Six near runway collisions were narrowly averted in just the last six months, leading the National Transportation Safety Board (NTSB) to reiterate that the issue of runway safety remains one of the most important issues that need to be addressed by the Federal Aviation Administration (FAA). But the Safety Board also believes that an exhausted air traffic controller workforce is now a major safety concern that needs to be addressed.
At a Nov. 8 public meeting, the Safety Board reviewed its “Most Wanted List” of transportation issues, a list first established in 1990 to focus attention on air safety.
Half of the 44 safety recommendations in the 15 federal issue areas on the Most Wanted List were issued to the FAA and the National Air Traffic Controllers Association (NATCA).
The NTSB added three safety recommendations on air traffic controller fatigue to the existing aviation issue area that addresses human fatigue among pilots and mechanics.
The Safety Board says flying and fixing planes, and controlling air traffic without adequate rest presents an unnecessary risk to the traveling public. The laws, rules, and regulations governing this aspect of transportation safety are archaic in many cases and are not adequate to address the problem.
It believes establishing scientifically based hours-of- service regulations that set limits on hours-of-service, provide predictable work and rest schedules, and consider human sleep and rest requirements is prudent. Additionally, a fatigue awareness and countermeasures training program should be developed for air traffic controllers.
The Safety Board is asking the FAA to develop a program to educate controllers and those who schedule them about the causes, effects and safety implications of fatigue. The NTSB concluded this year that controller fatigue may have played a role in at least one recent regional airline accident.
The Safety Board urges the FAA to work with NATCA in revising work-scheduling policies to reduce the incidence of fatigue on the job. “Since air traffic controllers play such a crucial role in the safety of our air transportation system, we must ensure that the performance of these professionals is not compromised by something as preventable as human fatigue,” said NTSB Chairman Mark V. Rosenker.
The Board expanded the issue area of runway incursions to include runway excursions, incidents when aircraft on the ground depart the runway environment. Three additional recommendations were added to this area, which was renamed “Improve Runway Safety.”
Two of the recommendations ask the FAA to require that aircraft not be allowed to cross any runway without specific authorization from air traffic controllers. They result from the NTSB’s investigation of the Aug. 27, 2006 crash of Comair Flight 5191, a Bombardier Regional Jet, after takeoff from the wrong runway at Lexington, Kentucky’s Blue Grass Airport.
The Safety Board recommended that the FAA require all runway crossing be authorized by specific air traffic clearance. The second advisement would require controllers to issue explicit crossing instructions when aircraft cross multiple runways.
The third recommendation, addressing the danger of runway excursions, requests that airline pilots be required to incorporate a 15% safety margin into landing distances calculations. It was issued in response to the Safety Board’s probe of the Dec. 8, 2005 fatal accident involving Southwest Flight 1248, a Boeing 737 that ran off the end of Runway 31 Center after landing in a snow storm at Chicago Midway International Airport.
The NTSB’s safety recommendation calls on the FAA “to immediately require operators to conduct arrival landing distance assessments before every landing based on existing performance data, actual conditions, and incorporating a minimum safety margin of 15 percent.”
While the FAA is in the process of developing and testing new technologies to make ground operation of aircraft safer, runway safety incidents continue to occur with alarming frequency and consistency, according to the Safety Board.
The FAA indicates that during fiscal year (FY) 2006 there were 330 incursions and during FY2007 there were 371. A system being installed at airports by the FAA provides warning to air traffic controllers, but not to the flight crews, a situation that greatly reduces the amount of time that pilots have to react to an impending incursion.
The Board’s recommends a direct warning to the cockpit.
Meanwhile, the NTSB believes operating transport-category airplanes with flammable fuel/air vapors in fuel tanks presents a risk of explosion that is avoidable. Center wing fuel tank explosions have resulted in 346 fatalities in four accidents since 1989.
After the TWA 800 accident in 1996, the Board issued recommendations to reduce the potential for flammable fuel/air vapors in aircraft fuel tanks. The FAA developed a proposed rule in 2004 to reduce fuel tank flammability and submitted the rulemaking package to the Department of Transportation. But the final rule won’t be issued before February 2008.
Rosenker said he is “disturbed, disappointed and confused” in not seeing a final rule on nitrogen fuel tank inerting. “This issue has been under discussion for more than a decade…This technology will go a go long way in avoiding another Trans World Airlines Flight 800.”
Board Member Deborah Hersman is also unhappy with the numerous delays in issuing a final fuel tank rule. When told by a senior NTSB staffer that he ‘hopes’ to see a final rule in February, Hersman said “hope is not a strategy.”
The consequences of operating an airplane in icing conditions without first having thoroughly demonstrated adequate handling/controllability in those conditions are sufficiently severe that they warrant a thorough certification test program. The FAA has not adopted a systematic and proactive approach to the certification and operational issues of airplane icing.
The NTSB urged the FAA to complete efforts to revise icing certification criteria, testing requirements, and restrictions on operations in icing conditions, evaluating all aircraft certified for flight in icing conditions using the new criteria and standards.
Board members said investigators must work rapidly, effectively and efficiently to determine the factors related to an accident. Automatic information recording devices, such as Cockpit Voice Recorders (CVRs) and Flight Data Recorders (FDRs) have proven to be very useful in gathering pure factual information.
The addition of video recording devices would provide critical information to investigators about the actions in the cockpit of small aircraft not equipped with CVRs or FDRs, and would supplement the recorded data already provided on large aircraft. The NTSB believes these additional information components will aid in the development of timely, more precise safety recommendations that are likely to reduce future similar accidents.
In addition to adopting a two-hour CVR requirement, the Safety Board would require the retrofit of existing aircraft CVR systems with Recorder Independent Power Supplies (RIPS), and require that for existing aircraft, the FDR and CVR be on separate generator buses with the highest reliable power, so that any single electrical failure does not disable both. The NTSB would also like to see video recording systems in small and large aircraft and additional FDR data for Boeing 737s.
Part 121 and scheduled Part 135 operators are required to provide pilots with CRM training in which accidents are reviewed and skills and techniques for effective crew coordination are presented. The Safety Board has investigated several fatal aviation accidents involving Part 135 on-demand operators where the carrier either did not have a CRM program, or the CRM program was much less comprehensive than would be required for a Part 121 carrier. Although the FAA has agreed in principal with the recommendation, no discernable progress has been made.
The NTSB believes that Part 135 on-demand charter operators that conduct dual-pilot operations should establish and implement an FAA-approved CRM training program for pilots in accordance with Part 121.