NTSB's most wanted list gets update

 - April 26, 2010, 11:56 AM

In its annual review of most wanted transportation safety improvements, the NTSB updated its list of items requiring rapid attention and added a new urgent concern to the aviation category as a result of the investigation into last year's Colgan Air crash. The addition involves improvement in the oversight of pilot proficiency based on a pair of the Safety Board's previous recommendations calling for the FAA to require Part 121 and Part 135 operators to obtain histories of flight-check failures by pilots seeking employment, and to mandate special remedial training for pilots who have demonstrated performance deficiencies.  

Under the current provisions of the Pilot Record Improvement Act of 1996, carriers could gain additional information about pilot applicants from the FAA-including notices of disapproval-only if the applicant provided a signed letter of permission, and the NTSB recommended that all Part 121 and 135 carriers request such permission as a standard procedure. The FAA had promised to conduct a survey of carriers to gauge how many were complying with the recommendation, but it has not yet done so, according to the NTSB. In the case of the Colgan accident, the airline was not aware of the previous checkride failures of the pilots involved, and it was not required to be. 

The Board in 2005 also recommended that Part 121 carriers institute remedial training programs for pilots who have demonstrated performance deficiencies. Last October, the FAA reported that only 29 of 82 carriers had such programs in place, but just this past January, the agency stated that most air carriers now have established appropriate remedial training courses. According to Board member Robert Sumwalt, during last May's public hearing on the Colgan accident, the FAA's principal operations inspector assigned to the airline testified that he was unaware of the agency's notice A-900.71, which discussed verification of remedial training programs for Part 121 carriers, which was issued by the agency the previous month. 

Until the Board can corroborate the FAA's latest assessment, it has added it to its list of most wanted improvements with an urgent/unacceptable response status. “We have seen, most tragically in the Colgan Air accident that killed 50, that pilot proficiency is essential to the safety of flight, and that's just as true for Part 135 on-demand air taxis as it is for Part 121 scheduled airlines like Colgan,” NTSB chairman Debbie Hersman told AIN. “This is why improving the oversight of pilot proficiency for all of these different types of flight operations was added to the NTSB's Most Wanted List of Safety Improvements and why we will continue to advocate for the needed changes to make the skies safer for everyone.”

Areas of Progress

While no items were removed from last year's list, three areas did show progress and were moved by the Board from unacceptable to slowly progressing. The issue of runway safety-which has been on the list since its inception in 1990-has been upgraded to acceptable response, based largely on the FAA's current evaluation of several new technologies including final approach occupancy signals, runway status lights, improved airport lighting at airports around the country approximately a decade after their recommendation by the Board. The agency is also testing low-cost ground surveillance systems in four towers that currently do not have such systems. 

Another area where the board has seen recent progress is in its recommendation for changes in ATC procedures that would require specific clearances for aircraft to cross runways rather than relying on implied clearances, an improvement the NTSB believes would reduce the chance of a runway incursion. Without such a clearance, the pilot would be required to hold short. The FAA recently advised the Safety Board that it will be revising its ATC procedures to incorporate the recommendation.

An area where the Board has not seen sufficient progress is in its recommendation that all Part 91K, 121, and 135 operators install on their aircraft 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. “I think that the Safety Board has expanded its definition of runway safety in the last few years following the [August, 2006] Comair accident,” said Hersman. “It used to be just runway incursions that we were concerned about, but with Comair we realized that safety on the airport surface and making sure that people are where they should be and where they think they are is just as critical as making sure that aircraft are separated and don't collide.” 

Sumwalt cited a study from the Commercial Aviation Safety Team analyzing historic runway excursions and estimated that a large percentage of the incidents attributable to pilot deviation could have been avoided by the use of moving maps with airport diagrams and own-ship positioning. The FAA has stated it has developed an issued standard for moving map technology and electronic flight bags with moving map displays, and while it has not made them a requirement, it has pledged funds as an incentive for aircraft owners who equip their aircraft with such systems. 

To combat the problem of runway excursions, the Board has previously recommended that flight crews should be required to make a landing distance assessment before each landing. While the FAA has encouraged operators to comply with that recommendation, it has not yet made landing distance assessments mandatory. 

Another issue area on the Board's watch list is improving crew resource management. The NTSB has recommended that all Part 135 providers that conduct dual pilot operations establish and implement FAA approved crew resource management (CRM) training programs for their flight crews in accordance with the standards that have been in effect for Part 121 operators since 1998, and which are also required for fractional flight crews. 

The recommendation stemmed from the Board's investigation of several business jet accidents where deficient crew performance was a factor, and sufficient CRM training was lacking. The issue has been on the most wanted list since 2006, and last May the FAA issued an NPRM calling for initial and recurrent CRM training for all Part 135 operators with not only dual-pilot flights, but also for aircraft flown with a single pilot. The proposed rule also specifies the minimum course content required. Unlike the requirements for Part 121, the proposed rule would excuse pilots with previous CRM training from requiring initial training with a new employer, which the board finds objectionable due to the wide range of variables that exist among operators. Based on the issuance of the NPRM, the NTSB upgraded the status of the recommendation to acceptable progress.

HEMS Safety in Question

Last year the Board conducted a four-day hearing in the aftermath of the deadliest year for the helicopter EMS industry. 2008 saw eight fatal accidents that killed 29 people. The Safety Board added EMS flights to its most wanted list last year. While the Board noted some improvements, the issue retained its overall unacceptable progress status on the list. The Board applauded the new operations specification mandating that all VFR legs of EMS helicopter flights be conducted within stringent pre-defined altitude and weather minimums derived from preflight planning, which according to the FAA has achieved a 100-percent compliance rate among HEMS operators. 

The NTSB also found improvement in its request for industry-wide implementation of formalized flight following and dispatch after a May 2008 FAA advisory circular specified tasks that needed to be completed by operators' operational control centers. According to an FAA survey last year, 89 percent of all HEMS operators at the time had operational control centers, a number that was expected to increase this year.

But the NTSB found unacceptable the FAA's lack of progress on adopting Part 135 flight and duty time rules for the industry, flight-risk evaluation protocols, and a Taws mandate. A 2006 report by the Board on HEMS crashes found that 17 of the 55 accidents cited could have been avoided with the use of Taws While the FAA has mandated the use of Taws on turbine powered aircraft with six or more passenger seats, it has not extended such regulations to EMS helicopters.

No Progress on Cockpit Image Recording

The only issue area concerning aviation flight recording devices still on the NTSB's most wanted list is a requirement for cockpit image recorders on large transport-category aircraft and on smaller commercial aircraft that are not currently equipped with flight recorders. In this area the Board downgraded the FAA's response from slowly progressing to unacceptable. Last September, the FAA told the NTSB that it would not initiate any mandates involving cockpit image recordings, stating that the provisions of its March 2008 ruling on cockpit voice recorder and digital flight data recorder regulations would mitigate the need for image recording. Currently scheduled for implementation by December 6, the recently amended final rule calls for equipage with new two-hour CVRs, with digital datalink capabilities and increased sample rate on certain flight control parameters in all new-manufacture Part 121, 125 and 135 aircraft. New-manufacture Part 91 aircraft and older Part 121 aircraft would require retrofitting to that standard by 2012. 

In disagreement, the NTSB moved the status of this item to unacceptable in furtherance of its belief that cockpit imaging systems would provide invaluable information during future accident investigations, especially in those involving smaller turbine powered aircraft. Several flight data recorder manufacturers are either developing or have produced lightweight cockpit imaging systems, which the board hopes will find voluntarily acceptance by the industry.

The status of the remaining two perennial issues on the board's aviation safety most wanted list-reducing dangers to aircraft flying in icing conditions and reducing accidents and incidents caused by human fatigue in the aviation industry-remains at “unacceptable response.” The NTSB has called for upgraded icing certification standards that specifically take into account the effects of several icing conditions such as freezing rain, freezing drizzle and supercooled large droplets, in icing testing procedures. By mid-year, the FAA expects to issue-for transport-category airplanes-a proposed rule that will take into account large drop icing conditions. “The aircraft doesn't know whether it's a Part 91 or Part 121 or Part 135 operation, it doesn't care,” said Hersman. “The ice is going to treat it the same and the risk to the people on board is still the same.”

The Board has issued several recommendations on fatigue relating to working hours for flight crews, air traffic controllers and maintenance personnel, and the FAA has said it expects to issue a new proposed rule on crew fatigue management later this year, a time frame that has slipped twice already. The agency is also working with the National Air Traffic Controllers Association to develop an effective fatigue risk management system for its members. In the case of maintenance technicians, the FAA believes it can satisfy the NTSB's recommendation through the sponsoring and support of educational programs and training in fatigue management, rather than by the rulemaking process.