Category Archives: Transportation History

PTC, 50 Years After Darien

By Member Jennifer Homendy

Exactly 50 years ago today, two Penn Central commuter trains collided in Darien, Connecticut. Four people died and 43 others were injured. The collision led to our first recommendation related to positive train control (PTC). Today, I joined Senator Richard Blumenthal at a commemoration of the accident in New Haven. The senator and I share the same goal: to see PTC implementation completed.

In the past half century, we have investigated more than 150 PTC-preventable accidents that have taken the lives of more than 300 people and injured 6,700 others. PTC was on our first Most Wanted List in 1990, and it’s still on our Most Wanted List today.

In 2008, when it became clear that, even after a series of deadly crashes, the railroads and the Federal Railroad Administration (FRA) weren’t going to voluntarily implement PTC, Congress took action and made PTC implementation mandatory. The railroads have made progress—albeit slowly—in the past 11 years. Some have almost fully implemented PTC, but others lag far behind. The deadline for PTC implementation was extended to the end of 2018; however, if a railroad met certain benchmarks, it could qualify for a 24-month extension. Nearly all railroads satisfied the criteria to extend the deadline, which is now set for December 31, 2020.

The December 2020 extended deadline is fast approaching, yet a lot of work remains to be done. Some railroads are still installing equipment—which is a task that should’ve been completed by now. Railroads should be providing ongoing PTC training and actively working toward interoperability with other railroads on their lines. They should be getting their safety plans to the FRA for final certification and approval. Although there is a lot to accomplish over the next 16 months, our message is simple: No more extensions, no more excuses, and no more delays. It’s time to finish the job!

From the day that President Kennedy urged America to put a person on the moon to the day that Neil Armstrong took those historic steps, it was only 8 short years. Think about that—8 years to get a human to the moon. Yet, it’s been 50 since the accident in Darien, and we still haven’t managed to get PTC up and running on our country’s rails.

As I stood in my native Connecticut today, I thought about the four people killed there on August 20, 1969, a half century ago. It’s been over a decade since Congress mandated PTC, and the traveling public is still at unnecessary risk. It’s time for the railroads to finish the job.

August 20, 2019 Press Event in New Haven, Connecticut
In this photo, taken August 20, 2019, at Union Station in New Haven, Connecticut, NTSB Member Jennifer Homendy is with Connecticut Senator Richard Blumenthal at a press event to mark the fiftieth anniversary of a fatal train collision in Darien, Connecticut, and to call for the full implementation of Positive Train Control. NTSB photo by Stephanie Shaw

When an Aircraft Goes Missing

By Mike Hodges, Air Safety Investigator, NTSB Office of Aviation Safety

On August 9, 2008, a privately-owned Cessna 182E airplane was reported overdue near Juneau, Alaska. The NTSB immediately started monitoring search efforts being conducted by the US Coast Guard, the Alaska State Troopers, the Civil Air Patrol, and a host of good Samaritans. The search area was expansive and included remote inland fjords, coastal waterways, and steep mountainous terrain. In an effort to start gathering information that was potentially relevant to the accident, we interviewed other pilots flying in the area, as well as Federal Aviation Administration (FAA) Flight Service Station personnel to better understand weather conditions at the time the airplane disappeared. After an extensive but unsuccessful search, search-and-rescue activities were suspended on August 20, 2008.

For all aviation accidents such as this one, when initial search-and-rescue activities are suspended and no wreckage is found, the NTSB issues a preliminary report, available to the public in an aviation accident database that can be accessed through our website. If the wreckage is not located within 180 days from the initial date of disappearance, we complete a final report with a probable cause statement of “undetermined.” The final report includes all pertinent information that was initially gathered at the time the aircraft was reported missing. If the wreckage is eventually located after the initial 180 days, we reopen and complete the investigation.

On October 25, 2017, I was the on-call air safety investigator for the NTSB Alaska Regional Office. Alaska State Troopers notified me that a deer hunter had discovered airplane wreckage on Admiralty Island, about 15 miles south of Juneau, Alaska. We eventually determined that it was the missing Cessna 182E. So, 9 years after the airplane went missing, we reopened the case.

In Juneau, I met with an aviation safety inspector from the FAA, an Alaska State Trooper, and members of Juneau Mountain Rescue. As with most remote aircraft accidents in Alaska, traveling to the scene requires an airplane or helicopter because there are no roads. The NTSB chartered a commercial, float-equipped Cessna 206 airplane, and we flew to Young Lake on Admiralty Island in the Tongass National Forest—the largest intact temperate rainforest in the world.

Flying to Young Lake near the accident site
Flying to Young Lake near the accident site

As an air safety investigator working in Alaska, I often face unique challenges, whether it’s a hike to a remote area to reach an accident site or a wildlife encounter. In this case, after arriving at the northern end of Young Lake, we hiked nearly 2 miles to the accident site, each of us carrying either firearms or bear spray because of the large population of brown bears on the island. We also carried satellite phones because there’s no cell phone reception in the area. The wreckage was in densely‑forested, steep mountainous terrain a little over a mile northwest of the north end of Young Lake, at an elevation of about 1,075 ft. mean sea level. The average tree height at the accident site was about 100 ft.

Landing on Young Lake
Landing on Young Lake

When we arrived at the site, the FAA aviation safety inspector and I documented and examined the wreckage. The cockpit and fuselage were destroyed by a postimpact fire. The wreckage of the missing airplane was confirmed via the serial number located on the airframe data plate. Time and nature had taken their toll—the heavily corroded wreckage was covered with dirt, fungus, leaves, and branches. The Alaska State Trooper recovered the remains of the two occupants.

View of the wreckage
View of the wreckage

Once the investigative and recovery activities were completed, we hiked back to Young Lake, contacted the commercial aviation operator for pickup, and returned to Juneau. Because the location was so remote, the wreckage was not recovered.

NTSB Air Safety Investigator Mike Hodges
Mike Hodges using a satellite phone at Young Lake to provide an update to NTSB leadership

On-scene activity is just one part of our investigative process. In each investigation, we look at the roles of the human, the machine, and the environment. By learning about the factors that cause an accident, we can make recommendations to prevent similar accidents in the future. In this investigation, I reviewed the airplane’s maintenance records, considered the pilot’s aviation training and medical records, and examined meteorological and topographical data for the accident area. As a result of the investigation, the NTSB determined that the probable cause of the accident was the pilot’s decision to continue visual flight into an area of instrument meteorological conditions, which resulted in the pilot experiencing a loss of visual reference and subsequent controlled flight into terrain. The pilot’s self‑induced pressure to complete the flight also contributed to the crash. The final accident report can be viewed here.

If you ever happen to come across aircraft wreckage—or what you think is aircraft wreckage—no matter how old it appears to be, please notify local law enforcement and the NTSB Response Operations Center in Washington, DC. If you’re able, please provide latitude and longitude coordinates of the wreckage location, along with photographs of what you found. The NTSB can then continue investigating what happened, which can help prevent future accidents from occurring. Also, importantly, family and friends of those who died in the accident may be interested in the new information. If you ever have the chance to visit the NTSB Training Center in Ashburn, Virginia, you will see an etched window on the front of the building that states the building is dedicated to the victims of transportation accidents and their families. The display also summarizes the NTSB’s crucial work of improving transportation safety for our great nation: “from tragedy we draw knowledge to improve the safety of us all.”

NTSB Training Center display

Remember Bellingham

By Member Jennifer Homendy

Today marks the 20th anniversary of the Olympic Pipe Line rupture in Bellingham, Washington, which resulted in the release of about 237,000 gallons of gasoline into a creek that flowed through Whatcom Falls Park. Sometime after the rupture, the gasoline ignited and burned about 1.5 miles along the creek. Two 10-year-old boys and an 18-year-old young man named Liam Wood died; 8 others were injured.

Bellingham, WA
Postaccident aerial view of portion of Whatcom Creek showing fire damage.

Liam had just graduated from high school and was fly fishing when he was overcome with fumes from the rupture. Years later, I met Liam’s stepfather, Bruce Brabec, as a staffer on Capitol Hill. Since Liam’s death, Bruce has been a tireless advocate for closing gaping holes in pipeline safety regulations, many of which have been revealed as a result of our pipeline accident investigations.

This past fall, I saw Bruce at a pipeline safety conference. The discussions over the days that followed left me wondering how much we’ve accomplished over the last 20 years. Is our pipeline system truly safer?

From a numbers standpoint, it’s good news and bad news. According to the Pipeline and Hazardous Materials Safety Administration (PHMSA), there were 275 significant gas and hazardous liquid pipeline incidents in 1999, resulting in 22 fatalities and 208 injuries. Since that time, the number of significant incidents has fluctuated as PHMSA adopted new reporting criteria, with 288 significant incidents occurring in 2018.

Fatalities and injuries have decreased since 1999 to 7 fatalities and 92 injuries in 2018, but that provides no comfort for victims, their families, or their loved ones. The fact is, although pipelines are one of the safest ways to transport hazardous material, the impact of just one incident can be devastating. And although the number of accidents is low compared to other modes like highway and rail, there is much more that pipeline operators and federal regulators can do to get to zero incidents, zero fatalities, and zero injuries on our nation’s pipeline system.

Our recommendation for operators to install automatic or remote-control shut-off valves in high‑consequence areas is a perfect example. In 1994, we investigated a natural gas transmission pipeline rupture in Edison, New Jersey, which resulted in a fire that injured 112 people and destroyed 8 buildings. Pipeline operators were unable to shut down the gas flow to the rupture for 2½ hours. Our report on the accident recommended that the Research and Special Programs Administration (RSPA), PHMSA’s predecessor, expedite requirements that automatic- or remote‑operated mainline valves be installed on high-pressure pipelines in urban and environmentally sensitive areas so that failed pipeline segments can be rapidly shut down. We have been recommending valve installation in some form on pipelines since 1971.

In response, RSPA issued a regulation requiring operators to install a valve only if the operator determines it will efficiently protect a high-consequence area in the event of a gas release.

Fast forward to September 9, 2010, when an intrastate natural gas transmission pipeline owned and operated by the Pacific Gas and Electric Company ruptured in a residential area in San Bruno, California. The rupture produced a crater about 72 feet long by 26 feet wide. The section of pipe that ruptured was found 100 feet south of the crater. The released natural gas ignited, resulting in a fire that destroyed 38 homes and damaged 70. Eight people were killed, many were injured, and many more were evacuated from the area.

In our report on the accident, we once again recommended that PHMSA expedite the installation of automatic shutoff valves and remote-control valves on transmission lines in populated areas, drinking water sources, and unusually sensitive ecological resources. Congress then required PHMSA to implement the recommendation in the Pipeline Safety, Regulatory Certainty, and Job Creation Act of 2011 (PL 112-90).

It’s been a decade since San Bruno, and PHMSA is nowhere near issuing a final rule to implement our recommendation. This issue is highlighted on our 2019–2020 Most Wanted List of transportation safety improvements (Ensure the Safe Shipment of Hazardous Materials).

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It’s my hope that over the next few years, we’ll see some real improvements in pipeline safety and avoid tragedies like the ones in Bellingham and San Bruno. With the technology we have readily available today, there’s absolutely no reason for any parent to have to face the loss of a child because of a pipeline accident. I hope that the next time I see Bruce Brabec, we’ll finally have the regulations in place that he’s worked so hard for on Liam’s behalf.

 

 

 

 

The Golden Spike at 150

By Member Jennifer Homendy

The ceremony for the driving of the golden spike at Promontory Summit, Utah on May 10, 1869; completion of the First Transcontinental Railroad. At center left, Samuel S. Montague, Central Pacific Railroad, shakes hands with Grenville M. Dodge, Union Pacific Railroad (center right). (Source: Wikimedia)

On May 10, 1869, 150 years ago today, a golden spike was driven home at Promontory Summit, in what was then the Utah Territory, by Central Pacific Railroad President Leland Stanford. This momentous event joined the Central Pacific and Union Pacific Railroads, completing the first transcontinental railroad, just 7 years after President Abraham Lincoln signed the Pacific Railway Act authorizing land grants and government financing to US railroads for the purpose of joining the east and the west.

As we know, the project was a tremendous success, but it certainly had its challenges.

In 1863, another act established the gauge for the project at 4 ft., 8½ inches (which became the standard gauge). At the time, gauges varied among railways in the United States. The goal of the transcontinental railroad was to ensure that two railroads met in Utah and were “interoperable” when it came time to begin service. A small difference in width would mean no transcontinental railroad: passengers and freight would have to be offloaded to a new train when incompatible rails met, creating a bottleneck affecting thousands of miles of track.

It wouldn’t have inspired confidence in the transcontinental railroad if the four final spikes couldn’t be driven in because the railroad gauges didn’t match!

Leland Stanford, the man who drove the golden spike, went on to found Stanford University. He could not imagine the contributions to transportation that his namesake university would make, including those to the global positioning system used in positive train control (PTC) systems.

Just as the Central Pacific and Union Pacific Railroads worked to ensure their track was seamless, today’s railroads are focused on implementing PTC by ensuring interoperability among many systems­—passenger, commuter, and freight trains must be able to seamlessly communicate and operate across all railroad networks.

PTC isn’t new. The NTSB has been urging railroads to implement it, in some form, since 1970, 1 year after the United States met President John F. Kennedy’s challenge to land a man on the moon. Since then, the NTSB has investigated 152 PTC-preventable accidents that resulted in more than 300 fatalities and 6,700 injuries. PTC remains on our Most Wanted List of transportation safety improvements.

Seven years passed between when Lincoln signed the Pacific Railway Act in 1862 to when the golden spike was driven home at Promontory Summit. Eight years passed from JFK’s speech to Congress about a moonshot in 1961 to Neil Armstrong’s first steps on the gray dust of the lunar surface. PTC was mandated by Congress in the Rail Safety Improvement Act of 2008. It has now been more than 10 years since the act was signed into law.

Today’s golden spike celebration might well feature photos of two locomotives posed head-to-head, as they were for the original golden spike celebration 150 years ago. Perhaps that would also be a fitting image to promote PTC, which, among other safety benefits, would automatically stop trains in time to prevent train-to-train collisions.

As we commemorate 1869’s golden spike, the NTSB continues to await implementation of fully operational PTC, which is long overdue. Let’s end the wait and start planning our own commemoration of the day we finally made all rail travel exponentially safer.

 

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.

 

Another Step Toward Safer Skies in Africa

By Dennis Jones, NTSB Managing Director

In my recent blog post, I talked about the NTSB’s visit to South Africa as part of the US Department of Transportation’s Safe Skies for Africa (SSFA) program. Last week, the NTSB team returned to Africa—this time, to the east African nation of Kenya—in continued support of the SSFA program, the aviation safety capacity-building initiative that includes collaboration between African countries and several US government agencies. In Kenya, as in South Africa, we once again shared investigative lessons learned with more than 150 air safety investigators, aviation trainers and operators, government officials, and safety advocates from Kenya and countries in the surrounding region.

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I was particularly excited about this trip because I first traveled to Kenya for accident investigation purposes 20 years ago, and later, based in the capital city of Nairobi, I worked to implement the NTSB’s SSFA program responsibilities. The goal of the SSFA program in Kenya was to help the country achieve FAA Category 1 status and pave the way for direct scheduled commercial air service between the United States and Kenya. The NTSB’s contribution toward this goal was to help Kenya’s accident investigation program meet international standards in accordance with the provisions of the International Civil Aviation Organization’s (ICAO’s) Annex 13. Our activities included working with the Air Accident Investigation Division of Kenya (AAID) to develop its program, which included on-the-job investigator training; establishing policy, procedures, and practices for the organization; and producing memoranda of understanding between AAID and other domestic government agencies. The NTSB partnered with ICAO as part of the SSFA program to conduct aircraft accident investigation workshops throughout Africa; the first such event was held in Nairobi in 2007.

It took some time but, thanks to Kenya’s painstaking and diligent efforts, and the assistance provided by the SSFA program, Kenya achieved an FAA Category 1 rating in February 2017. Consequently, US and Kenya air carriers can now, with the approval of their respective regulatory agencies, travel between the two countries. Kenya Airways, Kenya’s national carrier, will launch its inaugural flight to the United States, destined to JFK International Airport in New York, in October 2018.

Although Kenya’s government is focused on improving aviation safety, the country—and, more broadly, the continent—still faces challenges that the region’s stakeholders are dedicated to overcoming. General aviation (GA) safety issues have been formidable in the region, just as they are in the United States, and we sought to share some of our experience addressing this issue. Further, through the SSFA initiative, NTSB representatives have recognized other modal transportation safety issues and safety advocacy opportunities for future consideration as the agency formulates its international scope of activities.

After accompanying the NTSB team to South Africa last month, I was fully confident in its ability to conduct the workshop in Nairobi. The team was composed of professionals representative of the superb workforce at the NTSB, and they delivered powerful presentations sharing lessons learned.

Shamicka Fulson, a program manager in the Office of the Managing Director, coordinated the development of the workshops in South Africa and Kenya. She delivered opening remarks and provided an overview of the agency and the SSFA program to begin the workshop in Nairobi.

Clint Crookshanks, an aerospace engineer in the Office of Aviation Safety, facilitated a workshop related to identifying common aviation safety lexicon. He reviewed different accident case studies with the audience and discussed ways to interpret the generalized and vague definitions often found in aviation investigations, such as “substantial damage to aircraft,” or the distinction between an “accident” and an “incident.”

Luke Schiada, Deputy Chief of Aviation Safety for the Eastern Region, presented accident case studies that highlighted international cooperation. Luke told the audience that he believed “international cooperation is, in large part, about building relationships and trust.” He stressed the importance of interacting with and learning from the collective knowledge and experiences of participants in settings like the SSFA workshops. I can’t agree more; after all, we can’t improve within unless we are willing and able to learn from without. Even sharing enables learning and growth.

Dennis Hogenson, Deputy Regional Chief of Aviation Safety for the Western Pacific Region, focused on GA safety improvements. He pointed out that, like Africa, the United States is seeing a high incidence of GA crashes. He told his audience that, while airline accidents have become rare, GA accidents account for most aviation fatalities. 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. Dennis encouraged his African counterparts to initiate more training and increase awareness of technology that can help prevent these tragedies; this is something we continue to strive to do in the United States via our Most Wanted List issue addressing loss-of-control in flight.

Nicholas Worrell, Chief of the Safety Advocacy Division in the Office of Safety Blog Image 2.jpgRecommendations and Communications, urged attendees—most of whom were investigators—to go beyond investigations to see real improvements in safety. The work doesn’t end with the report findings issued after the investigation; the work to improve safety just begins, he said. African safety organizations need to develop advocacy efforts and strategies to ensure their safety recommendations are implemented. Nick encouraged the audience to look to some of Kenya’s most notable leaders, like Jomo Kenyatta, political activist and Kenya’s first president, and Wangari Maathai, Nobel Peace Prize winner, both of whom saw a need for and executed effective advocacy to improve laws, policies, and practices.

The goal of our visit to Kenya was to continue fostering the development of a safer aviation transportation system in East Africa. It is integral to our mission at the NTSB to share globally what we have learned from 51 years of safety investigations. As the NTSB team supporting the SSFA program has shown, improving transportation safety is a collaborative process that doesn’t end at our borders.

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.

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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.

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NTSB Managing Director and staff with symposium attendees