general aviation and the ntsb most wanted...

General Aviation and

the NTSB

Most Wanted List

Earl F. Weener, Ph.D.

Member, NTSB AirVenture Forum

July 20, 2015

2

N6529R - B36TC Bonanza

2

3

The NTSB is an independent US federal agency

charged with determining the probable cause(s)

of transportation accidents, making

recommendations to prevent their recurrence,

conducting special studies and investigations,

and coordinating resources to assist victims and

their families after an accident.

NTSB Mission

4

Topics

• General Aviation Accident Trends

• Most Wanted List – 2015

– Distractions

– Substance Impairment

– Fitness for Duty

– Procedural Compliance

– Loss of Control

5

All GA Accidents

1492 1402 1371 1389

1305 1350 1215

1366 1292 1205 1169 1202 1198

1001 968

345

325 345 352

314 321

308

288 277

275 271 268 273

221 253

0

200

400

600

800

1000

1200

1400

1600

1800

2000

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Non-Fatal Fatal Accidents

Nu

mb

er

of

ac

cid

en

ts

6

GA Accident-involved Fatalities

0

100

200

300

400

500

600

700

800

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

To

tal

Fata

liti

es

7

GA Accident Rates

1.00

2.00

3.00

4.00

5.00

6.00

7.00

8.00

9.00

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Accid

en

ts p

er

100

k F

lig

ht

Ho

urs

Fatal Total

*The 2011 GA Survey is currently not available. FAA is actively engaged in

re-calibration efforts and expect to have validated 2011 data published at a later date..

8

Accident Rates per 100k Flight Hours



0

2

4

6

8

10

12

14

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

All GA

Corporate

Business

Instructional

Personal

Accid

en

t R

ate

s p

er

100

k F

lig

ht

Ho

urs

9

Fatal Accident Rates per 100k Flight Hours



0.00

0.50

1.00

1.50

2.00

2.50

3.00

20002001200220032004200520062007200820092010201120122013

All GA

Corporate

Business

Instructional

Personal

Fata

l A

ccid

en

ts p

er

100

k H

ou

rs

10

Defining Fatal Accident Events

All Part 91 GA 2008-2014

• Maneuvering

• Initial Climb

• Maneuvering-Low-alt Flying

• Takeoff

• Enroute-Cruise

11

Why GA on the Most Wanted List?

• NTSB investigates approximately 1500 GA

accidents per year over the last decade

• Overall GA accident rate flat

– Has improved little over the last decade

– Airline accident rate decreased more than 80%

• Personal flying accident rate

– Increased 20% over last 10 years

– Fatal rate increased 25% over that period

• GA safety needs attention

12

NTSB 2015 Most Wanted List

• Disconnect from Deadly Distractions

• End Substance Impairment in

Transportation

• Enhance Public Helicopter Safety

• Implement Positive Train Control in

2015

• Improve Rail Tank Car Safety

• Make Mass Transit Safer

• Prevent Loss of Control in Flight in

General Aviation

• Require Medical Fitness for Duty

• Strengthen Commercial Trucking Safety

• Strengthen Procedural Compliance

13

Gray Summit, MO – bus/vehicle/truck crash

14

Distraction

15

Distraction

16

Distraction

17

2015 MWL - Distractions

• Disconnect from Deadly

Distractions

– A factor in all modes of transportation

• Aviation emphasis • Sterile Cockpit

• Appropriate use of PEDs

• Manage distractions

18

2015 MWL - Impairment

• End Substance Impairment in

Transportation

– A factor in all modes

• Fatally injured pilots - potentially

impairing drugs

– 11% average 1990 - 1997

– 23% average 2008 - 2012

19

Toxicology Findings by Category, 1990-2012

0%

5%

10%

15%

20%

25%

1990-1997 1998-2002 2003-2007 2008-2012

Pe

rce

nt

of

Stu

dy

Pil

ots

wit

h P

osi

tiv

e

Fin

din

gs

PotentiallyImpairing Drugs

PotentiallyImpairingCondition

ControlledSubstances

Illicit Drugs

20

Most Common Drugs

• Sedating antihistamines

– Most common category

• Diphenhydramine

– Most common individual drug

– Most common potentially impairing drug

– Use INCREASING

21

2

1

Toxicology Findings by Certificate, 2005-2012

0%

10%

20%

30%

40%

ATP Commercial Private Sport

Pe

rce

nt

of

Stu

dy

Pil

ots

Highest Airman Certificate Held

Potentially Impairing Drugs Potentially Impairing ConditionControlled Substances Illicit

(n = 272) (n = 610) (n = 955) (n = 30)

Toxicology Findings by Medical, 2005-2012

0%

10%

20%

30%

40%

FAA Medical Within Duration ofThird Class

Expired / No Medical

Pe

rce

nt

of

Stu

dy

Pil

ots

wit

h P

osi

tiv

e

Fin

din

gs

by

Ca

teg

ory

Potentially Impairing Drugs Potentially Impairing ConditionControlled Substances Illicit

(n = 1,676) (n = 260)

24

Medical Resources for Pilots

• FAA Publications

– Medications and Flying

– Guide for Aviation Medical Examiners

• Aircraft Owners and Pilots Association

(AOPA)

– Member resources

25

Medical Resources for Pilots

• General Aviation Joint Steering

Committee (GAJSC)

– 2013 Letter to pilots

– 2014 Initiatives

• Drug database

• Training course

26

Fitness for Duty

27

2015 MWL – Fitness for Duty

• Require Medical Fitness for Duty

– A factor in all modes

• Airman Medical – fitness at exam time

• Pilots must self-assess fitness

– Need for appropriate flight preparations

• Focus on medical conditions

– Example – Obstructive Sleep Apnea

• Enhance medical knowledge

28

Lubbock, TX – ATR 42-320 Cargo Aircraft

29

Procedural Compliance

30

2015 MWL – Procedural Compliance

• Strengthen Procedural Compliance

– More than a dozen related commercial

aircraft accidents in last ten years

– Equally applicable to corporate and

business operations

• Implement well developed procedures

• Train to the procedures

• Emphasize and reinforce operations to the

procedures

31

Loss of Control

32

Loss of Control

33

2015 MWL – Loss of Control

• Prevent Loss of Control in Flight

in General Aviation

• More than 40% GA accidents were

LOC during 2004 – 2014

• Most deadly flight phases

– Approach to landing

– Maneuvering

– Climb

34

Business Flying, 2008-2014

1

1

1

2

4

4

5

11

18

0 2 4 6 8 10 12 14 16 18

Windshear/Thunderstorm

Turbulence Encounter

Ground Handling

Unknown

System/Component Failure - Powerplant

System/Component Failure - Non-powerplant

Fuel Related

Controlled Flight Into Terrain

Loss of Control In-Flight

Number of Fatal Accidents

35

Instructional Flying, 2008-2014

1

1

1

2

2

2

3

3

4

4

5

7

8

10

0 10 20 30 40 50 60

Unintended Flight Into IMC

Simulated/training event

Fuel Related

Loss of control on Ground

Ground Handling

Abnormal Runway Contact

Unknown

Collision on Takeoff or Landing

Low Altitude Operation

Abrupt Maneuver

Other


System/Component Failure-Powerplant

Midair



36

Personal Flying, 2008-2014

11

15

19

19

27

33

39

47

60

62

66

116

149

601

0 100 200 300 400 500 600 700

Loss of Control on Ground

Abnormal Runway Contact

Collision on Takeoff or Landing

Abrupt Maneuver

Midair

Low Altitude Operation

Fuel Related

Unknown

Unintended Flight Into IMC

System/Component Failure - Non-…

Other


System/Component Failure - Powerplant



37

Loss of Control In-Flight, 2008-2014

5

18

69

601

0 100 200 300 400 500 600 700

Corporate Flying

Business Flying

Instructional Flying

Personal Flying


38

Boeing Annual Statistical Summery

39

Primary category of accidents

Personal flying

Instructional flying

Business flying

Corporate flying

Airline flying

– LOC

– LOC

– LOC

– LOC

– LOC

40

Fatal Airport LOC 2008-2014

41

Loss-of-control Working Group

Safety Enhancements Identified

• AOA – New, Current, Retrofit

• Aeronautical Decision Making

• Stabilized Approach

• Single Pilot CRM

• Medication effects

• Weather Technologies

• Etc…

28 Safety Enhancements

42

Lower Cost AOA Displays

• Stall occurs at a specific

Angle-of-Attack

– But not necessarily at the same

airspeed

FAA

installation

policy changed

First of AOA

indicators built

to ASTM stds

and installed

as a minor mod

43

Stall Recovery

• Reduce the angle-of-attack below

stall AOA (Max CL)

– Push over to eliminate stall warning

• Level wings

• Adjust thrust

– Avoid overspeed and high G levels

• Pitch back to level flight

• Don’t try to “Power out of a stall”

44

NTSB Safety Alerts

Preventing Aerodynamic Stalls

Reduced Visual References

Is Your Aircraft Talking to You

Risk Management for Pilots

Risk Management for

Mechanics

Available on www.NTSB.gov

45

Alfred Sheinwold

“Learn all you can from the mistakes

of others. You won’t have time to

make them all yourself”

46

Accident Investigations

• NTSB accident files

are on-line

• Many recent accident

Dockets are on-line

– Factual reports,

– Interviews

– Photographs

• www.ntsb.gov

http://www.ntsb.gov/doclib/reports/2011/ARA1101.pdf

47

Douglas Adams

“Human beings, who are almost

unique in having ability to learn from

the experience of others, are also

remarkable for their apparent

disinclination to do so.”

49

Accident Statistics - 2013

• 1,298 Total Accidents (Down from

1,537 in 2012)

• 236 Fatal Accidents

• 429 Fatalities

• 1,224 General Aviation Accidents

• 222 Fatal Accident

• 390 Fatalities

• 51 Part 135 Accidents

• 12 Fatal Accidents

• 30 Fatalities

50

Preliminary Accident Statistics - 2014

• 1,264 Total accidents (down from 1298) – 258 Fatal accidents (up from 236)

• 1,202 General Aviation Accidents (down from 1224) – 250 Fatal Accidents (up from 222)

• 405 Fatalities (up from 380)

• 38 Part 135 Accidents (down from 51) • 8 Fatal Accidents (down from 12)

• 20 Fatalities (down from 30)

• 33 Accidents Business/Corporate

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