Senate Commerce, Science and Transportation Subcommittee on Aviation Operations, Safety, and Security Hearing
Good afternoon Chairman Ayotte, Ranking Member Cantwell, and the Members of the Subcommittee. Thank you for inviting the
The NTSB is an independent Federal agency charged by
Since its inception, the NTSB has investigated more than 140,500 aviation accidents and thousands of surface transportation accidents. On call 24 hours a day, 365 days a year, NTSB investigators travel throughout the country and internationally to investigate significant accidents and develop factual records and safety recommendations with one aim--to ensure that such accidents never happen again. The NTSB's annual Most Wanted List highlights safety-critical actions that the
To date, we have issued over 14,000 safety recommendations to nearly 2,300 recipients. Because we have no formal authority to regulate the transportation industry, our effectiveness depends on our reputation for conducting thorough, accurate, and independent investigations and for producing timely, well-considered recommendations to enhance transportation safety.
In January, the NTSB released its Most Wanted List for 2015. n1 It identifies our top 10 areas for transportation safety improvements. Each year, we develop our Most Wanted List based on safety issues we identify as a result of our accident investigations. This year our priority areas include three multimodal items that affect aviation safety as well as three aviation-specific issues --
* Preventing Loss of Control in Flight in
* Strengthening Crewmembers' Procedural Compliance
*
* Ending Substance Impairment in Transportation
* Disconnecting from Deadly Distractions
* Enhancing Public Helicopter Safety
Each of these Most Wanted List issues emphasizes the need for critical actions by the aviation safety regulator - the
General Aviation Safety
The U.S. commercial aviation system is experiencing an unprecedented level of safety. With regard to general aviation (GA) accidents, there has been a decrease in all measures. The total number of general aviation accidents decreased by 249 in 2013, bringing the number to 1,222. n2 The number of fatal accidents (221) and fatalities (387) also declined from the previous year; however, the accident rate per 100,000 flight hours (5.85) has remained relatively the same. Although GA represented almost 50 percent of the estimated total flight time of all U.S. civil aviation in 2013, it accounted for 94 percent of fatal accidents. As required by statute, the NTSB determines the probable cause of all aviation accidents, and one thing we have learned is that unfortunately, the same factors continue to cause most of the accidents.
The leading causes of GA accidents are loss of control, engine failure, flying in conditions that are beyond the pilot or aircraft's abilities, and collision with terrain. GA is essentially an airline of one, which means the entire aviation community must work harder to reach each pilot or mechanic who populates this community to address these issues and prevent accidents. Preventing Loss of Control in Flight in GA is on the NTSB's 2015 Most Wanted List in order to bring attention to the issue. n3
Last month, the NTSB issued four Safety Alerts, which are included with my testimony, and last week we issued a Video Safety Alert. n4 The NTSB's purpose in issuing these safety alerts and video is to increase awareness, education, and training for private pilots and aviation maintenance technicians. The alerts are brief information bulletins that pinpoint particular safety hazards and offer practical remedies to address these risks. They also serve to focus the NTSB's GA outreach efforts during the coming year. Three of the safety alerts are geared towards pilots and address mountain flying skills and survival equipment considerations, transition training before flying an unfamiliar aircraft with different flight characteristics or avionics, and performing thorough and advanced preflight checks on aircraft that have just received flight control or trim system maintenance. The Safety Alert aimed at mechanics discusses flight control and trim system misrigging problems. Each Safety Alert includes accident summaries from some of our accident investigations and the role the safety issue played in those accidents. The Video Safety Alert titled, Airplane Misrigging: Lessons Learned from a Close Call, highlights an inflight emergency that occurred near
Additionally, over the past five years, the NTSB has conducted several GA safety studies. In 2014, we examined the prevalence of drug use by all pilots who died in crashes and found an upward trend in the use of both potentially impairing medications and illicit drugs. n5 Almost all of the crashes - 96 percent - were in general aviation. I will discuss this study in more detail later. Last year, NTSB also issued a Special Investigation Report on the Safety of Agricultural Aircraft Operations. n6 As a result of the safety issues identified in the study, the NTSB issued safety recommendations to the
We will continue our efforts to improve the safety record of general aviation, and we look forward to finding new and innovative ways to communicate this message to more pilots and mechanics.
Strengthening Procedural Compliance
The NTSB continues to seek new ways to strengthen procedural compliance, from identifying inadequate procedures, to ensuring comprehensive training, to reemphasizing practices that reinforce crew compliance. Recent accidents underscore the importance of procedural compliance. In 2013 there were two major controlled flight into terrain accidents in which crews did not follow standard operating procedures --
Sometimes crews do not comply with air carriers' standard operating procedures, such as flying stabilized approaches, making required callouts, maintaining quiet (or sterile) cockpits, and monitoring critical flight parameters like airspeed. But other times, the procedures themselves aren't good enough. For example, an airplane ran off the end of the runway in a case in which an airline did not require crews to calculate landing distance on arrival. n10 This is only one of many such cases. In other cases, training does not adequately prepare crews. n11
Aviation accidents and incidents can be prevented through collaborative efforts by crews, operators, and regulators. Working together, they can develop effective procedures and training, and ensure that crews do what they are trained to do. I am a strong believer in the power of collaboration to produce continuous improvement because of the amazing safety improvement that this industry has enjoyed as a result of its collaborative process known as CAST, the Commercial Aviation Safety Team. The core of the CAST process is very simple: everyone who is involved with this issue - in this case, further reducing the risk of aviation fatalities and improving a safety record that is already very good - should be involved in developing the solution, including industry, organizations representing employees, and government agencies. This model has more recently been extended to the general aviation community through the
Pilot Training and Professionalism and Disconnecting from Distractions
The 2010 Act included a mandate for the
In addition to
* In the
* In the
* An engine fire on an American Airlines MD-80 in 2007 involved a crew engaged in non-pertinent discussion during taxi and after landing "indicating that a casual atmosphere existed in the cockpit." This casual atmosphere "before takeoff affected and set a precedent for the pilots' responses to the situations in flight and after landing, eroding the margins of safety provided by the SOPs and checklists, and increased the risk to passengers and crews." n19
* In the 2006 fatal wrong runway takeoff accident in
Another concern for the NTSB is the mode confusion that can result from increasing automation. A classic accident of this type was the crash of
Last but not least, while new connectivity has enabled new safety technologies, it has also enabled new forms of distraction, leading to accidents, even in the most strictly regulated transportation enterprise of aviation. As a result of the NTSB's investigation of both Northwest Flight 188 that overflew its
Requiring Fitness for Duty, Ending Substance Impairment, and Addressing Human Fatigue
Requiring Medical Fitness for Duty is on the NTSB's 2015 Most Wanted List in order to bring attention to this critical issue in all modes of transportation. n26 Medical conditions and treatments that impair transportation professionals' performance directly affect safety. To mitigate the risk to the public, the NTSB has made recommendations for a comprehensive medical certification system for safety-critical transportation personnel, including these features:
* a complete medical history of the applicant, taken at prescribed intervals, that includes medications, conditions, and treatments as well as a physical examination
* specific historical questions and physical examination procedures to identify applicants at high risk for sleep disorders
* identification of specific conditions, treatments, and medications that initially disqualify applicants for duty, with certification contingent on further testing (specific to each condition)
* explicit and uniform processes and criteria for determining when the applicant has a treated but otherwise disqualifying condition
* certificates that are good only for a limited time for applicants with conditions that are currently stable but known to be likely to deteriorate, to ensure appropriate retesting
* medical examiners who
. are licensed or registered to both perform examinations and prescribe medication in a given state;
. are specifically trained and certified to perform medical certification exams; and
. have ready access to information regarding disqualifying conditions and required further evaluation
* a review system for medical examiners' work product(s) with both the information and capacity to identify and correct errors and substandard performance
* the capacity to prevent applicants who have been deferred or denied certification from finding another provider who will certify them
* a process for dealing with conditions which could impair safety and are diagnosed between certification exams.
The medical requirements for pilots are robust. These standards are important because of the impact that accidents can have on public safety and passengers, and we find in all modes that adverse health conditions can lead to accidents. Some pilots are not medically fit to operate aircraft, and those suffering from impairing medical disorders should not be at the controls unless and until they receive medical treatment that mitigates the risk to the public.
In addition, NTSB investigations have found impairment by various substances as a cause or a contributing factor in transportation accidents, and use of over-the-counter (OTC) and prescription medications as well as illicit drugs is generally increasing. Since there is a great amount of overlap among these groups - the same substance may be available by prescription or over the counter and many medications are also used illicitly by people without a prescription for their psychoactive effects - I will use the term "drugs" broadly to mean any of these substances. Aircraft are complex machinery that require pilots to be at their best - not impaired by alcohol or drugs. In
As a result of this safety study, the NTSB recommended that
In addition, fatigue remains an issue of concern. For more than 20 years, the issue of reducing accidents caused by fatigue was on the NTSB's Most Wanted List of safety improvements. Since 1972, the NTSB has issued more than 200 human fatigue-related safety recommendations in all modes of transportation, including more than 53 recommendations addressing fatigue in aviation. n30 For example, we have recommended that all pilots be appropriately evaluated for obstructive sleep apnea and treated, if necessary.
We removed fatigue from our Most Wanted List in
Enhancing Public Helicopter Safety
On
As a result of the 2008 USFS accident in
Since 2004, the NTSB has investigated more than 130 accidents involving federal, state, and local public helicopter operations, including the 4 mentioned above. Fifty people lost their lives and nearly 40 were seriously injured in these accidents. The lessons learned as a result of these investigations have the potential to make federal, state, and local public helicopter operations safer.
Aircraft Recorder Recommendations
Notwithstanding the NTSB's nearly 50 years of aviation accident investigations and role in securing improvements in recorder capabilities and locator technologies, the NTSB clearly recognizes that sophisticated aircraft accident investigation and analysis cannot be accomplished without recorded flight data. In order for our important work to continue and make a difference in saving lives, we must ensure that the technologies are available to locate aircraft wreckage and recorders after an accident and that critical flight data can be recovered.
The NTSB has long been concerned about rapid recovery of recorded information to guide investigations, help determine accident causes, and develop recommendations to prevent recurrences. To focus attention on this issue, the NTSB convened its
* The need for improved technologies to locate aircraft wreckage and flight recorders following an accident in a remote location or over water
* The need for timely recovery of critical flight data following an accident in a remote location or over water
Other noteworthy information provided at the forum includes the following:
* Deployable recorder technologies: These technologies can be used to recover flight data without the delay of a long and expensive underwater recovery. Deployable recorders have been used in military and over water helicopter applications since the 1960s and are currently available from several manufacturers. They combine traditional flight data recorder and cockpit voice recorder functions into one unit and are capable of providing a comparable amount of flight data. They are designed to separate from the aircraft upon fuselage structural deformation or when submersed in water. If in water, they float indefinitely on the surface. These units are also equipped with emergency locator transmitters that operate on the 121.5 megahertz and 406 megahertz frequencies for location and recovery. Standards already exist for automatically deploying flight recorders.
* Triggered flight data transmission: A manufacturer of flight data transmission technology testified that triggered flight data transmission was not only feasible, but already in service on some aircraft. Additionally, at this time, manufacturers and operators are equipping their aircraft with commercial satellite communications systems that can support broadband video, voice, and data transmissions. Commercial satellite systems on the market today are primarily used for passenger and crew connectivity and can support speeds of 200-400 kilobits per second. Higher speed capability is forthcoming. Such bandwidth would enable real-time parametric flight data transmission to begin after a triggering event as well as transmission of a limited amount of stored flight data recorded before the triggering event.
On
The NTSB recommendations urge the
* Require that all aircraft used in extended overwater operations (i.e., operations that occur over water at a distance of more than 50 nm from the nearest shoreline) and operating under Part 121 or Part 135 of the FAR that are required to have a flight data recorder and cockpit voice recorder 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, and
. an airframe low frequency underwater locating device that will function for at least 90 days and that can be detected by equipment available on military, search and rescue, and salvage assets commonly used to search for and recover wreckage.
* Require that all newly manufactured aircraft used in extended overwater operations and operating under Part 121 or Part 135 of the FAR that are required to have a flight data recorder and cockpit voice recorder be equipped with a means to recover, at a minimum, mandatory flight data parameters; the means of recovery should not require underwater retrieval. Data should be captured from a triggering event until the end of the flight and for as long a time period before the triggering event as possible.
* Coordinate with other international regulatory authorities and ICAO to harmonize the implementation of the above-identified requirements recommended by the NTSB for locating where an aircraft terminates flight as the result of an accident and recovery of mandatory flight data parameters.
* Identify ways to incorporate adequate protections against disabling flight recorder systems on all existing transport category aircraft.
* Require that all newly manufactured transport category aircraft incorporate adequate protections against disabling flight recorder systems.
In addition, the NTSB has continued to re-emphasize the need for cockpit image recorders on commercial airplanes. In 2000, the NTSB issued two safety recommendations to the
In the
Air Transportation of Lithium Batteries
There are two types of lithium batteries: primary and secondary. Primary lithium batteries are non-rechargeable and are commonly used in items such as watches and pocket calculators. They contain metallic lithium that is sealed in a metal casing. The metallic lithium will burn when exposed to air if the metal casing is damaged, compromised, or exposed to sustained heating. Secondary lithium batteries, also known as lithium-ion batteries, are rechargeable and are commonly used in items such as cameras, cell phones, laptop computers, and hand power tools. Secondary lithium batteries contain electrically charged lithium ions, and a flammable liquid electrolyte. External damage or overheating of the battery can result in thermal runaway or the discharge of flammable electrolyte. Another type of secondary battery, known as lithium polymer batteries, contains a flammable polymeric material rather than a liquid, as the electrolyte. Halon suppression systems, the only fire suppression systems certified for aviation, can be used to help control flames in lithium battery fires but will not extinguish the fire.
The demand for primary and secondary lithium batteries has skyrocketed since the mid-1990s as the popularity and use of electronic equipment of all types has grown. As the use of lithium batteries has increased, the number of incidents involving fires or overheating of lithium batteries, particularly in aviation, has likewise grown. The NTSB has investigated three such aviation accidents:
The fires in these accidents included both primary and secondary lithium batteries, and the NTSB issued several recommendations as a result of these investigations. As a result of its investigation of the
Following the
In
The NTSB held a public forum in
When
The NTSB notes the DOT has for some years worked to ensure that the HMR are compatible with international standards and, accordingly, has been very active in the development of international standards for the transportation of hazardous materials. However, the DOT has never relinquished its rulemaking authority to an international body. The NTSB concurs with that position and firmly believes the DOT should implement more stringent standards in US regulations if deemed necessary.
Update on Crash of Scaled Composites' SpaceShip Two
On
Closing
Madame Chairman, the NTSB has a long record of support for improving aviation safety. As you know, our mission is to promote safety, and the implementation of our recommendations in these areas would help promote and improve safety.
Thank you for the opportunity to testify before you today. I look forward to responding to your questions.
n1 See www.ntsb.gov/mostwanted for more details.
n2 http://www.ntsb.gov/investigations/data/SiteAssets/Pages/Accident-data-review/2013%20Preliminary%.
n3 http://www.ntsb.gov/safety/mwl/Documents/MWL_2015_Factsheet_07.pdf.
n4
n5 NTSB, Drug Use Trends in Aviation: Assessing the Risk of Pilot Impairment, No. NTSB/SS-14/01 (
n6 NTSB, Special Investigation Report on the Safety of Agricultural Aircraft Operations, No. NTSB/SIR-14/01 (
n7 NTSB, The Safety of Experimental Amateur-Built Aircraft, No. NTSB/SS-12/01 (
n8 NTSB, Airbag Performance in General Aviation Restraint Systems, No. NTSB/SS-11/01 (
n9 NTSB, Introduction of
n10 NTSB, Runway Overrun and Collision Southwest Airlines Flight 1248, Boeing 737-7H4, N471WN,
n11 See e.g., NTSB, Runway Overrun During Rejected Takeoff,
n12 NTSB, Loss of Control on Approach:
n13 A-10-10 through -34; reiterated recommendations A-05-1, A-05-14, and A-07-13.
n14 Pub. L. 111-216,
n15 A-10-17 through -20.
n16 Recommendations A-10-10, -16, and -30 have been closed with unacceptable action. Recommendations A-10-13, -14, -15, and -22 remain open with unacceptable responses.
n17 NTSB,
n18 NTSB,
n19 NTSB, In-Flight Left Engine Fire American Airlines Flight 1400, McDonnell Douglas DC-9-82, N454AA,
n20 NTSB, Attempted Takeoff From Wrong Runway, Comair Flight 5191
n21 NTSB, Descent Below Visual Glidepath and Impact With Seawall, Asiana Airlines Flight 214 Boeing 777-200ER, HL7742,
n22 A-10-30.
n23 78 Fed. Reg. 2912 (
n24 79 Fed. Reg. 8257 (
n25 NTSB, Crash Following Loss of Engine Power Due to Fuel Exhaustion Air Methods Corporation Eurocopter AS350 B2, N352LN, Near
n26 http://www.ntsb.gov/safety/mwl/Documents/MWL_2015_Factsheet_08.pdf.
n27 NTSB, Drug Use Trends in Aviation: Assessing the Risk of Pilot Impairment, No. NTSB/SS-14/01 (
n28 A-14-92 through -95.
n29
n30 See, e.g., A-06-10, A-08-44, and A-09-61 through -66.
n31 A-10-149.
n32 A-10-150.
n33
n34 Additional information about the forum is available at http://www.ntsb.gov/news/events/Pages/2014_Flight_Data_Locator_FRM.aspx.
n35 A-15-1 through -6.
n36 A-00-30. In 2006, the NTSB reiterated A-00-30 as a result of its investigation of a 2004 accident involving Corporate Airlines Flight 5966, a BAE-J3201 aircraft, in
n37 A-00-31.
n38 75 Fed. Reg. 1302 (
n39 79 Fed. Reg. 46012 (
n40 Foreign investigative entities have authority equivalent to the NTSB under ICAO Annex 13. For this accident, in particular, the NTSB has been involved as the accredited representative as the State of Operator, Registration, and Manufacturer. The operator, manufacturers, and regulator (
n41
n42 Additional information about the forum is available at http://www.ntsb.gov/news/events/Pages/2013_Lithium_Batteries_FRM.aspx.
n43 78 Fed. Reg. 1119 (
n44 79 Fed. Reg. 46012 (
Read this original document at: http://www.commerce.senate.gov/public/?a=Files.Serve&File_id=e7d696ab-17bf-4acb-9fd9-7590befb7ed4
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