Category Archives: Aviation Safety

A Call to Action from Kennedy

By Chair Jennifer Homendy

This week, I visited NASA, Boeing, Blue Origin, and Space-X at Kennedy Space Center (KSC) in Florida. KSC has been a leader in space exploration for over 50 years. The Apollo, Skylab, and Space Shuttle programs took off from there, as did the Hubble Space Telescope, the Mars Rover project, and New Horizons, the first spacecraft to visit Pluto.

To visit Launch Complex 39A and stand where the Apollo and Space Shuttle astronauts once stood before they launched into space was humbling, and as I watched Space-X’s Transporter-5 launch and land from the balcony of Operation Support Building 2 and the return of Boeing’s Starliner Spacecraft virtually, I was reminded of how important it is that we learn from the past as we advance into our future.

Exactly sixty-one years earlier, to the day, on May 25, 1961, President Kennedy addressed a joint session of Congress and laid out a truly ambitious goal: landing a man on the Moon. Not just landing a man on the Moon but returning him safely to Earth. He called for national leadership and implored Congress and the country to take a firm and sustained commitment to a new course of action, “a clearly leading role in space achievement, which in many ways may hold the key to our future on earth.” And he demanded that the whole of government, working together as one, dedicate themselves to jumpstarting a future he knew was in the best interests of our country.

The vision that President Kennedy laid out 61 years ago continues to shape our nation and the world. Today, NASA is developing its deep space rocket, the most powerful rocket it has ever built, the Space Launch System (SLS), while commercial space companies transport cargo for the federal government and private businesses to space as well as to the International Space Station (ISS). These companies have also begun transporting passengers.

Commercial spaceflight is a rapidly evolving industry and shows tremendous promise. Over the last decade, Federal Aviation Administration (FAA)-licensed commercial launches and re-entries have grown tremendously, from 1 licensed launch and 0 licensed re-entries in 2011 to 54 licensed launches and 6 licensed re-entries in 2021. The federal government needs to be prepared for these exciting technological advances. For NTSB, that means ensuring we remain ready if an accident occurs. If the past has taught us anything, it’s not a matter of “if” an accident will occur, it’s a matter of when.

The NTSB has investigated accidents involving space vehicles for over 30 years. In 1986, we participated in the investigation in the Space Shuttle Challenger disaster; in 1993, we investigated the Orbital Sciences Pegasus accident; we again participated when the Space Shuttle Columbia disintegrated on reentry and 7 astronauts died, in 2003; and in 2004, we assisted NASA with the Genesis Sample-Return Capsule crash investigation. More recently, in 2014, we investigated the in-flight explosion of SpaceShip Two.

All this is to say, we aren’t new to commercial space. The fact is NTSB is world renowned for its reputation as the “gold standard” for thorough, fact-based, independent investigations of accidents in all modes of transportation, whether those accidents occur on our roads, railways, waterways, or in our skies. We have been at the forefront of safety and the advancement of new technologies and new ways of moving people and goods for decades. We’re used to new challenges, and we’re ready for them.

The key to our success is our independence. That independence is what sets us apart. We aren’t tasked with exploring space; that’s NASA’s mission. We aren’t tasked with promoting, licensing, or regulating the safety of the commercial space industry; that’s the job of the FAA. Our entire mission is focused on determining what happened when a tragedy occurs, why it happened, and issuing safety recommendations aimed at preventing it from happening again. In other words, our one and only goal is to save lives and prevent the reoccurrence of terrible tragedies.

These past few months, I’ve spent time with our safety partners at FAA and NASA in hopes of ensuring we’re all prepared should tragedy occur. I’ve done this because I believe that the disparate arms of the federal government must work together to ensure the safety and success of this burgeoning industry. The commercial space industry is American innovation at its finest. As a government, we don’t want to get in the way of awe-inspiring technological innovations we once thought unimaginable, but we want to provide guardrails and cooperation, guidance and protection of the public, and we all need to work together as one to make that happen.

Sixty-one years ago, President Kennedy called on us to work together for the best interests of our country. The need for all of us to work together resonates as much today. I call on our safety partners at NASA, at FAA, at the Departments of Commerce and Defense to work with us and the stakeholders who I visited this week, among others, to ensure that safety remains a top priority alongside commercial space innovation.

Improving Safety in the Second-Largest Continent

By Nicholas Worrell, Chief, NTSB Safety Advocacy Division

In August, 2019, I wrote that Safe Skies for Africa was ending, but that the safety journey would go on in Africa, the world’s second-largest and second-most-populous continent. Earlier this month, it was my pleasure to represent the NTSB in a presentation about best practices in safety advocacy at the Civil Aviation Operational Safety Workshop in Cape Verde.

The occasion was Aviation Safety Week, which gathered together transportation safety leaders from seven African nations, the EU, and the United States to share safety knowledge. Attendees were interested to learn from my presentation that in the United States, the accident investigator—the NTSB—has no power whatsoever to require change.

Enter Advocacy.

It’s been said that information + persuasion = advocacy. The idea is never to misrepresent; rather, it is to present information that makes the case most compellingly. If the case is compelling enough, your advocacy might inspire people to act. Then, they might influence others to act as well, creating a critical force multiplier. I spoke to my audience about advocacy methodology, messaging, and tools, and the absolute need for collaboration, working with and through others. I reminded my audience, though, that advocacy differs with the context and the organization. At the NTSB, for example, it’s the one way we can bring about change and encourage implementation of our recommendations. However, I urged safety leaders in Africa to be mindful that all advocacy is local. What might work in the United States might not necessarily work for all of Africa.

Ultimately, wherever it is done, advocacy done right moves the needle toward saving lives. As transportation safety leaders, I told my audience, we must communicate our work to gain the desired impact and outcomes. We must be proactive and go to our audience, not sit back waiting for them to come to us.

It was an honor addressing these passionate transportation safety leaders from the African region. We should always remember that our transportation safety work crosses air, land, and sea. When we share our lessons learned and best practices, and when others share theirs with us, we may save lives not just nationally, but globally, as well.

The 2021-2022 MWL After One Year: Noticeable Progress But Few Closed Recommendations

By Kathryn Catania, Acting Director, NTSB Office of Safety Recommendations and Communications

Since the unveiling a year ago of the 2021-2022 cycle of the NTSB’s Most Wanted List of Transportation Safety Improvements, we have seen increased awareness and discussion of safety items, high levels of engagement from the public, and incremental progress toward implementation of many recommendations.

In the past year, the NTSB has already successfully closed eight safety recommendations associated with this MWL cycle. But that is not enough. There are 167 other key recommendations that, if implemented, would save lives, and prevent injuries.

Soon after the unveiling of the MWL last year, NTSB Board members and staff sprang into action to educate, engage, and amplify the critical safety messages of our 10 safety improvements. Here’s a quick look by mode, starting with Highway, which makes up 5 of our 10 safety improvements. 

Highway

In recent years, we have increasingly expressed our highway safety goals in the language of the Safe System Approach—the very approach that we use in our own safety investigations. (We first discussed the approach in our 2017 report on reducing speeding.)

The Safe System Approach views every aspect of the crash as an opportunity to interrupt the series of events leading to it, and an opportunity to mitigate the harm that the crash does. People make mistakes, but safe roads, safe vehicles, safe road users, safe speeds, and post-crash care can combine to prevent the crash entirely, or failing that, to prevent the deaths or serious injuries of road users.

This paradigm shift applies to each of the highway safety improvements on the MWL, and is mentioned by name in “Protect Vulnerable Road Users Through a Safe System Approach,”

Between May 2021 and February 2022, we produced seven virtual roundtables to explain the approach and call for its adoption.  National and international experts discussed the approach and shared their successes and challenges. More than 1,000 advocates, regulators, academics, and others attended our webinars.

Included in the series hosted by Chair Homendy was a Safe Speeds Roundtable that explored the “Implement a Comprehensive Strategy to Eliminate Speeding-Related Crashes” safety improvement. Additionally, a “Behind the Scene @NTSB” podcast featured discussion on speeding and vulnerable road users.

In 2021, the Department of Transportation and Congress incorporated the approach into the DOT’s National Roadway Safety Strategy and the Infrastructure Investment and Jobs Act, respectively.

Will the new model result in lifesaving protections? Only final, and positive, closure of our recommendations will answer that. But the signs are very good, with the alignment of Congress, the DOT, and the road safety community.

Our MWL safety improvement, “Require Collision-Avoidance and Connected-Vehicle Technologies on all Vehicles,” could result in far superior situational awareness on our roads… if sufficient spectrum is available for the safety improvement.

Vehicle to everything (V2X) technology can save lives but has been delayed, and might be reduced or stopped, due to FCC rulings limiting the spectrum for safety operations. We released a four-part video series in which Member Graham interviewed some of the leading experts in V2X technologies—including academics, researchers, automakers, and policymakers—to discuss what can be done to find a way forward to deployment. 

In progress toward Eliminating Distracted Driving,  Vice Chairman Landsberg and staff joined government officials, industry, academia, insurers, and transportation safety advocates to announce the launch of a new National Distracted Driving Coalition. This is the first such broad national coalition on distracted driving.

We kept working with states considering lowering their BAC limit from .08 to .05 or lower, to help Prevent Alcohol- and Other Drug-Impairment. The National Highway Traffic Safety Administration (NHTSA) has now evaluated the results from Utah, which has made the change to .05. Not surprisingly, the lower threshold prevented drinking and driving and saved lives. NHTSA’s study showed that the state’s fatal crash rate dropped by 19.8% in 2019, the first year under the lower legal limit, and the fatality rate decreased by 18.3%.

Aviation

To highlight our two aviation MWL safety items, “Require and Verify the Effectiveness of Safety Management Systems in all Revenue Passenger-Carrying Aviation Operations” and “​Install Crash-Resistant Recorders and Establish Flight Data Monitoring Programs,” we met with operators and pilots from the Helicopter Association International, General Aviation Manufacturers Association, and National Business Aviation Association, among others. In webinars, podcasts, and at in-person national conferences, Board members talked with Part 135 and Part 91 operators and pilots to identify challenges. Our outreach meetings alone reached more than 1,500 operators nationwide.

Marine

With an increasing number of deadly fishing vessel accidents in recent years, Office of Marine Safety Director Morgan Turrell and Chair Homendy hosted a virtual roundtable on improving fishing vessel safety that was viewed by over 1,000 people. Panelists discussed what can be done to address commercial fishing safety, implement NTSB safety recommendations, and improve the safety of fishing operations in the United States.

Pipeline and Hazardous Materials

Our MWL calls for pipeline and hazardous materials (hazmat) stakeholders to “Improve Pipeline Leak Detection and Mitigation” by equipping all pipeline systems with leak-detection systems and automatic shutoff or remote-control valves. These valves allow for quick detection and mitigation.

Additionally, we produced a video featuring Member Michael Graham and Hazardous Materials Investigator Rachael Gunaratnam, which explores cases in which odorants failed as a natural gas leak-detection strategy, and promotes both required natural gas leak detectors, and voluntary adoption of such detectors until they are required.

Rail

To highlight the dangers to rail roadway workers and to help Improve Rail Worker Safety, Member Tom Chapman wrote a blog on rail worker safety, discussing how the railroad regulators—the Federal Railroad Administration (FRA), the Federal Transit Administration (FTA), and the Pipeline and Hazardous Material Safety Administration (PHMSA)— are in the best position to make change.

We also completed our investigation of the April 24, 2018, accident in which an Amtrak rail watchman was killed in Bowie, Maryland. As a result of this investigation, we called on the FRA and Amtrak to put an immediate end to the use of train approach warning (TAW) systems as the sole method of on-track safety in areas covered by positive train control.

To mark the anniversary of the January 2017 train collision in Edgemont, South Dakota, we also issued a media statement again urging railroads to act to better protect rail roadway workers.

Looking ahead

We are pleased by the engagement of so many of our safety advocacy partners, industry groups, and associations in the past year, to promote our recommendations and highlight transportation safety concerns. Also, we acknowledge that many industry groups and operators are making voluntary efforts to improve safety, including on some of our recommendations. However, without mandates, many others may not act.

We remain disappointed by the lack of movement by regulators to implement the safety recommendations associated with our MWL. While there has been some progress during this first year, much more needs to be done to implement the 167 remaining safety recommendations associated with the current list. The longer these authorities wait to implement our recommendations, the greater the risk to the traveling public. Safety delayed is safety denied.

The NTSB will not stand by quietly and watch as regulators, industry, and other recommendation recipients ignore and dismiss our safety recommendations—and neither should the public. As NTSB Chair Homendy expressed in recent remarks to the largest highway safety gathering in the U.S, “The horrific toll of people who’ve died on our roads and their families… millions of people who were injured… are counting on us to “fight like hell” for the next family. To give a voice to those who no longer have one.” 

All our lives are on the line, and no death in transportation is acceptable. It is our mission to advocate for the changes outlined in our safety recommendations which, if implemented, will save lives.

Safety is a shared responsibility. We all play a role in getting us to zero transportation deaths. The NTSB cannot do this alone. We need each of you, individually and collectively, to help us advocate for these critical safety improvements.

BEFORE LANDING CHECKLIST to Pilot: “Remember me?”

By Leah Read, NTSB Senior Air Safety Investigator

“N555$$, call the tower.  N555$$ call the tower…your gear isn’t down!”

As a newly minted certified flight instructor (CFI) in the early 90s, I loved reading the latest addition of Flight Training magazine. I’ll never forget reading a funny quip about a pilot who was on final approach to land at a controlled airport and forgot to extend his landing gear. The control tower tried to contact the pilot numerous times to warn him, but he never responded and landed gear up. Once the pilot realized what happened and came to a stop on the runway, he called the tower and learned that the tower had tried to contact him several times. The pilot responded, “Sorry, I didn’t hear you because there was a horn going off in the cockpit!” To this day, whenever I fly a retractable gear airplane, I always think of that story. I’ve only had one gear-up landing in my 33 years of flying, and that was due to mechanical failure that prevented the gear from extending. I can say from experience: landing gear‑up involves a lot of loud scraping noises, a shortened roll out, and an even shorter step out of the airplane.

As part of my duties as a regional NTSB investigator, I take “phone duty” for the entire eastern region of the Unites States during on-call periods. As the duty officer, I receive all the incident and accident notifications from the Federal Aviation Administration (FAA) or directly from pilots, and I’m surprised by the amount of gear-up landings we process. Now, some of these are due to mechanical issues like I experienced, but most of them are due to pilots (who admit) they either got complacent or distracted (or both!) and simply forgot to extend the gear.

Photo of King Air taken by SRQ Airport Operations

Gear-up landings usually don’t result in serious injuries to pilots and passengers, but they are a big ego buster. They also cost a lot of money in unnecessary damage to the airplane’s propellers, engines, structure, antennae, and skin. Often a mechanic needs to be hired to remove skin so the damage can be better evaluated. More money! And, if the damage is substantial, you’ll also be dealing with an “accident” as defined by 49 Code of Federal Regulations 830.2, and you’ll not only be getting a call from your local FAA inspector, but also from your friendly NTSB investigator. Nobody has time for that!

So, how do you make sure you never forget to put your gear down?

  1. Use your BEFORE LANDING checklist—it’s there for a reason!
  2. Repeat your GUMPS check (gas, undercarriage, mixture, propeller, seat belts and switches) OUT LOUD several times before you land.
  3. Visually (if possible) confirm the gear is extended.
  4. Stay ALERT and FOCUSED on flying (configuring) the airplane in the traffic pattern. AVOID unnecessary conversation and MAINTAIN situational awareness. Traffic patterns can get hectic, and things can happen fast.
  5. Do some online research for articles about avoiding gear-up landings. There are some good articles and case studies out there written by CFIs and highly experienced pilots.

And remember: keep the rubber side down!

Happy flying!

February 20: International Day Commemorating Air Crash Victims and Families

By Elias Kontanis, Chief, NTSB Transportation Disaster Assistance Division

This year, the International Civil Aviation Organization (ICAO) designated February 20 the International Day Commemorating Air Crash Victims and Families. Although ICAO has addressed various aspects of family assistance for decades, this is the first time a day has been set aside to remember and honor all who lost their lives in air disasters and their families.

ICAO’s interest in family assistance dates to 1976, with the inclusion of a recommended practice in Annex 13, the document that outlines standards and recommended practices for accident investigations. The following is a brief timeline of significant ICAO activities related to family assistance.

  • 1976: Contracting States (that is, countries) whose citizens are involved in a crash are granted access to information about the crash investigation and play a direct role in identifying their citizens. This recommended practice was strengthened to a standard in 2001.
  • 1998: The ICAO Assembly acknowledges that “the policy of the ICAO should be to ensure that the mental, physical and spiritual well-being of victims involved in civil aviation accidents and their families are considered and accommodated by ICAO and its Contracting States.”[1]
  • 2001: In response to Assembly Resolution A32-7, ICAO issues Circ 285, “Guidance on Assistance to Aircraft Accident Victims and their Families,” a keystone document for countries interested in developing family assistance programs. Circ 285 provides guidance on the various aspects of a comprehensive family assistance operation.
  • 2005: Provisions are included in Annex 9, “Facilitation,” to enable victims’ family members to expeditiously enter the State in which the accident occurred. Additional provisions address repatriation of remains and emergency travel documents for family members and accident survivors.
  • 2013: ICAO issues Doc 9998, “ICAO Policy on Assistance to Aircraft Accident Victims and Their Families,” and Doc 9973, “Manual on Assistance to Aircraft Accident Victims and Their Families.”
  • 2015: Annex 9 is further amended with Recommended Practice 8.46, which encourages Contracting States to establish legislation, regulations, and/or policies in support of assistance to aircraft accident victims and their families.
  • 2021: ICAO convenes its first International Symposium on Assistance to Aircraft Accident Victims and Their Families. This 3-day event, hosted by the governments of Spain and the Canary Islands, provides an opportunity for participants to share best practices and lessons learned to support the development of family assistance programs. NTSB Chair Jennifer Homendy and I were honored to participate as guest speakers at this important event.
  • 2021: ICAO’s Global Aviation Training Section begins developing a 3-day course designed to provide Contracting States, as well as aircraft and airport operators, the foundational knowledge to develop family assistance plans. The NTSB is a proud partner in this effort.
  • 2021: ICAO proposes elevating Recommended Practice 8.46 to a standard and developing a new recommended practice encouraging aircraft and airport operators to develop family assistance plans. Again, the United States stands with a significant number of other States in support of this initiative.

Through the Aviation Disaster Family Assistance Act of 1996, the United States committed to addressing the needs of passengers’ families following an aviation disaster. This commitment continues to grow. Today, the NTSB is the lead federal agency responsible for coordinating federal resources to support the families of air crash victims, as well as the victims of any other transportation disaster the NTSB investigates.

As family assistance specialists, my team and I work every day with the families of those lost in transportation crashes, trying to shed what light we can during some of their darkest days. We provide information during a time of uncertainty, address questions, and facilitate access to services that help loved ones navigate the loss they have suffered.

We have this charge in common with family assistance specialists all around the world, and we work collaboratively with international colleagues to enhance family assistance programs worldwide. We offer representatives of ICAO Contracting States seats in our family assistance course to help them develop or enhance their family assistance programs. We deliver presentations and participate in discussion panels overseas on family assistance, and we assist ICAO in developing its 3-day family assistance course.

Over the decades, the strength of survivors and victims’ families has humbled us. We have seen them organize not only to support each other through the grieving process, but also to advocate for change to enhance transportation safety so that others never have to face the same kind of loss.

We at the NTSB stand alongside our international colleagues in honoring the International Day Commemorating Air Crash Victims and Families. No traveler likes to ponder the possibility, however remote, that a flight will crash. But, if the unthinkable happens, the NTSB and our counterparts around the globe are dedicated to supporting crash survivors and family members.


[1] International Civil Aviation Organization. Assembly Resolution A32-7. Resolutions Adopted at the 32nd Session of the Assembly. Montreal, Quebec; Sept. 22–Oct. 2, 1998.