Category Archives: Aviation Safety

A New Year’s Resolution We All Can Make: Prioritize Safety

By Nicholas Worrell, Chief, NTSB Safety Advocacy Division

As 2021 ends, it’s time to reflect on the past 12 months and begin to set goals for the year ahead. After all, as Zig Ziglar once said, “if you aim at nothing, you will hit it every time.” So, let us all aim to improve the safety of our transportation system in 2022.

The NTSB recognizes the need for improvements in all modes of transportation–on the roads, rails, waterways, pipelines, and in the sky. Our 2021–2022 NTSB Most Wanted List of Transportation Safety Improvements (MWL), released in April this year, highlights the transportation safety improvements we believe are needed now to prevent accidents and crashes, reduce injuries, and save lives. We use the list to focus our advocacy efforts and to serve as an important call to action. We ask lawmakers, industry, advocacy, community organizations, and the traveling public to act and champion safety.

As a fellow safety advocate, I ask you to join me in a New Year’s resolution: I pledge to do my part to make transportation safer for all.

To help you take steps to accomplish this resolution, our MWL outlines actions you can take to make transportation safer:

  1. Require and Verify the Effectiveness of Safety Management Systems in all Revenue Passenger-Carrying Aviation Operations
  1. Install Crash-Resistant Recorders and Establish Flight Data Monitoring Programs
  1. Implement a Comprehensive Strategy to Eliminate Speeding-Related Crashes
  1. Protect Vulnerable Road Users through a Safe System Approach 
  1. Prevent Alcohol- and Other Drug-Impaired Driving
  1. Require Collision-Avoidance and Connected-Vehicle Technologies on all Vehicles
  1. Eliminate Distracted Driving
  1. Improve Passenger and Fishing Vessel Safety
  1. Improve Pipeline Leak Detection and Mitigation
  1. Improve Rail Worker Safety

Achieving these improvements is possible; otherwise, they wouldn’t be on our list. The NTSB MWL includes tangible changes and solutions that will, undoubtedly, save lives. But it’s only words on a list if no action is taken. Unlike Times Square on New Year’s Eve, we cannot drop the ball on improvements to transportation safety. The clock is ticking, and the countdown has begun—we can’t afford to waste any more time. Make the resolution to do your part to make transportation safer for all!

In closing, I’d like to thank the transportation safety stakeholders, industry, lawmakers, and advocates we have worked with in 2021 and we look forward to working together in 2022 and beyond.

Paying Passengers Deserve Safety on All Flights

By Member Michael Graham

In 2015, the Federal Aviation Administration (FAA) required commercial airlines to develop a comprehensive safety management system (SMS) to improve safety for the flying public. An SMS is an organization-wide system that ensures operators are properly identifying, assessing, and mitigating the conditions that exist for an accident to occur.

The FAA, however, has not required the same for revenue passenger-carrying operations under Title 14 Code of Federal Regulations Parts 91 and 135, leaving passengers on these flights at unnecessary risk. Similar to passengers of commercial airlines, those passengers who pay for a charter flight, skydiving experience, or hot air balloon ride exercise no control and bear no responsibility over the airworthiness or operation of which they are being flown. Therefore, paying passengers of Part 91 and Part 135 flights deserve a similar level of safety as those who fly on a commercial airline. That is why Require and Verify the Effectiveness of Safety Management Systems in all Revenue Passenger-Carrying Aviation Operations is on the NTSB’s 2021–2022 Most Wanted List of Transportation Safety Improvements.

The Problem

Togiak, AK – Separated section of empennage with vertical and horizontal stabilizers and rudder attached.

Since the airlines were required to develop an SMS in 2015, the NTSB continues to investigate Part 91 and Part 135 accidents that could have been prevented by an effective SMS—all involving paying passengers—including the following:

  • On October 2, 2016, Ravn Connect flight 3153, a turbine-powered Cessna 208B Grand Caravan airplane operated under Part 135, collided with steep, mountainous terrain northwest of Togiak Airport in Alaska, killing both commercial pilots and their passenger. The operator did not have an SMS, and we found that after experiencing two previous controlled flight into terrain (CFIT) accidents in the preceding three years the company had missed opportunities to adequately assess this CFIT-related risks and implement more effective strategies for preventing such accidents.
  • On May 15, 2017, a Learjet 35A departed controlled flight while on a circling approach to runway 1 at Teterboro Airport in New Jersey, and impacted a commercial building and parking lot. The pilot-in-command (PIC) and the second-in-command (SIC) died. The operator lacked both an SMS and a flight data monitoring program, and the company did not identify or mitigate hazards that contributed to this accident, including the pairing of pilots who had exhibited difficulties in training, the informal practice of some captains who allowed unapproved copilots to serve as pilot flying, and other patterns of flight crew procedural noncompliance.
  • On March 11, 2018, an Airbus Helicopters AS350 B2 lost engine power during an aerial photography flight and ditched on the East River in New York City. The pilot sustained minor injuries and his five passengers drowned. Again, the operator lacked an SMS and, although the operator’s employees were aware of the potential hazards that led to the accident, the operator did not have a robust safety program that could adequately prioritize and address hazards that played a role in this accident, including the potential for entanglement of a passenger harness/tether system with floor-mounted engine controls, the inability of passengers to evacuate without assistance, and the possibility the emergency flotation system might only partially inflate due to difficulties with the float activation mechanism.
  • On June 21, 2019, a Beech King Air 65-A90 airplane, N256TA, impacted terrain after takeoff from Dillingham Airfield, Mokuleia, Hawaii. The pilot and 10 passengers were fatally injured, and the airplane was destroyed by impact forces and a postcrash fire. In this accident, the operator failed to address numerous safety issues that a formal SMS would likely have identified as significant risks and prevented the accident. These included allowing passengers to be transported in a poorly maintained airplane, not implementing any standard operating procedures (SOPs) or written guidance for the company’s parachute operations, providing no structured initial or recurrent training for company pilots, using flawed methods in calculating the weight and balance of its flights, and allowing its pilot to routinely violate numerous Federal Aviation Regulations. In April 2021, the NTSB issued Safety Recommendation A-21-13, which asked the FAA to require SMS for the revenue passenger-carrying operations discussed in the Part 91 aviation investigation report; these operations included parachute jump flights.

These accidents seemingly had little in common, yet, in each case, an effective SMS might have helped the operator identify hazards or better mitigate those that were already known.

An Effective SMS

Any operator can print out the four pillars of an SMS, put up a poster, and add an anonymous comment box to the breakroom. However, implementing an effective SMS that changes safety behavior in an organization is not a box-checking exercise. An effective SMS is a management system that brings safety conscious behaviors to the forefront of an organization, which aids in identifying and mitigating risks inherent in flight operations and other activities. Every day, every task.

An effective SMS must fully address the following four pillars:

  • Safety policy
    • Sets objectives, assigns responsibilities, and develops standards
    • Clearly defines roles and responsibilities
    • Engages accountable executive
  • Safety risk management
    • Systematic processes for identifying hazards and mitigating risks
  • Safety assurance
    • Monitors, measures, audits, and assesses the performance of SMS
  • Safety promotion
    • Ensures a positive and just safety culture
    • Circulates and incorporates safety lessons
    • Advocates, communicates, and trains the principles of SMS

By establishing an effective SMS and creating a safety culture that fosters the free flow of safety-related information and organizational learning about the nature of operational risks, operators will reduce the likelihood of an accident and improve the safety of their flight operations.

What Can Be Done

Oversight is necessary to ensure operators adhere to the principles and processes of an effective SMS to provide sufficient safety to paying passengers. The NTSB has investigated numerous accidents involving operators whose deficient SMS failed to identify and mitigate the conditions that contributed to the accident. Therefore, the NTSB calls on the FAA to require SMS for all revenue passenger-carrying Part 91 and Part 135 operations and provide ongoing oversight.

To operators, the NTSB’s investigations repeatedly demonstrate that an effective SMS could have identified the hazards and mitigated the risks that led to the accidents. Do not wait for an accident to occur or a FAA mandate to invest in the safety of your passengers, pilots, and other personnel, voluntarily implement an effective SMS today.

Accident or Incident? Explaining Aircraft Damage Assessment

By Mike Hodges, Air Safety Investigator, and Clint Crookshanks, Aerospace Engineer (Structures)

When an aircraft crashes, National Transportation Safety Board (NTSB) air safety investigators and aerospace engineers must determine if the event can be classified as an accident or an incident, as defined by Title 49 Code of Federal Regulations (CFR) Part 830.

An accident is:

“…an occurrence associated with the operation of an aircraft which takes place between the time any person boards the aircraft with the intention of flight and all such persons have disembarked, and in which any person suffers death or serious injury, or in which the aircraft receives substantial damage.”

An incident is:

“…an occurrence other than an accident, associated with the operation of an aircraft, which affects or could affect the safety of operations.”

Although the determination of an accident focuses on damage as well as injuries, here we will focus on damage assessment.

So, when assessing the damage, how do we decide what’s an accident and what’s an incident? When we’re first notified about an adverse aircraft event, we begin to assess the aircraft damage. NTSB investigators and engineers attempt to obtain as much information as possible about the damage. Sometimes we’re given information that makes it obvious the aircraft sustained substantial damage, such as the photos showing the extent of the damage (see Figures 1–3). Figures 1-3 show the substantial damage as indicated by the arrows.

Figure 1. A Cessna 170 airplane sustained substantial damage to the left wing, due to ground impact after an aerodynamic stall on takeoff in Arctic Village, Alaska.
Figure 2. An Enstrom F280-F helicopter sustained substantial damage to the tail boom, during a practice run-on landing in Sodus, New York.
Figure 3. A Piper PA-24-250 airplane sustained substantial damage to the left wing, after impacting a light pole during an instrument approach in Sturgis, South Dakota.

Other times, we can’t tell the extent of damage right away and we need to dig deeper. Figures 4- 6 illustrate this scenario and show the substantial damage as indicated by the arrows. For figure 4, additional information surrounding the circumstances of the object impact, a tracked drilling unit, along with the damage sustained to the main rotor blades was obtained from the Federal Aviation Administration (FAA) and the operator. For figure 5, the airplane’s structural repair manual for the damage sustained to the right wing from the bird strike was studied during the damage assessment process. For figure 6, the interior of the fuselage had to be inspected to identify the substantial damage sustained during the hard landing sequence.

Figure 4. A Eurocopter AS 350 B3 helicopter sustained substantial damage to the main rotor blades after impacting a tracked drilling unit in Delta Junction, Alaska.
Figure 5. A Cessna 208B airplane sustained substantial damage to the right wing due to a bird strike in Sacramento, California.
Figure 6. A Beech 1900C airplane sustained substantial damage to the lower aft fuselage after a hard landing in Gambell, Alaska.

When the damage sustained is not obviously substantial, NTSB air safety investigators and aerospace engineers may take additional steps to assess wreckage, such as the following:

  • Working with pilots, operators, mechanics, repair stations, FAA Flight Standards District Offices, aviation insurance adjustors, and aircraft recovery companies to obtain additional damage photographs or damage information
  • Consulting the airframe manufacturer’s air safety and engineering departments
  • Obtaining documents, such as the structural repair manual or illustrated parts catalog, from the airframe manufacturer
  • Considering other unique factors that may determine the damage level, such as airframe fire damage or the aircraft being immersed in a body of water
  • Inspecting the area in question (such as spars in wings, structural areas behind firewalls, driveshafts in helicopters, gearboxes in helicopters, etc.) once the aircraft is recovered
  • Removing components, panels, or skin and using tools to access hard-to-view areas (such as mirrors or electronic borescopes)

We would also determine:

  • if the damaged area is classified as a primary structure (primary structure is defined by the FAA as that structure which carries flight, ground, or pressurization loads, and whose failure would reduce the structural integrity)
  • what repairs are required
  • which components will be replaced to repair the damaged area
  • if the aircraft’s performance or flight characteristics were affected

(The cost or feasibility of repairing an aircraft, as determined by an aircraft insurance company, will not be considered when determining whether an aircraft has sustained substantial damage.)

The damage assessment timeline can vary, depending on how obvious the damage is initially. We might make a substantial determination in a few hours, or, if additional information is needed, the damage assessment can take several weeks. If the aircraft needs to be recovered from a remote area to obtain additional information, the damage assessment could extend even longer.

Although the FAA is always a party member to our investigations, the NTSB is the final authority for determining a damage classification. For those that are involved in an adverse aircraft event, some basic knowledge can help during the assessment, such as:

  • Understanding the definitions and reporting requirements in 49 CFR Part 830
  • Knowing how to directly contact the NTSB
  • Having multiple, high-quality, high-definition photographs from all around the aircraft, showing the aircraft in its entirety
  • Having multiple, high-quality, high-definition photographs of the damaged areas, including close-ups
  • Knowing what repairs are required to the damaged area, along with what components will be replaced to repair the damage (when possible)

Being involved in an accident or incident, regardless of the outcome, is stressful for those involved. The NTSB works diligently with various stakeholders to provide as many answers regarding the damage classification as possible, whether it is determined to be an accident or an incident.

Comair 5191 Crash Led to Air Traffic Control Changes

By Jeff Marcus, Chief, NTSB Safety Recommendations Division

Fifteen years ago today, on August 27, 2006, Comair flight 5191, a Bombardier CL-600-2B19, lined up on the wrong runway and crashed during takeoff from Blue Grass Airport, Lexington, Kentucky (LEX), killing 49 people, including the captain and flight attendant. The first officer, who was seriously injured, was the only survivor. This investigation led to several improvements that furthered safety for all air travelers.

What Happened

The flight crew was instructed to take off from runway 22, a 7,000-foot-long air carrier runway. Instead, they lined up the airplane on runway 26, a 3,500-foot-long general aviation runway, and began the takeoff roll without cross-checking and verifying that the airplane was on the correct runway before takeoff.

Because runway 26 was too short for the takeoff, the airplane ran off the end of the runway, became momentarily airborne, and crashed into the airport perimeter fence, trees, and terrain. The airplane was destroyed by impact forces and postcrash fire.

What We Found

The NTSB investigation determined that there were adequate cues on the airport surface and resources were available in the cockpit to allow the flight crew to successfully navigate from the air carrier ramp to the runway 22 threshold. The flight crew believed that they were taking off on runway 22, even though it was dark when flight 5191 tried to take off and runway 26 was unlighted. We determined the crash was due to:

  • the flight crewmembers’ failure to use available cues and aids to identify the airplane’s location on the airport surface during taxi, and
  • their failure to cross-check and verify that the airplane was on the correct runway before takeoff.

We also found that the flight crew was engaged in nonpertinent conversation during taxi, resulting in a loss of positional awareness, contributing to the accident. This is a violation of the FAA’s sterile cockpit rule, which bans nonpertinent conversation in critical phases of flight. (As awareness of distraction spread to other modes of transportation—and to distraction by other means—the sterile cockpit rule began to be seen as a forerunner of later anti-distraction measures.)

Our Recommendations

Although, the probable cause pointed to flight crew actions, our recommended changes covered all aspects of the aviation industry. We not only recommended improving flight crew procedures, but also recommended that moving map displays be required in cockpits to improve situational awareness to help prevent similar accidents in the future.

In addition, we saw other aspects of the aviation industry that could be improved to help prevent similar accidents: improving air traffic control practices and procedures.

Also contributing to the crash was the Federal Aviation Administration’s (FAA) failure to require that all runway crossings be authorized only by specific air traffic control clearances. In this case, the air traffic controller on duty, like the pilots, had the ability to head off the accident, if he was alert and aware of the flight’s surface movements.

But the tower controller who could see the airplane on the airport surface did not detect the flight crew’s lining up to take off on the wrong runway. Instead of monitoring the airplane’s departure, he was not looking inside the control tower while he performed a lower-priority administrative task that could have waited until after transferring responsibility for the airplane.

The controller’s duty times, and sleep patterns indicated that he was most likely experiencing fatigue at the time of the accident. However, his routine practices did not consistently include the monitoring of takeoff. What’s more, the FAA’s policies and procedures at the time were not optimized to prioritize controller monitoring of aircraft surface operations over administrative tasks.

Lessons Learned

Followers of aviation safety know that the loss of Comair flight 5191 was an accident that brought a focus on preventing fatigue in air traffic controllers. The NTSB recommended, and the FAA implemented, numerous measures improving air traffic control practices and procedures. These included fatigue management programs, training, and, together with the National Air Traffic Controllers Association, working to improve scheduling practices.

Many other recommendations which came out of the tragedy were implemented, advancing crew resource management and airport surface painting and markings, and prohibiting the issuance of a takeoff clearance during an airplane’s taxi to its departure runway until after the airplane has crossed all intersecting runways.

Because the NTSB’s mission is to improve safety, not to punish, finding a human error was by no means the end of the investigation. Instead, the actions of the flight crew were only the beginning. What conditions led to the human error? Was there anything that could have been done to capture the error? Were there other errors in other parts of the transportation system that allowed the crash to transpire? What could prevent the next crash?

The result is that revisions have been made to ensure that the same set of circumstances at play in LEX during the early morning of August 27, 2006, will not lead to another fatal accident.

Learn More

Aviation Accident Report: Attempted Takeoff from Wrong Runway Comair Flight 5191, Lexington, KY, August 27, 2006

Aviation Investigation Docket: Attempted Takeoff from Wrong Runway Comair Flight 5191, Lexington, KY, August 2006

Episode 42: TWA Flight 800

In this episode of Behind-the-Scene @NTSB, NTSB Managing Director, Sharon Bryson and Frank Hilldrup, Chief Technical Advisor for International Affairs, NTSB Office of Aviation Safety, talk about the July 17, 1996, TWA flight 800 accident.  We discuss what happened, the findings and safety recommendations that came out of the investigation, its tremendous impact on aviation safety, how the Aviation Disaster Family Assistance Act of 1996 led to the establishment of NTSB’s disaster assistance program, and the decommissioning of the TWA flight 800 reconstruction.

The NTSB final report for the TWA flight 800 in-flight breakup mentioned in this episode and the NTSB docket for investigation is also available on our website.

To learn more about the NTSB Transportation Disaster Assistance (TDA) Program, visit our TDA web page.     

To learn more about the NTSB Most Wanted List (MWL), visit our MWL web page. You can also access the MWL archive  on our website.

Information about upcoming NTSB virtual training courses are available on our Training Center web page.                                                               

Get the latest episode on Apple Podcasts , on Google PlayStitcher, or your favorite podcast platform.

And find more ways to listen here: https://www.blubrry.com/behind_the_scene_ntsb/