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.

FMI: www.ntsb.gov/Publictn/2010/SPC1001.htm