The National Transportation Safety Board (NTSB) has permanently retired its “Most Wanted List” of transportation safety improvements. This list was a safety advocacy tool to bring awareness to the top issues affecting all modes of transportation. It had a good run. After 35 years, the Board will now become nimbler and use other forms of media to advocate for emerging safety issues and its safety priorities.
As an aviation safety professional, I would eagerly await the release of “the list” that was published every other year. For me, and other safety nerds around the world, it was as highly anticipated as college basketball’s March Madness tournament brackets or the publication of the annual football bowl schedules.
But now it’s gone. I didn’t wager any bets, but like my favorite sports teams (go Michigan!), I would always root for the most pressing safety issues or safety programs that I’d grown to love to make the NTSB’s list.
In recent years, there was a strong push for organizations to implement safety management systems (SMS) and flight data monitoring programs. Those programs worked well with the airlines and made them the safest mode of transportation in the world. Certainly, a scaled-down version would benefit smaller operators.
In past years, terrain awareness equipment for helicopters and improved certification standards for aircraft equipped for flight into known icing conditions made the NTSB’s list; now these safety enhancements have been implemented and are saving lives.
For comparison, I looked to Canada and Australia to see what those countries' safety agencies felt were the top aviation safety issues. Canada’s Transportation Safety Board (TSB) and the Australian Transport Safety Bureau (ATSB) agreed on three main issues that are worth fixing: those included runway incursions, SMS implementation, and fatigue management.
Most Wanted Safety Improvements for 2024
So, what about 2024? What is the over/under on the top issues affecting aviation safety? Based on the amount of news coverage, runway incursions and pilot mental health would be safe bets to make the list. Would that list be applicable to operators of business aviation aircraft?
To get a better understanding of the top safety threats or issues affecting business aviation, I reached out to three editors at AIN: editor-in-chief Matt Thurber, AIN monthly editor Kerry Lynch, and news editor Chad Trautvetter. Combined, they have over 115 years of experience reporting on business aviation. That’s impressive; they have in-depth knowledge of many issues related to the industry.
In addition, I reached out to Air Charter Safety Foundation (ACSF) president Bryan Burns and Wyvern CEO Sonnie Bates. Both are highly regarded safety professionals; each touches hundreds of operators per year and is in tune with the issues affecting business aviation safety.
The ACSF employs several tools to make operators safer, such as safety audits, a flight data monitoring program, SMS software, and an organizational-based aviation safety action program (ASAP). ACSF ASAP now has more than 230 operators enrolled in the program and processes some 2,000 reports each year.
Wyvern helps operators create and implement effective safety management systems through training, consulting, certifications, audits, and highly integrated software tools. Last year, the company had more than 600 operators enrolled in its various safety programs.
To get a handle on the top threats to aviation safety, I asked each safety pro an open-ended question, hoping to establish a list of at least five issues. Each respondent provided their input on the top events while providing additional context on related contributing factors. The combined results created a comprehensive list that ranged from very specific issues (such as runway incursions) to wider-ranging issues (such as pilot professionalism).
The List
1. Runway safety: Prevent runway incursions and runway excursions.
Runway incursions. Fresh in the mind of each respondent was the fiery crash of Japan Airlines Flight 516—an Airbus A350-900—that collided with a Japanese Coast Guard Bombardier Dash 8 aircraft while landing at Haneda Airport in Tokyo. Five of the six occupants of the Dash 8 died. Everyone on the A350 survived. That event earlier this month followed a rash of high-profile runway incursions in the U.S. last year. The most serious of those events involved two business jets colliding at a runway intersection at Houston Hobby Airport. Fortunately, no one was injured in that accident.
Most alarming is the fact that last year’s data—when compared to previous years—showed an increase in the most serious type of runway incursions: Category A incidents. Those are the ones where a collision between two aircraft was narrowly avoided.
Contributing to this problem are poor communications between ATC and pilots—an area that must be improved. In many of the runway incursion events, pilots simply failed to comply with common ATC clearances such as “line up and wait.” Distraction and fatigue experienced by both pilots and ATC controllers may also contribute to these runway incursions.
Runway excursions. Last year, an aircraft overrunning or veering off a runway surface was the most common accident type for business aviation aircraft. A total of 71 turbine business aircraft were involved in runway excursions in 2023; 28 were classified as accidents, with one fatal accident killing all four onboard.
Often, adverse weather contributes to a runway excursion event. Respondents surveyed also identified a lack of competency or proficiency as a factor during these events. Similarly, a pilot’s ego or a history of noncompliance with established procedures (those designed to prevent a runway excursion) may contribute to a runway excursion due to an unstable approach without a go-around, for example.
2. Health: Act to improve the FAA’s policy on mental health.
Mental health. Several events last year put a spotlight on mental health and the FAA’s inability to address the issue in a progressive, positive manner. As a result, pilots simply do not report or discuss any mental issues with their aviation medical examiner for fear that they will get caught up in the FAA’s bureaucratic loop that would force them out of the cockpit for months (if not indefinitely) and jeopardize their livelihood.
One report stated, “Pilots are crying out for help” due to the FAA’s outdated and prohibitive health policies. This has manifested itself in several events where pilots reach the breaking point. While I do not advocate swinging an ax at a gate in the employee parking lot, taking hallucinogens before riding in a cockpit jump seat, or pointing a weapon at a fellow crewmember in flight (all actual events in recent months), I do advocate for a non-punitive system that supports pilots in need.
In December, the NTSB took the first step to address the issue by hosting a summit on mental health concerns in the aviation community. NTSB Chair Jennifer Homendy said, “Everyone should feel safe speaking up, getting the mental health care they need regardless of their profession. Current federal rules incentivize people to either lie about their needs or avoid seeking help in the first place—and that’s not safe for anyone.”
One day before the NTSB summit on mental health concerns, the FAA established the mental health and aviation medical clearances rulemaking committee (ARC). According to the agency, “The ARC will provide recommendations to the FAA on ways to identify and break down any remaining barriers that discourage pilots from reporting and seeking care for mental health issues.”
3. Humans: Focus on elevating pilot professionalism and leadership.
Professionalism and leadership. According to Wyvern’s Sonnie Bates, poor leadership is a universal threat to aviation safety. Accident reports are filled with “artifacts” of poor leadership. Examples include the captain who allows an unstable approach to continue or, worse, the captain who continues to fly the unstable approach and land, discounting SOPs that would have otherwise dictated a go-around.
In one example, the PIC (pilot flying) of a Gulfstream G150 repeatedly ignored the regulatory 250-knot airspeed limit below 10,000 feet. The CVR captured the PIC stating, “I’ll speed up. I’ll go really fast here.”
Later during the approach, the aircraft was both high and fast. During the final approach segment, the CVR would record several “sink rate” and “pull up” GPWS warnings—indicating the aircraft was grossly unstable. The PIC continued the approach and ignored warnings by the SIC.
The aircraft touched down 1,000 feet past the runway threshold (on a 4,200-foot-long runway) and came to rest 400 feet off the end of the runway in a marshy area. There were no injuries, but the aircraft was substantially damaged.
AIN’s Trautvetter admittedly “went off script” and cited several causal factors that contributed to business aviation accidents. He suggested that in recent accidents, the outcomes would be different if there were improved checklist adherence, improved procedural/SOP compliance, better communications, increased discipline, more professionalism, and keeping a pilot’s ego in check—these skills would all contribute positively to safer flights.
4. Organizations: Managing safety in a changing environment.
SMS: “Implementing and establishing an effective SMS and creating a safety culture aimed at making safety a focus first and always” was included in the final NTSB Most Wanted List. Through this, the NTSB added, “Operators will improve aviation safety and reduce the risk of accidents.”
Airlines in the U.S. first adopted SMS in 2018; this created a more formal, businesslike approach to managing safety. In January 2023, the FAA proposed mandatory SMS implementation for Part 135 charter, air taxi, and air tour operators.
Safety programs. Many consider SMS to be a strategic plan to manage safety, but for it to survive and thrive, it needs safety data. Data comes from many sources, including employee reporting forms, ASAP, and flight data management or flight operational quality assurance (FOQA) programs.
ACSF’s Burns provided some aggregate data from its ASAP program. This is real data from real Part 91 and 135 operators.
As you may recall, ASAP reports are filed by pilots to identify safety issues. The data provided is a year-by-year comparison; it is great for identifying trend information, good or bad. The top events identified through the ACSF ASAP program were altitude deviations, traffic proximity events (TCAS), coordination/communication issues, flight diversions, and aircraft mechanical issues.
Altitude deviations were the top event, but year-over-year these events are trending down by nearly 10 percent. This is a great example of communicating the results and potentially finding troubling areas with a high prevalence of altitude deviations such as on SIDS and STARS. TCAS events ranked second on the list and had increased year-over-year—this can be explained by an increase in traffic during the same period.
Workforce turnover and experience. AIN’s Thurber and Lynch both identified workforce turnover as a threat to aviation safety. Over the past few years, there have been a record number of pilots being hired by major airlines in the U.S. Many of those pilots leave business aviation seeking more predictable schedules, more time off, and better pay and retirement benefits. This has created an increase in turnover in flight departments and a decrease in experience.
This phenomenon not only affects business aircraft pilots but also impacts the experience levels of A&P mechanics and flight instructors. (ATC controller turnover and shortages will be addressed in a future article).
5. Regulator: A steep climb for the FAA.
Regulatory oversight and rigidity. Beyond changing policies that affect mental health and aviation medical clearances, the FAA was mentioned in many of the respondents’ comments. Items mentioned most were the lack of FAA regulatory oversight in the design, manufacturing, and maintenance of aircraft.
The Boeing 737 Max (and, most recently, the Max 9) and its rocky entry into service deeply impacted the reputation of both the FAA and Boeing. Concerns extend far beyond the 737 Max and Boeing—one A&P, for example, recently expressed frustration and concern about the level of technical expertise within the FAA when writing airworthiness directives. Others believe the FAA should allow more flexibility for training providers to adapt or change their training programs.
Conclusion
Creating a list of safety improvements in aviation is a challenge. It’s understandable why the NTSB wants to adopt a more flexible approach to advocacy—aviation is very dynamic. For this list, there was near consensus on some of aviation’s most pressing issues. However, by the time this blog is published, there may very well be some new topic that is worthy of inclusion on “the list.”