NTSB, ‘frustrated’ and ‘disheartened,’ tries a new tactic

Investigators who are general aviation pilots themselves expressed “frustration,” and said the steady toll of accidents with preventable roots has left them “disheartened.” On March 12, the National Transportation Safety Board adopted a set of recommendations for GA pilots to consider, addressing the most common causes of accidents, each illustrated by a somber recounting of facts and circumstances from recent investigations.

Unlike many of the board’s proceedings, the session included personal accounts from investigators about how knowledge gained through investigations has shaped their own flying careers, helping them to avoid their own disasters.

“I, for one, would not be alive if it wasn’t for the valuable lessons I learned early in my career after reading and learning from the NTSB report of one particular high-profile spatial disorientation accident,” said staff investigator Eliot Simpson, referring to the 1999 crash that claimed the lives of John F. Kennedy Jr., his wife, and her sister. Simpson said he found himself in similar circumstances, and opted to stay on the ground—even though it meant his aircraft was grounded for days, far from home. “I would urge, at minimum, that pilots simply make a habit of reading and learning from the mistakes of others.”

The board spent more than three hours doing just that, recounting a litany of flights that ended in tragedy, and the chain of events and decisions that led to the outcome. Slides depicted radar tracks with a distinctive hook pattern characteristic of pilot disorientation in low visibility, photographs of wreckage showing smoking rivets that had not been repaired before launch, and bullet points detailing missed opportunities to break the chain of events leading to an accident. The goal, board members and staff said more than once, was not to assign blame (no accident pilots were mentioned by name), or support new regulations, but simply to get the attention of pilots, and “reach the unreachable.”

While commercial air transportation has virtually eliminated fatal accidents in recent years, Part 91 operators continue to come to grief at a steady pace: about 1,500 accidents a year, with about 475 fatalities each year. Board member (and pilot) Earl F. Weener said, “it’s worse than that”: The accident rate for personal flights has increased about 20 percent in the past decade, with a 25-percent increase in fatalities on personal flights, “and that’s the wrong direction.”

The board adopted a set of five “safety alerts” for GA pilots, focusing on common causes that all have aeronautical decision-making at their roots.

• Prevent aerodynamic stalls at low altitude
• Reduced visual references require vigilance
• Is your aircraft talking to you? Listen!
• Mechanics: Manage risks to ensure safety
• Pilots: Manage risks to ensure safety

Investigators detailed three accidents illustrating each of these points, and promised forthcoming videos that will recap individual investigations and resulting recommendations.

“I’m really hopeful that what we’re doing here is going to move the needle,” Weener said. “What we really need is to figure out how to change behavior.”

Board members and staff acknowledged contributions already made in that regard by the AOPA Foundation’s Air Safety Institute. A number of Air Safety Institute courses and programs were developed to address the specific root causes of the most common accidents.

Investigator Cahty Gagne said the topics of the alerts were chosen based on data, though it is challenging to be specific when it comes to causes and numbers.

The NTSB staff studied a range of common accident causes, including controlled flight into terrain, loss of control leading to stalls and/or spins (often the result of spatial disorientation), engine failure (often when known deficiencies are overlooked or dismissed), failure of other components, and unintentional flight into instrument meteorological conditions.

“Those five, we took and we sliced them up based on mitigation strategies,” Gagne said.

Board member Robert L. Sumwalt, who is also a pilot, wondered aloud if the safety alerts, videos, and a recording of the March 12 meeting itself were going to change anything.

“Is it really going to move the needle?” Sumwalt asked.

NTSB Aviation Safety Director John DeLisi said he hoped so.

“Our goal for these safety alerts is to try to catch the pilot who hasn’t had their accident, yet,” DeLisi said. “Maybe change the course of history.”

Chairman Deborah A.P. Hersman noted that cuts required by the so-called sequestration of federal spending will curtail the agency’s ability to travel, particularly for outreach.

“I think that will be our best vehicle, those packaged videos,” DeLisi said. “I think they would make a great resource on a rainy day, for a flight instructor to sit down with a student and spend a few minutes watching some videos.”

The board noted the alerts themselves have no regulatory effect, and said there’s no practical way to force Part 91 operators to adopt the same practices and procedures required of air carriers under Part 121, though Weener said he’d welcome that.

“I would really like to see the threat and error management construct adapted to the Part 91 kind of operations,” Weener said, inviting comments from staff. A few seconds passed in silence.

“Well, perhaps we’re taking the first step toward that today,” said DeLisi, “by highlighting this in a safety alert, and trying to inject that into the flying community.”