Most Wanted

Transportation Safety

Improvements

 

  Automatic Information Recording Devices
 

Importance

In order to effectively and efficiently determine the factors related to an accident, the Safety Board’s investigators must have as much information as possible.  Automatic information recording devices have proven to be very useful in gathering pure factual information.  The fact that this information is recorded immediately prior to and during the accident sequence often gives investigators the ability to quickly determine and correct a problem.

 

Safety Recommendations

 

A-98-54 (FAA)

Issued July 10, 1998

Status:  Open—Acceptable Response

Require maintenance checks for all [flight data recorders] FDRs of aircraft operated under 14 CFR Part 121, 129, 125, and 135 every 12 months or after any maintenance affecting the performance of the FDR system, until the effectiveness of the proposed advisory circular and new FAA inspector guidance on continuing FDR airworthiness (maintenance and inspections) is proven; further, these checks should require air carriers to attach to the maintenance job card records a computer printout, or equivalent document, showing recording data, verifying that the parameters were functioning properly during the FDR maintenance check and require that this document be part of the permanent reporting and recordkeeping maintenance system.  (Source: Fine Airlines, Inc. Crash After Take Off at Miami International Airport in Miami, Florida, August 7, 1997)

 

A-99-16 (FAA)

Issued March 9, 1999

Status:  Open—Unacceptable Response

Require retrofit after January 1, 2005, of all cockpit voice recorders (CVRs) on all airplanes required to carry both a CVR and an FDR with a CVR that (a) meets Technical Standard Order (TSO) C123a, (b) is capable of recording the last 2 hours of audio, and (c) is fitted with an independent power source that is located with the digital CVR and that automatically engages and provides 10 minutes of operation whenever aircraft power to the recorder ceases, either by normal shutdown or by a loss of power to the bus.  (Source: A safety recommendation letter dated March 9, 1999, based on the lack of complete cockpit and flight data in the September 2, 1998, crash of Swissair Flight 111, into the waters near Peggy’s Cove, Nova Scotia)

 

A-99-17 (FAA)

Issued March 9, 1999

Status:  Open—Unacceptable Response

Require all aircraft manufactured after January 1, 2003, that must carry both a cockpit voice recorder (CVR) and a digital flight data recorder (DFDR) to be equipped with two combination (CVR/DFDR) recording systems.  One system should be located as close to the cockpit as practicable and the other as far aft as practicable.  Both recording systems should be capable of recording all mandatory data parameters covering the previous 25 hours of operation and all cockpit audio including controller–pilot data link messages for the previous 2 hours of operation.  The system located near the cockpit should be provided with an independent power source that is located with the combination recorder, and that automatically engages and provides                10 minutes of operation whenever normal aircraft power ceases, either by normal shutdown or by a loss of power to the bus.  The aft system should be powered by the bus that provides the maximum reliability for operation without jeopardizing service to essential or emergency loads, whereas the system near the cockpit should be powered by the bus that provides the second highest reliability for operation without jeopardizing service to essential or emergency loads.  (Source: A safety recommendation letter dated March 9, 1999, based on the lack of complete cockpit and flight data in the September 2, 1998, crash of Swissair Flight 111, into the waters near Peggy’s Cove, Nova Scotia)

 

A-99-18 (FAA)

Issued March 9, 1999

Status:  Open—Unacceptable Response

Amend Title 14 CFR Parts 25.1457 (cockpit voice recorders) and 25.1459 (flight data recorders) to require that CVRs, FDRs, and redundant combination flight recorders be powered from separate generator buses with the highest reliability.  (Source: A safety recommendation letter dated March 9, 1999, based on the lack of complete cockpit and flight data in the September 2, 1998, crash of Swissair Flight 111, into the waters near Peggy’s Cove, Nova Scotia)

 

A-99-28 (FAA)

Issued April 16, 1999

Status:  Open—Unacceptable Response

Require that each 737 airplane operated under 14 CFR Parts 121 or 125 that currently has a flight data acquisition unit be equipped, by July 1, 2000, with a flight data recorder system that records, at a minimum, the parameters required by the FAA Final Rule 121.344, 125.226 dated July 17, 1997, applicable to that airplane plus the following parameters: pitch trim, trailing edge flaps, leading edge flaps, thrust reverser position (each engine), yaw damper command, yaw damper on/off discrete, standby rudder on/off discrete, and control wheel, control column, and rudder pedal forces (with yaw damper command, yaw damper on/off discrete, and control wheel, control column, and rudder pedal forces sampled at a minimum rate of twice-per-second).  (Source: A safety recommendation letter dated April 16, 1999, based on the September 8, 1994, crash of USAir Flight 427, Boeing 737 at Aliquippa, Pennsylvania [NTSB/AAR-99-01])

 

A-99-29 (FAA)

Issued April 16, 1999

Status:  Open—Unacceptable Response

Require that all 737 airplanes operated under 14 CFR Parts 121 or 125 not equipped with a flight data acquisition unit be equipped, at the earliest time practicable, but no later than August 1, 2001, with a flight data recorder system that records, at a minimum, the parameters required by FAA Final Rule 121.344, 125.226 dated July 17, 1997, applicable to that airplane plus the following parameters: pitch trim, trailing edge flaps, leading edge flaps, thrust reverser position (each engine), yaw damper command, yaw damper on/off discrete, standby rudder on/off discrete, and control wheel, control column, and rudder pedal forces (with yaw damper command, yaw damper on/off discrete, and control wheel, control column, and rudder pedal forces sampled at a minimum rate of twice-per-second).  (Source: A safety recommendation letter dated April 16, 1999, based on the September 8, 1994, Crash of USAir Flight 427, Boeing 737 at Aliquippa, Pennsylvania [NTSB/AAR-99-01])

 

A-99-59 (FAA)

Issued February 8, 2000

Status:  Open—Acceptable Response

Incorporate the European Organization for Civil Aviation Equipment's proposed standards for a crash-protective video recording system into a technical standard order.  (Source: A safety recommendation letter dated April 16, 1999, based on the October 8, 1997, Crash of a Cessna 208B Operated by the Department of Interior, Which Collided with Terrain at the 9,900-foot level on the Uncompahgre Plateau, About 18 Nautical Miles [nm] Southwest of Montrose, Colorado)

 

A-99-60 (FAA)

Issued February 8, 2000

Status:  Open—Unacceptable Response

Require, within 5 years of a technical standards order's issuance, the installation of a crash-protective video recording system on all turbine-powered nonexperimental, nonrestricted-category aircraft in 14 CFR Part 135 operations that are not currently required to be equipped with a crashworthy flight recorder device.  (Source: A safety recommendation letter dated April 16, 1999, based on the October 8, 1997, Crash of a Cessna 208B Operated by the Department of Interior, Which Collided with Terrain at the 9,900-foot level on the Uncompahgre Plateau, About 18 Nautical Miles (nm) Southwest of Montrose, Colorado)

 

A-00-30 (FAA)

Issued April 11, 2000

Status:  Open—Unacceptable Response

Require that all aircraft operated under title 14 CFR Part 121, 125, or 135 and currently required to be equipped with a cockpit voice recorder (CVR) and digital flight data recorder (DFDR) be retrofitted by January 1, 2005, with a crash-protected cockpit image recording system.  The cockpit image recorder system should have a 2-hour recording duration, as a minimum, and be capable of recording, in color, a view of the entire cockpit including each control position and each action (such as display selections or system activations) taken by people in the cockpit.  The recording of these video images should be at a frame rate and resolution sufficient for capturing such actions.  The cockpit image recorder should be mounted in the aft portion of the aircraft for maximum survivability and should be equipped with an independent auxiliary power supply that automatically engages and provides 10 minutes of operation whenever aircraft power to the cockpit image recorder and associated cockpit camera system ceases, either by normal shutdown or by a loss of power to the bus.  The circuit breaker for the cockpit image recorder system, as well as the circuit breakers for the CVR and the DFDR, should not be accessible to the flight crew during flight.  (Source: A safety recommendation letter dated April 16, 1999, prompted by the lack of valuable cockpit information during the investigations of several aircraft incidents and accidents, including USAir Flight 105 on September 8, 1989 [NTSB/AAR-90-04], ValuJet Flight 592 on May 11, 1996 [NTSB/AAR-97-06], SilkAir Flight 185 on December 19, 1997, Swissair Flight 111 on September 2, 1998, and EgyptAir Flight 990 on October 31, 1999 [NTSB/AAB-02-01])

 

A-00-31 (FAA)

Issued April 11, 2000

Status:  Open—Unacceptable Response

Require that all aircraft manufactured after January 1, 2003, operated under Title 14 CFR Part 121, 125, or 135 and required to be equipped with a cockpit voice recorder (CVR) and digital flight data recorder (DFDR) also be equipped with two crash-protected cockpit image recording systems.  The cockpit image recorder systems should have a 2-hour recording duration, as a minimum, and be capable of recording, in color, a view of the entire cockpit including each control position and each action (such as display selections or system activations) taken by people in the cockpit.  The recording of these video images should be at a frame rate and resolution sufficient for capturing such actions.  One recorder should be located as close to the cockpit as practicable and the other as far aft as practicable.  These recorders should be equipped with independent auxiliary power supplies that automatically engage and provide 10 minutes of operation whenever aircraft power to the cockpit image recorders and associated cockpit camera systems ceases, either by normal shutdown or by a loss of power to the bus.  The circuit breaker for the cockpit image recorder systems, as well as the circuit breakers for the CVR's and the DFDR's, should not be accessible to the flight crew during flight.  (Source: A safety recommendation letter dated April 16, 1999, prompted by the lack of valuable cockpit information during the investigations of several aircraft incidents and accidents, including USAir Flight 105 on September 8, 1989 [NTSB/AAR-90-04], ValuJet Flight 592 on May 11, 1996 [NTSB/AAR-97-06], SilkAir Flight 185 on December 19, 1997, Swissair Flight 111 on September 2, 1998, and EgyptAir Flight 990 on October 31, 1999 [NTSB/AAB-02-01])

 

H-99-53 (NHTSA)

Issued November 2, 1999

Status:  Open—Acceptable Response

Require that all school buses and motorcoaches manufactured after                January 1, 2003, be equipped with on-board recording systems that record vehicle parameters, including, at a minimum, lateral acceleration, longitudinal acceleration, vertical acceleration, heading, vehicle speed, engine speed, driver’s seat belt status, braking input, steering input, gear selection, turn signal status (left/right), brake light status (on/off), head/tail light status (on/off), passenger door status (open/closed), emergency door status (open/closed), hazard light status (on/off), brake system status (normal/warning), and flashing red light status (on/off) (school buses only).  For those buses so equipped, the following should also be recorded: status of additional seat belts, airbag deployment criteria, airbag deployment time, and airbag deployment energy.  The on-board recording system should record data at a sampling rate that is sufficient to define vehicle dynamics and should be capable of preserving data in the event of a vehicle crash or an electrical power loss.  In addition, the on-board recording system should be mounted to the bus body, not the chassis, to ensure that the data necessary for defining bus body motion are recorded.  (Source: Special Investigation Report, Bus Crashworthiness Issues [NTSB/SIR-99/04])

 

H-99-54 (NHTSA)

Issued November 2, 1999

Status:  Open—Acceptable Response

Develop and implement, in cooperation with other government agencies and industry, standards for on-board recording of bus crash data that address, at a minimum, parameters to be recorded, data sampling rates, duration of recording, interface configurations, data storage format, incorporation of fleet management tools, fluid immersion survivability, impact shock survivability, crush and penetration survivability, fire survivability, independent power supply, and ability to accommodate future requirements and technological advances.  (Source: Special Investigation Report, Bus Crashworthiness Issues [NTSB/SIR-99/04])

 

M-95-6 (USCG)

Issued July 17, 1995

Status:  Open—Acceptable Response

Propose to the International Maritime Organization that it require all vessels over 500 gross tons to be equipped with voyage event recorders.  (Source: Collision of the Netherlands Antilles Passenger Ship NOORDAM and the Maltese Bulk Carrier      MOUNT YMITOS Near the Entrance to the Mississippi River Near Southwest Pass, Louisiana, November 16, 1993 [NTSB/MAR-95-01])

 

R-97-9 (FRA)

Issued August 28, 1997

Status:  Open—Unacceptable Response

Amend 49 CFR Part 229 to require the recording of train crewmembers’ voice communications for exclusive use in accident investigations and with appropriate limitations on the public release of such recordings.  (Source: Collision and Derailment of MARC Train 286 and Amtrak Train 29, near Silver Spring, Maryland, on February 16, 1996 [NTSB/RAR-97-02])

 

R-98-30 (FRA)

Issued June 25, 1998

Status:  Open—Unacceptable Response

Working with the railroad industry, develop and implement event             recorder crashworthiness standards for all new or rebuilt locomotives by                        January 1, 2000.  (Source: Head-on Collision of Two Freight Trains in Devine, Texas, on            June 22, 1997 [NTSB/RAR-98-02])

 

Summary of Action

 

Aviation

A-98-54

Recommendation A-98-54 calls for an annual check of FDR data until the effectiveness of the FAA's FDR advisory circular and inspector-training program on FDR airworthiness can be assessed.  The FAA also promised to conduct a survey of operators with 11-parameter retrofit FDRs to assess the adequacy of their FDR maintenance program.  This survey was scheduled to be completed by February 2001, but to date, the Safety Board has not been notified of the survey findings or whether it has been completed.  The Safety Board's experience in recent years indicates that in spite of the FAA's FDR advisory circular and inspector-training program, investigations continue to be hindered by poor-quality FDR data and system documentation.

 

A-99-16 through -18 and A-99-28 and -29

In July 2001, the Board told the FAA that it considers vehicle recorders critically important to transportation safety.  The Board noted that it regarded as unacceptable the lack of progress made to implement these safety recommendations.  The Board urged the FAA to act expeditiously and complete the rulemaking project.  On November 16, 2001, the FAA reported that the final rule for Boeing 737s to record additional parameters (A-99-28 and -29) was completed and in executive coordination. It has not yet been issued.  The Board has recently been advised by the FAA that the NPRM concerning the 2-hour CVR with an independent 10-minute power supply (A-99-16) has been returned from the Department of Transportation.  The reason given was that it was going to be too expensive and burdensome for the industry to implement.

 

A-99-59 and -60

For A-99-59, the FAA, along with the Board's staff, is participating in the working group with EUROCAE to develop minimum operational performance standards for the use of video recording systems in aircraft.  The FAA intends to incorporate these standards into a Technical Standard Order (TSO).  The committee working on the EUROCAE document concluded its work and submitted a finished document to the central EUROCAE committee in January 2003.  The approval from EUROCAE is expected very soon.

 

For A-99-60, in its May 3, 2000, response, the FAA stated that it agreed with the intent of this safety recommendation, but could not commit to the timeframe requested by the Board.  The FAA believes that the issue of installation of crash-protective video recording equipment in airplanes and the appropriate timeframe for the installation should be submitted to the Radio Technical Commission of Aeronautics (RTCA) Future Flight Data Collection Committee for consideration.  The committee will look at the future trends in flight data collection to support both safety investigations and operational efficiencies, with primary focus on the appropriateness, timing, economic impact, and social acceptance of the proposed data collection concepts.

 

The Board replied on September 8, 2000, that it disagreed with the FAA on the appropriateness of the RTCA committee's involvement in the implementation of this safety recommendation.  The committee's goal is to look 10-15 years into the future to set the course for recorder technology and determine how it will be used to solve problems.  The Board does not believe it appropriate to refer this recommendation to the RTCA committee.

 

A-00-30 and -31

Recommendations A-00-30 and A-00-31 call for the installation of cockpit image recorders in large transport aircraft to provide information that can supplement existing CVR and FDR data in accident investigations.  This kind of additional information would have been extremely valuable in a number of recent investigations, including ValuJet 592 near Miami, Silk Air 185 in Indonesia, Swissair 111 near Peggy’s Cove, Nova Scotia, and EgyptAir 990.  The RTCA Future Flight Data Collection Committee considered the issue of video recording and concluded that this methodology would provide useful information to accident investigation, and that it was technologically feasible.  The Committee did note concerns about the protection from disclosure outside of accident investigation, particularly for international flights.  The Board’s last reauthorization extended the protections that have long been in place for CVRs to image recorders.

 

In a February 4, 2002, letter, the Safety Board acknowledged that the RTCA committee had issued its final report, which was favorable to the concept of using video technology in the cockpit. The letter urged the FAA to promptly initiate rulemaking activity for the recording requirements outlined in these recommendations.

 

Highway

The NHTSA has established an event data recorder working group made up of government and industry officials to encourage manufacturers to obtain large-scale deployment of crash sensing and recording devices.  NHTSA is defining functional and performance requirements for electronic data recorders, understanding present technology, developing a set of data definitions, discussing various uses of the data, and resolving legal and privacy issues.

 

Marine

The Maritime Safety Committee of the IMO approved the use of voyage data recorders (VDR) in December 2000.  The requirements for VDR usage are in SOLAS V, regulation 20.  By July 1, 2002, all roll-on/roll-off passenger vessels, all                        new passenger vessels, and all new cargo vessels (including tankers) on          international voyages and of 3,000 tons or more will be required to have VDRs.  By February 1, 2004, all existing passenger vessels on international voyages will be required to have VDRs.  Existing cargo vessels, including tankers, are not included in this requirement.

 

The Coast Guard is on record at the IMO with a request to include existing cargo vessels under the VDR requirements.  This is still under discussion at the IMO.

 

Rail

R-97-9

The FRA stated in its most recent response, dated May 5, 2003, that it was still not persuaded that the additional information yielded by voice recordings would be sufficient to offset the costs of installing the technology, maintaining it, and conducting sufficient compliance oversight to reasonably assure its proper functioning.

 

The Safety Board continues to believe that there is more than enough experience in other modes of transportation for the FRA to begin the process leading to the use of voice recorders in the railroad industry, and that voice recordings are a necessary addition to data collected during investigations.

 

This follows a summer of 2002 meeting between the FRA administrator and staff and the Safety Board chairman and staff, in which the FRA again indicated that it was highly unlikely that any progress or effort would be made toward the implementation of voice recorders.

 

R-98-30

Recommendation R-98-30 asked the FRA to develop and implement crashworthiness standards for railroad event recorders by January of 2000.  Numerous rail event recorders have been lost to fire and impact forces in the past several years.  Safety Board staff have participated with the FRA and industry representatives since 1995 in an RSAC Locomotive Event Recorder Crashworthiness Working Group.  In a letter, dated May 5, 2003, the FRA said it plans to issue an NPRM by November 30, 2003, that would guarantee the crashworthiness of rail event recorders and also add important data elements to those currently required by FRA regulations.  The NPRM still would have to pass the full RSAC and FRA before it could be issued.  Obviously, rulemaking is still a very long time in the future.  The technology to accomplish the protection of rail recorders is mature and the need is well demonstrated.

 

Action(s) Remaining

Upgrade the parameters and capabilities of CVRs and FDRs and provide redundancy.

Enhance maintenance checks of FDRs.

Continue efforts to require recorders on highway vehicles and to require high maintenance and crashworthiness standards for recorders in all modes.

 

Most Wanted Intermodal

Most Wanted Home

NTSB Home

from this link

 
   
 

To Hot Off the Press