Category Archives: Aviation Safety

Don’t Press the Envelope

By Mike Folkerts

Loss of control in flight—when a pilot fails to maintain or regain control of an aircraft—is the leading cause of general aviation fatalities. From 2011 to 2015, nearly half of all fatal fixed-wing accidents in the United States involved pilots losing control of their aircraft, resulting in 819 fatalities. Far too many NTSB investigations have shown how a loss of aircraft attitude control is often preceded by the loss of a pilot’s mental attitude control.

April 27, 2013, Piper PA-28R-180 airplane crash near Norfolk, Nebraska.
April 27, 2013, Piper PA-28R-180 airplane crash near Norfolk, Nebraska.

In the fatal accidents that I have investigated, this loss of mental control seems to be a conscious decision by the pilot to “press the envelope”—a term made famous in the 1983 film The Right Stuff, an adaptation of Tom Wolfe’s best‑selling book about the military test pilots who became Project Mercury astronauts. As the United States sought to achieve supersonic flight and put a human on the moon, these test pilots pressed the envelope, pushing the boundaries of both aircraft and human performance. Their efforts were based on national objectives and security, and many of these aviators paid the ultimate price in that pursuit.

Unfortunately, in far too many general aviation accidents, pilots choose to press the envelope for relatively minor (and often selfish) reasons, like “pressing the weather” to get home for dinner, flying at low altitude or maneuvering aggressively for an extra boost of adrenaline, or “pressing a known aircraft issue” to get a job done. Although a “git-r-done” attitude is certainly commendable, pilots too often forget to trust the little voice inside that warns them to steer clear of unwarranted risks, or they fail to guard against the temptation to make extreme efforts to please or impress others. General aviation flying very rarely requires the need to press the envelope, and pressing far too often ends in a tragic loss of control.

The NTSB is so concerned with this phenomenon that, for the last 3 years, we have placed “Prevent Loss of Control in Flight in General Aviation” on our Most Wanted List of transportation safety improvements to help bring attention to the issue. Last week, NTSB Board Member Earl Weener even attended the Sun ‘n Fun International Fly-In—one of the world’s largest general aviation enthusiasts’ training events—to talk to pilots about the dangers of losing control.

Whatever a pilot’s motivation may be for wanting to press the envelope, in general aviation, it’s not worth risking loss of control. Never underestimate the connection between mental attitude and aircraft attitude.

Mike Folkerts is an aviation safety investigator in the NTSB Office of Aviation Safety.


Fahrenheit 1,100: Lithium Batteries in Aviation

By Robert L. Sumwalt

There is no place for a fire on an airplane. And if there is a fire, it should not overwhelm fire-suppression equipment.

No-brainer, right?

Poster image for Most Wated List issue area Ensure the Safe Shipment of Hazardous MaterialsHere is another no-brainer: lightweight, portable energy is necessary for our modern way of life. Smartphones, laptops, power tools, and even some vehicles depend on lithium batteries. The ubiquitous nature of these modern electronic devices has, in turn, increased the need to ship the batteries that power them.

The same high-energy density that makes lithium batteries such a great way to store electricity can also introduce a fire hazard. A fault in the battery, such as a flaw in the manufacturing process, can cause a fire. Even if a fire starts elsewhere, a lithium battery makes for formidable fuel. When a fire spreads from cell to cell within a lithium-ion battery, it can burn at 1,100 degrees Fahrenheit.

While international air regulations prohibit bulk shipment of lithium batteries on passenger airplanes, the NTSB investigated one cargo aircraft fire in the U.S., and we participated in two foreign-led accident investigations of cargo aircraft where lithium battery fires were suspected.

In late 2010, UPS flight 006 crashed minutes after takeoff from Dubai, UAE. The crew reported an onboard fire but was unable to land their 747 before fire consumed the aircraft. Both crewmembers lost their lives, and the aircraft and cargo was destroyed. The investigation found that a large fire that developed in palletized cargo on the main deck caused the crash. This cargo consisted of consignments of mixed cargo that included a significant number of lithium-type batteries and other combustible materials. The fire escalated rapidly into a catastrophic uncontained fire. The hazardous smoke and fumes entered the cockpit and upper deck simultaneously, obscuring the crew’s view and creating a toxic environment.

Ten months later, Asiana Airlines flight 991, a 747 cargo flight, crashed on its way from Incheon, South Korea, to Shanghai, China. The two pilots on board the aircraft died. The NTSB assisted Korea’s Aviation and Railway Accident Investigation Board (ARAIB) in investigating the crash. The ARAIB determined that a cargo fire that developed on or near two pallets containing dangerous goods (hazardous materials), including hybrid-electric vehicle lithium-ion batteries and flammable liquids, caused the crash. The ARAIB could not pinpoint the cause of the fire, but it determined that the flammable materials and lithium-ion batteries that were loaded together were a contributing factor.

This year, we recommended that the Pipeline and Hazardous Materials Safety Administration (PHMSA) take action in response to the 2011 crash. We asked PHMSA to take the following steps:

PHMSA has suggested other actions that could also meet our intent. Whatever solution

PHMSA develops, U.S. aviation cannot ignore this potential hazard.

Thankfully, lithium battery failures are rare, and new research and meaningful efforts are underway to make them rarer still. On April 11 and 12, 2013, we conducted a public forum on lithium battery safety. Since then, the Federal Aviation Administration (FAA), in conjunction with the Commercial Aviation Safety Team, has established a joint government–industry working group. The group is developing ways to make lithium battery fires less likely in aviation and to reduce the consequences in case they do occur.

We have issued several other lithium battery-related safety recommendations to the FAA and PHMSA encouraging them to share critical safety lessons learned, implement mitigations, and conduct research into safety improvements. Other NTSB recommendations about the certification and testing of lithium batteries aim to make such fires less likely.

We continue to share our lithium battery investigation findings and advocate safety recommendations. We participate in the UL-initiated Battery Safety Council and attend industry outreach events and seminars, such as the NASA battery forum and seminars from the Knowledge Foundation.

Lithium batteries are not going away; they are far too useful. But we must ensure that each and every shipment of lithium batteries poses minimal safety risk. That is why our Most Wanted List calls on regulators and others to Ensure the Safe Shipment of Hazardous Materials, including lithium batteries in aviation.

Just the Facts

By Sharon Bryson

The NTSB is an independent federal agency charged with improving transportation safety, and a significant part of that mission is accomplished by investigating every civil aviation accident and significant accidents in other modes of transportation. Fast approaching its 50 anniversary, this small agency takes pride in its independence, transparency, and collaborative approach to accident investigations. As a key measure of our effectiveness, we maintain strong working relationship with all transportation stakeholders. We work hard to build and maintain the trust and confidence of those stakeholders while we carefully, thoroughly and independently gather all the facts surrounding an accident to maintain credibility with the public.

You may have had the opportunity to view the recently released movie about the Jan. 15, 2009, US Airways flight 1549, ditching on the Hudson River.  (NTSB report title: “Loss of Thrust in Both Engines After Encountering a Flock of Birds and Subsequent Ditching on the Hudson River”). As an employee of the National Transportation Safety Board I can appreciate the movie’s treatment of the ditching of U.S. Airways Flight 1549 – it’s certainly a movie-worthy moment in aviation history. However, the movie is a fictionalized version of the NTSB’s investigation of the accident, and as such, it portrays the NTSB as the antagonist. That’s unfortunate because it misrepresents the purpose of our investigation and in doing so, undermines the important safety lessons learned and recommendations that we issued.

The purpose of the investigation was to gather the facts surrounding the accident, understand what happened, and make recommendations to prevent recurrence and improve aviation safety. Thankfully, this accident had a successful outcome because of the performance of a very skilled crew and the exceptional rescue efforts by many that day. As good as the outcome was, the NTSB knew there was much to learn from the accident, as there is in every accident we investigate.

The ditching of US Airways flight 1549 presented the NTSB with one of the best moments to learn ‘the facts’ and recommend improvements to reduce future accidents because everyone survived – and isn’t that the best time and the best way to improve safety?

The NTSB issued its report May 4, 2010, along with 35 safety recommendations designed to keep you and your loved ones safer.

The facts of this investigation, including the final accident report, related safety recommendations, a webcast (and associated transcript) of the June 2009 three–day investigative hearing, nearly 4000 pages of investigative materials from the accident docket, and an accident animation, are publicly available on the NTSB’s web page for the accident so you can too, get the facts.

Sharon Bryson is the Director of the NTSB’s Office of Safety Recommendations and Communications.

Reflecting back on 10 years as a Board Member

By Robert Sumwalt

On August 21, 2006, I was sworn in as the 37th member of the National Transportation Safety Board. At the same time, I was appointed by President George W. Bush to serve as NTSB Vice Chairman. In 2011, President Barack Obama reappointed me for an additional five-year term as a board member.

Robert Sumwalt, taking the oath of office, administered by then-NTSB Chairman Mark V. Rosenker on August 21, 2006.
Robert Sumwalt, taking the oath of office, administered by then-NTSB Chairman Mark V. Rosenker on August 21, 2006.

As I reflect on 10 years as an NTSB board member, there are several things that stand out. First, is the mission. Our role in transportation safety quickly became apparent when, on my seventh day on the job, I launched to an airline crash in Lexington, Kentucky. Tragically, that crash claimed 49 lives.

But, the NTSB’s primary mission involves more than just investigating accidents. It also involves determining the cause of accidents, and then, most importantly, issuing safety recommendations to prevent future accidents. At the entrance to our training center, we have an etched glass window that says, “From tragedy we draw knowledge to protect the safety of us all.” And that’s exactly what we do – we learn from tragedy so we can keep it from happening again.

Recently, one of our investigators wrote to me about a rail accident he investigated where fire and explosion claimed multiple lives. He told of meeting a man who was glaring at the carnage as he pushed a baby in a carriage. As it turned out, the man’s wife – the baby’s mother – had been killed in the disaster. Our investigator promised the man that the NTSB would get to the bottom of why this event occurred so other accidents could be prevented. “I also watched a man standing outside of the exclusion zone peering over the barrier in tears as a backhoe demolished his home,” the investigator explained in his note to me. “My thoughts were of those victims, and it was clear that we were being called upon to do this for them.”

Yes, we are here to give a voice to those who don’t have a voice—the victims and their families of transportation accidents. I take great solace knowing our work really does make a difference and keeps others from enduring similar tragedies.

The NTSB is an independent federal agency – meaning, we are not attached to a larger federal organization such as the U.S. Department of Transportation. In my opinion, independence is one of our greatest virtues because it allows the agency to conduct investigations and explore safety issues without being encumbered by actual or perceived political pressures. As I’ve often said, our independence allows us to “call it the way we see it.”

What also stands out to me is the dedication of the men and women of the NTSB. Their passion and determination to find the truth is uplifting. In the most recent employee viewpoint survey, 96 percent of respondents replied positively to the statement, “When needed I am willing to put in the extra effort to get a job done.” That demonstrates the commitment and dedication NTSB employees share for fulfilling our mission.

In addition to investigative activities, there is a proactive side to the NTSB. Our staff conducts safety studies, tracks and follows up on our safety recommendations, and advocates for safety improvements by providing testimony on safety issues, promoting our Most Wanted List, bringing important safety issues into the public discussion via social media efforts, and organizing safety events such as roundtable discussions.

One of the NTSB’s values is transparency; we are open and honest with the public about our work. We post on our website all accident reports and publications, as well as the docket for each accident. The docket provides reams of background information for accidents, such as interviews, photos, and technical information that may not be in the actual accident report. Our board meetings are webcast and open to the public. And, our Office of Safety Recommendations and Communications ensures the media are informed of the status of investigations by answering questions, arranging interviews, issuing press releases, and releasing updates through social media.

Many are surprised to learn that the NTSB also serves as a court of appeals for pilots, aircraft mechanics, and mariners who receive violation notices from the Federal Aviation Administration and U.S Coast Guard. The NTSB’s Office of Administrative Law Judges (ALJ) processes those cases, and our three ALJs hold hearings to adjudicate those matters.

The NTSB’s Office of Transportation Disaster Assistance – a highly trained group with expertise in social services, emergency management, and forensics – works closely with various organizations to meet the needs of disaster victims and their families. This group also serves as the primary point of contact for family members and disaster victims, providing updates regarding the status of NTSB investigations and addressing their questions. It takes a special person to do the work they do, and I’m always appreciative of how well they do it.

There are other parts of the agency that aren’t often acknowledged, but nevertheless are important to allowing the agency to function. As in any organization, job openings need to be posted and filled, bills paid, contracts written and executed, and our computers maintained. The employees who perform these functions are as dedicated as those performing the agency’s core mission.

To put it simply, I’m so proud to be part of this agency. Our mission, independence, transparency, and people are all so important. I’m honored to have served with them for the past 10 years.

Robert Sumwalt is an NTSB board member.

EAA AirVenture – Opportunity to Educate Pilots on Lessons Learned from Crashes

By Jeff Marcus

Logo for EAA AirVenture Fly In 2016For one week each year the control tower at Wittman Regional Airport in Oshkosh, Wisconsin, becomes the busiest in the world when 10,000 airplanes fly in for the Experimental Aircraft Association’s AirVenture. EAA AirVenture is one of the largest airshows in the world, with more than 500,000 visitors arriving over the week. This large gathering of general aviation pilots and aviation enthusiasts offers NTSB a great opportunity to share important information about safety with the flying public, and I am excited to be a presenter at this year’s event.

During the week-long event, Chairman Christopher Hart, Member Earl Weener, and 10 NTSB staff will provide accident case studies, share lessons learned, and give presentations on various safety issues related to general aviation.

As in years’ past, the NTSB will host an information booth in the Federal Pavilion. NTSB personnel will be on hand to address questions related to our recommendations and what we have seen from our crash investigations. Additionally, during this week NTSB investigators will discuss the recent Safety Alert issued by the NTSB on “Arriving at Major Fly-In Events” and, in another session, steps for avoiding construction and maintenance errors for experimental aircraft. We also use this event as an opportunity to stay abreast of the latest industry developments, so we can remain smart about our own recommendations for safety improvements.

Many of the NTSB presentations at EAA AirVenture, including mine, will focus on the actions pilots must take to avoid loss of control accidents.

Loss of aircraft control is the most common cause of general aviation accidents. Between 2008 and 2014, about 47 percent of fatal fixed-wing general aviation accidents in the United States involved pilots losing control of their aircraft in flight, resulting in 1,210 fatalities. As a result, preventing loss of control in flight in general aviation is one of the issues on the NTSB’s Most Wanted List of transportation safety improvements.

While airline accidents have become relatively rare in the United States, general aviation accidents occur at much higher rates than airline accidents. The rate of accidents has been declining in commercial aviation, but the general aviation accident rate has remained largely unchanged. The NTSB has investigated, on average, about 1,366 general aviation accidents each year over the last five years. We must change this deadly trend of accidents—and events like this give us an important opportunity to work toward that goal.

I will be making a presentation on several NTSB recommendations that address the underlying causes of some loss of control accidents, including:

  1. Incompatibilities of modifications to airplanes
  2. Guidance for amateur builders of kit airplanes
  3. Pilot knowledge of how their “glass cockpit” displays react to common failure modes like a blocked pitot tube
  4. Clarification of policies regarding the use of marijuana by general aviation pilots
  5. Information for pilots on the side effects of some common over-the-counter medications available without a prescription
  6. Impairments to pilot’s night vision caused by cataracts

The last three topics relate to Impairment and Medical Fitness for Duty, other concerns for the pilot community that are also on our Most Wanted List. Other NTSB presentations at EAA AirVenture will discuss additional safety issues related to loss of control accidents, including weather issues.

I look forward to attending and presenting at EAA AirVenture this year, and I encourage all pilots and aviation enthusiasts to attend, as well. If you will be attending, please stop by the NTSB booth in the Federal Pavilion or attend one of the NTSB presentations.

To view our complete schedule of presentations, visit our website.

Jeff Marcus is an aviation transportation safety specialist in NTSB’s Office of Safety Recommendations & Communications.

Weather…or not

By Robert L. Sumwalt

Graphic Logo for the Forum: PIREPs: Pay it Forward...Because Weather for One is Weather for NoneThere’s an old saying, “everybody talks about the weather, but nobody does anything about it.” Well, this week, the NTSB intends to do something about it.

Tomorrow and Wednesday, June 21 and 22, NTSB will have a forum on pilot weather reports (PIREPs). Why is this topic important? We became interested in PIREPs by accident – several of them, in fact. As our accident investigators will discuss in the forum, after several years of weather encounter-related accident and incident investigations, we found that there were too many instances where weather information had been observed but had not made it into the cockpits of those who needed it most.

Photo of a Learjet 35 A with icingOne such event occurred in March 2012, in Anchorage, Alaska. A Learjet 35A encountered severe in-flight icing conditions that exceeded the capabilities of the airplane’s windscreen anti-ice systems, and the airplane’s windscreen abruptly iced over. As a result, the flight crew lost all forward visibility, and the airplane veered off the runway during landing and came to rest in a snow bank.

The NTSB found that the severe icing conditions had been conveyed about 15 minutes before the Learjet encountered them.

A pilot in an F-16 conducting an approach to an Air Force Base about 7 miles northeast reported “severe icing on final” and initiated a go-around to “wait until his windshield…cleared.” The controller handling the F-16 shared this information with the controller who later handled the Learjet; however, the controller handling the Learjet did not relay the urgent PIREP to the Learjet flight crew.

In this case, the NTSB determined that the approach controller’s failure to relay the PIREP was a contributing factor to the incident.

The problem doesn’t lie solely with ATC not disseminating weather information. As a former airline pilot and line check airman, I know that sometimes pilots do not relay weather information to ATC. And, when they do, the information is prone to inaccuracies, especially regarding time, location, and weather intensity.

To their credit, many people have been trying for years to get the PIREP system to work better, and many of them will be participating in the forum. That’s precisely why we wanted to have this event – to bring together key players with knowledge of the PIREP system to begin a conversation about improving it. And we hope that this conversation continues, planting the seed for collaborative action.

The forum will be open to the public and will also be webcast. We hope you can join us, either in person or online.

Robert L. Sumwalt is an NTSB Board Member.

Part 23 NPRM – A New Horizon

By John DeLisi

In 1977, I took my first flying lesson in a Cessna 150 parked on the flight line at Long Island MacArthur Airport. If you head out to a flight line today, you’ll see that many of the general aviation airplanes have changed little since then.

The FAA’s recent Notice of Proposed Rulemaking for Part 23, Revision of Airworthiness Standards for Normal, Utility, Acrobatic, and Commuter Category Airplanes, proposes significant changes in the design of new general aviation aircraft and the introduction of new technologies to modernize the general aviation fleet.

Through our accident investigations, the NTSB has learned many safety lessons over the years. The comments we submitted on the proposed rulemaking highlight areas in which safety improvements recommended by the NTSB can help further enhance the streamlining of Part 23. We are optimistic that the proposed process will address many of our outstanding safety recommendations.

I have seen technology advancements that are far beyond what can be found in the cockpit of many general aviation aircraft, and the NPRM proposes to make the introduction and certification of new safety technologies quicker and less burdensome for manufacturers. For example, with Inflight Loss of Control in General Aviation on the NTSB’s Most Wanted List, we understand the advantages that angle of attack indicators can bring to preventing loss of control accidents, and we support their incorporation into general aviation cockpits. The FAA indicates that the proposed rule will dramatically reduce loss of control accidents, and we look forward to learning more about the ways the proposed rule can help meet this goal.

We see great potential for the proposed rule to allow manufacturers to more rapidly introduce safety improvements into the fleet, as compared against the current pace associated with the FAA approval processes. By streamlining these processes, the proposed rule will help change the introduction of innovative new safety technologies from something that is nearly impossible to something that is encouraged and sought after.

The potential safety advancements made available through the adoption of the NPRM are exciting to consider. We look forward to the next steps that the FAA will take; steps that we believe will help save lives.

John DeLisi is Director of the NTSB Office of Aviation Safety.