Wish Lists

The U.S. National Transportation Safety Board (NTSB) has included improving the safety of public helicopter operations, preventing loss of control–in flight accidents in general aviation and strengthening procedural compliance among commercial air transport pilots on its Most Wanted List for 2015. On an annual basis, NTSB updates its list of the top 10 areas that need safety improvements.

“The Most Wanted List is our roadmap for 2015,” said NTSB Acting Chairman Christopher A. Hart, in releasing the list on Jan. 13. “We want it to be a roadmap for policy makers and legislators as well. These are safety improvements for which the time is ripe for action.” In addition to aviation, the list covers safety issues concerning rail transportation, trucking and other surface transportation, and mass transit.

The Transportation Safety Board (TSB) of Canada recently updated its Watchlist of issues that it says pose the greatest risk to Canada’s marine, rail and air transportation sectors. The Watchlist for 2014, released in late November, includes the risk of collisions on runways and approach and landing accidents (ALAs) as air ­transportation–specific issues, and safety management and oversight as a multi-modal issue.

“Our role at the TSB is to shine a spotlight on the areas where strong action must be taken by the regulator and transportation industry officials, and our evidence is found in hundreds of accident investigations, thousands of hours of research, and dozens of TSB recommendations,” said Kathy Fox, chair of the TSB. The Watchlist is updated every two years.

Helicopter operations were first added to NTSB’s Most Wanted List in 2014. At the time, NTSB said that between January 2003 and May 2013, there had been 1,470 helicopter accidents, with 477 fatalities and 274 serious injuries.

In focusing this year specifically on the safety of helicopters operated by federal, state and local governments, NTSB said it has investigated more than 130 accidents involving such operations since 2004. In these accidents, involving emergency medical services, law enforcement support, and search and rescue and other missions, 50 people were fatally injured and 40 more were seriously injured. In outlining its concerns, NTSB cited three specific accidents, including the crash of an Alaska Department of Public Safety helicopter in March 2013 (see “Punitive Culture”), in which the pilot accepted and attempted to complete the mission even when faced with poor weather at night. All three helicopters crashed before reaching their destinations, killing a total of nine people.

NTSB said that “because public operator safety is not generally governed by Federal Aviation Administration (FAA) regulations, a safety net does not necessarily exist; the safety decisions and programs are solely the responsibility of public operators.” NTSB cited a number of actions that could be taken to improve public helicopter operations safety, including: developing and implementing safety management systems that include sound risk management practices, particularly flight-risk evaluation programs and formalized dispatch and flight-following procedures; implementing best practices for flight crews that include scenario-based training and fatigue management; developing and implementing training scenarios that expose pilots to inadvertent flight into instrument meteorological conditions; installing radio altimeters, night vision imaging systems and terrain awareness and warning systems; and installing crash-resistant flight recorder systems in all aircraft.

While noting that airline accidents have become relatively rare in the United States, NTSB said that “pilots and passengers involved in general aviation (GA) operations still die at alarming rates every year due to loss of aircraft control by the pilot.” Between 2001 and 2011, more than 40 percent of all fixed-wing GA fatal accidents occurred because pilots lost control of their airplanes, NTSB said, adding that statistically, approach to landing, maneuvering and climb are the deadliest phases of flight for loss of control accidents. Also, NTSB said that GA pilot proficiency requirements are much less rigorous than those of airline pilots and that GA pilots are more likely to have longer intervals between training sessions and longer intervals between flights.

NTSB recommends that pilots avoid conditions that can lead to an aerodynamic stall, especially situations involving a critical angle-of-attack and/or an unplanned decrease in airspeed. Also, pilots should seek training to ensure that they fully understand stall phenomena. They should be prepared to recognize the warning signs of an impending stall and to apply appropriate recovery techniques; be honest with themselves about their knowledge of stalls and their ability to recognize and handle them; manage distractions so that they do not interfere with situational awareness; and understand, properly train and maintain currency in the equipment they operate. NTSB also said airplane owners should consider installing an angle-of-attack indicator.

GA also was on NTSB’s 2014 list, with the focus on identifying and communicating hazardous weather, and, in one form or another, on every list that NTSB has issued since 2011.

New to NTSB’s list in 2015 is strengthening procedural compliance, which can be done by rooting out inadequate company procedures, ensuring comprehensive training, and reemphasizing and reinforcing flight crew compliance. In 2013, there were two major controlled flight into terrain (CFIT) accidents in the United States in which crews did not follow company procedures: One was Asiana Airlines Flight 214, which struck a seawall just short of a runway at San Francisco International Airport in July 2013; and the other was UPS Flight 1354, which crashed on approach to Birmingham (Alabama, U.S.)–Shuttlesworth International Airport in August 2013 (see “False Expectations”).

Over the past 10 years, NTSB has investigated more than a dozen airline or commuter/on-demand operator accidents involving procedural, training and compliance issues. “Such accidents can be prevented through collaborative efforts by crews, operators and the regulator,” NTSB said. “Working together, they can develop effective procedures and training, and ensure that crews do what they are trained to do.”

NTSB said it has made recommendations that would strengthen compliance by ensuring that air carrier procedures are adequate, that air carriers adequately train pilots on those procedures and that flight crews follow those procedures, but FAA and industry still have work to do.

In addition to the aviation-specific items on the list, NTSB also included “require medical fitness for duty,” which is applicable across transportation modes. To mitigate the risk of medical conditions and treatments that impair transportation professionals’ performance, NTSB said it has made recommendations for a comprehensive medical certification system for safety-critical personnel.

The TSB’s Watchlist comprises eight items, including two that are specific to aviation and another that is considered multi-modal. According to TSB, there is an ongoing risk of aircraft colliding with vehicles or other aircraft on the ground at Canada’s airports. Operations at airports require aircraft and vehicles to move between ramps, taxiways and runways, and this movement sometimes creates conflicts between aircraft, or between aircraft and vehicles. In the 10 years from 2004 through 2013, there were 4,153 of these conflictions, or runway incursions, in Canada.

TSB said it first placed this issue on its Watchlist in 2010, but the number of occurrences has remained too high (Figure 1). The board noted that there are ongoing efforts by industry and the regulator to share data and to improve local airport procedures, but that more leadership on the issue is required from Transport Canada. “In particular, few new technological defences have been seriously considered or implemented in Canada,” TSB said. “The Board remains concerned that incursions and the risk of collisions will continue until better defences are put in place. Improved procedures and enhanced collision warning systems must be implemented at Canada’s airports.”

From 2009 to 2013, Canadian-registered aircraft were involved in an average of 150 ALAs each year, of which 6 percent were runway-overrun accidents. Operators, regulators and air navigation service providers need to take more action to prevent ALAs and to minimize the rise of adverse consequences if a runway overrun occurs, TSB said. It noted that stable approaches may significantly increase the chances of a safe landing, but without improvements in stable-approach policy compliance, most unstable approaches will continue to a landing. Also, because pilots must calculate landing distances required, they need timely and accurate runway surface condition information.

When an overrun does occur, it is important that there be an adequate runway end safety area (RESA), TSB said, noting that at some airports, RESAs have not been implemented. “There is currently no requirement in Canada requiring runways to meet international standards and recommended practices for safety areas,” TSB said.

ALAs were first added to the Watchlist in 2010, and there has been some progress on the issue since then. Some airports have improved runway surfaces and safety areas, and NAV CANADA has taken measures to improve runway surface condition reporting for pilots. It also provides guidance for stabilized approaches. Also, Transport Canada is conducting a risk-based analysis to revise its RESA standards.

TSB said Transport Canada and operators must do more to reduce the number of unstable approaches that continue to landing; Transport Canada must complete its risk-based analysis and move forward with regulatory changes; and airports must develop tailored solutions to lengthen RESAs or install other engineered systems and structures to safely stop airplanes that overrun runways.

On the issue of safety management and oversight, TSB said Transport Canada must implement regulations requiring all operators in the aviation and marine industries to have formal safety management processes, and must oversee these processes. Companies that do have safety management systems must demonstrate that the systems are working. When companies are unable to effectively manage safety, Transport Canada must not only intervene, “but do so in a manner that succeeds in changing unsafe operating practices,” TSB said.