Tue May 21 2002, 03:06 PM
BFHead of Safety Board Questions Effectiveness of 'Most Wanted' List
From Air Safety Week:
Head of Safety Board Questions Effectiveness of 'Most Wanted' List
Identity crisis: 'A lean, mean fighting machine or a lumbering bandwagon?'
The "Most Wanted" list of aviation safety improvements may be losing its punch.
The persistence with which the same issues appear might in fact be causing the opposite of the intended effect: rather than focusing attention on the need for urgent action, the appearance of the same issues year after year may in fact erode the sense of urgency.
This year's list is no exception. It is a virtual repeat of the issues highlighted in last year's "Most Wanted" list. Published annually by the National Transportation Safety Board (NTSB) since 1990, the "Most Wanted" list has been seen as a means to highlight the highest-priority safety issues - where correction would have the most immediate impact on safety.
"I am concerned about its overall static quality," remarked NTSB chairwoman Marion Blakey. "This is my first year going through its composition," she said, adding, "We have to be very clear about what we've done over the past year to move these items."
Take a look
Blakey called for a review of the criteria by which safety issues are placed on the "Most Wanted" list, and for a more creative approach to publicizing the safety issues of top concern.
Elaine Weinstein, director of the NTSB's office of safety recommendations and accomplishments, conceded that the fundamental nature of the "Most Wanted" list has changed since its inception. The first list encompassed some 13 discrete recommendations but now includes more than 50 under the dozen or so major categories. This trend may have diffused the desired focus.
The question now, Weinstein said, is whether the "Most Wanted" list should be "a lean, mean fighting machine or a lumbering bandwagon?"
Top issues
In part, the repetitive nature of the "Most Wanted" items reflects the importance with which the NTSB views their life-saving potential. First, we will review of the latest "Most Wanted" action items. Second, we will offer some observations on why the "Most Wanted" list does not appear to have generated corresponding corrective action.
The 2002 list includes three aviation-specific items (the same as on the 2001 list) and three items covering all modes of transportation.
Aviation specific:
Runway incursions. Actions to prevent incursions, sometimes characterized as near-collisions, remain a top concern. The safety board placed runway incursions on the "Most Wanted" list after a ground collision occurred at Atlanta's Hartsfield International Airport in January 1990. Five subsequent incursion-related accidents in the United States have occurred, and the potential for a catastrophic accident with large loss of life, continues to exist.
John Clark, director of the NTSB's office of aviation safety, pointed to the October 2000 crash of a Singapore Airlines jet while attempting to take off on a closed runway at Taipei, Taiwan (see ASW, May 6). He added that a similar event occurred Sept. 25, 2001, in the United States, when a United Parcel Service [UPS] B757 freighter took off on a closed runway at Denver. The case was eerily similar to the Singapore accident. According to the NTSB report:
"Runway 8 was closed because of construction workers and equipment operating on taxiway R7. The aircraft passed within 32 feet of a light standard erected near taxiway R7 to illuminate the construction area. No injuries were reported on the ground or aboard the aircraft, and the flight continued to its destination. The incident occurred in nighttime visual meteorological conditions."
Clark also mentioned the fatal September 2001 ground collision at Italy's Milan (Linate) airport, after a Cessna Citation entered a runway in front of a departing SAS MD-87.
"Both collisions occurred under low visibility conditions, and tower controllers had no functioning surface radar or conflict detection systems to assist them in monitoring the aircraft involved," he explained.
"Similar scenarios cannot be ruled out here. Close calls continue to occur and I have no doubt we have not heard about all of them," Clark cautioned. In fact, Clark presented data showing that incursions occur in the United States at a rate of more than one per day in 2001 (383 for the year, down slightly from 431 in 2000).
The Federal Aviation Administration (FAA) is deploying a system known as the Airport Movement Area Safety System (AMASS). It is at 10 towers now and 24 more systems will be commissioned by the end of 2003. In addition, a system known as Airport Surface Detection Equipment-X (ASDE-X) is under development. It uses other sensors in addition to radar to track aircraft and vehicles.
However, more than 300 airports with scheduled operations remain uncovered. Furthermore, neither system meets the safety board's primary concern. Both AMASS and ASDE-X warn controllers (and with as little as 8 to 11 seconds time with AMASS).
"Why is available warning time a problem?" Clark asked, going on to explain:
"The controller will hear an incursion warning or see an alert on a separate screen. He must then look at the flashing symbols and determine what is going on. He must determine the location of the event and identify the airplanes involved. Remember, some of these airplanes may not be under his control. He must then figure out the best course of action without knowing what the pilots are intending to do. He must then issue directions to try to mitigate the problem. Some of the airplanes may not be on his frequency, some of the pilots may not have good language skills, and some may not realize the controller is talking to them. And, finally, the crew must respond. Of course, you can use up a lot more than 8 to 10 seconds."
"This is why we believe the warnings must go straight to the crew," Clark said.
The Dreadle concept articulated in this publication does satisfy this criterion (see ASW, July 16, 2001). It will simultaneously warn all pilots and controllers of an incipient incursion with a distinct warbling tone - and detects direction of travel. Any pilot thinking he's triggered the alarm would immediately stop and check his position. A nosewheel-activated strobe light would immediately pinpoint the perpetrator. Yet this simple system of twin pressure-sensitive transducers does not appear to be under any sort of active research. As John Sampson, who formulated the Dreadle concept argued, "Because the problem is runway incursions, you have to put the burglar alarm on the runway access itself."
FAA officials have advised the Safety Board that they are looking at ground induction loops as a cost-effective alternative to AMASS and ASDE-X. A ground induction loop is an electrical conductor installed in runway and taxiway pavement that senses aircraft and vehicles passing over it. Such loop arrays can provide data to a processing unit, which then displays speed, size and direction of the aircraft (or vehicle), to the local controller. Therein lies the weakness. Like ASDE-X and AMASS, a ground induction loop system, unlike Dreadle, would still require timely air traffic controller attention, interpretation, resolution, and communication - prior to pilot action (which is the only thing that can "save the day").
The Dreadle concept might be deployed more expeditiously, and at lower cost, than cockpit moving map displays suggested by Taiwan's Aviation Safety Council (ASC) or various ground radar and satellite signal-based systems being researched by the National Aeronautics and Space Administration (NASA).
Airframe structural icing. This item has been on the "Most Wanted" list since 1999. It was an outgrowth of a fatal January 1997 crash of a Comair [COMR] Emb-120 twin-turboprop at Monroe, Mich. (see ASW, Aug. 31, 1998 and Sept. 7, 1998). The NTSB wants certification standards upgraded to account for the hazard posed by supercooled liquid droplets (SLD), revised operational procedures in icing conditions, and more aggressive research into ice detection and protection systems.
Added impetus was provided by the near-crash of another Comair EMB-120 on March 19, 2001, near West Palm Beach, Fla. (see ASW, April 2, 2001, and April 23, 200). The airplane dove 7,500 feet before the crew was able to regain control. Several "roll excursions" were involved and the tail structure was severely damaged.
The incident was consistent with ice buildup. Before control was lost, the crew had activated the de-icing boots for the low-rate cycle. In that mode the boots inflate every three minutes. However, ice can accrete quickly to an unsafe level - faster than in that three-minute period.
In the immediate aftermath of the 2001 incident, Clark said EMB-120 manufacturer Embraer "has taken significant steps to alleviate the problem."
"They have added a warning if the speed drops below 155 knots in icing conditions. They have eliminated the switch for a low rate boot cycle. Only the high rate boot cycle is now available. They are planning a change to activate the stall warning system at lower angles-of-attack to get more stall margin in icing conditions," Clark explained.
"The fact is that these changes were prompted after this airplane came dangerously close to crashing," Clark declared. "FAA needs to assure that equivalent levels of safety are present on all turboprop airplanes."
Explosive mixtures in fuel tanks. The safety board wants a long-term solution to the hazard posed by flammable vapors in fuel tanks of transport-category aircraft. This item has been on the "Most Wanted" list since 1997, the year after the fatal center wing tank (CWT) explosion of TWA Flight 800. In March 2001, a Thai Airways B737 exploded on the ground, bringing to four the number of CWT explosions in the past 13 years.
These fuel tank explosions are happening repeatedly, Clark said. However, he pointed out that actions to date have focused on the identification and elimination of potential ignition sources. The safety board wants the flammable vapors to be eliminated, which will require some form of fuel tank inerting.
Clark recounted the actions taken by the FAA since the loss of the TWA B747:
"Actions have included revised fuel tank design, maintenance and inspection criteria. A Special Federal Aviation Rule (SFAR) was issued for this purpose [see ASW, May 14, 2001]. Final rules have been adopted that address some design issues and to some extent explosive fuel/air mixtures in new designs. FAA has conducted a wide-ranging design review for failure modes and [has] issued appropriate airworthiness directives.
"However, these actions do not get to the heart of the problem. These actions are part of the never-ending hunt for ignition sources." [Emphasis added]
Clark lauded the FAA's research program into inerting. "Any final actions should not be based on the assumption that all airplane ignition sources can be eliminated," he emphasized.
Aviation-related "Most Wanted" for all modes of transportation:
Child occupant safety. The Safety Board would like to see infants in proper restraints, thereby eliminating the hazard posed by "lap children" (they tend to fly out of their parent's arms in the event of a crash). Former NTSB Chairman James Hall urged the same level of safety for the littlest passengers as for adults and older children. Declaring 1999 "the year of child transportation safety," Hall said at a cabin safety conference that year, "It is astonishing that regulations require everything in an airplane to be secure during takeoff, landing and turbulence - except our smallest children." (See ASW, Feb. 1, 1999)
Later that year, at a conference devoted specifically to child safety, FAA Administrator Jane Garvey declared flatly, "The heart and soul of our mission at the FAA is safety, for young and old alike. We are committed to mandating child restraint systems in aircraft to provide equal protection for adults and children."
That mandate has yet to occur. Safety board members remarked that the delay appears to stem from an effort to fit infant seats into airliners. More infant restraint seats for cars are being designed to latch into an anchored fitting, not onto the seat belt. This improved safety feature makes it more difficult to use the seats on an airliner.
"I saw someone struggling for 10 minutes [to fit such a seat in an airliner] and finally gave up," remarked NTSB Member George Black.
Dual-use (auto/airplanes) child restraints may be a non-starter. This was one of the major findings at the December 1999 symposium on child safety seats. After extensive testing, Virgin Atlantic Airways determined that only seats designed specifically for aircraft use provide adequate impact protection for infants. The carrier prohibits the use of car seats. It provides its aircraft-certified seats to parents of travelling infants and checks the auto seats into hold baggage at no extra charge.
NTSB Chair Blakey expressed concern that if lap children were prohibited, parents might opt to travel by car rather than air, thereby placing infants at greater risk of mayhem on the highways. However, as has been documented in this publication, auto travel is not necessarily more hazardous. Moreover, infants in automobiles are more likely to be in restraint seats than in airliners. Furthermore, as revealed during the 1999 child safety symposium, requiring infants to be restrained in their own seats, and offering parents a 50 percent discount on the ticket price, would divert only two percent of these families.
Fatigue/Hours-of-work. "Little progress has been made to revise regulations. I'm hard-pressed to see any bright lights," lamented the NTSB's Dr. Vern Ellingstad.
Blakey observed, "Obviously, this is one of the toughest issues, since it involves labor-management relations."
Recording devices. For the B737, the safety board wants upgraded flight data recorders (FDRs) installed to capture pilots' control forces on the rudder pedals, and to record functioning of the yaw damper. This call is an outgrowth of two fatal crashes involving the B737, in which uncommanded rudder movement was suspected. Second, as an outgrowth of the fatal 1998 crash of a Swissair MD-11, the safety board wants a two-hour capability for the cockpit voice recorder (CVR), and dual installation of CVR/FDR, one set in the back of the aircraft, and another in the front. In addition, separate busses should power these two sets. And, finally, the safety board is seeking video image recorders for the cockpit.
Much more remains to be done than has been accomplished to date in these regards.
Wanted: Corrective action
It may be useful to offer a few observations as to why items seem to remain, if not languish, on the "Most Wanted" list for five years or more. Indeed, the runway incursion item has been on the list for every one of its 13 years of existence (1990-2002).
For one thing, the list comprises some of the toughest, most intractable and most controversial safety issues. The overall acceptance rate of NTSB recommendations provides an insight. In recent years, the NTSB has embarked on a campaign to close outstanding recommendations. This effort (Cont'd on p. 6) has resulted in a decline in the acceptance rate from 90 percent to about 81 percent. This trend suggests that the tougher the issue, the harder it may be to achieve concurrence.
Second, the NTSB and the FAA are not on the same page in terms of their respective priorities. The FAA is focused on its Commercial Aviation Safety Team (CAST) effort to reduce the fatal accident rate. The CAST effort is also known as the "Safer Skies" program; it is looking at all fatal accidents in the United States from 1988 to 1997 to isolate the major causes, and to address them in hopes of reducing the toll from these accidents some 80 percent by 2007 (see ASW, April 2, 2001). The safety board believes it is looking at the big killers, too, but a simple lay down of the "Most Wanted" improvements from the NTSB and the CAST priorities show that the two lists overlap in only two areas - runway incursions and child safety seats.
Third, the FAA has limited resources and is not the sole arbiter of safety. "We had the resources to work the additional parameters for the B737 FDR or the two-hour CVR capability," an FAA official explained.
"Our position is that we need to get the B737 effort through first, then address the recommendations coming out of Swissair Flight 111."
Regarding the additional FDR parameters for the B737, this official said the FAA's proposed rulemaking was returned Sept. 14, 2001, from the Office of Management and Budget (OMB) for reconsideration.
"OMB kicked it back saying the additional parameters may not be needed in light of the other activity" for two separate FDR/CVR installations, this official said.
"We intend to send the B737 rule back to OMB," he added.
With regard to the NTSB's call for video recorders in the cockpit, the FAA referred the issue to a future flight data capability committee (FFDCC) operating under the aegis of the RTCA (Requirements and Technical Concepts for Aviation).
Given the potential for bureaucratic inertia, a number of sources said if the NTSB hopes to see its "Most Wanted" safety improvements implemented with greater alacrity, the most direct means may be through congressional legislation. These sources point out that it took an act of Congress to mandate TCAS (Traffic Alert Collision Avoidance System) technology for cargo aircraft.
Fri November 21 2003, 07:38 PM
BFOh the absurdity!:
From Air Safety Week:
$1.3 Billion per Death Prevented
Effects & Costs of Requiring Child-Restraint Systems for Young Children on Commercial Airplanes, from Archives of Pediatrics & Adolescent Medicine, October, 2003 (extracts):
Child-restraint seat use could prevent about 0.4 child air crash deaths per year in the United States. Increased deaths as a result of car travel could exceed deaths prevented by restraint use if the proportion of families switching from air to car travel exceeded about 5 percent to 10 percent.
Assuming no increase in car travel, for each dollar increase in the cost of implementing the regulation per round trip per family, the cost per death prevented would increase by about $6.4 million.
For example, if the additional cost per round trip were $200 per young child, the cost per death prevented, ignoring car crash deaths, would be about $1.3 billion.
There are many factors we did not consider in this analysis ... the reduction in nonfatal injuries from CRS [child restraint system] use is likely to be small ... we did not consider decreased anxiety of parents and airline personnel and reduction of injuries to young children during turbulence and to surrounding passengers from unrestrained young children during crashes.
(ASW note: The full article may be viewed at
http://archpedi.ama-assn.org/cgi/content/full/157/10/969. Corresponding author Dr. Thomas Newman can be contacted by e-mail at newman@itsa.ucsf.edu)
Two reactions:
Former NTSB Chairman James Hall:
"Following the pediatrician's line of reasoning, we should pull the plug on research to eliminate childhood diseases that only kill a small percentage of children. What an absurd thought. It is almost as absurd as the authors' attempt to use cost analysis to accept or reject a regulation designed to keep children safe. All children are priceless regardless of their mode of transportation. A federal regulation that saves just one child's life or keeps just one child safe during in-flight turbulence deserves our wholehearted support." >> Hall, e-mail jhall@hallassoc.net <<
Jan Lohr, former flight attendant, survivor of 1989 DC-10 crash at Sioux City, Iowa, in which a lap infant was killed:
"It is quite ridiculous for these doctors to return to that 'old saw' of parents taking to the highways if forced to buy a ticket. They are going against the American Academy of Pediatrics' strong recommendation of November 2001 in favor of safety for the under two-year-old group. All these psychobabbling statistics overshadow more than the paramount safety of the infant or toddler, they discount the safety of every passenger in the same airplane cabin. It is totally contradictory to enforce the stowing of a laptop for takeoff or landing and allow a small human being and equally potential missile to sit on a lap unrestrained.
"The study considers only the 'few' deaths. Consider the infant girl who was propelled to the ceiling on a cross-country flight in 1999 and who subsequently died from a skull fracture. Since she wasn't listed as an in-flight death, her case must be considered an injury, the death occurring once off the plane.
"Pets in a cabin are charged a fee while being far safer in their pet carriers than children on a parent's lap. In over 23 years of flying, I never once heard a pet owner complain about the charge.
"
There is NO air passenger safety until ALL passengers are safely buckled in. The bottom line is not dollars, it's sense - as in plain old common!" Lohr, e-mail janlohr28@aol.com
I can tell you this much from losing Tara- One preventable loss of a child's life is TOO MANY.
Fri August 06 2004, 04:21 AM
CD Child seats urged for air travelBy Alan Levin, USA TODAY
Posted 8/3/2004 10:49 PM
Updated 8/4/2004 2:38 PM
WASHINGTON "” The National Transportation Safety Board on Tuesday renewed its call for mandatory child safety seats on airline flights, calling their absence "unacceptable."
But the agency responsible for investigating aviation accidents can't force airlines to require the restraints.
The NTSB's unanimous vote is the latest move in a 25-year battle over how to protect children younger than 2 on flights. Three children who were riding in a parent's lap have died in crashes in the past 20 years when the impact flung them across the cabin.
The Federal Aviation Administration, which regulates airlines, supports use of child safety seats but has not required them. The agency says studies show that some families would drive instead of flying if forced to buy seat tickets for children younger than 2. That would prompt more fatalities on the road than it would save on planes, the agency believes.
Under current rules, children younger than 2 can fly free if they sit in a parent's lap. Most airlines accommodate passengers who want to use car safety seats if they buy a ticket for their child. Most child safety seats designed for autos also work in airliners.
NTSB member Debbie Hersman, the mother of boys ages 3 and 2, said she found the issue "heart-wrenching. As a mother I can't ever imagine knowingly putting my children into a situation where they are less safe than I am," she said. "But I have done that. Before I became a member of the board, I made trips with my boys on my lap."
Research by NTSB staffers contradicted other findings showing that requiring child restraints on planes would lead to more highway deaths.
The agency identified three periods since 1980 in which large numbers of people stopped flying: the 1981 air traffic controller strike, the 1991 Gulf War and the Sept. 11, 2001, terrorist attacks. However, highway deaths were down or flat during those years.
The FAA and the National Highway Traffic Safety Administration remain unconvinced. "Aviation is substantially safer than highway travel," said Peggy Gilligan, deputy chief of the FAA's safety division.
NTSB investigators have examined three accidents since 1984 in which small children died because they were not belted in and several others in which babies were seriously injured.
One young child died and three others suffered minor injuries when they flew out of their parents' arms in the 1989 crash landing of a United Airlines DC-10 in Sioux City, Iowa.
USA Today article...