NTSB Recommendations would be better understood if written in SMS

Republic EMB 175 and NTSB
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NTSB recommendations not adopted as fast or often as desired

SMS adopted by airlines under FAR as urged by NTSB

Might the NTSB proposed actions be better received in SMS terms

assessment of the risk severity and risk probabilities 

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The NTSB recently recommended before a final determination “stricter guidelines” for a Brazilian certificated aircraft which constitutes a major portion of US airliners. The six changes are directed at ANAC and its US equivalent. The bases seem to be strong and actually follow problems identified in previous Embraer Service Bulletins. The Board’s release suggests frustration with the FAA, ANAC, Embraer and the US carriers for not responding to the previous warnings.

Part of that miscommunication may be a self-inflicted wound. As the below NTSB quote makes clear, it has been a staunch advocate for Safety Management Systems (see 14 CFR Part 5) for all modes of transportation.

NTSB on Safety Management Systems

NTSB SMS chart

“What is the issue?

For over three decades, the NTSB has expressed concern about the lack of safety management and preventive maintenance. NTSB accident investigations have revealed that, in numerous cases, safety management system (SMS) or system safety programs could have prevented loss of life and injuries. Although an impaired operator or mechanic, a broken vehicle part, or severe weather may be the initiating factor in a transportation accident, there frequently is evidence of a continuous safety problem long before the accident occurred. These programs continually monitor operations and collect appropriate data to identify emerging and developing safety problems before they result in death, injury, or significant property damage. Having identified these risks, these programs then devise interventions and evaluate how well they perform at successfully mitigating risk.  

These programs establish processes to collect and analyze data on potential safety problems and then evaluate mitigations to resolve the safety risk before an accident happens.   They help to predict and correct problems to prevent accidents, but they are also a natural complement to investigations when accidents do occur. A fundamental principle of such systems is nonpunitive reporting that applies to both operating companies and the personnel involved in transportation organizations.

SMS and system safety programs can be effective in all organizations regardless of size. It is important to have information on how to scale these programs—from the smallest operators with just a few personnel and vehicles, to large organizations with thousands of employees and large numbers of vehicles and facilities. Regardless of the size of the organization, it is possible and necessary to foster a safety conscious environment that will identify hazards early on and mitigate the associated risks.

However, the Board seems reluctant to speak in the terms of SMS in its own actions:

AVIATION SAFETYFAA MARCH 1, 2016

NTSB Should Shift Its Vocabulary To SMS’s More Problem-Solving Words

NTSB seal and pictures

ACCIDENT INVESTIGATIONAVIATION ASSOCIATIONSAVIATION SAFETYFAA OCTOBER 20, 2016

NTSB Crash Lesson— Part 135 Carriers Need SMS; Here’s A Way

NTSB seal in background


ACCIDENT INVESTIGATION
NTSB AUGUST 29, 2018

NTSB Answers The Probable Cause Question, But Should Have Asked An SMS Question?

FedEx  accident


In issuing a recommendation, might the NTSB use the vocabulary and metrics of SMS (Particularly true of its Most Wanted List). By using a matrix like the below, the Board would emphasize its assessment of the risk severity and risk probability.  Those quantitative and qualitative determinations by the Board would be instructive for all reading the Recommendation(s). Such a transmission would facilitate the recipient to incorporate this action into its risk list and help prioritize the recommendations. In fact, Republic Airlines is a dedicated SMS proponent and adherent to this safety discipline.

NTSB SMS RISK CHART

 

 

 

E-Jet Pitch Control Problem Prompts NTSB Recommendations

emb 170

The National Transportation Safety Board on Wednesday recommended to U.S. and Brazilian aviation authorities that they issue stricter guidelines for inspecting and replacing wiring in the control column of Embraer E-Jets and Lineage 1000 business jets following a November 6 incident in which a Republic Airways E175 experienced pitch-related flight control degradation. The airplane, carrying six passengers, returned safely to Atlanta Hartsfield International Airport 15 minutes after takeoff.

NTSB RECOMMENDATIONS

The NTSB issued six safety recommendations to the National Civil Aviation Agency of Brazil (ANAC) and four to the Federal Aviation Administration. They address areas of concern including wire chafing, application of Embraer service bulletins relating to the pitch trim switch, and potential limitations in checklist memory items for pilots to address the unintended operation of the pitch trim system.ANAC HDQ

 

The first recommendation to ANAC calls for the Brazilian authority to require Embraer to devise new wiring inspection and replacement instructions and to ensure proper clearance from adjacent components, including the forward mechanical stop bolt and its safety wire. NTSB WIRE PICTURES

The remainder of the recommendations relates to operators’ responsibilities for carrying out the directives.

During the November 6 incident, the flight crew declared an emergency shortly after takeoff from Hartsfield-Jackson Atlanta International Airport, reporting a pitch trim-related flight control problem that caused a nose-up attitude and difficulty controlling the airplane.

Although the cause of the incident remains under investigation, post-incident examination of the airplane revealed chafed insulation around wires connecting the horizontal stabilizer actuator control electronics to the captain’s pitch trim switch and autopilot/trim disconnect button. Contact with the incorrectly untucked pigtail of the forward mechanical stop bolt safety wire caused the chafing (see Figure 2), found the NTSB.

When investigators removed the captain’s pitch trim switch from the yoke, they observed marks that indicated at some point before the incident flight, mechanics installed the pitch trim switch in an inverted position. Embraer previously issued three service bulletins related to pitch trim switch installation error following reports from flight crews in 2015 about flight control system difficulties. However, neither the ⇒FAA nor the ANAC required incorporation of the service bulletins. While investigators haven’t determined whether the inverted switch installation proved a factor in the incident, the NTSB expressed concern the condition could lead to flight crew confusion, delaying appropriate recognition of and response to increased control forces.

Preliminary information from the NTSB’s investigation also suggests that the condition might mask unintended pitch trim operation during certain phases of flight, such as during takeoff. Further, limitations in the checklist memory items might delay pilots in properly responding to and regaining control of the airplane. The NTSB said the crew’s application of the memory items on the E175 Pitch Trim Runaway checklist might not comprehensively address the circumstances of the trim system operation in a timely manner. 

NTSB Chair Sumwalt

 

“Issuing these 10 safety recommendations early in the investigation demonstrates the NTSB’s commitment to take action as soon as we’ve identified and verified a safety issue that needs to be addressed,” said NTSB Chairman Robert Sumwalt. We don’t need to wait for an investigation to be completed before issuing safety recommendations. We have the responsibility to issue recommendations that when implemented by recipients, can correct safety deficiencies, prevent accidents, and save lives.”

sms chart




 

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