Aviation News, Headlines & Alerts
 
Category: <span>NTSB Advisory</span>

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NTSB Issues 9 New Safety Recommendations

NTSB Issues Nine New Safety Recommendations as a Result of Its Investigation of the 8/26/2011 Crash of a Eurocopter AS350 B2 Near Mosby, Missouri

May 6, 2013 The National Transportation Safety Board Issues the Following Recommendations to the Following Organizations:

  • Prohibit flight crewmembers in 14 Code of Federal Regulations Part 135 and 91 subpart K operations from using a portable electronic device for nonoperational use while at their duty station on the flight deck while the aircraft is being operated. (A-13-007)
  • Require all 14 Code of Federal Regulations Part 121, 135, and 91 subpart K operators to incorporate into their initial and recurrent pilot training programs information on the detrimental effects that distraction due to the nonoperational use of portable electronic devices can have on performance of safety-critical ground and flight operations. (A-13-008)
  • Require all 14 Code of Federal Regulations Part 121, 135, and 91 subpart K operators to review their respective general operations manuals to ensure that procedures are in place that prohibit the nonoperational use of portable electronic devices by operational personnel while in flight and during safety-critical preparatory and planning activities on the ground in advance of flight. (A-13-009)
  • Inform pilots of helicopters with low inertia rotor systems about the circumstances of this accident, particularly emphasizing the findings of the simulator flight evaluations, and advise them of the importance of simultaneously applying aft cyclic and down collective to achieve a successful autorotation entry at cruise airspeeds. (A-13-010)
  • Revise the Helicopter Flying Handbook to include a discussion of the entry phase of autorotations that explains the factors affecting rotor rpm decay and informs pilots that immediate and simultaneous control inputs may be required to enter an autorotation. (A-13-011)
  • Require the installation of a crash-resistant flight recorder system on all newly manufactured turbine-powered, nonexperimental, nonrestricted-category aircraft that are not equipped with a flight data recorder and a cockpit voice recorder and are operating under 14 Code of Federal Regulations Parts 91, 121, or 135. The crash-resistant flight recorder system should record cockpit audio and images with a view of the cockpit environment to include as much of the outside view as possible, and parametric data per aircraft and system installation, all as specified in Technical Standard Order C197, “Information Collection and Monitoring Systems.” (A-13-012)
  • Require all existing turbine-powered, nonexperimental, nonrestricted-category aircraft that are not equipped with a flight data recorder or cockpit voice recorder and are operating under 14 Code of Federal Regulations Parts 91, 121, or 135 to be retrofitted with a crash-resistant flight recorder system. The crash-resistant flight recorder system should record cockpit audio and images with a view of the cockpit environment to include as much of the outside view as possible, and parametric data per aircraft and system installation, all as specified in Technical Standard Order C197, “Information Collection and Monitoring Systems.” (A-13-013)

    To Air Methods Corporation:

  • Expand your policy on portable electronic devices to prohibit their nonoperational use during safety-critical ground activities, such as flight planning and preflight inspection, as well as in flight. (A-13-014)
  • Revise company procedures so that pilots are no longer solely responsible for nonroutine operational decisions but are required to consult with the Air Methods Operational Control Center for approval to accept or continue a mission when confronted with elevated risk situations, such as fuel-related issues and unplanned deviations. (A-13-015)

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NTSB Safety Recommendations


The NTSB issued 10new recommendations, including five to the FederalAviation Administration, three to the Flight Test Safety Committee, and the following two recommendations to Gulfstream
Aerospace Corporation:

A-12-62
Commission an audit by qualified independent safety experts, before the start of the next major certification flight test program, to evaluate the company’s flight test safety management system, with special attention given to the areas of weakness identified in this
report, and address all areas of concern identified by the audit.

A-12-63
Provide information about the lessons learned from the implementation of its flight test safety management system to interested manufacturers, flight test industry groups, and other appropriate parties.

Safety Recommendations


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NTSB Warns Old Weather Data on Pilot Displays Can Contribute to Plane Crashes

The NTSB has sent out a safety alert concerning weather information that is up to twenty minutes old, although it may be advertised as real time data. The discrepancy in time can be fatal when weather conditions are in rapid flux. The NTSB has related this old weather information to two recent crashes that occurred at night:

  • March 2010 med-evac helicopter Tennessee crash where the pilot was racing to home base trying to beat a storm
  • December 2011 Piper PA-32 Bryan Texas where the plane broke up in stormy weather.

In both these crashes, “the time stamps indicated the one-minute time interval used to create the image, and not the actual age of the data used to create the image.”

The Tennessee crash involved information five minutes old; the Texas crash involved information six to eight minutes old.

The night crashes in particular are affected by old data. Pilots need to be aware that the data can be old, and not use the weather display to navigate around bad weather.


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NTSB Safety Recommendations

National Transportation Safety Board
Washington, DC 20594

April 10, 2012

The National Transportation Safety Board makes the following
recommendations to the Reno Air Racing Association:

Require aircraft owners, as a condition of eligibility to
participate in the Reno National Championship Air Races, to
provide an engineering evaluation that includes flight
demonstrations and analysis within the anticipated flight
envelope for aircraft with any major modification, such as
to the structure or flight controls. (A-12-13)

Evaluate the design of the unlimited class course and safety
areas to minimize maneuvering near and potential conflicts
with spectators; if warranted by the results of the
evaluation, implement changes to the race course. (A-12-14)

Take the following actions to raise the level of safety for
spectators and personnel near the race course: (1) relocate
the fuel truck away from the ramp area and (2) in front of
any area where spectators are present, install barriers more
substantial than those currently in place. (A-12-15)

Provide high g training to pilots, including techniques to
mitigate the potential effects of high g exposure, as part
of preparations before the Reno National Championship Air
Races (NCAR) and during daily briefs at the NCAR. (A-12-16)

Evaluate the feasibility of requiring pilots to wear g suits
when racing at the Reno National Championship Air Races; if
the evaluation determines it is feasible, implement a
requirement. (A-12-17)


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NTSB Safety Recommendation A-12-7


The National Transportation Safety Board makes the following recommendation to the Federal Aviation Administration:

Require repetitive inspection of Engine Components, Inc. cylinder assemblies produced between May 2003 and October 2009 (serial numbers 7709 through 52884) installed on Teledyne Continental Motors model 520 and 550 engines and removal of these cylinder assemblies once they reach the engine manufacturer’s recommended normal time (hours) in service between overhauls. (A-12-7)


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Kotaite Lecture on the Future of Aviation Safety

National Transportation Safety Board Chairman Deborah A. P. Hersman delivered the 8th Annual Assad Kotaite Lecture last evening at the International Civil Aviation Organization (ICAO) Headquarters in Montreal, Quebec, Canada. Hosted by the Montreal Branch of the Royal Aeronautical Society, the annual lecture is a tribute to Dr.Assad Kotaite, former Secretary General of ICAO and President of the Council of ICAO.

Chairman Hersman’s talk, “Assuring Safety in Aviation’s Second Century,” highlighted the past, present, and future of accident investigation and addressed how accident investigation must adapt to play an even more pivotal rolein creating civil aviation’s safer and stronger future. Citing examples from recent accident investigations, Hersman said that it’s clear that future accident investigations will depend far more on data and cooperation than in the past.

“While traditional tin-kicking will never go away, it is increasingly being joined by sophisticated data analysis,” Hersman said. “In this era of dynamic growth and greater complexity, data is more important than ever.”

Hersman applauded the agreement reached last year at the 37th ICAO Assembly to foster data sharing through the creation of the Global Safety Information Exchange. This information can be vital to investigators as they seek to learn what really happened and determine what can be done to
improve safety.

“Data and cooperation is how the aviation community will maintain – and enhance – its strong safety record into the second century of powered flight,” Hersman said.

See Speech Here


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NTSB SAFETY RECOMMENDATION

National Transportation Safety Board
Washington, DC 20594

July 7, 2011
http://www.ntsb.gov/doclib/recletters/2011/A-11-056-059.pdf
The National Transportation Safety Board makes the following recommendations to the Airborne Law Enforcement Association:

Revise your standards to define pilot rest and ensure that pilots receive protected rest periods that are sufficient to minimize the likelihood of pilot fatigue during aviation operations. (A-11-56)

Revise your accreditation standards to require that all pilots receive training in methods for safely exiting inadvertently encountered instrument meteorological conditions for all aircraft categories in which they operate. (A-11-57)

Encourage your members to install 406-megahertz emergency locator transmitters on all of their aircraft. (A-11-58)

Encourage your members to install flight-tracking equipment on all public aircraft that would allow for near-continuous flight tracking during missions. (A-11-59)


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NTSB Directive Contradicts Boeing Statement

On April 25, the NTSB released information about the April 1 Southwest Airlines Boeing 737-300 fuselage incident where the rupture in the fuselage caused depressurization and forced pilots to make an emergency landing in Yuma.

From the release

The NTSB Materials Laboratory work is actively conducting additional inspections and examinations in the following areas:

  1. Removal of rivets and examination of rivet hole dimensions, rivet dimensions, and rivet hole alignment between upper and lower skins.
  2. Detailed fractographic analysis of the skin fractures emanating from the rivet holes using optical and scanning electron microscopes.
  3. Fatigue striation analysis using a scanning electron microscope of specific skin fractures to determine the rate of crack propagation.
  4. Additional portions of the lap joints from the accident aircraft.

Of 136 airplanes inspected worldwide four had crack indications at a single rivet and one plane was found to have crack indications at two rivets.

In spite of these findings, Boeing Chief Executive Jim McNerney told Reuters“I think the initial data that I think we’re all seeing is suggesting a possible workmanship issue on an airplane, rather than a design issue across a fleet of airplanes.”

If Boeing believes that the problem was workmanship on a single plane, then how did other planes reveal conditions precursing the same type of rupture incident as was incurred on Southwest Airlines Flight 812?


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NTSB Releases Safety Recommendations

Partial summary of what is included

  • incorporate in Aircraft Flight Manuals a committed-to-stop point in the landing sequence
  • subpart K operators and Part 142 training schools to incorporate the information
  • establish, and ensure that pilots adhere to, standard operating procedures.
  • principal operations inspectors ensure that pilots use the same checklists in operations that they used during training for normal, abnormal, and emergency conditions.
  • require manufacturers to revise existing, checklists to require pilots to clearly call out and respond with the actual flap position
  • revise/describe terms severe thunderstorms, such as “bow echo,” “derecho,” and “mesoscale convective system.”
  • revise regulations and policies to permit appropriate prescription use
  • require fatigue education (training and policy for doctors and pilots)
  • runway excursion prevention development
  • wet runway landing data information provided to pilots
  • pilot in command line checks demonstrating expertise

Safety Recommendation .pdf


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NTSB Safety Recommendation A-11-7 through -11

National Transportation Safety Board
Washington, DC 20594

The National Transportation Safety Board recommends that the Federal Aviation Administration:

Require Boeing to develop a method to protect the elevator power control unit input arm assembly on 737-300 through -500 series airplanes from foreign object debris. (A-11-7)

Once Boeing has developed a method to protect the elevator power control unit input arm assembly on 737-300 through -500 series airplanes from foreign object debris as requested in
Safety Recommendation A-11-7, require operators to modify their airplanes with this method of protection. (A-11-8)

Require Boeing to redesign the 737-300 through -500 series airplane elevator control system such that a single-point jam will not restrict the movement of the elevator control system and prevent continued safe flight and landing. (A-11-9)

Once the 737-300 through -500 series airplane elevator control system is redesigned as requested in Safety Recommendation A-11-9, require operators to implement the new design. (A-11-10)

Require Boeing to develop recovery strategies (for example, checklists, procedures, or memory items) for pilots of 737 airplanes that do not have a mechanical override feature for a jammed elevator in the event of a full control deflection of the elevator system and incorporate those strategies into pilot guidance. Within those recovery strategies, the consequences of removing all hydraulic power to the airplane as a response to any uncommanded control surface should be clarified. (A-11-11)


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NTSB SENDING TEAM TO ASSIST IRELAND IN METROLINER INVESTIGATION

NTSB Advisory
National Transportation Safety Board
Washington, DC 20594
February 10, 2011

NTSB SENDING TEAM TO ASSIST IRELAND IN METROLINER INVESTIGATION

The National Transportation Safety Board is sending three investigators to assist the Government of Ireland as it investigates the crash of an airliner this morning.

At about 9:45 a.m. local time today, a Swearingen SA-227 Metroliner (Spanish registration EC-ITP), operated by Flightline/Manx2 Air as flight 7100 from Belfast, Northern Ireland, crashed after attempting a landing at Cork Airport, Cork, Ireland. Twelve people were aboard the aircraft, and there are reports of both fatalities and survivors.

NTSB senior air safety investigator Dan Bower has been designated the U.S. Accredited Representative and is being assisted by an NTSB systems investigator and an NTSB operations investigator. A Federal Aviation Administration investigator is also joining the team.

Information about the progress of the investigation will be released by the Air Accident Investigation Unit of Ireland, +353 (0) 1-604-1293.

###


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NTSB INVESTIGATING OPERATIONAL ERROR NEAR NEW YORK

The National Transportation Safety Board has been investigating an operational error that occurred near New York City in January.

The Safety Board was notified of a Traffic Collision and Alerting System (TCAS) resolution advisory that occurred due to a near midair collision involving American Airlines flight 951 on January 20, 2011, at about 10:30 p.m. Eastern Standard Time. The American Airlines aircraft, a Boeing 777-200 (N7CA), had taken off from John F. Kennedy International Airport en route to Sao Paulo, Brazil and was flying southeast. A flight of two U.S. Air Force C-17s was heading northwest toward McGuire Air Force Base, New Jersey. There were no injuries in the incident.

The NTSB has interviewed air traffic controllers on duty at the time of the incident, and is gathering information from American Airlines and the Air Force.

The air traffic controllers talking to each of the aircraft received conflict alerts, and immediately provided traffic advisories and turned their aircraft to resolve the conflict. In addition, the American Airlines crew responded to directions provided by TCAS. Radar data indicate that the aircraft came within a mile of each other at their closest point. The incident occurred about 80 miles southeast of New York City.

Betty Koschig has been designated the NTSB’s Investigator-in-Charge for this incident. Further information will be released as it becomes available.


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NTSB TO HOST INTERNATIONAL FAMILY ASSISTANCE CONFERENCE

National Transportation Safety Board
Washington, DC 20594

FOR IMMEDIATE RELEASE: February 3, 2011
SB-11-06

Washington, DC – The National Transportation Safety Board is hosting a conference to share best practices and promote post-accident family assistance in all modes of transportation. Family Assistance: Promoting an International Approach for the Transportation Industry, will be held in Washington, DC on March 28 and 29, 2011. The conference will bring together family members, transportation accident investigation agencies, industry representatives, government agencies, and the news media to share perspectives on lessons learned in providing family assistance following transportation accidents in an international context.

“Following a major aviation or passenger rail accident in the US, the NTSB has the responsibility to coordinate support for survivors and families,” said NTSB Chairman Deborah A.P. Hersman. “With this conference, we are marking the 15th anniversary of the enactment of the Aviation Disaster Family Assistance Act and the 10th anniversary of ICAO Circular 285, with a unique forum to identify lessons learned and draw from international experiences to improve the support for families in the wake of transportation tragedies worldwide.”

The first day of the conference will include panel discussions featuring family members, transportation industry representatives, vendors, non-governmental organizations, transportation accident investigative agencies, and the news media examining their perspectives on transportation family assistance.

The second day will feature a series of presentations by NTSB Transportation Disaster Assistance staff as they discuss the Board’s family assistance model from an operational perspective.

This conference, being held at NTSB’s headquarters, is provided free of charge to those interested in the provision of family assistance in all modes of transportation. A complete agenda and list of speakers will be published prior to the conference. The first day will be webcast at www.ntsb.gov.


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NTSB INVESTIGATING OPERATIONAL ERROR NEAR NEW YORK

National Transportation Safety Board
Washington, DC 20594

February 4, 2011

The National Transportation Safety Board has been investigating an operational error that occurred near New York City in January.

The Safety Board was notified of a Traffic Collision and Alerting System (TCAS) resolution advisory that occurred due to a near midair collision involving American Airlines flight 951 on January 20, 2011, at about 10:30 p.m. EasternStandard Time. The American Airlines aircraft, a Boeing777-200 (N7CA), had taken off from John F. Kennedy International Airport en route to Sao Paulo, Brazil and wasflying southeast. A flight of two U.S. Air Force C-17s was heading northwest toward McGuire Air Force Base, New Jersey. There were no injuries in the incident.

The NTSB has interviewed air traffic controllers on duty at the time of the incident, and is gathering information from American Airlines and the Air Force.

The air traffic controllers talking to each of the aircraft received conflict alerts, and immediately provided traffic advisories and turned their aircraft to resolve the conflict. In addition, the American Airlines crew responded to directions provided by TCAS. Radar data indicate that the aircraft came within a mile of each other at their closest point. The incident occurred about 80 miles southeast of New York City.

Betty Koschig has been designated the NTSB’s Investigator-in-Charge for this incident. Further information will be released as it becomes available.


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NTSB Holding Family Assistance Symposium

NTSB Holding Family Assistance Symposium
Panel discussions during the March 28-29 event will help the transportation industry, the media, and investigative agencies learn how families are helped after accidents around the world.

The National Transportation Safety Board will hold a two-day conference March 28-29 for family members, transportation accident investigation agencies, transportation industry representatives, government agencies, and the media to discuss family assistance after transportation accidents in an international context. The event coincides with the 15th anniversary of the Aviation Disaster Family Assistance Act and the 10th anniversary of ICAO Circular 285 and will give those who attend the chance to learn firsthand from those involved worldwide in family assistance, according to NTSB.

Day one features four panel discussions and will be webcast. Day two includes training by the NTSB Transportation Disaster Assistance staff, who will give an overview of the NTSB model for family assistance operations.

The tentative agenda shows the panel discussions will be:

Family Members: Perspectives from those affected by accidents, a discussion of their needs, and how those needs are met through family assistance programs.
Transportation industry, vendors, and non-governmental organizations: Responsibilities of the industry, their vendors, and non-governmental organizations.

Government transportation accident investigation agencies: How investigative agencies provide information about accident investigations and their role in family assistance.

Media: How the media report on family members following accidents and how family assistance has affected such reporting.

The event will take place at the NTSB Conference Center, 429 L’Enfant Plaza SW, Washington, DC 20594. Registration is free and is being conducted separately for each day. Visit this page to register and for links to transportation family assistance resources.

Tentative Agenda

Perspectives from Family Members, Industry, Government, and Media

Welcome and Introductions: The Honorable Deborah A.P. Hersman
Commemoration of the 15th Anniversary of the Aviation Disaster Family Assistance Act
Four high-level panel discussions designed to share best practices and lessons learned in the provision of family assistance in transportation accidents internationally.
Family Members: Perspectives from those impacted by accidents, a discussion of their needs, and ways in which those needs are met through family assistance programs.
Transportation industry, vendors, and non-governmental organizations: Perspectives on the responsibilities of the industry, their vendors, and non-governmental organizations in providing assistance.
Government transportation accident investigation agencies: How investigative agencies provide information about the accident investigation and their role in family assistance.
Media: How the media reports on family members following accidents and how family assistance has impacted such reporting.
March 29, 2011

The NTSB Family Assistance Model: An Introduction

NTSB family assistance legislation overview; information flow and timelines; family assistance operations; conducting effective family briefings; personal effects best practices; victim identification concerns; site visits, memorials, anniversaries.

SEE AGENDA


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NTSB Safety Recommendations A-11-1 through -6

National Transportation Safety Board
Washington, DC 20594
February 1, 2011

The National Transportation Safety Board makes the following safety recommendations to the Federal Aviation Administration:

Require Cessna Aircraft Company and other manufacturers whose restraint system designs permit an occupant to use an inactive airbag restraint system not intended for use in his or her seat to modify their restraint system designs to eliminate that possibility, and require them to modify restraint systems in existing airplanes to eliminate the possibility of misuse.

Revise the guidance and certification standards concerning restraint systems to recognize and prevent potential misuse scenarios, including those documented in this safety study.

Modify the special conditions for the installation of inflatable restraints on general aviation airplanes (at Federal Register, vol. 73, no. 217 [November 7, 2008], p. 66163) to provide specific guidance to manufacturers as to how they should demonstrate that the protection is effective for occupants that range from the 5th percentile female to the 95th percentile male.

Require the retrofitting of shoulder harnesses on all general aviation airplanes that are not currently equipped with such restraints in accordance with Advisory Circular (AC) 21-34, issued June 4, 1993.

Evaluate the potential safety benefits and feasibility of requiring airbag-equipped aircraft to have the capability to capture and record, at a minimum, data concerning crash dynamics and airbag deployment criteria that can be reviewed after a crash to determine whether the system performed as designed.

Develop a system to track individual aircraft information about aircraft safety equipment, such as restraint systems, airbags, aircraft parachutes, and other specific aircraft equipment, designed to improve crash outcomes.


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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 MEETS TO CONSIDER SAFETY STUDY ON THE USE OF AIRBAGS IN GENERAL AVIATION AIRCRAFT

National Transportation Safety Board
Washington, DC 20594

January 6, 2011

The National Transportation Safety Board will hold a public
Board meeting to consider a safety study on the
effectiveness of airbags in general aviation (GA) aircraft.

The NTSB initiated the safety study to 1) examine the
effectiveness of airbags in mitigating occupant injury in a
survivable GA accident, 2) identify any unintended
consequences of airbag deployments, and 3) develop
procedures to assist investigators in documenting airbag
systems in future investigations.

During the course of the study, investigators became aware
of several potential issues that could compromise occupant
safety associated with the use, adjustment and design of
restraint systems. All of these findings will be presented
to the five-Member Board for their consideration.

The meeting will be held on Tuesday, January 11, at 9:30
a.m., in its Board Room and Conference Center, 429 L’Enfant
Plaza, S.W., Washington, D.C.

A live and archived webcast of the proceedings will be
available on the Board’s website at
http://www.ntsb.gov/Events/Boardmeeting.htm. Technical
support details are available under “Board Meetings.” To
report any problems, please call 703-993-3100 and ask for
Webcast Technical Support.

A summary of the safety study, which will include its
findings and safety recommendations, will appear on the
website shortly after the conclusion of the meeting. The
entire study will appear on the website several weeks later.


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NTSB ISSUES RECOMMENDATIONS DEALING WITH EMERGENCY LOCATOR TRANSMITTERS IN GENERAL AVIATION AIRCRAFT FOLLOWING CRASH INVOLVING SENATOR STEVENS

FOR IMMEDIATE RELEASE: January 5, 2011
SB-11-02

The National Transportation Safety Board today issued two safety recommendations to the Federal Aviation Administration requiring a detailed inspection of all emergency locator transmitters (ELT) installed on general aviation aircraft to ensure that their mountings maintain their retention capabilities during an accident sequence.

An ELT is designed to broadcast a signal through an externally mounted antenna that contains the aircraft’s registration information and the global positioning system coordinates of the original signal. Also, the “homing signal” can be detected locally by other aircraft, air traffic control facilities, or rescue personnel who use a compatible receiver.

“In this case, the airplane was equipped with a functioning 406 megahertz ELT, which can be a tremendous aid to search and rescue operations,” said NTSB Chairman Deborah A.P. Hersman. “But this vital life-saving technology won’t do anyone any good if it doesn’t stay connected to the antenna.”

On August 9, 2010, a de Havilland turbine Otter airplane crashed in mountainous tree-covered terrain approximately 10 miles from Aleknagik, Alaska. Nearly five hours after the crash, volunteer airborne search personnel located the aircraft approximately 19 miles from where the flight originated. The pilot and four passengers, including former U.S. Senator Ted Stevens, sustained fatal injuries. The other four passengers were seriously injured.

Aircraft involved in the search and rescue efforts and satellites did not detect any ELT signals. Following the discovery of the airplane, a pararescuer found the ELT loose on the floor of the airplane. The ELT had activated but had separated from its mounting bracket and antenna.


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NTSB ISSUES RECOMMENDATIONS DEALING WITH EMERGENCY LOCATOR TRANSMITTERS IN GENERAL AVIATION AIRCRAFT FOLLOWING CRASH INVOLVING SENATOR STEVENS

National Transportation Safety Board
Washington, DC 20594

FOR IMMEDIATE RELEASE: January 5, 2011

Washington, DC – The National Transportation Safety Board
today issued two safety recommendations to the Federal
Aviation Administration requiring a detailed inspection of
all emergency locator transmitters (ELT) installed on
general aviation aircraft to ensure that their mountings
maintain their retention capabilities during an accident
sequence.

An ELT is designed to broadcast a signal through an
externally mounted antenna that contains the aircraft’s
registration information and the global positioning system
coordinates of the original signal. Also, the “homing
signal” can be detected locally by other aircraft, air
traffic control facilities, or rescue personnel who use a
compatible receiver.

“In this case, the airplane was equipped with a functioning
406 megahertz ELT, which can be a tremendous aid to search
and rescue operations,” said NTSB Chairman Deborah A.P.
Hersman. “But this vital life-saving technology won’t do
anyone any good if it doesn’t stay connected to the
antenna.”

On August 9, 2010, a de Havilland turbine Otter airplane
crashed in mountainous tree-covered terrain approximately 10
miles from Aleknagik, Alaska. Nearly five hours after the
crash, volunteer airborne search personnel located the
aircraft approximately 19 miles from where the flight
originated. The pilot and four passengers, including former
U.S. Senator Ted Stevens, sustained fatal injuries. The
other four passengers were seriously injured.

Aircraft involved in the search and rescue efforts and
satellites did not detect any ELT signals. Following the
discovery of the airplane, a pararescuer found the ELT loose
on the floor of the airplane. The ELT had activated but had
separated from its mounting bracket and antenna.


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NTSB ISSUES UPDATE ON JACKSON HOLE B-757 RUNWAY OVERRUN INCIDENT

NTSB Advisory
National Transportation Safety Board
Washington, DC 20594
December 31, 2010

In its continuing investigation of the runway overrun of a jetliner in Jackson Hole, Wyo., the National Transportation Safety Board has developed the following factual information:

At about 11:38 am MT on Wednesday, December 29, American Airlines flight 2253, a B-757-200 (N668AA) inbound from Chicago O’Hare International Airport, ran off the end of runway 19 in snowy conditions while landing at Jackson Hole Airport. No injuries were reported among the 181 passengers and crew on board.

The aircraft came to rest in hard packed snow about 350 feet beyond the runway overrun area. An initial inspection did not reveal any structural damage to the aircraft. Shortly after the aircraft came to a stop, in accordance with American Airlines’ procedures, the pilots pulled the circuit breaker to the cockpit voice recorder (CVR) to preserve all of the recorded information for investigators.

The CVR and DFDR (digital flight data recorder) arrived at the Safety Board’s recorder laboratory on Thursday evening, Dec. 30, where investigators were standing by to download the contents of both recorders. The CVR provided a two-hour recording of excellent quality audio; the voices of each of the pilots on the flight deck were clearly audible. The DFDR provided 1200 recorded parameters of flight data and captured the entire incident.

The crew, who were interviewed on Thursday evening, indicated that they saw the runway prior to reaching the minimum descent altitude before touchdown. Both crewmembers characterized the flight and approach to landing as uneventful prior to the runway overrun. The first officer was the flying pilot.

The accident docket, which will contain additional factual information, is expected to be opened in 60-90 days. It will be available on the docket section of the NTSB website at http://go.usa.gov/rjR

PROTOCALS FOR TRANSPORTING AIRCRAFT RECORDERS IN INCIDENT INVESTIGATIONS

The Safety Board has long-established protocols for the handling and transportation of CVRs and DFDRs that contain recorded information from a commercial aviation incident, which by definition is one where no serious injuries or substantial damage to the aircraft or other property has occurred.

In such incident investigations, the Safety Board frequently asks the airline involved to transport the recorders on their own aircraft as such an arrangement often provides the most expeditious means of conveying the devices to Safety Board labs in Washington. The airline is instructed to transport the recorders without delay and without accessing the information contained within them by any means. This practice has worked efficiently and without complication for more than 40 years.

During this incident investigation, the Safety Board learned that the recorders were flown to Tulsa, Okla., where American Airlines technicians downloaded information from the DFDR; the CVR was not accessed by American.

“Although a thorough examination by our investigators determined that no information from the DFDR was missing or altered in any way, the breach of protocol by American Airlines personnel violates the Safety Board’s standards of conduct for any organization granted party status in an NTSB investigation,” said NTSB Chairman Deborah A.P. Hersman. “Because maintaining and enforcing strict investigative protocols and procedures is vital to the integrity of our investigative processes, we have revoked the party status of American Airlines and excused them from further participation in this incident investigation.”

American Airlines has assured the Safety Board that a full review of proper procedures and internal controls would be undertaken to ensure that such an occurrence is not repeated.

Despite their removal from party standing, the NTSB will provide American Airlines with any and all information needed to ensure a timely response to operational safety deficiencies identified in the course of the investigation.


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NTSB Safety Recommendations A-10-159 through -168

the National Transportation Safety Board recommends that the U.S. Forest Service:

Develop mission-specific operating standards for firefighter transport operations that include procedures for completing load calculations and verifying that actual aircraft performance matches predicted performance, require adherence to aircraft operating limitations, and detail the specific 14 Code of Federal Regulations Part 135 regulations that are to be complied with by its contractors. (A-10-159)

Require its contractors to conduct firefighter transport operations in accordance with the mission-specific operating standards specified in Safety Recommendation A-10-159. (A-10-160)

Create an oversight program that can reliably monitor and ensure that contractors comply with the mission-specific operating requirements specified in Safety Recommendation A-10-159. (A-10-161)

Provide specific training to inspector pilots on performance calculations and operating procedures for the types of aircraft in which they give evaluations. (A-10-162)

Require a hover-out-of-ground-effect power check to be performed before every takeoff carrying passengers from helispots in confined areas, pinnacles, and ridgelines. (A-10-163)

Review and revise policies regarding the type and use of gloves by firefighting personnel during transport operations, including but not limited to, compatibility with passenger restraints and opening emergency exits. (A-10-164) Review and revise your contract requirements for passenger transport by aircraft so that the requirement to install shoulder harnesses on passenger seats provides improved occupant crashworthiness protection consistent with the seat design. (A-10-165)

Require that helispots have basic weather instrumentation that has the capability to measure wind speed and direction, temperature, and pressure and provide training to helitack personnel in the proper use of this instrumentation. (A-10-166) Modify your standard manifest form to provide a place to record basic weather information and require that this information be recorded for each flight. (A-10-167)

Require all contracted transport-category helicopters to be equipped with a cockpit voice recorder and a flight data recorder or a cockpit image recorder with the capability of recording cockpit audio, crew communications, and aircraft parametric data. (A-10-168)


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NTSB SAFETY RECOMMENDATION

The National Transportation Safety Board recommends that the Federal Aviation Administration:

Require that the hover performance charts published by helicopter manufacturers reflect the true performance of the helicopter in all conditions for which the charts are applicable, including light and variable wind conditions. (A-10-148)

Develop and implement a surveillance program specifically for 14 Code of Federal Regulations (CFR) Part 135 operators with aircraft that can operate both as public aircraft and as civil aircraft to maintain continual oversight ensuring compliance with 14 CFR Part 135 requirements. (A-10-149)

Take appropriate actions to clarify Federal Aviation Administration (FAA) authority over public aircraft, as well as identify and document where such oversight responsibilities reside in the absence of FAA authority. (A-10-150)

Require the installation of fuel tanks that meet the requirements of 14 Code of Federal Regulations 29.952 on S-61 helicopters that are used for passenger transport. (A-10-151) Require that S-61 helicopters that are used for passenger transport be equipped with passenger seats and seat mounting structures that provide substantial improvement over the requirements of Civil Air Regulations 7.260, such as complying with portions of 14 Code of Federal Regulations 29.561 and 29.562. (A-10-152)

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. (A-10-153)

Require that Advisory Circular 21-34 be used to evaluate all shoulder harness retrofit installations and to determine that the installations reduce the risk of occupant injury. (A-10-154)

Require operators of Sikorsky S-61 helicopters with General Electric model CT58-140 engines to install 10-micron airframe fuel filters. (A-10-155)

Require Carson Helicopters, Inc., to put a conspicuous notification on the title page of the Instructions for Continuing Airworthiness that accompany its supplemental type certificate for installing side-mounted seats indicating that the installation does not provide enhanced occupant protection over that provided by the originally installed seats and meets Civil Air Regulations 7.260 standards. (A-10-156)

Require all applicants for supplemental type certificate (STC) seat installations in any type of aircraft to put a conspicuous notification on the title page of the Instructions for Continuing Airworthiness that accompany the STC indicating whether the installation provides enhanced occupant protection over that provided by the originally installed seats and the certification standard level met by the seating system. (A-10-157)

Require supplemental type certificate (STC) applicants to improve the crashworthiness design of the seating system, such as complying with portions of 14 Code of Federal Regulations 29.561 and 29.562, when granting STC approval for older transport-category rotorcraft certificated to Civil Air Regulations 7.260 standards. (A-10-158)

Also, the National Transportation Safety Board reiterates the following previously issued recommendation to the Federal Aviation Administration:

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. (A-06-18)


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NTSB INVESTIGATING TODAY’S JETLINER RUNWAY EXCURSION IN WYOMING

The National Transportation Safety Board has opened an investigation into an incident in which a passenger jetliner departed the runway while landing at Jackson Hole Airport in Wyoming.

At about 11:38 am MT today, American Airlines flight 2253, a B-757 (N668AA) inbound from Chicago O’Hare International Airport, ran off the end of runway 19 while landing at Jackson Hole Airport. No injuries were reported among the 181 passengers and crew on board.

The aircraft came to rest in hard packed snow about 350 feet beyond the runway overrun area. The weather was reported to be snowing at the time of the incident. No damage to the aircraft has been reported.

Senior NTSB Air Safety Investigator Joseph Sedor has been designated as the Investigator-In-Charge.

At this time, parties to the investigation are American Airlines, Boeing, the Allied Pilots Association, and the Federal Aviation Administration.

Improving runway safety has been on the NTSB’s Most Wanted List of Safety Improvements since its inception in 1990: http://go.usa.gov/rTn

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