Nearly 140 Aviation Safety Recommendations Were Made By The
Board In 2009
The National Transportation Safety Board delivered its 2009
Annual Report to Congress Thursday, which provides a comprehensive
accounting of ongoing and completed investigations, as well as
other agency activities. The report also highlights successes
for the Most Wanted List of Transportation Safety Improvements.
"The NTSB is dedicated to executing thorough accident
investigations and issuing recommendations for improved
transportation safety," said Chairman Deborah A.P. Hersman. "The
report issued today shows this dedication through detailed and
clear accounts of our work and achievements in 2009."
New to the 2009 report are enhanced features that illustrate the
scope and complexity of the NTSB's work. Among these features
are: maps of regional office locations in addition to investigation
launch-site maps; additional information describing how
non-investigative units support the NTSB mission; key industry
facts showing the impact and breadth of completed agency work; and
updated "At A Glance" boxes calling out the status of
recommendations, investigation and report production statistics,
and staff demographics.
Among the highlights from the year's activity described in the
report are that the NTSB issued 240 new safety recommendations
across all transportation modes. Closed recommendations
encompass 42 aviation, 10 highway, 14 marine, 6 railroad, and 2
pipeline safety improvements. During 2009, the NTSB also
initiated 13 major accident launches and released 19 major
investigative reports.
In the aviation "Most Wanted" safety recommendations, The NTSB
is urging the FAA to “Improve Oversight of Pilot
Proficiency.” The issue area addresses the NTSB’s
concerns with the hiring and training of pilots highlighted by the
NTSB’s recent Board meeting and report on its investigation
of the accident involving a Colgan Air Inc., Bombardier Dash
8-Q400, N200WQ, d.b.a. Continental Connection flight 3407, which
crashed during an instrument approach to runway 23 at the
Buffalo-Niagara International Airport, Buffalo, New York. The issue
area asks the FAA to (1) evaluate prior flight check failures for
pilot applicants before hiring, and (2) provide training and
additional oversight that considers full performance histories for
flight crewmembers demonstrating pilot deficiencies.
The NTSB added Safety Recommendations A-08-44 and -45 from the
Kirksville, Missouri, accident investigation to the issue area
“Reduce Accidents and Incidents Caused by Human Fatigue in
the Aviation Industry.” These recommendations address fatigue
management systems, which constitute a complement to, but not a
substitute for, regulations to prevent fatigue.
NTSB Chair Deborah A.P. Hersman
As far as specific recommendation, the NTSB says the FAA
should:
- Improve Oversight of Pilot Proficiency by evaluating prior
flight check failures for pilot applicants before hiring, and
providing training and additional oversight that considers full
performance histories for flight crewmembers demonstrating
performance deficiencies.
- Install crash-protected image recorders in cockpits to give
investigators more information to solve complex accidents.
- Improve the Safety of Emergency Medical Services (EMS) Flights
by requiring flights with medical personnel on board to be
conducted in accordance with stricter commuter aircraft
regulations, developing and implementing flight risk evaluation
programs for EMS operators, requiring formalized dispatch and
flight-following procedures including up-to-date weather
information, and installing terrain awareness and warning systems
(TAWS) on aircraft used for EMS operations.
- Reduce Dangers to Aircraft Flying in Icing Conditions by using
current research on freezing rain and large water droplets to
revise the way aircraft are designed and approved for flight in
icing conditions, applying revised icing requirements to currently
certificated aircraft, and requiring that airplanes with pneumatic
deice boots activate the boots as soon as the airplane enters icing
conditions.
- Reduce Accidents and Incidents Caused by Human Fatigue in the
Aviation Industry by setting working hour limits for flight crews,
aviation mechanics, and air traffic controllers based on fatigue
research, circadian rhythms, and sleep and rest requirements,
developing a fatigue awareness and countermeasures training program
for controllers and those who schedule them for duty, as well as
guidance for operators to establish fatigue management systems,
including a methodology that will continually assess the
effectiveness of these systems.
- Improve Runway Safety by giving immediate warnings of probable
collisions/incursions directly to flight crews in the cockpit,
requiring specific air traffic control (ATC) clearance for each
runway crossing, requiring operators to install cockpit moving map
displays or an automatic system that alerts pilots when a takeoff
is attempted on a taxiway or a runway other than the one intended,
and requiring a landing distance assessment with an adequate safety
margin for every landing.
- Improve Crew Resource Management by requiring commuter and
on-demand air taxi flight crews to receive crew resource management
training.
There have been 138 aviation safety recommendations made by the
NTSB over the past year. The office of aviation safety has
completed 7 major reports and held 4 public hearings. The office
has 10 major investigations currently in progress, each of which
will be presented to the NTSB Board members for their deliberation
at a Sunshine Meeting.