2011 ‘Most Wanted’ List Still a Pig in Lipstick

Fri, Jul 1, 2011 — David Evans

Articles, Featured

The “Most Wanted” list of safety improvements has been upgraded to reflect a more contemporary appearance, but no effort has been devoted to making the list more effective. Result: recommendations deemed especially critical languish on the list for years then disappear into a black hole of unrequited initiatives.

The National Transportation Safety Board (NTSB) revealed its new “Most Wanted” format on 23 June 2011 to reflect the most critical issue that need to be addressed this year to improve safety and save lives. Of the 10 critical changes, 6 deal with aviation; the others deal with busses, motorcycles, teenage driver safety, and alcohol impair driving.

The new format dispenses with the color coding of recommendations. A green circle was used to denote an acceptable response. A yellow circle was used to signify untoward delay; a red circle was used to mark an unacceptable response from the FAA. Since the vast majority of “Most Wanted” recommendations in the past were characterized with yellow or red circles – a potential embarrassment to the NTSB and the FAA – this feature has been dropped from the “new look”.

NTSB Chairman Deborah Hersman

Regarding the new format, Deborah Hersman, NTSB chairman, said:

“The NTSB’s ability to influence transportation safety depends on our ability to communicate and advocate for changes. The ‘Most Wanted’ list is the most powerful tool we have to highlight our priorities.”

If the “Most Wanted” list is the “most powerful” vehicle available to the NTSB, one must conclude that it really comprises a fairly weak tool. Improving the format of the list is not the same thing as getting the recommendations implemented.

Recall that the issue of child restraint systems was on the NTSB’s “Most Wanted” list for years. When the Federal Aviation Administration (FAA) refused to implement rulemaking that would mandate an end to infants and small children being held in an adult’s lap, the NTSB simply dropped its 1996 call for child restraints from the “Most Wanted” list in 2006.

Regarding fuel tank safety, the NTSB had a “Most Wanted” recommendation that all airliner fuel tanks should be inerted. That is, the void space in the tank should be filled with an inert gas to preclude an explosion if a spark or lighting discharge found its way into the tank. The FAA decided that only center wing tanks (inside the fuselage) with adjacent heat sources (e.g., air conditioning packs) need be inerted, and to a higher level of oxygen (12%) than earlier estimated (10%). The NTSB hailed the FAA action as a great leap forward for safety when in fact it fell considerably short of the NTSB’s goal: all fuel tanks inerted (heated, unheated, center wing tanks, wing tanks, auxiliary tanks, and tanks in the empennage).and to 10% or lower of residual oxygen. Finally, airplanes with heated center wing tanks will be permitted to fly without modification until 2018. This date is fully 22 years after TWA Flight 800, a B747, was destroyed in 1996 by a center wing tank explosion.

Not to mention that recommendations often reside, unrequited, on the “Most Wanted” list for years, then are implemented only partially if at all.

We have agued that the “Most Wanted” list has been carefully crafted by the NTSB to significantly improve aviation safety and, as such, the recommendations ought not be slow-rolled and halfheartedly implemented by the FAA. Indeed, the FAA should be required, under force of a court order, to explain its dilatory action. Under a writ of mandamus (Latin for “we order”), a court can direct a government body like the FAA to implement a recommendation when it has neglected a refused to do so. (See Aviation Safety Journal, February 2010, “Time to Revamp ‘Most Wanted’ System”)

The effect of taking the FAA to court would have a number of salutary effects:

1. The NTSB would not be seen as toothless and ineffectual.

2. The NTSB would have to convincingly explain why a particular recommendation rose to the level of “Most Wanted”. Concurrently, the FAA would have to explain why implementation was delayed.

3. The mere threat of such legal action may stimulate the FAA to more seriously consider the price of inaction.

4. Such court proceedings would certainly interest the oversight committees in Congress as to why the FAA was being dragged before the bar to explain itself (with obvious implications for FAA staffing and funding).

The NTSB has a clear choice: either take steps to ensure that its “Most Wanted” recommendations are implemented (not just “accepted” by the FAA), or drop the program as an unfortunate annual reminder of the toothless pleading for progress. Dressing up the “Most Wanted” list in a new format is akin to putting the proverbial lipstick on a pig – it’s still a pig, and the “Most Wanted” recommendations remain not acted upon, or poorly and tardily implemented by the FAA. As the saying goes, “Safety delayed is safety denied” and the phrase applies with particular force to the “Most Wanted” list.

Herewith, the aviation recommendation on the 2011 list (NTSB position followed by an Aviation Safety Journal comment in italics):

Addressing Human Fatigue

What is the issue? Airplanes, trucks, buses, and ships are complex machines that require the full attention of the operator, maintenance person, and other individuals performing safety-critical functions. Consequently, the cognitive impairments to these individuals that result from fatigue due to insufficient or poor quality sleep are critical factors to consider in improving transportation safety …

What can be done? Since its creation, the NTSB has issued more than 180 separate safety recommendations to address the problem of human fatigue in all modes of transportation … Because “powering through” fatigue is simply not an acceptable option, fatigue management systems need to allow individuals to acknowledge fatigue without jeopardizing their employment.

ASJ comment: the NTSB has 12 aviation-related recommendations outstanding in this area. In other words, dating back to 1994 the FAA has been dithering. In September 2010 the FAA published a long-awaited Notice of Proposed Rulemaking (NPRM) addressing the subject. Interspersed throughout the NPRM are questions for which the FAA “seeks comment”. The FAA seems more interested in cost than safety, as indicated by this remark:

 “We are particularly interested in receiving recommendations that would provide the same or better protection against the problem of fatigue at lower costs.” [Emphasis added]

 In other words, ideas that entail hiring more pilots or providing sleeping facilities in ready rooms (or adjacent thereto) are not desired.

Many pilots commute to their bases across multiple time zones and/or hundreds of miles. For example, the two pilots killed in the crash of the Colgan Air Dash 8-Q400 turboprop in February 2009 had spent the night before commuting to their duty station at Newark, NJ. Capt. Marvin Renslow commuted from Florida. F.O. Rebecca Shaw commuted from the West Coast.

 The FAA response in the NPRM to the issue of commuting features plenty of rhetoric and no proposed regulation:

 “The FAA … believes it is inappropriate to rely on existing requirements … to report to work fit for duty. The FAA believes a primary reason that pilots engage in irresponsible commuting practices is a lack of education on what activities are fatiguing and how to mitigate developing fatigue. The FAA has developed a draft fitness for duty AC 9advisory circular) that elaborates on the pilot’s responsibility to be physically fit for flight prior to accepting any flight assignment, which includes the pilot being properly rested. Additionally, the AC outlines the certificate holder’s responsibility to ensure each flightcrew member is properly rested before assigning that flightcrew member to any flight.”

 Let the record reflect that an AC does not have the force of regulation. There is nothing in the AC that restrains poorly-paid pilots from residing in low cost-of-living areas and commuting to their bases, such as Colgan’s in Newark. There is nothing in the AC that requires Colgan – or any other operator – to minimize the effects of commuting.

In short, there is nothing in the NPRM to prevent a repeat of the crew fatigue strongly suspected as having played a role in the Colgan Air crash. If the NTSB were still color-coding responses from the FAA, this one would rate a prominent red blot. (See Aviation Safety Journal, September 2010, “Rule Proposed on Pilot Rest Requirements”)

General Aviation Safety

What is the issue? The United States has not had a fatal commercial aviation accident since February 2009, but the story is very different in the world of general aviation (GA). Each year hundreds of people – 450 in 2010 – are killed in GA accidents, and thousands more are injured. GA continues to have the highest accidents rates within civil aviation: about 6 times higher than small commuter and air taxi operations and over 40 times higher than larger transport category operations. Perhaps what is most distressing is that the causes of GA accidents are almost always a repeat of the circumstances of previous accidents.

What can be done? Reducing GA fatality rates requires improvements to the aircraft, flying environment, and pilot performance. Maintenance personnel need to remain current in their training and pay particular attention to key systems, such as electrical systems. Aircraft design should address icing. GA aircraft should also have the best occupant protection systems available and working emergency locator transmitters to facilitate timely discovery and rescue by emergency responders …

ASJ comment: The NTSB lists 10 extant GA recommendations, indicating – at best – a yellow color code. General Aviation and the word “safety” should not be used in the same sentence.

 It should be noted that the DHC-3T airplane in which Sen. Ted Stevens and others were killed in August 2010 had the very latest terrain warning technology, which the pilot had switched to the “inhibit” mode. The crash probably could have been avoided if that system had been activated. The pilot was killed in the crash, but the NTSB did not question other pilots in Alaska about their propensity to inhibit this life saving system.

 The GA fatal accident rate is equivalent to a B747 loaded fully with passengers, and the toll at this rate continues year after year. GA safety deserves to be on the “Most Wanted” list but the NTSB should have developed further the notion that even with technological improvements to the flying environment, those systems need to be used. (See Aviation Safety Journal, “Crash in Alaska & Lack of Probing About Key Safety System”)

Safety Management Systems

What is the issue? For over three decades, the NTSB has expressed concern about the lack of safety management and preventive maintenance. NTSB accident investigations have revealed that, in numerous cases, safety management systems (SMS) or system safety programs could have prevented loss of life and injuries …

What can be done? Aviation, railroad, highway and marine organizations should establish SMS or system safety programs …

ASJ comment: The NTSB has 11 aviation-related recommendations in this area awaiting full implementation. The FAA has indicated it will relegate SMS to one of voluntary compliance by the airlines. In Canada, SMS implementation has been required by the FAA’s equivalent agency, Transport Canada.

Runway Safety

What is the issue? Takeoffs and landings, in which the risk of a catastrophic accident is particularly high, are considered the most critical phases of flight … In the United States, the deadliest runway incursion accident occurred in August 2006 when Comair Flight 5191, a regional jet, crashed after attempting to take off from the wrong runway, killing 49 of the 50 people on board.

What can be done? Reducing the likelihood of runway collisions is dependent on the situational awareness of the pilots and time available to take action –often a matter of just a few seconds. A direct in-cockpit warning of a probable collision or of a takeoff attempt on the wrong runway can give pilots advance notice of these dangers …

ASJ comment: the NTSB has 5 open recommendations in this area. None of the FAA’s proposed actions provide a direct warning to the pilots but rather focus on warning the tower controllers, who will in turn relay the impending hazard to the pilots.

Pilot and Air Traffic Controller Professionalism

What is the issue? Recent accidents and incidents have highlighted the hazards to aviation safety associated with departures by pilots and air traffic controllers from standard operating procedures and established best practices. NTSB aviation accident reports describe the errors and catastrophic outcomes that can result from such lapses, and – though the NTSB has issued recommendations to reduce and mitigate such human failures – accidents and incidents continue. The cost of these events extend beyond fatalities, injuries and economic losses: they erode the public trust …

What can be done? The industry can provide better guidance on expected standards of performance and professional behavior … And, though there is no way to guarantee that every pilot and controller will make the right choice in every situation, monitoring performance and holding them accountable will reinforce the absolute importance of maintaining the highest level of professionalism.

ASJ comment: The NTSB has 7 outstanding recommendations in this area. The head of the FAA, Randolph Babbitt, said in August 2009, “We can’t regulate professionalism.” No regulatory action can be expected in this area. Before the revised “Most Wanted” format, this area would be color-coded bright red to denote an unresponsive FAA. (See Aviation Safety Journal, August 2009, “We Can’t Regulate Professionalism”, May 2010, “Definition of Professionalism Not Coming Anytime Soon”)


What is the issue? Over the decades, new recorder technologies have been developed, increasing the likelihood of identifying the cause of an accident that 20 years ago would have gone unsolved. However, certain categories of aircraft … are not equipped with some of these technologies, which would aid in identifying crash causal factors by providing critical information on vehicle dynamics and occupant kinematics.

What can be done? Most of the difficult work has already been accomplished by the industry. Low-cost, compact image recorders capable of storing several hours of information are readily available. We simply need the regulations to require their use, where the expectations for promoting safety are higher and therefore outweigh some privacy concerns. Other low cost data/audio/image crash resistant recorders are also readily available and can be easily installed in [aircraft] that currently do not require crash hardened recorders (such as aircraft cockpit voice recorders).

ASJ comment: the NTSB lists 9 recommendations to the FAA awaiting action. On the issue of low cost image recorders, the FAA has indicated it has no intention of mandating these for GA aircraft. Deployable recorders and real-time downloading of recorder data remain far back in the swampy backwaters of regulatory activity. (See Aviation Safety Journal, February 2011, “The Case for Deployable Recorders”)

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