NTSB MWLs qualitative not SMS quantitative, less impactful

NTSB Board members
Share this article: FacebooktwitterlinkedinFacebooktwitterlinkedin

NTSB’s Most Wanted List = policy leverage

Appeals to general public with qualitative, episodic information

Quantitative SMS-like analysis would be more compelling before FAA, OMB/OIRA & Industry

The 2021-2022 MWL report card was recently issued. The tone and text[1] castigate the entities cited as responsible for meeting the expectations created by this list. While it is fair to say that the items, in a perfect world, should be adopted soon, there are serious questions whether the governmental body assigned blame CAN do what the Board deems appropriate.

The NTSB is an odd governmental entity that makes findings but cannot enforce them. To put some force behind their recommendations, the five position (only 4 in place now) Board has issued annually a MOST WANTED LIST (MWL) which was first issued in 1990, then called the  NTSB Most Wanted List of Transportation Safety Improvements. The audience for the MWL includes lawmakers, industry, advocacy and community organizations, and every American.”

The recent MWL for aviation point at the failure to mandate and/or voluntarily install-

Require and Verify the Effectiveness of Safety Management Systems in all Revenue Passenger-Carrying Aviation Operations​

​Install Crash-Resistant Recorders and Establish Flight Data Monitoring Programs

The Board rebukes the FAA and industry for failing to do what the NTSB announced that they should have done already.Benefit Cost Amnalysis

The FAA and even the operators do not have absolute autonomy, even to implement safety advice. Any rule, proposed by the FAA to meet a MWL, must be reviewed by OMB’s OIRA. Even though the Biden analysts there are a little less rigid, Congress mandated that in considering any significant regulatory proposal, OIRA must meet an exacting Benefit Cost Analysis. Similarly when an airline’s SVP goes to her/his Board for approval of a major capital expense, the vote by the Members will look for a similar analysis.

OMB OIRAThe Board’s recommendations intuitively seem justified, yet the supporting justifications offered for adopting these changes lists qualitative and/r episodic bases. Numbers, hard quantification drive decisions to take the MWL actions.

The irony is that the very same institution– demanding action of its MWL without any economic justification—advocates for highly quantitative calculations for all aspects of aviation—Safety Management Systems (SMS). In fact, this MWL states that all revenue carriers should use this decision tool. Risk analysis prioritizes actions before the FAA and each airline. The Board has a very  large data base of accidents, by multiple categories, which would result in an extremely credible risk assessment.

Washington policy makers and airline decision makers depend on numbers to make big decisions. Saying that a major expense is “wanted”, without a more precise statement of value delivered, is not adequate to carry the decision. An MWL with such a careful estimate would actually increase the credibility of the proposed solution. OMB and corporate decision makers would have to acknowledge this judgment.

numbers rule DC policy makers and Boards

numbers rule DC policy makers and Boards

 

Recent history of MWLs may provide added context to this issue:

Tracking The NTSB Most Wanted List

NTSB’s 10 Most Wanted List Is Out After 10 Months, But To Rate A 10 For Aviation, It Could Include More

Observations On The NTSB Most Wanted Lists: 2016, 2015 & 2014

The Board is composed of well-qualified Members who truly are committed to safety. Their influence would be enhanced if SMS became a discipline within the L’Enfant Headquarters .

NTSB HDQ


 

NTSB MWL header

​​​​​​​​​​​​The NTSB’s Most Wanted List (MWL) highlights transportation safety improvements needed now to​ prevent accidents, reduce injuries, and save lives. We use the list to focus our advocacy efforts during the current MWL cycle.

The NTSB urges lawmakers, industry, advocacy and community organizations, and every American to learn more about what they can do to implement ​ and champion the 2021-2022 MWL. Adopting NTSB safety recommendations associated with these safety items will save lives.

Aviation

Require and Verify the Effectiveness of Safety Management Systems in all Revenue Passenger-Carrying Aviation Operations

Install Crash-Resistant Recorders and Establish Flight Data Monitoring Programs

Install Crash-Resistant Recorders and Establish Flight Data Monitoring Programs

​​​​​​​​​​​​​​​​When planes crash, we want to know what happened. The good news is that there’s technology available today th​at would give us the answers. The bad news is that the Federal Aviation Administration (FAA) has not mandated that aircraft operators install it [the tech], citing privacy, security, cost, and other concerns.

Commercial airliners are required to have only flight data recorders and cockpit voice recorders, commonly called “black boxes”, but the NTSB has long called for cockpit image recorders, as well. Such video would have been extremely helpful in determining flight crew actions in recent crashes in Texas, Indonesia, and Ethiopia.

The NTSB believes other types of passenger-carrying commercial aircraft, such as charter planes and air tours, should be equipped with data, audio, and video recording devices. These operators should also have programs in place that analyze the data derived from these devices. Recorders and flight data management programs would not only help investigators solve accidents, but they would also help aircraft operators prevent crashes in the first place by allowing crew actions to be evaluated regularly.

Regardless of the recorder type, it must be able to survive a crash.​

Lessons Learned: NTSB Investigations​

​The following crashes best exemplify why this safety improvement is needed.

Rapid Descent Into Terrain Island Express Helicopters Inc. Sikorsky S-76B, N72EX Calabasas, CA | January 2020

helicopter

 

 

 

 

 

 

Loss of Control at Takeoff Air Methods Corporation Airbus Helicopters AS350 B3e, N390LG Frisco, CO | July 2015

 

Loss of Control

 

Crash Following Loss of Engine Power Due to Fuel Exhaustion Air Methods Corporation Eurocopter AS350 B2, N352LNNear Mosby, MO | August 2011

Fuel Exhaustion

 

 

 

 

Stats to Know

20

Years the NTSB has been calling for cockpit image recorders

0

FAA-mandated cockpit image recorders in commercial airliner cockpits

83%

Turbine-powered, nonexperimental, nonrestricted-category aircraft (operating under 14 CFR Part 91 or 135) in which flight crew were killed investigated by the NTSB between 2005 and 2020 where no recording equipment was installed.

Our Solutions . . . Take Action Now!

The FAA should mandate crash-resistant recorders in all passenger-carrying operations and require data monitoring and analysis programs. Operators should not wait for mandates to do so; they can realize the safety benefits of these technologies now.

Regulators should:

      • Require aircraft operating under 14 Code of Federal Regulations (CFR) Parts 91, 121, or 135 to install a crash-resistant flight recorder system on all newly manufactured turbine-powered, nonexperimental, nonrestricted-category aircraft; and/or require the retrofit of existing aircraft with such equipment.
      • The crash-resistant flight recorder system should record cockpit audio and images with a view of the cockpit environment.
      • Require that all existing and newly manufactured aircraft operated under 14 CFR Parts 121 or 135 and currently required to have a cockpit voice recorder and a flight data recorder be retrofitted with a crash-protected cockpit image recording system.
      • Require aircraft operating under 14 CFR Part 135 to:
        • ​install flight data recording devices capable of supporting a flight data monitoring program, and
        • ​require a structured flight data monitoring program that reviews all available data sources to identify deviations from established norms and procedures as well as other potential safety issues.

Industry should:

      • Install a crash-resistant flight recorder system that records cockpit audio and images with a view of the cockpit environment on all:
        • newly manufactured and existing turbine-powered helicopters that are not equipped with a flight data recorder and a cockpit voice recorder.
        • existing turbine-powered helicopters that are not equipped with a flight data recorder or a cockpit voice recorder.
      • Install a crash-protected cockpit image recorder system on all:
      • newly manufactured and existing turbine-powered helicopters that are equipped with a flight data recorder and a cockpit voice recorder.
      • existing turbine-powered helicopters that are equipped with a flight data recorder and a cockpit voice recorder.

See our specific detailed recommendations.


Require and Verify the Effectiveness of Safety Management Systems in all Revenue Passenger-Carrying Aviation Operations

​​​​​​​​​​​​​​​​ By establishing an effective safety management system (SMS) and creating a safety culture aimed at making safety a focus first and always, operators will improve aviation safety and reduce the risk of accidents.

An SMS is a formal, top-down, organization-wide approach to managing safety risk and assuring the effectiveness of safety risk controls. An SMS should address four components: safety policy, safety risk management, safety assurance, safety promotion. It can be scalable to the size and complexity of operations, yet too many operators either do not have one in place or have an ineffective one.​

In 2015, the Federal Aviation Administration (FAA) required commercial airliners to develop a comprehensive SMS to improve safety for the flying public. Yet the FAA has not required other revenue passenger-carrying operators to have one.

Although we have seen some voluntary adoption of SMS programs, a vast majority of operators continue operating without an SMS in place. It’s time more got on board. The risk to the flying public is too great not to.

​Lessons Learned: NTSB Investigations

The following accidents best exemplify why this safety improvement is needed.

 

Collision with Terrain Hageland Aviation Services, Inc. dba Ravn Connect Flight 3153 Cessna 208B, N208SD Togiak, AK | October 2016

Ravn crash

 

 

 

 

 

Departure From Controlled Flight Trans-Pacific Air Charter, LLC, Learjet 35A, N452DA Teterboro, NJ | May 2017

 

Red Lear Jet

Inadvertent Activation of the Fuel Shutoff Lever and Subsequent Ditching Liberty Helicopters Inc., Operating a FlyNYON Doors-Off Flight Airbus Helicopters AS350 B2, N350LH New York, NY | March 2018

red helicopter

 

 

 

 

 

Stats to Know

30 out of ​1,940

​​certificate holders authorized to conduct Part 135 operations have an FAA-accepted SMS; 165 others have applied for FAA acceptance (Source: FAA)

 

5

Times NTSB has reiterated SMS recommendation to the FAA

Our Solutions . . . Take Action Now!

SMSs can improve safety and, if required by the FAA, provide an effective means of ensuring a culture of safety. Operators and states] shouldn’t wait for regulations; they should implement an SMS now.

Regulators should:

    • Require all 14 Code of Federal Regulations (CFR) Part 135 operators and all commercial air​ tour operators, regardless of their operating rule, and all Part 91 revenue passenger-carrying operators to establish SMS programs.
    • Require all 14 CFR Part 135 operators to install flight data recording devices capable of supporting a flight data monitoring program and require operators to establish a structured flight data monitoring program that reviews all available data sources to identify deviations from established norms and procedures and other potential safety issues.

Operators should:

    • Implement an SMS program that includes effective risk management practices, such as establishing an SMS under the FAA SMS voluntary program that includes compliance with Advisory Circular 120-92B, “Safety Management Systems for Aviation Service Providers.”
    • Participate in the FAA’s safety management system voluntary program.
    • Establish a culture that fosters and promotes the successful implementation and administration of a successful SMS.

 

States, territories should:

    •  Develop and implement a comprehensive SMS for aircraft operations

 

See our specific detailed recommendations.

 

[1] Contrast NTSB MWL Update Is Both Positive In Its Message And More Collaborative

NTSB go team deplaning and at site



 

Share this article: FacebooktwitterlinkedinFacebooktwitterlinkedin

Be the first to comment on "NTSB MWLs qualitative not SMS quantitative, less impactful"

Leave a comment