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Fatal Accident a ‘Merger of Missteps’

Fri, Sep 17, 2010 — David Evans

Articles

Opening statement at 14 September hearing by

Deborah Hersman

Chairman, National Transportation Safety Board

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A little over a year ago, on August 8, 2009, a single-engine Piper aircraft that had departed Teterboro, New Jersey on its way to Ocean City, New Jersey, collided in mid-air with a sight-seeing tour helicopter, over the Hudson River, near Hoboken, New Jersey.

The Piper was operating as directed by air traffic control, hugging the airspace at about 1,100 feet, and waiting for authorization to climb higher. Meanwhile, the tour operator, travelling southbound along the Hudson River towards the Statue of Liberty, was rising beneath the Piper, climbing to about 1,100 feet. In mid-air, the two aircraft collided, killing all 9 aboard.

Mid-air collisions are not a new phenomenon. One of the most tragic mid-air collisions occurred on June 30, 1956, when two commercial airplanes collided over the Grand Canyon, killing all 128 on board.

The Grand Canyon collision was, at that time, the deadliest aviation accident in history, and it helped change the course for how we regulate our airspace. In its aftermath, we ushered in sweeping changes that included modernization of the Air Traffic Control system, and, ultimately, creation of the Federal Aviation Agency (FAA).

Sadly, this accident is a grim reminder that, despite a half century of regulatory changes and technological advances, mid-air collisions, like this one, still happen. Today, we have more control of the airspace, more equipment in the cockpit, and more aircraft in the skies than ever before. However, even with all of these improvements, in the last 25 years almost 700 people have died in mid-air collisions in the United States. And, on August 8, 2009, a merger of missteps, that began minutes before the accident, set these two aircraft on a collision course.

The view from the Piper less than a second before impact.

The view from the Piper less than a second before impact.

Today, we will discuss those missteps, and how the technology designed to prevent such a collision, and the concept of “see and avoid” other aircraft, both failed. [See Aviation Safety Journal, “Mid-Air Collision Reveals Limitations of ‘See and Avoid’ ”]

What I find so striking about this accident is that the airplane pilot was simply following his directions. And although the helicopter’s conspicuity was improved by anticollision lights and a high-visibility paint scheme on the blades – these enhancements didn’t help. Both aircraft were equipped with radios and traffic information systems, yet they didn’t hear or see each other, and the technology did not prevent the accident, and the air traffic system neither separated them nor alerted them that they were about to collide.

Much of our discussion today will focus on how to improve the safety of flight in dense traffic corridors, including the Hudson River, and let me say, that these safety improvements are critically needed …

Within days of the accident, the FAA convened a task force – the New York Visual Flight Rule Airspace Task Force – made up of ATO (the Air Traffic Organization), NATCA [National Air Traffic Controllers Association], and representatives from local FAA air traffic control facilities, Flight Standards, representatives of fixed-wing and helicopter operators, and the Port Authority of New York and New Jersey. The task force looked at how aircraft operate in the New York City area, and within weeks, issued safety recommendations. Many of those recommendations mirrored early recommendations issued by the Safety Board. [See Aviation Safety Journal, August 2009, “Calm Urged Until Hudson Mid-Air Is Thoroughly Investigated,” and September 2009, “Plans to Enhance New York Airspace Safety Breathlessly Announced”]

The FAA also published a final rule modifying the airspace above the Hudson River and defining how aircraft should operate there, including new maps issued by November, just three months after the accident.

Beyond that, the FAA has revised its Letters of Agreement (or LOAs) with air tour operators in the area, as well as established new LOAs with the towers for the major airports and with New York TRACON [Terminal Radar Approach Control]. The modified agreements include changes to procedures, among other things, so that transiting aircraft are handled by ATC and do not operate in the Hudson River corridor.

While some improvements were focused exclusively on the New York/New Jersey area, some changes in the last year have national implications. For example, the FAA has accelerated its nation-wide deployment of the Traffic Analysis Review Program (TARP) – software that automatically detects losses of aircraft separation at terminal facilities. In addition, the controllers and the FAA have been working to address fatigue in a cooperative manner.

Of all these improvements, perhaps the most encouraging has been the FAA and NATCA’s efforts to establish the ASTAP (Air Traffic Safety Action Program) nationwide. And while recent headlines have highlighted the high number of ASTAP reports, the value of the system is that we are now getting those reports. By encouraging non-punitive, open reporting and then mining the data, the industry can identify safety threats and precursors – before catastrophe strikes.

I might add that the ability to avoid future accidents like this one is dependent on a fully implemented ADS-B (automatic dependence surveillance-broadcast) program. The FAA has taken initial steps to move towards an ADS-B-based ATC environment, but that is an expensive proposition. If we are serious about changing the paradigm and moving forward, then its critical that ADS-B, both in and out, be a part of this next phase of safety for collision avoidance. [Note, ADS-B out refers to information provided controllers. ADS-B in refers to information the system provides pilots. In its initial application, the FAA will implement ADS-B out only. The big jets are equipped with TCAS for avoiding mid-air collisions. Without an upgrade to the Traffic Information System, or TIS, small aircraft like the Piper in this accident will have no improvement to their collision awareness tool.]

In light of the many positive developments we have seen – steps that occurred in advance of our final report – I am hopeful that this is the prologue to the future and that, when it comes to embracing change to improve the system, the recommendations we issue today will see that same proactive response.


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