The NTSB released its annual report to Congress, filled with important updates and recommendations to transportation safety. The report highlighted the urgent recommendations and updates on ongoing investigations, like the requirement for a Bell 407 tail boom inspection and special regulations for air tours in Alaska.
In 2022, the NTSB Office of Aviation Safety issued 1,808 investigation reports, 10 involving safety issues that led to 31 recommendations. The Office of Aviation Safety investigates all air carrier, commuter and air taxi accidents. The office investigates some serious incidents, fatal and nonfatal general aviation accidents and serious incidents, unmanned aircraft systems and public aircraft accidents and serious incidents, and commercial space launch/reentry accidents. Preliminary reports are issued up to two weeks after an incident and the final report comes in between one and two years.
CFIT: Hawaii
Controlled flight into terrain is one of the top three causes of GA accidents, claiming nearly 17 percent of all GA fatalities. CFIT occurs hen an aircraft under pilot control is unintentionally flown into terrain, a body of water or an obstacle. A pilot is often completely unaware of what is happening until it is too late.
On Dec. 26, 2019 an Airbus AS350 B2 helicopter flew into terrain in a remote, wooded area north of Kekeha, Hawaii killing the pilot and all six passengers. The air tour flight was operated under visual flight rules. The NTSB report found that the probably cause was the pilot’s decision to continue under VFR into instrument meteorological conditions, resulting in CFIT. The NTSB also found that the management company, Safari Aviation, also played a role in its lack of safety management processes to identify potential hazards and mitigate associated risks influencing pilots to continue VFR flight into IMC.
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The NTSB put some of the blame on the FAA, stating a lack of initiative and preventative action also led to the fatal crash. The delayed implementation of a Hawaii aviation weather camera program and lack of leadership in the development of a cue-based weather training program for the air tour pilots, as well as an ineffective oversight and monitoring of the weather-related practices were blamed in the accident.
Six safety issues were identified from the crash investigation. First, the factors that influenced the pilot to continue a VFR flight in reduced visibility conditions, including a lack of the company’s safety management processes and effective weather-related training. Second was the limitations of aviation safety infrastructure and the need for aviation weather cameras and an increase in radio communications and automatic dependent surveillance-broadcast coverage.
Third was the need for SMS, flight data monitoring programs, and the incorporation of onboard videos and ADS-B data reviews into safety assurance processes. The fourth safety issue discussed was the need for improved FAA oversight of air tour operations in Hawaii and the fifth was the need for crash-resistant flight recorder systems. The final safety issue identified for this crash was the need to implement available helicopter safety technologies to prevent accidents that occur after an unexpected encounter with IMC.
Tail boom findings
The NTSB released urgent recommendations from an ongoing investigation of a Kalea, Hawaii air tour accident involving a Bell 407 helicopter that crashed after an in-flight separation of the tail boom. The crash occurred on June 8, 2022 and injured five passengers and the pilot. Of the six people on board, three were seriously injured and three sustained only minor injuries. The tail boom reportedly separated at an altitude of about 1,000 feet.
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After the crash, the operator elected to replace the tail boom attachment hardware on the remaining five Bell 407 helicopters as a precautionary measure. The accident helicopter has 23,009.9 flight hours and its last inspection was May 29, 2022. The accident flight was the fourth of the day for the helicopter and the pilot told the NTSB he had performed a thorough pre-flight inspection before the first flight and everything appeared to be in order.
About 35 minutes into the flight at 1,500 feet the helicopter made a sudden and violent yaw and pitch change. The pilot attempted to control the aircraft and maintain level flight while looking for an emergency landing flight. He made two mayday calls and told the passengers to brace for impact before the crash.
Tail boom inspections are typically performed at 300-hour intervals and the last inspection for the accident helicopter was at 114 hours. The NTSB issued two urgent safety recommendations, one for fractured or missing tail boom attachment hardware that can lead to in-fight separation. The second urgent recommendation stressed the need for a more conservative torque inspection to find any abnormalities with the tail boom attachment hardware.
Air tour regulations
In November the NTSB called on the FAA to implement special regulations for air tour operations in Ketchikan, Alaska in response to several airplane crashes in the area since 2007.
“There have been too many air tour tragedies in Ketchikan, a place with unique — but well understood — safety hazards that endanger the lives of pilots and passengers alike,” NTSB Chair Jennifer Homendy said. “Unless the FAA acts swiftly, experience tells us to expect even more heartbreak and preventable loss of life.”
A report sent out addressed the seven air tour crashes in the Ketchikan area that have occurred since 2007, resulting in 31 fatalities and 13 serious injuries. The organization addressed the need for a stronger approach to reduce risks to passengers and pilots on air tours. The recommendations in the report were derived from an air tour crash on Aug. 5, 2021 involving a de Havilland DHC-2.
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Recommendations made in the November report include changing flight visibility minimums and enhancing weather training. The recommendations from the recent report to Congress include two new identified safety issues. First, the NTSB identified that the FAA’s lack of operational safety requirements for the area that has a unique geography and distinct operational hazards. The second safety issue identified was the need for improved pilot training on reducing the risk of weather-related accidents for air tours in the Ketchikan area.
Inspection of de Havilland DHC-3 after Mutiny Bay crash
The NTSB issued urgent recommendations from the investigation of the Sept. 4, 2022 crash involving a de Havilland Canada DHC-3 plane in Mutiny Bay near Freeland, Washington that killed the pilot and nine passengers. The DHC-3 entered a nose-low, near-vertical descent before crashing into the water. During the initial search, the NTSB said that investigators discovered components of the horizontal stabilizer actuator were not connected and the lock ring which normally secures the components together was missing.
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According to witnesses near the scene, the plane was in a level flight before it entered a slight climb and then pitched down into the descent. The NTSB report stated that some people saw the plane “spinning,” “rotating,” or spiraling” during portions of the steep descent. Urgent recommendations were issued in the wake of the crash, identifying possible safety issues.
A missing or improperly installed horizontal stabilizer actuator lock ring is a safety hazard that can result in a reduction or loss of pitch control during flight. The NTSB urges a one-time immediate inspection of the horizontal stabilizer actuator to ensure it in place and installed properly.
Graphical forecast for icing conditions in Alaska
Pilots operating in regions in Alaska can benefit from graphical forecasts of potential supercooled large droplet icing areas to prevent flight into a risky environment.
Check for icing conditions before your next flight with GlobalAir.com
The recommendation to address this need stems from an investigation of a Cessna 208B that encountered SLD icing conditions after takeoff from Fairbanks, Alaska and entered an uncommanded right bank followed by a nose-down spiraling descent, from which the pilot recovered.
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The FAA Advisory Circular 00-45H “Aviation Weather Services” states that icing conditions are outside of the icing certification envelopes for many aircraft. Conditions like this can prove hazardous for the aircraft, even with preventative icing tools and measures in place for the plane.
The NTSB identified the need for graphical forecast depicting potential areas of SLD icing conditions to help Alaskan pilots avoid flight into hazardous conditions.
Cessna Citation Excel parking brakes
Investigations into two incidents involving a Cessna Citation Excel in which the parking brake pressure was not fully released before an attempted takeoff. The condition prevented the plane from rotating for takeoff. At this phase, the plane was beyond a point where it could be stopped safely, leading to serious injuries or death.
The NTSB identified three issues regarding the parking brake concerns. First, the lack of a cockpit indication that alerts pilots when the parking brakes are not fully released before takeoff was due to the Excel being certified before the standard requirement of such a feature was in place. Second, the NTSB recommended the certification of the XL and subsequent derivative aircraft. The third issue the NTSB found was the failure of the XL checklists to direct pilots to fully release the parking brakes before takeoff.
Cirrus SR22T engine power
Six different accidents involving Cirrus SR22T aircraft identified an issue in which excessive fuel was introduced to the engine during takeoff climb, leading to engine power loss. While excessive fuel flow was found to be the cause for engine failure in all six investigations, the cause for the excessive flow was different in half of the accidents and undetermined in the other half. The examination of the investigations led the NTSB to suggest the lack of safety assessments in identifying all potential causes of excessive fueling.
In April 2022 the NTSB urged Cirrus Aircraft and the FAA to take action on this recommendation. Fuel flow data was retrieved from recoverable data modules in five of the involved aircraft and in each instance, it indicated a high fuel flow to the engine right before the loss of power. Investigations into two of the cases indicated the suspected incorrect selection of the fuel pump’s HIGH BOOST/PRIME position caused the excessive fuel flow and the third implied an improperly adjusted slope controller anf fuel pump.
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Cirrus has taken steps in recent years to address this potential problem. It has also implemented software changes to prevent the improper operation of the electric fuel boost pump through a lockout feature. This would lock the high boost function of the pump until the aircraft had reached a pressure altitude of 10,000 feet.
The NTSB identified a safety issue in its report to Congress. It found the need for all potential causes and mitigating actions for the loss of engine power due to excessive fuel flow to be identified and the need for the FAA to require the implementation of appropriate risk-reduction methods to prevent future accidents.
Common traffic advisory frequency areas
The NTSB issued a recommendation to address the lack of a singular, common traffic advisory frequency in areas with numerous airports or scenic landmarks and the associated risk for midair collisions. The organization also addressed the lack of communication requirements for the areas where one CTAF had been established.
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These recommendations come from the investigation of a deadly midair involving a DHC-2 and a Piper PA-12. The two aircraft collided in uncontrolled airspace near Soldotna, Alaska and both pilots and the five passengers were killed. The investigation found there were 21 airports in a 30-mile radius of the collision location, with five different charted communication frequencies. Many of these frequencies were overlapped.
Additional dedicated CTAF areas in regions where the pilot is at a higher risk of a collision would allow the pilots to become more aware of the nearby traffic and communicate on a single frequency in one area. This could help mitigate collision risks.
Carbon steel rudder post failure
A recommendation was issued as a result of two investigations into crashes involving Piper airplanes that experienced structural failures of the rudders in flight. The NTSB identified two safety issues for the report. First, the susceptibility of the carbon steel rudder posts to fatigue cracking under normal service conditions and second, the diminished controllability of the plane after the rudder post fracture. The NTSB identified the rudder posts were made out of 1025 carbon steel.
Carbon monoxide detectors in GA aircraft
Following the report of accidents in which undetected carbon monoxide poisoning led to pilot impairment and serious injuries or death due to crashes. In each of these accidents, the pilot was not alerted to the CO entering the cabin in the amount of time needed to counteract the effects. The report also noted that the FAA does not require CO detectors on enclosed-cabin aircraft.
The NTSB identified the risk of CO poisoning and the lack of requirements for detectors. It urged the requirement of CO detectors in GA aircraft to mitigate the risk of accidents due to CO poisoning.
Ongoing investigations and international reports
As of Dec. 31, 2022 there were 1,274 open domestic investigations. This includes notable crashes like the Wings Over Dallas midair collision involving a B-17 Flying Fortress and a Bell P-63 Kingcobra on Nov. 12, 2022. The deadly airshow accident killed six and the NTSB preliminary reports stated there was no altitude deconfliction before the flight or while the aircraft were in the air. The report indicated that the air boss had directed both formations to maneuver southwest of the runway before returning to the performance area. The tail boom crash in Hawaii is still ongoing.
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The NTSB investigates aviation accidents and has good authority to make these recommendations to agencies like the FAA. The investigations enable the organization to find potential risks and make the public aware of possible factors that could lead to an incident.
The NTSB is often called out to foreign accidents, like the Boeing 737 Max crash in Ethiopia. The organization will help with the investigation directly or give guidance and opinions when requested. The Office of Aviation Safety was notified of 989 international investigations and assisted with 98 of them. Of these, investigators traveled to support in four of these investigations.
Safety is a priority in aviation and the gold standard for the industry is the NTSB, which continues to keep safety and preventative action at the forefront of the organization.
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