List of NTSB 'Most Wanted' Safety Improvements Languish

The status accorded the National Transportation Safety Board (NTSB) to its "Most Wanted" list of recommendations ranges from "unacceptable response" to "progressing too slowly." None of the board's aviation-related recommendations received a green light in terms of the basic Federal Aviation Administration (FAA) response or the alacrity with which the board's recommendations are being implemented.

At a Nov. 15 hearing to update the situation, Acting Chairman Mark Rosenker said, "We are encouraged by the progress that we have seen in the acceptance rate of our recommendations." However, he was referring to the total. On its "Most Wanted" list for aviation, the NTSB has 22 recommendations, and they have either been rejected outright or are receiving a slow roll in terms of implementation. The FAA's response may reflect a combination of industry resistance, dispute over the need, and maybe even a concern for the cost.

Indeed, there was some discussion among board members about whether the resistance to the recommendations is politically or financially motivated. However, the cost issue may be a canard, if one considers amortization over a period of years. Many of the "Most Wanted" recommendations have languished for nine years or more, and the cost of implementation, stretched over that period of time, is small. To be sure, accidents avoided is a huge cost saving for the industry.

Herewith, the box score on the "Most Wanted" recommendations:

Stop runway incursions and ground collisions of aircraft. "There is an urgent need" for improved warning direct to aircrews, said Sandy Rowlett, an NTSB staffer. This need is based on three near collisions in the past six months, where the FAA's airport movement area safety system (AMASS) did not provide timely warning to air traffic controllers, who would then pass warnings along to aircrews. Either the AMASS was turned off to avoid false alarms in the rain, or it was not configured to provide alerts for intersecting runways. A good example of this was provided June 9 at Boston's Logan International Airport, when an Aer Lingus A330 and a US Airways B737 came frighteningly close on takeoff. A total of 336 people were aboard the two airplanes.

In his statement to investigators, the first officer on the US Airways jet said, "After passing V1, I noticed an Aer Lingus A330 rotating just prior to the intersection and stated 'keep it down' and pushed the control column forward to prevent the captain [the pilot flying] from rotating the aircraft. The Airbus passed overhead our aircraft with very little separation, and once clear of the intersection the captain rotated and lifted off towards the end of the runway."

Rowlett said AMASS was installed without the capability of detecting impending collisions on intersection runways "to get something" deployed to curb runway incursions. The FAA designated Boston the test facility on 11 Nov. for assessing the intersecting runway software for AMASS. However, Rowlett pointed out that AMASS warns controllers, not aircrews, and that when this recommendation was made in 2000, the FAA was asked specifically to develop a system "that would provide direct warnings to flight crews, thus providing pilots with additional time to react to potential hazards."

NTSB Member Deborah Hersman pointed out that the FAA is recording three operational errors each day, and one severe operational error every nine days. "I think one severe high-risk event every nine days warrants a higher priority, and to provide direct warning to pilots," she said.

Rowlett noted that the Mitre Corp. is conducting experiments and simulations for the FAA of a lighting system on the runway centerline to provide this kind of direct warning to pilots.

Recommendation: implement a safety system for ground movement that will ensure safe movement of airplanes on the ground and provide a direct warning to the flight crew. Status: "Open - Unacceptable Response." The recommendation has a red color-coded timeliness classification, signifying an unacceptable response.

Reduce dangers to aircraft flying in icing conditions. The NTSB maintains that the FAA has not adopted a systematic and proactive approach to the certification and operational issues of transport-category airplane icing. As NTSB icing expert Dan Bower said, "The certification standards need to be upgraded." He noted the laggard response to the NTSB recommendation dating back to 1996 to account for supercooled liquid droplets (SLD) in certification.

The FAA has recently proposed new certification standards for icing, but they do not include SLD. "The response to the [NTSB] recommendation is taking nine years," he pointed out.

On top of which, the notice of proposed rulemaking published Nov. 4 is only a proposal (see ASW, Nov. 14). Hersman asked, "Is there any confidence that the rule will get finalized?"

"I'm hopeful," Bower replied. He pointed out that the industry may not yet fully appreciate the danger of even a small amount of ice on upper wing surfaces. He cited the icing-related crash on takeoff Nov. 29, 2004, at Montrose, Colo., of a Bombardier Challenger CL-600 jet. Upper wing ice contamination is being investigated. Bower quoted from a Colorado news report, "A pilot, and president of a worldwide charter aircraft referral service, said the Challenger's engines were powerful enough to take off even with icy wings." The article had this individual saying, "The extra weight of ice and snow shouldn't have made a difference; it should have been able to bully its way through."

But as Bower pointed out, "Research results have shown that fine particles of frost or ice, the size of a grain of table salt and distributed as sparsely as one per square centimeter over an airplane wing's upper surface can destroy enough lift to prevent that airplane from taking off." And of course, in some aircraft types, a loss of smooth laminar flow over the wings will have a direct effect upon tailplane airflows and its effectiveness for generating rotation (nosewheel off on takeoff).

In addition to not covering SLD, Hersman noted that the new rule, if adopted, applies to new-production airplanes only. That is a far cry from "reducing the dangers to aircraft flying in icing conditions," which by definition applies to the existing fleet as well.

Recommendation: complete research on aircraft structural icing and continue to revise icing certification criteria, testing requirements, and restrictions on operations in icing conditions. Status: "Open - Unacceptable Response." The recommendation has a red color-coded timeliness classification, signifying an unacceptable response.

Eliminate flammable fuel/air vapors in fuel tanks on transport category aircraft. "The issue before us is totally unacceptable," said NTSB member Ellen Engleman-Conners. Specifically, the short-term recommendation issued nine years ago, to modify operations "to reduce the potential for fuel-air mixtures in the fuel tanks of transport category aircraft" was closed by the NTSB after it became apparent that the FAA would not act on it. This recommendation basically involved near term actions to reduce the temperature in center fuel tanks (such as by loading them with chilled fuel).

The NTSB also called for "design modifications such as nitrogen-inerting and insulation between heat-generating equipment and fuel tanks." In response to this recommendation, the FAA developed an inerting system using nitrogen- enriched air three years ago, but it took until Nov. 14 for the FAA to issue an NPRM suggesting that the system be deployed on new and existing airplanes with heated center wing tanks, about one-third of the fleet [this NPRM will be discussed in the next issue of ASW]. Airplanes without heated center wing tanks, i.e., without heat-generating air conditioning packs under the tanks, will not need to be inerted. This caveat applies to wing tanks as well, which avoids the issue that overheated or faulting fuel pumps can occur in any tank (the scenario involving the fuel tank explosion in a Phillipine Airlines B737 in 1990). It also ignores dangerous electrical arcing outside the tank, whose energy may find its way into a low-power circuit within the tank (the likely scenario regarding the center wing tank explosion on a TWA B747 in 1996).

The NTSB's resident expert on fuel/air flammability, Bob Swaim, noted that the European Aviation Safety Agency (EASA) plans to mandate inerting as a production cut-in in 2008, but that does not include the Airbus A380, which does not feature a heated center wing tank, and no retrofit of inerting to the existing fleet is planned. "The EASA recommendation will cover 300-400 airplanes, and the safety board disagrees with the position taken on the A380," he noted.

Because the FAA took no action on the short-term recommendation, it was closed as unacceptable action.

Recommendation: complete rulemaking efforts to preclude the operation of transport-category airplanes with flammable fuel/air vapors in the fuel tanks on all aircraft. Status: "Open - Acceptable Response." The recommendation has a yellow color-coded timeliness classification, signifying that the response is acceptable but progressing too slowly.

Improve aviation audio and data recorders and require cockpit video recorders. The NTSB wants five things: (1) retrofit 30-minute cockpit voice recorders (CVRs) to 2-hour CVRs, (2) provide 10-minutes of independent back up power for recorders, (3) fit aircraft with fore and aft dual-redundant CVRs and flight data recorders (FDRs), (4) provide additional recorder parameters for the B737 to better discriminate between pilot control inputs and system flaws in the event of rudder reversals, and (5) equip aircraft with cockpit image recorders.

It's a lot, and so far the FAA has delivered very little. In February 2005 the FAA issued an NPRM calling for 2-hour CVRs to be retrofitted (see ASW, Feb. 28). However, the NPRM called for the 10-minutes of independent backup power to be installed only on new aircraft, and it did not call for dual redundant CVRs/FDRs.

Jim Cash, the NTSB's recorder expert, noted that the new Embraer EMB-190 and the Boeing B787 will have, or at least sport as options, both fore and aft recorders.

The FAA is now digesting comments submitted on the NPRM and is expected to issue a final rule in 2006.

The FAA has yet to issue requirements, proposed or otherwise, on B737 FDR parameters, although the FAA has not decreed that the rudder system redesign of the B737 meets the safety board's standard for "reliable redundancy."

Regarding image recorders, there are two parts to the NTSB's wish list. First, it wants the recorders in transport category aircraft to complement the voice and data captured by the CVR/FDR. The image recorders would enable investigators to see the instruments and controls, and to gauge pilot actions (and note movement in and out of the cockpit, and how many personnel are in the cockpit). The image recorder recommendation is an outgrowth of the EgyptAir Flight 990 accident, where a relief pilot is thought to have plunged the aircraft into its death dive, and of Swissair Flight 111, in which the cockpit crew was overwhelmed by an inflight fire and in which there was a critical 6- minute gap in recorded information as a result of the loss of power.

Second, the NTSB seeks image recorders in all Part 121/135 turbine aircraft not required to be outfitted with CVRs/FDRs. By this means, at least some record of the flight, instrument displays, control positions and pilot actions will be attained. The FAA has flight tested one such video recorder, and hopes to issue a technical standard order (TSO) sometime in 2006 indicating how the system will be set up and working. However, the FAA has not issued a proposed requirement for video recorders, either as a complement to existing CVRs/FDRs or as a stand-alone recorder for those aircraft not equipped with any CVR/FDR capability

Recommendation: In addition to adopting the 2-hour CVR requirement, require the retrofit of existing CVRs with Recorder Independent Power Supply (RIPS), and require that the existing FDR and CVR be on separate generator busses with the highest reliable power so that any single electrical failure does not disable both. Require the installation of video recording systems in small and large aircraft. Require the recording of additional needed FDR data for B737s. Status: "Open - Unacceptable Response." The recommendation has a red color-coded timeliness classification, signifying an unacceptable rate of progress.

Require restraint systems for children under age 2. The board members were visibly dismayed by the FAA's action Aug. 26 withdrawing an advance notice of proposed rulemaking (ANPRM) that would have required restraint systems for infants and small children (see ASW, Sept. 12).

In October, the FAA separately informed the NTSB that child restraints will not be required. The FAA's rationale is that making parents buy a seat for the at-present lap children will encourage highway travel, which is more dangerous and therefore more infants will be killed or injured. The FAA's argument was based on two academic studies of the increase in highway travel over air following the 9/11 attacks.

Member Engleman-Conners sniffed, "Anything based on 9/11 data is subject to significant review" regarding the diversion of air passengers to another mode of transportation.

Member Hersman pointed out that the diversion of passengers because of post-9/11 security requirements was not addressed. "The FAA hasn't raised the diversion argument for anything other than children," she pointed out.

In addition, she said, neither FAA-cited study addressed the deaths of children.

An education effort, which is all the FAA is willing to commit to, appears to have yielded very superficial results. The FAA has a Web page devoted to child safety, but one has to know of its existence.

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