Observations on the NTSB Most Wanted Lists: 2016, 2015 & 2014

NTSB Most Wanted List 2016
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NTSB Chairman Hart explained, in his message accompanying the issuance of the Most Wanted List (MWL), the “how” and “why” of the Board’s selection of the things transportation should improve:

NTSB Most Wanted List 2016How do we decide what goes on the List each year? The extent to which an improvement can help save lives and reduce injuries is a factor, but not the only factor. If it were, all of the items would relate to highway crashes, where the vast majority of transportation deaths and injuries occur.

We also look at so-called bang for the buck – how to use our limited resources most effectively to improve safety. The fact that an issue is not on our list does not mean that we are not interested in it; rather, it means that there are more effective and efficient ways for us to improve safety.”

[emphasis added]

While the criteria of the NTSB are accepted, aviation safety currently places great value in trend analysis; so it appears to be useful to look at the MWL for 2014, 2015 and 2016. Instead of examining each year as a single picture (e.g. 2012, 2013 [2], 2014, 2015), it may be informative to review a “movie” of three years.

  • Is there significance to multiple inclusions?
  • What does deletion mean? (“there are more effective and efficient ways”)
  • Do the variations in word choice matter?

Here is a table of the verbatim annual headlines of the MWLs, focusing on aviation safety (note there have been significant stylistic and explanatory improvements in the MLW presentations since 2014):

2016 2015 2014
Prevent Loss of Control in Flight in General Aviation PREVENT LOSS OF CONTROL IN FLIGHT IN GENERAL AVIATION General Aviation
Reduce Fatigue-Related Accidents
Disconnect from Deadly Distractions DISCONNECT FROM DEADLY DISTRACTIONS Distraction
Strengthen Occupant Protection Occupant protection
End Substance Impairment in Transportation END SUBSTANCE IMPAIRMENT IN TRANSPORTATION Substance-Impaired Driving
Require Medical Fitness for Duty REQUIRE MEDICAL FITNESS FOR DUTY
Promote Completion of Rail Safety Initiatives IMPROVE RAIL TANK CAR SAFETY
Promote Availability Of Collision Avoidance Technologies in Highway Vehicles IMPLEMENT POSITIVE TRAIN CONTROL IN 2015 Positive Train Control
Improve Rail Transit Safety Oversight MAKE MASS TRANSIT SAFER
Fire Safety
Pipeline Safety


1. General Aviation Safety has been on the list since 2012 (or 2011). The 2016 version (see below abbreviated NTSB aviation safety comments) cited a Board Forum, technology solutions (AOA indicators) and training (understanding AOA concepts and how elements such as weight, center of gravity, turbulence, maneuvering loads, and other factors can affect an airplane’s stall characteristics).

The action items were assigned to the FAA, GA trade associations, OEMs and aircraft type clubs. NBAA immediately said that the NTSB’s 2016 “Most Wanted” safety improvements…are in step with the safety focus areas of NBAA’s Safety Committee.” While AOPA accepted the remedial steps, it took offense to the Board’s failure to acknowledge how much GA safety has improved.

  • What is unsaid is why GA safety has made the MLW for five consecutive years?
  • Was this recommendation made at a higher level of urgency?
  • This MWL statement is more specific than the prior reviews; does that mean that the “probable cause” is better identified?
  • Why did the NTSB hold a forum on this subject? Did the Board think that their investigations had discerned something new? Or was the Board frustrated with the inadequacy of other stakeholders?
  • What will be the response of the GA community?
  • What level of improvement or what specific improvements in criteria will take GA off the 2017 list?

2. Fatigue is an addition to the 2016 MWL and the inclusion of aviation is a bit odd. In 2015 the FAA issued a state-of-the-art Final Rule, 14 CFR Part 117, on pilot fatigue. The MWL statement mentions air traffic control fatigue, but it only mentioned in a citation the problems asserted by cargo pilots. It would have seemed appropriate to give credit to the FAA for its Fatigue Risk Management and Fatigue Education advances.

  • Aviation’s inclusion on this MWL—does it signify that the FAA should be working on fatigue and Controllers /Cargo Pilots?
  • Does the exclusion of Part 117 in the MWL signify that the NTSB does not regard its preventative actions highly?

3. Distraction is a repeat MWL for aviation, but again the aviation aspect seems to be minor. PDAs have been allowed in the cabin and tablets have been a major safety addition to the cockpit. The aviation accident cited involves an EMS helicopter pilot texting, but the MWL does indicate that “…aviation has recognized the need for ‘sterile cockpit’ procedures that restrict activities and conversations to the task at hand.” Aviation’s #1 cockpit problem is the pilots’ reliance on technology and lack of skills to regain control when the computer fails. This MWL selection appears to be more about surface transportation.

4. Substance Impairment has made the MWL for three years in a row. Its aviation reappearance stems from a recent NTSB study of pilots after accidents. Pilots, it is urged, should also tell their physicians to assess their medications and possible impacts on flying.

5. Occupant Protection returns to MWL from 2014. The specifics include the two passengers on the Asiana SFO crash, children being held during flights, the need for GA passengers to have shoulder harnesses and emphasis on passenger evacuation procedures. None of those observations are new. Curiously, the MWL does not mention specifically the prioritization made by NTSB alumnus, John Goglia, on proper child restraint systems. Query: how the SMS process would evaluate these recommendations in comparison to other initiatives? 

6. Medical Fitness for Duty is a repeat from 2015. Interestingly enough, the high profile Mental Fitness issue created by GermanWings is not mentioned. The Board mentions how a pilot’s color blindness contributed to a fatal crash and credits “[t]he aviation medical certification system may be the most robust, but pilots are increasingly testing positive for over-the-counter sedating medications.” The rationale for aviation’s inclusion on this MWL point is not well supported. Perhaps unions would negatively react to any mental health issue or more invasive examination?

  • It would be informative to know why 2015 MWL’s helicopter safety and PROCEDURAL COMPLIANCE are not on 2016 MWL? What about the last year’s safety record in these two points merits their deletion from this high profile status?
  • The MWL 2016 recommendation Promote Availability Of Collision Avoidance Technologies in Highway Vehicles should carefully examine the aviation experience in Cockpit Automation. The designers of the Collision Avoidance system should be mindful of the aviation experience with similar computerization of this function. There is a need to keep the human involved in the operation of the vehicle; so in the event of a requirement to take full responsibility, the human can function.


2016 NTSB Most Wanted List—Aviation sections

1. Prevent Loss of Control in Flight in General Aviation—Between 2008 and 2014, about 47 percent of fatal fixed-wing GA accidents in the United States involved pilots losing control of their aircraft in flight, resulting in 1,210 fatalities.GA pilot proficiency requirements are much less rigorous than those of airline pilots.

GA pilots are much more likely to have longer intervals between training sessions and longer intervals between flights…In October 2015, the NTSB held a forum on “Humans and Hardware: Preventing General Aviation Inflight Loss of Control”… The 2015 forum provided potential hardware solutions, such as the use of AOA indicators, and human solutions, such as increased pilot training to ensure a full understanding of stall phenomena. This training should also include understanding AOA concepts and how elements such as weight, center of gravity, turbulence, maneuvering loads, and other factors can affect an airplane’s stall characteristics…The Federal Aviation Administration, aviation advocacy groups, type clubs, and manufacturers, including kit manufacturers, are creating and maintaining educational initiatives that include general principles, best practices, and operational specifics as they relate to loss of control. These resources can be helpful in learning effectiveness countermeasures.

Pilots should:

  • Be prepared to recognize stall characteristics and warning signs, and be able to apply appropriate recovery techniques before stall onset.
  • Be honest with themselves about their knowledge level of stalls, and their ability to recognize and handle them.
  • 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.
  • Understand, properly train, and maintain currency in the equipment and airplanes they operate.
  • Take advantage of available commercial trainer, type club, and transition training opportunities.
  • Realize stall characteristics can vary with aircraft loading and are usually worse at aft CG (center of gravity).

Airplane owners should consider installing an AOA indicator, which, coupled with pilot understanding and training on how best to use it, can enhance situational awareness during critical or high-workload phases of flight.

The Federal Aviation Administration, aviation advocacy groups, type clubs, and manufacturers, including kit manufacturers, are creating and maintaining educational initiatives that include general principles, best practices, and operational specifics as they relate to loss of control. These resources can be helpful in learning effectiveness countermeasures.

2. Reduce Fatigue-Related Accidents—The NTSB has issued more than 200 safety recommendations addressing fatigue-related problems across all modes of transportation…Some of our earliest recommendations called for research to better understand the problem of fatigue in transportation, and, over the past three decades, a great deal of research has been done.

But research only goes so far; we must implement what we have learned…Fatigue risk management programs take a comprehensive, tailored approach to the issue of fatigue within an industry or workplace, helping to address the problem of fatigue in an operational environment. Such programs include policies or practices to address scheduling, attendance, education, medical screening and treatment, personal responsibility during non-work periods, task/workload issues, rest environments, and commuting and/or napping. FAA?

3. Disconnect from Deadly Distractions—Quite simply, drivers, pilots, and other vehicle operators do not always have their minds on the road, waterway, sky, or track. But focusing on any other task other than what’s up ahead impairs performance and can lead to deadly consequences…The first step toward removing deadly distractions will be to disconnect from non-mission-critical information.

For decades, aviation has recognized the need for “sterile cockpit” procedures that restrict activities and conversations to the task at hand. But all modes of transportation need to rise to today’s distraction challenges. That’s why, in December 2012, we called for a driver ban for all PEDs. We have issued similar recommendations for aviation, marine, and rail…Likewise, we need to continue to build our technical understanding of distraction arising from auxiliary tasks in regulated transportation, especially as regards new vehicle technologies that require real-time operator attention. Advances in these areas will support regulatory efforts and lead us toward a cultural norm that encourages and supports operators to remain disconnected from deadly distractions.

4. End Substance Impairment in Transportation—But our new reality is this: impaired driving does not just involve alcohol. Drugs can also affect the ability to drive or operate any vehicle. Illegal, prescription, or over-the-counter drugs can have impairing side effects. But, unlike alcohol, drugs can affect each person differently, which makes tackling drugged-impaired driving or vehicle operation a particularly challenging endeavor.

The NTSB recently studied drug use among fatally injured pilots. The prevalence of potentially impairing drugs increased from an average of 11 percent of fatally-injured accident pilots during the period from 1990-1997 to an average of 23 percent of accident pilots during the period 2008-2012. During the same time periods, positive marijuana results increased from 1.6 percent to 3.0 percent.

But the most commonly found impairing substance in fatal crashes was diphenhydramine, a sedating antihistamine found in over-the-counter medications…Additionally, drivers of any vehicle type should discuss their transportation activities with their doctor before taking a medication, and discuss the impairing effect of any medical condition as it might increase their risk of having an accident. A person’s medical condition and medications should not always exclude them from operating a vehicle, but such conditions and medications need to be monitored. If any medication label warns against operating heavy machinery, that warning includes vehicles.

5. Strengthen Occupant Protection—In commercial aviation, the NTSB saw how a lack of restraint use led to some tragic consequences in San Francisco in 2013 as a result of the crash of Asiana flight 214. While 99 percent of passengers survived the Asiana accident, two of the three fatally injured passengers were ejected from the airplane because they were unrestrained….While we are required to secure our luggage and even small items such as snacks and beverages during take off and landing, the Federal Aviation Administration exempts the most vulnerable passengers—children under age 2—allowing them to travel unrestrained, on an adult’s lap.

And when accidents occur, the NTSB notes that problems with evacuation decision making and execution continue to exist among cockpit and cabin crews…People involved in general aviation accidents have suffered serious and fatal injuries as a result of shoulder harnesses not being installed on the aircraft, a seat belt failing, or occupants simply choosing to not wear their seat belts…The first step to strengthening occupant protection in aviation and on roadways is to increase use of available occupant restraint systems…In the air, all occupants are best protected when using a restraint, regardless of the aircraft type.

General aviation pilots and passengers should use shoulder restraints whenever possible, and we should all be as diligent in securing our small children in an appropriately-sized restraint as we are in our passenger cars. It is also critical that commercial flight and cabin crews have proper training and procedures to conduct timely and professional evacuations when conditions warrant.

6. Require Medical Fitness for Duty—When safety-critical personnel, such as public vehicle operators, have untreated medical conditions that prevent them from doing their jobs effectively, people can be seriously injured or die. In fact, they have done so in many accidents investigated by the NTSB. Requiring medical fitness for duty can prevent the accidents leading to these and other tragic outcomes…In a July 2002 aviation accident, a FedEx Boeing 727 flew into the ground while approaching the Tallahassee, Florida, airport because the flying pilot had a severe color vision deficiency which made it difficult for him to correctly identify the color of the airport’s PAPI lights that were warning that the flight was too low. The aviation medical certification system may be the most robust, but pilots are increasingly testing positive for over-the-counter sedating medications.

Moreover, although the NTSB has found that obstructive sleep apnea has been a factor in multiple accidents, most transportation modes still lack a complete screening process for this condition. The NTSB has made recommendations for a comprehensive medical certification system for safety-critical transportation personnel that include these features:

  • a complete medical history of the applicant, 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 both 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 product(s) 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 which 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.

7. Improve Rail Transit Safety Oversight

8. Promote Availability Of Collision Avoidance Technologies in Highway Vehicles


ARTICLE: 2016 Most Wanted List

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