Aircraft Accidents and Lessons Unlearned LXI: The NTSB 10 Most Wanted

For the last two decades, the Presidential podium was used by both parties to hammer at the other party’s members, monopolizing the media to make their view the only view that mattered. This podium has been nicknamed the ‘Bully Pulpit’ for its one-sided ability to talk over opposing voices. That is not to say that the opposing voices are wrong, just that the occupier of the bully pulpit doesn’t care to listen to them.

The National Transportation Safety Board (NTSB) has their own version of the ‘bully pulpit’ called the NTSB’s 10 Most Wanted List (10MWL), found at www.ntsb.gov/advocacy/mwl/pages/default.aspx. We must understand the relationship and the effects of such a ‘bully pulpit’, not only on safety, but on the focus of safety advocacy. Anyone in the aviation industry, including the Federal Aviation Administration (FAA), can be considered an opposing voice. Ignoring the NTSB’s 10MWL is not to avoid safety, but to assure that safety be sensibly accomplished for the benefit of all. The 10MWL is really an NTSB Wish List, not a Wanted List. Apologies to former President Reagan for the liberty, but “The trouble with our [NTSB] friends is not that they’re ignorant; it’s just that they know so much that isn’t so.” Ignorance doesn’t mean one is wrong, it just means one doesn’t know they aren’t right.

I never fail to criticize the NTSB’s lack of experience and basic aviation industry knowledge because I witnessed it firsthand. The NTSB always distanced itself from industry. Their indifference to certificate holder oversight and regulatory interactions included being dismissive of training from either the air carriers or at the FAA Academy where I taught. NTSB investigators never learned about how FAA oversight works; they never encouraged their investigators to become subject matter professionals. This NTSB mindset reminds me of my younger sister, an unmarried, childless high school teacher, who always had advice about how parents should raise their teenagers. Those who don’t know are experts.

Where, then, does the NTSB draw its 10MWL from? Is 10MWL accurate or is it even close? Where to begin. On the NTSB’s 10MWL webpage is a plea: “The NTSB urges lawmakers, industry, advocacy and community organizations, and every American to learn more about what they can do to implement and champion the 2021-2022 MWL. Adopting NTSB safety recommendations associated with these safety items will save lives.” How? Can the NTSB qualify the phrase “… these safety items will save lives?”

This plea is an error of purpose, one that assumes NTSB recommendations are/were well-researched and factual, that accident investigations and recommendations (AI&R) are for the sole purpose of saving lives. They are not. AI&Rs are for improving safety – first. Lives are preserved by getting the safety part right. Remember, it is an aircraft accident investigation. Unless the passengers were instrumental in the accident’s cause, their presence did not affect the accident. The topic of fatalities distracts attention from the investigation, clouding the findings, as in the seat track anchor issues raised with Ryan Air 103, 11/23/1987. Excessive attention was misdirected to seat tracks, a non-issue. Regrettably, many NTSB investigations and hearings dwelt on fatalities to promote recommendations – not facts.

Recommendations to alter an aircraft’s type design need more than the NTSB’s insistence. In the ValuJet 592 accident, the NTSB pushed for a change from a Class D cargo compartment – the forward belly compartment – to a Class E compartment that added smoke detectors and fire suppression systems to numerous aircraft type designs; this meant changes to each type certificate (TC). The TC change required alterations (at the time) in the DC-9, DC-8, B727, B737, B757 and others.

There are only two ways to get a TC change: an Amended Type Certificate (ATC), which only the manufacturer can write and install, and a supplemental type certificate (STC), which any one qualified can write … and sell. However, there was one problem; the root cause of the ValuJet 592 accident wasn’t the Class D compartment. It was a failure to follow ValuJet’s Operations procedures. Recommendation A-97-56 was pushed through despite almost five decades of revenue flights where Class D cargo compartments were not misloaded. Was the Class D to Class E change successful? One way to check its end result is to go back and see if A-97-56 fixed the safety issue(s) or did it miss the mark entirely?

The ValuJet accident report, AAR 97/06’s recommendation A-97-56 stated: “Expedite final rulemaking to require smoke detection and fire suppression systems for all class D cargo compartments.” The NTSB argument was that so many lives were lost from the inflight fire, therefore, the redesign from a Class D compartment to a Class E compartment should have prevented any future inflight fires and … save lives.

I understand this subject; I loaded B727 Class D compartments for years, maintained them as a mechanic and taught Air Cargo at the FAA Academy, so I feel qualified to speak to these four outstanding points about A-97-56. 1 – Why were the hazardous materials – oxygen generators (O2Gens) – loaded in the Class D cargo compartment? 2 – Would the fire have started to begin with? 3 – Would the smoke alarms have sounded if were they installed, and 4 – Would the fire, after having started, been extinguished by a cargo compartment fire suppressant?

1 – The O2Gens were loaded in defiance of ValuJet’s Ramp manual; the accepted procedures for the loading of hazardous materials were not followed. This is significant and unequalled in importance. The ValuJet load crew did not employ checks-and-balances. Whether the O2Gens were mislabeled or knowingly loaded, packing hazardous materials into the Class D compartment was the root cause of the accident and would’ve been duplicated in a new Class E compartment as in the Class D compartment.

2 – An unrestrained main gear tire initiated the O2Gens’ ignition. Page 20 of the ValuJet 592 accident report, AAR-97/06 stated, “… one of the large tires was lying flat on the compartment floor, with the small [nose gear] tire laying on its side …”, “… the second large tire [main] was standing on its edge between the two other tires …” If all tires were restrained as required and the second large tire was not able to move and roll, the fire would never have started. Again, the event that led to the fire would have happened in a Class E compartment just like in the Class D compartment.

3 – The NTSB investigator(s) conducting the interviews never discerned if the luggage and freight was loaded above the red line, which marked the height limit the compartment was allowed to be loaded to. Since the one responsible for loading the luggage disobeyed rules for tie-downs and hazardous materials, it was likely that there were other unsafe practices. If luggage and freight were loaded to the ceiling, they would have blocked the Class E smoke detectors and suppression system. Per the cockpit voice recorder (CVR) transcript, the fire started well into the flight, too late to get back to Miami safely. Item 3 alone cannot be proven. However, if the load crew loaded above the red line, it would have been disastrous in a Class E compartment, more so than a Class D compartment.

4 – Finally, fire suppression systems act by evacuating all the oxygen from the compartment, which starves a fire. In this case the fire was fed by the O2Gens, a constant supply of oxygen. The fire, despite the suppression system, would have been fed and spread in both the Class D and Class E compartments.

Conclusion: The change to Class E compartments did not fix the safety issue. The NTSB did not follow up to see if the Class E compartment worked. Instead, billions of dollars were spent on redesigns that did … absolutely nothing … to advance safety. Even with a Class E compartment redesign, the fire would have started, raged out of control, the plane would have crashed, the people would have died.

Unfortunately, ValuJet 592 was the NTSB’s second miss concerning this issue. Documented in AAR-97/06, section 1.6.3.2 Safety Board Recommendations, was a reference to American Airlines flight 132. On February 3, 1988, an American DC-9 had an inflight fire from a hazardous material, where hydrogen peroxide (an oxidizer) was misloaded in a Class D compartment. Oxidizers combine with oxygen. With American 132’s recommendations A-88-122 and A-88-123 aimed at requiring smoke detection and fire suppressant systems in Class D cargo compartments, was the NTSB years ahead at pointing out the fire dangers of Class D compartments?

No! If the NTSB had correctly determined why American Airlines’ operations procedures were ignored with American 132, that oxidizers were loaded in a Class D cargo compartment, then in 1988, the NTSB should have recommended that the FAA write and enforce stronger cargo standards, industry-wide, that could have prevented the loading of any hazardous materials in a Class D compartment. In other words, if the NTSB had acted correctly in 1988, then the ValuJet 592 accident might not have happened.

This scenario demonstrates that the NTSB misunderstood the FAA’s job and the commercial airline industry it oversees. By reviewing the failure of Recommendation A-97-56, we learned that … today, anyone flying on a B757, B737, MD-88 or A320 series airliner could be cruising at 35,000 feet in an airliner where a fire could burn out of control in the cargo bay. Worse, any of these aircraft flying extended twin-engine operations – ETOPS – 3 to 5 hours from land will – if possible – land in the ocean, whether it’s in a B737 going from the mainland to Hawaii or a B757 from Kennedy to Paris, the same deadly scenario that led to ValuJet 592 could happen.

This fact brings this article back to the first matter: the NTSB’s Ten Most Wanted List. How can the NTSB, an agency that got the ValuJet 592 accident so wrong, who after 50 years still does not understand the FAA or industry, expect anyone to follow its recommendations or believe its reports?

Returning to the NTSB 10MWL webpages, https://data.ntsb.gov/carol-main-public/sr-details/A-16-036, let’s review a recommendation that made the 10MWL, A-16-36: “Require all 14 Code of Federal Regulations Part 135 operators to establish safety management system programs.” As of May 2022, the NTSB shows the FAA’s response to recommendation A-16-36 as: Open – Unacceptable Response. Yet, the FAA had responded with an accurate response. The NTSB just didn’t understand it.

The safety management system (SMS) the NTSB wanted forced on the Title 14 Code of Federal Regulations (CFR) Part 135 industry did not function quite the way the NTSB thought it did. Per Advisory Circular (AC) 120-92B, “An SMS is an organization-wide comprehensive and preventative approach to managing safety. An SMS includes a safety policy, formal methods for identifying hazards and mitigating risk, and promotion of a positive safety culture.”

What AC 120-92B says is an SMS is not a ‘one size, fits all’ program. SMS was designed for Title 14 CFR Part 121 operators – aka the airlines. SMS was not designed for what is considered small Part 135 operators called ‘9-[passengers]-or-less’. For Part 135 operators this small, SMS is not feasible. It does not work because the number of employees cannot support it; the data would not show trends needed for SMS to work. To the NTSB, terms like ‘SMS’ are buzz words, they’re catchphrases. Nobody at NTSB took the time to research SMS and, thus, don’t realize that SMS in a Part 135 ‘9-or-less’ doesn’t work. ACs are not regulatory; ACs like 120-92B are construction guidance for building one’s own program … like SMS. The NTSB needs to understand how and why SMS is used by both industry and the FAA. In the meantime, the NTSB should remove A-16-36 from the NTSB 10MWL.

There are too many Aviation 10MWL items that demonstrate how the NTSB doesn’t comprehend its own function. One that stands out is one that has languished in the NTSB’s hope chest, one of the many NTSB Most Wished For items. On webpage https://www.ntsb.gov/Advocacy/mwl/Pages/mwl-21-22/mwl-as-02.aspx is the call to, “Install Crash-Resistant recorders and Establish Flight Data Monitoring Programs.” Per the webpage, it has been, “20 years [that] the NTSB has been calling for cockpit image recorders.” Installing a cockpit image recorder (CIR) is unnecessary and does not benefit pilots. What promise of safety is realized by a CIR? Where would a CIR be mounted? Will it be facing the pilots? Behind the pilots? Will it hang like a disco ball over the pedestal? Will there be multiple cameras and why? The CIR might be taken seriously if NTSB management explained why it is crucial to safety. Aside from camera manufacturers, the NTSB is the only group pushing for CIRs and demonstrates how the NTSB did not – does not – understand what the aviation industry needs to operate safely. Instead, they employ their bully pulpit to shame industry to … SAVE LIVES.

To the point, any recording device, such as the CVR and CIR, only serves the NTSB’s needs. Recorders are vital because the NTSB is dependent on them. Yet, recorders, especially the CVR, are so fallible, their data is corruptible and subject to extraneous noises inside and outside the cockpit. They are more miss, than hit. Yet, the NTSB insists: Recorders … Will … Save … Lives.

Aviation safety is not guaranteed by demonstrations of self-importance or monopolizing the conversation; it is not secured from drawing a line in the sand or dismissing any opposing argument. Aviation safety is not about being right; it is about being correct – factually correct.

The NTSB’s 10MWL website encourages, “… every American to learn more about what they can do to implement and champion the 2021-2022 MWL.” This is NTSB’s ‘bully pulpit’, distracting from what the NTSB thinks sounds safe and what really is safe. In the wake of the COVID pandemic disruptions, the aviation industry and the FAA are facing serious safety obstacles, many of which are now presenting themselves. The last thing needed is virtue signaling to adopt ineffective recommendations or attempts to guilt-trip serious aviation professionals with distractions that will misdirect serious time and resources. The truth is facts count more than opinions because, frankly, the travelling public deserves better.