Media Advisory: 2021 – 2022 Most Wanted List of Transportation Safety Improvements Subject of NTSB Meeting6 months ago
WASHINGTON (April 1, 2021) — The National Transportation Safety Board announced Thursday its intent to hold a public board meeting April 6, 9:30 a.m. Eastern time, to finalize its 2021 – 2022 Most Wanted List of Transportation Safety Improvements.The NTSB’s Most Wanted List of Transportation Safety Improvements is a communication tool through which the agency identifies its top safety improvements that when made will prevent accidents, reduce the number and severity of injuries, and save lives. In keeping with established federal and local social distancing guidelines to prevent the spread of the coronavirus, while also ensuring the NTSB’s compliance with the Government in the Sunshine Act, the board meeting for the Most Wanted List will be webcast to the public, with the board members and NTSB staff meeting virtually. There will be no physical gathering to facilitate the board meeting. WHO: NTSB staff and Board Members.WHAT: A webcast of a virtual board meeting to determine the 2021 – 2022 Most Wanted List of Transportation Safety Improvements.WHEN: Tuesday, April 6, 2021, 9:30 a.m. Eastern time.HOW: The board meeting will be webcast only, there will not be a public gathering of NTSB staff or board members. A link to the webcast will be available shortly before the start of the meeting at http://ntsb.windrosemedia.com/. MEDIA AVAILABILITY: NTSB Chairman Robert Sumwalt is scheduled to hold a virtual media availability that will begin 30 minutes after the board meeting concludes.The virtual media availability with Chairman Sumwalt will be conducted via Microsoft Teams Live Event. Journalists who RSVP to firstname.lastname@example.org will receive an email with the link to and information about how the availability will be conducted. A recording of the availability will be made available on the NTSB’s YouTube channel as soon as practicable.
WASHINGTON (April 6, 2021) — The National Transportation Safety Board finalized its 2021 – 2022 Most Wanted List of Transportation Safety Improvements during a board meeting held Tuesday.The five-member board voted to include 10 items in the 2021-2022 Most Wanted List of Transportation Safety Improvements:Require and Verify the Effectiveness of Safety Management Systems in All Revenue Passenger Carrying Aviation OperationsPrevent Alcohol and other Drug Impaired DrivingRequire Collision Avoidance and Connected Vehicle Technologies on All VehiclesEliminate Distracted DrivingImplement a Comprehensive Strategy to Eliminate Speeding-Related CrashesInstall Crash Resistant Recorders and Establish Flight Data Monitoring ProgramsProtect Vulnerable Road Users through a Safe System ApproachImprove Pipeline Leak Detection and MitigationImprove Rail Worker Safety (page/content under development)Improve Passenger and Fishing Vessel Safety (page/content under development) Since 1990 the NTSB has used its Most Wanted List as the principal advocacy tool to build support for the implementation of NTSB-issued safety recommendations associated with the list.“Board members of the NTSB and our advocacy team continuously seek opportunities to communicate about items on our Most Wanted List,” said NTSB Chairman Robert Sumwalt. “As we begin advocacy efforts for the 2021 – 2022 MWL, we call upon our advocacy partners to amplify our safety messages and help us bring about the safety improvements that will make transportation safer for us all.The 2021 – 2022 MWL draws attention to more than 100 safety recommendations associated with the 10 items on the list. These recommendations, if implemented, can save lives, reduce the number and severity of injuries and prevent transportation accidents and crashes. The 2021-2022 MWL features 10 mode-specific safety improvements, unlike previous lists that featured 10 broad, multi-modal safety issues tied to hundreds of recommendations.
WASHINGTON (April 8, 2021) – The National Transportation Safety Board Thursday found that the erratic steering of a supply vessel led to a 2019 collision resulting in more than 6,000 gallons of diesel oil being dumped into the Sabine Pass, a busy waterway between Texas and Louisiana.The NTSB Thursday released Marine Accident Brief 21/08 detailing its investigation of the collision between offshore supply vessel Cheramie Bo Truc No 22 and the Mariya Moran/Texas on Nov. 14, 2019, in the Sabine Pass Jetty Channel, Port Arthur, Texas.The NTSB said the probable cause of the collision was the Cheramie Bo Truc No 22 turning into the path of the Mariya Moran/Texas. Damages from the collision exceeded $1.8 million, and the waterway was closed for a time for the diesel oil spill cleanup. (The Cheramie Bo Truc No 22 before the Nov. 14, 2019, collision with the Mariya Moran/Texas. Source: shipspotting.com)During the accident sequence, the on-watch AB and engineer expressed concern to the mate of the Cheramie Bo Truc No 22 regarding his erratic steering. The mate ignored them, yet neither the on-watch AB nor the engineer notified the captain.A post-collision alcohol test administered by the captain indicated the mate had drank recently but did not demonstrate conclusively that the mate was impaired by alcohol.“However, attempting to use the autopilot in a channel, nearly colliding with stationary jack-ups, weaving across the channel, ignoring the warnings from the on-watch AB and engineer in the wheelhouse, and suddenly turning in front of the [Mariya Moran/Texas] all indicate a degree of misjudgment, impairment, and/or incompetence,'' the NTSB's report said.Contributing to the collision was a lack of early communication from both vessels.“Safe and effective navigation is not one person's job,'' the NTSB's report said. “Bridge resource management includes the concept of teamwork, which is an essential defense against human error. A good team should anticipate dangerous situations and recognize the development of an error chain. If in doubt, team members should speak up or notify a higher authority. Vessel operators should train their crews on and enforce their safety policies."The full report, Marine Accident Brief 21/08 can be found at https://go.usa.gov/xHgwf.
Inadequate Flight Training, Poorly Maintained Airplane, Insufficient Oversight, Contributed to Parachute Jump Flight Accident6 months ago
WASHINGTON (April 13, 2021) — The National Transportation Safety Board detailed in an accident report issued Tuesday the circumstances that led to the June 21, 2019, crash of a parachute jump flight that killed all 11 people on board.The NTSB determined that the probable cause of the accident was the pilot's aggressive takeoff maneuver, which led to an accelerated stall and a subsequent loss of control at an altitude too low for recovery. Safety issues found during this investigation were discussed at the March 23, 2021, public board meeting on Part 91 revenue passenger-carrying operations. The twin-engine Beech King Air 65-A90 airplane, which was operated by Oahu Parachute Center, crashed adjacent to the runway shortly after departing Dillingham Airfield in Mokuleia, Hawaii, with one pilot and 10 passengers aboard. (In this photo, taken on June 23, 2019, NTSB Investigator-in-Charge Eliott Simpson and Board Member Jennifer Homendy examine wreckage at the scene of the Mokuleia, Hawaii, June 21, 2019, crash of a Beech 65-A90. The airplane crashed shortly after departing Dillingham Airfield for a parachute jump flight. NTSB photo by Eric Weiss.)The airplane was involved in a stall/spin accident in 2016 during a parachute jump flight in California while it was operated by another company and flown by another pilot. Although no one was injured during the aerodynamic stall and subsequent series of spins, the plane shed parts and a wing was twisted during the inflight recovery. During the investigation of the June 2019 crash, NTSB investigators discovered the twisted left wing, from the 2016 incident, was not repaired, leaving the airplane in an unairworthy condition. The NTSB said the damage reduced the left wing's stall margin and could cause the airplane to roll left in certain flight conditions. The NTSB said the failure of Oahu Parachute Center and its contract mechanic to maintain the airplane in an airworthy condition contributed to the accident.Investigators found the pilot's flight instructor provided substandard initial instruction, and that Oahu Parachute Center provided insufficient training in the operation of the airplane. Although the pilot was properly certificated to fly the accident airplane, investigators said his lack of adequate training and experience in the handling qualities of the airplane in particular flight conditions contributed to the accident. The NTSB detailed these deficiencies in the report and issued a series of safety recommendations in January to address this safety issue. The NTSB noted the Federal Aviation Administration did perform inspections of Oahu Parachute Center, but those inspections, which failed to identify the damaged left wing of the accident airplane, were insufficient to ensure the safety of that commercial passenger-carrying operation. The FAA's insufficient regulatory framework for overseeing parachute jump operations was discussed in the NTSB's report, Enhance Safety of Revenue Passenger-Carrying Operations Conducted Under Title 14 Code of Federal Regulations Part 91. In that report, the NTSB issued a recommendation to the FAA to develop a new regulatory framework for these operations, which include parachute jump flights. The full accident report, Collision with Terrain During Takeoff of Parachute Jump Flight, Beech King Air 65-A90, Mokuleia, Hawaii, June 21, 2019, is available online at https://go.usa.gov/xHbt8.Enhance Safety of Revenue Passenger-Carrying Operations Conducted Under Title 14 Code of Federal Regulations Part 91 is available online at https://go.usa.gov/xHbMj.
Pilot’s Actions, Maintenance Issues, Ineffective Safety Management System and Oversight, all Contributed to Fatal Crash of Historic B-17 Airplane6 months ago
WASHINGTON (April 13, 2021) — The National Transportation Safety Board detailed in an accident report issued Tuesday the circumstances that led to the crash of a Boeing B-17G airplane that killed seven people and injured seven others.The NTSB determined the probable cause of the accident was the pilot's failure to properly manage the airplane's configuration and airspeed following a loss of engine power. Safety issues found during this investigation were discussed during a March 23, 2021, public board meeting on Part 91 revenue passenger-carrying operations.The Word War II-era Boeing B-17G airplane had just departed Bradley International Airport in Windsor Locks, Connecticut, Oct. 2, 2019, on a “living history flight experience" flight with 10 passengers when the pilot radioed controllers that the airplane was returning to the field because of an engine problem. The airplane struck approach lights, contacted the ground before reaching the runway and collided with unoccupied airport vehicles; the majority of the fuselage was consumed by a post-crash fire.(This figure shows the airplane's flightpath on Oct. 2, 2019, between 9:46 a.m., when the airplane was cleared for takeoff, and 9:51 a.m., when one of the pilots reported the airplane was at midfield. The locations when the airplane reached 400, 300, and 150 feet above ground level are also shown. NTSB graphic overlay on Google Earth image.)Flightpath data indicated that during the return to the airport the landing gear was extended prematurely, adding drag to an airplane that had lost some engine power. An NTSB airplane performance study showed the B-17 could likely have overflown the approach lights and landed on the runway had the pilot kept the landing gear retracted and accelerated to 120 mph until it was evident the airplane would reach the runway.The pilot also served as the director of maintenance for the Collings Foundation, which operated the airplane, and was responsible for the airplane's maintenance while it was on tour in the United States. Investigators said the partial loss of power in two of the four engines was due to the pilot's inadequate maintenance, which contributed to the cause of the accident.The NTSB also determined that although the Collings Foundation had a voluntary safety management system in place, it was ineffective and failed to identify and mitigate numerous hazards, including the safety issues related to the pilot's inadequate maintenance of the airplane.The Federal Aviation Administration's oversight of the Collings Foundation safety management system was also ineffective, the NTSB said, and cited both as contributing to the accident.The Federal Aviation Administration's inadequate oversight was discussed in the NTSB's report, Enhance Safety of Revenue Passenger-Carrying Operations Conducted Under Title 14 Code of Federal Regulations Part 91. In that report, the NTSB recommended the FAA require safety management systems for the revenue passenger-carrying operations discussed in the report, which included living history flight experience flights such as the B-17 flight.The NTSB also issued recommendations to the FAA that would enhance the safety of revenue passenger-carrying operations conducted under Part 91, including those conducted with a living history flight experience exemption, which currently allows sightseeing tours aboard former military aircraft to be operated under less stringent safety standards than other commercial operations.The full accident report, Impact with Terrain Short of the Runway, Boeing B-17G, Bradley International Airport, Windsor Locks, Connecticut, Oct. 2, 2019, is available online at https://go.usa.gov/xHbMw.Enhance Safety of Revenue Passenger-Carrying Operations Conducted Under Title 14 Code of Federal Regulations Part 91 is available online at https://go.usa.gov/xHbMj.
WASHINGTON (April 15, 2021) — The National Transportation Safety Board announced Thursday its intent to hold a public board meeting April 20, 2021, 9:30 a.m. Eastern time, to determine the probable cause of a fatal midair collision involving two air tour operators in Alaska.On May 13, 2019, a float-equipped de Havilland DHC-2 Beaver and a float-equipped de Havilland DHC-3 Turbine Otter collided in flight about eight miles northeast of Ketchikan, Alaska. The DHC-2 pilot and four passengers suffered fatal injuries; the DHC-3 pilot suffered minor injuries, nine passengers were seriously injured, and one passenger suffered fatal injuries.The NTSB’s five-member board will vote on the findings, probable cause and recommendations as well as any changes to the draft final report. (In this photo taken on May 15, 2019, NTSB investigator Clint Crookshanks and Member Jennifer Homendy are near the wreckage of the DHC-2 Beaver involved in the May 13, 2019, midair collision near Ketchikan, Alaska. NTSB photo by Peter Knudson)In keeping with established federal and local social distancing guidelines to prevent the spread of the coronavirus, while also ensuring the NTSB’s compliance with the Government in the Sunshine Act, the board meeting for this event will be webcast to the public, with the board members and investigative staff meeting virtually. There will be no physical gathering to facilitate the board meeting.WHO: NTSB investigative staff and board members.WHAT: A webcast of a virtual board meeting.WHEN: Tuesday, April 20, 2021, 9:30 a.m. Eastern time.HOW: The board meeting will be webcast only, there will not be a public gathering of NTSB investigative staff or board members. A link to the webcast will be available shortly before the start of the meeting at http://ntsb.windrosemedia.com/.MEDIA AVAILABILITY: NTSB Chairman Robert Sumwalt is scheduled to hold a virtual media availability that will begin 30 minutes after the board meeting concludes.The virtual media availability with Chairman Sumwalt will be conducted using Microsoft Teams Live Event. Journalists who RSVP to email@example.com will receive an email with the link and information about how the availability will be conducted. A recording of the availability will be made available on the NTSB’s YouTube channel as soon as practicable.
WASHINGTON (April 20, 2021) — A midair collision of two air tour airplanes was caused by “the inherent limitations of the see-and-avoid concept" along with the absence of alerts from both airplanes' traffic display systems, the National Transportation Safety Board announced during a public meeting Tuesday.“From the earliest days of powered flight, pilots have been taught to avoid other airplanes by watching out for them," said NTSB Chairman Robert L. Sumwalt. “This accident clearly demonstrates why that's just not enough. Our investigation revealed that it was unlikely that these two experienced pilots could have seen the other airplane in time to avoid this tragic outcome."The two airplanes, a float-equipped de Havilland DHC-2 Beaver operated by Mountain Air Service and a float-equipped de Havilland DHC-3 Otter operated by Taquan Air, collided at an altitude of 3,350 feet about eight miles northeast of Ketchikan, Alaska, May 13, 2019. The DHC-2 pilot and four passengers died; the DHC-3 pilot suffered minor injuries, nine passengers were seriously injured, and one passenger died.(This graphic shows the flightpaths of the DHC-2 and DHC-3 airplanes from the Misty Fjords National Monument area to the location of the collision eight miles northeast of Ketchikan, Alaska, May 13, 2019. NTSB overlay on a Google Earth image.)To understand the opportunity each pilot had to identify the other airplane as the two converged, the NTSB conducted a cockpit visibility study. Using 3D laser scans of a cockpit of a DHC-2 and a DHC-3, passenger photos, recorded avionics and flight track data, investigators determined that the pilot of the DHC-2 would not have had the opportunity to see and avoid the DHC-3 because his view was obscured by the cockpit structure, right wing and a passenger in the copilot's seat. The lack of apparent motion of the DHC-2 when viewed from the DHC-3, and the obscuration of the DHC-2 by the window post for 11 seconds before the collision, made it difficult for the DHC-3 pilot to see the DHC-2 airplane.Both airplanes' traffic display systems were equipped with ADS-B Out and In, technology designed to enhance a pilot's awareness of aircraft that may present a collision risk by providing information on the other airplanes' position (latitude, longitude, and altitude) and velocity.Although the traffic display system installed on the DHC-3 depicted aircraft in the area, it could not provide aural or visual alerts to warn of a potential collision. The pilot of the DHC-3 last recalled looking at his traffic display about four minutes before the accident and did not identify any collision threats. A traffic alerting feature previously available in the DHC-3 was disabled by a 2015 equipment upgrade.Unlike the DHC-3, the pilot of the DHC-2 airplane had access to a traffic display system that could provide aural and visual alerts, but the DHC-2 pilot would not have received any such alerts because the DHC-3 airplane was not broadcasting required altitude information. "There's technology available to alert pilots to a collision risk when the see-and-avoid concept fails them," said Sumwalt. "But there were no alerts. A safety management system might have identified and mitigated the various risks associated with the limitations of the traffic display systems on each airplane. That's yet another example of why safety management systems is again on the NTSB's Most Wanted List of Transportation Safety Improvements."Investigators said that midair collisions accounted for about seven percent of Part 135 air tour operators' fatal accidents between 1982 and 2020, more than three times the percentage of fatal midair collisions for all other aviation operations in the U.S. Requiring all Part 135 operators, as well as all air tour operators in high-traffic areas, to be equipped with collision avoidance technology that provides visual and aural alerts, were two of the six new recommendations made to the Federal Aviation Administration Tuesday. The NTSB also reiterated a safety recommendation to the FAA for the sixth time in five years. That recommendation asked the agency to require all Part 135 operators to establish safety management systems. Additional safety recommendations were issued to aviation industry groups asking them to inform their members of the circumstances of this midair collision and encourage their members to address ways to maximize the safety potential of traffic display and alerting equipment.The NTSB also made recommendations to Taquan Air and the mobile application manufacturer ForeFlight.Investigators' presentations and an abstract including the findings, probable cause and safety recommendations is available at https://go.usa.gov/xH8gj. The complete final report is expected to be published in the coming weeks.The accident animation presented at the board meeting is available at https://www.youtube.com/watch?v=D52PoHHmcSI.The NTSB issued a Safety Alert on collision avoidance in November 2016: https://go.usa.gov/xH8gX.The NTSB's 2021-2022 Most Wanted List of Transportation Safety Improvements is available online at https://go.usa.gov/xH4X8.
WASHINGTON (April 21, 2021) – The National Transportation Safety Board found Wednesday that an improperly loaded barge resulted in the loss of 21 cargo containers into the ocean off the coast of Hawaii last year. The June 22, 2020 accident, 6.9 nautical miles north-northwest of Hilo, Hawaii, resulted in $1.6 million in damages. There were no injuries. The barge Ho'omaka Hou, owned and operated by Young Brothers, LLC, was being towed by the Hoku Loa at the time.The NTSB determined in Marine Accident Brief 21/09 that the probable cause of the collapse of container stacks onboard the barge was the company not providing the barge team with an initial barge load plan, as well as inadequate procedures for monitoring stack weights. That led to the undetected reverse stratification of container stacks that subjected the stacks' securing arrangements to increased forces while in transit at sea.(The collapsed row of containers on the barge Ho'omaka Hou in Hilo, Hawaii. Photo credit: U.S. Coast Guard.)The NTSB conducted a study to determine the locations of the centers of gravity for each stack in the collapsed row of containers on the Ho'omaka Hou based on the weights of each container as provided by the company. The NTSB study showed that most were loaded in a manner that produced reverse stratification — meaning that heavier containers were loaded above lighter containers. Normal stratification is preferred because it creates a stack having the lowest possible center of gravity.The containers were secured primarily with stacking cones, which provided little protection against the containers leaning or tipping. It is likely that when the barge turned about 30 degrees to a new south-southeasterly course the dynamic rolling from the seas on the vessel's beam resulted in forces on the container stacks with the greatest reverse stratification, likely causing the containers to tip over, causing the row to collapse, the NTSB found.“It is important for cargo planners to have tools, such as stow plans and calculations, to assist with determining proper stowage and the sufficiency of securing arrangements for containers stacked on barges, the report said. “These tools should address the potential that container stacks may be stacked in a reverse stratified manner."Marine Accident Brief 21/09 is available online at https://go.usa.gov/xH8JA.
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