Every year, planes crash in accidents that could have been avoided.

Ice can build up on the wings of a plane like it did in 1997 when a plane trying to land at the Detroit airport lost speed and plummeted to the ground, killing all 29 on board.

Sometimes the hazard is on the runway, as when a 2006 Comair flight made a wrong turn onto a short runway in Lexington, Ky. The plane couldn’t get airborne and crashed, killing 49.

The problem might be a poor repair job. That was the case in 2005 when the right wing fell off of a Chalk’s Ocean Airways flight just after takeoff from Miami. Two crew members and all 18 passengers died.

And then there are the times when a pilot is just too exhausted to fly and does so anyway. That is what investigators believe happened in 2004 when a Corporate Airlines plane crashed short of the runway in Kirksville, Mo. The two pilots had been working for nearly 15 hours and were on their sixth flight of the day.

The Federal Aviation Administration lists pilot error as the leading cause of plane accidents, but pilot error is almost always part of a chain of events that starts with something like an iced-up wing, a piece of equipment that fails or a close encounter on a runway.

An analysis of accident data by the News21 reporting project and the Center for Public Integrity ^[1] shows that the major causes of air accidents include ice buildup on aircraft, problems on runways, faulty aircraft maintenance and repairs and overtired pilots.

For four decades, the nation’s transportation safety board has urged the FAA to take steps to reduce the likelihood of these kinds of accidents. The National Transportation Safety Board has issued more than 520 recommendations related to icing, runways, repairs and fatigue.

But in many cases those recommendations have languished, even while accidents continue to happen and people continue to die, according to a review of accident data and government documents and interviews with dozens of industry and safety specialists. Among the News21-Center for Public Integrity findings:

• More than 710 people have died in crashes in which ice has built up on the wings of aircraft since 1981, when the NTSB first recommended ways to solve in-flight icing problems.

• Runway collisions have killed at least 112 people since 1990. There have been at least 79 collisions and 342 near-collisions on the nation’s runways and thousands more violations of runway safety over the past 20 years.

• At least 160 accidents on passenger planes resulted at least in part from poor maintenance or repairs. These accidents have killed 756 and injured 805 people since 1973, when the FAA started keeping records.

• More than 745 people have died while in the hands of tired pilots in at least 342 accidents since 1971, around the time the NTSB first named fatigue as a major issue and suggested solutions.

Planes are still a comparatively safe way for Americans to travel. People are about six times more likely to die in car crashes than plane crashes, according to Bureau of Transportation Statistics data from 2004-2008. However, there’s little doubt that air travel would be safer if the airline industry and the FAA – the federal agency charged with making sure that air flight is safe for Americans – would comply with safety recommendations.

Recommendations languish for many reasons: The process of changing rules is long and complex; industries resist expensive fixes; unions fight changes in work requirements; and sometimes years of research and product development are needed.

But many believe that the biggest cause of delay lies with the FAA itself.

An examination of hundreds of letters between the NTSB and the FAA reveals a pattern of resistance dating back decades.

“We have said publicly many times that it takes too long for the FAA to conduct rule-makings and to implement the NTSB’s recommendations,” House Aviation Subcommittee Chairman Jerry Costello said in an interview. “Rule-making does take time. But there is no excuse to have issues like fatigue and icing take more than a decade.”

The FAA said in a prepared statement that the agency agrees with the NTSB on a course of action most of the time. When disagreements do arise, it’s usually over “whether voluntary action or rulemaking is the best approach or on the time required to accomplish a safety improvement. We rarely disagree that some safety action is warranted.”

Icing

Tricia Coffman still breaks down in tears when she remembers the phone call telling her that her husband died in a plane crash in Pueblo, Colo., along with seven others in 2005.

“I sat on the floor and I remember repeating over and over again, ‘No good can come from this. No good can come from this,’” Coffman said. “I couldn’t fathom that losing my husband could in any way ever bring anything positive.

But she couldn’t let it end like that. “Losing him can’t be for nothing,” she thought. So she joined the National Air Disaster Alliance Foundation, a group that represents survivors and family members of aviation accidents.

She started digging into the cause of the crash that killed her husband and learned that a similar accident had taken place 10 years earlier.

The 1994 American Eagle flight 4184 was in a holding pattern over Chicago O’Hare International Airport for 30 minutes. When the plane was finally given clearance to descend, the right wing made a dramatic dip, and the plane went into a spiral at 8,000 feet – a drop from which few pilots can recover. The plane crashed in Roselawn, Ind., killing all 68 people on board.

NTSB investigators said the crash was caused by the plane flying into freezing rain.

Thirteen years earlier, the NTSB had urged the FAA to certify airplanes based on how each craft might respond to different icing conditions, including freezing rain.

The Roselawn crash, investigators said, was a direct result of the FAA’s “failure to ensure that aircraft icing certification requirements… adequately accounted for the hazards that can result from flight in freezing rain.”

Dozens of letters between the NTSB and FAA between 1981 and 2010 show that the FAA consistently fought changing how it certifies planes in icing conditions, citing cost and lack of research.

In one response to the NTSB dated Dec. 21, 1981, the FAA wrote, “These conditions have a low probability of occurrence, and indications are that it would be excessively penalizing and economically prohibitive to require compliance with such criteria as part of a normal icing certification.”

After the Roselawn accident, the FAA formed a task force to start the expensive and time-consuming work of researching and analyzing how rare weather events like freezing rain affect certain types of planes.

Seven years later, the NTSB fired off a letter expressing concern about the slow pace of the work and urging the agency to “give this rule-making project a high priority.”

A year and a half later, a Circuit City-chartered Cessna Citation 560 went down in Pueblo, Colo., with Tricia Coffman’s husband on board.

And once again, NTSB investigators reached the same conclusion as in Roselawn 11 years earlier: “Contributing to the accident was the Federal Aviation Administration’s failure to establish adequate certification requirements for flight into icing conditions.”

The FAA said in a prepared statement that icing presents particularly challenging technical issues and thus takes longer to address than many other problems. For example, the FAA is developing an ice detector that would alert pilots to internal engine icing.

In an e-mail interview, Deputy Assistant Administrator for Public Affairs Laura Brown said that while freezing drizzle and rain have long been considered a potential hazard to planes “their actual effect on performance and handling characteristics were not fully understood until recently.”

Brown said the FAA has stepped up action, issuing several proposed rules and more than 200 directives aimed at reducing icing hazards for more than 50 kinds of aircraft, with the result that icing accidents have dropped by half in the past decade.

A government investigation released in July confirmed that the directives have helped, but the Government Accountability Office also said the FAA needs to do more. The report noted that at least 188 large passenger flights reported icing problems from 1998 to 2007 and that the FAA has not updated its 1997 plan for improving safety in icing conditions.

NTSB icing expert Dan Bower added that the FAA’s latest proposed rules apply only to new planes, which leaves many unprotected.

Tricia Coffman is encouraged by progress in recent years, but she thinks it comes late.

“Of course, I think if these things had been addressed then my husband could still be alive,” she said.

Runway Safety

Every day, U.S. air traffic controllers conduct a complex choreography of almost 150,000 takeoffs and landings – more than 50 million a year.

The number of actual crashes is relatively low: Since 1990, there have been at least 79 collisions on runways, according to an analysis of NTSB and FAA data. But the potential for accidents is high, especially as air traffic grows and runways get more crowded, said Sandy Rowlett of NTSB’s Office of Aviation Safety.

“It is a major safety issue. Every single airplane lands and takes off. That means there’s a chance (of a runway accident) twice in one flight,” Rowlett said. “With the congestion that’s going on and as busy as pilots and controllers are, it’s something to be concerned about.”

In fact, the worst aviation accident in history happened on a runway. Two Boeing 747s collided on the ground in the Canary Islands in 1977. One plane was taking off while the other plane was crossing the runway. The death toll was 583.

That accident, plus a 1979 non-fatal collision at Memphis International Airport and two near collisions in New York and Chicago around the same time, prompted the NTSB to issue its first runway safety recommendation in 1979. The board asked the FAA to study the severity of the problem and to come up with fixes at high-priority airports.

Two years after the study was requested in 1979, the FAA had its report. However, it was another four years before the FAA actually sent the report to the NTSB.

The NTSB responded by noting the report was four years old and that in the meantime it had started its own study, which it expected to “provide more specific recommendations.”

That study, completed in 1986, spawned another round of suggestions that resulted in more delays.

For example, the NTSB asked for better signs and markings on runways that could help prevent accidents. It took the FAA five years to figure out what the signs should say. Meanwhile, two planes collided on runways in Detroit in 1990 and Los Angeles in 1991, killing a total of 42 people.

The NTSB’s Rowlett was an air traffic manager at Los Angeles International Airport during the 1991 accident.

“‘Slow’ is the best word that comes to mind,” she said when asked to describe the FAA’s history of acting on runway safety recommendations. “Some (delays) I can understand. Technical solutions take awhile. They have to do the funding.”

But even changes that don’t require much money can take years to implement. In 2000, the NTSB asked the FAA to put in place a new rule to prevent planes from colliding at runway intersections. The rule, which didn’t take effect until June of this year, requires pilots to get explicit permission from an air traffic controller before crossing each runway rather than one clearance to cross several runways.

“That doesn’t cost a dime,” Rowlett said. “And it took 10 years for them to implement … Now that I don’t understand.”

The FAA’s Brown said in an e-mail that “reducing the number and severity of runway incursions is one of the FAA’s top priorities.” She said the FAA has taken a number of steps to prevent runway accidents, such as placing lights on runways that signal whether they are being used and digital displays that tell air traffic towers where planes are on runways. The result has been fewer runway accidents in the last decade, she said.

The agency also has invested in infrastructure at 28 airports to make it safer when planes veer off the runway, which account for 97 percent of runway accidents, according to a 2007 Flight Safety Foundation study.

But the FAA has resisted the technology that most safety experts say would do the most to prevent runway collisions. At present, sensor systems detect when something is amiss on a runway – a person standing where he shouldn’t or a plane that has taken a wrong turn. The warning is relayed to air traffic controllers, who, in turn, transmit the message to pilots.

A pilot might have 10 to 15 seconds to avoid a collision, Rowlett said. “Those are crucial seconds” that could be saved if warnings were routed directly to the cockpit, she said.

The NTSB has recommended some kind of direct warning system since 2000. It remains on the board’s “Most Wanted” list of priority safety recommendations.

The FAA has told the NTSB that it is working on technologies to alert pilots of dangers and should have improvements in place at some airports next year – 11 years after the recommendation was issued.

In the meantime, a pilot made a wrong turn at an airport in Lexington, Ky., and tried to take off from a runway that was too short. The 2006 accident killed 49 people.

The NTSB said there have been other close calls in Charlotte, N.C.; Cleveland; Traverse City, Mich., and elsewhere.

Maintenance

The elevator is the part on the tail that makes the plane go up or down.

In 2003, a maintenance worker failed to properly tighten a cable on the elevator of an Air Midwest plane. His superior missed the error. One day later, the plane ^[2] took off from Charlotte, N.C., tilted more than 50 degrees upward, stalled and fell out of the sky, killing all 21 people on board.

Improper maintenance is the second-leading cause of air accidents and incidents, according to FAA data. Poor maintenance or repairs were responsible, in part, for at least 15,000 accidents or safety incidents since 1973, when the FAA started keeping such records. In these accidents, at least 2,599 people died and 4,189 people were injured, according to a News21 analysis.

The NTSB issued 21 recommendations after the Air Midwest crash. The FAA still has not complied with two of them: to prohibit the person training a mechanic from serving as the inspector on that same part and to increase oversight of work done by contracted mechanics.

A FAA spokesman said current inspection practices already address those issues and the agency has met the intent of the recommendations.

In a 2004 letter to the NTSB, the agency offered to remind its inspectors that repairs done by outside shops should be the same quality as those done by airlines. The NTSB called the response unacceptable.

The NTSB called the response unacceptable.

Part of the problem is monitoring the quality of repairs done by hundreds of small and large repair shops here and abroad. Over the past decade, airlines have dramatically increased their use of outside repair shops.

In 2003, nine of the country’s major air carriers outsourced 34 percent of their major repair and maintenance work, according to a 2008 U.S. Department of Transportation Inspector General’s report. Four years later, the number had more than doubled to 71 percent.

In the case of the Air Midwest accident, the maintenance worker who failed to secure the elevator did not work for the airline. He didn’t even work for the company that Air Midwest contracted to do the work; he worked for a repair shop hired by the first company.

Airlines are not required to disclose how much of their maintenance is outsourced or whether repairs are being performed at shops in the U.S. or at any of the hundreds that have sprung up overseas. And while the FAA checks the quality of work at both foreign and domestic shops that it certifies, airlines are not required to use FAA certified repair stations.

Congress has discussed raising the bar on foreign repairs. Proposals include requiring employees at foreign shops to undergo drug and alcohol testing, requiring FAA inspectors to visit the stations at least twice a year and requiring airlines to disclose which non-certified repair shops they use to fix aircraft.

In a written response to questions about oversight of airplane repairs, the FAA said it is doing more to make sure that outsourced repairs meet quality standards by hiring more inspectors and requiring regular audits of maintenance providers.

Recently, the agency also cracked down on some companies for poor maintenance. In 2009, the agency dished out one of its largest fines ever – $10.2 million – to Southwest Airlines for flying more than 30 planes without inspecting the bodies. FAA inspectors found cracks up to 4 inches long on some of the airline’s planes.

And in late June, the FAA said it would seek a $2.47 million fine against Trans States Airlines and GoJet Airlines, which fly for US Airways, for violating a host of repair procedures. The airlines flew 320 flights using aircraft that were out of compliance with maintenance rules.

“Air carriers cannot ignore maintenance requirements or allow employees to take a pass on following regulations,” FAA Administrator Randy Babbitt said after the fine was announced. “Safety depends not only on maintenance work being done correctly but also being recorded properly.”

Safety advocates worry that increasingly strapped airlines will try to further cut costs for repairs and maintenance.

“We believe that it’s like anything else. You get what you pay for,” said Linda Goodrich, a longtime FAA inspector who now serves as a vice president of Professional Aviation Safety Specialists, the union for FAA safety inspectors. “There’s nothing wrong with people trying to save money, but not at the expense of safety.”

Fatigue

The pilots flying Corporate Airlines Flight 5966 were on their sixth flight of the day as they approached Kirksville, Mo., the night of Oct. 19, 2004. Because it was dark and overcast, they were supposed to use their instruments to land the plane.

Instead the captain and first officer decided to find the runway by sight. They missed, crashing and killing themselves and 11 of 13 passengers.

The pilots had started their day at 4 a.m. and worked 14.5 hours. In its report, the NTSB noted that “fatigue likely contributed to (the pilots’) degraded performance.”

The safety board told the FAA it needed to come up with new scheduling rules for pilots to ensure they are rested. It was the same message the board had delivered at least 30 times before.

The issue of tired pilots dates back 75 years to when the director of the Department of Air Commerce requested a study on pilot fatigue.

In 1962, NTSB’s predecessor, the Civil Aeronautics Board, again questioned the amount of rest pilots were getting. The NTSB issued its first formal recommendation to limit pilot flying times 10 years later when it became an independent agency.

The FAA has tried several times to impose more limited shifts and more rest time between shifts – including new proposals issued in mid-September that would overhaul pilot work rules to reduce fatigue. Public comments are being accepted on those proposals, but industry groups are expected to object.

Opposition from airlines and pilot unions has derailed such proposals in the past. Airlines have said the measures would cost too much, and unions have expressed concern that while pilots’ days would be shorter, pilots would actually end up flying more hours in a day.

In the meantime, fatigue has contributed to more than 320 accidents and incidents since 1971 and killed more than 745 people, according to the News21-Center for Public Integrity analysis of FAA and NTSB data.

That includes a Colgan Airlines flight that crashed near Buffalo, N.Y., in 2009, killing 50. NTSB investigators said fatigue was a factor.

The accident produced an outcry from family members, safety advocates and politicians, and it led to a directive to reduce pilot fatigue that was included in the Airline Safety and Federal Aviation Administration Extension Act ^[3] signed by President Obama in early August. The FAA released a proposal for public comment this month.

“It took an act of Congress,” said Jim Oberstar, D-Minn., chair of the House Committee on Transportation and Infrastructure. “Fatigue is one area that without a doubt has had the greatest resistance by airlines and which the FAA has been sporadic, to say the best.”

Future Concerns

While decades-old problems continue to bring down planes, experts worry that a projected growth in air travel could make things worse. Airplanes are more likely to encounter accidents on increasingly crowded runways. Cash-strapped airlines will be under pressure to reduce costs on repairs and maintenance. They may not be able to hire enough qualified pilots.

U.S. air traffic is expected to grow by more than 3 percent each year over the next decade, according to the FAA. And that means more planes competing for space on airport runways – and more chances for accidents to happen.

The trend also raises concerns about the quality of pilots, the size of the available pilot pool and how air traffic controllers will track planes in the sky.

At a public forum this summer, the NTSB expressed worry about what it calls pilot professionalism. Today’s pilots may be less qualified when they’re hired, get less training and have less time to learn on the job before taking command of a plane, safety experts said.

The result, said former military pilot and air safety expert Anthony Kern, is an industry that is “becoming infected with complacency, casual noncompliance and sloppiness.”

Several major crashes in the past five years involved pilots who were found to have violated basic rules of conduct in the cockpit. They include a 2006 runway accident in Kentucky that killed 49. The NTSB said the pilots’ “non-pertinent conversation” likely contributed to them taking off on the wrong runway, which was too short for the plane to get airborne.

The NTSB has not yet recommended specific action to the FAA, but members warned that they might if problems aren’t addressed.

Meanwhile, Congress has raised hiring standards ^[3] for pilots. They will be required to log more flight hours and get more training on how to deal with problem situations before they climb into the cockpit of a passenger plane. That could mean fewer available pilots to hire in the first place.

Compounding the problem is declining enrollment at flight schools as well as a drop in the number of trained pilots leaving the military for jobs in the private sector.

“And so what’s going to happen in the next two to four years when hiring goes up?” asked Judy Tarver, former chief of hiring for American Airlines who is now vice president of FltOps.com, which publishes airline job information. “That pool has to come from somewhere. And you can’t just take an aspiring pilot off the street and put them in the cockpit in a couple of months.”

Increased air traffic also will put pressure on the nation’s air traffic control system, which already faces a massive shift from radar-based air tracking systems to a satellite-based system called the Next Generation Air Transportation System, or NextGen.

Tens of billions of dollars have been allocated to developing technology that the FAA hopes will boost capacity and reduce delays. But safety advocates say there is a finite number of takeoffs and landings that can occur on the nation’s runways. Transportation safety lobbyist and former NTSB managing director Peter Goelz said pushing the boundaries of work for air traffic controllers under NextGen will stretch the limits of safety.

“Clearly air traffic control is going to be one of the next significant areas where safety is going to have to be monitored very carefully,” he said.

News21 reporters Stevie Mathieu, Charlie Litton and Tessa Muggeridge and Center for Public Integrity staff members Michael Pell and Nick Schwellenbach contributed reporting to this story.

Sept. 26, 2010