The NTSB issues safety recommendations to address specific safety concerns uncovered during investigations and to specify actions to help prevent similar accidents from occurring in the future. Safety recommendations are our most important product because they alert government, industry, and the public to the critical changes that are needed to prevent transportation accidents and crashes, reduce injuries, and save lives.
We:
- issue recommendations to the organizations best able to take corrective action, such as the US DOT and its modal administrations, the Coast Guard, other federal and state agencies, manufacturers, operators, labor unions, and industry and trade organizations.
- issue safety recommendations at any point during the investigation of transportation accidents and in connection with safety studies.
- monitor the progress of action to implement each recommendation until it is closed, which usually takes several years.
Find Our Recommendations
CAROL (Case Analysis and Reporting Online) is our search tool for investigations and safety recommendations across all modes. CAROL includes all NTSB recommendations. See the
Field Descriptions page for specific information about safety recommendations data fields.
Recommendation Spotlight
Each month, we shine the spotlight on a few recommendations that have been successfully implemented (closed acceptable action) and are helping to further safety. These recommendations span all modes of transportation and recommendation recipients. Visit the
Recommendation Spotlight Archive to see previous safety wins.
We urge recommendation recipients to keep us informed of the progress on implementing recommendations. If you do, you may see your recommendation spotlighted here. Read more about responding to our safety recommendations.
FAA Tackles Spatial Disorientation Training Gaps Identified in NTSB Aviation Accident Investigations
The FAA estimates that about 5 to 10 percent of all general aviation accidents can be attributed to spatial disorientation, 90 percent of which are fatal, including the 2020 Sikorsky S–76B helicopter crash in Calabasas, Calif., that killed nine people.
In our investigation of the Calabasas crash, we determined that the probable cause of the accident was the pilot’s decision to continue to fly under visual flight rules into instrument meteorological conditions. Without good visual cues, the pilot became spatially disoriented and lost control of the helicopter.
Improving Pilot Training
To address the spatial disorientation hazard in the Calabasas crash, we asked the FAA in safety recommendation A-21-006 to evaluate spatial disorientation simulation technologies and identify which are most effective for training pilots to recognize and successfully mitigate the onset of spatial disorientation. We also asked the FAA to report its findings publicly.
The FAA tapped the Air Carrier Training (ACT) Aviation Rulemaking Committee (ARC), which provides a forum for the U.S. aviation community to discuss, prioritize, and provide recommendations to the FAA concerning general aviation operations and specifically addresses air carrier training.
To address NTSB’s recommendation, the ACT formed a Spatial Disorientation Training working group that found well-defined training requirements on spatial disorientation did not exist at any level. The group called spatial disorientation training “foundational” and should be taught at all levels of certification during a pilot’s career. As a result, the working group made several recommendations to strengthen spatial disorientation training for Part 135 helicopter operations.
The working group also published a comprehensive report on simulation training devices suitable for training air carrier pilots to recognize the onset of spatial disorientation and successfully mitigate it.
In May, the NTSB closed safety recommendation, A-21-006, acceptably. The FAA is reviewing the ACT ARC’s recommendations to determine an appropriate action plan; the agency also plans to report its progress to NTSB by the end of this summer.
Improving Air Traffic Controller Training
Following our investigation of a 2015 Cessna 152 crash in New Smyrna Beach, Fla., that killed the pilot, we issued two safety recommendations to the FAA to improve air traffic controllers' management of emergencies, including those caused by spatial disorientation.
Before the New Smyrna Beach crash, the pilot tried to obtain ATC assistance landing her plane when she no longer felt comfortable flying under visual flight rules because night instrument meteorological conditions (IMC) prevailed.
However, the controller who assisted her made missteps in standardized procedures for assisting pilots in emergencies, prompting NTSB to issue two safety recommendations to the FAA (A-16-18 and A-16-19).
In May, we closed those recommendations acceptably after the FAA reported that it had developed scenario-based recurrent training delivered nationally to air traffic controllers and annually revised with the latest lessons learned and best practices from across the National Airspace System on several common aviation emergencies.
The FAA also said the recurrent training on emergencies has been delivered several times since 2019 and is updating it for 2024.
Safety Recommendations at a Glance
We have issued over 15,400 safety Recommendations since the agency was established in 1967.
Total safety recommendations by mode
Total safety recommendations by Recipient
2023 Safety Recommendation Statistics
Issued Safety Recommendations
| 65
|
Issued Urgent Safety Recommendations
| 0
|
Closed Acceptable Recommendations
| 163
|
Urgent Closed Recommendations
| 2
|
Closed Unacceptable Recommendations
| 33
|
Each recommendation issued is reported as one recommendation, regardless of the number of recipients. Because some recommendations are issued to more than one recipient, however, recommendations closed are reported by the number of recipients for whom a recommendation was closed during the year.
