Category Archives: Aviation Safety

Prioritizing Safety This Holiday Travel Season

By Stephanie Shaw, Acting Chief, NTSB Safety Advocacy Division

This week, families and friends will gather to celebrate the Thanksgiving holiday. According to estimates from AAA, nearly 55 million people will travel away from home this year, with about 49 million of them taking to the roads.

As we mark the beginning of the holiday travel season, we want to ensure that everyone arrives safely at their destinations. Unfortunately, travel on our roads can be the riskiest mode of travel during the holiday season.

NTSB investigations continue to highlight actions needed by regulators, legislators, and industry to ensure the safest transportation system for the traveling public. Our Most Wanted List (MWL) identifies specific transportation safety improvements needed across all modes. It includes five road safety improvements that address pervasive problems like speeding, alcohol and other drug impairment, and distraction. The MWL also calls for collision-avoidance and connected vehicle technologies and implementation of a Safe System Approach to better protect all road users.

At the NTSB, we believe that safety is a shared responsibility, so for the traveling public, we’ve highlighted some ways you can keep yourself and others safe, regardless of the travel mode you choose.

By Car

Impairment by alcohol and other drugs, unsafe speeds, fatigue, and distraction continue to play major roles in crashes. Here’s what you can do:

  • Designate a sober driver, or call a taxi, or ridesharing service if your holiday celebrations involve alcohol or other impairing drugs.
  • Follow safe speeds. In bad weather, safe speeds are often below the designated speed limit. Speeding increases the chance of being involved in a crash and intensifies the severity of crash injuries.
  • Make sure you’re well rested! A fatigued driver is just as dangerous as one impaired by alcohol or other drugs.
  • Avoid distractions. Don’t take or make calls or text 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.
  • Make sure to use the correct safety restraint for child passengers, and be sure it’s installed correctly.
  • Ensure you and all your passengers are buckled up! In a crash, seat belts (and proper child restraints) are your best protection against death and serious injuries.

By Bus

The NTSB has made recommendations to improve 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.
  • Ask your driver to give you a safety briefing if you’re unsure of where the exits are or how to use them.
  • Use your seat belt when they’re available!

By Plane or Boat

These tips can help you and your loved ones in an emergency on planes or vessels.

  • 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.
  • Know where to find the nearest emergency exit and flotation device whether you’re on an airplane or a boat.
  • Confirm that you and your traveling companions—even children under age 2—have your own seats and are buckled up when flying.
  • Don’t forget your child’s car seat. The label will usually tell you if your child car seat is certified for airplane use; the owner’s manual always has this information.
  • Call the airline and ask what the rules are for using a child’s car seat on your flight, if you don’t already know.
  • Follow crewmember instructions and remain calm in an emergency.

By Train

The NTSB has made recommendations to improve passenger rail operations and vehicle crashworthiness, but travelers should also follow these safety tips.

  • Stow carry-ons in the locations provided (overhead and racks). Don’t block aisles.
  • Review your trains safety information which may be provided as a safety card in your seat pocket or displayed in your railcar.
  • Follow crewmember instructions and remain calm in an emergency.

No matter how you travel, make a commitment to put safety first.

We wish everyone a safe and happy Thanksgiving.

Episode 49: EAA Air Venture Oshkosh 2022

In this episode of Behind-the-Scene @NTSB we talk with Tim LeBaron, Director; Kristi Dunks, Acting Deputy Director for Regional Operations; and Aaron Sauer, Senior Air Safety Investigator, in the Office of Aviation Safety, about their work to improve general aviation safety and the NTSB’s participation in the upcoming EAA AirVenture Oshkosh event. Hear more about our “Fly Like a Pro” presentation theme for this year, the safety messages being shared with the GA community, including our updated Safety Alert on fly-ins and other safety resources, and where you can find Member Mike Graham and NTSB staff throughout the event.

For more information about NTSB at the EAA Air Venture Oshkosh event, visit our webpage.

To learn more about NTSB aviation investigations, and to access investigative reports, visit our investigations webpage.

NTSB Safety Alerts are also available on our website.

Subscribe to the podcast on Apple PodcastsStitcher or your favorite podcast platform.

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

Ready to Answer the Call

By Lorenda Ward, Chief, NTSB Air Carrier and Space Investigations Division

When I read the Chair’s blog, “A Call to Action from Kennedy,” I asked myself, “Are we ready?” Not for commercial space exploration, but for the next commercial space accident investigation.

One of my responsibilities as the chief of the NTSB’s Air Carrier and Space Investigations Division is to ensure that our senior aviation investigators are prepared to respond to a commercial space accident. As the Chair outlined in her blog post, with the growth of commercial space launches and reentries, it is not a matter of “if,” but a matter of when.

What if we get the call today?

The NTSB has done a lot over the last several decades to prepare, including establishing the Quad-Agency Working Group with the Federal Aviation Administration (FAA), NASA, and the US Space Force, to build those important relationships between the agencies before a bad day happens. We meet regularly to discuss lessons learned and best practices from past investigations to ensure we are ready for the next investigation.

We also have a lot of training opportunities for our investigators that are above and beyond just attending industry conferences. Several years ago, I helped create a spacecraft design and systems engineering training course, as well as a commercial space externship program for our investigators to learn about the different space vehicles. We also take part in mishap tabletop exercises where we discuss the NTSB party process with both government and industry organizations. By far though, our best training opportunities have been the “on-the-job training” investigations that we’ve taken part in over the years. These investigations have provided us a great understanding of multiple launch vehicles and systems.

Responding to the Call

I remember leading the last fatal commercial space accident involving Scaled Composite SpaceShipTwo (SS2). I was actually at the site of another commercial space mishap, examining the recovered ordnance, when the SS2 accident occurred. Because of the possibility that cellphone signals could detonate unexploded munitions, our whole team had left our phones on the bus while we were at the storage location.

An FAA investigator who had stayed back came running into the bunker, saying we need to go now. I didn’t ask any questions and it wasn’t until I got back on the bus that I saw my boss had been repeatedly calling me for half an hour.

When I finally talked with my boss, he told me I would be the investigator-in-charge (IIC) of the go-team to investigate the first fatal commercial space launch accident. All the federal investigators (NTSB and FAA) had to work our way back from Wallops Island, Virginia, to DC. I had to keep pulling over to be patched into conference calls, so the commute took a lot longer than usual. At NTSB, we do not take calls while driving as distracted driving is a serious issue on our roadways. We have an agency-wide policy that prohibits staff from using a cell phone while driving. I remember at one point telling management I would never make it back to DC if I had to keep pulling over.

For the next 9 months, my focus was determining what happened to SpaceShipTwo. The accident occurred on October 31, 2014, when SS2 broke up during its fourth rocket-powered test flight and impacted terrain over a 5-mile area near Koehn Dry Lake, California. One test pilot (the co-pilot) was fatally injured, and the other test pilot was seriously injured. SS2, a reusable suborbital rocket, had released from WhiteKnightTwo, the carrier vehicle, about 13 seconds before the breakup. SS2 was destroyed, no one on the ground was injured by the falling debris, and WhiteKnightTwo made an uneventful landing.

SpaceShipTwo released from WhiteKnightTwo (Source: Virgin Galactic WK2)

Scaled Composites (“Scaled”) was operating SS2 under an experimental permit issued by the FAA Office of Commercial Space Transportation (AST) according to the provisions of 14 Code of Federal Regulations Part 437. The investigation identified several safety issues, to include the lack of human factors guidance for commercial space operators, missed opportunities during the FAA/AST’s evaluations of Scaled Composite’s hazard analyses, FAA/AST granting waivers from regulatory requirements, and an incomplete commercial space flight database for mishap lessons learned. The full report, safety recommendations and docket material, are available on the NTSB investigation page.

What Went Wrong?

The probable cause of the breakup was Scaled Composite’s failure to consider and protect against the possibility that a single human error could result in a catastrophic hazard to the SS2 vehicle. This failure set the stage for the copilot’s premature unlocking of the feather system which led to uncommanded feather extension and the subsequent overload and in-flight breakup of the vehicle. The accident vehicle had onboard video recording (cockpit image recorder) capability and the recording was obtained from a telemetry ground station located in Scaled’s control room at Mojave Airport, Mojave, California. This video was a key part of the investigation, showing cockpit displays and what actions the crew members took.

The Party System

All of our investigations use a party system, meaning that the operator and the regulator will be part of our investigation, at a minimum. For the SpaceShipTwo investigation, we invited Scaled, Virgin Galactic, Butler Parachute Systems, and the FAA to be parties. Scaled built and tested SS2 and had delivered WhiteKnightTwo to Virgin Galactic before the accident. Scaled had planned on transitioning SS2 to Virgin Galactic toward the end of 2014.

WhiteKnightTwo hangar visit during on scene phase of investigation, Nov. 2, 2014, Mojave, CA (Source: NTSB)

At the end of the investigation, a couple of the party members mentioned that when we first arrived on scene, wearing our blue jackets with giant yellow letters, they had no idea what to expect or what they were in for. They thought they were being invaded. For this reason, and others, we like to meet with commercial space operators before an accident, so we can explain the NTSB investigation process before we show up on their doorstep for an accident investigation. That initial reaction turned to one of trust as the investigation progressed. They said they were glad we led the investigation and had learned a lot from us. We, in turn, also learned a lot from all the parties.  

Some party members also mentioned that they felt like full participants in the investigation, and that their voices were heard. To that point, the investigation would not have been completed in 9 months if we did not have the professionalism, openness, responsiveness, and willingness of the parties to trust our process.

To return to the question that I asked myself on reading the Chair’s blog: “Are we ready?”

Yes, we are ready. Nobody is more ready. This is what we do: Investigate. Communicate. Advocate.

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.