‘Most Wanted’ Transportation Safety Improvements Languishing in Bureaucratic Swamp of Inactivity

It is that time of year when the agency responsible for conducting aviation accidents reveals its utter impotence at influencing real change. On 13 January 2016 the National Transportation Safety Board (NTSB) held its annual press conference announcing its “Most Wanted” list of aviation safety improvements. Since the NTSB issues recommendations, the “Most Wanted” list, as in years past, is likely to be slow-rolled, ignored or rejected outright by the Federal Aviation Administration (FAA).

It is time to consider an approach that would put real heat on the FAA.

The NTSB declares its “Most Wanted” list features “critical changes needed to reduce transportation accidents and save lives.” Note use of the word “critical”. The NTSB really wants its “Most Wanted” recommendations translated into regulatory action that would compel long overdue changes.

As NTSB Chairman Christopher Hart said at the press conference: “For more than 25 years, we have issued our Most Wanted List to help spur action on these unimplemented recommendations. Our Most Wanted List is our roadmap from lessons learned to lives saved.” (See http://www.ntsb.gov/news/speeches/CHart/Pages/hart_20160113.aspx)


NTSB Chairman Christopher Hart

NTSB Chairman Christopher Hart

But, given the frustrating history of Most Wanted recommendations — either languishing in the bureaucratic backwaters of the FAA or rejected outright — the “roadmap” delineates for the NTSB the triumph of hope over experience. Each year the NTSB issues its Most Wanted list of transportation safety improvements, and each year the regulators continue their stately deliberations and inaction. (NTSB Unveils 2016 Most Wanted List, Stresses Technology, see www.ntsb.gov/Safety/MWL/Pages/default.aspx)

For 2016, the Most Wanted recommendations for aviation include:

Reduce Fatigue-Related Accidents

The NTSB said:

“Human fatigue affects the safety of the traveling public in all modes of transportation. Twenty percent of the 182 major NTSB investigations completed between 2001 and 2012 identified fatigue as a probably cause, contributing factor, or a finding. Combating fatigue requires a comprehensive approach focused on research, education and training, technologies, treatment of sleep disorders, hours-of-service regulations, and on- and off-duty scheduling policies and practices.” (See www.ntsb.gov/mostwanted)

Not said is that pilot commuting from home to the base station does not factor into hours of service. Yet such commuting can include a fatiguing cross-country trip prior to the assumption of duty.


Fatigue remains a major issue

Fatigue remains a major issue

The NTSB has a whopping total of 29 aviation-related recommendations in this category of “Most Wanted” items. Here are a few recommendations with, so far, an unacceptable response from the FAA:

“Require all … Part 121, 135, and 91 subpart K operators [scheduled airline, non-scheduled transport category, and general aviation] to address fatigue risks associated with commuting [to the departure airfield], including identifying pilots who commute, establishing policy and guidance to mitigate fatigue risks … and developing or identifying rest facilities for commuting pilots.” (Under current regulations, pilots can commute across the country and assume their flying duty without rest.)

“Establish duty-time regulations for maintenance personnel working under … Parts 121, 135, 145 and 91 subpart K that take into consideration factors such as start time, workload, shift changes, adequate rest time, and other factors …” (Under current regulations, there is nothing to prevent an aircraft mechanic from undertaking two back-to-back 8 hour shifts.)

“Expedite rule-making which would make flight time and duty time limitations, and rest requirements for commuter air carriers the same as those specified for domestic air carrier crew members under [Part] 121 [the scheduled airlines].” (This is an especially galling loophole given that commuter airlines are often painted in the livery of the scheduled airlines with home they are partnered, with only a small sign on the fuselage denoting the commuter airline with which the passenger is actually flying.)

“Expedite the development and implementation of the air traffic controller performance assessment program … to detect and alleviate stress and fatigue among controllers.”

Maybe the FAA would have responded positively if senior FAA managers were required to put in the allowable hours now permitted for pilots, mechanics and air traffic controllers.

Disconnect From Deadly Distractions

The NTSB declared:

“Since 2003, the NTSB has found PED [personal electronic device] distraction as a cause or contributing factor in accidents across all modes of transportation. A cultural change is needed for drivers and operators to disconnect from deadly distractions. In regulated transportation [such as aviation], the strict rules minimizing the threat of distraction must be embraced by every operator on every trip. Removing unnecessary distractions is the first step in safely operating any vehicle.”

The NTSB has five recommendations in “Most Wanted” status. Below, a recommendation that is typical of the lot and is in “unacceptable response” limbo:

“Require … operators to incorporate explicit guidance to pilots, including checklist reminders as appropriate, prohibiting the use of personal portable electronic devices on the flight deck.”

Prevent Loss of Control in Flight for General Aviation

The NTSB lamented that:

“While airline accidents have become relatively rare in the United States, pilots and passengers involved in general aviation still die at alarming rates. Between 2008 and 2014, about 47 percent of fatal fixed-wing GA accidents in the U.S. involved pilots losing control of their aircraft in flight, resulting in 1,210 fatalities. Pilots can reduce these accidents through education, technologies, flight currency, self-assessment, and vigilant self-awareness in the cockpit.”

It should be noted that “self-assessment” and “vigilant self-awareness” are notoriously unreliable means for a pilot to avoid loss of airplane control. Involvement in unusual attitude recovery training can help sensitize a pilot to the subtle indicators of imminent loss of control, but such training in recovery from unusual attitudes is not required.

To be sure, the difference between accident rates for scheduled airlines (where the piloting is performed by company employees) and non-scheduled general aviation (in which aircraft owners do their own piloting) is truly shocking. According to the latest NTSB statistics, general aviation accidents occur in the U.S. at an average rate of three per day in 2013 — the most recent year for which the NTSB has compiled statistics. Fatal accidents occur in general aviation on average about once every two days, totaling nearly 400 deaths in 2013.


On average, one person is killed every single day in general aviation (Part 91)

On average, one person is killed every single day in general aviation (Part 91)

In contrast, commercial airline accidents occurred in 2013 at an average rate of one every two weeks. The table below summarizes the stark difference:

Accident Summary 2013

Segment Total hours Accidents Fatal accidents Fatalities
Part 121, scheduled airlines 18 million flight hours 23 2 9
Part 91, general aviation 20 million flight hours 1,224 222 390
Source: NTSB Aviation Data & Stats, www.ntsb.gov/investigations/data/Pages/AviationDataStats.aspx

The difference between Part 121 and Part 91 accidents is no anomaly for 2013. Year after year, the same difference — 50 times more accidents in Part 91, same roughly comparable flying hours — reflects unbelievable mayhem in general aviation.

Despite the continuing bloodshed, the FAA has been sluggish in responding to 14 NTSB “Most Wanted” recommendations. The examples below indicate the NTSB recommendations have been paid in blood, are modest and implementable, but the FAA remained unmoved. Thirteen of the 14 recommendations remain in an “Open” classification , in many cases “Open — Unacceptable Response”,  while the 14th recommendation is classified as “Closed — Unacceptable Action”. The FAA’s record in this area is frankly unbelievable:

“Revise airman knowledge tests to include questions regarding electronic flight and navigation displays … and the interpretation of malfunctions and aircraft attitudes.”

“For pilots holding a private, commercial, or airline transport pilot certificate in the airplane category who do not receive recurrent instrument training, add a specific requirement that the biennial flight review include a demonstration of control and maneuvering of an aircraft solely by reference to instruments, including straight and level flight, constant airspeed climbs and descents, turns to a heading, and recovery from unusual flight attitudes.”

“(I)nclude a certification standard that will ensure safe handling qualities in the yaw axis throughout the flight envelope, including limits for rudder pedal sensitivity.”

End Substance Impairment in Transportation

Alcohol and drugs affect one’s ability to drive a truck or pilot an airliner. According to the NTSB, more and better data will contribute to understanding the scope of the problem and the effectiveness of countermeasures.

In this category, the NTSB has 11 aviation-related recommendations in which the FAA response has been to slow-roll implementation or reject the idea outright.

Among the NTSB’s modest proposals:

“Require commercial operators to collect … toxicological specimens from surviving crewmembers involved in … aircraft incidents or accidents.”

“Review the research and literature on the potential effects on pilot performance of both licit and illicit drugs, in both therapeutic and abnormal levels, and use that to develop and actively disseminate to pilots usable guidelines on potential drug interactions with piloting ability.”

Require Medical Fitness for Duty

When safety-critical personnel have untreated or undiagnosed medical conditions preventing them from doing their job safely, people can be injured or die. The NTSB wants comprehensive medical certification to ensure that safety-critical personnel are medically fit for their duty.


  Safety-critical personnel must be certifiably fit for duty

Safety-critical personnel must be certifiably fit for duty

The NTSB has nine specific aviation-related recommendations in the “Most Wanted” category regarding medical fitness for duty. These recommendations are “open” or “closed” with either an unacceptable response from the FAA or no response has been received from the FAA. Among the NTSB recommendations:

“Develop a standard battery of tests … that would prevent applicants with color vision deficiencies that could impair their ability to perform color-related critical aviation tasks from being certificated without limitations.”

“Implement a program to identify pilots at high risk for obstructive sleep apnea and require those pilots provide evidence … of having been appropriately evaluated and, if treatment is needed, effectively treated for that disorder before being granted unrestricted medical certification.”

“Revise the current … guidance on issuance of medical certification subsequent to ischemic stroke or intracerebral hemorrhage to ensure that it is … includes specific requirements for a neuropsychological evaluation and the appropriate assessment of the risk of recurrence or other adverse consequences subsequent to such events.”

Strengthen Occupant Protection

The NTSB declared that improved occupant protection could have saved lives and reduced injuries. Needed improvements include increased use of restraint systems and better design of occupant protection that preserves survivable space while ensuring speedy evacuation.


The worst way to ensure the safety of infants, holding them in a parent's lap

The worst way to ensure the safety of infants, holding them in a parent’s lap

The NTSB has a total of 16 aviation-related “Most Wanted” recommendations in this category. One of these recommendations concerns unrestrained “lap infants” and the need for these occupants to be in their own safety seats. This initiative has been supported by independent child safety experts for years, but the recommendation languishes in the bureaucratic swamp of inaction. Improved occupant protection involves modest costs, the methods of accomplishing it are well understood, yet the FAA does nothing.

Below, a sampling of unrequited NTSB “Most Wanted” recommendations:

“Amend … Parts 121 [scheduled airlines] and 135 [nonscheduled airlines] to require each person who is less than 2 years of age to be restrained in a separate seat position by an appropriate child restraint system during takeoff, landing, and turbulence.” (It should be noted that the FAA currently requires all galley equipment to be secured during these periods of flight. Coffee pots are restrained; infants are not.)

“Explore the feasibility of requiring, on a retrofit basis, non-injurious handholds on the back risers of aisle seats in order to provide an immediate form of restraint for standing persons.”

“Require operators of transport-category helicopters to equip all passenger seats with restraints that have an appropriate release mechanism that can be released with minimal difficulty under emergency conditions.”

The NTSB recommendations regarding occupant protection are modest, doable and affordable, yet the FAA rejects them.

Expand Use of Recorders to Enhance Transportation Safety

Investigators must have an accurate picture of an accident in order to help prevent future catastrophes. No tool has been more helpful at determining what went wrong than recorders, yet certain categories of aircraft are still not equipped with these critical technologies.


The 'black box' is actually orange

The ‘black box’ is actually orange

The NTSB has an astonishing 49 outstanding aviation-related recommendations in this category. Most are classified “unacceptable response” from the FAA. Below, a sampling of the NTSB’s frustration:

“(R)equire all turbine-powered, non-experimental, non-restricted-category aircraft that have the capability of seating six or more passengers to be equipped with an approved 2-hour cockpit voice recorder that is operated continuously from the start of the use of the checklist (before starting engines for the purpose of flight), to completion of the final  checklist at the termination of the flight.”

“Do not permit exemptions or exceptions to the flight recorder regulations that allow transport-category rotorcraft to operate without flight recorders, and withdraw the current exemptions and exceptions that allow transport-category rotorcraft to operate without flight recorders.”

“Require all existing turbine-powered … aircraft that are not equipped with a flight data recorders … to be retrofitted with a crash-resistant flight recorder system. The … recorder system should record cockpit audio C197, ‘Information Collection and Monitoring Systems’.” (This recommendation requires the installation of cockpit imaging systems, which the FAA and its industry allies have stoutly resisted.)

“Require that all aircraft used in extended overwater operations and operating under … Part 121 or Part 135 … be equipped with a tamper resistant method to broadcast to a ground station sufficient information to establish the location where an aircraft terminates flight as the result of an accident within 6 nautical miles of the point of impact.” (This recommendation is a direct result of the disappearance of Malaysian Airlines flight MH370 in March 2014.)

The NTSB is not the only investigative agency frustrated at the lack of progress in implementing necessary, modest and well within state-of-the-art recommendations. For example, in its January 2016 report on the fatal fertilizer explosion in West, Texas in 2013, the Chemical Safety and Hazard Investigation Board (CSB) recalled an earlier recommendation:

” ‘Revise the Accidental Release Prevention Requirements … to explicitly cover catastrophic reactive hazards [specifically, fertilizer grade ammonium nitrate storage practices] that have the potential to seriously impact the public, including those resulting from self-reactive chemicals …’ ”

“Unfortunately, EPA has not issued rulemaking consistent with CSB’s recommendation more than 10 years since its issuance. Therefore, CSB has categorized the status of this recommendation as ‘Open — Unacceptable Response’ “. (CSB Investigation Report, West Fertilizer Company Fire and Explosion, Report 2013-02-I-TX, page 192; see www.csb.gov/assets/1/7/West_Fertilizer_FINAL_Report_for_website.pdf)

The NTSB is not alone in facing foot-dragging and excuse-prone resistance from agencies responsible for assuring the safety of the public.

In the case of the NTSB’s yet-to-be-enacted transportation safety recommendations, the course outlined below seems reasonable and overdue:

The NTSB forwards its 2016 “Most Wanted” safety recommendations — 133 for aviation alone — to the Transportation & Infrastructure Committee of the U.S. House of Representatives.

  • Committee Chairman Bill Shuster (PA-R) convenes a hearing.
  • At the hearing, NTSB officials testify as to why recommendations are on the “Most Wanted” list.
  • At the hearing, FAA officials must explain their languid activity, under oath.
  • Where explanations are wanting, Congress enacts legislation requiring the FAA to act.

Follow-up hearings would be held to document FAA compliance with the Congressional directives. Where reasonable progress is lacking, Congress votes “no confidence” in the head of the FAA and his immediate subordinates. These individuals would be denied performance bonuses. The list of said persons to be forwarded to the White House with a statement that such persons will not be approved by Congress for re-appointment or promotion.

Guaranteed, in this regime, the “Most Wanted” safety recommendations would receive positive attention in a suddenly fully-attentive FAA.

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