Category Archives: Recorders

FAA Must Take Action on Recorder Safety Recommendations

By Member Jennifer Homendy

Crash-protected flight recording systems, such as cockpit voice recorders (CVRs) and flight data recorders (FDRs), often called “black boxes,” are required on most commercial aircraft by the Federal Aviation Administration (FAA). CVRs record sounds like engine noises and pilots’ voices in aircraft cockpits. FDRs record important data on a plane’s operating condition during flight, like altitude and airspeed. Both are installed in a part of the aircraft most likely to “survive” a crash—usually the tail. These instruments have proven invaluable to determining the causes of a crash and preventing similar accidents from occurring; yet, the FAA doesn’t require them on most helicopters.

Nearly 4 months ago, a helicopter carrying nine people collided with a mountainside in Calabasas, California, tragically killing all on board. As the Board member on duty, I launched to Calabasas with a team of NTSB investigators just a few hours after learning of the crash. In the days following the accident, our team of investigators thoroughly examined the details surrounding the collision and I relayed our initial findings to the public. At our final press conference, I highlighted a 2006 safety recommendation issued to the FAA that the agency had refused to implement: require all transport-category rotorcraft operating under Title 14 Code of Federal Regulations Part 91 (requirements for general aviation operations in the United States) and Part 135 (requirements for operating charter and on-demand flights) to be equipped with a CVR and an FDR. The transport-category helicopter in the Calabasas crash was operating under Part 135, but was not equipped with either a CVR or an FDR.

Calabasas CA
CALABASAS, California — In this photo taken Jan. 27, NTSB investigator Carol Horgan examines wreckage as part of the NTSB’s investigation of the the crash of a Sikorsky S76B helicopter near Calabasas, California, Jan. 26. The eight passengers and pilot aboard the helicopter were fatally injured and the helicopter was destroyed. (NTSB photo by James Anderson)

Although it’s too soon in the ongoing Calabasas helicopter investigation to know how the lack of recorders will affect our investigative work, the NTSB has long seen the value of using flight recorders to conduct comprehensive accident investigations, including those involving helicopters. At the time of the Calabasas accident, The Late Show host Stephen Colbert spoke about how a CVR was instrumental in determining what caused Eastern Air Lines flight 212 to crash in 1974, killing 72 people on board—including his father and two brothers. Colbert appealed to the FAA to require that helicopters be equipped with black boxes so we can learn more about what occurred in a crash and prevent the next one from happening.

Unfortunately, the absence of a CVR and an FDR in the Calabasas crash was not unique. In fact, the NTSB has investigated several helicopter crashes and issued recommendations to address the lack of crash-resistant flight recording technology onboard helicopters as far back as 1999 (A‑99‑60). We followed up with comparable recommendations in 2003 (A-03-62 to -65) and 2009 (A-09-9 to -11), and recently released a safety recommendation report detailing several helicopter crashes in which recorded flight data would’ve helped us better identify potential safety issues.

On May 19, the Board adopted a report on the January 29, 2019, crash of an air ambulance near Zaleski, Ohio. The investigation found that if cockpit image data had been captured, investigators would have been able to better understand why the pilot failed to maintain altitude in the final moments of the air ambulance’s flight. We reiterated two previous recommendations (A-13-12 and -13) that the FAA require crash-resistant flight recorder systems on new and existing aircraft operating under Parts 91, 121 (domestic operating requirements), and 135. As we learned at the Board meeting, these crash-resistant devices are available on the market today.

We also reiterated a recommendation (A-16-35) that the FAA require all Part 135 operators to create flight data monitoring (FDM) programs “to identify deviations from established norms and procedures and other potential safety issues.” In the Zaleski investigation, although the helicopter was equipped with FDM devices, the data was not used to verify and improve safety.

Expanding the use of recorders has been on the NTSB’s Most Wanted List (MWL) going back to 2011. The MWLs in 2014 and 2015 both specifically called for crash-resistant flight recorder systems to be adopted to enhance helicopter safety. Our most current MWL, which spans 2019 and 2020, calls on regulators to “require all Part 135 operators to install data recording devices” to meet the same safety requirements as commercial airlines.

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The NTSB’s history of recommendations on flight recording systems has not gone unnoticed by lawmakers. Following a June 2019 helicopter crash in Manhattan that killed the pilot and started a fire on top of a Midtown skyscraper, Senate Minority Leader Charles Schumer and New York Senator Kirsten Gillibrand urged the FAA to require FDRs in helicopters, just as they are required for commercial planes. In their press release, Senator Schumer stated “to know that the NTSB has been trying for years, without success, to compel the FAA to take action as it relates to making helicopters more valuable to safety by installing flight data recorders is cause for serious concern.” He went on to say that the FAA “must take another look” at the NTSB’s recommendations on FDRs.

To date, the FAA has not acted on our repeated recommendations regarding crash‑resistant and crash-protected flight recording systems for helicopters. Although the FAA encourages helicopter operators to voluntarily use crash-resistant flight recording systems, the agency stops short of mandating CVRs and FDRs. This is especially disappointing because, although flight recording systems are undoubtedly crucial to improving aviation safety, they serve another important function: they provide grieving families with answers.

The benefits of crash-resistant flight recording systems well outweigh their cost; it’s beyond time for the FAA to take action on our safety recommendations regarding them.

 

When it Comes to Safety, Not All Flights are Created Equal

By Chairman Robert L. Sumwalt

Last week, we officially adopted our final report on the tragic May 15, 2017, crash of a Learjet 35A on a circling approach to Teterboro Airport in New Jersey. The crash took the lives of the two occupants—the aircraft’s pilots. The probable cause of the accident was the pilot‑in‑command’s (PIC’s) attempt to salvage an unstabilized visual approach, which resulted in an aerodynamic stall at low altitude.

The accident airplane’s operator offered on-demand flights under Part 135 of the Federal Aviation Regulations. (The air carriers that most people are more familiar with, which fly regularly scheduled routes, are regulated under Part 121.) The accident flight was a positioning flight subject to Part 91 rules; however, the procedures that the operator used, the pilots’ training, and the Federal Aviation Administration’s (FAA’s) ongoing oversight duties all pertained to Part 135 aviation.

Imagine knowing that some of what was happening on this accident flight was going on in your regularly scheduled air carrier flight. First, the PIC was not flying the airplane until just before the accident, when the second-in-command (SIC) relinquished control, despite the fact that, by the company’s own standard operating procedures (SOPs), the SIC was not experienced enough to be flying. This was only one of many instances during the flight of an SOP violation or the failure to use required SOPs.

Additionally, during initial training, the PIC and the SIC both had difficulty flying circling approaches in a simulator. This Part 135 carrier, however, did not have a program in place to follow up with pilots who had exhibited issues during training. What’s more, despite both pilots’ training problems flying a circling approach, they were teamed together for this flight.

This accident flight was also an example of poor crew resource management (CRM). CRM done well results in SOP adherence and effective communication and workload management. However, during this flight, the captain had to extensively coach the SIC while also fulfilling his pilot monitoring responsibilities. He did neither well. Both pilots lacked situational awareness.

Contributing to the accident was the PIC’s decision to allow an unapproved SIC to act as pilot flying, and the PIC’s inadequate and incomplete preflight planning. Also contributing to the accident was the carrier’s lack of any safety programs that could identify and correct patterns of poor performance and procedural noncompliance, and the FAA’s ineffective safety assurance system procedures, which failed to identify the company’s oversight deficiencies.

In response to this accident, among other things, we recommended that the FAA require Part 135 operators to establish programs to address and correct performance deficiencies, as well as to publish clear guidance for Part 135 operators to create and implement effective CRM training.

This accident illustrates that Part 135 flight crew members don’t always follow the same procedures or exhibit the same discipline as professionals in Part 121 operations. Before the accident at Teterboro, we found that pilot performance either caused or was a major contributing factor in seven major aviation accidents involving Part 135 on‑demand operators between 2000 and 2015. A total of 53 people were killed and 4 were seriously injured in these accidents. This year, we added “Improve the Safety of Part 135 Aircraft Flight Operations” to our Most Wanted List of transportation safety improvements to help draw attention to this problem.

MWL06s_Part135

Many air carriers operating under Part 121 are required to continually seek and identify risks, and once the risk assessment is done, put measures in place to mitigate those risks through safety management systems (SMSs). Conversely, while some Part 135 operators have implemented SMS, most have not.  In response to the Teterboro accident, we reiterated a previous recommendation to the FAA to require that all Part 135 carriers in the United States have an SMS in place.  In Part 121 training, performance deficiencies are required to be followed up on; there’s no such requirement for Part 135 operators to monitor deficiencies in their pilots’ training.

Further, although Part 135 operators, like their Part 121 counterparts, are required to provide CRM training, they receive less thorough guidance on what constitutes effective CRM training. This shortcoming was evident in the Teterboro accident, where the crew did not display good CRM during the accident flight.

I’ve had two very interesting roles in life – being an airline pilot and serving as an NTSB Board Member. While serving as an airline pilot, I was also a member of a flight operational quality assurance (FOQA) team. In that role, I looked at minor procedural deviations in nonaccident flights with the purpose of learning where potential problems were. In this accident, we reiterated previous recommendations to the FAA to require flight data monitoring (FDM) programs to accomplish the same kind of oversight for Part 135 aviation, and that Part 135 operators install the necessary equipment to acquire FDM data.

In my role as an NTSB Board member, I have seen too many cases where accidents occur in part due to procedural noncompliance and lack of professionalism. A pilot might be born with certain aptitudes, but no one is a born professional; it takes work and constant discipline. Professionalism is a mindset that includes hallmarks such as precise checklist use, callouts, and compliance with SOPs and regulations. Those traits were conspicuously absent on this accident flight. And, now as my role as a frequent airline passenger, I’m glad that airlines are required to have SMS programs; I know they make my flights safer.

The NTSB believes that tools such as an effective SMS should be required and used in Part 135 aviation as well as by Part 121 carriers. We hope that including “Improve the Safety of Part 135 Aircraft Flight Operations” on our Most Wanted List for 2019–2020 will encourage action on this issue.

 

Too Close for Comfort in San Francisco

By Bruce Landsberg, Vice Chairman

On March 27, 1977, two Boeing 747s collided on a foggy runway in Tenerife, Spain. The crash took 583 lives, marking it as the deadliest aviation accident in history. Although commercial airline safety has made huge strides since then, a disaster potentially twice as deadly as Tenerife was recently averted by only about 13 feet.

In the late evening hours of July 7, 2017, an Air Canada Airbus A320 inbound from Toronto almost collided with four jetliners awaiting take off at San Francisco International airport (SFO). The night was clear and calm, with no weather to obscure the visual approach to Runway 28 Right.

The Air Canada pilots, not realizing the parallel runway (28 Left) was closed, lined up on a nearby taxiway rather than their assigned runway. As the waiting airliners flashed their landing lights to alert the errant Airbus, one of the pilots on the control tower frequency ground broadcast can be heard saying “Where’s this guy going?” and “He’s on the taxiway!” In the last few seconds, the Air Canada crew recognized their error and aborted the landing.  Simultaneously, the tower controller ordered the Airbus to go around.

Upon landing, the captain called the tower to discuss the incident, and then went to bed. It was 3 am by his body clock and he was exhausted. Although he was required to do so as soon as possible, the captain did not inform Air Canada’s dispatcher about the incident until 16 hours later, by which time the aircraft had already departed on a morning flight, resulting in the required 2-hours of cockpit voice recorder (CVR) data being overwritten.

With all the equipment, training, and safety management systems implemented since Tenerife, it’s astonishing how a near miss like this could happen. But as our investigation revealed, a long and intricate chain of events was to blame. We clearly understand now what happened, but, because the CVR data was lost, we only know part of the why.

We made several recommendations to address the safety issues our investigation uncovered. The incident report, which is available at ntsb.gov, should be required reading for pilots of both large and small aircraft. Here are some of the most important takeaways.

Knowing what to expect. Before flight, all pilots are required to check for Notices to Airmen (NOTAMs), which inform them of anything unusual that has recently changed at the departure or arrival airport, as well as navigational outages along the way. In practice, NOTAMs contain dozens of notices of varying importance, such as closed taxiways, wet runways, and small, unlit towers miles from the airport. Information about closed runways, however, is critical.

From a human factors perspective, we found that the presentation of information in the NOTAM the crew received did not effectively convey the information about the runway closure. This Air Canada crew missed two warnings about the closed runway at SFO, first in predeparture, and then via datalink before landing. Had they been aware of the closure, the pilots almost certainly would’ve suspected an unusual airport configuration with changed lighting patterns.

The current NOTAM system lists everything that could, even under the most unlikely circumstance, affect a flight. It lays an unnecessarily heavy burden on individual pilots, crews, and dispatchers to sort through dozens of irrelevant items to find the critical and important ones. When an important item is missed—as is common—and a violation or incident occurs, the pilot is blamed for not finding what amounts to a needle in a haystack.

Further, NOTAMs are published in hard-to-read codes. Using plain language and conventional date and time configuration in both local and universal (UTC) time could go a long way toward making flight safety information easier to understand. The Federal Aviation Administration (FAA) has been aware of the NOTAM problem for more than 15 years. In 2012, Public Law 112-153 (Pilot’s Bill of Rights) gave the FAA 1 year to fix the problem. The incident at SFO makes it clear that there is still much more work to be done. This is a safety issue that calls for urgent action.

The fatigue factor. Fatigue continues to be a recurring factor in accidents and incidents. The Air Canada captain had been awake for 19 hours at the time of the incident. It’s estimated that he awoke around 0800 eastern time (ET); the incident occurred at 0300 ET the following day. The captain was not technically “on duty” that whole time, and, under Canadian regulations for reserve crew members, he still could have been available for duty for another 9 hours.

During postaccident interviews, the captain said he did not make a timely incident report to Air Canada’s dispatch after landing because it was “very late” and he was “very tired.” If the captain is too tired to make a phone call to report an incident, should the rules allow him to fly a challenging night approach with the lives of 139 passengers and crew in the balance? If we expect solid human performance where lives are at stake, fatigue rules need to be based on human factors science. The NTSB has recommended that Canada’s fatigue regulations be modified.

Cockpit voice recorders and beyond. The Airbus’s CVR would have provided much more information on what happened, but it was overwritten during the first flight following the incident (current CVRs are only required to store a minimum of 2 hours of audio). Without the CVR data, we may never understand all the reasons behind the numerous procedural failures, but we know one thing for sure: the CVR would have provided a much better picture of just how this incident came close to being a catastrophic accident.

Cockpit image recording could provide a much richer source of critical information. We initially issued an image recorder recommendation as long ago as 2000.

We have had far more success with image-recording technology in every mode of public transportation except commercial aviation. Some pilot groups are concerned about the flight crew’s right to privacy and that the information gathered will be used punitively. Workplace right to privacy has been extensively debated, but for employees in safety-critical positions, privacy should take a backseat to human life.

Unlike written transcripts, cockpit audio and video recordings are protected by federal law and never released by the NTSB. Likewise, video recordings are protected by law from being released. Over-the-air transmissions, such as communications between a pilot and air traffic controllers, are in the public domain, by definition, but in-cockpit audio and video recordings are protected by the NTSB against public disclosure.

More importantly, image recorder data gathered routinely before an accident will be invaluable in preventing the next tragedy. This approach has been highly effective in flight operational quality assurance (FOQA). This approach may pose some technical challenges, but it will significantly increase safety and accountability.

Learn and forgive. One of the best practices used in aviation is the concept of “just culture,” or nonpunitive corrective action. Most people put their best foot forward and attempt to minimize a critical error when they make one, which is perfectly understandable. Yet, some supervisors want to mete out sanctions to “teach a lesson” or to make an example of a crew. Unless someone is habitually error prone or intentionally ignoring safety procedures, a punitive response is completely inappropriate to critical performance environments in all modes of transportation.

This Air Canada flight crew will almost certainly never make such a mistake again, and my hope is that they will continue to fly to the normal end of their careers.

We gain much more from being introspective rather than judgmental about this incident. We should celebrate when someone confesses a mistake and learns from it. This is one of the key factors in the decades-long decline in commercial aviation’s accident rate. Fortunately, we’ll get another chance to put some fixes in place to make a highly improbable event even less likely to recur. Let’s not squander it.

 

Reduce Fatigue-Related Accidents and Expand Recorder Use to Enhance Safety are topic areas on the NTSB 2017-2018 Most Wanted List.

 

The Value of Video

By Jennifer Morrison, NTSB Investigator-in-Charge, Office of Highway Safety

 On January 19, 2016, a Greyhound bus with 22 people on board was traveling on a California interstate in the dark in moderate-to-heavy wind and rain. The driver intended to take the left exit, en route to the next stop in San Jose, but instead crashed the bus head-on into the end of a concrete barrier. The bus jumped the barrier and rotated onto its side. Two passengers were ejected and died; the driver and 13 passengers were injured.

The crash occurred at 6:37 in the morning, after the driver had been on duty, commuting to his route and driving the bus, for about 12 hours. Tempting as it was to assume this crash resulted from driver fatigue, our investigation soon revealed that other factors were at play.

HWY16MH005_prelim[1]
Final rest position of bus and remains of REACT 350 crash attenuator base
When I arrived on scene with the rest of the “go team,” we discovered that the highway interchange where the crash occurred had four through lanes, two right exit lanes, and a single left exit lane. When the driver moved the bus left to what he thought was the left exit lane, he instead unintentionally entered a 990-foot-long unmarked gore area that separated the through lanes from the left exit lane. The gore area ended at the concrete barrier where the crash occurred. The crash attenuator at the end of the barrier likely absorbed some crash energy, but it was not designed to redirect a large commercial vehicle like a Greyhound bus.

What was interesting about the crash attenuator was that it had been hit before; our investigation found that damage from the previous impact had ripped the reflective sheeting off its face. Records showed that the California Department of Transportation had placed temporary barricades but had never finished the repair.

Fortunately for our investigation, the bus, like most of Greyhound’s buses now, was equipped with a video camera system. Video recovered from the bus showed that the temporary barricades had blown over, possibly in the wind and rain that morning. As we watched the forward-facing and inward-facing videos, the scene became clear: the driver was attentive as he signaled and moved into the gore area, interpreting it to be a travel lane. At 1 second before impact, a dark black barrel (the first part of the crash attenuator) appeared in the middle of the “lane” (see Figure 1). There was no reflective sheeting on its face, and there were no temporary barricades set up to identify the hazard.

Without the video camera system onboard the bus, it would’ve been impossible to know that the barricades had blown over prior to the crash, rather than simply been displaced by the event. Without the video evidence, it would have been easy to assume that the driver was just too tired or otherwise distracted by fatigue to see the warning. But the video showed clearly and indisputably the events leading up to the crash.

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Still image of onboard video at 1 second prior to impact.

Onboard video systems provide investigators and fleet owners with the invaluable, unbiased evidence to interpret—and work to prevent—crashes like this one. That’s why we’ve strongly recommended they be installed on all highway vehicles for decades. We even emphasize the importance of these systems on our Most Wanted List of transportation safety improvements. This crash illustrates why this technology is important, and we continue to urge operators to install it across their fleets.

NTSB Most Wanted List of Transportation Safety Improvements 2017-2018

To learn more about this issue, join us Thursday, September 13 at 2 PM EST, for our “Reducing CMV Crashes Through the Use of Video Recorders webinar.” In our 1-hr webinar, NTSB Member Bella Dinh-Zarr, investigators and recorder analysts from the Office of Highway Safety and Office of Research and Engineering, along with commercial fleet owners representing the truck and bus industries, will discuss why and how their organizations use video recorders to improve safety. NTSB investigators will provide an in-depth discussion into the Greyhound crash discussed in this blog and will also highlight a truck case study. For more details or to register, visit this link.

 

 

 

Most Wanted List Progress Report: Rail Safety

By: Chairman Robert L. Sumwalt

 The NTSB is releasing a series of blogs highlighting the progress the transportation community is making in each mode to advance issues on our 2017–2018 Most Wanted List. This series sheds light on the progress made and what needs to be done going forward to improve transportation safety. This is the fourth and final blog of the series.

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Chairman Sumwalt and Robert Hall, Director, NTSB Office of Railroad, Pipeline and Hazardous Materials Investigations talk with attendees at the Most Wanted List midpoint meeting

On November 14, 2017, the day before our Most Wanted List (MWL) progress meeting, we concluded our investigation into the April 2016 Amtrak train derailment in Chester, Pennsylvania. As I offer the closing words of this blog series highlighting the progress made  to address issues on our list, the NTSB is presently investigating the December 2017 Amtrak train derailment in DuPont, Washington, and the February 2018 Amtrak train and CSX freight train collision near Cayce, South Carolina. And, on February 15, I testified before the US Congress regarding the urgency for the industry to fully implement positive train control (PTC) by year’s end. That same day, we also issued three urgent safety recommendations to address findings from our investigations into the Cayce accident and the June 2017 Long Island Rail Road accident in Queens Village, New York.

At our midpoint meeting, I joined members from our Office of Rail, Pipeline, and Hazardous Materials Investigations to lead a discussion on rail safety. While there has been progress with implementing some of the NTSB’s recommendations, the Chester and DuPont derailments and the Cayce collision tragically illustrate that more needs to be done – and quickly!

A deficient safety management system and impairment were factors in the fatal Chester accident. And, like many accidents we’ve investigated, distraction played a role. When the accident occurred, the dispatcher was speaking to his spouse on a landline. We’ve recommended that Amtrak prohibit such calls while dispatchers are on duty and responsible for safe train operations.

The Chester accident also illustrated the fact that drug use by rail workers has been on the rise in recent years, playing a part in seven accidents in the last 3 years and nine accidents in the last decade, compared to only one accident in the prior decade. In the Chester accident, a backhoe operator who was killed had cocaine in his system, and two different opioids were discovered in the track supervisor’s system. During our investigation, the Federal Railroad Administration (FRA) moved quickly to require random urine drug screening for maintenance‑of‑way workers, effective April 2018. Additionally, the Amtrak locomotive engineer tested positive for marijuana, although there was no operational evidence that his prior drug use impaired his performance on the morning of the accident. What it did show, however, is that despite DOT random drug testing requirements for locomotive engineers, such a program did not deter his use of an illicit drug.

Fatigue and medical fitness are other significant MWL issues for rail, and we’re disappointed that the FRA and the Federal Motor Carrier Safety Administration have withdrawn an advanced notice of proposed rulemaking that would’ve supported sleep apnea screening for railroads and for commercial highway carriers. Clearly, there’s still important work to do on these issues.

Regarding another significant MWL issue for rail, strengthen occupant protection, the FRA has made progress toward developing a performance standard for keeping window glazing in place during an accident. Unfortunately, meaningful improvements related to the safety of corner posts, door designs, restraint systems, and locomotive cab crashworthiness have been slow.

The MWL’s safe transport of hazardous materials issue area focuses on transporting energy products in safer tank cars, built to the DOT-117 rather than DOT-111 and CPC 1232 standards. We are pleased to see that the more robust DOT-117 standard is being used for transport of crude oil. Ethanol transport, however, still widely relies on the DOT-111 and CPC 1232 standards. We urge stakeholders to move to using the DOT-117 standard when carrying ethanol as soon as possible, ahead of the mandated deadlines.

There has been little, if any, progress to improve transit safety oversight since we released the current MWL. To exercise effective oversight, the Federal Transit Administration (FTA) must continue to use the authority it gained with the Fixing America’s Surface Transportation Act and Moving Ahead for Progress in the 21st Century Act to promulgate safety rules.

Finally, on the issue of expanding recorder use, the industry is moving forward with installing inward-facing video cameras on passenger trains, which is a step in the right direction. However, we would like to see the FRA move forward on requiring the installation and that the requirement be expanded to include audio recording, and we believe that the freight rule should follow suit. The FTA still has no such requirements for transit rail.

As I offer the last thoughts on our MWL midpoint meeting blog series, I want to thank all those who attended for taking the time to offer suggestions and share their perspectives on the issues affecting the safety of our nation’s transportation system. As we move into the second year of this MWL cycle, I challenge our stakeholders to target one or more recommendations on which they can make measurable progress before this year is over. We all want to have the safest transportation in the world, and it will take us working together to accomplish it.