Category Archives: General Aviation

Roundtable Discussion Yields Key Insights, Critical Actions Needed for Improving Safety of Part 135 Flight Operations in Alaska

By Chairman Robert Sumwalt

On September 6, in Anchorage, Alaska, I facilitated a first-of-a-kind roundtable of industry operators, government officials, educators, and aviation associations. Troubled by investigations into too many crashes involving Part 135 flight operations (which include air medical service, air taxi, air tours, charter, and on-demand flights) in Alaska, we called together some of the brightest experts across industry, academia, and government to help answer one question: How can we improve the safety of flight operations involving these aircraft?

We had some ideas on how to answer that question already; the issue is on our Most Wanted List of transportation safety improvements. For example, we know that safety management systems (SMS), flight data monitoring (FDM), and controlled-flight-into-terrain (CFIT) training can help ensure that operators manage their planes and pilots in the safest possible way, reducing the chances of a crash. But we wanted to hear ideas from others—specifically those flying in Alaska, where Part 135 crashes are so prevalent—and urge operators and regulators to make some of the changes we believe will help.

Between January 2008 and June 2019, we investigated 204 fatal accidents in Alaska

fatal part 135 alaska accidents
Fatal Part 135 Alaska Accidents – Accident data from January 1, 2008 to August 12, 2019

involving fixed-wing aircraft and helicopters, scheduled and nonscheduled, in Part 135 operations. These accidents killed 80 people. At the roundtable, Dana Schulze, the NTSB’s Director of Aviation Safety, briefed us on the leading causes of Part 135 accidents in Alaska, reporting that nearly 80 percent of fatal accidents in Alaska are due to CFIT, loss of control in flight, midair collisions, and unintended instrument meteorological conditions.

Alaska has several challenges compared to the “lower 48,” such as unique terrain conditions, difficult weather, and congested airspace. That’s why we thought it important to talk specifically to those navigating this terrain. However, the deadly consequences of a crash are the same, regardless of where it occurs, and aviators across the country should be concerned with the issues we discussed at the roundtable.

I kicked off the roundtable of 29 experts, many of whom were operators, with a reminder that there is a business case for safety. I challenged the panel to come up with concrete solutions that we could collectively address. From the start, we agreed on one thing: the September 6 roundtable wouldn’t just be a conversation; it would be a call to action.

Chairman addresses panel about risk management
NTSB Chairman Robert Sumwalt talks with panelists about risk management during the September 6 roundtable on Alaska Part 135 Flight Operations

Our panelists discussed four key areas: training, risk management, technology, and infrastructure. We were pleased to see that many of their ideas related to these topics aligned with recommendations the NTSB has already issued, which are noted below. However, we welcome a discussion about any and all other potential improvement areas. Areas which the panelists agreed that they will evaluate further and perhaps pursue individually and collectively included:

Training

  • Cue-based (simulator) training has an impact on pilot decision-making and should be encouraged and required. Pilots taking CFIT training on a simulator performed significantly better on subsequent real-world flights than those who didn’t. (Note: the NTSB supports and has made recommendations to improve CFIT training for pilots).
  • To improve safety, operators must consider five safety principles: knowledgeable pilots, training, proficiency, reliable equipment, and culture.
  • The five things every operation must do are (1) realize it needs to change, (2) have a project champion, (3) create clearly defined standard operating procedures, (4) offer quality assurance systems, and (5) mentor/train employees.
  • We must do a better job of training the trainers.

As part of our training discussion, we talked about the recent closing of the Medallion Foundation, a flight safety advocacy organization in Alaska, and its impact on the industry. Medallion simulators will continue to be available to Alaska’s pilot community after the Federal Aviation Administration (FAA) determines where those simulators will be placed.

Risk Management

  • An SMS is important and worthwhile for improving safety, but it should be scalable
    Panelist Jens Hennig from GAMA with Corey Stephens FAA in background
    Panelists Jens Hennig, GAMA and Corey Stephens, FAA 

    depending on the size of the operator. Smaller operators may find it economically wise to outsource their safety assurance/FDM programs. (Note: As mentioned earlier in the blog, the NTSB has issued recommendations requiring SMS and FDM). One roundtable participant pointed out that there are 303 Part 135 operators in Alaska; of those, only eight are in the FAA’s SMS program.

  • Safety management requires the commitment of company leadership, but it’s just as important to involve pilots, mechanics, and management in the process so they recognize the value of an SMS, too.
  • An SMS should be a required prerequisite to participate in any federally funded programs, such as U.S. mail delivery and Medicare/Medicaid transport.
  • Useful data can be found in the FAA’s Aviation Safety Action Program. Carriers can benefit from the aggregated data collected in this information-sharing program.

Technology

  • Operators should equip their planes, either voluntarily or by requirement, with automatic dependent surveillance-broadcast (ADS-B) technology, and the FAA should consider helping smaller operators fund such an improvement. In Alaska, ADS-B is only required in the Class C airspace above Ted Stevens International Airport, and above 18,000 feet. We discussed the FAA requiring ADS-B in high-risk airspace, such as around the village of Bethel.
  • Pilots and air traffic controllers need more ground-based station coverage in strategic locations.
  • A terrain alert warning system (TAWS) should be an aid, not a navigational tool. There’s a tendency for some operators to inhibit their TAWS because of its low-altitude nuisance alerts; this is a hazard that needs to be mitigated. (Note: the NTSB has made recommendations in this area).
  • Technologies such as digital cockpit, 406 emergency locator transmitters, FDM equipment, and flight-following equipment look promising and should be considered.
  • When it comes to weather management, a meteorological automatic weather station isn’t authorized as a weather tool, but flight service will provide it as a supplement upon request. Satellite programs are showing promise for predicting icing and cloudy conditions.

Infrastructure

  • We need to enable more flights to operate under instrument flight rules and improve visual flight rules (VFR) operations (weather camera stations). Alaska should consider establishing a common traffic advisory frequency division across the state.
  • ADS-B can help in remote locations. Special VFRs and letters of agreement would also be helpful.
  • Federal money should be committed to improving infrastructure. For example, the FAA could establish a Capstone II program in Alaska, but very small carriers will need help with funding.
  • We need more pilot information reports to validate radar returns and polar satellites, and to fill in the gaps of weather station coverage.
  • Operators and pilots should better use air traffic control services.

We at the NTSB are committed to doing our part to improve Part 135 safety. Currently, the FAA does not apply the same requirements to Part 135 operators as it does to Part 121 commercial airlines. We believe that, regardless of the purpose of flight, one thing is for sure: all flights should be safe. But we don’t have to wait for the FAA to regulate; we know that operators can—and should—make the appropriate changes.

Perhaps the most significant takeaway and critical action suggested at the roundtable—upon which the entire group agreed—was related to the need for one group, organization, or entity to focus on flight operation safety issues in Alaska. I agree. FAA Administrator Stephen Dickson has also indicated that this concept of a “single focal point” in Alaska may be worthwhile. It looks like the time to act is now.

We greatly appreciate all the experts who came to this event and participated in our vigorous discussion. We are convinced that this roundtable will lead to life-saving improvements in Alaska that will then serve as models for the rest of the world.

This event would not have been successful without the dedicated NTSB staff who worked tirelessly to plan and execute it, and the great participation of the panelists.

Thanks for all for the contributions!

For more details on this event, including participants and agenda, or to learn more about Part 135 safety, watch the event recording and see our event web page.

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

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.

Working for Safety

By Robert L. Sumwalt, Chairman

 Labor Day and Memorial Day both have specific relevance that can be lost in seasonal associations. The meaning of Memorial Day as a time to honor those lost in our nation’s wars can be eclipsed by its unofficial role as the “kickoff day” for summer. Similarly, all too often, we think of Labor Day only as summer’s end rather than as a commemoration of the contributions of the nation’s working men and women.

This Labor Day, I’d like to take a moment to express my appreciation for the men and women who work every day in transportation, doing everything right so that there’s not an accident for the NTSB to investigate.

TranspWorker_ThankYou2

From owner-operators of long-haul trucks to employees of the biggest trucking companies; from captains of small fishing boats to employees of the biggest cruise lines and marine cargo companies; from air-tour operators to airline pilots and cabin crews; and throughout railroad and pipeline transportation, safe transportation depends on the dedication and hard work of the people on the front lines: individual transportation workers.

At the NTSB, we investigate what goes wrong in transportation. In each accident, we look at the human, the machine, and the environment. When we find a lapse in any of those areas, we look for ways to eliminate the opportunity for error. Meanwhile, day in and day out, good men and women go to work every day and do everything right. We don’t investigate the truck that stayed on the road because its conscientious drivers got plenty of sleep, or the ship that didn’t run aground because its captain and crew were well-trained and attentive. We’ll never hold a Board meeting to discuss one of the millions of safe airline flights every year, or to talk about the pipeline operators and railroad employees who found the safety defect among thousands of miles of rail or pipe before it caused an accident.

Although technology and design innovations have greatly improved transportation safety, we haven’t yet managed to eliminate everything that can go wrong in transportation. That’s why we depend so heavily on the nation’s transportation workers, who face rigorous rules and laws, to ensure safety. Commercial truckers and pilots log their rest and duty time to prevent fatigue. While the general driving public is subjected to a .08-percent blood alcohol content (BAC) legal limit, for commercial drivers, the limit is already .04 percent. And then there are all the safety procedures these professionals are required to know—and follow—throughout their commercial transportation careers.

The majority of our nation’s transportation professionals meet these high standards and are intent on preventing transportation tragedies. As Chairman of the NTSB and a member of the traveling public, I want to express my appreciation for all those transportation workers who are quietly doing things right, day in and day out.

Professor James Reason once said that safety professionals live with a “chronic unease.” Safety is a matter of constantly searching out the unassessed hazard, the unmitigated risk. Transportation operators at every level embrace this difficult challenge every day. On this Labor Day, I gratefully tip my hat to each one of you who takes safety seriously.

 

National Aviation Day

By Chairman Robert L. Sumwalt

Sunday, August 19 is National Aviation Day. It’s a day to celebrate more than a century of innovation and progress in aviation, certainly, but August 19 is also the birthday of a bicycle-maker—albeit one more famous for his contributions to aviation.

National Aviation Day.jpgAugust 19 was chosen to be National Aviation Day in honor of Orville Wright’s birthday while Wright was still alive to enjoy the honor. (Wilbur Wright had passed away in 1912, less than a decade after their landmark flight near Kitty Hawk, North Carolina.) There’s a lesson in how the Wright brothers came to play their pivotal role in the story of aviation, and it’s especially worth mentioning on this day.

Wilbur was an early adopter of what was called the “ordinary” bicycle—a contraption with a high front wheel and a seat many feet off the ground. There had been earlier bicycles without the high wheel, but also without gears; the high wheel was necessary to get better performance out of limited muscle power.

The “safety bicycle” added gears, enabling good performance without using a high front wheel. It had two advantages: a center of gravity that was lower and rear of the front axle, and a shorter distance for the rider to fall. The popularity of pedaling exploded, and the Wright brothers saw a niche. From their shop in Dayton, Ohio, they began repairing, then renting, selling, and manufacturing bicycles—and, of course, tinkering with improvements.

Meanwhile, both were drawn to news of attempts at powered flight. Unlike other aviation pioneers, however, Wilbur and Orville insisted on three-axis control, using wing warping (deforming the shape of the wing) to control roll. Some competitors didn’t believe that a pilot could respond quickly enough to mechanically control all the required surfaces, but Orville and Wilbur had tested their concepts thoroughly (another advantage over some competitors). Through glider testing, they learned that an airplane could be controlled on all three axes and, in the bicycle trade, the Wright brothers had learned firsthand how innovation and safety could go hand-in-hand, providing control even when a platform seemed unstable.

It is an understatement to say that aircraft design has continued to evolve. Wing warping to control roll has given way to ailerons (precursors to amazing potential new technology reminiscent of the Wright brothers’ approach). The elevator has migrated from the front of the airplane to the rear. Wood has given way to aircraft aluminum and composites. Sticks and pulleys have given way to fly-by-wire and automation. But the Wright brothers’ insistence on three-axis control remains a foundational principle in modern powered flight, whether in the airlines or in general aviation. Because Orville and Wilbur Wright dared to believe in full control of all three axes, an industry was born.

Today, certification rules have changed to make it easier than ever to install innovative technology to maintain control of an aircraft. Angle-of-attack indicators and envelope protection are available not only in airliners, but for general aviation craft, as well. However, loss of control in flight continues to be the leading cause of fatal general aviation crashes.

NTSB Most Wanted List of Transportation Safety Improvements 2017-2018
Prevent loss of control in flight in general aviation

Why not celebrate National Aviation Day by reading up on current and innovative training and technology solutions that could eliminate loss of control in flight? You may find yourself surprised by how far aviation has come since the Wright brothers, and by how far there remains to go.

NTSB Supports ‘Safe Skies for Africa’ Program

By Dennis Jones, NTSB Managing Director

Last week, as part of the U.S. Department of Transportation’s Safe Skies for Africa program, I led a team of NTSB investigators and communications specialists to South Africa to share lessons we’ve learned from our accident investigations. The Safe Skies for Africa program, created 20 years ago, aims to improve the safety and security of aviation on the continent. Our team shared some NTSB strategies with our international counterparts to help them achieve similar outcomes in their region.

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Managing Director, Dennis Jones, talks with attendees at the Safe Skies Symposium in Johannesburg, SA

From my perspective, the Safe Skies program is working. After spending about 20 years in Africa participating in accident investigations, conducting workshops, helping improve accident investigation programs, and training investigators, I’ve seen increased commercial air service between the United States and Africa (for example, there are now US commercial flights to Africa, which wasn’t the case earlier in my career), improved investigation quality, and a reduced rate of accidents involving commercial aircraft.

On this trip, the NTSB team shared a variety of lessons learned from different disciplines. Dennis Hogenson, Western Pacific Region Deputy Regional Chief for Aviation Safety, pointed out that, like Africa, the United States is seeing a high incidence of general aviation (GA) crashes. He told his audience that, while airline accidents have become rare, GA accidents account for most aviation fatalities in the United States. We investigate about 1,500 GA accidents each year; those involving loss of control in flight still result in more than 100 fatalities annually. 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, particularly in questionable weather conditions, and their inability to appropriately recover from stalls often resulted in deadly accidents. Dennis encouraged his African counterparts to initiate more training and increase awareness of technology, such as angle-of-attack indicators, that can help prevent these tragedies.

Bill Bramble, a human factors investigator, outlined our investigation process and explained how we examine all factors—machine, human, and environment—to understand an accident and make recommendations to prevent it from happening again. Bill highlighted several accidents we investigated in which human factors played a role. But even when a probable cause statement focuses on factors not normally associated with human performance, it’s impossible to totally remove humans from the accident chain.

“Humans designed it, built it, operated it, maintained it, managed it, and regulated it. Human factors are always involved in complex system failures,” Bramble said.

To prevent accidents and improve the safety of air travel in Africa, it’s important that operating aircraft are airworthy, meaning that all structure, systems, and engines are intact and maintained in accordance with the regulations. To emphasize this point, NTSB aerospace engineer, Clint Crookshanks presented a series of case studies discussing airworthiness issues and offered guidance on ways to classify damage to aircraft.

Chihoon “Chich” Shin, an NTSB aerospace engineer, addressed helicopter safety. The number of helicopter operations (emergency medical services, tourist, and law enforcement support) in Africa is increasing, and so is the number of helicopter accidents. Chich presented case studies and highlighted some important safety issues from an engineering perspective.

“The metal doesn’t lie,” Shin said. He called for increased awareness of the safety issues affecting helicopter safety and encouraged action from key stakeholders, such as regulatory agencies and helicopter manufacturers and operators, to help reduce accidents and fatalities. He also touted the importance of crash-resistant recording devices to help investigators determine what happened in a crash and work to prevent it from happening again.

NTSB communications staff emphasized another side of our work in transportation safety. Stephanie Matonek, a transportation disaster assistance specialist, discussed the importance of planning for family assistance after an accident occurs.

“Having a family assistance plan in place, identifying your family assistance partners, and addressing the fundamental concerns for families and survivors that cross all cultures is not only a crucial step but the right thing to do,” she said.

Nicholas Worrell, Chief of the Office of Safety Advocacy, addressed messaging, encouraging attendees to go beyond investigations to teach their safety lessons effectively. He encouraged investigators to raise awareness of the safety issues they uncover to spur action on their recommendations.

Aviation is a global business. Our mission is to make transportation safer the world over by conducting independent accident investigations and advocating for safety improvements. With outreach activities like the one we just completed in Africa, we hope to make aviation safer, not only in Africa, but throughout the world. After all, transportation safety is a global challenge. When safety wins, we all win.

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NTSB Managing Director and staff with symposium attendees