Most Wanted
Transportation Safety
Improvements
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.
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