Williston and Beyond

By Member Christopher A. Hart

A car that is fully controlled by a computer doesn’t get drowsy or distracted. It doesn’t get drunk or impaired by other drugs. If it’s instructed not to go above the speed limit, it won’t. Human error, which is at least partly responsible for 94% of today’s highway crashes, can largely be eliminated if the human driver becomes just another passenger. And with the unacceptable carnage of more than 37,000 deaths in motor vehicle crashes in 2016 alone, we can use all the help we can get. There’s no question that the potential benefits of autonomous vehicles are nothing short of phenomenal.

Getting there, however, will not be as easy as many people think. We recently held a Board meeting to consider the crash in 2016 of a partially automated Tesla into a tractor‑trailer near Williston, Florida. The driver wasn’t paying attention to the road as he should’ve been, and the system allowed the driver to use its “Autopilot” feature in places where it wasn’t designed to operate. The automation system used torque on the steering wheel as a proxy for driver engagement and alerted the driver if too much time passed without detectable movement on the wheel, but the driver treated the alerts as nuisances, dutifully applying torque each time the alert sounded before taking his hands off the wheel again. Although the driver was ultimately responsible for the resulting crash in which he tragically lost his life, the automation allowed him to make unsafe choices.

2015 Tesla Model S 70D car involved in the May 7, 2016, Williston, Florida crash

Flash back to 1914. An airplane flies past reviewing stands full of spectators. The pilot holds his hands high in the air to demonstrate that the airplane is flying itself. The plane makes another pass, then another. According to aviation lore, by the third pass, the pilot, Lawrence Sperry, is walking on the wings. Sperry was showing off his entry in an international aviation safety exhibition: the world’s first primitive autopilot, the gyroscopic stabilizer. It allowed a plane to fly straight and level without pilot input for short periods at a time.

In the years since, aircraft automation has become much more sophisticated. In addition, planes now have systems that sense terrain, they use GPS to know where they are, and they employ a vehicle-to-vehicle technology called a traffic collision avoidance system to help them avoid other planes. Thanks, in large measure to these technologies, aviation has become much safer. Yet, in 2013, nearly 100 years after Sperry’s demonstration, Asiana Flight 214, with more than 300 people on board, approached San Francisco International Airport too low and too slow and crashed into a seawall, killing three passengers.

Fire damage to the fuselage of Asiana Flight 214

The Asiana crash demonstrated automation confusion: the pilot thought that the auto‑throttle was maintaining the speed he selected, but he had inadvertently and unknowingly caused the auto‑throttle to become inactive. It also demonstrated that, due to longstanding overreliance on the automation, the pilot’s manual flying skills had degraded so much that he was uneasy about landing the plane manually on a 2‑mile‑long runway (that’s a long runway!) on a beautiful, clear day.

We’ve investigated automation-related accidents in all modes of transportation. In fact, our investigators see accident after accident involving problems with the interface between the automation and the human operator; we also see far too often that humans are not reliable about passively monitoring automation. And in cases like the Asiana crash, we see that humans get rusty when they don’t use their skills.

The Williston crash showed error types that are not surprising with what’s called level 2 automation. The human driver was responsible for monitoring the environment, but the automation allowed him to shirk this responsibility. This result was foreseeable, given the unfortunate use of the moniker “Autopilot,” which may suggest to the ordinary driver that the car can fully control itself (as compared with pilots, who know that they must still be engaged even when their airplane is operating on autopilot). Thus, one lesson learned is that if the automation should only be usable in certain circumstances, it should be “geo-fenced” so that it will work only in those circumstances instead of depending on the driver to decide appropriately.

What can we expect as our cars move beyond level 2? The aviation experience has demonstrated that as automation increases, so do the challenges. As automation becomes more complicated, drivers are less likely to understand it, and as automation becomes more reliable, drivers will become more complacent, less skillful, and less vigilant to potential failures. As a result, if a failure occurs in a more complicated and reliable system, the likelihood increases that most drivers will not be able to recover successfully from the failure.

In the Asiana investigation, we found that the airline used the available automation as fully and as often as possible. After the crash, we recommended that the airline require more manual flying, both in training and in line operations—not because we’re against technology, but because we see what can happen when pilots lose their skills because they’re not using them.

Then there’s the question of removing the driver altogether. Airliners will have pilots for the foreseeable future because aviation experts have not yet developed a “graceful exit” regarding failure of the automation or what to do if it encounters unanticipated circumstances. Similarly, drivers will be in the picture until the industry develops a graceful exit for their automation failing or encountering unanticipated circumstances . . . and unanticipated circumstances are certainly abundant on our streets and highways.

In every one of our investigations, we study the human, the machine, and the environment. Even across modes, humans and their interactions with automation are a common denominator in an accident’s probable cause. For 50 years, we’ve been finding answers to help the transportation industry save lives, and when our recommendations are put into practice, the industry and the public generally realize safety benefits. We are excited about the opportunities to use the lessons we’ve learned over these many years to help the transportation industry move toward safer vehicles, regardless of who (or what) is operating them.

We’ve come a long way since Lawrence Sperry’s gyroscopic stabilizer, but as accidents like Asiana and Williston show, we’ve still got a way to go before automation can significantly reduce fatalities on our streets and highways. We look forward to continuing to work with vehicle manufacturers to help them develop safer and more reliable automated transportation.

Don’t Press the Envelope

By Mike Folkerts

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.

April 27, 2013, Piper PA-28R-180 airplane crash near Norfolk, Nebraska.

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.

 

Weather…or not

By Robert L. Sumwalt

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.

Robert L. Sumwalt is an NTSB Board Member.

Sun ‘n Fun: Talking General Aviation Safety One-on-One

By: Jeff Kennedy

NTSB staff Christy Spangler (far left), Dan Boggs, Jeff Kennedy, Jim, Silliman, and Scott Dunham at Sun ‘n Fun.

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.

The Compelling World of Helicopters, Where Safety is at the Forefront

By T. Bella Dinh-Zarr

I love helicopters!

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.

Vice Chairman (center, in blue) and Aviation Safety investigators and staff, from L-R, Ralph Hicks, Jeff Kennedy, Jim Silliman, Van McKenny, Chihoon Shin, and Clint Johnson.

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.

Vice Chairman with Louisville, KY, Mayor Greg Fischer (far left) and Kentucky Governor Matt Bevin (third from left) at expo.

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.