NTSB’s 10 Most Wanted List is out after 10 months, but to rate a 10 for aviation, it could include more

NTSB Most Wanted List
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NTSB Most Wanted List 2017 — 2018

A Substantive Safety Tool, Plus Could Include More

The regulation of aviation safety is complicated.

  • It starts with the individual entities, certificated to perform specific functions within flight, and they must meet the highest standards on a self-regulating basis.
  • The FAA issues standards which define what the criteria which those companies must meet at a minimum. The federal government does not have the resources to surveil the airlines and others within its purview; so, it relies on the carriers, manufacturers, MRO, pilots, manufacturers, etc. to adhere to the FARs. That relationship has become more comprehensive and preventative with SMS.
  • Last but not least, there is the National Transportation Safety Board; it is established to be an independent, impartial authority to determine the probable cause when accidents occur.

In that context, an important annual event occurred on November 14 and here is the description issued by its purpose and message:

This morning, the NTSB unveiled its Most Wanted List of transportation safety improvements for 2017-2018 [see video below], our roadmap from lessons learned to lives saved in all modes of transportation.

In no particular order, this list is as follows:

•  Eliminate Distractions
•  Reduce Fatigue-Related Accidents
•  Prevent Loss of Control in Flight in General Aviation
•  Improve Rail Transit Safety Oversight
•  End Alcohol and Other Drug Impairment in Transportation
•  Increase Implementation of Collision Avoidance Technologies
•  Expand Recorder Use to Enhance Safety
•  Require Medical Fitness
•  Strengthen Occupant Protection
•  Ensure the Safe Shipment of Hazardous Materials

Actions in these issue areas by government and industry can make transportation safer for all of us. But, as an individual, you do not have to wait for government or industry to act.

In many cases, you can take action now to make your own transportation safer. For example, you can and should commit to driving free of distractions, with enough rest, and without being impaired by alcohol or other drugs. You can also commit to protecting the passengers in your car – by using and requiring them to use the appropriate restraints. If you ride a motorcycle, you can commit to wearing a helmet that protects your face and head. Your own personal responsibility can also help you be safer in an airplane or any other mode of transportation.

The (NTSB) is an independent U.S. government investigative agency responsible for civil transportation accident investigation. Under 49 U.S.C. § 1131, the Board is authorized to investigate and report on aviation accidents and incidents, certain types of highway crashes, ship and marine accidents, pipeline incidents, and railroad accidents.

Since 1990, the NTSB has issued a Most Wanted List annually. Its rationale for issuing the MLW is based on the fact that Congress only authorized it to issue reports, not to mandate them. This announcement is intended as a form of public leverage to exert pressure on the relevant safety regulators, on Congress (+ state legislatures for other modes), on the industries and on the public to adopt their judgment as to what is the proper solution to the probable causes found. The (NTSB) is an independent U.S. government investigative agency responsible for civil transportation accident investigation. Under 49 U.S.C. § 1131, the Board is authorized to investigate and report on aviation accidents and incidents, certain types of highway crashes, ship and marine accidents, pipeline incidents, and railroad accidents.

It is easy to infer from this explanation that the regulators are callous in that they failed to adopt the NTSB regulators. Congress and OMB have imposed on all agencies proposing any regulation that the draft action must meet a Benefit/Cost Analysis. That is a complex econometric calculation which uses hard and soft factors to determine whether the NPRM makes good policy.

If, for example, the FAA required that aircraft were equipped to eliminate all risks of crashing, the Wright Brothers and all of today’s flights would not operate. The logic of the BCA test is to balance reasonable risks with a more than adequate set of protections. To put the concept in colloquial terms, “perfection is the enemy of the good.” (“Il meglio è nemico del bene the 1603 Proverbi italiani by Orlando Pescetti.)

Before reviewing the MWL, it is important to reiterate how technically competent the Members and their staff are and to stress how difficult and pressure filled assignments are! And as the NTSB frequently says, safety should always search for ways in which to get better; hopefully, these comments will be received in that spirit.

With all that said, it is important to note:

→  The NTSB issued an MWL 10 months ago.

→  In the future, there will be a biannual MLW issues with an intervening update.

→  By the NTSB’s own statements, the MLW is an advocacy campaign. Its primary audience appears to be the general public. As an investigatory Board, does highlight some causes as being more important than others result in some level of prejudging future investigations? It’s human nature to find what you have already said is bad.

→  It might be a useful feedback mechanism for the Board to include in its future MLW press conferences.

  • Examples of FAA responses to the MLW which have satisfied the Board’s prior expression of needs. Positive reinforcement helps.
  • Comments on technology advances made by industry which appear intended to satisfy the NTSB’s wants.
  • Recognition of trend lines indicating some progress. GA, for example, has been a repeated member of the MWL and the NTSB reports supported that this segment’s past performance in broad terms was bad. With new data trending toward lower accident rates, the NTSB now has focused on Loss of Control. The new target is justified, but the improvement was not noted with equal level of attention. The consequence of only seeking safer GA flight, without any recognition, is that the press can only mention the NTSB MLW citation of the “bad” news.
  • At the behest of ICAO and the NTSB, the FAA and airlines have adopted SMS as a primary means of reducing risk. That safety regimen relies heavily on quantitative analysis, in particular, macro data. The MLW’s reviews of specific items neither emphasizes the supporting numbers nor explains the support of why the specific MLW selection was designated over other risks identified by the NTSB methodology. Without some indication of precisely where the 2016-2017 target ranked on the Board’s scale over the unannounced MLW, the FAA and industry must guess how to incorporate the Board’s choice on individual carriers’ SMS priorities.

The NTSB’s Press Conference:

Here are quotes from the NTSB MWLs as applied to aviation:

  • ntsb most wanted list…Pilots must focus their attention on operationally relevant actions and information…
  • Procedures and training provide pilots with the strategies and skills to appropriately shift and direct their attention to operationally relevant information and to maintain flight safety. However, those procedures can be undermined when a pilot brings a self-imposed or internal distraction into the cockpit…
  • Nonessential conversation was an early form of internally-generated (self) distraction in the cockpit, and accident history shows it can severely interfere with pilots’ ability to complete tasks and maintain situational awareness…
  • “The consequences of fatigue on human performance can be subtle. Operators may not recognize loss of attention, slowed reaction times, and poor judgment until it is too late. The traveling public can unknowingly and unwillingly be placed at risk because a fatigued operator cannot safely execute his or her duty…
  • Human fatigue can be acute or chronic; both often arise from poor sleep and inadequate health management. Fatigue impairs performance and degrades a person’s ability to stay alert, attentive, and engaged in the task of controlling a vehicle safely…
  • We must acknowledge that fatigue is a manageable threat to transportation safety that can be mitigated through reasonable measures based on company practices and individual responsibility…
  • We must draw attention to the medical conditions that may affect sleep quality, such as obstructive sleep apnea (OSA)[1], insomnia, and restless legs syndrome. We must also draw attention to company best practices that allow operators to schedule adequate off-duty time for rest and to report, treat, and to track health conditions that affect the quality of their sleep…
  • Although commercial airline accidents have become relatively rare in the United States, accidents involving inflight loss of control (LOC) in general aviation (GA),[2] while trending downward, still occur at an unacceptable rate. From 2008 to 2014, nearly 48 percent of fatal fixed-wing GA accidents in the United States resulted from pilots losing control of their aircraft in flight. During this time, LOC in flight accounted for 1,194 fatalities…
  • More likely to have longer intervals between training sessions and between flights. They typically only need to complete a flight review, consisting of, at a minimum, 1 hour of ground training and 1 hour of flight training every 24 months. GA pilots almost exclusively maintain and improve their skills and update their knowledge of new technologies on their own. Their conduct of safe flight depends more on individual abilities and judgment than on robust training in emergency situations, potentially leaving them unprepared for situations that can lead to LOC.
  • To prevent LOC accidents, pilots should:
    • understand stall characteristics and warning signs, and be able to apply appropriate recovery techniques before stall onset.
    • realize that stall characteristics can vary with aircraft loading and are usually worse at aft CG positions.
    • be aware that stall can occur at a lower AOA in icing conditions.
    • use effective aeronautical decision-making techniques and flight risk assessment tools during both preflight planning and inflight operations.
    • manage distractions so that they do not interfere with situational awareness.
    • obtain training in emergency response skills so it is more natural to apply those skills in an emergency situation.
    • understand and maintain currency in the equipment and airplanes being operated.
    • take advantage of available commercial trainer, type club, and transition training opportunities.
    • consider installing new technology, such as an AOA indicator, which, when coupled with pilot understanding and training on how best to use it, can assist pilots during critical or high-workload phases of flight.
  • The FAA, aviation advocacy groups, type clubs, and manufacturers, including kit manufacturers, are creating and maintaining educational materials and initiatives that include general principles, best practices, and operational specifics related to LOC. For example, the FAA and various industry groups launched the “Fly Safe” national safety campaign to educate the GA community on how to prevent LOC accidents during the flying season.
ntsb most wanted list

The link to the aviation page did not work at the time of writing.

  • ntsb most wanted listAlthough we have addressed many of our concerns to the FAA, companies and operators should not wait for regulators to mandate that they take action. They should proactively procure recorder technology to improve the operational and safety oversight of their aircraft, then routinely review recorded information in structured programs.
  • For example, the Helicopter Air Ambulance, Commercial Helicopter, and Part 91 Helicopter Operations Final Rule, which was published on February 21, 2014, requires operators to equip helicopter air ambulances with flight data monitoring (FDM) systems and encourages operators to gather and analyze this information to improve safety in their day-today operations. This rule should also require helicopter air ambulance operators to establish the recommended FDM program.
  • We have made recommendations for a comprehensive medical certification system for safety critical transportation personnel that includes these features:
    • the applicant’s complete medical history, taken at prescribed intervals, that includes medications, conditions, and treatments as well as a physical examination;
    • specific historical questions and physical examination procedures to identify applicants at high risk for sleep disorders;
    • identification of specific conditions, treatments, and medications that initially disqualify applicants for duty, with certification contingent on further testing (specific to each condition);
    • explicit and uniform processes and criteria for determining when the applicant has a treated, but otherwise disqualifying, condition;
    • certificates that are good only for a limited time for applicants with conditions that are currently stable but known to be likely to deteriorate, to ensure appropriate retesting;
    • medical examiners who: — are licensed or registered to perform examinations and prescribe medication in a given state; — are specifically trained and certified to perform medical certification exams; and — have ready access to information regarding disqualifying conditions that require further evaluation.
    • a review system for medical examiners’ work products with both the information and capacity to identify and correct errors and substandard performance;
    • the capacity to prevent applicants who have been deferred or denied certification from finding another provider who will certify them;
    • a process for dealing with conditions that could impair safety and are diagnosed between certification exams; and
    • guidance for medical providers that should be used when the provider believes a medical condition disqualifies an individual for duty. The goal is simple: ensure safety-critical professionals are medically fit for duty before they operate a vehicle.

One of the audiences for this MLW is Congress. At the urging of AOPA and much of the GA community, a bill was enacted which mandates that the FAA lower its requirements for 3rd Class Medicals. The public record on this legislation did not include the above strong comments!

  • To minimize deaths and injuries, we need to see increased use of existing restraint systems and better design and implementation of occupant protection systems that preserve survivable space and ensure ease of evacuation.
  • General aviation pilots and passengers should use shoulder restraints whenever possible, and small children should be secured in appropriately sized restraints, just as they are in passenger cars.
  • Holding an infant in a lap during flight is not a sufficient safety measure; rather, car seats approved for use on aircraft ensure maximum safety for children, especially during take-off and landing.
  • Education campaigns about the benefits of seat belt and child restraint use enhance user knowledge about these issues and encourage proper use in all vehicles. In addition, we need improved implementation of evacuation procedures.

AGREED:

→ Real Knowledge, not passenger “expert” intuition, about the Best Way Out of an Airplane during an Emergency

→ Child Safety Restraints for airplanes: Goglia speaks; industry listens & must carry the message further

→ Passengers taking bags off during emergency = UNSAFE. Might FAA PSAs help change behavior?

  • We continue to share our lithium battery investigation findings and advocate safety recommendations through participation in industry safety working groups such as the UL initiated Battery Safety Council, and industry outreach events and seminars, such as the NASA battery forum and seminars from the Knowledge Foundation.

[DOT bans Samsung Galaxy Note7 only for carriage in airplanes; WHY not autos, buses, trains, transit & trucks?]

The NTSB’s MWL highlights the issues which the Board deems to be the most important safety concerns. Its message is stated in terms mostly directed to the general public. As a substantive safety tool, its utility for the aviation industry might benefit from some of these suggestions. In any event, all involved in flight read it carefully and learn from the Board’s insights.

 


THE NTSB’S MOST WANTED LIST…AND YOU

[1] It is interesting to remember that the FAA Flight Surgeon attempted to impose rigorous Sleep Apnea requirements for pilots. The industry opposition was substantial. The NTSB comments in support of the Flight Surgeon were not noticed.

[2] There is appropriate positive news buried in that otherwise negative point. How many reporters will repeat the positive
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1 Comment on "NTSB’s 10 Most Wanted List is out after 10 months, but to rate a 10 for aviation, it could include more"

  1. Lawrence McCray | November 21, 2018 at 5:22 pm | Reply

    Where can I find information on:

    [] NSTB’s criteria and process for comprising its Top Ten list?
    [] Budget and personnel assigned to the MWL program at NSTB?
    [] NTSB’s take on particularly effective past MWL cases?
    [] Whether the MWL programs covers research needs as well as action recommendations?

    — L. McCray, MIT Program on Emerging Technology

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