Tag Archives: Recorders

The Black Box

Bella Dinh-Zarr, PhD, MPH, Vice Chairman

The famous “black box.”

Mosaic image of data recorders for the Most Wanted List issue are Expand Recorder Use to Enhance SafetyReporters always ask us about it during high-profile aviation and rail investigations. After the sinking of the El Faro cargo ship during Hurricane Joaquin, the news media closely followed the recovery of the voyage data recorder, which was located in about 15,000 feet of water.

The black box, which is usually orange with reflective tape to make it easier to locate in wreckage, can be critical to our investigations at the NTSB. These devices can withstand enormous impact forces, intense temperatures, and the extreme pressures of ocean depths. Recorders capture a range of useful data, from crewmembers’ actions and conversations to vehicle parameters. We use these data to help identify the cause of an accident and to make recommendations to prevent such accidents from happening in the future. Industry can also use this information to make transportation safer.

We analyze recorder information in all modes of transportation. We transcribe audio from cockpit voice recorders and extract information from flight data recorders on aircraft. We review voyage data recorders that provide ship data, bridge audio, and radar images on vessels. We assess information from event recorders and forward- and inward-facing video recorders on trains. We analyze a variety of recorders and cameras that provide performance information on highway vehicles. No matter what type of recorder we encounter, we are required by law to protect the information obtained for our investigations.

Although the NTSB uses recorders to learn from one tragedy to prevent future ones, industry and operators can install recorders and develop programs to learn lessons from normal operations.

The NTSB urges the transportation industry to install recorders in their vehicles, vessels, trains, and aircraft, and to assess the data collected from them to prevent accidents and assess operator performance. Industry can use information from data, audio, and video recorders to identify issues of operational weakness or noncompliance with procedures. Airlines use the data they gather in everyday line operations through flight operational quality assurance (FOQA) programs to prevent accidents from occurring in the first place. Although most large aircraft are already required to have flight data and cockpit voice recorders, we have also recommended that they have cockpit video recording systems, and we have recommended that certain small aircraft that are not required to have recorders be required to carry recording devices that capture data. For smaller aircraft, recorders can provide crucial accident data, and they can also be a vital part of flight data management programs.

We appreciate the special value of data from video recorders, and that’s why many of our recent recommendations to regulators and operators propose that video recorders be installed to capture operator and crew behavior. Currently, investigators have no access to the visual information from an accident sequence. Although we can piece together key events in an airplane accident from cockpit audio and flight data, with video we have access to nonverbal communications and cockpit instrument manipulation. In fact, our NTSB scientists have even written software that reads needle positions and creates valuable data tables based on cockpit images! Reconstructing the accident sequence without video evidence requires additional time and effort—possibly delaying critical safety improvements.

What can be learned when inward-facing video is available? The answer is apparent from our 2014 investigation of the mid-air breakup of SpaceShipTwo during a test flight. SpaceShipTwo was equipped with data recorders, including video recorders to document the flight test. Because of those video images, the NTSB was able to identify quickly (by the second day of the on-scene investigation) that the co-pilot moved a lever at an inappropriate time, which ultimately resulted in the crash.

It is indisputable that we can make transportation safer by using information obtained from recorders. That’s why “Expand Recorder Use to Enhance Safety” is on the NTSB’s Most Wanted List of transportation safety improvements. And that’s why we urge transportation operators to install this important safety technology as soon as possible.

Recorders Improve Transportation Safety

By Dr. Bill Tuccio

A privately hired de Havilland DHC-3T “Otter” plane impacted mountainous terrain near Aleknagik, Alaska, August 9, 2010. The pilot and four passengers were killed, including Ted Stevens, U.S. Senator from Alaska. Four other passengers were injured.

Crash near Aleknagik, Alaska
Crash near Aleknagik, Alaska

The aircraft was not equipped with any electronic recording equipment, nor was it required to. NTSB investigators used information from sparse GPS position reports transmitted by satellite, engine instruments, and two surviving passengers who were seated in the rear of the aircraft to determine what happened in the accident. This limited information, however, did not reveal crucial details about the pilot’s actions (or lack of actions) in the final three minutes of the flight.

The NTSB determined the probable cause of the accident to be, “the pilot’s temporary unresponsiveness for reasons that could not be established from the available information.” Ultimately, the lack of a cockpit recorder system with the ability to capture audio, images, and parametric data hampered investigators’ ability to determine exactly what happened.

About two years after the NTSB concluded that investigation, an Alaska Department of Public Safety Eurocopter AS350 lost control and impacted terrain, near Talkeetna, Alaska, March 30, 2013. The pilot, an Alaska State Trooper, and a stranded snowmobiler were killed.

In this case the NTSB discovered exactly what happened. The NTSB determined the probable cause was, “the pilot’s decision to continue flight under visual flight rules into deteriorating weather conditions, which resulted in the pilot’s spatial disorientation and loss of control.” Significantly, investigators determined where the pilot’s attention was directed, his interaction with the helicopter controls and systems, and the status of cockpit instruments and system indicator lights. The investigation found that the pilot reset a key instrument at an inappropriate time – known as caging the attitude indicator. With these details known, the NTSB produced an animation of the accident flight.

Seen here, the DPS helicopter’s Appareo Systems Vision 1000 cockpit imaging and flight data monitoring device recovered from the March 30, 2013, crash of a Eurocopter AS350.
Seen here, the DPS helicopter’s Appareo Systems Vision 1000 cockpit imaging and flight data monitoring device recovered from the March 30, 2013, crash of a Eurocopter AS350.

In this case, a recorder—voluntarily installed and capable of recording cockpit audio, video, and parametric flight data—made all the difference. NTSB investigators were able to determine the details of what transpired in the cockpit.

Once again this year recorders are on the NTSB’s Most Wanted List of transportation safety improvements. We have been advocating for image recorders since 1999, and trying to follow the lineage of our repeated recommendations related to recorder technology is a complicated process. One of our most significant recommendations was issued to the Federal Aviation Administration in 2003—and it has yet to be implemented. Essentially, the NTSB asked the agency to require all turbine-powered, nonexperimental, nonrestricted-category aircraft manufactured prior to January 1, 2007, that are not equipped with a cockpit voice recorder, and, that are operating under Title 14, Code of Federal Regulations, Parts 91, 135, and 121, to be retrofitted with a crash-protected, image-recording system by January 1, 2007.

Operators shouldn’t wait for the FAA to act. (And, thankfully, the operator of that DPS helicopter didn’t wait to be told to install recorders.) With the reduced cost of micro-electronics and reduced size of components—including cameras—operators should look into the future and equip all modes of transportation with recorders. The data collected from these devices not only can inform investigators in the tragic—and hopefully unlikely—event of a crash, but can also be used by operators themselves to make critical changes to address safety problems—ideally, before the NTSB shows up at the scene.

Bill Tuccio is an aerospace engineer in the NTSB’s Vehicle Recorder Division, Office of Research & Engineering. He holds a PhD in Aviation.