Good morning and thank you for having me. And, more importantly, thank you for what you are doing to enhance general aviation (GA) safety. I want to acknowledge the good work of GAMA to facilitate the General Aviation Joint Steering Committee (GAJSC) and the US Helicopter Safety Team (USHST). As you know, the efforts of these groups are making a profound effect on lowering accident rates for their respective areas of focus.
We at the NTSB have both a personal and professional interest in general aviation. Each of our aviation safety investigators and many of our other staff are pilots. And look at the composition of the Board. Member Chris Hart has been a GA pilot since 1970 and has over 3,000 flight hours. He’s type rated (SIC) in the Cessna Citation Excel, where he has around 500 hours. Member Earl Weener owns a Bonanza, holds a CFI, and has over 50 years of GA flying experience. Bruce Landsberg, a name I’m sure many of you recognize from his days at AOPA, has been nominated by President Trump to fill a seat on the Board. He has his Senate confirmation hearing on Tuesday. Bruce flies his own Bonanza. And for me, well, I started flying at age 17 and was a CFI at 19. I instructed all through college and was hired by my university to be their full-time pilot when they purchased a brand-new Piper Navajo Chieftain in 1979. After my airline career I flew for, and managed, a business aviation flight department. I left in 2006 when I was appointed to the NTSB. So, we are big on GA! And, like you, we want this important segment of aviation to be even safer.
GAMA’s strategic plan includes a number of laudable areas that are focused on advancing aviation safety in the United States and around the world, including helping to reduce the US GA fatal accident rate to no more than 1.00 fatal accidents per 100,000 hours by FY2018. And, look at the latest figures – NTSB’s preliminary figures for 2016 indicate the fatal accident rate is 0.96 fatalities per 100,000 flight hours.
From looking at your strategic plan, I know that we share the common focus on improving aircraft crashworthiness, preventing loss-of-control (LOC) accidents, and aircraft icing.
As it relates to improving crashworthiness, the NTSB is very concerned with the lack of crash-resistant fuel systems (CRFS) in helicopters. In March, we completed the investigation of a AS350-B3 that crashed at Frisco, CO in 2013. The pilot did not properly configure the helicopter for takeoff and crashed shortly after takeoff. The impact forces were survivable, but the post-crash fire claimed the life of the pilot. One of the surviving flight nurses received burns over 90 percent of his body.
The accident helicopter was not equipped with a CRFS. Although not required for this helicopter, CRFS are intended to reduce the risk of a postcrash fire and, for more severe crashes, minimize fuel spillage near ignition sources to improve the evacuation time needed for crew and passengers to escape a postcrash fire. The NTSB believes that if this helicopter had been equipped with a CRFS, the potential for thermal injuries to the occupants would have been reduced or eliminated. We have issued recommendations to FAA and European Aviation Safety Agency (EASA) to require these important crashworthiness systems.
Turning now to LOC and aircraft icing, the December 2014 crash of an Embraer Phenom 100 at Gaithersburg MD provides a good example of these two issues. The NTSB determined that during the descent and approach, the aircraft flew in conditions conducive for structural icing for at least 15 minutes. Despite these conditions, the pilot did not activate the wing and tail deicing equipment. The icing conditions led to a stall prior to sounding of the aural stall warning or the activation of the stick shaker. Aircraft control was lost. Unfortunately, when the upset occurred, the aircraft was too low for a successful recovery. The aircraft struck the first house in a 110 degree left-wing-down attitude. The three occupants of the aircraft were killed, as was a young mother and her two children who were in a house that was consumed by the post-crash fire.
Although the NTSB could not positively ascertain why the pilot failed to activate the deicing equipment, one possible scenario the Board considered was that the pilot became task-saturated and forgot to turn on the equipment. The Board adopted a recommendation to GAMA to “work with the FAA to develop a system that can automatically alert pilots when the ice protection systems should be activated on turbofan airplanes that require a type rating and are certified for single-pilot operations and flight in icing conditions.” (NTSB recommendation A-16-13). This recommendation makes a lot of sense to me. A few of the air carrier aircraft that I flew – airplanes that required two pilots – had ice detector lights and aural indications to remind pilots of the need to activate the ice protection. If it was required on two-pilot airplanes where workload could be shared by two pilots, why would such a system not be installed on aircraft certified for single pilot operations? I’m pleased that GAMA followed up very quickly on this recommendation is actively working on it.
While I’m discussing this accident, let me give kudos to Embraer for their decision to install a cockpit voice recorder (CVR) and flight data recorder (FDR), even though these recorders were not required for an aircraft of this size. The report specifically stated: “Embraer’s decision to install a cockpit voice and data recorder in the [Phenom] fleet greatly benefited the NTSB’s investigation …. by ensuring investigators had access to critical information for determining the sequence of events that led to the accident and identifying actions needed to prevent a similar accident in the future.” Let me take this opportunity to challenge the leaders of the general aviation manufacturing community to move in a similar direction if you’re not already doing so.
We’ve also received good information from crashes involving Appareo image recorders. In our investigation of the 2013 accident involving an AS350 B3, operated by Alaska Department of Public Service, investigators found the Appareo unit to be extremely helpful in understanding the accident sequence. Although the Appareo unit was not a crash-resistant flight recorder system (nor was it required to be crash-resistant), the NTSB found that “it provided valuable information about the accident flight that helped investigators identify safety issues that would not have been otherwise detectable.” Because of the Appareo unit, our investigators were able to see “where the pilot’s attention was directed, his interaction with the helicopter controls and systems, and the status of cockpit instruments and system indicator lights, including those that provided information about the helicopter’s position (like the attitude indicator), engine operation, and systems.” It also enabled investigators to “conclusively determine that icing was not a factor in the accident and that there were no mechanical anomalies with the helicopter.”
Moving on, I know we’d all like to prevent the accident from occurring, but if there is an accident that involves your product, do you know how to interface with NTSB? Let me give you four take-home points.
First, become a party member. NTSB uses a party system whereby organizations that can provide technical expertise to the investigation actively participate in the NTSB’s investigation. Parties work alongside NTSB investigators to gather factual information pertinent to the investigation. By statue, FAA is always afforded party status. Other party members typically include the aircraft operator, aircraft and engine manufacturers, and labor organizations such as pilot, air traffic controller, and mechanic unions.
The advantages of the party system are numerous. It ensures the board has access to technical expertise in the fact-finding phase of the investigation, that all viewpoints are heard, and that the investigation itself is transparent. When you have FAA, airframe manufacturer, engine manufacturer, operator, and unions all participating, the fact that everyone is looking over each other’s shoulder has an amazing effect: in addition to tremendous synergies created by the process, it ensures that all perspectives are considered, and no stone is left unturned.
My second take-home point is for you to make a party submission. This is your opportunity to provide NTSB with your interpretation the facts surrounding the accident, along with your proposed findings, probable cause, and proposed recommendations. I make it a point to read all party submissions.
Third, and this is one thing many organizations don’t take advantage of – set up a meeting with each individual Board Members before the board meeting. This gives you the chance to explain your thoughts, and it also gives each Board Member thee opportunity to ask you questions.
This year is the NTSB’s 50th anniversary year. We generally get it right, but in spite of our best efforts, sometimes we miss something. And this leads to my fourth "take home" point - we have provisions for Petition for Reconsideration. The statute allows that if you have new information that may be relevant to the investigation or if there is erroneous information, a party may file a Petition for Reconsideration.
So, to sum it up, I recommend you become a party to the investigation, make a party submission, meet with Board Members, and finally, if you feel the Board got it wrong or missed something, you can file a Petition for Reconsideration.
In closing – back to my original points – I came here today to thank GAMA for your efforts to improve general aviation safety, and to show that we are aligned on many fronts. I sincerely appreciate all you’ve done in this regard. Keep up the great work!
Be safe and thank you!