Category Archives: Aviation Safety

Why We Care When Things Go Right

By Lorenda Ward, Sr. Investigator-In-Charge, NTSB Office of Aviation Safety

As an investigator-in-charge (IIC) at the National Transportation Safety Board (NTSB), part of my job is to launch to aviation accident scenes. When my team and I arrive at the scene of an accident, we come prepared to uncover the sequence of events that led to the accident—whether it was weather, human factors, or a problem with the plane’s structure, systems, or engines. It’s the NTSB’s responsibility to find out what occurred and provide recommendations to prevent future accidents.

When we investigate an accident, we don’t only look for the things that went wrong, but we also look for those that went right. Sometimes these “rights” ensure the accident didn’t become an even greater tragedy, and sharing them can help crewmembers and operators in the future ensure the safest flight possible. A good example of this is a recent accident we investigated in Michigan.

On March 8, 2017, an Ameristar Charters Boeing MD-83 ran off the end of the runway during a high-speed rejected takeoff at Ypsilanti Airport in Michigan. The plane was scheduled to carry 6 crewmembers and 110 passengers to Washington, DC—among them, the University of Michigan men’s basketball team, cheerleaders, band, coaches, and some parents. Fortunately, no one was killed, though some passengers sustained minor injuries.

March 8, 2017, Ypsilanti, Michigan, runway overrun during rejected takeoff
Rear view of accident scene

I led the small team that was launched to the accident site. On scene, we found that the right geared tab of the elevator flight control system had become jammed. Our investigation showed that this occurred during a strong windstorm that struck the area while the aircraft was parked at Ypsilanti Airport prior to the flight.

Seconds after the captain tried to “pitch,” or rotate, the airplane’s nose up, he quickly realized that the airplane was not going to get airborne. At that time, the airplane was traveling at a speed of 158 mph and was about 5,000 feet down the 7,500-foot runway. Because the elevator was jammed in the airplane nose-down position, no matter how far back the captain pulled the yoke, the nose refused to pitch up. The captain quickly called to abort the takeoff, but the plane was traveling too fast to be stopped on the remaining runway. It departed the end of the runway at about 115 mph, traveled 950 feet across a runway safety area, struck an airport fence, and came to rest after crossing a paved road.

Our investigation determined that the flight crew had completed all preflight checks appropriately, including a flight control test, and found no anomalies before initiating the takeoff. Furthermore, we determined that there was no way the pilot checks could have detected the flight control jam.

It’s important to note that, not only did the captain appropriately reject the takeoff once he felt the airplane was not able to fly, but the check airman did not try to countermand the rejected takeoff. And after the plane came to a rest, the cabin crew also followed procedures to coordinate a careful, safe passenger evacuation.

Also essential to the safe outcome was the fact that the passengers followed the crew’s instructions, so everyone got off quickly without any serious injuries. Unfortunately, too many times, we see passengers delay an evacuation by ignoring crew instructions to, say, retrieve their luggage.

Although the accident airplane crashed through a perimeter fence and crossed a road before coming to a stop, an extended runway safety area that was added to Ypsilanti airport between 2006 and 2009 allowed the airplane plenty of room and time to come to rest safely. This expansion was part of a national program started by the Federal Aviation Administration in 1999 in response to an NTSB recommendation to add runway safety areas to many commercial airports.

Our investigative team learned that three critical factors—things done “right”— helped prevent this accident from becoming a tragedy, in which numerous lives could have been lost:

1) The captain’s quick response

2) The crew’s adherence to procedures, which resulted in a quick and efficient evacuation

3) The addition of a compliant runway safety area

After 20-plus years of investigating accidents, it’s refreshing to me to see an accident in which more things went right than wrong, and where people lived to tell the tale because of good decision making. These cases don’t normally get a lot of attention, but it’s important for us to understand and report out all our findings—even the good—because we see lessons there, too.

I encourage everyone to read the full Ypsilanti report. A link to the accident docket and related news releases are also available at https://www.ntsb.gov/investigations/pages/2017-ypsilanti-mi.aspx.

When an Aircraft Goes Missing

By Mike Hodges, Air Safety Investigator, NTSB Office of Aviation Safety

On August 9, 2008, a privately-owned Cessna 182E airplane was reported overdue near Juneau, Alaska. The NTSB immediately started monitoring search efforts being conducted by the US Coast Guard, the Alaska State Troopers, the Civil Air Patrol, and a host of good Samaritans. The search area was expansive and included remote inland fjords, coastal waterways, and steep mountainous terrain. In an effort to start gathering information that was potentially relevant to the accident, we interviewed other pilots flying in the area, as well as Federal Aviation Administration (FAA) Flight Service Station personnel to better understand weather conditions at the time the airplane disappeared. After an extensive but unsuccessful search, search-and-rescue activities were suspended on August 20, 2008.

For all aviation accidents such as this one, when initial search-and-rescue activities are suspended and no wreckage is found, the NTSB issues a preliminary report, available to the public in an aviation accident database that can be accessed through our website. If the wreckage is not located within 180 days from the initial date of disappearance, we complete a final report with a probable cause statement of “undetermined.” The final report includes all pertinent information that was initially gathered at the time the aircraft was reported missing. If the wreckage is eventually located after the initial 180 days, we reopen and complete the investigation.

On October 25, 2017, I was the on-call air safety investigator for the NTSB Alaska Regional Office. Alaska State Troopers notified me that a deer hunter had discovered airplane wreckage on Admiralty Island, about 15 miles south of Juneau, Alaska. We eventually determined that it was the missing Cessna 182E. So, 9 years after the airplane went missing, we reopened the case.

In Juneau, I met with an aviation safety inspector from the FAA, an Alaska State Trooper, and members of Juneau Mountain Rescue. As with most remote aircraft accidents in Alaska, traveling to the scene requires an airplane or helicopter because there are no roads. The NTSB chartered a commercial, float-equipped Cessna 206 airplane, and we flew to Young Lake on Admiralty Island in the Tongass National Forest—the largest intact temperate rainforest in the world.

Flying to Young Lake near the accident site
Flying to Young Lake near the accident site

As an air safety investigator working in Alaska, I often face unique challenges, whether it’s a hike to a remote area to reach an accident site or a wildlife encounter. In this case, after arriving at the northern end of Young Lake, we hiked nearly 2 miles to the accident site, each of us carrying either firearms or bear spray because of the large population of brown bears on the island. We also carried satellite phones because there’s no cell phone reception in the area. The wreckage was in densely‑forested, steep mountainous terrain a little over a mile northwest of the north end of Young Lake, at an elevation of about 1,075 ft. mean sea level. The average tree height at the accident site was about 100 ft.

Landing on Young Lake
Landing on Young Lake

When we arrived at the site, the FAA aviation safety inspector and I documented and examined the wreckage. The cockpit and fuselage were destroyed by a postimpact fire. The wreckage of the missing airplane was confirmed via the serial number located on the airframe data plate. Time and nature had taken their toll—the heavily corroded wreckage was covered with dirt, fungus, leaves, and branches. The Alaska State Trooper recovered the remains of the two occupants.

View of the wreckage
View of the wreckage

Once the investigative and recovery activities were completed, we hiked back to Young Lake, contacted the commercial aviation operator for pickup, and returned to Juneau. Because the location was so remote, the wreckage was not recovered.

NTSB Air Safety Investigator Mike Hodges
Mike Hodges using a satellite phone at Young Lake to provide an update to NTSB leadership

On-scene activity is just one part of our investigative process. In each investigation, we look at the roles of the human, the machine, and the environment. By learning about the factors that cause an accident, we can make recommendations to prevent similar accidents in the future. In this investigation, I reviewed the airplane’s maintenance records, considered the pilot’s aviation training and medical records, and examined meteorological and topographical data for the accident area. As a result of the investigation, the NTSB determined that the probable cause of the accident was the pilot’s decision to continue visual flight into an area of instrument meteorological conditions, which resulted in the pilot experiencing a loss of visual reference and subsequent controlled flight into terrain. The pilot’s self‑induced pressure to complete the flight also contributed to the crash. The final accident report can be viewed here.

If you ever happen to come across aircraft wreckage—or what you think is aircraft wreckage—no matter how old it appears to be, please notify local law enforcement and the NTSB Response Operations Center in Washington, DC. If you’re able, please provide latitude and longitude coordinates of the wreckage location, along with photographs of what you found. The NTSB can then continue investigating what happened, which can help prevent future accidents from occurring. Also, importantly, family and friends of those who died in the accident may be interested in the new information. If you ever have the chance to visit the NTSB Training Center in Ashburn, Virginia, you will see an etched window on the front of the building that states the building is dedicated to the victims of transportation accidents and their families. The display also summarizes the NTSB’s crucial work of improving transportation safety for our great nation: “from tragedy we draw knowledge to improve the safety of us all.”

NTSB Training Center display

When it Comes to Safety, Not All Flights are Created Equal

By Chairman Robert L. Sumwalt

Last week, we officially adopted our final report on the tragic May 15, 2017, crash of a Learjet 35A on a circling approach to Teterboro Airport in New Jersey. The crash took the lives of the two occupants—the aircraft’s pilots. The probable cause of the accident was the pilot‑in‑command’s (PIC’s) attempt to salvage an unstabilized visual approach, which resulted in an aerodynamic stall at low altitude.

The accident airplane’s operator offered on-demand flights under Part 135 of the Federal Aviation Regulations. (The air carriers that most people are more familiar with, which fly regularly scheduled routes, are regulated under Part 121.) The accident flight was a positioning flight subject to Part 91 rules; however, the procedures that the operator used, the pilots’ training, and the Federal Aviation Administration’s (FAA’s) ongoing oversight duties all pertained to Part 135 aviation.

Imagine knowing that some of what was happening on this accident flight was going on in your regularly scheduled air carrier flight. First, the PIC was not flying the airplane until just before the accident, when the second-in-command (SIC) relinquished control, despite the fact that, by the company’s own standard operating procedures (SOPs), the SIC was not experienced enough to be flying. This was only one of many instances during the flight of an SOP violation or the failure to use required SOPs.

Additionally, during initial training, the PIC and the SIC both had difficulty flying circling approaches in a simulator. This Part 135 carrier, however, did not have a program in place to follow up with pilots who had exhibited issues during training. What’s more, despite both pilots’ training problems flying a circling approach, they were teamed together for this flight.

This accident flight was also an example of poor crew resource management (CRM). CRM done well results in SOP adherence and effective communication and workload management. However, during this flight, the captain had to extensively coach the SIC while also fulfilling his pilot monitoring responsibilities. He did neither well. Both pilots lacked situational awareness.

Contributing to the accident was the PIC’s decision to allow an unapproved SIC to act as pilot flying, and the PIC’s inadequate and incomplete preflight planning. Also contributing to the accident was the carrier’s lack of any safety programs that could identify and correct patterns of poor performance and procedural noncompliance, and the FAA’s ineffective safety assurance system procedures, which failed to identify the company’s oversight deficiencies.

In response to this accident, among other things, we recommended that the FAA require Part 135 operators to establish programs to address and correct performance deficiencies, as well as to publish clear guidance for Part 135 operators to create and implement effective CRM training.

This accident illustrates that Part 135 flight crew members don’t always follow the same procedures or exhibit the same discipline as professionals in Part 121 operations. Before the accident at Teterboro, we found that pilot performance either caused or was a major contributing factor in seven major aviation accidents involving Part 135 on‑demand operators between 2000 and 2015. A total of 53 people were killed and 4 were seriously injured in these accidents. This year, we added “Improve the Safety of Part 135 Aircraft Flight Operations” to our Most Wanted List of transportation safety improvements to help draw attention to this problem.

MWL06s_Part135

Many air carriers operating under Part 121 are required to continually seek and identify risks, and once the risk assessment is done, put measures in place to mitigate those risks through safety management systems (SMSs). Conversely, while some Part 135 operators have implemented SMS, most have not.  In response to the Teterboro accident, we reiterated a previous recommendation to the FAA to require that all Part 135 carriers in the United States have an SMS in place.  In Part 121 training, performance deficiencies are required to be followed up on; there’s no such requirement for Part 135 operators to monitor deficiencies in their pilots’ training.

Further, although Part 135 operators, like their Part 121 counterparts, are required to provide CRM training, they receive less thorough guidance on what constitutes effective CRM training. This shortcoming was evident in the Teterboro accident, where the crew did not display good CRM during the accident flight.

I’ve had two very interesting roles in life – being an airline pilot and serving as an NTSB Board Member. While serving as an airline pilot, I was also a member of a flight operational quality assurance (FOQA) team. In that role, I looked at minor procedural deviations in nonaccident flights with the purpose of learning where potential problems were. In this accident, we reiterated previous recommendations to the FAA to require flight data monitoring (FDM) programs to accomplish the same kind of oversight for Part 135 aviation, and that Part 135 operators install the necessary equipment to acquire FDM data.

In my role as an NTSB Board member, I have seen too many cases where accidents occur in part due to procedural noncompliance and lack of professionalism. A pilot might be born with certain aptitudes, but no one is a born professional; it takes work and constant discipline. Professionalism is a mindset that includes hallmarks such as precise checklist use, callouts, and compliance with SOPs and regulations. Those traits were conspicuously absent on this accident flight. And, now as my role as a frequent airline passenger, I’m glad that airlines are required to have SMS programs; I know they make my flights safer.

The NTSB believes that tools such as an effective SMS should be required and used in Part 135 aviation as well as by Part 121 carriers. We hope that including “Improve the Safety of Part 135 Aircraft Flight Operations” on our Most Wanted List for 2019–2020 will encourage action on this issue.

 

Ethiopia Airlines Flight 302, Annex 13, and the NTSB’s International Mission

By Chairman Robert Sumwalt

Yesterday, the NTSB issued a press release about our ongoing assistance to the Ethiopian Aircraft Accident Investigation Bureau in its investigation into the crash of Ethiopian Airlines flight 302.

Under the provisions of Annex 13 to the Convention on International Civil Aviation—or simply, Annex 13—Ethiopian authorities are responsible for investigating the accident because it happened in Ethiopia; however, because the airplane was designed and manufactured in the United States, the U.S. is invited by the host country to participate in the investigation. That role is carried out by the NTSB.  The NTSB did designate an accredited representative to lead the U.S. team of investigators assisting the Ethiopian investigation.

The accredited representative and other NTSB team members are currently on the ground in Addis Ababa. Additional NTSB investigators were dispatched to France to assist the Ethiopian investigators and the French Bureau d’Enquêtes et d’Analyses (BEA) with downloading and analyzing the accident flight recorders. The NTSB accredited representative in Ethiopia will coordinate all US input into the investigation—not just that from NTSB investigators, but also from the Federal Aviation Administration (FAA), Boeing, and others. The FAA can bring to the table nuanced knowledge of how the aircraft type is regulated and certificated. The airplane and engine manufacturers have detailed engineering and operational knowledge. They, and any other entities that can render technical assistance, are designated technical advisors—the rough equivalent of parties to a domestic investigation.

Annex 13 rights and responsibilities go both ways. For instance, many readers remember the NTSB’s investigation of the crash-landing of Asiana flight 214 in San Francisco in 2013. The NTSB was responsible for the investigation because the accident happened in the United States, and the Boeing 777 aircraft was designed and manufactured here. However, the airplane was registered in the Republic of Korea, and Asiana Airlines was a Korean operator. So, during that investigation, the Korean Aviation and Railway Accident Investigation Board (KARAIB) provided an accredited representative to assist the NTSB investigation.

With so many aircraft manufactured in the United States and flown by US airlines, the NTSB represents the US in numerous accident investigations the world over via Annex 13. Annex 13 sets down the objective of the investigation, which is in concert with our objective at the NTSB.

The sole objective of the investigation of an accident or incident shall be the prevention of accidents and incidents. It is not the purpose of this activity to apportion blame or liability.

Although it is not unheard-of for investigators to approach investigations somewhat differently, there is a shared commitment among participants to determine the facts and findings. Under Annex 13, investigators are able to investigate, by and large, with future aviation safety as their only goal. And every time an accident doesn’t occur, it’s in some part due to safety lessons learned though the roles and relationships established by Annex 13.

Annex 13 ensures that every investigation has access to the technical expertise and resources needed to learn safety lessons and prevent recurrences.

For more information on NTSB participation in foreign investigations go to: https://go.usa.gov/xEswV.

Add a Day of Remembrance for a Balanced Holiday Season

By Chairman Robert L. Sumwalt

Every year, I hear that the holiday season has gotten too long—that holiday music, commercials, and sales begin too early. Traditionally, the season starts on Thanksgiving, the fourth Thursday of November.

 

I think the season should actually start even earlier this year—on the third Sunday in November, World Day of Remembrance for Road Traffic Victims. Why? Because to truly give thanks for what we have, we have to imagine losing it. Around the world, about 1.3 million people lose their lives in automobile crashes every year; 20 to 50 million more survive a crash with injuries, many of which are life-altering. Here in the United States, annual traffic deaths number around 37,000—more than 100 a day—and a motor vehicle crash is the single most likely way for a teen to die.

WDR-Logo-FB

If you’ve lost somebody to a crash, you probably need no special reminder. Your loved one will be missed at the holiday dinner table, on the way to the home of a friend or out-of-town relative, and throughout the holidays. But for the rest of us, the Day of Remembrance is a time to think of those needlessly lost on our roads.

I encourage us all to go beyond remembering those lost in highway crashes, to thinking of victims of transportation accidents in all modes who won’t be joining family and friends this holiday season. Before we give thanks next Thursday, let’s take a moment to remember those who have been lost, and then take steps to make our own holiday travel safer.

By Car

Fatigue, impairment by alcohol and other drugs, and distraction continue to play major roles in highway crashes. Here’s what you can do to keep yourself and those around you safe on the road.

  • If your holiday celebrations involve alcohol, ask a friend or family member to be your designated driver, or call a taxi or ridesharing service.
  • In a crash, seat belts (and proper child restraints) are your best protection. Always make sure that you and all of your passengers are buckled up or buckled in!
  • Make sure to use the right restraint for child passengers, and be sure it’s installed correctly. If you have doubts, ask a Certified Child Passenger Safety Technician.
  • Make sure you’re well rested! A fatigued driver is just as dangerous as one impaired by alcohol or other drugs.
  • Avoid distractions. In this video, survivor-advocates share their stories of personal loss—and the changes they’re working for now.
  • Don’t take or make calls while driving, even using a hands-free device. Set your navigation system before you start driving. If you’re traveling with others, ask them to navigate.

By Bus or Train

We’ve made recommendations to regulators and industry to improve passenger rail and motorcoach operations and vehicle crashworthiness, but travelers should know what to do in an emergency.

  • Pay attention to safety briefings and know where the nearest emergency exit is. If it’s a window or roof hatch, make sure you know how to use it.
  • If you’re unsure of where the exits are or how to use them, or if you didn’t receive a safety briefing, ask your driver or train conductor to brief you.
  • Always use restraints when they’re available!

By Air or Sea

Airline and water travel have become incredibly safe, but these tips can help keep you and your loved ones safe in an emergency.

  • When flying, make sure that you and your traveling companions have your own seats—even children under age 2.
  • Don’t forget your child’s car seat. The label will usually tell you whether your child car seat is certified for airplane use; the owner’s manual always has this information.
  • If you don’t know the rules for using a child’s car seat on your flight, call the airline and ask what you need to know.
  • Pay close attention to the safety briefing! Airline and marine accidents have become very rare, but you and your family can be safer by being prepared.
  • Whether you’re on an airplane or a boat, know where to find the nearest flotation device.

This holiday season, no matter how you plan to get where you’re going, remember that, for many, this time of year is a time of loss. Honor survivors and remember traffic crash victims by doing your best to make sure you—and those around you—make only happy memories on your holiday travels.

Too Close for Comfort in San Francisco

By Bruce Landsberg, Vice Chairman

On March 27, 1977, two Boeing 747s collided on a foggy runway in Tenerife, Spain. The crash took 583 lives, marking it as the deadliest aviation accident in history. Although commercial airline safety has made huge strides since then, a disaster potentially twice as deadly as Tenerife was recently averted by only about 13 feet.

In the late evening hours of July 7, 2017, an Air Canada Airbus A320 inbound from Toronto almost collided with four jetliners awaiting take off at San Francisco International airport (SFO). The night was clear and calm, with no weather to obscure the visual approach to Runway 28 Right.

The Air Canada pilots, not realizing the parallel runway (28 Left) was closed, lined up on a nearby taxiway rather than their assigned runway. As the waiting airliners flashed their landing lights to alert the errant Airbus, one of the pilots on the control tower frequency ground broadcast can be heard saying “Where’s this guy going?” and “He’s on the taxiway!” In the last few seconds, the Air Canada crew recognized their error and aborted the landing.  Simultaneously, the tower controller ordered the Airbus to go around.

Upon landing, the captain called the tower to discuss the incident, and then went to bed. It was 3 am by his body clock and he was exhausted. Although he was required to do so as soon as possible, the captain did not inform Air Canada’s dispatcher about the incident until 16 hours later, by which time the aircraft had already departed on a morning flight, resulting in the required 2-hours of cockpit voice recorder (CVR) data being overwritten.

With all the equipment, training, and safety management systems implemented since Tenerife, it’s astonishing how a near miss like this could happen. But as our investigation revealed, a long and intricate chain of events was to blame. We clearly understand now what happened, but, because the CVR data was lost, we only know part of the why.

We made several recommendations to address the safety issues our investigation uncovered. The incident report, which is available at ntsb.gov, should be required reading for pilots of both large and small aircraft. Here are some of the most important takeaways.

Knowing what to expect. Before flight, all pilots are required to check for Notices to Airmen (NOTAMs), which inform them of anything unusual that has recently changed at the departure or arrival airport, as well as navigational outages along the way. In practice, NOTAMs contain dozens of notices of varying importance, such as closed taxiways, wet runways, and small, unlit towers miles from the airport. Information about closed runways, however, is critical.

From a human factors perspective, we found that the presentation of information in the NOTAM the crew received did not effectively convey the information about the runway closure. This Air Canada crew missed two warnings about the closed runway at SFO, first in predeparture, and then via datalink before landing. Had they been aware of the closure, the pilots almost certainly would’ve suspected an unusual airport configuration with changed lighting patterns.

The current NOTAM system lists everything that could, even under the most unlikely circumstance, affect a flight. It lays an unnecessarily heavy burden on individual pilots, crews, and dispatchers to sort through dozens of irrelevant items to find the critical and important ones. When an important item is missed—as is common—and a violation or incident occurs, the pilot is blamed for not finding what amounts to a needle in a haystack.

Further, NOTAMs are published in hard-to-read codes. Using plain language and conventional date and time configuration in both local and universal (UTC) time could go a long way toward making flight safety information easier to understand. The Federal Aviation Administration (FAA) has been aware of the NOTAM problem for more than 15 years. In 2012, Public Law 112-153 (Pilot’s Bill of Rights) gave the FAA 1 year to fix the problem. The incident at SFO makes it clear that there is still much more work to be done. This is a safety issue that calls for urgent action.

The fatigue factor. Fatigue continues to be a recurring factor in accidents and incidents. The Air Canada captain had been awake for 19 hours at the time of the incident. It’s estimated that he awoke around 0800 eastern time (ET); the incident occurred at 0300 ET the following day. The captain was not technically “on duty” that whole time, and, under Canadian regulations for reserve crew members, he still could have been available for duty for another 9 hours.

During postaccident interviews, the captain said he did not make a timely incident report to Air Canada’s dispatch after landing because it was “very late” and he was “very tired.” If the captain is too tired to make a phone call to report an incident, should the rules allow him to fly a challenging night approach with the lives of 139 passengers and crew in the balance? If we expect solid human performance where lives are at stake, fatigue rules need to be based on human factors science. The NTSB has recommended that Canada’s fatigue regulations be modified.

Cockpit voice recorders and beyond. The Airbus’s CVR would have provided much more information on what happened, but it was overwritten during the first flight following the incident (current CVRs are only required to store a minimum of 2 hours of audio). Without the CVR data, we may never understand all the reasons behind the numerous procedural failures, but we know one thing for sure: the CVR would have provided a much better picture of just how this incident came close to being a catastrophic accident.

Cockpit image recording could provide a much richer source of critical information. We initially issued an image recorder recommendation as long ago as 2000.

We have had far more success with image-recording technology in every mode of public transportation except commercial aviation. Some pilot groups are concerned about the flight crew’s right to privacy and that the information gathered will be used punitively. Workplace right to privacy has been extensively debated, but for employees in safety-critical positions, privacy should take a backseat to human life.

Unlike written transcripts, cockpit audio and video recordings are protected by federal law and never released by the NTSB. Likewise, video recordings are protected by law from being released. Over-the-air transmissions, such as communications between a pilot and air traffic controllers, are in the public domain, by definition, but in-cockpit audio and video recordings are protected by the NTSB against public disclosure.

More importantly, image recorder data gathered routinely before an accident will be invaluable in preventing the next tragedy. This approach has been highly effective in flight operational quality assurance (FOQA). This approach may pose some technical challenges, but it will significantly increase safety and accountability.

Learn and forgive. One of the best practices used in aviation is the concept of “just culture,” or nonpunitive corrective action. Most people put their best foot forward and attempt to minimize a critical error when they make one, which is perfectly understandable. Yet, some supervisors want to mete out sanctions to “teach a lesson” or to make an example of a crew. Unless someone is habitually error prone or intentionally ignoring safety procedures, a punitive response is completely inappropriate to critical performance environments in all modes of transportation.

This Air Canada flight crew will almost certainly never make such a mistake again, and my hope is that they will continue to fly to the normal end of their careers.

We gain much more from being introspective rather than judgmental about this incident. We should celebrate when someone confesses a mistake and learns from it. This is one of the key factors in the decades-long decline in commercial aviation’s accident rate. Fortunately, we’ll get another chance to put some fixes in place to make a highly improbable event even less likely to recur. Let’s not squander it.

 

Reduce Fatigue-Related Accidents and Expand Recorder Use to Enhance Safety are topic areas on the NTSB 2017-2018 Most Wanted List.

 

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.