Category Archives: Transportation Disaster Assistance

Episode 42: TWA Flight 800

In this episode of Behind-the-Scene @NTSB, NTSB Managing Director, Sharon Bryson and Frank Hilldrup, Chief Technical Advisor for International Affairs, NTSB Office of Aviation Safety, talk about the July 17, 1996, TWA flight 800 accident.  We discuss what happened, the findings and safety recommendations that came out of the investigation, its tremendous impact on aviation safety, how the Aviation Disaster Family Assistance Act of 1996 led to the establishment of NTSB’s disaster assistance program, and the decommissioning of the TWA flight 800 reconstruction.

The NTSB final report for the TWA flight 800 in-flight breakup mentioned in this episode and the NTSB docket for investigation is also available on our website.

To learn more about the NTSB Transportation Disaster Assistance (TDA) Program, visit our TDA web page.     

To learn more about the NTSB Most Wanted List (MWL), visit our MWL web page. You can also access the MWL archive  on our website.

Information about upcoming NTSB virtual training courses are available on our Training Center web page.                                                               

Get the latest episode on Apple Podcasts , on Google PlayStitcher, or your favorite podcast platform.

And find more ways to listen here: https://www.blubrry.com/behind_the_scene_ntsb/

I Lived My Dream: Looking Back on 15 years at NTSB

By Chairman Robert L. Sumwalt

I guess it all started on an overcast day in 1973, when I found myself on the scene of a fatal aviation crash for the first time. I had heard of the crash on my car radio, and, as a curious 17‑year-old, I decided to find the crash location. Once there, I saw the remains of a twin-engine airplane lodged in the bases of the surrounding pine trees. Seeing that accident scene sparked an acute interest within me for accident investigation. In college, I spent copious amounts of time in the government documents library reading NTSB aircraft accident reports. It was then, in the mid-1970s, that I began to dream of becoming an NTSB Board member. Today, as I wrap up 15 years with the agency, serving as Board member, vice chairman, and chairman, I can look back and say I have truly lived that dream.   

Photo of ‘The State’ newspaper article on the 1973 plane crash

I was sworn in as the 37th member of the NTSB in August 2006. Seven days later, I found myself on the scene of another aviation disaster. Comair flight 5191, a regional jet operated as a Delta Connection, crashed just off the departure end of a runway in Lexington, Kentucky. Forty-nine lives were lost that morning after the pilots inexplicitly attempted to take off on a short, closed, unlighted runway. The investigation found that the pilots’ casual attitude during preflight and during the brief taxi, including their engaging in nonpertinent conversation, enabled the crew’s errors. Quite simply, the crew wasn’t paying attention and lost positional awareness. As a result, we issued and reiterated several recommendations to prevent that same type of accident. Today, flights are safer because airline pilots use enhanced procedures to ensure they are aligned with the proper runway before departure, and pilots have electronic maps that provide real-time position information during taxi.

Since the Comair crash, I’ve been on the NTSB Go-Team and served as the Board member on scene for 35 transportation accidents and crashes, and I’ve been involved in the deliberation and determination of probable cause of over 250 accidents and crashes. I’ve met with grieving family members and friends of victims on the worst day of their lives. Through these interactions, the one thing that really stands out to me is just how precious life really is. I’ve often said that we are here to give a voice to those who don’t have a voice—the victims of transportation accidents and their families. I take great solace knowing our work really does make a difference and keeps others from enduring similar tragedies.

Looking back, I believe there are two things that allow the NTSB to truly be one of the “Best Places to Work in the Federal Government,” as ranked by the Partnership for Public Service: the agency’s mission, and our people.

First, the agency’s mission: Congress charged the NTSB with investigating transportation accidents and crashes, determining their cause, and issuing safety recommendations to prevent similar accidents and crashes, reduce injuries, and save lives. It’s an important calling—taking something tragic and learning from it so others don’t have to endure such a tragedy. Since the NTSB was formed in 1967, we have investigated over 150,000 aviation accidents, along with thousands of highway, marine, rail, pipeline, and hazardous materials accidents and incidents. In that period, we’ve issued over 15,000 safety recommendations, the majority of which have been successfully implemented.  

Our people: Even with a respectable mission, you’re nothing without great people. Fortunately, this is where the NTSB really takes the cake. We’re able to attract and retain dedicated, bright employees who love their work. We actively promote diversity and inclusion, and my hope is that the agency will continue to expand this effort. Our investigators’ passion and determination to find the truth is uplifting. Even throughout the pandemic, although working remotely, NTSB employees found ways to continue delivering our high-quality products. For example, before the pandemic, we had never conducted virtual Board meetings, where we deliberate accident findings, determine the probable cause, and adopt safety recommendations. Even with the challenges of 2020, our employees figured a way to get it done. We held 12 virtual Board meetings in a year, which compares favorably to a normal year of in-person meetings. Although I’ve always had high expectations of the NTSB workforce, I can honestly say that, considering the challenges we all faced during the pandemic, NTSB employees surpassed all expectations.

There are several other qualities that allow the NTSB to be a highly respected federal agency. One of our core values is transparency; we are open and honest with the public about our work. We realize that, when a transportation disaster occurs, the public needs to be assured that the government is conducting an open, competent, and thorough investigation. Therefore, we deliver fact-based information as we learn it. We don’t speculate—just the facts, ma’am. All NTSB Board meetings and hearings are open to the public (literally in person when not in pandemic times, and always via webcast). We post all our accident reports and publications on our website, along with the docket for each accident, which provides reams of background information such as interviews, photos, and technical information that may not be in the final accident report.

When I was sworn in for my first term at the agency in 2006, I told the audience something I had read: “Public service is one of the highest callings in the land. You have the opportunity to make a positive impact on families, communities, states, and sometimes the world.”

I followed up by saying, “I truly believe this statement applies so well to the work of the NTSB. When my term expires, I hope we can look back and say, ‘you know, we—Board members, professional staff, industry, labor, government—we all worked together, and we did make a positive impact.”

Indeed, looking back, I truly believe we have made a difference.

I will very much miss working with the incredibly dedicated men and women of the NTSB. It will be hard to stop referring to the NTSB as “we.” Although I will no longer be part of it, the NTSB will always be part of me. For that privilege, I am forever proud and grateful. I have lived my dream.

Safe and Sound at Work

By Chairman Robert L. Sumwalt

Last week, I kicked off Safe and Sound Week—an Occupational Safety and Health Administration initiative—with this video message. In the video, I reminded NTSB employees that one of the things our agency does is meet with victims’ family members on perhaps on the worst day of their lives. I told my colleagues that I’d consider it the ultimate failure to ever have to sit down with any of their family members to tell them that something bad had happened to them while they were on the job at the NTSB.

Workplace safety is not included in the NTSB’s statutory mission, but it certainly is “in our lane,” just as it’s in any organization’s lane. I believe workplace safety should be built into how we think and act at the NTSB. Our agency’s Occupational Safety and Health Program team recently challenged all of us to define what safety means. My answer was, “constantly anticipating bad things that can happen and then proactively taking actions to mitigate those things so that no one gets hurt.”

That answer was based on, among other things, a particular personal experience. I remember a street crossing near my home that was adjacent to a blind curve obstructed by shrubbery. It seemed a little dangerous, but I never really thought much of it until I had to dart back to the curb to avoid being struck by a car. After that, I found another crossing point about 15 feet away that was a little safer. Why hadn’t I found that safer crossing sooner? Because I hadn’t been constantly anticipating what could happen and working to mitigate the danger.

Now, take an example of the same lack of risk assessment to a broader scale. We recently completed our investigation of an accident near DuPont, Washington, where a transit train on its inaugural revenue service run failed to slow down from 78 mph when entering a curve with a speed restriction of 30 mph. The train derailed, sending several cars plummeting to the interstate below. Three passengers were killed, and 55 people were injured—including 8 in vehicles on the road. The transit agency responsible for assessing risk on this curve had determined one mitigation prior to the derailment: implementing positive train control (PTC); however, PTC implementation was delayed, and the transit agency didn’t find another means of mitigating the risk before carrying on with the inaugural run.

Just like me crossing the street near my home, the transit agency was not constantly anticipating what could happen and taking action to mitigate the worst-case scenario. That lack of action put not only the train’s passengers at risk, but the agency’s employees, as well.

Workplace safety doesn’t fall solely on an organization’s management, though. It’s a shared responsibility between an agency and each of its employees. Ask your workplace safety experts what to look for when assessing your workplace for safety risks. In my agency, the risks vary widely from an accident scene to the office, but we strive to address all possible scenarios to keep ourselves—and each other—safe. Wherever you work, slips, trips, falls, fire hazards, and other workplace safety concerns are undoubtedly “in your lane.” It’s up to all of us to assess our workplace risk and take actions to mitigate it.

NTSB Supports ‘Safe Skies for Africa’ Program

By Dennis Jones, NTSB Managing Director

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

1
Managing Director, Dennis Jones, talks with attendees at the Safe Skies Symposium in Johannesburg, SA

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

On this trip, the NTSB team shared a variety of lessons learned from different disciplines. Dennis Hogenson, Western Pacific Region Deputy Regional Chief for Aviation Safety, pointed out that, like Africa, the United States is seeing a high incidence of general aviation (GA) crashes. He told his audience that, while airline accidents have become rare, GA accidents account for most aviation fatalities in the United States. We investigate about 1,500 GA accidents each year; those involving loss of control in flight still result in more than 100 fatalities annually. In many of our GA accident investigations, we’ve discovered that pilots didn’t have the adequate knowledge, skills, or recurrent training to fly safely, particularly in questionable weather conditions, and their inability to appropriately recover from stalls often resulted in deadly accidents. Dennis encouraged his African counterparts to initiate more training and increase awareness of technology, such as angle-of-attack indicators, that can help prevent these tragedies.

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

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

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

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

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

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

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

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

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

dsc_8283.jpg
NTSB Managing Director and staff with symposium attendees

Reflecting back on 10 years as a Board Member

By Robert Sumwalt

On August 21, 2006, I was sworn in as the 37th member of the National Transportation Safety Board. At the same time, I was appointed by President George W. Bush to serve as NTSB Vice Chairman. In 2011, President Barack Obama reappointed me for an additional five-year term as a board member.

Robert Sumwalt, taking the oath of office, administered by then-NTSB Chairman Mark V. Rosenker on August 21, 2006.
Robert Sumwalt, taking the oath of office, administered by then-NTSB Chairman Mark V. Rosenker on August 21, 2006.

As I reflect on 10 years as an NTSB board member, there are several things that stand out. First, is the mission. Our role in transportation safety quickly became apparent when, on my seventh day on the job, I launched to an airline crash in Lexington, Kentucky. Tragically, that crash claimed 49 lives.

But, the NTSB’s primary mission involves more than just investigating accidents. It also involves determining the cause of accidents, and then, most importantly, issuing safety recommendations to prevent future accidents. At the entrance to our training center, we have an etched glass window that says, “From tragedy we draw knowledge to protect the safety of us all.” And that’s exactly what we do – we learn from tragedy so we can keep it from happening again.

Recently, one of our investigators wrote to me about a rail accident he investigated where fire and explosion claimed multiple lives. He told of meeting a man who was glaring at the carnage as he pushed a baby in a carriage. As it turned out, the man’s wife – the baby’s mother – had been killed in the disaster. Our investigator promised the man that the NTSB would get to the bottom of why this event occurred so other accidents could be prevented. “I also watched a man standing outside of the exclusion zone peering over the barrier in tears as a backhoe demolished his home,” the investigator explained in his note to me. “My thoughts were of those victims, and it was clear that we were being called upon to do this for them.”

Yes, we are here to give a voice to those who don’t have a voice—the victims and their families of transportation accidents. I take great solace knowing our work really does make a difference and keeps others from enduring similar tragedies.

The NTSB is an independent federal agency – meaning, we are not attached to a larger federal organization such as the U.S. Department of Transportation. In my opinion, independence is one of our greatest virtues because it allows the agency to conduct investigations and explore safety issues without being encumbered by actual or perceived political pressures. As I’ve often said, our independence allows us to “call it the way we see it.”

What also stands out to me is the dedication of the men and women of the NTSB. Their passion and determination to find the truth is uplifting. In the most recent employee viewpoint survey, 96 percent of respondents replied positively to the statement, “When needed I am willing to put in the extra effort to get a job done.” That demonstrates the commitment and dedication NTSB employees share for fulfilling our mission.

In addition to investigative activities, there is a proactive side to the NTSB. Our staff conducts safety studies, tracks and follows up on our safety recommendations, and advocates for safety improvements by providing testimony on safety issues, promoting our Most Wanted List, bringing important safety issues into the public discussion via social media efforts, and organizing safety events such as roundtable discussions.

One of the NTSB’s values is transparency; we are open and honest with the public about our work. We post on our website all accident reports and publications, as well as the docket for each accident. The docket provides reams of background information for accidents, such as interviews, photos, and technical information that may not be in the actual accident report. Our board meetings are webcast and open to the public. And, our Office of Safety Recommendations and Communications ensures the media are informed of the status of investigations by answering questions, arranging interviews, issuing press releases, and releasing updates through social media.

Many are surprised to learn that the NTSB also serves as a court of appeals for pilots, aircraft mechanics, and mariners who receive violation notices from the Federal Aviation Administration and U.S Coast Guard. The NTSB’s Office of Administrative Law Judges (ALJ) processes those cases, and our three ALJs hold hearings to adjudicate those matters.

The NTSB’s Office of Transportation Disaster Assistance – a highly trained group with expertise in social services, emergency management, and forensics – works closely with various organizations to meet the needs of disaster victims and their families. This group also serves as the primary point of contact for family members and disaster victims, providing updates regarding the status of NTSB investigations and addressing their questions. It takes a special person to do the work they do, and I’m always appreciative of how well they do it.

There are other parts of the agency that aren’t often acknowledged, but nevertheless are important to allowing the agency to function. As in any organization, job openings need to be posted and filled, bills paid, contracts written and executed, and our computers maintained. The employees who perform these functions are as dedicated as those performing the agency’s core mission.

To put it simply, I’m so proud to be part of this agency. Our mission, independence, transparency, and people are all so important. I’m honored to have served with them for the past 10 years.

Robert Sumwalt is an NTSB board member.