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.
“N555$$, call the tower. N555$$ call the tower…your gear isn’t down!”
As a newly minted certified flight instructor (CFI) in the early 90s, I loved reading the latest addition of Flight Training magazine. I’ll never forget reading a funny quip about a pilot who was on final approach to land at a controlled airport and forgot to extend his landing gear. The control tower tried to contact the pilot numerous times to warn him, but he never responded and landed gear up. Once the pilot realized what happened and came to a stop on the runway, he called the tower and learned that the tower had tried to contact him several times. The pilot responded, “Sorry, I didn’t hear you because there was a horn going off in the cockpit!” To this day, whenever I fly a retractable gear airplane, I always think of that story. I’ve only had one gear-up landing in my 33 years of flying, and that was due to mechanical failure that prevented the gear from extending. I can say from experience: landing gear‑up involves a lot of loud scraping noises, a shortened roll out, and an even shorter step out of the airplane.
As part of my duties as a regional NTSB investigator, I take “phone duty” for the entire eastern region of the Unites States during on-call periods. As the duty officer, I receive all the incident and accident notifications from the Federal Aviation Administration (FAA) or directly from pilots, and I’m surprised by the amount of gear-up landings we process. Now, some of these are due to mechanical issues like I experienced, but most of them are due to pilots (who admit) they either got complacent or distracted (or both!) and simply forgot to extend the gear.
Gear-up landings usually don’t result in serious injuries to pilots and passengers, but they are a big ego buster. They also cost a lot of money in unnecessary damage to the airplane’s propellers, engines, structure, antennae, and skin. Often a mechanic needs to be hired to remove skin so the damage can be better evaluated. More money! And, if the damage is substantial, you’ll also be dealing with an “accident” as defined by 49 Code of Federal Regulations 830.2, and you’ll not only be getting a call from your local FAA inspector, but also from your friendly NTSB investigator. Nobody has time for that!
So, how do you make sure you never forget to put your gear down?
Use your BEFORE LANDING checklist—it’s there for a reason!
Repeat your GUMPS check (gas, undercarriage, mixture, propeller, seat belts and switches) OUT LOUD several times before you land.
Visually (if possible) confirm the gear is extended.
Stay ALERT and FOCUSED on flying (configuring) the airplane in the traffic pattern. AVOID unnecessary conversation and MAINTAIN situational awareness. Traffic patterns can get hectic, and things can happen fast.
Do some online research for articles about avoiding gear-up landings. There are some good articles and case studies out there written by CFIs and highly experienced pilots.
By Nicholas Worrell, Chief, NTSB Safety Advocacy Division
As 2021 ends, it’s time to reflect on the past 12 months and begin to set goals for the year ahead. After all, as Zig Ziglar once said, “if you aim at nothing, you will hit it every time.” So, let us all aim to improve the safety of our transportation system in 2022.
The NTSB recognizes the need for improvements in all modes of transportation–on the roads, rails, waterways, pipelines, and in the sky. Our 2021–2022 NTSB Most Wanted List of Transportation Safety Improvements (MWL), released in April this year, highlights the transportation safety improvements we believe are needed now to prevent accidents and crashes, reduce injuries, and save lives. We use the list to focus our advocacy efforts and to serve as an important call to action. We ask lawmakers, industry, advocacy, community organizations, and the traveling public to act and champion safety.
As a fellow safety advocate, I ask you to join me in a New Year’s resolution: I pledge to do my part tomake transportation safer for all.
To help you take steps to accomplish this resolution, our MWL outlines actions you can take to make transportation safer:
Achieving these improvements is possible; otherwise, they wouldn’t be on our list. The NTSB MWL includes tangible changes and solutions that will, undoubtedly, save lives. But it’s only words on a list if no action is taken. Unlike Times Square on New Year’s Eve, we cannot drop the ball on improvements to transportation safety. The clock is ticking, and the countdown has begun—we can’t afford to waste any more time. Make the resolution to do your part to make transportation safer for all!
In closing, I’d like to thank the transportation safety stakeholders, industry, lawmakers, and advocates we have worked with in 2021 and we look forward to working together in 2022 and beyond.
By Mike Hodges, Air Safety Investigator, and Clint Crookshanks, Aerospace Engineer (Structures)
When an aircraft crashes, National Transportation Safety Board (NTSB) air safety investigators and aerospace engineers must determine if the event can be classified as an accident or an incident, as defined by Title 49 Code of Federal Regulations (CFR) Part 830.
An accident is:
“…an occurrence associated with the operation of an aircraft which takes place between the time any person boards the aircraft with the intention of flight and all such persons have disembarked, and in which any person suffers death or serious injury, or in which the aircraft receives substantial damage.”
An incident is:
“…an occurrence other than an accident, associated with the operation of an aircraft, which affects or could affect the safety of operations.”
Although the determination of an accident focuses on damage as well as injuries, here we will focus on damage assessment.
So, when assessing the damage, how do we decide what’s an accident and what’s an incident? When we’re first notified about an adverse aircraft event, we begin to assess the aircraft damage. NTSB investigators and engineers attempt to obtain as much information as possible about the damage. Sometimes we’re given information that makes it obvious the aircraft sustained substantial damage, such as the photos showing the extent of the damage (see Figures 1–3). Figures 1-3 show the substantial damage as indicated by the arrows.
Other times, we can’t tell the extent of damage right away and we need to dig deeper. Figures 4- 6 illustrate this scenario and show the substantial damage as indicated by the arrows. For figure 4, additional information surrounding the circumstances of the object impact, a tracked drilling unit, along with the damage sustained to the main rotor blades was obtained from the Federal Aviation Administration (FAA) and the operator. For figure 5, the airplane’s structural repair manual for the damage sustained to the right wing from the bird strike was studied during the damage assessment process. For figure 6, the interior of the fuselage had to be inspected to identify the substantial damage sustained during the hard landing sequence.
When the damage sustained is not obviously substantial, NTSB air safety investigators and aerospace engineers may take additional steps to assess wreckage, such as the following:
Working with pilots, operators, mechanics, repair stations, FAA Flight Standards District Offices, aviation insurance adjustors, and aircraft recovery companies to obtain additional damage photographs or damage information
Consulting the airframe manufacturer’s air safety and engineering departments
Obtaining documents, such as the structural repair manual or illustrated parts catalog, from the airframe manufacturer
Considering other unique factors that may determine the damage level, such as airframe fire damage or the aircraft being immersed in a body of water
Inspecting the area in question (such as spars in wings, structural areas behind firewalls, driveshafts in helicopters, gearboxes in helicopters, etc.) once the aircraft is recovered
Removing components, panels, or skin and using tools to access hard-to-view areas (such as mirrors or electronic borescopes)
We would also determine:
if the damaged area is classified as a primary structure (primary structure is defined by the FAA as that structure which carries flight, ground, or pressurization loads, and whose failure would reduce the structural integrity)
what repairs are required
which components will be replaced to repair the damaged area
if the aircraft’s performance or flight characteristics were affected
(The cost or feasibility of repairing an aircraft, as determined by an aircraft insurance company, will not be considered when determining whether an aircraft has sustained substantial damage.)
The damage assessment timeline can vary, depending on how obvious the damage is initially. We might make a substantial determination in a few hours, or, if additional information is needed, the damage assessment can take several weeks. If the aircraft needs to be recovered from a remote area to obtain additional information, the damage assessment could extend even longer.
Although the FAA is always a party member to our investigations, the NTSB is the final authority for determining a damage classification. For those that are involved in an adverse aircraft event, some basic knowledge can help during the assessment, such as:
Understanding the definitions and reporting requirements in 49 CFR Part 830
Having multiple, high-quality, high-definition photographs from all around the aircraft, showing the aircraft in its entirety
Having multiple, high-quality, high-definition photographs of the damaged areas, including close-ups
Knowing what repairs are required to the damaged area, along with what components will be replaced to repair the damage (when possible)
Being involved in an accident or incident, regardless of the outcome, is stressful for those involved. The NTSB works diligently with various stakeholders to provide as many answers regarding the damage classification as possible, whether it is determined to be an accident or an incident.
There was once a saying in the news media business to “get it first, get it right, but first get it right.” The NTSB strives to get it right above all, but we recognize that timeliness is essential, too. One of my goals even before joining the Board was to see if aviation crash processing time could be reduced on the less complex events. After all, the whole point of accident investigation is to become educated on what went wrong and get the word out as soon as possible to avoid a similar scenario.
But at the NTSB, it’s not all black and white. I want to take this opportunity to clear up some common misconceptions about how the agency functions and describe our process for those unfamiliar with its intricacies.
Congress requires us to evaluate all aviation accidents in the United States as well as significant accidents in all modes of transportation—rail, pipeline, highway, marine, and hazardous materials (how we determine what’s “significant” is a topic for another blog). Given this mandate, our resources are divided. Out of around 400 NTSB staff, only 45 accident field investigators are assigned to aviation. However, although we are required to investigate every civil aviation accident in the United States, as well as those occurring outside the country when they involve US-made equipment, that doesn’t mean we send an investigator to every crash. Often, it’s sufficient for an investigator to just interview a surviving pilot over the phone. In many cases, the Federal Aviation Administration (FAA) sends someone from its local office to an incident and shares the on-scene data with us.
Sometimes, though, an accident is more complex, and a deeper dive is required. For example, vital electronic data can be extracted from avionics, phones, or tablets that aren’t too damaged. Often that can be done in the field, but some devices must be sent to the NTSB lab in Washington, DC, for more thorough examination. There, our technicians painstakingly recover what they can, but—remember—they’re receiving devices from accident scenes in all the other transportation modes as well. The backlog can get lengthy. The lab must also decipher information from voice recorders (if any), vehicle monitors, onboard and external cameras, and metallurgical specimens, and conduct sound spectrum analysis, among other things, from every mode.
In addition to analyzing all the machine information we can, we also look at the human factors present in an accident. We send toxicology samples to the FAA’s medical lab in Oklahoma City for analysis. Autopsy data must be gathered from local medical examiners, whose schedules don’t always align with ours. In a perfect world all this back-end analysis could be completed quickly, but reality intrudes. Factors such as staffing in other state and local government entities, the sheer number of reports the agency is juggling at a time, and yes, inefficiency, can drag things out. Those situations are not always within NTSB control.
Still, many reports frankly took too long to complete, and the average time to complete reports has increased over the years. Recognizing these delays, in 2019, staff in our Office of Aviation Safety began assessing our report process to see if we could streamline it in any way we can control. The effort produced significant improvements, and the early results are encouraging. From March 2020 to March 2021, about 1,100 investigations were initiated, and about 1,500 were completed. This doesn’t include several hundred foreign investigations in which the NTSB participates every year. This contrasts favorably with the prior year, where from 2019 to March 2020, about 1,320 aviation investigations were initiated, and about 1,150 were completed, not including foreign investigations.
Naturally, everyone wants everything faster. Going forward, the less complex cases we investigate are being scaled to finish in 6 months or so, while the more complicated ones will continue to take longer—sometimes much longer. Although we recognize the importance of timeliness in our investigations, we strive for a level of accuracy that ensures we’ve left no stone unturned.
As we revamp our investigation report process to get accurate information out more quickly, I think the public will appreciate the result. But, like most things, the process is a work in progress. We will never sacrifice precision for speed, but rest assured that we’re taking a hard look to see how we can get lifesaving information out more efficiently. We all look forward to seeing the progress the agency makes as we implement new strategies.