Story ID: 113July17
NTSB Marks 50th Anniversary
By: Gordon Gilbert
Caption: In the five decades since being established, it has made more than 14,500 recommendations to improve transportation safety.
Word Count: 2162
The crash of a Platinum Jet Challenger operating under Part 135 at Teterboro in February 2005 was the result of the pilots’ failure to ensure the airplane was loaded within weight-and-balance limits and their attempt to take off with the center of gravity well ahead of the forward takeoff limit. But it was the contributing factors that sent ripples through the industry: Platinum Jet’s operation without proper FAA certification, failure to maintain operational control by Darby Aviation and a tacit approval by the FAA of the arrangement between Darby and Platinum Jet. The findings spurred one of the most comprehensive looks throughout the industry of the meaning of operational control.

Doug Carr, vice president for regulatory and international affairs for NBAA, called the accident and the subsequent NTSB findings an “industry-changing event,” saying it resulted in a wholesale change regarding the understanding and application of operational control. “Those changes are still something operators pay close attention to today,” Carr said.

The NTSB’s findings in this accident, as well as numerous others, such as the May 2014 crash of a Gulfstream IV in Bedford, Mass.; the 2004 Challenger crash in Montrose, Colo.; or the 2005 crash of a Circuit City Citation 560 in Pueblo, Colo. led to industry soul-searching and action on issues such as professionalism, compliance, de-icing practices and missed approaches, to name a few.

Those investigations are among the 132,000 aviation accidents the NTSB has engaged in since its founding in 1967. Since that time the agency has issued 14,500 safety recommendations throughout all modes to 2,500 recipients. Considering the agency has no regulatory authority, it has had remarkable success: 80 percent of those recommendations have been adopted.

The agency is celebrating its 50-year heritage this year, built on the thousands of investigations it has completed across aviation, highways, marine, pipeline and railroads and thousands of lives saved.

“The NTSB’s work throughout our 50-year history is responsible for the transformational improvements that make transportation safer for all of us today,” said acting chairman Robert Sumwalt. “The transportation industry is focused on a future with zero accidents. The men and women of the NTSB are committed to this vision and will continue to investigate accidents and to make recommendations that will help future generations enjoy an era free from transportation accidents.”

“Looking at the history,” Carr added, “a whole lot of good change has come from the NTSB’s investigations and the issues the Board has found. Any time the NTSB has a chance to do a deep dive into the causes of accidents, we are able to learn a little bit more how industry can improve.”

The roots of the NTSB actually trace back much earlier than 1967. Congress granted the first authority for aircraft accident investigation as early as 1926 under the Air Commerce Act. That investigation authority was strengthened to allow procedures such as public hearings after public interest heightened following crashes that killed Knute Rockne in 1931 and Will Rogers and Wiley Post in 1935, along with the crash of the Hindenberg in 1937, according to a historical accounting by the Rand research institute. Those crashes also led to the handing over the responsibility of accident investigation to the new Department of Commerce agency, the Civil Aeronautics Board (CAB), in 1940. The CAB held that responsibility for many years.

But the number of accidents swelled as the aviation industry began to take off, and after a TWA Constellation collided with a United Airlines DC-7 over the Grand Canyon, Congress passed the Federal Aviation Act in 1958, laying out a framework that would ultimately be incorporated into the modern NTSB.

In 1967 Congress created a new U.S. Department of Transportation to house all the various transportation agencies. As part of that move, a quasi-independent NTSB was established, led by a board of five presidential appointees. In creating the new agency, President Lyndon B. Johnson said the NTSB’s sole function “will be the safety of our travelers.” An initial staff of 185 was taken from the CAB’s Bureau of Safety.

Seven years later, Congress moved the agency outside the department, believing that “No federal agency can properly perform such (investigatory) functions unless it is totally separate and independent from any other...agency of the U.S.”

Since that time the NTSB’s role has expanded and evolved. In 1992, Congress passed a law to transfer the adjudication of enforcement actions to the NTSB from the FAA. This role, Carr said, improved notably nearly a decade later after the NTSB released a recommendation that gave more transparency into enforcement actions against certificate holders, Carr said.

As a result of the 1988 Pan Am 103 bombing over Scotland, the 1996 explosion of TWA 800 in New York and the 1996 crash of ValuJet 592 in the Florida Everglades, the NTSB was given the additional responsibility of coordinating assistance for family victims.

The agency also has taken on more outreach and educational duties, establishing the NTSB Academy in 2000. The academy not only provided technical training for the agency’s own employees, it opened its expertise to the community. The Board opened a facility to house the academy—now called the NTSB Training Center at the George Washington University Virginia campus in Ashburn, Va. in August 2003. That facility has since hosted hundreds, if not thousands, of seminars and classes surrounding transportation safety.

It is also home to a haunting display: a reconstruction from the wreckage of TWA 800. Thousands of pieces of the shattered 747 were patched together, providing a chilling glimpse into the difficulty of the agency’s work and the detailed detective work that it undertakes, sometimes under extreme weather, geographic and/or political conditions.

In the case of TWA 800, perhaps the agency’s most extensive, controversial and expensive accident investigation, most of the pieces of the airliner were excavated from the ocean floor and gathered into a warehouse on Long Island. The NTSB had to exert control over an investigation in which other agencies originally planned to take control out of fear that it was a terrorist attack. Carr recalled that almost as many agencies wanted a hand in the investigation as there were theories about the cause.

After painstaking re-creations and testing, the NTSB ultimately pointed to ignition of the flammable fuel/air mixture in the center wing fuel tank. The findings and associated recommendations spurred rules for transport category aircraft from fuel-tank design to mandatory wiring inspections. The investigation was among those that led to an MOU between the NTSB and FBI that reiterated that the Board has initial control over an aircraft accident scene.
Focus on Business Aviation
NTSB controversies weren’t limited to large-aircraft accidents. The investigation into the crash of the Cessna Citation 560 that was owned by Circuit City Stores and operated by charter/management firm Martinair led to a recommendation regarding procedures for the use of de-icing boots. The business aviation industry pushed back on that recommendation, Carr recalled, noting the procedures the Safety Board recommended were not viewed as the safest route for operators.

The Safety Board also came under fire by some pundits for its probable-cause finding in the Gulfstream IV crash in Bedford, Mass. The NTSB cited as the probable cause of the accident “the flight crewmembers’ failure to perform the flight-control check before takeoff, their attempt to take off with the gust lock system engaged, and their delayed execution of a rejected takeoff after they became aware that the controls were locked.”

The agency further cited “habitual noncompliance” with checklists, and said “the flight crew’s omission of a flight-control check before the accident takeoff indicates intentional, habitual noncompliance with standard operating procedures.”

Some pundits believed the NTSB should have faulted the gust lock system rather than the pilots. While the NTSB did recommend incorporation of a modified system, it also called on the business aviation industry itself to look at metrics to determine the extent of noncompliance and issued a safety alert to underscore the importance of following checklist procedures.

Some pundits complained, but most business aviation industry leaders embraced the recommendations. NBAA immediately responded that it “stands ready” to follow through on the recommendations, and the subjects involved in the recommendations were part of the agenda of the association’s inaugural National Safety Forum held just a few months later during its 2015 annual convention.
Industry Partnerships
The sharpened focus on business aviation professionalism and intentional non-compliance in the aftermath of the Bedford investigation remains a top issue today.

That accident produced one of nearly a dozen recommendations aimed directly at NBAA over the years. One of the earliest recommendations to the association came from the investigation of the September 1981 collision between a Bell 206B JetRanger and a Seminole Air Charter Piper PA-34 Seneca south of Teterboro. That recommendation surrounded the need for educational programs and communications that emphasize to pilots the importance of accurate position reporting to ATC.

Another association, the Air Charter Safety Foundation (ACSF), traces its beginnings to the investigations of a spate of high-profile accidents involving air charters in the 2000s, the Challenger crashes in Teterboro and Montrose among them, said ACSF president Bryan Burns. Those crashes not only raised the question of operational control, but shone a spotlight on charter brokering practices. “The NTSB did a tremendous job in raising awareness,” Burns said.

These investigations spurred the FAA to bring its concerns to the National Air Transportation Association (NATA), Burns said. NATA responded by creating the ACSF in 2007. It also led to the creation of the association’s industry audit standard.

The NTSB is an integral partner for the ACSF. Every year the NTSB Academy hosts the ACSF’s safety symposium, and frequently an NTSB member is among the speakers at the event. Burns noted that over the years, the ACSF began scrutinizing the agency’s “Most Wanted” list of safety improvements for topics that could be addressed at the symposium. This has led to key discussions in areas such as runway excursions, loss of control, procedural noncompliance and distraction, Burns said.

In addition to releasing a Most Wanted list to highlight its chief safety concerns, the NTSB has held a number of forums and issued safety alerts on pressing topics. A number of these in recent years have spotlighted general aviation in areas such as loss of control. The safety board has brought together leading industry safety experts to create a dialog on underlying causes and potential solutions.

In addition to shaping safety discussions, NTSB recommendations have effected numerous regulations, from mandatory installation of ground proximity warning systems to flight data recording requirements and actions regarding icing.

Not all recommendations become regulations. The Safety Board has for years pushed for installation of cockpit image recorders that would provide more insight into operations that led to accidents. But the FAA has maintained for years that it has not found compelling evidence to require installation of such recording systems. This long-standing disagreement between the Board and the FAA—dating back 17 years—is a function of the FAA’s responsibility to conduct cost-benefit analyses and the NTSB’s freedom from such strictures. The Safety Board is one of the few U.S. government agencies, if not the only one, that can recommend safety change without the examination of costs, Carr noted. “It is free from the consideration of the cost of the recommendation,” he said. “It has the bandwidth to really push the safety envelope.”

Even with that bandwidth, Carr cited the strong track record of acceptance of the NTSB safety recommendations. “The fact that 80 percent of the NTSB's 14,522 safety recommendations since 1967 have been acted upon favorably is testament to the work of NTSB employees,” the Safety Board said in celebrating its anniversary.

“The NTSB was established to ask ‘why?’ when an accident happened, and to ask ‘why not?’” Sumwalt said. “Why not improve regulations, training or a certain aspect of the vehicle or the environment?”

The NTSB now has a staff of 430, and each year it investigates an average of 1,600 aviation accidents and incidents and issues 280 safety recommendations. Sumwalt emphasized that the credit for safety improvements and success of the recommendations is shared. “In celebrating our 50th anniversary, we also celebrate those who read our investigations and recommendations, agreed with us and made the improvements happen, as well as those who made things not happen,” he said. “Together, we avoided preventable accidents. We saved lives that didn’t have to be lost in the first place.”

 “We are looking forward to another great 50 years with the NTSB,” added Carr, who pointed to the irony of the NTSB’s work: “We are looking forward to the time when we no longer have to deal with them.”

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