Anthony Lam, NTSB Transportation Safety Specialist, Office of Safety Recommendations and Communications
In a significant move toward enhancing aviation safety, the Federal Aviation Administration (FAA) recently mandated safety management systems (SMSs) for Part 135 operators, Part 91.147 air tour operators, and certain aircraft manufacturers. This ruling comes in response to the pressing need for proactive safety measures in revenue passenger-carrying operations. The NTSB swiftly responded to this development in a recent press release, commending the FAA for its decisive action while also stressing the need for further measures to ensure comprehensive protection for all passengers.
The journey toward this milestone ruling has been marked by the NTSB’s longstanding advocacy for SMS implementation in revenue passenger-carrying operations. The NTSB made its first aviation safety recommendation on SMS in 2007. This recommendation led the FAA to require commercial air carriers (Part 121) to implement an SMS. The agency’s ongoing advocacy for these systems in other revenue passenger-carrying operations is evidenced by six open safety recommendations to the FAA regarding SMS between 2016 and 2022, namely:
The NTSB hosted a panel discussion, “Improving the Safety of Part 135 Operations,” in 2020
Additionally, NTSB advocacy events and initiatives on SMS, such as our 2020 Part 135 safety panel discussion, 2021 NTSB blog post, and 2023 SMS virtual roundtable on the importance of implementing SMS in small to midsized aviation operations further underscore our dedication to promoting SMS in other aviation sectors. These advocacy events and initiatives, among others, highlight the critical role of proactive safety measures in aviation operations and underscore the NTSB’s dedication to promoting SMS in the aviation sector.
The NTSB hosted a virtual roundtable in 2023 to discuss the importance of implementing SMS in small to midsized aviation operations
The NTSB’s advocacy efforts, including the aforementioned events and initiatives, have played a crucial role in raising awareness and driving action toward SMS implementation in revenue passenger-carrying operations. These initiatives have paved the way for the FAA’s recent mandate, demonstrating the power of collaborative efforts in advancing aviation safety standards.
As we celebrate this milestone, it is imperative to acknowledge the collective efforts of all stakeholders involved. Moving forward, continued collaboration and proactive measures will be essential to addressing evolving risks and ensuring the comprehensive protection of passengers and crews alike. Together, we will continue to build a safer sky for all.
By Stephanie Matonek, NTSB Transportation Disaster Assistance Specialist
Today, the third International Day Commemorating Air Crash Victims and their Families, we join with survivors in remembering those they have lost.
Three years ago, the International Civil Aviation Organization (ICAO), in cooperation with the Air Crash Victims’ Families’ Federation International (ACVFFI), designated February 20 the International Day Commemorating Air Crash Victims and Their Families. This observance was established to ensure we never forget about the victims and their families, or the unimaginable journey these families faced in the aftermath of an aviation disaster.
In the United States, the NTSB’s Family Assistance program was established in part by the tireless efforts of survivors and family members advocating for change after experiencing loss and suffering from aviation disasters in the 80s and early 90s. Today, the NTSB’s Transportation Disaster Assistance (TDA) team continues this important work to ensure survivors and families are provided information, resources, and support after a disaster, no matter what mode of transportation it occurs in. Yet the TDA team that is responsible for this program cannot do this work alone. Over the decades since the NTSB’s family assistance program began, the partnerships we have made with organizations and agencies from around the world and involved in providing family assistance after transportation disasters have become an integral part of our existence. In fact, our team today is continuously reminded how important and valuable these partnerships are to ensuring we meet the fundamental needs of survivors and families when tragedy strikes.
One partnership in particular has been vital to the NTSB’s family assistance program since its inception: the American Red Cross. At the request of the TDA team, the Red Cross provides direct care and support to hundreds of families and survivors yearly. These efforts can be seen during NTSB public events, through direct requests by those TDA assists, and on-scene at accidents that NTSB investigates.
Today we remember each and every air crash victim we have lost, and their families. And we extend our appreciation to our family assistance partners that help us ensure that those who are affected most, survivors and families, get the care and support they need, no matter where or when a disaster occurs.
“Yes, And” Approach Also Retains Familiar Excel Tables
By NTSB Safety Advocacy Team
Before reading any further, start exploring this dashboard. Addictive, right? If you care about aviation accidents, the NTSB’s dashboards get the statistics to you in an interactive format that always seems to have another layer to discover.
If you use the NTSB’s static accident spreadsheets in Excel, you can keep using them. But you’re getting less information, with less control, than is available to you through the agency’s data dashboards. Many users grab the same data regularly to populate legacy products, but if you want to see the data from many points of view with more control, check out the data dashboards.
In the new US Civil Aviation Accident Dashboard, for example, you can customize a range of years, see the data on a map, and filter by accident details for Part 121, Part 135, and general aviation (GA) flights. Familiar Excel tables, such as Accidents by Defining Events and Phases of Flight, are still available, but the dashboard lets you further customize the selected data dynamically by operation type, injury level, and state, delivering many more possible data views than the tables provide.
Screen capture of the NTSB US Civil Aviation Summary Dashboard
“We rolled out the GA dashboard for Oshkosh (EAA Airventure),” says Senior Aviation Accident Analyst Nathan Doble, who made the annual US Civil Aviation data available and interactive in dashboard form. “We recognized that this is a new capability for many of our users, so we wanted to provide training and solicit their feedback.”
Chief Data Scientist Loren Groff adds the team was conscientious about enhancing customer experience. “We took a ‘Yes And . . .’ approach with all of the dashboards. We’ll give you that familiar government document and we’ll also give you the new dashboard version with so much more control by the user.”
“Then there is the state-by-state, monthly breakdown,” Groff explains. “We had a congressional requirement to report accidents in Alaska monthly. The NTSB data analytics team thought, if we’re doing it for Alaska, why not do it for all the states?” (The monthly data are actually updated daily and organized by year and month.)
You can bring up a list of accidents covered in all of the dashboards, which in turn link to accident reports, and plot the accidents on a map. For GA accidents, you can see what types of findings and what recommendations the NTSB has issued in connection with accidents that meet the users’ filters.
Screen capture of the General Aviation (GA) Dashboard
Groff, Doble, and the Safety Research Division are taking the agency’s accident data from static tables to powerful interactive dashboards defined by the user, and in the process offering increased content and capabilities. Stay tuned as the NTSB’s dashboard capabilities continue to grow.
By Jeff Marcus, Chief, NTSB Safety Recommendations Division
From the Wright brothers’ first flight on December 17, 1903, to today, aviation has made remarkable progress. The affordability, speed, capacity, comfort, and, most importantly, safety of flight have all improved to the point that flying is one of the safest modes of transportation.
But that safety has been hard won. In honor of National Aviation History Month, let’s reflect on how the aviation industry and Congressional action have evolved to further transportation safety.
The Early Days of Flying
Although most people are familiar with the Wright brothers, who did the research and development that produced the first airplane, many are unfamiliar with other important visionaries, such as Otto Lilienthal and Samuel Langley.
Otto Lilienthal with glider, 1895 Photo credit: Library of Congress
Karl Wilhelm “Otto” Lilienthal was a German pioneer of aviation who made the first successful flights with gliders, making the idea of a heavier-than-air machine a reality. His flight attempts in 1891 are seen as the beginning of human flight. Lilienthal made over 2,000 flights in self-designed gliders until his death on August 9, 1896, when he was unable to regain control after his glider stalled. Falling from about 50 ft, he broke his neck and died the next day. At the time of his death, Lilienthal’s total lifetime flying time was about 5 hours. The Wright brothers later cited Lilienthal’s death as the point when their serious interest in flight research began.
Samuel Langley’s Experimental Tandem Biplane on the Potomac River, 1896 Photo credit: Library of Congress
Another early aviation pioneer was Samuel Langley. In addition to being an American aviation innovator, Langley was the third secretary of the Smithsonian Institution. His first aviation success came on May 6, 1896, when his unpiloted, steam-powered, fixed-wing aircraft, weighing 25 pounds, made two flights—one 2,300 ft and the other 3,300 ft—after a catapult launch from a boat on the Potomac River. He followed that on November 11, 1896, with an improved aircraft model that flew more than 5,000 feet. In 1898, based on the success of his models, Langley received grants of $50,000 from the War Department and $20,000 from the Smithsonian to develop a piloted airplane.
Langley gave up on the project after two crashes on take-off on October 7 and December 8, 1903 (just a few days before the Wright brothers’ successful flight). The Smithsonian displayed Langley’s device as the first human-carrying airplane in the world capable of sustained free flight, triggering a decades-long feud with Orville Wright.
The first aviation fatality in a powered aircraft crash came on September 17, 1908, when, during a demonstration flight for the War Department in hopes of getting a military contract for their invention, Orville Wright crashed his aircraft, injured himself, and killed his passenger, Signal Corp Lieutenant Thomas Selfridge.
Lt. Selfridge & Mr. Wright stepping into the Wright airplane at Ft. Myer, 9/17/1908 Photo credit: Library of Congress
The Wright Flyer flew four circles around Fort Myer at an altitude of 150 feet. Halfway through the fifth, the right propeller broke, creating a vibration. The damaged propeller hit a guy-wire bracing the rear vertical rudder. The wire tore out of its fastening allowing the rudder to swivel to the horizontal sending the Flyer into a nosedive.
Wright cut the engine and glided to about 75 feet, but then the aircraft descended nose-down into the ground. Wright and Selfridge were thrown forward, and Selfridge struck one of the wooden uprights of the framework, fracturing the base of his skull. He died 3 hours later without regaining consciousness. Wright suffered severe injuries and was hospitalized for 7 weeks.
Despite the setback, aviation continued to develop worldwide, and on January 1, 1914, the St. Petersburg-Tampa Airboat Line became the world’s first scheduled airline. The airline provided service between St. Petersburg, Florida, and neighboring Tampa—a distance of about 23 miles with a travel time of 23 minutes (compared to 2 hours by boat). A one-way fare was $5.00 (approximately $130 in 2020 dollars), and flights rarely exceeded an altitude of 5 feet. The service terminated on May 5, 1914.
The Birth of Commercial Aviation
During the 1920s, airlines began to offer regular commercial air service. The were 24 fatal commercial airline crashes over 1926 and 1927, 16 in 1928. In 1929, which remains the worst year on record, there were 51 fatal crashes, about 1 for every 1,000,000 miles flown. In today’s world, this rate would result in 7,000 fatal airline accidents per year, or about 20 every day.
Partly in reaction to this accident rate, Congress passed the Air Commerce Act, which President Calvin Coolidge signed into law on May 20, 1926. The act established federal control over civil aviation by making the secretary of commerce responsible for improving air commerce by designating and establishing airways; establishing, operating, and maintaining aids to air navigation (but not airports); sponsoring and conducting research and development to improve such aids; licensing pilots; issuing airworthiness certificates for aircraft and major aircraft components; and investigating accidents.
On March 31, 1931, a Fokker F-10A operated by Transcontinental and Western Air (which evolved to become TWA) crashed near Bazaar, Kansas, after the wooden structure of one wing failed in flight. The crash killed eight people, including Notre Dame football coach Knute Rockne. The investigation found that the wooden wing became moist over time, causing the glue connecting the wing to the body to weaken, allowing the wing to separate. At the time, the investigation was publicly criticized for its secret nature. This crash brought about significant changes in the airplane industry, and was of cultural significance, given the death of Rockne and the public perception of aircraft safety. This accident, which killed a well-known public figure and the secretive nature of the investigation brought public attention to learning from accident investigations to prevent such disasters in the future. The intense public interest forced the Department of Commerce to make the results of aircraft accident investigations more transparent.
The investigation of the Bazaar, Kansas, crash resulted in a public expectation that the US government would objectively investigate crashes and publicly release its findings. In 1934, the Air Commerce Act was amended to require that reports on probable causes of fatal aircraft crashes be made public and banned the use of such reports and related evidence in court proceedings.
On May 6, 1935, a Douglas DC-2 operated by TWA crashed near Atlanta, Missouri. Its pilots were trying to make an emergency landing before their fuel ran out. The crash killed five, including Senator Bronson M. Cutting of New Mexico. Public debate and criticism over the cause of the accident showed the need for an independent investigative body.
Investigators from the Bureau of Air Commerce concluded that several factors led to the crash, including communications malfunctions, darkness, inaccurate weather forecasts, worsening weather at the destination airport, and errors in judgment, both from the airline dispatchers and the flight crew. They also found TWA in violation of several aviation regulations. Senator Cutting’s death drove Congress to investigate the Bureau of Air Commerce’s management of civil aviation. Senator Royal S. Copeland established a special subcommittee that harshly criticized the bureau in a report. Partly as a result, in 1938, President Franklin Roosevelt signed the Civil Aeronautics Act of 1938, which transferred federal responsibilities for nonmilitary aviation from the Bureau of Air Commerce to a new, independent agency: the Civil Aeronautics Authority.
Focus on Safety
On June 30, 1940, the Civil Aeronautic Authority was split into the Civil Aeronautics Administration (CAA) and the Civil Aeronautics Board (CAB). The CAA area of responsibility was air traffic control, safety programs, and airway development. The CAB focused on safety rulemaking, accident investigation, and economic regulation of the airlines.
During the 1950s, airline travel expanded. A midair collision on June 30, 1956, between a TWA Super Constellation and a United Air Lines DC-7 over the Grand Canyon killed all 128 occupants of the two airplanes. The collision occurred while the airliners were flying under visual flight rules in uncongested airspace. The accident showed that, even though US air traffic had more than doubled since the end of World War II, little had been done to expand the air traffic control system or to increase safeguards against midair collisions. This accident led directly to the Federal Aviation Act of 1958, which President Dwight Eisenhower signed on August 23, 1958. The law created the Federal Aviation Agency and led to the creation of the air traffic control system as we know it today.
Air traffic control booth with staff at Washington National Airport, Arlington, Virginia, 1958 Photo credit: Library of Congress
On October 15, 1966, President Lyndon Johnson signed the Department of Transportation (DOT) Act, which created the new cabinet-level department with five major agencies, including the Federal Aviation Administration. The DOT Act also created, within the DOT, an independent National Transportation Safety Board (NTSB) with authority to investigate accidents in all modes of transportation. The new DOT began operations on April 1, 1967.
President Lyndon Johnson signs the Department of Transportation Act that created the NTSB, 1966 Source: NTSB.gov
In 1974, Congress made the NTSB completely independent of the DOT with the Independent Safety Board Act of 1974, which also prohibits the use of any portion of an NTSB report as evidence in a lawsuit related to matters discussed in the report and, with few restrictive exceptions, bars discovery, admittance into evidence, and public release of transcripts or recordings of a “cockpit or surface vehicle . . . voice or video recorder,” if not made public by the NTSB. In 1996, the Aviation Disaster Family Assistance Act expanded the role of the NTSB to include coordinating victim and family assistance following a major aviation accident.
The history of aviation, and the remarkable safety enjoyed today, are the result of the detailed aviation accident investigations throughout the years. And that work continues at the NTSB today, because we know that, from tragedy, we draw knowledge to improve the safety of us all.
Jeff Marcus, Chief of the Safety Recommendations Division, is retiring from federal service on December 29 after 43 years.
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.
NTSB Safety Compass Blog 