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Safety Recommendation Details

Safety Recommendation A-15-007
Details
Synopsis: The NTSB has long been concerned about rapid recovery of recorded information to guide investigations, help determine accident causes, and develop recommendations to prevent recurrences. To focus attention on this issue, the NTSB convened its Emerging Flight Data and Locator Technology Forum on October 7, 2014, in Washington, D.C. Forum discussions among government, industry, and investigative experts helped identify the following safety issues: • Need for improved technologies to locate aircraft wreckage and flight recorders following an accident in a remote location or over water • Need for timely recovery of critical flight data following an accident in a remote location or over water This letter presents recommendations to address these safety issues and discusses open recommendations regarding cockpit image recorders and the need to protect flight recorder systems against intentional or inadvertent deactivation.
Recommendation: TO THE FEDERAL AVIATION ADMINISTRATION: Require that all existing aircraft operated under Title 14 Code of Federal Regulations (CFR) Part 121 or 135 and currently required to have a cockpit voice recorder and a flight data recorder be retrofitted with a crash-protected cockpit image recording system compliant with Technical Standard Order TSO-C176a, “Cockpit Image Recorder Equipment,” TSO-C176a or equivalent. The cockpit image recorder should be equipped with an independent power source consistent with that required for cockpit voice recorders in 14 CFR 25.1457. (Supersedes Safety Recommendation A-00-30)
Original recommendation transmittal letter: PDF
Overall Status: Open - Unacceptable Response
Mode: Aviation
Location: Washington, DC
Is Reiterated: No
Is Hazmat: No
Is NPRM: No
Accident #: DCA14SS009
Accident Reports:
Report #: None
Accident Date: 10/7/2014
Issue Date: 1/22/2015
Date Closed:
Addressee(s) and Addressee Status: FAA (Open - Unacceptable Response)
Keyword(s):

Safety Recommendation History
From: NTSB
To: FAA
Date: 12/13/2018
Response: We note that image recording was discussed at length at the ninth meeting of the ICAO FLIRECSWG, held in May 2016, and an update to Annex 6 recorder parameter requirements was proposed. This update, which became effective July 16, 2018, was incorporated into amendment 43, which requires that, after January 1, 2023, aircraft weighing over 27,000 kilograms record all information displayed to the flight crew from electronic displays, as well as the flight crew’s operation of switches and selectors. You believe that amendment 43 will provide accident investigators the ability to “see” all the information available to the flight crew and to determine crew actions via actuation of control knobs, switches, and flight controls. Although you are not considering requiring aircraft to record cockpit images, as recommended, as an alternative, you will consider requiring a system that records display and switch information after amendment 43 to ICAO Annex 6 goes into effect in 2023. We evaluated whether amendment 43 represents an alternative course of action that satisfies these recommendations. The table below shows accidents and incidents that we have previously cited as the basis for these recommendations or for Safety Recommendations A-00-30 and -31. We also show the needed information that was not available but that image recorders would have provided for each accident, as well as our evaluation of whether amendment 43-compliant recorders would have provided the needed information. Accident Issue Would amendment 43 supply information 1 September 8, 1989, USAir flt 105, Boeing 737, at Kansas City, Missouri Limitations of existing recorders to fully document flight crew actions and communications Yes 2 May 11, 1996, ValuJet flt 592, DC 9 32, returning to Miami, Florida, after reporting smoke and fire shortly after departure Exact smoke and fire conditions in last few minutes of flight not known No 3 December 19, 1997, SilkAir flt 185, Boeing 737, rapid descent from 35,000 feet, resulting in high speed impact in the Sumatran River near Palembang, Indonesia Pilot disconnected recorders, (covered by A-15-5 and -6, but images could have confirmed suicide) No 4 September 2, 1998, Swissair flt 111, MD-11, diverting to Halifax, Nova Scotia, after reported smoke in cockpit; crashed into the waters near Peggy’s Cove, Nova Scotia Cockpit smoke and fire conditions that led to decision to descend from cruise flight and to divert to Halifax are unknown No 5 October 31, 1999, EgyptAir flt 990, Boeing 767-366-ER, crashed in Atlantic Ocean 60 miles from Nantucket Island, Massachusetts Circumstances that caused the aircraft to descend; DFDR and CVR yielded some information, but exact cockpit environment prior to upset are not known No 6 October 19, 2004, Corporate Airlines flt 5966, BAE-J3201, in Kirksville, Missouri Limited number of FDR channels Yes 7 June 1, 2009, Air France flt 447, Airbus A330, crashed into the Atlantic Ocean during flight from Rio de Janeiro, Brazil, to Paris, France Difficulties reconstructing critical instrument panel indications available to flight crew Yes 8 September 3, 2010, United Parcel Service Boeing 747-44AF crashed while attempting to return to Dubai International Airport following an in-flight cargo fire Some critical information, such as flight instrument indications, switch positions, and aircraft system conditions, could not be confirmed No For three of the eight accidents and incidents that we have cited, amendment 43 would likely have provided accident investigators with additional needed information to understand the safety issues associated with these events. However, for the remaining five events, image recorders were needed to fully understand what led to the accident. Information about the cockpit environment was needed to fully understand the safety issues in accidents where an in-flight fire caused the accident. In other cases, information about crew interactions beyond setting aircraft controls was needed to understand the safety issues. In accident investigations where image recording information was available, we have been able to identify important safety issues that likely would not have been identified without the image data. In our investigation of the October 31, 2014, in-flight breakup during a test flight of Scaled Composites SpaceShipTwo, near Koehn Dry Lake, California, image data provided information on which controls the pilots had placed their hands, the interactions between the crew, and the effect of the severe vibration levels on the pilots’ ability to read the displayed information and locate and operate controls. In our investigation of the March 30, 2013, crash of an Alaska State Trooper Eurocopter AS350 B3 after encountering instrument meteorological conditions in Talkeetna, Alaska, a cockpit image recorder provided critically important information about the pilot’s actions (including that the pilot had reset the attitude indicator during the accident sequence) and the visibility condtions that may have contributed to the pilot taking this inappropriate action. Although amendment 43 represents some improvement, it does not satisfy Safety Recommendations A-15-7 and -8. We ask that, based on the information presented above, you reconsider your decision and require aircraft to record images of the cockpit, as recommended. Pending such a requirement, Safety Recommendations A 15-7 and -8 remain classified OPEN--UNACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 9/21/2018
Response: -From Daniel K. Elwell, Acting Administrator: Image recording is not only discussed within the United States, but amongst the international community. At the ninth ICAO Flight Recorder Specific Working Group in May 2016, image recording was discussed at length. The outcome of the meeting was a proposal to update Annex 6 recorder parameter requirements. These updates are incorporated in Amendment 43 and became effective July 16, 2018. Amendment 43 now mandates that after January I, 2023, aircraft over 27,000 kg record information displayed to the flight crew from electronic displays, as well as the operation of switches and selectors by the flight crew. This will provide accident investigators the ability to "see" all information available to the flight crews and to determine crew actions via actuation of control knobs, switches, and flight controls. The FAA is not considering requiring aircraft to record images of the cockpit per TSO-C 176a. Instead, the FAA will consider a forward fit requirement for a recording system that captures display and switch information once we see the full effect of amendment 43 to ICAO Annex 6. I will keep the Board informed of the FAA's progress on these safety recommendations and provide an update by June 2019.

From: NTSB
To: FAA
Date: 1/6/2017
Response: In your previous letter about these recommendations, you said that you would review the recommendations and determine how to address additional concerns raised at our October 7, 2014, forum. In your current letter, you state that, because image recorders were not discussed or addressed in any way at the forum, you have not found any compelling evidence to require installation of cockpit image recording systems; therefore, you have no plans to pursue the recommended rulemaking. Image recorders were not a main topic at our forum in 2014, as the focus of the forum was on emerging technology and we had previously held a public hearing on aviation image recording in 2004. However, image recorders were discussed at the forum. A copy of the transcript of the forum testimony may be found on our website. Mr. Marcus Costa from ICAO testified regarding the status of ICAO activities addressing issues discussed at our forum, including image recorders. Mr. Costa indicated that ICAO work on image recorders was pending, waiting for the results of ICAO’s efforts to further protect the privacy of the safety information obtained from image recorders; after that work is finished, proposals for airborne image recorders will follow. Further, in response to a question regarding voluntary standards versus requirements, Ms. Margaret Gilligan, the FAA’s Associate Administrator for Safety, began her reply by saying: Let me talk on the video imaging first of all. We in the FAA have shared the same concerns that you just heard Mr. Costa describe for ICAO. We believe that the protection of video data is even more difficult than the protection of some of the other data that we currently already collect for accident investigation, and that we need to be assured that there are strong protections for that kind of information in place as we look to whether or not to mandate that. We agree with Ms. Gilligan that the issues being considered by ICAO (assurance of strong protections for the kind of information collected by image recorders) will also be important for the FAA to consider when deciding whether to mandate image recorders; however, we have long maintained that the assurances of privacy and confidentiality for image data already provided by US law will ensure the same high level of protection as that for cockpit voice recorders. We acknowledge that, despite our belief that the laws in our country provide the needed protections for image data, the situation in other countries may be different. In your letter, you repeatedly pointed out that you are committed to harmonizing with ICAO requirements, and that you will not be able to do this until after ICAO completes its work regarding the issues discussed at our forum. Given that assertion, we disagree that you have effectively addressed these recommendations or that your actions are complete. Pending completion of the ICAO work on image recorders and adoption of the recommended mandate for image recorders, Safety Recommendations A-15-7 and -8 are classified OPEN—UNACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 9/13/2016
Response: -From Michael P. Huerta, Administrator: In our April 2015 response, we stated that we would review these new recommendations and determine the best feasible course of action to address additional concerns raised at the Emerging Flight Data and Locator Technology Forum. However, image recorders were not discussed or addressed in any way at the forum. Due to the silence on this issue at the forum, coupled with the lack of new infom1ation, the FAA has found no new compelling evidence to require installation of cockpit image recording systems in aircraft operated under 14 CFR parts 121 and 135. Therefore, the FAA has no plans to pursue rulemaking to address Recommendations A- 15-07 and -08 (formerly A-00-30 and A-00-31). I believe the FAA has effectively addressed these safety recommendations and consider our actions complete.

From: NTSB
To: FAA
Date: 11/19/2015
Response: Your letter repeated many of the justifications that you previously cited for not taking action to satisfy Safety Recommendations A-00-30 and -31, which Safety Recommendations A 15-7 and 8 superseded. Throughout the 15 years since we issued Safety Recommendations A 00-30 and 31, we have disagreed that these bases were valid reasons for not requiring the installation of cockpit image recording systems. In particular, we have disagreed that the RTCA’s Future Flight Data Collection Committee (FFDCC) was the appropriate organization to review these recommendations. Although your March 7, 2008, final rule regarding cockpit voice and flight data recorders made important regulatory changes that we had recommended for many years, it did not address either cockpit image recorders or the critical information that such recorders provide that neither cockpit voice nor flight data recorders can. In our January 22, 2015, letter issuing Safety Recommendations A-15-7 and -8, we discussed recent accident investigations that had been hampered in identifying important safety issues because of the lack of cockpit image data. We discussed the report of the French Bureau d’Enquêtes et d’Analyses (BEA) investigation of Air France flight 447, which crashed on June 1, 2009, in flight from Rio de Janeiro to Paris. The BEA investigation report cited difficulties in reconstructing critical instrument panel indications that had been available to the flight crew. Consequently, the BEA recommended that a cockpit image recorder that can record the instrument panel be required on public transport flights. The letter issuing Safety Recommendations A-15-7 and -8 also pointed out that, in the investigation of the September 3, 2010, accident involving a UPS Boeing 747-44AF flight that crashed while attempting to return to Dubai International Airport following an in-flight cargo fire, some critical information (such as flight instrument indications, switch positions, and aircraft system conditions) could not be confirmed with the available evidence. The final report on that accident, prepared by the United Arab Emirates General Civil Aviation Authority, cited the lack of cockpit imagery as a detriment to the timeliness of the investigation and delivery of critical safety recommendations. We continue to believe that the lack of cockpit image data limits the timely identification of important safety issues in aircraft accident investigations. We also believe that this lack of cockpit image data limits the ability of the FAA to use the results of our investigations when justifying needed safety regulatory reforms to the Office of Management and Budget. Your letter indicated that, despite the reasons you previously cited for not requiring cockpit image recorders, you will review Safety Recommendations A-15-7 and -8 to determine what additional actions are needed to address these recommendations. Pending your taking actions that satisfy Safety Recommendations A-15-7 and -8, they are classified OPEN—ACCEPTABLE RESPONSE.

From: FAA
To: NTSB
Date: 4/22/2015
Response: -From Michael P. Huerta, Administrator: As stated in previous FAA's responses to Safety Recommendations A-00-30 and -31, we found no compelling evidence to require installation of cockpit image recording systems in aircraft operated under parts 12 1, 125, and 135. Our conclusion was based on a report from the RTCA for Aeronautics Future Flight Data Collection Committee (FFDCC), co-sponsored by the FAA and the Board dated December 4, 2001. Should an operator or manufacturer wish to install a system that complies with TSO-C 176a, the FAA will work with the applicant to approve the installation. In our September 9, 2009, letter for A-00-30 thru -31, we notified the Board that aircraft operated under these parts, and required to be equipped with a cockpit voice recorder (CVR) and a digital flight data recorder (DFDR) must meet the requirements of the Revisions to Cockpit Voice Recorder and Digital Flight Data Recorder Regulations final rule (73 fR 12542), published on March 7, 2008. This rule increases the duration of certain CVR recordings and increases data recording rates for certain DFDR parameters. The rule also requires physical separation of the CVR and DFDR and improves the reliability of CVR and DFDR power supplies. These changes to the CVR and DFDR systems are intended to improve the quality and quantity of information recorded. It also increases the potential for retaining important information needed for accident and incident investigations. The FAA notes that the circuit protection for any electrical system that is active during flight should be accessible to the flight crew. Nevertheless, we will review these new recommendations and determine the best feasible course of action to address additional concerns raised at the Emerging Flight Data and Locator Technology Forum. I will keep the Board informed of the FAA's progress on these safety recommendations and provide an updated response by June 2016.