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NATA Safety 1st Flitebag – Issue 30 – 4th Quarter 2012

Welcome to Issue 30 of NATA’s Safety 1st Flitebag, our quarterly online safety newsletter,

supporting the NATA Safety 1st Management System (SMS) for Air Operators.

This quarterly newsletter highlights known and emerging trends, environmental and geographical matters, as well as advances in

operational efficiency and safety. Flight and ground safety have been enhanced and many accidents prevented because of shared

experiences.

Managing Fatigue: A Systematic Approach By: Lindsey McFarren

[email protected]

Managing Fatigue: A Systematic Approach

A fatigue risk management system (FRMS) is a

systematic method whereby an organization optimizes

the risks associated with fatigue related to error. Fatigue

management is a joint responsibility: both the

organization and the individual play critical roles in

managing fatigue and minimizing risk of errors.

The organization is responsible for managing the

workplace, including hours of work, work environment,

and workload, while the individual is responsible for

managing lifestyle and medical disorders.

FRMS: Fatigue Policies, Training, and Assessments

To develop and implement an FRMS, the organization

must first develop policies related to fatigue

management. Like a Safety Management System, an

FRMS must begin with the commitment and support of

the senior leadership of the company. Responsibilities

and duties, including fatigue-related event reporting

requirements, must be described. These reporting

requirements must include a non-punitive policy (except

for examples of non-compliance, drug or alcohol-related

scenarios, or acts of negligence or intentional error). A

“just culture” is a crucial component of FRMS.

The following policy is an example of an FRMS policy:

A fatigue risk assessment is required prior to all fights

with a high risk of fatigue, such as flights crossing

multiple time zones, flights operating on the “opposite

side of the clock”, flights with longer periods at cruise

altitude (three or more hours) or other flight profiles

identified by a risk assessment process. Further, for

these flights:

Circle-to-land approaches are prohibited

Higher approach minimums may be

temporarily established

Issue 30 4th

Quarter 2012

In This Issue: Managing Fatigue: A Systematic Approach ..................................1

ACSF News – ACSF By the Numbers, ASAP Program Participation

Grows, Operators Renew Audit Registration…...................................6

Industry News – NATA’s New President’s Blog, FAA Proposes

Changes to Contract Maintenance Requirements, FAA Publishes

International Operations Guidance, and More...................................10

NTSB News – NTSB Most Wanted List, Update on Air Race Safety,

NTSB Investigative Process, and Probable Cause for Reno Air Race

Accident…...........................................................................................15

Information For Operators (InFOs) ...............................................22

Safety Alert For Operators (SAFOs) ..............................................23


Crew members should monitor each other for fatigue symptoms, including:

o Fidgeting

o Frequent eye blinking

o Adjusting temperature down

o Yawning

o Head drooping

o Personality change (quieter than normal, withdrawn, or irritable)

An example of a simple flightcrew member fatigue assessment is included below.

The organization must also train all employees on fatigue, symptoms of fatigue, and possible risks related

to fatigue. Training should include discussion of the restorative power of napping and the importance of

good physical condition, including exercise and diet. Training should also cover the effective use of

caffeine and the negative impacts of alcohol and medications (prescription and over-the-counter).

Employees should be instructed on the possible impacts of social/family life, as well as commuting, on

work performance.

Finally, the organization must have a process to assess fatigue in the workplace. Some methods of

assessing fatigue include regular shift/flight assignment reviews, fatigue level assessments, and fatigue

management techniques. There are a number of software programs that attempt to assess fatigue level.

There are also some fancy models for assessing fatigue. At the end of the day, the fatigue assessment that

should work best for your organization is the one your employees should USE, so my advice is to keep it

simple.

Fatigue Mitigation Techniques

There may be occasions when operational demands require employees to work longer hours than

normal. A number of control factors can be put in place. If at any stage an employee feels unfit for work,

they should be relieved of duty and sent home or given an opportunity to rest.

A number of controls or strategies can be used to minimize the likelihood of errors when employees

experience low or moderate levels of fatigue. These include:

Napping

Supervisor and co-worker monitoring / team tasking

Task rotation and re-allocation


Additional breaks and strategic use of caffeine

Napping

Where appropriate, employees should be allowed to take a nap or controlled rest. Reasonable short-term

sleeping facilities should be provided for employees during working hours.

Highest priority for napping should be given to those with the highest fatigue-related risk. Naps should

be at least 20 minutes and no more than 2 hours, depending on operational constraints and fatigue risk

involved. Before returning to work after a nap, employees should be given sufficient time to overcome

the effects of sleep inertia. Typically, this is at least 10 minutes during the day, and up to 20 minutes in

the early hours of the morning.

Supervisory and co-worker monitoring / team tasking

In instances where operational demands require extended hours of work that may result in employees

working through higher levels of fatigue than normal, employees and supervisors should be proactive in

observing and acting on fatigue-related symptoms in one another. In cases where fatigue symptoms are

repeatedly observed in an employee, the supervisor should be informed and measures should be taken to

allow the employee to take a break or a nap, or use other strategies to improve alertness (such as exercise,

caffeine). Additional supervisory checks for safety-critical work should also take place.

Some tasks requiring extended hours of work or opposite side of the clock work might best be

accomplished by a two-person team.

Task rotation and task re-allocation

Rotation of tasks should be arranged during periods when operational demands may increase fatigue-

related risks. Monotonous tasks with little variety should be targeted in particular. Supervisors should

rotate work in consultation with concerned employees to ensure that all are assigned to familiar tasks. No

employee should be assigned to more than three different tasks during a given period.


In situations of increased fatigue-related risk, such as when an employee repeatedly exhibits symptoms of

fatigue, it may be necessary to re-schedule or re-assign some tasks. Any task sensitive to the effects of

fatigue should be re-scheduled or re-assigned.

Additional breaks and strategic use of caffeine

When operational requirements call for longer hours of work, additional breaks of 10 to 20 minutes

should be provided to employees on request. Employees are responsible for monitoring themselves and

for requesting a break when they feel it necessary to restore their performance levels. Employees should

also suggest breaks to co-workers if they observe fatigue symptoms. During these breaks, employees

should take necessary actions to counter fatigue effects (exercise, drink caffeine, etc.).

It should be noted that since habitual use diminishes the stimulating effects of caffeine, regular use of

caffeine to prevent fatigue is discouraged. However, it can be useful in contingency situations to help

increase alertness when required.

PILOT ALERTNESS ASSESSMENT FORM

Flightcrew employees are encouraged to complete this form prior to and during flights with high risk of

fatigue. Examples of these types of flights are:

Flights crossing multiple time zones

Flights operating on the “opposite side of the clock” (i.e. during the hours the pilot is typically

sleeping)

Flights with long segments at cruise altitude (more than 3 hours)

Other flights as identified by [Operator name]’s risk assessment process

REPORT TIME: ______ (UTC)

Flight stage at assessment (check one):

□ Preflight

□ Takeoff/climb

□ Cruise altitude

□ Top of descent

□ Approach

□ Post-flight


Please circle how you feel:

1. Fully alert, wide awake

2. Very lively, responsive, but not at peak

3. OK, somewhat fresh

4. A little tired, less than fresh

5. Moderately tired, let down

6. Extremely tired, very difficult to concentrate

7. Completely exhausted

Then mark the same score on the line below:

_______________________________________

Alert Exhausted

1 4 7

A score in the yellow range (4-5) should be discussed with your assigned co-crewmember immediately.

A score in the red range (6-7) should be discussed with the Chief Pilot, Assistant Director of Operations, or Director of

Operations immediately.

A score in the green range does not need to be submitted or reviewed.

Lindsey McFarren is the president of McFarren Aviation Consulting, which specializes in general aviation safety and

operations consulting. Lindsey was named one of the aviation industry’s Top 40 Under Forty in 2012.


THE AIR CHARTER SAFETY FOUNDATION BY THE NUMBERS

Ninety-five aviation companies, including Part 135 on-demand air charter operators, fractional aircraft

management companies, brokers, underwriters, consultants, and aircraft OEMs have become members of

the Air Charter Safety Foundation (ACSF) since the 501(c)(3) was founded in 2007. The ACSF’s membership

has more than doubled since November 2010, when the ACSF had 40 member organizations. Last year

during NBAA, the association had 60 members.

“I’m extremely proud of the progress that the Air Charter Safety Foundation has made to grow the value

we provide to our members,” said ACSF President Bryan Burns. “While we’re best known for creating the

leading Industry Audit Standard, we’ve worked hard to launch several new member benefits, such as

the Aviation Safety Action Program, which helps promote safety and mitigate risk throughout the air

charter and fractional industry.”

Number of ACSF Members


Types of ACSF Members

Regular members are aircraft operators, management companies and brokers;

Associate members are insurance companies, training centers, maintenance facilities, FBO’s, aircraft

manufacturers, and others.

Affiliate members are other non-profit organizations and small businesses, hospitals/medical

facilities, airport authorities, and government agencies.

Number of Programs Available to ACSF Members

ACSF Industry Audit Standard (IAS) – The only audit program that comprehensively and

independently evaluates an air charter operator’s and/or fractional ownership company’s safety and

regulatory compliance. It helps alleviate the substantial costs and redundancies associated with today’s

auditing environment, where operators are subject to multiple audits every year that consume precious

resources. Participating independent auditors are accredited by the ACSF.

Aviation Safety Information System (AVSiS) – A revolutionary software program for the on-

demand air charter and fractional aircraft ownership industry that addresses the need to maintain a

constant watch for emerging safety issues within their operations.

Aviation Safety Action Program (ASAP) – ASAP is a voluntary, self-reporting program that

identifies and reduces possible flight safety concerns, and mitigates risk. It encourages an employee of a

participating member company to voluntarily report safety issues, by offering enforcement-related

incentives. An ASAP is based on a safety partnership that includes the ACSF, the FAA and the participating

company.

Air Charter Safety Symposium – Annually the ACSF hosts the Air Charter Safety Symposium at

the National Transportation Safety Board Training Center, offering two days of learning and discussion on

topics such as reducing errors through empowered accountability and crew resource management.

Illegal Charter Reporting Hotline – A toll-free hotline (888-759-3581) is available for anyone to file a

report of suspected illegal commercial flights where an aircraft operator without a FAA Part 135 certificate

is accepting compensation for transportation.

Safety Updates – Topic-specific briefings are made available to members via email and the ACSF

Web-site based on recent FAA publications, notices/directives, and industry research/data.

Safety Management System (SMS) Resources – An online resource for members seeking research to

either implement or support the ongoing operation of their SMS.


Number of Registered Operators who completed the ACSF Industry Audit Standard in 2012

(Valid for 2 years)

Executive Fliteways

Flexjet by Bombardier

Key Air

Jet Solutions

Keystone Aviation

M&N Aviation

Mayo Aviation

Priester Aviation

Sun Air Jets

“I can attest to the fact that the ASCF audit changed my entire company for the better,” stated William F.

Haberstock, President, Keystone Aviation. “Our entire team took ownership of the process—from senior

executives to the front line—and we were able to complete the entire process in less than nine months.”

To become an ACSF member, download the membership application here.

N-JET AND PRIESTER AVIATION JOIN ACSF’S AVIATION SAFETY ACTION PROGRAM

The Air Charter Safety Foundation (ACSF) is pleased to announce that N-Jet of Wheeling, Illinois, and Priester Aviation of

Wheeling, Illinois, have become the latest on-demand air charter operators to participate in the ACSF Aviation Safety

Action Program (ASAP). They join Best Jets International of Minneapolis, Minnesota, and Bemidji Aviation Services of

Bemidji, Minnesota, who were the first operators to participate. "We're extremely pleased that these operators have joined

the ASAP program," said ACSF Chairman Dennis Keith. "This commitment will allow them to make a positive

contribution in risk reduction, and they are leading the way to improving the overall safety culture of our industry."

"I would like to personally thank the FAA Dupage Flight Standards District Office and the ACSF for selecting N-Jet as a

participant in the ASAP program," said N-Jet President Howard Seedorf. "I believe this program will provide N-Jet and

others with critical safety feedback that would have otherwise gone unreported. Most importantly, it will enhance the

safety of our stakeholders, including passengers and crews, by creating a more robust safety management system."


"Joining this important program affirms our commitment to continuously enhance our company safety culture and the

quality of our operation," said Priester Aviation President Andy Priester. "This is a win-win scenario for our employees,

customers and the charter industry."

An ASAP is a reporting program that allows employees of participating air carriers and repair station certificate holders

to identify and report safety issues to management and to the Federal Aviation Administration (FAA) for resolution,

without fear that the FAA will use reports accepted under the program to take legal enforcement action against them, or

that companies will use such information to take disciplinary action.

The objective of the ACSF ASAP program is to expand to other FAA regions, and to encourage charter operators that lack

the resources to establish their own ASAP program to participate and benefit from this valuable safety tool.

EXECUTIVE FLITEWAYS AND SUN AIR JETS RENEW ACSF INDUSTRY AUDIT STANDARD REGISTRATION

The Air Charter Safety Foundation (ACSF) is pleased to announce that Executive Fliteways, Ronkonkoma, NY and Sun

Air Jets, Camarillo, CA have renewed their status on the ACSF Industry Audit Standard (IAS) Registry.

“By renewing their status on the IAS Registry, they have demonstrated their commitment to high standards,” said ACSF

President Bryan Burns. “We congratulate them on their continued dedication.”

“Executive Fliteways is proud to be a part of the Air Charter Safety Foundation team,” said John Grillo, president and

CEO. “The recent audit by ACSF helped enhanced our practices and safety culture as we continue to pursue the safest

operation possible.”

The IAS is the first and only extensive audit program specifically created for on-demand operators by a committee of Part

135 and 91K industry leaders. It is conducted every 24 months and is in-depth in its evaluation of regulatory compliance

and the operator’s SMS program against both FAA and international standards.

“Sun Air Jets recognizes the incredible importance of providing the highest level of aviation safety, and commends our

team for a successful ACSF renewal,” said Charlie O’Dell, Director of Operations. “We have built our corporate culture

around continuous improvement of our safety systems and utilize the ACSF audit as a benchmark that we strive to

elevate each time our company is evaluated.”


Customers should look for the ACSF IAS registered logo and encourage their preferred charter provider to participate in

the program. The ACSF makes its operator registry and key company details available at no charge, so verification of IAS

registration is quick and easy. Charter consumers can view the registry by clicking here. Supporting materials are

available by clicking here. Operators wishing to initiate the audit process should contact Russ Lawton at 1-888-SAFE-135

(888-723-3135).

INDUSTRY NEWS

NATA PRESIDENT TOM HENDRICKS DISCUSSES INDUSTRY AND ASSOCIATION’S FUTURES ON NEW

“PRESIDENT’S MESSAGE” BLOG

After a busy and productive several weeks, I wanted to pause and give you an update on some exciting announcements

and several opportunities that I’ve had to tell the story of our industry.

At NBAA’s Annual Meeting and Convention, I participated on an Alliance for Aviation Across America (AAAA) press

conference with fellow AAAA board members Selena Shilad of AAAA, Ed Bolen of NBAA, Matt Zuccaro of HAI and Niel

Ritchie of the League of Rural Voters to discuss the important work of the AAAA and some of its achievements. Most

recently, AAAA launched a new website, http://www.aviationacrossamerica.org/. Among the many features is an

interactive map of the U.S. showing a snapshot of the economic impact of general aviation by state, community and, very

importantly, congressional district. To date, they have also been successful in garnering the support of 46 of the 50 state

governors through signed proclamations recognizing the value of general aviation. I also had an opportunity to meet

many of our members on the show floor and to attend the Air Charter Safety Foundation Board of Governors meeting.

On the way back to Washington on November 1, I had the great pleasure to speak at the opening of Auburn University’s

Aviation Management Advisory Board meeting. I expressed the vital importance of NATA to the aviation community,

the immense value of aviation to the country and finally the vast significance of their future role as leaders in

perpetuating and advancing this incredibly exciting and rewarding industry.

Just this past week, NATA concluded another successful Aviation Business Roundtable – my first. We followed this with

a very busy, yet productive Board of Directors Meeting. In these events, we made some major personnel announcements.

I was particularly pleased to announce that Jim Coon will be joining NATA as our executive vice president and Amy B.

Koranda is being promoted to vice president. Jim, currently the chief of staff of the U.S. House Representatives

Committee on Transportation and Infrastructure will lead NATA’s policy, strategy and advocacy efforts. Amy will add

several major association programs to her current responsibilities as head of NATA’s highly regarded Safety 1st Program.

With Jim and Amy rounding out our senior leadership team, we are poised to advance the association services and to

reposition NATA within Washington.


To cap the week off, I am honored to have been named to the Board of Governors of the Aero Club of Washington at this

week’s luncheon and annual meeting. For many years, the Aero Club of Washington has brought together people from

all areas of aviation to discuss the most pressing issues of our industry, and I am proud to serve on their board with

others who value aviation so highly in their lives and careers.

With the holidays approaching, it is a time for reflection and giving thanks. I am most thankful for my family, the

opportunity to work to protect and advance the wonderful aviation businesses that make up this dynamic organization,

the support of our membership and the tireless efforts of our board members and staff.

Past blog posts can be found here.

FAA PROPOSES REVISIONS TO AIR CARRIER USE OF CONTRACT MAINTENANCE PROVIDERS

What’s at Issue

The Federal Aviation Administration (FAA) issued a Notice of Proposed Rulemaking (NPRM), Air Carrier Contract

Maintenance, to require Part 135 operators with aircraft that are certificated for 10 or more passenger seats to revise their

maintenance program when utilizing contracted maintenance providers.

Why It’s Important

The revised regulations will require affected Part 135 operators to develop and implement FAA-approved policies,

procedures, methods and instructions for performing contract maintenance. Operators will also need to ensure that the

FAA is provided an up-to-date comprehensive list of all persons with whom they contract their maintenance and what

work those facilities provide.

Major Provisions

The NPRM is in response to a congressional mandate to impose new rules for outsourced maintenance on Part 121 air

carriers, but the FAA is electing to include Part 135 operators with aircraft having 10 or more passenger seats as well.

The FAA is proposing to create § 135.426, which will specifically address requirements for contract maintenance.

Proposed § 135.426 includes definitions for maintenance provider, covered work, directly in charge, and supervision and control.

These terms are used to define what functions are covered by the new requirements and the specific oversight

responsibilities of the air carrier. The certificate holder must establish policies and procedures to ensure that the

maintenance performed by a contract maintenance provider is in accordance with the operator’s maintenance program

and maintenance manual.

Operators must also provide a list that includes the name and address of each maintenance provider, as well as a

description of the work that will be performed. This list must be in a format acceptable to the FAA and carriers are

required to update the list no later than the last day of each calendar month.


NATA Position

NATA is reviewing the NPRM and will develop comments in coordination with the NATA Air Charter and Aircraft

Maintenance & Systems Technology committees.

Status

The NPRM was published on November 13, 2012. Comments will be accepted until February 11, 2013. Click

here to download the NPRM, which includes instructions for submitting comments.

WORKERS COMPENSTATION INSURANCE PROGRAM

NATA's new Workers Compensation Insurance Program is specifically designed for typical NATA members such as an

FBO, air charter operator, flight training provider, aircraft management services provider, aircraft maintenance and repair

providers, and airline services companies. The new program starts January 1, 2013. Click here for more program details

MEDXPRESS NOW MANDATORY

Beginning on October 1, all applications for an FAA Medical Certificate or Student Pilot Certificate must be submitted

electronically via the FAA's MedXpress prior to visiting an Aviation Medical Examiner. To complete Form 8500-8

electronically, applicants must first create a user account with MedXpress. More information on creating an account and

using the website can be found in the user guide by clicking here.

FAA SAFETY BRIEFING FOCUSES ON INTERNATIONAL GENERAL AVIATION OPERATIONS

The November/December 2012 issue of FAA Safety Briefing, posted on the FAA website at

http://www.faa.gov/news/safety_briefing/, explores the significance of general aviation on a global scale and focuses on

several tools and resources that can help you operate safely beyond our borders.

Among the articles in this internationally-themed issue include: a review of overseas flying requirements, how to master

the language of aviation, island-hopping in the Caribbean, and an inside look at how the International Civil Aviation

Organization (ICAO) can impact your flying. In addition, the issue’s Checklist department explores the International

Flight Information Manual (IFIM), a useful planning tool for flights outside the United States.

The issue also contains information on Aviation Maintenance Technician career opportunities with “A License to Skill”

and how to make sure you’re using approved parts for your aircraft in Nuts, Bolts, and Electrons.


FAA CREATES RESEARCH PARTNERSHIP WITH AVIATION ACADEMIA

U.S. Transportation Secretary Ray LaHood recently announced that the Federal Aviation Administration (FAA) has

selected a team of universities to lead a new Air Transportation Center of Excellence (COE) for general aviation. The COE

will focus research and testing efforts on safety, accessibility and sustainability to enhance the future of general aviation.

“The United States has the largest and most diverse general aviation community in the world, with more than 300,000

aircraft registered to fly through American skies,” said Secretary LaHood. “This innovative partnership with academia

and industry will help us take general aviation safety to the next level.”

The selected group is called the FAA Center of Excellence Partnership to Enhance General Aviation Safety, Accessibility

and Sustainability (PEGASAS), and will be led by Purdue University, The Ohio State University and the Georgia Institute

of Technology. The core team also will include the Florida Institute of Technology, Iowa State University and Texas A&M

University. Affiliate members include: Arizona State University, Florida A&M, Hampton University, Kent State

University, North Carolina A&T State University, Oklahoma State University, Southern Illinois University (Carbondale),

Tufts University, Western Michigan University and University of Minnesota, Duluth.

The FAA’s COE program is a cost-sharing research partnership between academia, industry and the federal government.

Research and development efforts by PEGASAS will cover a broad spectrum of general aviation safety issues, including

airport technology, propulsion and structures, airworthiness, flight safety, fire safety, human factors, system safety

management and weather.

The PEGASAS university members all have nationally recognized collegiate flight education programs, and three of the

core members (Purdue, Ohio State and Texas A&M) also own and operate their own airports. Research projects will be

performed through a partnership of principal investigators from the different universities. PEGASAS will engage both

graduate-level and undergraduate students in its research activities.

“The FAA continues its goal of working to reduce general aviation fatalities by 10 percent over a 10-year period, from

2009 to 2018,” said Acting FAA Administrator Michael Huerta. “The Center of Excellence program is a valuable tool in

providing the critical data we need to reduce those accidents.”

PEGASAS industry and organizational partners are GE Aviation; Battelle Memorial Institute; NetJets Inc.; Cessna;

Gulfstream; Piper; Raytheon; Rockwell Collins; Cirrus; Flight Safety Foundation; Guardian Mobility; Harris Corporation;

Jet Aviva; NextGen AeroSciences; Nelson

Consulting; Rolls-Royce; The Spectrum Group; Take Flight Solutions; Woolpert; the Flight Deck Display Research

Laboratory at NASA Ames; Columbus Regional, South Bend and Fort Wayne Airports; Florida, Georgia, Iowa and

Indiana Departments of Transportation; the National Business Aviation Association; the National Intercollegiate Flying


Association; and Ohio Aerospace Institute. These non-federal affiliates will provide matching contributions to help offset

the FAA’s investment in the COE’s general aviation research initiatives.

The FAA established the first Center of Excellence for General Aviation in 2001 through a 10-year agreement to conduct

general aviation research in airport and aircraft safety areas. The research topics included pilot training, human factors,

weather, Automatic Dependent Surveillance/Broadcast (ADS-B), remote airport lighting systems and other matters.

As the first Center of Excellence for General Aviation research concludes, the new team will continue critical research,

testing and education efforts. The FAA intends to invest a minimum of $500,000 per year during the first five years of the

new, 10-year agreement with PEGASAS.

Congress authorized Air Transportation Centers of Excellence under the Federal Aviation Administration Research,

Engineering and Development Authorization Act of 1990. This legislation enables the FAA to work with university

partners and industry affiliates to conduct research in airspace and airport planning and design, environment and

aviation safety, as well as to engage in other activities to assure a safe and efficient air transportation system.

The FAA has established Centers of Excellence in eight other topic areas, focusing on commercial space transportation,

airliner cabin environment and intermodal research, aircraft noise and aviation emissions mitigation, computational

modeling of aircraft structures, advanced materials, airport pavement and airport technology, operations research and

airworthiness assurance. For more information about the FAA Centers of Excellence program, visit the COE webpage at

http://www.faa.gov/go/coe.


NTSB’S MOST WANTED LIST IDENTIFIES TOP TEN TRANSPORTATION CHALLENGES FOR 2013

The National Transportation Safety Board recently released its 2013 Most Wanted List, with six of the ten issues focusing

on highway travel where most transportation fatalities take place and includes the number one killer on the list:

substance-impaired driving.

The new annual list of the independent federal safety agency's top advocacy priorities calls for ending distraction in all

modes of transportation. Distraction was the cause of multiple accidents investigated by the agency in recent years, and

its deadly effects will only continue to grow as a national safety threat.

"Transportation is safer than ever, but with 35,000 annual fatalities and hundreds of thousands of injuries, we can, and

must, do better," said NTSB Chairman Deborah A.P. Hersman. "The Most Wanted List is a roadmap to improving safety

for all of our nation's travelers."

The list covers all transportation modes. There are six new issue areas — distraction, fire safety, infrastructure integrity,

pipeline safety, positive train control and motor vehicle collision avoidance technologies.

"We're releasing the list now so it is available to policymakers at the state and federal levels as well as industry groups as

they craft their priorities for 2013," Hersman said. "We want to highlight the results of our investigations and ensure that

safety has a seat at the table when decisions are made."

The NTSB's 2013 Most Wanted List of transportation priorities includes:

Improve Safety of Airport Surface Operations

Preserve the Integrity of Transportation Infrastructure

Enhance Pipeline Safety

Implement Positive Train Control Systems

Eliminate Substance-Impaired Driving

Improve the Safety of Bus Operations

Eliminate Distraction in Transportation


Improve Fire Safety in Transportation

Improve General Aviation Safety

Mandate Motor Vehicle Collision Avoidance Technologies

Link for Most Wanted List Press Conference Video

THE INVESTIGATIVE PROCESS AT THE NTSB

The National Transportation Safety Board was established in 1967 to conduct independent investigations of all civil

aviation accidents in the United States and major accidents in the other modes of transportation. It is not part of the

Department of Transportation, nor organizationally affiliated with any of DOT's modal agencies, including the Federal

Aviation Administration. The Safety Board has no regulatory or enforcement powers.

To ensure that Safety Board investigations focus only on improving transportation safety, the Board's analysis of factual

information and its determination of probable cause cannot be entered as evidence in a court of law.

THE NTSB "GO TEAM"

At the core of NTSB investigations is the "Go Team." The purpose of the Safety Board Go Team is simple and effective:

Begin the investigation of a major accident at the accident scene, as quickly as possible, assembling the broad spectrum of

technical expertise that is needed to solve complex transportation safety problems.

The team can number from three or four to more than a dozen specialists from the Board's headquarters staff in

Washington, D.C., who are assigned on a rotational basis to respond as quickly as possible to the scene of the accident. Go

Teams travel by commercial airliner or government aircraft depending on circumstances and availability. Such teams

have been winging to catastrophic airline crash sites for more than 35 years. They also routinely handle investigations of

certain rail, highway, marine and pipeline accidents.

During their time on the "duty" rotation, members must be reachable 24 hours a day by telephone at the office or at home,

or by pager. Most Go Team members do not have a suitcase pre-packed because there's no way of knowing whether the

accident scene will be in Florida or Alaska, but they do have tools of their trade handy -- carefully selected wrenches,

screwdrivers and devices peculiar to their specialty. All carry flashlights, tape recorders, cameras, and lots of extra tape

and film.

The Go Team's immediate boss is the Investigator-in-Charge (IIC), a senior investigator with years of NTSB and industry

experience. Each investigator is a specialist responsible for a clearly defined portion of the accident investigation. In

aviation, these specialties and their responsibilities are:


OPERATIONS: The history of the accident flight and crewmembers' duties for as many days prior to the crash as appears

relevant.

STRUCTURES: Documentation of the airframe wreckage and the accident scene, including calculation of impact angles

to help determine the plane's pre-impact course and attitude.

POWERPLANTS: Examination of engines (and propellers) and engine accessories.

SYSTEMS: Study of components of the plane's hydraulic, electrical, pneumatic and associated systems, together with

instruments and elements of the flight control system.

AIR TRAFFIC CONTROL: Reconstruction of the air traffic services given the plane, including acquisition of ATC radar

data and transcripts of controller-pilot radio transmissions.

WEATHER: Gathering of all pertinent weather data from the National Weather Service, and sometimes from local TV

stations, for a broad area around the accident scene.

HUMAN PERFORMANCE: Study of crew performance and all before-the-accident factors that might be involved in

human error, including fatigue, medication, alcohol. Drugs, medical histories, training, workload, equipment design and

work environment.

SURVIVAL FACTORS: Documentation of impact forces and injuries, evacuation, community emergency planning and

all crash-fire-rescue efforts.

Under direction of the IIC, each of these NTSB investigators heads what is called a "working group" in one area of

expertise. Each is, in effect, a subcommittee of the overall investigating team. The groups are staffed by representatives of

the "parties" to the investigation (see the next section - The Party System) - the Federal Aviation Administration, the

airline, the pilots' and flight attendants' unions, airframe and engine manufacturers, and the like. Pilots would assist the

operations group; manufacturers' experts, the structures, systems and powerplants groups; etc. Often, added groups are

formed at the accident scene - aircraft performance, maintenance records, and eyewitnesses, for example. Flight data

recorder and cockpit voice recorder teams assemble at NTSB headquarters.

In surface accident investigations, teams are smaller and working groups fewer, but the team technique is the same.

Locomotive engineers, signal system specialists and track engineers head working groups at railroad accidents. The

specialists at a highway crash include a truck or bus mechanical expert and a highway engineer. The Board's weather,

human performance and survival factors specialists respond to accidents of all kinds.


At least once daily during the on-scene phase of an investigation, one of the five Members of the Safety Board itself, who

accompanies the team, briefs the media on the latest factual information developed by the team. While a career

investigator runs the inquiry as Investigator-in-Charge, the Board Member is the primary spokesperson for the

investigation. A public affairs officer also maintains contact with the media. Confirmed, factual information is released.

There is no speculation over cause.

At major accidents, transportation disaster assistance specialists also accompany the team to fulfill the Board's

responsibilities under the Aviation Disaster Family Assistance Act of 1996 and the Rail Passenger Disaster Family

Assistance Act of 2008. See the Disaster Assistance section of the NTSB' web site for details on this activity.

The individual working groups remain as long as necessary at the accident scene. This varies from a few days to several

weeks. Some then move on - powerplants to an engine teardown at a manufacturer or overhaul facility; systems to an

instrument manufacturer's plant; operations to the airline's training base, for example. Their work continues at

Washington headquarters, forming the basis for later analysis and drafting of a proposed report that goes to the Safety

Board itself perhaps 12 to 18 months from the date of the accident. Safety recommendations may be issued at any time

during the course of an investigation.

Aviation Go Teams respond only to accidents that occur on U.S. territory or in international waters. Elsewhere, the

investigator is the government in whose territory the accident occurs, usually assisted by a U.S. "accredited

representative" from the NTSB's staff of IICs if a U.S. carrier or U.S. manufactured plane is involved.

More information about Aviation investigations is available:

Major Investigations Manual

Major Investigations Manual - Appendices

NTSB Methodology for Investigating Operator Fatigue in a Transportation Accident

Cockpit Voice Recorder Handbook.pdf

Flight Data Recorder Handbook.pdf

THE PARTY SYSTEM

The Board investigates about 2,000 aviation accidents and incidents a year, and about 500 accidents in the other modes of

transportation - rail, highway, marine and pipeline. With about 400 employees, the Board accomplishes this task by

leveraging its resources. One way the Board does this is by designating other organizations or companies as parties to its

investigations.

The NTSB designates other organizations or corporations as parties to the investigation. Other than the FAA, which by

law is automatically designated a party, the NTSB has complete discretion over which organizations it designates as

parties to the investigation. Only those organizations or corporations that can provide expertise to the investigation are

granted party status and only those persons who can provide the Board with needed technical or specialized expertise are


permitted to serve on the investigation; persons in legal or litigation positions are not allowed to be assigned to the

investigation. All party members report to the NTSB.

Eventually, each investigative group chairman prepares a factual report and each of the parties in the group is asked to

verify the accuracy of the report. The factual reports are placed in the public docket.

NTSB Investigation Party Form

INVESTIGATIONS INVOLVING CRIMINAL ACTIVITY

In cases of suspected criminal activity, other agencies may participate in the investigation. The Safety Board does not

investigate criminal activity; in the past, once it has been established that a transportation tragedy is, in fact, a criminal

act, the FBI becomes the lead federal investigative body, with the NTSB providing any requested support.

One example would be the crash of a Pacific Southwest Airlines flight in San Luis Obispo, California on December 7, 1987.

All 43 persons aboard died in the crash of the Bae-146. Because of information conveyed over the radio by the flight crew

shortly before the crash, the FBI instituted its own investigation, parallel to the Safety Board's investigation, to determine

if a crime had been committed. Within days, it was learned that a former employee of the airline had boarded the plane

with a gun and, while the plane was in cruise flight, had shot the flight crew, causing the aircraft to crash. When that was

made evident, the FBI assumed control of the investigation.

More recently, on September 11, 2001, the crashes of all four airliners were obviously the result of criminal actions and the

Justice Department assumed control of the investigations. The NTSB provided requested technical support.

As the result of recent legislation, the NTSB will surrender lead status on a transportation accident only if the Attorney

General, in consultation with the Chairman of the Safety Board, notifies the Board that circumstances reasonably indicate

that the accident may have been caused by an intentional criminal act.

SAFETY RECOMMENDATIONS

Safety recommendations are the most important part of the Safety Board's mandate. The Board must address safety

deficiencies immediately, and therefore often issues recommendations before the completion of investigations.

Recommendations are based on findings of the investigation, and may address deficiencies that do not pertain directly to

what is ultimately determined to be the cause of the accident.

For example, in the course of its investigation of the crash of TWA flight 800, once it was determined that an explosion in

the center fuel tank caused the breakup of the aircraft, the Board issued an urgent safety recommendation and three other

recommendations in 1996, four years before completion of its investigation, that were aimed at eliminating explosive

fuel/air vapors in airliner fuel tanks. The Board issued an additional recommendation in 1997 regarding the detection of

explosives and six recommendations in 1998 to improve fuel quantity indication systems. When the Board issued its final


report on the TWA 800 accident in 2000, four additional safety recommendations were issued that focused on the aircraft

wiring systems.

PUBLIC HEARING

The Board may hold a public hearing as part of a major transportation accident investigation. The purpose of the hearing

is two-fold; first, to gather sworn testimony from subpoenaed witnesses on issues identified by the Board during the

course of the investigation, and, second, to allow the public to observe the progress of the investigation. Hearings are

usually held within six months of an accident, but may be delayed for complex investigations.

THE REMAINDER OF THE INVESTIGATION AND FINAL REPORT

More months of tests and analysis eventually lead to the preparation of a draft final report by Safety Board staff. Parties

do not participate in the analysis and report writing phase of NTSB investigations; however, they are invited to submit

their proposed findings of cause and proposed safety recommendations, which are made part of the public docket. The

Board then deliberates over the final report in a public Board meeting in Washington, D.C. Non-Safety Board personnel,

including parties and family members, cannot interact with the Board during that meeting.

Once a major report is adopted at a Board Meeting, an abstract of that report - containing the Board's conclusions,

probable cause and safety recommendations - is placed on the Board's web site under "Publications". The full report

typically appears on the web site several weeks later.

NTSB DETERMINES PROBABLE CAUSE OF THE RENO AIR RACES GALLOPING GHOST ACCIDENT

On September 16, 2011, about 1625 Pacific daylight time, an experimental, single-seat North American P-51D, N79111,

collided with the airport ramp in the spectator box seating area following a loss of control during the National

Championship Air Races unlimited class gold race at the Reno/Stead Airport (RTS), Reno, Nevada. The airplane was

registered to Aero-Trans Corp (dba Leeward Aeronautical Sales), Ocala, Florida, and operated by the commercial pilot as

Race 177, The Galloping Ghost, under the provisions of 14 Code of Federal Regulations Part 91. The pilot and 10 people on the

ground sustained fatal injuries, and at least 64 people on the ground were injured (at least 16 of whom were reported to

have sustained serious injuries). The airplane sustained substantial damage, fragmenting upon collision with the ramp.

Visual meteorological conditions prevailed, and no flight plan had been filed for the local air race flight, which departed

RTS about 10 minutes before the accident.

The accident airplane was in third place during the third lap of the six-lap race and was traveling about 445 knots when it

experienced a left roll upset and high-G pitch up. Subsequently, the airplane entered a right rolling climb maneuver.

During these events, the vertical acceleration peaked at 17.3 G, and, a few seconds later, a section of the left elevator trim

tab separated in flight. The characteristics of the airplane's pitch changes during the upset were such that the pilot's time


of useful consciousness was likely less than 1 second. As a result, the pilot soon became completely incapacitated, and the

airplane's continued climb and helical descent occurred without his control.

The accident airplane had undergone many structural and flight control modifications that were undocumented and for

which no flight testing or analysis had been performed to assess their effects on the airplane's structural strength,

performance, or flight characteristics. The investigation determined that some of these modifications had undesirable

effects. For example, the use of a single, controllable elevator trim tab (installed on the left elevator) increased the

aerodynamic load on the left trim tab (compared to a stock airplane, which has a controllable tab on each elevator). Also,

filler material on the elevator trim tabs (both the controllable left tab and the fixed right tab) increased the potential for

flutter because it increased the weight of the tabs and moved their center of gravity aft, and modifications to the elevator

counterweights and inertia weight made the airplane more sensitive in pitch control. It is likely that, had engineering

evaluations and diligent flight testing for the modifications been performed, many of the airplane's undesirable structural

and control characteristics could have been identified and corrected.

The investigation determined that the looseness of the elevator trim tab attachment screws (for both the controllable left

tab and the fixed right tab) and a fatigue crack in one of the screws caused a decrease in the structural stiffness of the

elevator trim system. At racing speeds, the decreased stiffness was sufficient to allow aerodynamic flutter of the elevator

trim tabs. Excitation of the flutter resulted in dynamic compressive loads in the left elevator trim tab's link assembly that

increased beyond its buckling strength, causing a bending fracture. The flutter and the failure of the left elevator trim tab's

link assembly excited the flutter of the right elevator trim tab, increasing the dynamic compressive loads in the right

elevator trim tab's fixed link assembly beyond its buckling strength, causing a bending fracture. The investigation found

that the condition of the trim tab attachment screws' locknut inserts, which showed evidence of age and reuse, rendered

them ineffective at providing sufficient clamping pressure on the trim tab attachment screws to keep the hinge surfaces

tight.

PROBABLE CAUSE

The National Transportation Safety Board (NTSB) determines that the probable cause of this accident was the reduced

stiffness of the elevator trim tab system that allowed aerodynamic flutter to occur at racing speeds. The reduced stiffness

was a result of deteriorated locknut inserts that allowed the trim tab attachment screws to become loose and to initiate

fatigue cracking in one screw sometime before the accident flight. Aerodynamic flutter of the trim tabs resulted in a

failure of the left trim tab link assembly, elevator movement, high flight loads, and a loss of control. Contributing to the

accident were the undocumented and untested major modifications to the airplane and the pilot's operation of the

airplane in the unique air racing environment without adequate flight testing.

As a result of this investigation and the NTSB's January 10, 2012, investigative hearing on air race and air show safety, on

April 10, 2012, the NTSB issued 10 safety recommendations to the Reno Air Racing Association, the National Air-racing

Group Unlimited Division, and the Federal Aviation Administration (FAA) with the intent of improving the safety of air


race operations. These recommendations addressed requiring engineering evaluations for aircraft with major

modifications, raising the level of safety for spectators and personnel near the race course, improving FAA guidance for

air races and course design, providing race pilots with high-G training, evaluating the feasibility of G-suit requirements

for race pilots, and tracking the resolution of race aircraft discrepancies identified during prerace technical inspections.

Each safety recommendation recipient has initiated or completed positive action in response to these safety

recommendations.

Information for Operators (InFO)

Each issue of the NATA Safety 1st Flitebag includes a review of the latest InFOs. If you have not read previous issues,

please review all InFOs by clicking here.

An InFO contains valuable information for operators that should help them meet certain administrative, regulator or operational

requirements with relatively low urgency or impact on safety. InFOs contain information or a combination of information and

recommended action to be taken by the respective operators identified in each individual InFO.

Number Title

12018 (PDF) 2012 ICAO Flight Plan Implementation, Change to the International Civil Aviation Organization

(ICAO) Flight Plan Format for Instrument Flight Rules (IFR) Flight Planning

12017 (PDF) Age 65 Law Update

12016 (PDF) Reduced Longitudinal Separation Minimum (RLongSM) Trial for Uploading

12015 (PDF) Classifying and Using a Belly Band System as a Portable Safety Device (PSD) in Part 133 Operations


Safety Alert for Operators (SAFOs)

Each issue of the NATA Safety 1st Flitebag includes a review of the latest SAFOs. If you have not read previous issues,

please review all SAFOs by clicking here.

What is a SAFO?

A SAFO contains important safety information and may include recommended action. SAFO content should be especially valuable to

air carriers in meeting their statutory duty to provide service with the highest possible degree of safety in the public interest.

Number Title

12007 (PDF) Re-categorization of Federal Aviation Administration (FAA) Wake Turbulence Separation Categories

at Memphis International Airport (MEM)

12006 (PDF) Possible Latch Failure on B/E Aerospace 64B Galleys of Boeing 737 Airplanes

12005 (PDF) Aircraft Approach Category as Defined Under Part 14, Code of Federal Regulations, Chapter I,

Subchapter F, Part 97, Subpart A § 97.3

The National Air Transportation Association (NATA), The Voice of Aviation Business, is

committed to raising the standard on air safety and implemented additional guidance through

NATA’s Safety 1st Management System (SMS) for Air Operators. The Flitebag provides

continuing education in support of the SMS program.

Subscribe to the NATA Safety 1st Flitebag. If you are not currently a subscriber to NATA Safety

1st Flitebag and would like to receive it on a regular basis, please email [email protected]. The

NATA Safety 1st Flitebag is distributed free of charge to NATA member companies and NATA

Safety 1st participants.

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