Category Archives: Aviation Safety

FAA Must Take Action on Recorder Safety Recommendations

By Member Jennifer Homendy

Crash-protected flight recording systems, such as cockpit voice recorders (CVRs) and flight data recorders (FDRs), often called “black boxes,” are required on most commercial aircraft by the Federal Aviation Administration (FAA). CVRs record sounds like engine noises and pilots’ voices in aircraft cockpits. FDRs record important data on a plane’s operating condition during flight, like altitude and airspeed. Both are installed in a part of the aircraft most likely to “survive” a crash—usually the tail. These instruments have proven invaluable to determining the causes of a crash and preventing similar accidents from occurring; yet, the FAA doesn’t require them on most helicopters.

Nearly 4 months ago, a helicopter carrying nine people collided with a mountainside in Calabasas, California, tragically killing all on board. As the Board member on duty, I launched to Calabasas with a team of NTSB investigators just a few hours after learning of the crash. In the days following the accident, our team of investigators thoroughly examined the details surrounding the collision and I relayed our initial findings to the public. At our final press conference, I highlighted a 2006 safety recommendation issued to the FAA that the agency had refused to implement: require all transport-category rotorcraft operating under Title 14 Code of Federal Regulations Part 91 (requirements for general aviation operations in the United States) and Part 135 (requirements for operating charter and on-demand flights) to be equipped with a CVR and an FDR. The transport-category helicopter in the Calabasas crash was operating under Part 135, but was not equipped with either a CVR or an FDR.

Calabasas CA
CALABASAS, California — In this photo taken Jan. 27, NTSB investigator Carol Horgan examines wreckage as part of the NTSB’s investigation of the the crash of a Sikorsky S76B helicopter near Calabasas, California, Jan. 26. The eight passengers and pilot aboard the helicopter were fatally injured and the helicopter was destroyed. (NTSB photo by James Anderson)

Although it’s too soon in the ongoing Calabasas helicopter investigation to know how the lack of recorders will affect our investigative work, the NTSB has long seen the value of using flight recorders to conduct comprehensive accident investigations, including those involving helicopters. At the time of the Calabasas accident, The Late Show host Stephen Colbert spoke about how a CVR was instrumental in determining what caused Eastern Air Lines flight 212 to crash in 1974, killing 72 people on board—including his father and two brothers. Colbert appealed to the FAA to require that helicopters be equipped with black boxes so we can learn more about what occurred in a crash and prevent the next one from happening.

Unfortunately, the absence of a CVR and an FDR in the Calabasas crash was not unique. In fact, the NTSB has investigated several helicopter crashes and issued recommendations to address the lack of crash-resistant flight recording technology onboard helicopters as far back as 1999 (A‑99‑60). We followed up with comparable recommendations in 2003 (A-03-62 to -65) and 2009 (A-09-9 to -11), and recently released a safety recommendation report detailing several helicopter crashes in which recorded flight data would’ve helped us better identify potential safety issues.

On May 19, the Board adopted a report on the January 29, 2019, crash of an air ambulance near Zaleski, Ohio. The investigation found that if cockpit image data had been captured, investigators would have been able to better understand why the pilot failed to maintain altitude in the final moments of the air ambulance’s flight. We reiterated two previous recommendations (A-13-12 and -13) that the FAA require crash-resistant flight recorder systems on new and existing aircraft operating under Parts 91, 121 (domestic operating requirements), and 135. As we learned at the Board meeting, these crash-resistant devices are available on the market today.

We also reiterated a recommendation (A-16-35) that the FAA require all Part 135 operators to create flight data monitoring (FDM) programs “to identify deviations from established norms and procedures and other potential safety issues.” In the Zaleski investigation, although the helicopter was equipped with FDM devices, the data was not used to verify and improve safety.

Expanding the use of recorders has been on the NTSB’s Most Wanted List (MWL) going back to 2011. The MWLs in 2014 and 2015 both specifically called for crash-resistant flight recorder systems to be adopted to enhance helicopter safety. Our most current MWL, which spans 2019 and 2020, calls on regulators to “require all Part 135 operators to install data recording devices” to meet the same safety requirements as commercial airlines.

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The NTSB’s history of recommendations on flight recording systems has not gone unnoticed by lawmakers. Following a June 2019 helicopter crash in Manhattan that killed the pilot and started a fire on top of a Midtown skyscraper, Senate Minority Leader Charles Schumer and New York Senator Kirsten Gillibrand urged the FAA to require FDRs in helicopters, just as they are required for commercial planes. In their press release, Senator Schumer stated “to know that the NTSB has been trying for years, without success, to compel the FAA to take action as it relates to making helicopters more valuable to safety by installing flight data recorders is cause for serious concern.” He went on to say that the FAA “must take another look” at the NTSB’s recommendations on FDRs.

To date, the FAA has not acted on our repeated recommendations regarding crash‑resistant and crash-protected flight recording systems for helicopters. Although the FAA encourages helicopter operators to voluntarily use crash-resistant flight recording systems, the agency stops short of mandating CVRs and FDRs. This is especially disappointing because, although flight recording systems are undoubtedly crucial to improving aviation safety, they serve another important function: they provide grieving families with answers.

The benefits of crash-resistant flight recording systems well outweigh their cost; it’s beyond time for the FAA to take action on our safety recommendations regarding them.

 

Remembering Tenerife

By Jeff Marcus, Chief, NTSB Safety Recommendations Division

Forty-three years ago, on March 27, 1977, two Boeing 747s, KLM flight 4805 and Pan Am flight 1736, collided on a runway at Los Rodeos Airport in Tenerife, Canary Islands, killing 583 people. It was the single greatest loss of life in aviation accident history.

The crash was the result of an unlikely series of events—and a flight crew’s responses to them.

To begin with, neither of the two aircraft was initially supposed to be at Los Rodeos Airport in the first place. Both planes had been scheduled to arrive at Las Palmas Airport, also in the Canary Islands; however, Las Palmas had just been the target of a terrorist attack, and the terminal had been evacuated and the airport closed. The two 747s, as well as other arriving traffic, were diverted to the smaller Los Rodeos airport in Tenerife, where they landed safely.

The Los Rodeos Airport had not been equipped to handle the influx of diverted flights and, because of that, on March 27, the airport was congested, and maneuverability issues arose when the airplanes were ready to depart. Pan Am 1736 was ready to depart Los Rodeos to resume its itinerary, but had to wait until KLM 4805, which was obstructing the taxiway, had completed taking on fuel from a refueling vehicle. The captain of the KLM flight was instructed to back taxi down the entire runway, then perform a 180-degree turn in preparation for departure. The Pan Am captain was instructed by air traffic control to back taxi down the runway, then exit on the third taxiway to their left, and to report leaving the runway. The taxiways at the airport were unmarked and the centerline lights were out of service.

Los Rodeos airport was subject to fast-appearing, thick fog, and as the KLM airplane lined up for its takeoff roll, fog enveloped the runway. The Pan Am airplane missed its exit, and its crew did not appear to know their position on the runway. Neither crew could see the other plane, and the tower couldn’t see either plane. The airport was not equipped with ground radar.

Having lost so many sources of information, one last source of information failed: verbal communication between the airplanes and the tower.

Immediately after lining up, the KLM captain who had a sense of urgency to depart before exceeding duty limits advanced the throttles and the aircraft started to move forward. The KLM first officer advised the captain that air traffic control (ATC) clearance had not yet been given. The captain replied, “No, I know that. Go ahead, ask.” The first officer radioed the tower that they were ready for takeoff and waiting for ATC clearance. The KLM crew then received instructions that specified the route that the aircraft was to follow after takeoff. The instructions used the word “takeoff,” but didn’t include an explicit statement that the aircraft was cleared for takeoff. The first officer then read the clearance back to the controller, completing the readback with the nonstandard statement: “We are now at takeoff.” The KLM captain interrupted the first officer’s read-back with the comment, “We’re going.”

The controller, who could not see the runway due to the fog, initially responded with the nonstandard terminology “OK,” which reinforced the KLM captain’s misinterpretation that they had been cleared for takeoff. The controller then immediately added “stand by for takeoff, I will call you,” indicating that he had not intended the clearance to be interpreted as a takeoff clearance. However, a simultaneous radio call from the Pan Am crew caused mutual interference on the radio frequency, which was audible in the KLM flight deck as a 3-second-long shrill sound. This caused the KLM crew to miss the crucial latter portion of the tower’s response. The simultaneous message from the Pan Am crew, “We’re still taxiing down the runway, the Clipper 1736!” was also blocked by the interference and inaudible to the KLM crew. Either message, if heard in the KLM flight deck, would have alerted the crew to the situation and given them time to abort the takeoff attempt.

After the KLM plane started its takeoff roll, the tower instructed the Pan Am crew to “report when runway clear.” The Pan Am crew replied, “OK, will report when we’re clear.” On hearing this, the KLM flight engineer expressed his concern about the Pan Am aircraft not being clear of the runway by asking the pilots in his own cockpit, “Is he not clear, that Pan American?” The KLM captain emphatically replied, “Oh, yes,” and continued with the takeoff.

By the time the KLM captain saw the Pan Am airplane, he could only try to fly over it. The tail of the KLM airplane struck the Pan Am airplane, tearing through the center of its fuselage above the wing. Fuel spilled and ignited on impact. Of the Pan Am passengers and crew, 335 died, mainly as a result of ensuing fire and explosions, and 61 survived.

The KLM airplane lost one engine on impact, and the wings were damaged. The airplane rolled sharply and crashed about 500 feet past the point of collision. All 248 passengers and crew died in the crash and the post-crash fire.

The Tenerife accident provided early lessons for the concept of crew resource management (CRM), which emphasizes that all flight crew members should actively voice their safety concerns, and all crew, particularly senior crew members like the captain, must acknowledge the safety concerns of any crew member. In the Tenerife accident, the captain rushed the takeoff, despite the first officer pointing out that they had not received clearance, and the flight engineer recognizing that the Pan Am airplane had not yet cleared the runway. Despite the flight engineer highlighting the dangerous situation, the KLM captain dismissed the concern and continued the takeoff, which resulted in the tragedy a few seconds later.

The Tenerife accident was a milestone in the study of human factors in aviation accidents. The pressures of the day’s events and delays; the logistics pressures in a regional airport handling a major airport’s arrivals; the communications misunderstanding; and the failure to understand and use CRM practices all led to bad decisions at various points in the accident chain.

Aviation has changed and become safer by leaps and bounds since the crash. As a result of Tenerife, there has been greater emphasis on English as the single working language of aviation, and on the use of standard, concise, and unequivocal aeronautical language.

Tenerife was influential in recognizing that all crew members should feel empowered to speak up, and captains should listen to their safety concerns—an important principle of CRM. The principles of CRM have even been extended beyond aviation  to marine safety, where it is known as bridge resource management, and to medicine, where all doctors and technicians in an operating room are encouraged to voice their concerns, and senior, highly esteemed surgeons are trained to listen to and evaluate any safety concern expressed, regardless of who has the concern.

Humans are an integral part of the aviation system and the system must protect for human error. In 2017, many links of an accident chain were in place at San Francisco International Airport when an Air Canada airplane almost landed on a taxiway occupied by four airliners waiting to takeoff. There were over 1,000 people in those four airliners; the accident would have equaled or even surpassed the death toll at Tenerife more than 40 years earlier. That close call was another reminder of how much is on the line every time human pilots and passengers take to the skies—and how much of a role human factors can play in such tragedies and near misses.

Ensuring Transportation Safety, Even During a Crisis

By Member Jennifer L. Homendy

For the past few weeks, I’ve woken up every morning to a text message from the Virginia Railway Express (VRE) updating riders on its continued service and modified schedule. It’s hard not to think of all the VRE and Amtrak locomotive engineers and conductors that I’ve come to recognize (or know by name—Hi, Willie and Samantha!) over the years, and how dedicated they are to continuing to serve the public during this national emergency. You and your colleagues across the country are heroes. Thank you for all you do.

The safety of transportation workers across all modes is extremely important especially during times of crisis. Our nation’s transportation workforce is essential to getting critical goods to states and local communities and to ensuring that those serving on the frontlines of this pandemic, like medical personnel, grocery store employees, and other essential personnel, are able to continue the fight against COVID-19. Without all of them, we’d be in a much more dire situation. Still, we need to make sure that the transportation workers who are putting their lives at risk daily to make deliveries or get people to work are also safe. That not only means providing them with necessary personal protective gear, but also ensuring any regulatory waivers do not jeopardize their safety or the safety of others.

Since the start of this national emergency, many transportation entities facing staffing shortages due to illness and the need to quarantine have requested emergency relief from certain safety regulations. These entities cite concerns about their ability to deliver critical goods and materials necessary for the country’s welfare while meeting regulatory requirements for inspections, training, and maintenance, to name a few. Although regulatory relief from certain requirements may be necessary during this difficult time, I urge the US Department of Transportation (DOT) to carefully review each request and put measures in place to ensure that the safety of transportation workers, and all others who must travel, remains a priority.

We are all being challenged in ways that we could not have imagined a month ago. People are staying safe by traveling only when absolutely necessary and maintaining a safe social distance from others. Those in the transportation industry are also doing what they can to stay safe while continuing to do the important work of moving the people and goods that keep our nation pushing forward during this crisis.

It’s important that any regulatory relief the DOT determines is appropriate is only temporary. This crisis can seem overwhelming, but as a nation, we will prevail. It’s important that when our lives start to take the path back to “normal,” safety regulations—many of which the NTSB has long advocated for following tragic crashes—are reinstituted. Temporary measures to address a crisis should not become the new normal. An efficient transportation network is key to our nation’s success during this challenging time, but we must not forget the importance of ensuring the safety of transportation workers and the traveling public both now and in the future.

A Tribute to NTSB Employees

By Chairman Robert L. Sumwalt

What do you get when you cross a transportation-related life-saving mission with some of the best people in the federal government?

 The National Transportation Safety Board, of course!

 And that is no April Fool’s joke.

 On this day 53 years ago, the NTSB was formed by an act of Congress. The agency’s mission is to investigate every civil aviation accident in the United States and significant accidents in other modes of transportation, determine their probable causes, and issue safety recommendations aimed at preventing future accidents. In addition, we conduct special studies concerning transportation safety, and we coordinate the resources of the federal government and other organizations to provide assistance to victims and their family members impacted by major transportation disasters. We also adjudicate appeals from civil enforcement actions by the Federal Aviation Administration and the United States Coast Guard.

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Since 1967, the NTSB has investigated more than 149,000 aviation accidents and thousands of surface transportation accidents. We’ve issued more than 15,000 safety recommendations—the vast majority of which ultimately are implemented. Some of the safety measures that have arisen, at least in part, from our safety recommendations include:

Aviation

  • Floor-level escape lighting, fire-blocking seat coverings, lavatory smoke detectors, stronger cabin seats
  • Terrain avoidance and warning systems requirements
  • Inert gas use to eliminate fuel tank explosions
  • Shoulder harnesses in general aviation

Highway

  • Raising the legal drinking age to 21 and .05 percent BAC drinking and driving laws
  • Child passenger safety
  • Enforcement of commercial vehicle regulations

Marine

  • Boating-while-intoxicated laws
  • Cruise ship fire safety
  • Emergency position-indicating radio beacons (EPIRBs) on vessels

Railroad & Rail Transit

  • Positive train control
  • Passenger rail car safety standards
  • Toll-free emergency number posting at grade crossings
  • Tank car enhancements

Pipeline

  • One-call systems before excavation (“Call 811 Before You Dig”)
  • Integrity management programs
  • Facility response plan effectiveness and oversight

HAZMAT

  • Hazard communications training for first responders, community planning, and preparedness

I’m often reminded that you can have an important mission, but if you don’t have devoted, talented employees, you really don’t have a great agency. Fortunately, the NTSB has both.

Our mission generates dedication, which often translates to retention; some of our longest-serving employees have been at the agency for over 40 years. But don’t misinterpret that longevity as complacency. In the most recent Federal Employee Viewpoint Survey, of the 70% of NTSB employees who completed the survey, 97% responded favorably to the statement, “When needed I am willing to put in the extra effort to get a job done.” Bear in mind that in many cases, “extra effort” is in addition to routine travel to remote accident sites with only hours’ notice!

During more than 13 years at the agency, including the past 3 as Chairman, I’ve had the pleasure to be surrounded by, and to work with, these professionals. As Chairman, I have relied on them to help formulate strategic decisions, advise me on technical details, and echo and amplify my own thirst for safety improvements.

Many of our air safety investigators are pilots and aircraft mechanics themselves—and each of them can tear down an engine. Several have built their own airplanes. Many of our highway safety investigators come from law enforcement backgrounds. Our marine investigators generally maintain licenses first earned as deck and engine officers or have Coast Guard investigative or regulatory experience. Our railroad and pipeline investigators are veterans of those industries and their regulators as well. Although doctoral degrees are common throughout the agency, the environment is as far as you can imagine from an ivory tower.

The NTSB workforce is among the best in the federal government, which is what fuels my desire to make the NTSB the best place to work in the federal government—even if, for now, we have temporarily moved that workplace into our homes.

Today, like many workforces, we are physically distant from one another, but we are not alone. We are physically separate, but we will get through this together. I’m grateful for the dedication and resilience of every one of NTSB’s employees. And that, too, is no April Fool’s joke.

Safe Travels This Holiday Season

At the NTSB, we determine the cause of transportation crashes and accidents, and issue safety recommendations that, if implemented, could save lives and minimize injuries. Unfortunately, we see far too many tragedies that could have been easily prevented. As we head into the holiday season, Vice Chairman Bruce Landsberg and Member Jennifer Homendy share some travel safety tips to keep you and your loved ones safe on our roads, on our rails, on our waterways and in the air.