US crash investigators most wanted list!

Aviation safety doesn’t just happen. It’s hard-won, composed of lessons learned from accidents and incidents. Its’ the job of the U.S. National Transportation Safety Board, one of the smallest yet hardest-working organizations in Washington, D.C., to chronicle what goes wrong when an airplane crashes and issue recommendations to fix the problems.

The Safety Board just issued its ‘Most Wanted’ list for 2016, improvements aimed at making almost all modes of transportation safer. As often happens, aviation concerns either led, or were near the top of, the list. At least five of the ten ‘Most Wanted’ improvements are related to commercial aviation. The NTSB wants U.S. regulators to:

Require medical fitness for duty
NTSB says, “When safety-critical personnel, such as public vehicle operators (in many cases that means pilots) have untreated medical conditions that prevent them from doing their jobs effectively, people can be seriously injured or die.” 

The Safety board cites a case in which a FedEx Boeing 727 cargo jet flew into the ground while on approach to Tallahassee, Florida “because the pilot had a severe color vision deficiency which made it difficult for him to correctly identify the color of the airport’s PAPI lights that were warning him the flight was too low.” Three people were injured in the crash.

NTSB recommends a comprehensive medical certification system for safety-critical transportation personnel that includes—among other things—a complete medical history taken at prescribed intervals that includes medications, conditions and treatments as well as physical exams; and an exam to identify personnel at high-risk for sleep disorders. 

End substance abuse in transportation
The Safety Board says, “Our new reality” is that drugs or alcohol can affect the ability to operate any vehicle, including aircraft. NTSB recently studied drug use among all fatally-injured pilots. What it found was sobering: “The prevalence of potentially impairing drugs increased from an average of 11 percent of fatally-injured accident pilots during the period from 1990-1997 to an average of 23 percent of accident pilots during the period 2008-2012…The most commonly found impairing substance was diphenhydramine, a sedating antihistamine found in over-the-counter medications.”

As to what can be done, the Safety Board concedes, “Unfortunately, for most drugs, the relationship between the amount consumed and crash risk is not well understood. We need more and better data to better understand the scope of the problem and the effectiveness of countermeasures.” 

Expand the use of recorders to enhance transportation safety
Stating flat-out that “no single tool has helped determine what went wrong [in an accident] more than recorders,” NTSB recommends the use of cockpit image recorders—not merely voice and flight data reorders. Noting that in a crash “data and/or voice recorders may have been present. But some questions could have been answered only through the data provided by an image recorder. Image recorders can help fill in the gaps.”

This isn’t a new recommendation on the part of the Safety Board. Previous suggestions that video recorders be installed in the cockpits of airliners have been met with opposition among some pilots.

Strengthen occupant protection
The Safety Board says it’s investigated “many accidents where improved occupant protection systems…could have reduced injuries and saved lives.” 

The 2013 crash of an Asiana Boring 777 at San Francisco International illustrates the issue, where “a lack of restraint use led to some tragic consequences.” NTSB says, “While 99 percent of passengers survived…two of the three fatally injured passengers were ejected from the airplane because they were unrestrained.”

The Safety Board is especially keen to see improvements in rules regulating child restraint. Ironically, “While we are required to secure our luggage and even small items such as snacks and beverages during takeoff and landing, the [U.S.] Federal Aviation Administration exempts the most vulnerable passengers—children underage two—allowing them to travel unrestrained, or on an adult’s lap.”

The Safety Board wants to see increased use of existing restraint systems, systems that “preserve survivable space and ensure ease of evacuation.”

Reduce fatigue-related accidents
Fatigue can have terrible consequences. “Nearly 20 percent of the 182 major NTSB investigations [of accidents affecting all modes of transportation] completed between January 1, 2001 and December 31, 2012 identified fatigue as a probable cause, contributing factor or finding.” One of the most glaring instances was the August 14, 2013 crash of a UPS A300 cargo aircraft at Birmingham, Alabama. Both the captain and first officer died.

As to what can be done, the Safety Board says, “Over the past three decades a great deal of research has been done. But research only goes so far; we must implement what we have learned.”

Lessons that were hard-won indeed.