Category Archives: Events

Remembering Captain Al Haynes

By Jeff Marcus, Chief, NTSB Safety Recommendations Division

This past Sunday, August 25, 2019, Captain Al Haynes died a week shy of his 88th birthday. Captain Haynes was a remarkable pilot who, 30 years ago last month, brought United Airlines flight 232 to an emergency landing in Sioux City, Iowa, with no means of control except the ability to vary the thrust produced by the airplane’s two engines (the DC-10’s third engine had experienced an uncontained engine failure). Although 111 passengers ultimately perished in the accident, the actions of Captain Haynes and the other crewmembers saved the lives of 184 others on the flight.

The sequence of events started when the airplane’s central engine in the tail failed, sending heavy, high-speed shrapnel spraying through the rear of the airplane. The shrapnel cut all three of the airplane’s hydraulic lines and all hydraulic pressure was lost. This left no way for the pilots to control the airplane—at least, no way intentionally designed for that purpose. Hydraulic pressure was needed to move the airplane’s control surfaces and allow it to turn, climb or descend in response to pilot input, and to configure the airplane for landing by extending the flaps.

After the engine failure, the airplane started banking to the right and its nose dropped. The crew tried to stop the bank and bring the nose up, but the airplane did not respond. The only controls that worked were the throttles for the remaining two engines, one on each wing. By varying how much power each engine produced—that is, applying differential thrust—the pilots were able to stop the turn and bring the airplane level.

The plane pulled right, and slowly oscillated vertically in what is called a phugoid cycle, losing approximately 1,500 feet of altitude with each cycle. Among the passengers on the flight was Captain Dennis Fitch, a United pilot and training check airman, who came to the cockpit and offered Captain Haynes any help that he could provide. Captain Haynes welcomed Captain Fitch’s help.

Captain Fitch began to apply differential thrust, and that way, regained some control of the airplane. He was able to minimize the phugoid and gain some directional control, although the airplane could only turn to the right. The decision was made to make an emergency landing at the airport in Sioux City, Iowa.

The crew was able to use differential thrust alone to control the airplane’s direction of travel and descent, and line up the DC-10 with the runway. But, with no hydraulics, the flaps could not be extended. When the DC-10 was designed and approved, the total loss of hydraulic-powered flight controls was considered so unlikely that there was no need to develop and approve a procedure to deal with such a situation. Because flaps control both the minimum required airspeed and sink rate, however, the flight 232 crew could control neither.

Just prior to landing, the airplane was going 220 knots and descending at 1,850 feet per minute, well above the normal targets of 140 knots and a 300-feet-per-minute descent. As the plane touched down, the right wing tip hit the runway first, and the plane began to break up and catch fire, ultimately resulting in the fatalities of 111 people. For 184 others, Captain Haynes and his flight crew are credited with their improbable deliverance from an unlikely accident cause.

In our investigation of this accident, we pointed out that the interaction of the pilots, including the check airman, during the emergency showed the value of crew resource management (CRM – then known as cockpit resource management) training, which had been practiced at United Airlines for a decade. Ten years before the United flight 232 accident, we recommended that CRM training be required for all airline flight crews.

Flight simulator reenactments of the accident airplane’s flight profile carried out as part of our investigation revealed that it was virtually impossible to control all parameters simultaneously needed to land safely at a predetermined point. After observing the performance of a control group of DC-l0-qualified pilots in the simulator, we concluded that Captain Haynes’s damaged DC-10 airplane, although flyable, could not have been successfully landed on a runway after the loss of all hydraulic flight controls, and that, under the circumstances, United flight 232’s flightcrew reacted commendably and beyond reasonable expectations.

But the benefits of CRM training were clear. The flight crew, lead by Captain Haynes, used CRM to deal with a situation considered so unlikely that there were no procedures or training on how to respond. When talking about the accident later, Captain Haynes said, “If I hadn’t used CRM, if we had not let everybody put their input in, it’s a cinch we wouldn’t have made it.”

Although he always denied that he was a hero, Captain Haynes was the right man at the right time for an event considered to be so unlikely that it was virtually impossible. Thirty years after that accident, and mere days after Captain Haynes’s death, we at the NTSB remember how his CRM practice saved over half the people on United flight 232. Aviation is safer the world over thanks to Captain Haynes.

Safe Skies for Africa Ends, but the Safety Journey Continues

By: Nicholas Worrell, Chief, Office of Safety Advocacy

August 2019 Safe Skies for Africa symposium, Lagos, Nigeria
NTSB staff and attendees at the Safe Skies for Africa symposium in Lagos, Nigeria

After 21 years, the Safe Skies for Africa (SSFA) program officially came to an end last week at a symposium in Lagos, Nigeria. The program was established in 1998 in part to increase direct commercial air service between the United States and Africa, which was minimal at the time. Administered by the US Department of Transportation and funded by the US State Department, the SSFA program has accomplished many of its original objectives since inception, including improving the safety and security of aviation on the African continent. Over a dozen symposia and workshops have been held over the life of the program, and we organized past SSFA symposia with the South Africa Civil Aviation Authority and Kenya’s Air Accident Investigation Department. This year’s event was hosted by the Air Investigation Bureau-Nigeria (AIB-N), who also sent a team of accident investigators and industry representative to participate.

Former NTSB Managing Director (and program pioneer) Dennis Jones spent nearly 20 years in the SSFA program, participating in accident investigations, conducting workshops, helping improve accident investigation programs, and training investigators. In his opinion, the Safe Skies program has done what it was created to do. At the outset of the program, few African airlines and hardly any US airlines were flying to Africa, even though it’s the world’s second-largest continent. Today, two US carriers provide direct service to Africa, and six African countries (Egypt, Ethiopia, South Africa, Morocco, Cape Verde, and Kenya) have direct routes to the United States.

Along with increased US commercial air service to Africa, air investigation quality has improved, resulting in a lower accident rate and greater safety in commercial aviation in Africa. Many African nations now have their own accident investigation agencies, and some are even developing multimodal agencies based on the NTSB model.

We were honored to again join other NTSB communications specialists and experts, as well as former NTSB Managing Director Dennis Jones, for the final symposium. The symposium focused on the following topics:

  • The NTSB’s background and history
  • Emerging aviation safety issues
  • The investigative process and human factors
  • Accident classification and substantial damage
  • Helicopter operations
  • The challenges of providing family assistance
  • Effective safety advocacy: creating positive change in transportation safety

Our team shared lessons learned from NTSB accident investigations, as well as strategies to help our international counterparts take steps in their own aviation safety journey. The AIB-N participants were focused and receptive to our presentations, and the event was bittersweet as we parted ways with old colleagues and brought the program to a close.

Although the SSFA program has resulted in many improvements over its 21 years, more remains to be done. Safe and reliable aviation connects people all over the world, in more ways than you may realize. Aircraft components, engines, and airframes come from manufacturers all over the world. The airplanes they comprise might be flown by airlines in any country. We are all stakeholders in aviation safety, regardless of what continent we inhabit.

We look forward to more programs like SSFA that will advance international collaboration on aviation safety issues. I’m confident that new safety ambassadors will follow in the footsteps of those who participated in the SSFA program, and I look forward to working with the pioneers who participate in these programs going forward.

For our blogs on the other NTSB SSFA symposia in South Africa and Kenya, please see links below:

https://safetycompass.wordpress.com/2018/08/09/ntsb-supports-safe-skies-for-africa-initiative/

https://safetycompass.wordpress.com/2018/10/01/another-step-toward-safer-skies-in-africa/

 

Oshkosh AirVenture 2019: Raise the Bar of Your Safety Culture

By Aaron Sauer, NTSB Senior Air Safety Investigator, and Amy Terrone, NTSB Safety Advocate

Loss of control and midair accidents, drones in accident investigations, startle effects and distraction, general aviation safety trends, and survivor stories (oh my!)—these are just a few of the topics NTSB staff will present at this year’s Experimental Aircraft Association AirVenture in Oshkosh, Wisconsin. The goal of our presentations is to encourage every aviator and aviation professional to raise the bar of their safety culture.

Safety culture comprises an organization’s attitudes, beliefs, behaviors, and values regarding safety. It’s an idea with its roots in the safety of organizations; however, pilots have their own unique safety culture, as well, exchanging information informally about aircraft characteristics, avionics, and even en-route concerns, such as weather and notices to airmen (NOTAMs), that might affect a flight.

In fact, every organization has a culture, but not all culture is related to a formal organization. We are interested in helping pilots raise the safety culture bar within the broader aviation community. That’s why nearly 20 NTSB investigators, vehicle recorder specialists, safety advocates, and even the NTSB’s own Chairman Robert Sumwalt will be walking the AirVenture grounds daily July 22–28, sharing insights and learning from others.

Oshkosh forum series graphic

AirVenture is billed as the largest annual gathering of aviation enthusiasts in the United States, and maybe even the world. One week each summer, more than 500,000 EAA members, aviation enthusiasts, and pilots from 80 countries come to Wittman Regional Airport in Oshkosh. Attendees watch air shows and aerobatics and pyrotechnics displays, and attend educational forums, workshops, and demonstrations. In addition to those in the aviation industry, the event also draws members of the general public interested in aviation.

We’ve maintained an exhibit booth and delivered informative presentations at AirVenture for the past 15 years. In addition to presenting, NTSB investigators are always on hand to begin the on‑scene phase of an investigation if needed, because, unfortunately, at least one or two accidents occur each year as aircraft fly into the event. In fact, these fly-in accidents have led us to publish a safety alert urging pilots to keep their focus on safety while arriving at a major fly-in event like AirVenture, where there are more planes in the parking lot than cars.

This year we’ve asked some of the industry’s leading safety experts and those with unique insights to help us spread our safety culture message.

We’ll work with Patty Wagstaff, a legendary acrobatic pilot, to kick off the first day of the event with a discussion about what it means to “Raise the Bar of Your Safety Culture with Challenging Training.” Tim LeBaron, the deputy director for the NTSB Office of Aviation Safety Regional Operations, will introduce Wagstaff and offer preliminary comments on this issue.

The rest of the week will be filled with opportunities to learn more about how pilots can play their part in building a stronger safety culture. Staff will present several accident case studies that highlight pilot errors, lack of proficiency, and decisions that led to loss of control in flight. They will include a case study of a Teterboro, New Jersey, crash that illustrates our new Most Wanted List (MWL) issue area, “Improve the Safety of Part 135 Aircraft Flight Operations.”

MWL06s_Part135

We will also talk about weather challenges—a significant concern in general aviation flying—and how to manage and overcome a variety of scenarios, and we’ll share several safety alerts related to weather. Our research team will present general aviation safety trends and new statistics, and we’ll discuss distraction, a long-time MWL issue that is dramatically affected by the proliferation of technology in the cockpit.

But perhaps the most important presentations we will give are the ones that remind us of why we do what we do—that is, issue safety recommendations to prevent accidents and crashes.

We’ve also teamed up with two accident survivors to help drive our message home. These speakers will share their harrowing stories in the hopes that they can motivate other pilots to avoid the same mistakes. Dan Bass will offer the riveting story of how he survived an in-flight loss of consciousness due to a carbon monoxide leak, a serious safety concern that has prompted us to release several safety alerts on the topic. Trent Palmer and Nikk Audenried will share their story about a loss-of-control accident they experienced that was widely shared via YouTube. Preventing loss of control in flight has been featured on the NTSB MWL for several years.

If you’re attending AirVenture, plan to visit our booth in Exhibit Hangar D in the Federal Pavilion to meet investigators, touch a real-life “black box” (actually orange), and learn about our most important general aviation safety issues and our current MWL. You’ll likely find the Chairman engaging with pilots around our booth, and you can tune into EAA radio during the week for some of his key general aviation safety insights. We would certainly like to see you join us for our presentations and you can plan your itinerary by visiting https://www.ntsb.gov/news/events/Pages/2019-EAA-AirVenture-EVT.aspx.

Even if you can’t make it to AirVenture 2019, rest assured that we’re using opportunities like AirVenture throughout the year to encourage general aviation aviators and aviation professionals to raise the bar when it comes to safety.

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

Remember Bellingham

By Member Jennifer Homendy

Today marks the 20th anniversary of the Olympic Pipe Line rupture in Bellingham, Washington, which resulted in the release of about 237,000 gallons of gasoline into a creek that flowed through Whatcom Falls Park. Sometime after the rupture, the gasoline ignited and burned about 1.5 miles along the creek. Two 10-year-old boys and an 18-year-old young man named Liam Wood died; 8 others were injured.

Bellingham, WA
Postaccident aerial view of portion of Whatcom Creek showing fire damage.

Liam had just graduated from high school and was fly fishing when he was overcome with fumes from the rupture. Years later, I met Liam’s stepfather, Bruce Brabec, as a staffer on Capitol Hill. Since Liam’s death, Bruce has been a tireless advocate for closing gaping holes in pipeline safety regulations, many of which have been revealed as a result of our pipeline accident investigations.

This past fall, I saw Bruce at a pipeline safety conference. The discussions over the days that followed left me wondering how much we’ve accomplished over the last 20 years. Is our pipeline system truly safer?

From a numbers standpoint, it’s good news and bad news. According to the Pipeline and Hazardous Materials Safety Administration (PHMSA), there were 275 significant gas and hazardous liquid pipeline incidents in 1999, resulting in 22 fatalities and 208 injuries. Since that time, the number of significant incidents has fluctuated as PHMSA adopted new reporting criteria, with 288 significant incidents occurring in 2018.

Fatalities and injuries have decreased since 1999 to 7 fatalities and 92 injuries in 2018, but that provides no comfort for victims, their families, or their loved ones. The fact is, although pipelines are one of the safest ways to transport hazardous material, the impact of just one incident can be devastating. And although the number of accidents is low compared to other modes like highway and rail, there is much more that pipeline operators and federal regulators can do to get to zero incidents, zero fatalities, and zero injuries on our nation’s pipeline system.

Our recommendation for operators to install automatic or remote-control shut-off valves in high‑consequence areas is a perfect example. In 1994, we investigated a natural gas transmission pipeline rupture in Edison, New Jersey, which resulted in a fire that injured 112 people and destroyed 8 buildings. Pipeline operators were unable to shut down the gas flow to the rupture for 2½ hours. Our report on the accident recommended that the Research and Special Programs Administration (RSPA), PHMSA’s predecessor, expedite requirements that automatic- or remote‑operated mainline valves be installed on high-pressure pipelines in urban and environmentally sensitive areas so that failed pipeline segments can be rapidly shut down. We have been recommending valve installation in some form on pipelines since 1971.

In response, RSPA issued a regulation requiring operators to install a valve only if the operator determines it will efficiently protect a high-consequence area in the event of a gas release.

Fast forward to September 9, 2010, when an intrastate natural gas transmission pipeline owned and operated by the Pacific Gas and Electric Company ruptured in a residential area in San Bruno, California. The rupture produced a crater about 72 feet long by 26 feet wide. The section of pipe that ruptured was found 100 feet south of the crater. The released natural gas ignited, resulting in a fire that destroyed 38 homes and damaged 70. Eight people were killed, many were injured, and many more were evacuated from the area.

In our report on the accident, we once again recommended that PHMSA expedite the installation of automatic shutoff valves and remote-control valves on transmission lines in populated areas, drinking water sources, and unusually sensitive ecological resources. Congress then required PHMSA to implement the recommendation in the Pipeline Safety, Regulatory Certainty, and Job Creation Act of 2011 (PL 112-90).

It’s been a decade since San Bruno, and PHMSA is nowhere near issuing a final rule to implement our recommendation. This issue is highlighted on our 2019–2020 Most Wanted List of transportation safety improvements (Ensure the Safe Shipment of Hazardous Materials).

MWL03s_HazMat

It’s my hope that over the next few years, we’ll see some real improvements in pipeline safety and avoid tragedies like the ones in Bellingham and San Bruno. With the technology we have readily available today, there’s absolutely no reason for any parent to have to face the loss of a child because of a pipeline accident. I hope that the next time I see Bruce Brabec, we’ll finally have the regulations in place that he’s worked so hard for on Liam’s behalf.

 

 

 

 

Eliminate Distractions

By Vice Chairman Bruce Landsberg

The NTSB has investigated distraction-linked crashes in all modes of transportation. Our 2017 distracted driving roundtable, “Act to End Deadly Distraction,” made one thing very clear:

We don’t feel these losses in a statistical table. We feel them at the dinner table. We also don’t call them “accidents” because they are totally predictable.

More than 100 people die every day on our roads and highways, nine or ten of them per day in distraction-involved crashes alone. More than 1,000 people per day—391,000 in one year—are injured in distraction-involved crashes. And it’s certain that this number is greatly under-counted. Many of these injuries are life-altering, disfiguring and permanently crippling. My apologies for being graphic – but ask anyone who’s been involved whether the distraction that caused the crash was worth it.

Listen to stories told in our 2017 roundtable by survivor advocates. Or, simply ask around. It won’t take long to find someone with a story of a friend, business colleague or loved one lost to a distracted driver.

What too many of these crashes have in common is a portable electronic device – the universal cell phone. When the NTSB made its first recommendation about driver distraction by “wireless telephone” in 2003, cell phones were primarily just that: tools for making voice calls. Although some cell phones had keypads, the word “texting” does not appear in that early report.

In 2011, the NTSB recommended that the states ban non-emergency driver use of all portable electronic devices that did not support the driving task. To date, no state’s laws have gone that far. Why?

And since drivers look to the law for guidance, no state’s drivers have gone so far as to voluntarily stop driving while visually, manually, and/or cognitively distracted. Why?

Now, a second 2011 NTSB safety recommendation is becoming steadily more feasible: Safety Recommendation H-11-47. We recommended that CTIA—the wireless association, and the Consumer Electronics Association, encourage the development of technology that can disable portable electronic devices within reach of the driver when a vehicle is in motion (with the ability to permit emergency use of the device while the vehicle is in motion, and the capability of identifying occupant seating position so that passengers can use their devices).

Unfortunately, the recommendation has not been adopted, despite smartphones and apps that will allow the driver to opt out of calls and texts while driving. So, why hasn’t there been more action on this recommendation?

The best safety solution is always to design out the problem. Rather than just encourage people to do the right thing, don’t give them the opportunity to do the wrong thing… and possibly take a life or maim someone.

Don’t misunderstand, we endorse a solid tech solution, but such a solution won’t work in every situation. It must be a belt-and-suspenders effort, together with the familiar three-legged stool of highway safety (awareness, tough laws, and high-visibility enforcement).

This year many more loved ones will be lost to distraction, but surveys tell us that most people think distracted driving is a bad idea. Until, that is, we have to put our own phone down. Hypocritical? It couldn’t possibly happen to me – I’m too good a driver! The numbers prove otherwise.

Time, tide and tech wait for no man or woman, to coin a phrase. By the end of today a thousand more families will be dealing with tremendous loss and pain.

This month, the NTSB will host its third Roundtable on Distracted Driving: Perspectives from the Trucking Industry. During the roundtable, members of the trucking community, victim advocacy groups, the business community and legislators will come together to discuss the problem of distracted driving and potential countermeasures. We also hope to hear about new efforts to close Safety Recommendation H-11-47.

To kickoff Distracted Driving Awareness Month, on April 3, we will also host, with Impact Teen Drivers and the California Highway Patrol, the Western States Teen Safe Driving Roundtable to talk about the state of teen driving and the proven strategies for preventing teen-driving related crashes.  Now, what are you going to do about it?

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.