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    LIMITATIONS OF “SEE AND AVOID” CONCEPT AND DISTRACTED AIR TRAFFIC CONTROLLER LED TO MID-AIR COLLISION OVER HUDSON RIVER, NTSB DETERMINES

    National Transportation Safety Board
    Washington, DC 20594
    FOR IMMEDIATE RELEASE: September 14, 2010
    SB-10-37

    The National Transportation Safety Board today determined that the probable cause of last year’s midair collision over the Hudson River that resulted in the deaths of all nine persons aboard the two aircraft were the inherent limitations of “see-and-avoid” concept and a Teterboro Airport air traffic controller’s nonpertinent telephone conversation at the time of the collision. The see-and-avoid technique of averting mid-air collisions was not effective because of the difficulty the airplane pilot had in seeing the helicopter until the final seconds before the collision. In addition, the Teterboro Airport local controller engaged in a personal telephone conversation, which distracted him from his air traffic control duties, including the timely transfer of communications for the accident airplane to the Newark Liberty International Airport (EWR) tower and correcting the airplane pilot’s incorrect read-back of the EWR tower frequency.

    The Safety Board met today in a five-hour public meeting to determine the probable cause of the accident and issued five recommendations to the Federal Aviation Administration for improving the safety of the national airspace, and in particular, the airspace over the Hudson River near New York City. The Safety Board noted that contributing to the cause of the accident were the ineffective use by both pilots of their aircrafts’ electronic advisory system to maintain awareness of other air traffic, FAA’s procedures for transfer of communications among air traffic facilities near the Hudson River, and FAA regulations that did not provide for adequate vertical separation of aircraft operating over the Hudson River.

    On August 8, 2009, a Piper PA-32R-300 airplane, N71MC, and a Eurocopter AS350BA helicopter, N401LH, operated by Liberty Helicopters, collided over the Hudson River near Hoboken, New Jersey. The airplane flight was operating under the provisions of 14 Code of Federal Regulations (CFR) Part 91, with a pilot and two passengers. The helicopter flight, which carried a pilot and five passengers, was conducting an air tour of the area under the provisions of 14 CFR Parts 135 and 136. No flight plans were filed or were required for either flight, and visual meteorological conditions prevailed at the time of the accident.

    “This collision could have been prevented,” NTSB Chairman Deborah A.P. Hersman said. “While traffic alerts go a long way in helping pilots “see and avoid” other aircraft, these technologies are not, in and of themselves, enough to keep us safe. Strong operating procedures, professionalism, and commitment to the task at hand – these are all essential to safety.”

    As a result of the accident investigation, the NTSB made recommendations to the FAA regarding changes within the special flight rules area (SFRA) surrounding the Hudson River corridor; vertical separation among aircraft operating in the Hudson River SFRA; see-and-avoid guidance; and helicopter electronic traffic advisory systems.

    A synopsis of the Board’s report, including the probable cause, conclusions, and recommendations, is available on the NTSB’s website, at http://ntsb.gov/Publictn/2010/AAR1005.html.

    The Board’s full report will be available on the website in several weeks.

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    NTSB Release: Probable Cause of Denver Runway Accident Cited

    National Transportation Safety Board
    Washington, DC 20594

    FOR IMMEDIATE RELEASE: July 13, 2010

    Lack of Rules Requiring Dissemination of Wind Condition Data and Pilot’s Insufficient Rudder Control Cited as Probablye Cause of 2008 Denver Runway Accident

    Washington, DC – The National Transportation Safety Board today determined that the probable cause of the 2008 Continental Airlines flight 1404 runway excursion accident was the captain’s cessation of rudder input, which was needed to maintain directional control of the airplane, about 4 seconds before the aircraft departed the runway, when the airplane encountered a strong and gusty crosswind that exceeded the captain’s training and experience.

    Contributing to the accident was the air traffic control system that did not require or facilitate the dissemination of key available wind information to air traffic controllers and pilots, and inadequate cross wind training in the airline industry due to deficient simulator wind gust modeling.

    On December 20, 2008, Continental Airlines flight 1404 veered off the left side of runway 34R during a takeoff from Denver International Airport. As a result, the captain initiated a rejected takeoff and the airplane came to rest between runways 34R and 34L. There was a post-crash fire.
    All 110 passengers and 5 crewmembers evacuated the airplane immediately after it came to rest. The captain and five passengers were seriously injured.

    At the time of the accident, mountain wave and downsloping wind conditions existed in the Denver area and the strong localized winds associated with these conditions resulted in pulses of strong wind gusts at the surface that posed a threat to operations at Denver International Airport.

    “This aircraft happened to be in the direct path of a perfect storm of circumstances that resulted in an unexpected excursion in an airport with one of the most sophisticated wind sensing systems in the country,” said NTSB Chairman Deborah A.P. Hersman. “It is critical that pilots receive training to operate aircraft when high wind conditions and significant gusts are present, and that sufficient airport-specific wind information be provided to ATC controllers and pilots as well.”

    As a result of this accident the NTSB issued 14 recommendations to the Federal Aviation Administration regarding mountain waves, wind dissemination to flightcrews, runway selection, pilot training for crosswind takeoffs, and crashworthiness.

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    NTSB INVESTIGATING NEAR MIDAIR COLLISION

    National Transportation Safety Board
    Washington, DC 20594

    September 23, 2010

    NTSB INVESTIGATING NEAR MIDAIR COLLISION OVER MINNEAPOLISINVOLVING COMMERCIAL JETLINER AND SMALL CARGO AIRCRAFT

    The National Transportation Safety Board is investigating a near midair collision between a commercial jetliner and a small cargo aircraft that came within an estimated 50 to 100 feet of colliding near the Minneapolis-St. Paul Airport (MSP).

    On September 16, 2010, about 6:49 a.m. CDT, US Airways flight 1848 (AWE 1848), an Airbus 320, was cleared for takeoff on runway 30R en route to Philadelphia, Pennsylvania, carrying five crewmembers and 90 passengers. At the same time, Bemidji Aviation Services flight 46 (BMJ46), a Beech 99 cargo flight with only the pilot aboard, was cleared for takeoff on runway 30L en route to La Crosse, Wisconsin. Weather conditions at the time were reported as a 900-foot ceiling and 10 miles visibility below the clouds.

    Immediately after departure, the tower instructed the US Airways crew to turn left and head west, causing the flight to cross paths with the cargo aircraft approximately one- half mile past the end of runway 30L. Neither pilot saw the
    other aircraft because they were in the clouds, although the captain of the US Airways flight reported hearing the Beech 99 pass nearby. Estimates based on recorded radar data indicate that the two aircraft had 50 to 100 feet of vertical separation as they passed each other approximately 1500 feet above the ground.

    The US Airways aircraft was equipped with a Traffic Alert and Collision Avoidance System (TCAS) that issued climb instructions to the crew to avert collision. The Beech 99 was not equipped with TCAS and the pilot was unaware of the proximity of the Airbus. There were no reports of damage or injuries as a result of the incident.

    NTSB and FAA investigators conducted a preliminary investigation at the Minneapolis airport traffic control tower on September 18th and 19th and are continuing to review the circumstances of this incident.

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  • NTSB Chairman Opens Child and Youth Transportation Safety Initiative at Safety Seat Check Event

    National Transportation Safety Board
    Washington, DC 20594

    FOR IMMEDIATE RELEASE: January 24, 2011

    National Transportation Safety Board Chairman Deborah A.P. Hersman recently launched the agency’s initiative to promote child and youth safety across alltransportation modes, with a particular focus on educating parents and
    caregivers about ways to keep children safe when traveling. The yearlong effort was first announced at the NTSB’s forum on Child Passenger Safety in the Air and in Automobiles in December.

    At a child safety seat check event in Bristow, Virginia sponsored by the Prince William County Fire and Rescue, Chairman Hersman spoke about child passenger safety and her own plans to renew her certification as a CPS technician.

    “These community-sponsored seat checks give parents peace of mind,” Hersman said. “Every parent wants their child to be safe, so knowing that trained and knowledgeable CPS technicians are available to make sure that their child safety seats have been installed properly is invaluable to them.”

    To view the video that captured highlights of the event, please visit: www.ntsb.gov/children.

    Chairman Hersman noted that not all states have adequate child passenger safety laws. “As state legislatures begin their 2011 sessions, the NTSB is calling upon legislators to pass laws that ensure that all children up to 8 years old are using child safety and booster seats.”

    Florida, the most lenient in child passenger safety laws, requires child safety seats only for children age 3 years or younger. The laws in Arizona, South Dakota, American Samoa and Puerto Rico are only slightly more
    protective, covering children age 4 years or younger. Twelve states (Alabama, Arkansas, California, Georgia, Iowa, Louisiana, Montana, Nebraska, Nevada, New Hampshire, Oklahoma, and South Carolina) mandate child restraints for children age 5 or younger and six states (Connecticut, Idaho, Kentucky, Mississippi, New Mexico, and North Dakota) only cover children age 6 or younger.

    The issue of improving child occupant protection has been on the NTSB’s Most Wanted List of Transportation Safety Improvements since 1997.

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    NTSB STUDY SHOWS THAT AIRBAGS CAN PROVIDE OCCUPANT PROTECTION IN GENERAL AVIATION ACCIDENTS

    National Transportation Safety Board
    Washington, DC 20594

    FOR IMMEDIATE RELEASE: January 11, 2011
    SB-11-03

    Today the National Transportation Safety Board adopted a study that concluded that general aviation (GA) airplanes equipped with airbags provide additional protection to occupants in accidents involving survivable forward impacts.

    Airbags are designed to mitigate head and upper body injuries and are installed in the lap belt or shoulder harness portions of the restraint system. They were first approved for use in the pilot and co-pilot seats in GA aircraft in 2003. Currently, there are nearly 18,000 airbag- equipped seats in over 7,000 of the 224,000 GA aircraft in the United States.

    “Although airbags have been mandated in automobiles for over a decade, the aviation industry has no such requirement for small aircraft,” said NTSB Chairman Deborah A.P. Hersman. “The good news is that over 30 manufacturers have stepped up to the plate and offer airbags as standard or optional equipment.”

    The study, which examined 88 accidents involving airbag- equipped airplanes that occurred between 2006 and 2009, found no instances where the airbag caused harm in properly restrained occupants. In addition, the study found 10 survivable accidents in which the crash forces were severe enough to cause injury and/or to deploy the airbag.

    Within the group of 10 accidents, 12 occupants experienced airbag deployments, and the study found that the airbag likely mitigated injuries for two of the occupants.

    The study also noted that there were no negative consequences as a result of airbag deployments. For instance, there were no cases in which the airbags were expected to deploy but did not. Nor were there any cases that involved airbags deploying under unexpected circumstances, hindering egress, fueling post-crash fires or interfering with rescue attempts. Yet investigators did uncover some safety issues with restraint systems.

    One such issue involved the incorrect usage or adjustment of seat belts. In certain aircraft types, the seat belts in the left and right seats can become reversed, which could result in the wrong airbag being activated if only one of the seats is occupied.

    There were also concerns with optimal airbag protection for occupants whose body mass indexes (BMI) classified them as either overweight or obese (BMIs of 25 or higher). The NTSB questions whether the airbag-equipped restraints were designed and tested with the high-BMI population in mind.

    An additional finding of this study was the strong affirmation that correctly installed shoulder harness/lap belt combinations provide significantly greater protection in GA accidents than that offered by a lap belt alone. Based on an analysis of over 37,000 GA accidents, the Board concluded that the risk of fatal or serious injury was 50 percent higher when an occupant was only restrained by a lap belt as compared to the combination lap belt and shoulder harness.

    “The simplest and cheapest improvement to the safety of general aviation aircraft occupants is the mandatory installation of shoulder harnesses,” said Hersman.

    The five-Member Board voted to adopt six safety recommendations, all directed to the Federal Aviation Administration:

    1. Require manufacturers to modify restraint systems vulnerable to being used incorrectly in newly built GA airplanes and to modify restraints in existing airplanes.

    2. Revise the guidance and certification standards for restraint systems to reduce the likelihood of misuse.

    3. Modify the guidance to GA airbag manufacturers as to how they should demonstrate that an airbag design provides adequate protection for a greater range of body sizes, including very small and very large individuals.

    4. Require the retrofitting of shoulder harnesses on all general aviation airplanes that are not currently equipped with such restraints.

    5. Evaluate the feasibility of requiring airbag-equipped aircraft to capture and record crash dynamics data to determine whether the system performed as designed.

    6. Develop a system to track safety equipment, such as restraint systems, airbags, and aircraft parachutes, designed to improve crash outcomes.

    The complete safety study will be available at www.ntsb.gov in several weeks.

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    NTSB KICKS OFF YEAR-LONG EFFORT ON CHILD PASSENGER SAFETY, DEBUTS EDUCATIONAL VIDEO

    National Transportation Safety Board
    Washington, DC 20594

    FOR IMMEDIATE RELEASE: December 9, 2010

    The National Transportation Safety Board today concluded its public forum, Child Passenger Safety in the Air and in Automobiles. NTSB Chairman Deborah A.P. Hersman announced in her opening remarks that the forum marked the beginning of a year-long effort by the Board to promote child passenger safety across all modes of transportation.

    “Safety for our smallest travelers should not be considered optional or a luxury,” said Chairman Hersman.

    As part of the NTSB’s safety advocacy efforts, a short video focusing on the importance of properly securing children in cars and on airplanes was debuted at the start of the forum. The full video is now at www.ntsb.gov/children, as well as two shorter versions – one focused on highway safety and one focused on aviation safety. All three versions soon will be available in Spanish.

    “The laws of physics don’t change, whether you are on an airplane or in an automobile,” said Chairman Hersman. “Children rely on their parents to know what is safest for them. The purpose of our forum was to make sure that parents have the information to do the right thing.”

    Chairman Hersman also noted that 18 other states, as well as American Samoa and Puerto Rico, should amend their existing booster seat laws to reflect the Safety Board’s longstanding recommendation.

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