Category Archives: Aviation Safety

Another Step Toward Safer Skies in Africa

By Dennis Jones, NTSB Managing Director

In my recent blog post, I talked about the NTSB’s visit to South Africa as part of the US Department of Transportation’s Safe Skies for Africa (SSFA) program. Last week, the NTSB team returned to Africa—this time, to the east African nation of Kenya—in continued support of the SSFA program, the aviation safety capacity-building initiative that includes collaboration between African countries and several US government agencies. In Kenya, as in South Africa, we once again shared investigative lessons learned with more than 150 air safety investigators, aviation trainers and operators, government officials, and safety advocates from Kenya and countries in the surrounding region.

Blog Image 1

I was particularly excited about this trip because I first traveled to Kenya for accident investigation purposes 20 years ago, and later, based in the capital city of Nairobi, I worked to implement the NTSB’s SSFA program responsibilities. The goal of the SSFA program in Kenya was to help the country achieve FAA Category 1 status and pave the way for direct scheduled commercial air service between the United States and Kenya. The NTSB’s contribution toward this goal was to help Kenya’s accident investigation program meet international standards in accordance with the provisions of the International Civil Aviation Organization’s (ICAO’s) Annex 13. Our activities included working with the Air Accident Investigation Division of Kenya (AAID) to develop its program, which included on-the-job investigator training; establishing policy, procedures, and practices for the organization; and producing memoranda of understanding between AAID and other domestic government agencies. The NTSB partnered with ICAO as part of the SSFA program to conduct aircraft accident investigation workshops throughout Africa; the first such event was held in Nairobi in 2007.

It took some time but, thanks to Kenya’s painstaking and diligent efforts, and the assistance provided by the SSFA program, Kenya achieved an FAA Category 1 rating in February 2017. Consequently, US and Kenya air carriers can now, with the approval of their respective regulatory agencies, travel between the two countries. Kenya Airways, Kenya’s national carrier, will launch its inaugural flight to the United States, destined to JFK International Airport in New York, in October 2018.

Although Kenya’s government is focused on improving aviation safety, the country—and, more broadly, the continent—still faces challenges that the region’s stakeholders are dedicated to overcoming. General aviation (GA) safety issues have been formidable in the region, just as they are in the United States, and we sought to share some of our experience addressing this issue. Further, through the SSFA initiative, NTSB representatives have recognized other modal transportation safety issues and safety advocacy opportunities for future consideration as the agency formulates its international scope of activities.

After accompanying the NTSB team to South Africa last month, I was fully confident in its ability to conduct the workshop in Nairobi. The team was composed of professionals representative of the superb workforce at the NTSB, and they delivered powerful presentations sharing lessons learned.

Shamicka Fulson, a program manager in the Office of the Managing Director, coordinated the development of the workshops in South Africa and Kenya. She delivered opening remarks and provided an overview of the agency and the SSFA program to begin the workshop in Nairobi.

Clint Crookshanks, an aerospace engineer in the Office of Aviation Safety, facilitated a workshop related to identifying common aviation safety lexicon. He reviewed different accident case studies with the audience and discussed ways to interpret the generalized and vague definitions often found in aviation investigations, such as “substantial damage to aircraft,” or the distinction between an “accident” and an “incident.”

Luke Schiada, Deputy Chief of Aviation Safety for the Eastern Region, presented accident case studies that highlighted international cooperation. Luke told the audience that he believed “international cooperation is, in large part, about building relationships and trust.” He stressed the importance of interacting with and learning from the collective knowledge and experiences of participants in settings like the SSFA workshops. I can’t agree more; after all, we can’t improve within unless we are willing and able to learn from without. Even sharing enables learning and growth.

Dennis Hogenson, Deputy Regional Chief of Aviation Safety for the Western Pacific Region, focused on GA safety improvements. He pointed out that, like Africa, the United States is seeing a high incidence of GA crashes. He told his audience that, while airline accidents have become rare, GA accidents account for most aviation fatalities. In many of our GA accident investigations, we’ve discovered that pilots didn’t have the adequate knowledge, skills, or recurrent training to fly safely. Dennis encouraged his African counterparts to initiate more training and increase awareness of technology that can help prevent these tragedies; this is something we continue to strive to do in the United States via our Most Wanted List issue addressing loss-of-control in flight.

Nicholas Worrell, Chief of the Safety Advocacy Division in the Office of Safety Blog Image 2.jpgRecommendations and Communications, urged attendees—most of whom were investigators—to go beyond investigations to see real improvements in safety. The work doesn’t end with the report findings issued after the investigation; the work to improve safety just begins, he said. African safety organizations need to develop advocacy efforts and strategies to ensure their safety recommendations are implemented. Nick encouraged the audience to look to some of Kenya’s most notable leaders, like Jomo Kenyatta, political activist and Kenya’s first president, and Wangari Maathai, Nobel Peace Prize winner, both of whom saw a need for and executed effective advocacy to improve laws, policies, and practices.

The goal of our visit to Kenya was to continue fostering the development of a safer aviation transportation system in East Africa. It is integral to our mission at the NTSB to share globally what we have learned from 51 years of safety investigations. As the NTSB team supporting the SSFA program has shown, improving transportation safety is a collaborative process that doesn’t end at our borders.

Working for Safety

By Robert L. Sumwalt, Chairman

 Labor Day and Memorial Day both have specific relevance that can be lost in seasonal associations. The meaning of Memorial Day as a time to honor those lost in our nation’s wars can be eclipsed by its unofficial role as the “kickoff day” for summer. Similarly, all too often, we think of Labor Day only as summer’s end rather than as a commemoration of the contributions of the nation’s working men and women.

This Labor Day, I’d like to take a moment to express my appreciation for the men and women who work every day in transportation, doing everything right so that there’s not an accident for the NTSB to investigate.

TranspWorker_ThankYou2

From owner-operators of long-haul trucks to employees of the biggest trucking companies; from captains of small fishing boats to employees of the biggest cruise lines and marine cargo companies; from air-tour operators to airline pilots and cabin crews; and throughout railroad and pipeline transportation, safe transportation depends on the dedication and hard work of the people on the front lines: individual transportation workers.

At the NTSB, we investigate what goes wrong in transportation. In each accident, we look at the human, the machine, and the environment. When we find a lapse in any of those areas, we look for ways to eliminate the opportunity for error. Meanwhile, day in and day out, good men and women go to work every day and do everything right. We don’t investigate the truck that stayed on the road because its conscientious drivers got plenty of sleep, or the ship that didn’t run aground because its captain and crew were well-trained and attentive. We’ll never hold a Board meeting to discuss one of the millions of safe airline flights every year, or to talk about the pipeline operators and railroad employees who found the safety defect among thousands of miles of rail or pipe before it caused an accident.

Although technology and design innovations have greatly improved transportation safety, we haven’t yet managed to eliminate everything that can go wrong in transportation. That’s why we depend so heavily on the nation’s transportation workers, who face rigorous rules and laws, to ensure safety. Commercial truckers and pilots log their rest and duty time to prevent fatigue. While the general driving public is subjected to a .08-percent blood alcohol content (BAC) legal limit, for commercial drivers, the limit is already .04 percent. And then there are all the safety procedures these professionals are required to know—and follow—throughout their commercial transportation careers.

The majority of our nation’s transportation professionals meet these high standards and are intent on preventing transportation tragedies. As Chairman of the NTSB and a member of the traveling public, I want to express my appreciation for all those transportation workers who are quietly doing things right, day in and day out.

Professor James Reason once said that safety professionals live with a “chronic unease.” Safety is a matter of constantly searching out the unassessed hazard, the unmitigated risk. Transportation operators at every level embrace this difficult challenge every day. On this Labor Day, I gratefully tip my hat to each one of you who takes safety seriously.

 

Two Years and Counting . . . Still no FAA Action

By Chairman Robert L. Sumwalt

Saturday, July 30, 2016.

The day started like most summer days in central Texas—hot and muggy, with the Lockhart Blog.jpgchance of foggy and cloudy conditions around daybreak. I can only imagine the feelings of excitement—perhaps even a few fleeting moments of apprehension—as the pilot and his 15 passengers climbed into the basket of the enormous hot air balloon. The large smiley face that adorned the side of the balloon was emblematic of what the day’s flight was supposed to be for these paying passengers, who were celebrating birthdays, anniversaries, and even, belatedly, Mother’s Day. Tragically, about 45 minutes after lifting off, the balloon careened into high-tension powerlines that crisscrossed the Texas countryside. The balloon plunged to the ground, claiming all 16 lives on board.

This was the deadliest balloon crash in U.S. history. Furthermore, it was the deadliest U.S. aviation accident in more than 7 years.

We determined the probable cause of the crash was “the pilot’s pattern of poor decision-making that led to the initial launch, continued flight in fog and above clouds, and descent near or through clouds that decreased the pilot’s ability to see and avoid obstacles.” Further, we pointed out that “contributing to the accident were (1) the pilot’s impairing medical conditions and medications and (2) the Federal Aviation Administration’s [FAA’s] policy to not require a medical certificate for commercial balloon pilots.”

Our investigation revealed that the pilot had several medical conditions that would have precluded his legal ability to operate any aircraft, including a balloon. He was also taking medications prohibited when piloting. He had been arrested on four occasions for driving under the influence. Any of these conditions or circumstances would have barred his ability to obtain an FAA medical certificate.

Lockhart Blog 2
Post accident photo of the basket

But, here’s the odd thing: unlike commercial airplane and helicopter air tour pilots, commercial air tour balloon pilots are not required to have an FAA medical certificate. Our accident investigation report made clear: “The [FAA’s] exemption of balloon pilots from medical certification requirements eliminated the potential for (1) an aviation medical examiner to identify the pilot’s potentially impairing medical conditions and medications and/or (2) FAA awareness of his history of drug-and alcohol-related offenses, which could have led to [his pilot certificate being revoked or suspended] until satisfactorily resolved.” To close this loophole, we recommended a logical solution—that the FAA begin requiring medical certificates for commercial balloon pilots (Safety Recommendation A-17-34). “Require Medical Fitness” has been a focus of our Most Wanted List of critical transportation safety improvements since 2015.

As we wrapped up the Board meeting we held to deliberate this tragedy, I expressed my optimism that “today’s recommendations, if acted upon, will help to bring the safety standards and oversight of commercial passenger balloon operations closer to those that apply to powered flight.”

Sadly, it appears that optimism was misplaced. Two years after the Lockhart tragedy, and nearly 10 months after we issued this recommendation, we still haven’t received any indication that the FAA plans to require commercial balloon pilots to hold valid medical certificates.

The FAA should act. The victims of this horrible accident and their families deserve nothing less, and future balloon passengers deserve better.

National Aviation Day

By Chairman Robert L. Sumwalt

Sunday, August 19 is National Aviation Day. It’s a day to celebrate more than a century of innovation and progress in aviation, certainly, but August 19 is also the birthday of a bicycle-maker—albeit one more famous for his contributions to aviation.

National Aviation Day.jpgAugust 19 was chosen to be National Aviation Day in honor of Orville Wright’s birthday while Wright was still alive to enjoy the honor. (Wilbur Wright had passed away in 1912, less than a decade after their landmark flight near Kitty Hawk, North Carolina.) There’s a lesson in how the Wright brothers came to play their pivotal role in the story of aviation, and it’s especially worth mentioning on this day.

Wilbur was an early adopter of what was called the “ordinary” bicycle—a contraption with a high front wheel and a seat many feet off the ground. There had been earlier bicycles without the high wheel, but also without gears; the high wheel was necessary to get better performance out of limited muscle power.

The “safety bicycle” added gears, enabling good performance without using a high front wheel. It had two advantages: a center of gravity that was lower and rear of the front axle, and a shorter distance for the rider to fall. The popularity of pedaling exploded, and the Wright brothers saw a niche. From their shop in Dayton, Ohio, they began repairing, then renting, selling, and manufacturing bicycles—and, of course, tinkering with improvements.

Meanwhile, both were drawn to news of attempts at powered flight. Unlike other aviation pioneers, however, Wilbur and Orville insisted on three-axis control, using wing warping (deforming the shape of the wing) to control roll. Some competitors didn’t believe that a pilot could respond quickly enough to mechanically control all the required surfaces, but Orville and Wilbur had tested their concepts thoroughly (another advantage over some competitors). Through glider testing, they learned that an airplane could be controlled on all three axes and, in the bicycle trade, the Wright brothers had learned firsthand how innovation and safety could go hand-in-hand, providing control even when a platform seemed unstable.

It is an understatement to say that aircraft design has continued to evolve. Wing warping to control roll has given way to ailerons (precursors to amazing potential new technology reminiscent of the Wright brothers’ approach). The elevator has migrated from the front of the airplane to the rear. Wood has given way to aircraft aluminum and composites. Sticks and pulleys have given way to fly-by-wire and automation. But the Wright brothers’ insistence on three-axis control remains a foundational principle in modern powered flight, whether in the airlines or in general aviation. Because Orville and Wilbur Wright dared to believe in full control of all three axes, an industry was born.

Today, certification rules have changed to make it easier than ever to install innovative technology to maintain control of an aircraft. Angle-of-attack indicators and envelope protection are available not only in airliners, but for general aviation craft, as well. However, loss of control in flight continues to be the leading cause of fatal general aviation crashes.

NTSB Most Wanted List of Transportation Safety Improvements 2017-2018
Prevent loss of control in flight in general aviation

Why not celebrate National Aviation Day by reading up on current and innovative training and technology solutions that could eliminate loss of control in flight? You may find yourself surprised by how far aviation has come since the Wright brothers, and by how far there remains to go.

NTSB Supports ‘Safe Skies for Africa’ Program

By Dennis Jones, NTSB Managing Director

Last week, as part of the U.S. Department of Transportation’s Safe Skies for Africa program, I led a team of NTSB investigators and communications specialists to South Africa to share lessons we’ve learned from our accident investigations. The Safe Skies for Africa program, created 20 years ago, aims to improve the safety and security of aviation on the continent. Our team shared some NTSB strategies with our international counterparts to help them achieve similar outcomes in their region.

1
Managing Director, Dennis Jones, talks with attendees at the Safe Skies Symposium in Johannesburg, SA

From my perspective, the Safe Skies program is working. After spending about 20 years in Africa participating in accident investigations, conducting workshops, helping improve accident investigation programs, and training investigators, I’ve seen increased commercial air service between the United States and Africa (for example, there are now US commercial flights to Africa, which wasn’t the case earlier in my career), improved investigation quality, and a reduced rate of accidents involving commercial aircraft.

On this trip, the NTSB team shared a variety of lessons learned from different disciplines. Dennis Hogenson, Western Pacific Region Deputy Regional Chief for Aviation Safety, pointed out that, like Africa, the United States is seeing a high incidence of general aviation (GA) crashes. He told his audience that, while airline accidents have become rare, GA accidents account for most aviation fatalities in the United States. We investigate about 1,500 GA accidents each year; those involving loss of control in flight still result in more than 100 fatalities annually. In many of our GA accident investigations, we’ve discovered that pilots didn’t have the adequate knowledge, skills, or recurrent training to fly safely, particularly in questionable weather conditions, and their inability to appropriately recover from stalls often resulted in deadly accidents. Dennis encouraged his African counterparts to initiate more training and increase awareness of technology, such as angle-of-attack indicators, that can help prevent these tragedies.

Bill Bramble, a human factors investigator, outlined our investigation process and explained how we examine all factors—machine, human, and environment—to understand an accident and make recommendations to prevent it from happening again. Bill highlighted several accidents we investigated in which human factors played a role. But even when a probable cause statement focuses on factors not normally associated with human performance, it’s impossible to totally remove humans from the accident chain.

“Humans designed it, built it, operated it, maintained it, managed it, and regulated it. Human factors are always involved in complex system failures,” Bramble said.

To prevent accidents and improve the safety of air travel in Africa, it’s important that operating aircraft are airworthy, meaning that all structure, systems, and engines are intact and maintained in accordance with the regulations. To emphasize this point, NTSB aerospace engineer, Clint Crookshanks presented a series of case studies discussing airworthiness issues and offered guidance on ways to classify damage to aircraft.

Chihoon “Chich” Shin, an NTSB aerospace engineer, addressed helicopter safety. The number of helicopter operations (emergency medical services, tourist, and law enforcement support) in Africa is increasing, and so is the number of helicopter accidents. Chich presented case studies and highlighted some important safety issues from an engineering perspective.

“The metal doesn’t lie,” Shin said. He called for increased awareness of the safety issues affecting helicopter safety and encouraged action from key stakeholders, such as regulatory agencies and helicopter manufacturers and operators, to help reduce accidents and fatalities. He also touted the importance of crash-resistant recording devices to help investigators determine what happened in a crash and work to prevent it from happening again.

NTSB communications staff emphasized another side of our work in transportation safety. Stephanie Matonek, a transportation disaster assistance specialist, discussed the importance of planning for family assistance after an accident occurs.

“Having a family assistance plan in place, identifying your family assistance partners, and addressing the fundamental concerns for families and survivors that cross all cultures is not only a crucial step but the right thing to do,” she said.

Nicholas Worrell, Chief of the Office of Safety Advocacy, addressed messaging, encouraging attendees to go beyond investigations to teach their safety lessons effectively. He encouraged investigators to raise awareness of the safety issues they uncover to spur action on their recommendations.

Aviation is a global business. Our mission is to make transportation safer the world over by conducting independent accident investigations and advocating for safety improvements. With outreach activities like the one we just completed in Africa, we hope to make aviation safer, not only in Africa, but throughout the world. After all, transportation safety is a global challenge. When safety wins, we all win.

dsc_8283.jpg
NTSB Managing Director and staff with symposium attendees

3D Modeling: A Valuable Investigative Tool

By Michael Bauer

On February 10, 2018, an air tour helicopter descended into a canyon wash and collided with terrain while on approach to land at Quartermaster landing zone in the Grand Canyon near Peach Springs, Arizona. As part of this ongoing investigation, NTSB engineers needed a three-dimensional (3D) digital model of the accident site and surrounding terrain to thoroughly understand the terrain features in the local area. Although the main effort involved the use of a FARO laser scanner to create the 3D model, the NTSB small unmanned aircraft systems (sUAS) team recognized an opportunity to exercise our sUAS imagery-collection capabilities using photogrammetry and sUAS in a challenging environment to support this investigation and allow for a comparison of the data gathered from the two techniques for future investigations.

Map1
Excerpt from Grand Canyon VFR Aeronautical Chart (FAA)

Since 2016, the NTSB has used sUASs, or drones, to create orthomosaic maps of wreckage sites and provide 3D digital models of terrain and vehicles for use by investigators in all transportation modes. Recently, we’ve launched the drone team to rail accidents (including the Hyndman, Pennsylvania, and Alexandria, Virginia derailments) highway crashes (including the Amtrak grade crossing collision with a refuse truck in Crozet, Virginia), and aviation accidents (including the crash of a cargo airplane in Charleston, West Virginia; the rejected takeoff and runway excursion at Willow Run Airport in Ypsilanti, Michigan; and multiple general aviation accidents at sites across the country). None of these missions, however, presented terrain challenges like those in the Grand Canyon.

Because the Grand Canyon is a combination of National Park Service and tribal lands, planning for the mission started weeks in advance. We needed to obtain permission from various tribal and governmental entities to operate a drone within that airspace and the special flight rules area (SFRA). The area is heavily used by numerous helicopter tour operators in the region, so planning involved coordinating with and notifying the various local operators of our intended sUAS mission. Without the support of the Federal Aviation Administration, the Hualapai Nation, the National Park Service, and Papillion Helicopters, this mission wouldn’t have left the ground.

After we received the appropriate approvals, we assembled in Boulder City, Nevada, to load a helicopter for the short trip into the canyon. Unlike other sUAS missions I’ve conducted, the remoteness of the canyon location introduced many challenges. For example, at the site, there were no electrical outlets or a generator, so we needed to plan the mission carefully in advance to ensure that it could be completed within the flight time enabled by the available batteries—recharging was not an option. Also, cellular coverage (including wifi) was nonexistent; thus, we had to access the Internet for the ground station software before departing for the canyon. In addition, when we use the sUAS to map an accident site, we use ground control points (GCPs) that we typically mark with paint. However, out of respect for the sacred land of the Hualapai Nation where the operation took place, we instead used lightweight, removable targets as GCPs. In total, I took 65 pounds of gear into the canyon to support the sUAS operation.

 

This slideshow requires JavaScript.

We conducted the sUAS flight early in the morning in light wind conditions suitable for drone flying and low temperatures, which was welcome compared to the triple-digit temperatures expected later in the day. We conducted our flights concurrent with the laser‑scanning effort in the canyon wash. As remote pilot in command (RPIC), I arranged for our helicopter pilot to work with me as the visual observer (VO) for the mission. The VO monitored the local traffic frequency for inbound and outbound traffic and relayed information back to me. During a few flights, I paused the mission to land the drone to ensure safe separation from tour helicopters. We accomplished the mission in just over an hour of sUAS flying time, which included a 12-minute, 10-acre mapping mission. The effort provided a detailed 3D model of the canyon wash for the engineers and stunning visual imagery of the local terrain area. The data are currently being analyzed by investigative staff.

Figure 3
NTSB sUAS flying in the Grand Canyon

Through this investigation and others, we’ve found that the ability to create 3D models of accident scenes is a valuable tool in the investigator’s tool box. Moreover, the ability of the sUAS to provide the imagery needed for these models in unique, complex environments in a short time and with low acquisition cost will aid our investigators for years to come. The NTSB sUAS team continues to explore the possibilities of sUAS imagery collection within the envelope of safe drone operations to further understand the capabilities and limitations of the technologies as they relate to the agency’s mission.

Michael Bauer is an aerospace engineering investigator in the NTSB Office of Aviation Safety.

Part 135 Flight Data Monitoring: The Best Way to Ensure Pilots Fly Safely

By John DeLisi, Director, Office of Aviation Safety

 

On November 10, 2015, a Hawker 700A operating as a Part 135 charter flight crashed on approach to Akron Fulton International Airport in Akron, Ohio. The crash killed 9 people. During our investigation, we learned that the first officer was flying the airplane, although it was company practice for the captain to fly charter flights. We also discovered that the crew did not complete the approach briefing or make the many callouts required during approach. Additionally, the flight crew did not configure the airplane properly, the approach was unstabilized, and the flight descended below the minimum descent altitude without the runway in sight.

Akron, Ohio
NTSB investigators at the scene of the crash of a Hawker 125-700 into an apartment building in Akron, Ohio

How could this happen? Wasn’t the flight crew trained to follow standard operating procedures (SOPs)? (Yes, they were.) Didn’t they know when to lower the flaps? (Yes, they did.) Yet, weren’t they flying the airplane contrary to the way they were trained? (Yes, they were.)

The crew ignored, forgot, or improvised their company’s SOPs and the airplane’s flight manual information. Even more disconcerting was that, upon our review of the cockpit voice recorder (CVR), it appeared that this type of haphazard approach was fairly routine for them. How could that be?

The NTSB investigators discovered that no one at the company was monitoring—or had ever monitored—the way this crew flew the airplane. Because the airplane was not equipped with a flight data recorder, a quick access recorder, or any type of data monitoring device, the operator had no insight into what was happening inside the cockpit or how this crew was flying its airplane. The fact was that this crew was able to fly an airplane carrying passengers in an unsafe, noncompliant manner, which ultimately led to tragic consequences. If the operator had better insight into the behavior of its flight crew and had taken the appropriate actions, this accident may have been prevented.

That is a lesson learned the hard way—and we have seen similar such situations in several accidents the NTSB has investigated in recent years.

It’s time to be proactive about aviation safety and accident prevention! The NTSB believes flight data monitoring (FDM) programs for Part 135 operators—which includes charter flights, air tours, air ambulance flights, and cargo flights—is one answer to this problem.

An FDM program can help an operator identify issues with pilot performance, such as noncompliance with SOPs, and can lead to mitigations that will prevent future accidents. Too many Part 135 operations occur in which the operator has no means to determine if the flight was being flown safely. An FDM program can help companies identify deficiencies early on and address patterns of nonstandard crew performance. Most importantly, with an FDM program, pilots will know that their performance is being monitored. As a result of the Akron investigation, the NTSB recommended that the Federal Aviation Administration (FAA) require all Part 135 operators to install flight data recording devices. But it’s not enough to just capture the data; we also recommend that operators establish an FDM program to use the data to correct unsafe practices. The FAA has yet to act.

But some Part 135 flight operators aren’t waiting for FAA mandates; they have already made the investment in such a proactive safety program—and with great success. One operator I read about started an FDM program recently and is having success using the data in a nonpunitive fashion to monitor approaches. With this critical data at its fingertips, the operator is attempting to identify instances of incorrect aircraft configuration or exceedances of stabilized approach parameters. Designated line pilots assess the data captured in the FDM program to determine if further follow up is needed.

Another Part 135 operator involved in an accident near Togiak, Alaska, investigated by the NTSB recently made the commitment to equip every airplane in its fleet with a flight data recorder. The operator told us the data will “further enable [the company] to review compliance with company procedures through data analysis, similar to a Part 121 operation.”

Togniak, AK
NTSB Member Earl F. Weener (center), Director of the Office of Aviation Safety, John DeLisi (right) and Loren Groff (left), Senior Research Analyst in the NTSB’s Office of Research and Engineering served as the board of inquiry for an investigative hearing held in Anchorage as part of the ongoing investigation of the crash of flight 3153 near Togiak, Alaska

Kudos to both these operators for learning from past lessons and committing to a culture of safety.

Last year, a Learjet that was being repositioned following a charter flight crashed on approach to an airport in Teterboro, New Jersey. Both crewmembers died. While the final NTSB report on this accident has not yet been released, our analysis of the CVR revealed that the first officer, who was not permitted by the company to fly the airplane, was, in fact, flying the airplane. During this flight, the captain was attempting to coach the first officer. The first officer flew a circling approach; however, when the airplane was one mile from the runway, the circling maneuver had not yet begun. The first officer gave the controls to the captain, who proceeded to bank the airplane so steeply that the tower controller said the wings were “almost perpendicular to the ground” just prior to impact.

It comes as no surprise that the performance of this flight crew was not being monitored by any FDM program.

Isn’t it time to make passenger-flying operations safer? We see this type of program on major commercial Part 121 airlines, so why not on Part 135 aircraft? After all, flight data monitoring is the best way to ensure pilots are flying safely and passengers reach their destinations.