To drive distracted, fatigued, or impaired is to forget the danger and impact our decisions can have on families, friends, and our communities.

Remembrance is not only an honorable response to tragedy, but a sacred duty to protect each other from future crashes and loss of life. Before you get behind the wheel, make sure you’re rested and sober. Put the phone away. Don’t speed. Remember that your life, and the lives of others, can be changed irrevocably by just one bad driving decision.

Remember those lost to protect the future of loved ones still with us.

Flight Attendants Continue to Be Seriously Injured in Turbulence

Action Needed Now to Prevent Future Injuries and Accidents

By Jana Price, PhD, NTSB National Resource Specialist

In 2021, the National Transportation Safety Board (NTSB) published a safety research report about preventing turbulence-related injuries. We found that turbulence was involved in more than a third (38%) of Part 121 air carrier accidents between 2009 and 2018. The NTSB report included 24 recommendations aimed at reducing the incidence of turbulence accidents and associated injuries.

The good news for travelers is that wearing a seat belt while flying virtually eliminates the risk of being injured if an airplane experiences turbulence. Our research found that passengers accounted for just 21% of those who were seriously injured due to turbulence, and nearly all of those passengers were unbelted when the turbulence occurred.

When turbulence occurs, it’s usually flight attendants who suffer. Flight attendants accounted for 79% of all seriously injured occupants in the turbulence-related accidents we studied. These injuries often occur as flight attendants prepare the cabin for landing; that is, when the seat belt sign is typically illuminated for passengers. In our 2021 report, the NTSB concluded that having flight attendants seated with their seat belts fastened earlier in the descent phase of flight would reduce the rate of flight attendant injuries due to turbulence (and, consequently, the rate of turbulence-related accidents overall). Our report recommended that the Federal Aviation Administration (FAA) revise the turbulence guidance it provides to airlines, including revisions concerning the phases of flight and associated altitudes at which flight attendants should be secured in their seats. However, 2 years later, the FAA has not yet acted on this recommendation.

The NTSB is not the first to recommend that flight attendants be seated and buckled in altitudes where turbulence risk is higher. More than 20 years ago, the Commercial Aviation Safety Team, a government-industry working group, recommended a policy to remain seated from takeoff to cruise and from 20,000 feet until landing. However, such a policy was never widely adopted, and serious injuries from turbulence under 20,000 feet have continued to occur. Since the NTSB turbulence safety research report was published in August 2021, as shown in the table, there have been 30 air carrier accidents involving turbulence. Reports are completed and publicly available for 11 of those accidents, and more than half of them involve flight attendants who were seriously injured when the airplane experienced turbulence at or below 20,000 feet. The following are examples of these accidents.

Part 121 air carrier accidents involving turbulence between August 2021 and September 2023. See the list of turbulence-related Part 121 air carrier accidents since 2008.

• On August 21, 2021, as American Airlines flight 2760 descended to land in Chicago, Illinois, the aircraft encountered turbulence at 7,000 feet. A flight attendant who had been walking through the aisle to prepare for landing fell to her knees because of the turbulence and fractured her kneecap.
• On August 19, 2022, as United Airlines flight 1400 descended to land in Columbus, Ohio, the aircraft encountered turbulence at 10,000 feet. A flight attendant in the rear of the aircraft fell and fractured her ankle.
• On August 29, 2022, as Delta Air Lines flight 2968 descended to land in Detroit, Michigan, at approximately 20,000 feet, the flight began to experience turbulence. A flight attendant was thrown into a galley counter, fracturing her rib.
• On September 1, 2022, as United Airlines flight 1675 descended to land in Denver, Colorado, below 13,000 feet, the aircraft encountered turbulence as the flight attendants were taking their seats. A flight attendant placed her hand on the jump seat to lower it when severe turbulence occurred, causing her to fracture her hand.
• On September 4, 2022, as Delta Air Lines flight 673 descended to land in New York City, at 13,000 feet, the aircraft encountered turbulence, which caused a flight attendant to fall and subsequently break her foot.
• On November 10, 2022, as American Airlines flight 2548 descended to land in Miami, Florida, at 18,000 feet, the aircraft encountered unexpected turbulence. As a result, a flight attendant in the aft galley was thrown to the floor and fractured her spine.
• On February 16, 2023, as Spirit Airlines flight 641 descended to land in New Orleans, Louisiana, at 7,000 feet, the aircraft encountered turbulence. Three flight attendants fell to the floor. One flight attendant fractured her ankle. The other two flight attendants received medical treatment for minor injuries.

In each of these cases, the seat belt sign was illuminated, and the passengers were belted. In some cases, the flight crew knew turbulence was possible during the descent and communicated this to one or more flight attendants, but the flight attendants were not seated in time. In other cases, the turbulence was unexpected. However, in every case described here, if there had been a policy for flight attendants to be seated and belted at 20,000 feet, these serious injuries would likely have been prevented.

Flight attendants spend their careers working to keep us safe. Our 2021 safety research report concluded that asking flight attendants to be seated earlier during the descent phase of flight could reduce serious injuries and accidents related to turbulence. The FAA has not made updating its guidance in this area a priority, but the agency must do so to avoid serious injuries that are entirely preventable.