Category Archives: Inside NTSB

February 20: International Day Commemorating Air Crash Victims and Families

By Elias Kontanis, Chief, NTSB Transportation Disaster Assistance Division

This year, the International Civil Aviation Organization (ICAO) designated February 20 the International Day Commemorating Air Crash Victims and Families. Although ICAO has addressed various aspects of family assistance for decades, this is the first time a day has been set aside to remember and honor all who lost their lives in air disasters and their families.

ICAO’s interest in family assistance dates to 1976, with the inclusion of a recommended practice in Annex 13, the document that outlines standards and recommended practices for accident investigations. The following is a brief timeline of significant ICAO activities related to family assistance.

  • 1976: Contracting States (that is, countries) whose citizens are involved in a crash are granted access to information about the crash investigation and play a direct role in identifying their citizens. This recommended practice was strengthened to a standard in 2001.
  • 1998: The ICAO Assembly acknowledges that “the policy of the ICAO should be to ensure that the mental, physical and spiritual well-being of victims involved in civil aviation accidents and their families are considered and accommodated by ICAO and its Contracting States.”[1]
  • 2001: In response to Assembly Resolution A32-7, ICAO issues Circ 285, “Guidance on Assistance to Aircraft Accident Victims and their Families,” a keystone document for countries interested in developing family assistance programs. Circ 285 provides guidance on the various aspects of a comprehensive family assistance operation.
  • 2005: Provisions are included in Annex 9, “Facilitation,” to enable victims’ family members to expeditiously enter the State in which the accident occurred. Additional provisions address repatriation of remains and emergency travel documents for family members and accident survivors.
  • 2013: ICAO issues Doc 9998, “ICAO Policy on Assistance to Aircraft Accident Victims and Their Families,” and Doc 9973, “Manual on Assistance to Aircraft Accident Victims and Their Families.”
  • 2015: Annex 9 is further amended with Recommended Practice 8.46, which encourages Contracting States to establish legislation, regulations, and/or policies in support of assistance to aircraft accident victims and their families.
  • 2021: ICAO convenes its first International Symposium on Assistance to Aircraft Accident Victims and Their Families. This 3-day event, hosted by the governments of Spain and the Canary Islands, provides an opportunity for participants to share best practices and lessons learned to support the development of family assistance programs. NTSB Chair Jennifer Homendy and I were honored to participate as guest speakers at this important event.
  • 2021: ICAO’s Global Aviation Training Section begins developing a 3-day course designed to provide Contracting States, as well as aircraft and airport operators, the foundational knowledge to develop family assistance plans. The NTSB is a proud partner in this effort.
  • 2021: ICAO proposes elevating Recommended Practice 8.46 to a standard and developing a new recommended practice encouraging aircraft and airport operators to develop family assistance plans. Again, the United States stands with a significant number of other States in support of this initiative.

Through the Aviation Disaster Family Assistance Act of 1996, the United States committed to addressing the needs of passengers’ families following an aviation disaster. This commitment continues to grow. Today, the NTSB is the lead federal agency responsible for coordinating federal resources to support the families of air crash victims, as well as the victims of any other transportation disaster the NTSB investigates.

As family assistance specialists, my team and I work every day with the families of those lost in transportation crashes, trying to shed what light we can during some of their darkest days. We provide information during a time of uncertainty, address questions, and facilitate access to services that help loved ones navigate the loss they have suffered.

We have this charge in common with family assistance specialists all around the world, and we work collaboratively with international colleagues to enhance family assistance programs worldwide. We offer representatives of ICAO Contracting States seats in our family assistance course to help them develop or enhance their family assistance programs. We deliver presentations and participate in discussion panels overseas on family assistance, and we assist ICAO in developing its 3-day family assistance course.

Over the decades, the strength of survivors and victims’ families has humbled us. We have seen them organize not only to support each other through the grieving process, but also to advocate for change to enhance transportation safety so that others never have to face the same kind of loss.

We at the NTSB stand alongside our international colleagues in honoring the International Day Commemorating Air Crash Victims and Families. No traveler likes to ponder the possibility, however remote, that a flight will crash. But, if the unthinkable happens, the NTSB and our counterparts around the globe are dedicated to supporting crash survivors and family members.

[1] International Civil Aviation Organization. Assembly Resolution A32-7. Resolutions Adopted at the 32nd Session of the Assembly. Montreal, Quebec; Sept. 22–Oct. 2, 1998.

Recognizing a Quarter Century of 24/7 Response

By Chair Jennifer Homendy

Blue jackets. Devastating scenes. Calm in the wake of tragedy.

This is how many people describe their first impressions of NTSB. It’s not surprising given the international visibility of our on-scene work.

But today is all about who you don’t see: the folks who make the agency’s headline-grabbing work possible.

I’m talking about the incredible people of NTSB’s Response Operations Center, which is today celebrating 25 years of uninterrupted service to our nation.

What is the ROC?

It’s no exaggeration to say the Response Operations Center — or “ROC,” as we affectionally call it — is the agency’s central nervous system.

The ROC is staffed 24-hours-a-day, seven days a week by at least two watch officers. They work three or four consecutive, 12-hour shifts, for a total of about seven shifts over two weeks. 

The room looks as you would imagine: a dozen televisions line the wall in front of desks staffed by watch officers. Newscasters deliver the day’s stories from C-SPAN, the Weather Channel, CNN, MSNBC, Fox News, and various local stations.

NTSB’s Response Operations Center. The photo was taken before the pandemic required the use of masks in our office.

This is where the team takes in reports of transportation-related events around the clock. In addition to monitoring the news outlets, the team fields phone calls and emails from around the world, triages them, and rapidly pushes out the news to NTSB leadership and investigators who need to respond.

But most importantly, the ROC initiates the launch process by notifying the appropriate modal duty officers when an accident or crash occurs. 

As the investigation team members pack their gear, the ROC staff help prepare everything for the launch. This includes setting up conference calls, reserving hotel rooms, and booking rental cars. As for flights, many of the Washington, DC-based go-team members will expedite their travels to investigation destinations using one of the jets managed and operated by the Federal Aviation Administration (FAA).

The NTSB has access to two jets managed and operated by the Federal Aviation Administration.

Origin Story

The first NTSB communications center opened its doors on February 3, 1997, in a conference room at NTSB headquarters.

NTSB’s first communication center in 1997.

The idea to launch a command center came from former NTSB Chairman Jim Hall, who was on scene for the July 17, 1996, Trans World Airlines flight 800 explosion. It was the third-deadliest aviation tragedy in U.S. history.

Befitting its status as “central” to our mission, the agency relocated the ROC in 2014 to a room in the literal center of the building.

What It Takes to Operate for 9,125 Consecutive Days — and Counting

Once settled into its current location, the agency invested in everything needed to operate the ROC without interruption, no matter what.

Here are some examples of what it takes to keep the ROC ready for anything:

  • Computers specifically built to run nonstop, complete with special air filters to keep their internal systems clean.
  • A standalone HVAC system that runs independently from that of the building.
  • A full kitchen to ensure ROC staff can eat and prepare food even if local restaurants are closed.
  • Ever mindful of workplace safety, even the chairs in the ROC are ergonomically designed for continuous use.
  • Regular drills to ensure preparedness. 

The View from the ROC

For many working in the ROC, having a front seat to transportation tragedies can take an emotional toll.  

When asked how they cope, here’s what some team members had to share:

“For me, when these bad things happen, it is sort of like a wake-up call. It helps me appreciate life more.”

“The way I cope is by not following a crash after we play our role in the ROC. I don’t keep tabs on what is going on with them. I have to let go.”

The serious nature of the work may explain why the ROC team has named the electronic voice from its primary notification system.

Similar to the voice from your favorite smart speaker, “Helga” alerts ROC staff when notifications arrive from the FAA, Federal Railroad Administration, or the National Response Center. She’s been a constant in the ROC.

One team member shared that giving the system a persona is another coping mechanism, adding: “If it ever gets lonely in the ROC, there is always Helga to keep you company.”  

Celebrating 25 Years of 24/7 Response

Even as we celebrate the dedicated service of our ROC team, every NTSB employee is working to put ourselves out of a job by making transportation safer.

Until that day arrives, consider sending a mental “thank you” to the incredible professionals of the ROC the next time you’re enjoying the weekend, celebrating a holiday, or enjoying a quiet night at home.

The duty officers are always there, monitoring the safety of our transportation system.

Just as they have for the last 25 years.

Get it Right: Addressing the Timeliness of NTSB Investigations

By Acting Chairman Bruce Landsberg

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.

Sometimes, despite hours or days of lab effort, no data survives, which makes determining probable cause much more difficult. That’s why our 2021–2022 Most Wanted List of Transportation Safety Improvements includes “Install Crash-Resistant Recorders and Establish Flight Data Monitoring Programs.” Unbiased and accurate device readouts speed investigations up tremendously compared to relying solely on eyewitnesses, who are far less reliable.

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.

We Can Do Big Things. Just Look at Positive Train Control

By Member Jennifer Homendy

After 50 years of investigation, advocacy, and persistence by the NTSB, positive train control (PTC) is now a reality across the country!

This video highlights the NTSB’s more than 50 year effort in investigating PTC-preventable accidents and advocacy for this life-saving technology.

PTC systems use GPS and other technology to prevent certain train collisions and derailments. It could have been lifesaving in the 154 rail accidents that have killed more than 300 people, and injured more than 6,800 passengers, crewmembers, and track workers in major accidents stretching across the nation, from Darien, Connecticut, in 1969, to Chatsworth, California, in 2008, to Philadelphia, Pennsylvania, in 2015, and DuPont, Washington, in 2017.

But let’s step back and marvel at this real achievement—and the effort it took. Safety improvements are never easy or quick. It took more than 50 years of advocacy by the NTSB and historic action by Congress to make PTC a reality. For many of these years, the NTSB was a lonely voice for safety, pushing for PTC despite opposition from railroads over the price tag and technological hurdles.

I know how tough the battle was because I was there. As staff director for the House subcommittee charged with overseeing rail safety, I played a role in ensuring that any effort to move legislation forward to improve rail safety included the NTSB’s recommendation to implement PTC. When I got to the NTSB, one of my priorities was to ensure that mandate was implemented.

It truly is remarkable in Washington to keep such clear focus on PTC across so many administrations, through so many changes in Congress and at the NTSB.

Earlier this month, I had the honor of moderating a panel of current and former NTSB leaders and staff who recalled the long, bumpy road to PTC implementation. NTSB Chairman Robert Sumwalt and former agency heads Chris Hart, Debbie Hersman, and Jim Hall recalled their own contributions and noted how remarkable the agency’s sheer persistence was in a time of short attention spans and quickly changing priorities.

It was so uplifting to hear their personal reflections of their time on the Board fighting for PTC, and their continued commitment to the agency and its critical safety mission. But it was the staff panel that really defined persistence. Generations of rail investigators and other staff worked every one of the 154 PTC-preventable accidents over the decades, launching to horrific crash scenes only to discover similarities pointing to the same solution: PTC. They spent holidays working. Missed birthdays and anniversaries. Completed their important jobs regardless of on-scene obstacles and personal priorities.

Recording of the January 14, 2021, NTSB live‑streamed discussion about Positive Train Control implementation.

The public doesn’t often see what goes on behind the scenes at accident investigations, after investigations are completed when recommendations need to be implemented, and the tremendous work required to keep those recommendations at the forefront of discussions to improve safety. As stated in the first panel, board members come and go, but it’s the staff that keep these critical safety issues alive. It was truly remarkable and heartwarming to hear their reflections of the agency’s work and how that work has impacted public safety, as well as how it affected them personally. I hope it gave the public a sense of what it takes to stay focused on an issue for five full decades.

Was it worth it? You bet. PTC will save lives.

Other safety improvements have also taken many years to implement. Midair collisions were dramatically reduced by the Traffic Alert and Collision Avoidance System (TCAS). That took decades to put in place. Airliner fuel-tank inerting systems, which addressed fuel tank explosions like the one that brought down TWA Flight 800 in 1996, also took years. And let’s not forget about the long fight for airbags and seat belts in passenger vehicles. All these transportation safety improvements were strongly and relentlessly advocated for by the NTSB.

We can do big things in America. We can save more lives on our rails, in the sky, in communities where pipelines are located, on the water, and on the highway. But major safety improvements like PTC take time, money and, perhaps most of all, incredible perseverance.

Where the Action is in Safety

By Dolline Hatchett, Director, Office of Safety Recommendations and Communications

As the Director of the NTSB’s Office of Safety Recommendations and Communications (SRC), I lead a group that is focused on getting the whole story of accident investigations to the public. When there is a transportation disaster, my group is on scene alongside the frontline investigators, recording B-roll (video imagery of the accident site), and helping prepare NTSB spokespeople for on-scene press conferences.

But that’s just the leading edge of the investigation—and of our communications responsibility. For major investigations, we also focus attention on the public Board meeting. And, equally important but often overlooked, we help craft safety recommendations and advocate for them to be enacted, following up with recipients—sometimes for years—to see the job through.

My division’s mission runs the gamut, from fine points of grammar and usage to getting the right information out so that the people who need it have access to it. And lately, I’ve been thinking about how our language affects how we think—and what we do—about safety.

The Chairman of the NTSB has said that safety is not something that you can get or own, it’s something that you do, day after day. How does that relate to how we talk and write about safety? Well, if safety is something that we do, it’s not safety the noun (or the modifiers safe or safely). At heart, safety is a verb: to save.

To save lives. To save people from injury, and to save property and the environment from damage. How do we do this? By identifying hazards and mitigating risk (more action words—things we do to save ourselves, others, and our world!).

Why is this important? I notice too often that things that we do “for safety” are easily waved off. They’re thought of as things we do just in case something unlikely happens, but that cost time and money for the usual case when those measures aren’t needed. But the unlikely occurrence is out there, ready to happen, if that procedure isn’t followed or that safe design fails. We can’t be lax about safety, even if the likelihood of something going wrong is very low.

Those who are not deeply passionate about safety might dismissively explain that a feature is “for safety.” Think about the last automobile commercial you saw. I’m certain you heard something like “safety features” mentioned as flashy footage of that new car raced around coastline curves. I bet you weren’t thinking at all about what that term—safety features—even meant. It wasn’t made out to be as important as the car’s horsepower or built-in infotainment system. But what if the commercial narrator used a different term? Would you pay more attention if the narrator said, “To save your life, this vehicle is equipped with . . .” before summarizing the car’s safety features?

As you may have concluded, I truly appreciate the power of verbs—as far as language goes, they’re where the action is, where the rubber meets the road. By the same token, safety recommendations are where the rubber meets the road in the NTSB’s mission to improve safety. They’re about actions that can be taken to save people from death or injury, or to save property or the environment.

For example, although we recommend and advocate for transportation operators to use safety management systems (SMSs), implementing an SMS means starting and continuing a process. Although this process does include documents (safety policy), it does not begin and end there. A company must also do safety every day. Complying with rules is a good foundation, but to move ahead in a safety journey, we need the verb to save, which means making an ongoing, active effort. What does it mean to continually save in all that we do? It means following all the safety rules, of course, as a first step. But it also means continually scanning the horizon for the next hazard, to save lives, save others or ourselves from injuries, and save property and the environment from damage. This continual vigilance aligns with the proactive, recurring feedback necessary for a successful SMS.

We can all take a page from the safety professional’s book and forget safety the noun. Especially in today’s environment, safety is not something that we get or own. It’s something that we do, and continue to do, every day.

Safety is, by all rights, a verb. It calls for action. Make safety something you do, and keep doing it.