Loss of control in flight—when a pilot fails to maintain or regain control of an aircraft—is the leading cause of general aviation fatalities. From 2011 to 2015, nearly half of all fatal fixed-wing accidents in the United States involved pilots losing control of their aircraft, resulting in 819 fatalities. Far too many NTSB investigations have shown how a loss of aircraft attitude control is often preceded by the loss of a pilot’s mental attitude control.
In the fatal accidents that I have investigated, this loss of mental control seems to be a conscious decision by the pilot to “press the envelope”—a term made famous in the 1983 film The Right Stuff, an adaptation of Tom Wolfe’s best‑selling book about the military test pilots who became Project Mercury astronauts. As the United States sought to achieve supersonic flight and put a human on the moon, these test pilots pressed the envelope, pushing the boundaries of both aircraft and human performance. Their efforts were based on national objectives and security, and many of these aviators paid the ultimate price in that pursuit.
Unfortunately, in far too many general aviation accidents, pilots choose to press the envelope for relatively minor (and often selfish) reasons, like “pressing the weather” to get home for dinner, flying at low altitude or maneuvering aggressively for an extra boost of adrenaline, or “pressing a known aircraft issue” to get a job done. Although a “git-r-done” attitude is certainly commendable, pilots too often forget to trust the little voice inside that warns them to steer clear of unwarranted risks, or they fail to guard against the temptation to make extreme efforts to please or impress others. General aviation flying very rarely requires the need to press the envelope, and pressing far too often ends in a tragic loss of control.
The NTSB is so concerned with this phenomenon that, for the last 3 years, we have placed “Prevent Loss of Control in Flight in General Aviation” on our Most Wanted List of transportation safety improvements to help bring attention to the issue. Last week, NTSB Board Member Earl Weener even attended the Sun ‘n Fun International Fly-In—one of the world’s largest general aviation enthusiasts’ training events—to talk to pilots about the dangers of losing control.
Whatever a pilot’s motivation may be for wanting to press the envelope, in general aviation, it’s not worth risking loss of control. Never underestimate the connection between mental attitude and aircraft attitude.
Mike Folkerts is an aviation safety investigator in the NTSB Office of Aviation Safety.
There’s an old saying, “everybody talks about the weather, but nobody does anything about it.” Well, this week, the NTSB intends to do something about it.
Tomorrow and Wednesday, June 21 and 22, NTSB will have a forum on pilot weather reports (PIREPs). Why is this topic important? We became interested in PIREPs by accident – several of them, in fact. As our accident investigators will discuss in the forum, after several years of weather encounter-related accident and incident investigations, we found that there were too many instances where weather information had been observed but had not made it into the cockpits of those who needed it most.
One such event occurred in March 2012, in Anchorage, Alaska. A Learjet 35A encountered severe in-flight icing conditions that exceeded the capabilities of the airplane’s windscreen anti-ice systems, and the airplane’s windscreen abruptly iced over. As a result, the flight crew lost all forward visibility, and the airplane veered off the runway during landing and came to rest in a snow bank.
The NTSB found that the severe icing conditions had been conveyed about 15 minutes before the Learjet encountered them.
A pilot in an F-16 conducting an approach to an Air Force Base about 7 miles northeast reported “severe icing on final” and initiated a go-around to “wait until his windshield…cleared.” The controller handling the F-16 shared this information with the controller who later handled the Learjet; however, the controller handling the Learjet did not relay the urgent PIREP to the Learjet flight crew.
In this case, the NTSB determined that the approach controller’s failure to relay the PIREP was a contributing factor to the incident.
The problem doesn’t lie solely with ATC not disseminating weather information. As a former airline pilot and line check airman, I know that sometimes pilots do not relay weather information to ATC. And, when they do, the information is prone to inaccuracies, especially regarding time, location, and weather intensity.
To their credit, many people have been trying for years to get the PIREP system to work better, and many of them will be participating in the forum. That’s precisely why we wanted to have this event – to bring together key players with knowledge of the PIREP system to begin a conversation about improving it. And we hope that this conversation continues, planting the seed for collaborative action.
The forum will be open to the public and will also be webcast. We hope you can join us, either in person or online.
Aviation enthusiasts and pilots have gathered every year since 1974 for the annual Sun ‘n Fun International Fly-in and Expo. This extraordinary experience features many events of interest to the general aviation community and is attended by thousands of people.
Last week the National Transportation Safety Board again brought its message of safe flying and accident prevention to the general aviation community and Sun ‘n Fun attendees.
Aviation safety investigators discussed a variety of safety issues one-on-one with the hundreds, perhaps thousands, of visitors to the NTSB exhibit booth during the six-day expo. The booth featured video vignettes of aviation accident investigations, safety alerts, brochures on general aviation safety, the 2016 Most Wanted List, and the new ntsb.gov/air brochure, “A Guide to NTSB Aviation Information Resources.” NTSB employees at the booth helped visitors access the NTSB’s online investigative products including NTSB reports, accident dockets, and animations.
In advance of this year’s annual fly-ins, the NTSB issued a new Safety Alert (SA-053), Arriving at a Fly-in Event, Keep Your Focus on Safety. This safety alert was intended to directly engage general aviation pilots who fly-in to events such as Sun‘n Fun and the Experimental Aircraft Association’s (EAA) AirVenture, the largest convergence of pilots in the U.S. The NTSB believed the safety alert was merited as the agency has seen several crashes at fly-ins as pilots are exposed to the unique challenges associated with these events, including high-density traffic, special flight and communication procedures, a rapidly changing environment, and changes to air traffic control separation standards.
NTSB Board Member Earl Weener and air safety investigators also gave presentations on pilot reports, amateur‐built aircraft construction errors, flying into large airshows, and inflight loss of control prevention (an issue on the 2016 Most Wanted List). The hour-long presentations, which included Q&A sessions, were held at the Sun ‘n Fun FAA Safety Center and at the Central Florida Aerospace Academy, a charter high school.
The considerable gathering of aviators at events like Sun ‘n Fun and the upcoming Air Venture present an excellent opportunity for the NTSB to engage pilots and convey important safety information. Training, technology, and situational awareness are all factors that can improve safety in general aviation. Safety is the NTSB’s focus – and should be a focus for all in aviation.
I have a great appreciation for the training and skill it takes to fly a helicopter. Rotorcraft are vital to our transportation system; they have remarkable agility and go where no other transport vehicles can go. They often serve the common good and help our economy by providing medical care, fighting fires, assisting law enforcement, serving as “aerial cranes” in construction, transporting workers to inaccessible locations, and generally doing work that no other vehicles can do.
Helicopters have personal significance for me, too. Before I was born, an American-trained Choctaw CH-34 pilot saved my parents and three older brothers by flying them to safety during the Tet Offensive in Vietnam. One of those brothers, now a surgeon, has been able to help traffic crash victims, thanks to the emergency medical helicopters that transport him to those who are injured far from his Level 1 trauma center.
So, with that background, I was particularly excited to attend my first HAI Heli-Expo, the world’s largest helicopter conference and exposition. An annual event sponsored by the Helicopter Association International (HAI), this year’s event took place in Louisville, Kentucky, and was attended by nearly 20,000 owner-operators, pilots, mechanics, manufacturers, and helicopter vendors. A key focus of the event, as usual, was safety.
I came to this Heli-Expo to learn. I wanted to know about the safety issues and concerns for the industry. I also came with a message from NTSB to the helicopter community: Thank you for your strong efforts to improve rotorcraft safety, and let’s continue to work together to address important safety issues.
At the Safety Symposium prior to the official start of the conference, the Federal Aviation Administration (FAA) and members of the International Helicopter Safety Team/US Helicopter Safety Team (IHST/USHST) discussed crash rates and how safety affects the bottom line. While helicopter safety is not a standalone issue this year on NTSB’s “Most Wanted List” of transportation safety improvements, I reminded folks that helicopter safety is still a key component of many of our Most Wanted List issues, such as recorders, impairment, fatigue, distraction, and occupant protection.
In 2015, the NTSB investigated 127 U.S.-registered helicopter accidents in the United States, and 18 of them were fatal (resulting in the deaths of 29 people). Nine of those fatalities came from helicopter air ambulance (HAA)/helicopter emergency medical services (HEMS).
As we can all agree, any fatality is one too many.
I am pleased that this “vision zero” is also the driving theme of the IHST/USHST, which announced a goal of working (for as long as it takes) to achieve zero helicopter accidents, with a particular focus on fatal accidents. The HAI is also advancing safety through its new safety accreditation program certifying safety programs from different types of helicopter operations and by working with academia under a grant from the Federal Aviation Administration (FAA) to develop a flight data monitoring program that assesses data from the industry to identify trends and make safety improvements. With all these efforts underway, the industry will take a giant leap toward improved safety.
I am confident that helicopter safety will continue to get better and better, with the leadership of industry groups like HAI and the voluntary efforts of owner-operators to implement safety improvements, even before federal regulations have passed.
Take, for example, the flight training school owner-operator I met from Colorado. In our Safety Symposium session, he talked about proactively implementing safety management systems and risk assessment programs, investing in high-quality scenario-based simulator training for pilots-in-training, and implementing flight data monitoring systems in all of his helicopters. He also changed the flight pattern to enable safer landings and takeoffs around his school. While this owner-operator focused on safety because it was the right thing to do, and despite expecting to lose money, he saw a financial return in many areas, such as insurance savings, earned media, employee retention, and student simulator rental. Perhaps, most importantly, he lowered the risk of accidents and injuries to his instructors, pilots-in-training, and passengers.
It is inspiring to hear from hardworking business owners that safety improvements can – and should – be made, and that, in the end, such initiatives save both lives and money.
The lifesaving improvements we talked about at Heli-Expo are all recommendations the NTSB has made over the years to the helicopter industry, most recently to public and HAA/HEMS-category helicopters.
During the conference, we discussed the importance of recorder technology in improving safety. Over the last decade, the NTSB has made more than 30 recommendations to the FAA and industry requiring the installation of crash-resistant flight recorder systems on all newly manufactured helicopters not already equipped with a flight data recorder and a cockpit voice recorder. “Expand Use of Recorders to Enhance Transportation Safety” is on our 2016 Most Wanted List. Had recorders been installed in many of the tragic crashes we have seen in recent years, the industry might have had more information and data about how and why accidents happened.
I was also proud to see the presentations given by our Aviation Safety team regarding another of our very important recommendations: requiring crashworthy fuel tanks in all newly manufactured helicopters – not just those designed before 1994, when the original standard was issued by the FAA. Those who survive accidents should not have to succumb to post-crash fires, a tragedy we have seen in our investigations, such as the HAA/EMS crash in Wichita Falls, Texas, in October 2014, and the July 2015 accident in Frisco, Colorado.
Our NTSB aviation experts reminded the industry not to wait for regulators to issue a mandate but to aggressively work with equipment manufacturers to identify retrofits or improvements that could reduce the possibility of post-crash fires. We know this is not an inexpensive or easy change, but we also know that, in the end, it will save lives and prevent injuries.
Additionally, one of our investigators presented two accident case studies that involved complete loss of engine power, which demonstrated the need for the pilot to enter an autorotation within 2 seconds. The NTSB has issued recommendations on the proper technique for performing autorotations, and we were pleased to hear that the FAA recently announced it has added an addendum to its Helicopter Flying Handbook (FAA-H-8083) that addresses our concerns.
Before leaving Heli-Expo, I had the privilege of addressing the general membership of HAI, alongside the Governor of Kentucky and the Mayor of Louisville. I thanked helicopter operators for their efforts in implementing NTSB’s safety recommendations and I applauded their unique talents and their contribution to our communities, our nation, and our world. I also was honored to take a tour of the expo floor, where I was impressed by the extraordinary display of helicopter ingenuity and the commitment to continual improvement through new technologies and services offered.
Helicopters make a positive difference in our world. I left the conference with even more admiration for the helicopter community’s passion for their work and their dedication to safety.
I look forward to working with them to keep everyone who flies in rotorcraft – whether as a pilot or a passenger – safe and sound.
At the NTSB’s March 31 Roundtable — Disconnect from Deadly Distractions— an interesting discussion emerged about the “addictive” nature of staying connected through our personal electronic devices (PEDs). “There is nothing more interesting to the human brain than other people,” stated Dr. Paul Atchley. He explained that dopamine is one of the brain’s reward chemicals that produces positive feelings and sensations. “There is nothing more rewarding than the opportunity to talk to someone else,” said Dr. Atchley. Because connecting with others produces a release of dopamine into the brain’s midsection, it is very difficult for us to ignore the urge to connect with others.
Andrea Brands of AT&T followed-up on that point by mentioning a survey the company conducted last year through Dr. David Greenfield, founder of The Center for Internet and Technology Addiction. They found that 74% of the 1004 people surveyed admitted to engaging in texting or checking social media while driving. A large percentage of the survey respondents rationalized that behavior even though they knew it was dangerous — a true sign of addictive behavior, said Ms. Brands.
Dr. Greenfield stated in a November 2014 interview, “We compulsively check our phones because every time we get an update through text, email or social media, we experience an elevation of dopamine, which is a neurochemical in the brain that makes us feel happy. If that desire for a dopamine fix leads us to check our phones while we’re driving, a simple text can turn deadly.”
Whether we call it addictive, compulsive, or just a habit, the fact remains that using a PED while operating any vehicle is dangerous business. It can be deadly.
Nowhere was this fact more apparent than in the NTSB’s investigation of the August 5, 2010, multi-vehicle crash near Gray Summit, Missouri. In this accident, a 19-year-old pickup truck driver slammed into the back of a stopped tractor trailer, setting up a chain reaction crash involving two school buses following behind. In the thirteen minutes immediately before the crash, the 19-year-old driver sent and received 11 text messages on his phone. The tragic result of his choice to drive distracted was the loss not only of his own life, but also the life of a 15-year-old student aboard one of the buses.
The NTSB is very concerned with distractions in all modes of transportation. Please, give yourself the permission to disconnect from deadly distractions. Break the addiction, and save lives.
Often, I get some confused looks when I tell people I’m doing an internship at the National Transportation Safety Board (NTSB) as part of my joint public health and business degrees at Johns Hopkins University. “What does transportation have to do with public health?” they ask.
Actually, transportation has a whole lot to do with public health. How did you get to work or school today? If you walked, drove, cycled, or took a bus, you were in danger of a life-changing incident. You could’ve been struck by another vehicle. Imagine the hospital bills, the lost productivity, and the debilitating consequences. Flown on a plane recently? Did your palms sweat a little when the turbulence started? You probably arrived at your destination safely, nonetheless. That’s because your pilot was well trained, following safety protocols and mitigating the inclement weather that in another situation, could have brought the plane down.
If you believe that you have the right to cross the street without worrying about being hit, injured, or killed by a drunk driver, or you believe that you have the right to board a plane, take off, and land safely – then you believe in transportation safety, and you believe in public health.
The two are integrally linked – think about the effects of a transportation incident on our public’s health. When a bus carrying an entire high school band crashes, it has a ripple effect, impacting the rest of the transportation system, the health system, and of course, the victims’ families. Miles of bumper-to-bumper traffic will follow, which could lead to further crashes, along with lost productivity when you, and everyone else caught in traffic, are late to work. Hospitals nearby will receive an influx of patients. In major incidents, it’s often more than one hospital can handle. Victims may not be able to function at the same level thereafter, and their families might be permanently scarred, in desperate need of mental health services.
When a pipeline bursts (pipelines are a mode of transportation, as they bring something from one place to another), it has economic, environmental and health repercussions. Remember the 2010 pipeline rupture and fire in San Bruno, California? More than 4 years later, that community is still rebuilding homes and infrastructure; families are still trying to pick up the pieces. Transportation incidents don’t occur in a bubble, they affect society at large, which inherently includes, of course, the public’s health.
What is it about public health that uniquely positions the field to address transportation, and particularly traffic, safety? Public health is about protecting and improving the health and safety of the population. Public health figures out what’s hurting and killing people, and then uses evidence-based initiatives to fix it. We call that preventing morbidity and mortality. And, according to the Centers for Disease Control and Prevention (CDC) and the National Highway Traffic Safety Administration, motor vehicle crashes are a leading cause of injury in our country – 2,362,000 injured and 33,561 killed in 2012. The CDC estimates that Americans spend over one million days in the hospital each year from crash related injuries. In 2012, that translated into $18 billion in lifetime medical costs, and $33 billion lost in lifetime work, such as lost wages or benefits. That’s a lot of lives changed, expenses incurred, and productivity lost.
Though it may not seem like it, transportation incidents have a lot of characteristics similar to a disease, which public health analyzes through the lens of a host, agent, and the environment. In a car crash, the host could be the young driver; the agent, the impact of the car hitting another car; and the environment, the slippery roads at night. Like a disease, public health can intervene in a number of ways to reduce the occurrence of crashes – for example, implementing graduated driver’s licenses so youth can gain more experience before having full driving privileges, incorporating airbags and seat belts into cars to reduce the impact of a crash, or equipping roads with reflectors and guard rails to make it easier to see at night and in the rain, and harder to veer into oncoming traffic. Also like a disease, the incidence of these crashes can be tracked, so we can see if our interventions are working and revise them when they’re not.
The government recognizes that it has a responsibility to keep the public safe from incidents while using our transportation system, and that’s why they’ve created organizations like the NTSB. It’s not a public health agency, but that doesn’t mean it doesn’t address public health issues. And the good news is that through the help of agencies like the NTSB, we can work towards decreasing crash rates. The NTSB investigates accidents, determines probable cause, assists families, and then issues recommendations to federal agencies to prevent future accidents. This leads to life-saving changes.
At the NTSB, though, I didn’t sit at a desk and analyze crash data. I helped the NTSB address all elements of the public health triad – the host, the agent, and the environment. In the Safety Advocacy Division of the Office of Communications, I helped craft messages to internal and external stakeholders, to obtain support for our recommendations. Working with staff from the Office of Aviation Safety, I’ve drafted some of the web content for the NTSB’s Most Wanted List. I also wrote advocacy blogs about traffic safety, and tweets for forums. Building on my prior drunk driving prevention work, I’ve researched state laws addressing ignition interlocks (breathalyzers on cars to prevent drunk driving), and Automatic License Revocation. Some of these projects I’ve dreamed of working on for years, since I first became involved in traffic safety after the tragic death of a friend in college who was hit and killed by a drunk driver.
Throughout my internship, I’ve picked up invaluable skills. I’m fortunate to work for an outstanding group who were equally committed to developing my skills, providing constructive feedback, while at the same time, finding the synergy between their important safety work and mine. They are equally as talented and dedicated, and they’ve given me the opportunity to work with them on a variety of topics and projects. This team is representative of many of NTSB’s employees, some of the smartest, most driven people I’ve encountered. So, what does traffic safety have to do with public health? Everything.
Natalie Draisin was a graduate student intern in the Safety Advocacy Division.
7:18 Friday evening, US Airways flight 1782, an Airbus A321, sailed 35,000 feet over America’s heartland at 610 mph. At the controls of the San Francisco to Charlotte flight was a 34 ½ year airline veteran, Captain Bill Weeks. Due to reaching mandatory airline pilot retirement age, Captain Weeks’ landing in Charlotte would be his last as an airline pilot.
Bill started flying at 16. After college he flew for the USAF for 6 years, followed by a distinguished airline career, where — in addition to his piloting duties — he served as instructor, check airman, air safety investigator, and air safety representative for the Air Line Pilots Association.
Bill was a mentor and role model for many during his 25,000 hours of flight time and 49 years as a pilot. One of those who was deeply influenced by his professionalism was me. In 1983, he and I were selected to be part of a small team to travel to The Netherlands to be trained on an airplane that our airline would be soon be placing into service. For six weeks, Bill and I grilled each other on various aircraft systems, limitations, and procedures so that when the final check flight came, our qualifications would be unquestioned.
My learning experience didn’t stop there, however. From that point forward, when faced with tough decisions as a new captain and years afterward, I would often ask myself, “What would Bill do?” Our paths continued to cross, as we were both detailed to work in the airline’s safety department.
I recently asked Bill to reflect back on his vast experience and provide three tips that he’d like share.
1) “When things get time-compressed, slow down.” Two of the most important controls in the cockpit are the parking brake and the microphone. When on the ground, the pilot can reduce the tempo by setting the parking brake and not releasing it until things are at a more comfortable pace. Likewise, use the microphone to request delaying vectors or a holding pattern. As the saying goes, “take time to make time.” When Bill and I did safety work together, we would review events where rushing was a factor. One of Bill’s mantras was, “Don’t let ATC fly your aircraft.”
2) “If you can avoid continuing an unstabilized approach or doing a high speed rejected takeoff, you’ll probably have a long career.” To further Bill’s point, this summer the NTSB completed two air carrier accident investigations where, if the crew had discontinued an unstabilized approach, the accident could have been prevented.
3) “Don’t take off or land when convective weather is on or near the field.” Bill relayed a recent flight where a thunderstorm was over the airport. ATC asked each flight in the queue awaiting take off if they were able to depart, and with the exception of one, each flight declined. Fifteen minutes later, the storm had passed over the airport and skies along the departure corridor were completely clear. His point is certainly valid: When the weather is questionable, it’s not worth the risk of trying to takeoff or land. Allow the weather to move through before attempting to go.
Good advice from someone who is a professional in every way. Wishing Bill and his family Godspeed.