Category Archives: Recorders

The 2021-2022 MWL After One Year: Noticeable Progress But Few Closed Recommendations

By Kathryn Catania, Acting Director, NTSB Office of Safety Recommendations and Communications

Since the unveiling a year ago of the 2021-2022 cycle of the NTSB’s Most Wanted List of Transportation Safety Improvements, we have seen increased awareness and discussion of safety items, high levels of engagement from the public, and incremental progress toward implementation of many recommendations.

In the past year, the NTSB has already successfully closed eight safety recommendations associated with this MWL cycle. But that is not enough. There are 167 other key recommendations that, if implemented, would save lives, and prevent injuries.

Soon after the unveiling of the MWL last year, NTSB Board members and staff sprang into action to educate, engage, and amplify the critical safety messages of our 10 safety improvements. Here’s a quick look by mode, starting with Highway, which makes up 5 of our 10 safety improvements. 

Highway

In recent years, we have increasingly expressed our highway safety goals in the language of the Safe System Approach—the very approach that we use in our own safety investigations. (We first discussed the approach in our 2017 report on reducing speeding.)

The Safe System Approach views every aspect of the crash as an opportunity to interrupt the series of events leading to it, and an opportunity to mitigate the harm that the crash does. People make mistakes, but safe roads, safe vehicles, safe road users, safe speeds, and post-crash care can combine to prevent the crash entirely, or failing that, to prevent the deaths or serious injuries of road users.

This paradigm shift applies to each of the highway safety improvements on the MWL, and is mentioned by name in “Protect Vulnerable Road Users Through a Safe System Approach,”

Between May 2021 and February 2022, we produced seven virtual roundtables to explain the approach and call for its adoption.  National and international experts discussed the approach and shared their successes and challenges. More than 1,000 advocates, regulators, academics, and others attended our webinars.

Included in the series hosted by Chair Homendy was a Safe Speeds Roundtable that explored the “Implement a Comprehensive Strategy to Eliminate Speeding-Related Crashes” safety improvement. Additionally, a “Behind the Scene @NTSB” podcast featured discussion on speeding and vulnerable road users.

In 2021, the Department of Transportation and Congress incorporated the approach into the DOT’s National Roadway Safety Strategy and the Infrastructure Investment and Jobs Act, respectively.

Will the new model result in lifesaving protections? Only final, and positive, closure of our recommendations will answer that. But the signs are very good, with the alignment of Congress, the DOT, and the road safety community.

Our MWL safety improvement, “Require Collision-Avoidance and Connected-Vehicle Technologies on all Vehicles,” could result in far superior situational awareness on our roads… if sufficient spectrum is available for the safety improvement.

Vehicle to everything (V2X) technology can save lives but has been delayed, and might be reduced or stopped, due to FCC rulings limiting the spectrum for safety operations. We released a four-part video series in which Member Graham interviewed some of the leading experts in V2X technologies—including academics, researchers, automakers, and policymakers—to discuss what can be done to find a way forward to deployment. 

In progress toward Eliminating Distracted Driving,  Vice Chairman Landsberg and staff joined government officials, industry, academia, insurers, and transportation safety advocates to announce the launch of a new National Distracted Driving Coalition. This is the first such broad national coalition on distracted driving.

We kept working with states considering lowering their BAC limit from .08 to .05 or lower, to help Prevent Alcohol- and Other Drug-Impairment. The National Highway Traffic Safety Administration (NHTSA) has now evaluated the results from Utah, which has made the change to .05. Not surprisingly, the lower threshold prevented drinking and driving and saved lives. NHTSA’s study showed that the state’s fatal crash rate dropped by 19.8% in 2019, the first year under the lower legal limit, and the fatality rate decreased by 18.3%.

Aviation

To highlight our two aviation MWL safety items, “Require and Verify the Effectiveness of Safety Management Systems in all Revenue Passenger-Carrying Aviation Operations” and “​Install Crash-Resistant Recorders and Establish Flight Data Monitoring Programs,” we met with operators and pilots from the Helicopter Association International, General Aviation Manufacturers Association, and National Business Aviation Association, among others. In webinars, podcasts, and at in-person national conferences, Board members talked with Part 135 and Part 91 operators and pilots to identify challenges. Our outreach meetings alone reached more than 1,500 operators nationwide.

Marine

With an increasing number of deadly fishing vessel accidents in recent years, Office of Marine Safety Director Morgan Turrell and Chair Homendy hosted a virtual roundtable on improving fishing vessel safety that was viewed by over 1,000 people. Panelists discussed what can be done to address commercial fishing safety, implement NTSB safety recommendations, and improve the safety of fishing operations in the United States.

Pipeline and Hazardous Materials

Our MWL calls for pipeline and hazardous materials (hazmat) stakeholders to “Improve Pipeline Leak Detection and Mitigation” by equipping all pipeline systems with leak-detection systems and automatic shutoff or remote-control valves. These valves allow for quick detection and mitigation.

Additionally, we produced a video featuring Member Michael Graham and Hazardous Materials Investigator Rachael Gunaratnam, which explores cases in which odorants failed as a natural gas leak-detection strategy, and promotes both required natural gas leak detectors, and voluntary adoption of such detectors until they are required.

Rail

To highlight the dangers to rail roadway workers and to help Improve Rail Worker Safety, Member Tom Chapman wrote a blog on rail worker safety, discussing how the railroad regulators—the Federal Railroad Administration (FRA), the Federal Transit Administration (FTA), and the Pipeline and Hazardous Material Safety Administration (PHMSA)— are in the best position to make change.

We also completed our investigation of the April 24, 2018, accident in which an Amtrak rail watchman was killed in Bowie, Maryland. As a result of this investigation, we called on the FRA and Amtrak to put an immediate end to the use of train approach warning (TAW) systems as the sole method of on-track safety in areas covered by positive train control.

To mark the anniversary of the January 2017 train collision in Edgemont, South Dakota, we also issued a media statement again urging railroads to act to better protect rail roadway workers.

Looking ahead

We are pleased by the engagement of so many of our safety advocacy partners, industry groups, and associations in the past year, to promote our recommendations and highlight transportation safety concerns. Also, we acknowledge that many industry groups and operators are making voluntary efforts to improve safety, including on some of our recommendations. However, without mandates, many others may not act.

We remain disappointed by the lack of movement by regulators to implement the safety recommendations associated with our MWL. While there has been some progress during this first year, much more needs to be done to implement the 167 remaining safety recommendations associated with the current list. The longer these authorities wait to implement our recommendations, the greater the risk to the traveling public. Safety delayed is safety denied.

The NTSB will not stand by quietly and watch as regulators, industry, and other recommendation recipients ignore and dismiss our safety recommendations—and neither should the public. As NTSB Chair Homendy expressed in recent remarks to the largest highway safety gathering in the U.S, “The horrific toll of people who’ve died on our roads and their families… millions of people who were injured… are counting on us to “fight like hell” for the next family. To give a voice to those who no longer have one.” 

All our lives are on the line, and no death in transportation is acceptable. It is our mission to advocate for the changes outlined in our safety recommendations which, if implemented, will save lives.

Safety is a shared responsibility. We all play a role in getting us to zero transportation deaths. The NTSB cannot do this alone. We need each of you, individually and collectively, to help us advocate for these critical safety improvements.

How EMS Workers Can Improve Air Ambulance Safety

By Chair Jennifer Homendy

Adapted from i-Chiefs magazine, originally published Feb 2021

Imagine for a moment that you’re an emergency medical services (EMS) worker.

You’re assisting a patient who requires transport to another facility. You decide to request a helicopter air ambulance (HAA). How do you pick the safest HAA operator?

In a perfect world, all companies would conduct a risk assessment before accepting the flight request to ensure everyone’s safety. They would consider factors such as weather, flight conditions, and which pilot is on duty. How — and if — those risks are assessed and mitigated can determine whether the medical transport flight you’re requesting is safe…or leads to tragedy.

Three years ago, we launched to a crash involving a medical transport flight where this scenario played out. Based on our investigation, we’ve learned that there are steps EMS workers and, indeed, anyone requesting air medical transport can take to improve safety.

Photograph of helicopter before crash (Source: The Columbus Dispatch)

Remembering Zaleski, Ohio

On January 29, 2019, a patient at Holzer Meigs Emergency Department in Pomeroy, Ohio, required transport to another hospital, located approximately 70 nautical miles away in Columbus. The emergency room technician contacted three helicopter air ambulance companies to help move the patient.

The first company immediately declined the flight request due to icing probability and snow squalls. The second company stated they would call back after conducting a weather check. Before hearing back, the emergency room technician reached out to a third company, Survival Flight, which quickly accepted the request. The second company then called back to decline the flight due to weather-related safety concerns.

Three Survival Flight crew members, the pilot, flight nurse, and flight paramedic departed for Pomeroy to pick up the patient. About 22 minutes into the flight, the pilot encountered two snow bands that decreased her visibility. The pilot attempted a maneuver to escape from the inadvertent instrument meteorological conditions (IIMC), in keeping with standard operating procedures, but did not maintain altitude. Tragically, the Survival Flight helicopter crashed into forested terrain near Zaleski, Ohio. All three crew members died.

What Went Wrong?

The NTSB was called in to investigate. Our investigation revealed numerous safety deficiencies that we can learn from. Here’s what went wrong.

Lack of comprehensive and effective flight risk assessment and risk management procedures. This means the pilot was unaware that other operators had refused to accept the flight due to weather concerns.

The lack of both a positive safety culture and a comprehensive safety management system (SMS). The casual behavior of Survival Flight management regarding risk assessment and safety programs was not indicative of a company with an established SMS program, which operators use to evaluate and address risk, as well as their pilots’ skills and flight behavior. The NTSB has long advocated for the adoption of a SMS in all flight operations. Indeed, this recommendation is so important that it has been associated with several issues on our Most Wanted List of Transportation Safety Improvements over the years.

Need for flight data monitoring (FDM) programs for HAA operators. Although the Federal Aviation Administration (FAA) requires helicopter air ambulance operators to have FDM recorders installed, it does not require that operators use the recorders and the data collected. But an FDM program that is part of a broader SMS has great potential to identify risky situations and make changes before a crash occurs. For example, an FDM program would have allowed Survival Flight to identify deviations from normal operations and potential safety issues.

Lack of HAA experience for principal operations inspector. The investigation revealed the FAA principal operations inspector assigned to oversee Survival Flight’s operation was unaware of deficiencies that were later identified in Survival Flight’s flight risk assessment.  

Lack of accurate terminal doppler weather radar data available on the HEMS (helicopter emergency medical services) Weather Tool. The current version of the HEMS Weather Tool does not incorporate terminal doppler weather radar data to display precipitation. As a result, the pilot could not tell if there were gaps in the data or if there were, in fact, no precipitation.  

Lack of a flight recorder. If a recorder system that captured cockpit audio, images, and parametric data had been installed, it would have enabled NTSB investigators to reconstruct the final moments of the crash and determine why the pilot did not maintain the helicopter’s altitude and successfully exit the IIMC encounter.

How You Can Promote Safe Air Medical Transports

Don’t underestimate the “power of the purse” to encourage the safest operating practices when selecting an air ambulance operator: only give your business to operators that take safety seriously. Here are some practical steps that can help you make an informed decision:

  • Vet the companies in your area before you need air transport. Consider selecting a company that has earned accreditation from a respected third party. For example, the Commission on Accreditation of Medical Transport Systems (CAMTS) accredits medical transport organizations that pass their audit and agree to abide by certain best practices, which are usually more stringent than those required by regulations. It’s important to note that most helicopter air ambulance programs in the United States are CAMTS-accredited; in fact, the U.S. Department of Defense requires CAMTS accreditation for civilian contracts. Despite this being the “gold standard” for auditing and accrediting helicopter air ambulances, Survival Flight was not CAMTS accredited.
  • Meet the helicopter air ambulance companies that serve your area. Some offer a shadowing opportunity for EMS workers. Ask the crew members you meet how they determine which flights to accept.
  • Do some research. Find out which operators have shown a commitment to the highest levels of safety by obtaining FAA approval for an SMS program and have an FDM program that regularly evaluates data collected to identify and address flight safety issues. While HAA operators are not yet required by FAA to have either, some have implemented these measures voluntarily. Your patients and crews deserve the safety benefits that accompany SMS and FDM programs.

Finally, never hesitate to reevaluate the necessity of air transport as weather conditions change, especially when other helicopter operators turn down the same request due to weather or other safety concerns.

Do it not just for your patient, but for the helicopter crew. Do it to honor the lives lost in Zaleski three years ago.

A New Year’s Resolution We All Can Make: Prioritize Safety

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 to make transportation safer for all.

To help you take steps to accomplish this resolution, our MWL outlines actions you can take to make transportation safer:

  1. Require and Verify the Effectiveness of Safety Management Systems in all Revenue Passenger-Carrying Aviation Operations
  1. Install Crash-Resistant Recorders and Establish Flight Data Monitoring Programs
  1. Implement a Comprehensive Strategy to Eliminate Speeding-Related Crashes
  1. Protect Vulnerable Road Users through a Safe System Approach 
  1. Prevent Alcohol- and Other Drug-Impaired Driving
  1. Require Collision-Avoidance and Connected-Vehicle Technologies on all Vehicles
  1. Eliminate Distracted Driving
  1. Improve Passenger and Fishing Vessel Safety
  1. Improve Pipeline Leak Detection and Mitigation
  1. Improve Rail Worker Safety

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.

Accident Data for Investigations, Routine Flight Data for Prevention

By Acting Chairman Bruce Landsberg

Most people are familiar with the nightly news image of NTSB investigators at the scene of an accident, searching for the “black (orange) box.” The flight data recorder (FDR), which records aircraft control inputs and operational conditions, and the cockpit voice recorder (CVR), which records pilot conversations, are at the heart of modern aviation accident investigations on all airline aircraft. The devices have helped to improve the safety of airline operations tremendously. They are used, of course, in crash investigations but most airlines also use them routinely to monitor pilot and aircraft performance and correct problems before they result in a crash.  

However, these devices designed to help in investigations are not required or used in most air-taxi or charter operations. For example, no recording equipment was installed in 86 percent of the turbine-powered aircraft involved in fatal accidents between 2005 and 2017. As a result, valuable information was missing to fully understand what happened and to prevent a crash from happening in the first place if the operator had used the predictive approach that the systems provide.

We believe recorders and analysis of their data before a crash offer tremendous safety benefits. That’s one reason why Install Crash-Resistant Recorders and Establish Flight Data Monitoring Programs is on the NTSB’s Most Wanted List of Transportation Safety Improvements (MWL).  

Cockpit Image Recorders

Even after an FDR and CVR are analyzed, investigators still don’t know for sure how the flight crew interacted with the aircraft systems or what visibility was like inside or outside the cockpit. Even the most modern flight data recorders leave some questions unanswered. That’s where a cockpit image recorder (CIR) can be useful. For more than 20 years, the NTSB has called for CIRs in addition to FDRs and CVRs. The images CIRs provide could quickly reveal a pilot’s actions without ambiguity. Some in the industry claim that it’s an invasion of privacy or that video will be used by the media for sensationalist purposes. Federal law prevents the release of CVR or CIR data except in transcript form and there has never been a breach of that trust! Please note that most other modes of commercial transportation (trucks, busses, railroads and marine) have already installed this equipment and are reaping the benefits.

A  CIR was vital to our investigation of the in-flight breakup of Scaled Composite’s SpaceShipTwo over California in 2014. Cockpit images show a test pilot inadvertently deploying a feature called the “feather,” (similar to a thrust reverser) which led to the in-flight breakup. Without a CIR, the investigation would have taken months, or years, to evaluate the wreckage and understand if the feather lock mechanism mechanically failed or was deployed as a result of a crew action.  

Too many investigations have been hindered by a lack of CIRs. For example, had the Atlas Air Inc. flight 3591, a Boeing 767-375BCF, that crashed near Houston in 2019 been equipped with a crash-resistant image recording system investigators might have had relevant information about the data available to the flight crew and the flight crew’s actions during the accident flight. This information would have been critical in determining what happened and while there’s a very plausible idea of what happened some uncertainty of precise causal factors remains.

Recorders should be able to survive crash dynamics that include impact, submersion or fire. In the 2019 Sikorsky helicopter crash in Calabasas, California, visual cues associated with the adverse weather and the pilot’s focus of attention could not be conclusively determined because the helicopter wasn’t equipped with a CIR. A crash-resistant flight recorder system with audio and image functions could have provided valuable information to possibly identify additional safety issues and prevent a similar crash in the future.

Flight Data Recorders and Monitoring Programs

As an investigative agency, NTSB has a vested interest in recorders because they yield essential evidence, that can often be used to prevent future crashes. Required flight data monitors (FDMs) and FDM programs like Flight Operations Quality Assurance (FOQA) at the airlines have improved safety through the analysis of data collected by these recorders. Other segments of commercial aviation, like corporate and on-demand charter operations, could similarly benefit from FDMs and FDM programs.

On May 15, 2017, a Learjet 35A departed controlled flight while on a circling approach to Teterboro Airport in New Jersey impacting a commercial building and parking lot. Both pilots died.  The investigation again identified the need for FDM programs (and supporting recording devices) for 14 CFR Part 135 operators. The operator lacked safety programs that would have enabled it to identify and correct poor performance and procedural noncompliance which was the primary cause of the crash. Without an FDM program, the operator couldn’t identify the flight crew’s prior deviations from policy and procedures and had no way to determine if previous operations were conducted properly.

The NTSB has long recognized the value of FDM programs for Part 135 operators, having first issued a safety recommendation for data recording devices and monitoring programs for helicopter air ambulance operators in 2009. FDM programs typically involve the use of an onboard device capable of recording various flight parameters. Periodic routine review of the recorded data enables an operator to identify deviations from procedures and observe potential safety issues. Data reviews help a company take proactive measures and corrective action BEFORE a crash occurs. FDM should be integrated into safety management systems (SMS), another pillar of safety in modern aviation. Read more about SMSs on our MWL webpage.

Flight crews are an asset to every operator, who clearly has a vested interest in the safety and performance of the flight crew. Therefore, an FDM program should never be used in a punitive way, but rather to identify and correct safety issues.

Expanding Aviation Lessons for Safety

Through decades of accident investigations, many of which were aided by key evidence gleaned from recorders, airline travel in the United States has become extraordinarily safe. But to keep this strong safety record going, and to make progress elsewhere in aviation through lessons learned, it is essential to install recorders on an even broader scale appropriate to the activity. Devices built to survive a crash and supplemented with FDM programs, will enable operators to identify deviations and safety concerns prior to an accident.

Operators don’t need to wait for government mandates to install them; they can realize the safety benefits of this technology today and just one crash prevented will be highly cost effective for that operator and certainly for the people involved! The fact that an operator, without an FDM program and an effective SMS, hasn’t had a crash as we’ve seen too many times, doesn’t mean that they were good, merely lucky.

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.