NTSB Calls For Cockpit Image Recorders, SMS Programs


The National Transportation Safety Board (NTSB) released its 2021-2022 Most Wanted List of Transportation Safety Improvements on Tuesday, calling for the installation of crash-resistant cockpit image recorders and the implementation of safety management systems (SMS) in all revenue passenger carrying operations. According to the Board, the installation of cockpit image recorders in passenger-carrying commercial aircraft, along with putting programs in place to analyze recorder data, would help with accidents investigations and “prevent crashes in the first place by allowing crew actions to be evaluated regularly.” The NTSB noted that it has been advocating for image recorders in the cockpit for 20 years.

In recommending expanded implementation of SMS programs, the NTSB reported that, while it has seen some voluntary SMS program adoption, the majority of revenue passenger carrying operations do not employ them. “By establishing an effective safety management system (SMS) and creating a safety culture aimed at making safety a focus first and always, operators will improve aviation safety and reduce the risk of accidents,” the NTSB said. “It can be scalable to the size and complexity of operations yet, too many operators either do not have one in place or have an ineffective one.”

In addition to the two recommended aviation safety improvements, the NTSB’s 2021-2022 Most Wanted List includes five highway safety improvements, one marine improvement, one rail improvement and one pipeline improvement.

Kate O'Connor
Kate O’Connor works as AVweb's Editor-in-Chief. She is a private pilot, certificated aircraft dispatcher, and graduate of Embry-Riddle Aeronautical University.

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  1. Image recorders sound and feel like a policing program. SMS on the other hand if done properly is a good friend. I’ll have to trust the NTSB for which I have a high degree of respect on the image recorder idea because personally I can’t imagine it would be effective. But i will go to bat with them on the SMS idea.

    I fully expect the next comment on this story to excoriate the SMS initiative because of how unsuccessful it has been in the experience of many. My personal opinion is that where SMS has been unsuccessful it is because SMS initially and quickly turned out to be three things: 1) a silly marketing tool, 2) something which if you didn’t have as a GA operator you would be hassled if not outright banned from destinations like Le Bourget or Nice, France, and 3) a nit noidy compliance IS-BAO test.

    The result of these three factors was that operations bought canned SMS programs, put them on the shelf and left them on the shelf but told flight and maintenance personnel to comply and threatened them if they didn’t comply. The way SMS should have been implemented was to suggest, not mandate a basic outline of what a safety management system should look like and how it should work, and ask each operator to design and implement a very basic home grown SMS which reflected their operation and worked for it. Instead what the industry got was mixed messages about how your SMS should work for you but, oh, here is a list of ingredients which it needs to contain or it will not be blessed by IS-BAO. Oh and then there are various stages of IS-BAO certification which if your operation gets to stage 3 somehow the god of gods has favored you with special recognition. No wonder SMS has had mixed reviews in the GA world.

    In my experience the way to create and implement an effective SMS is to sit down at a conference table on a regular basis and design it with the particular operation in mind, make it useable and friendly, train it, continuously review it for relevance, and for goodness’ sake don’t make a hammer out of it with which to beat folks over the head.

    Also in the next comment I fully expect to read that SMS is no good if it does not get owner/CEO buy-in. I couldn’t agree more with the notion of buy-in at the top, but the reality is that buy-in at the top will not always happen. When buy-in doesn’t happen at the top, you do what you can. For example, you don’t need owner buy-in to establish a stabilized approach policy. You don’t need owner buy-in to establish a sterile cockpit policy. You don’t need owner buy-in to establish runway crossing procedures. You don’t need owner buy-in to establish a set of standard callouts. If you can’t get owner buy-in, you do what you can for yourself and your passengers and you work with ownership/top company management on the rest.

    SMS is no panacea and I hope the NTSB does not portray it as such, but SMS if designed to be accessible, relevant, useable and friendly, it is invaluable.

    • The issues you describe above for SMS are not unique to SMS. I’ve seen the same thing happen in other industries too: a guideline of how to ensure safety and efficiency is developed for that industry and marketing folks try to sell it to everyone in the industry as a great tool that you adapt to your specific processes. And if it actually got implemented that way, it would meet its goals. But higher-ups only want to sign on to it to use for their own marketing purposes and get it implemented as soon as possible without regard to the time it takes to taylor to their specific operations. So it gets rushed into place using the guideline template that was never meant to be used by a real company, and as a result it ends up only making operations less efficient and more prone to failures.

      There’s nothing wrong with SMS as a concept. Unfortunately, constructs like SMS often don’t get implemented in a smart way, giving them an undeserved bad rap.

  2. I was one of those management personnel that didn’t believe in SMS. I challenged it’s usefulness. “If this SMS problem solving system works? Then it should solve the problem of me thinking it’s a silly waste of time and money.” “Show Me.”

    I’ll try and keep this simple, short and basic so as to create interest:

    Similar to Alcoholics Anonymous (AA) the first step; recognize there’s a problem. Define the problem for discussion and documentation. The next series of problem solving steps is strictly up to the organization’s character. Don’t make it any more difficult then good old fashion “Common Sense”. The most important part of the SMS program: “DOCUMENT” The Problem – Discussion – Possible Resolves – Trial (if necessary) and How This Information Is Distributed. If you and your fellow organization members spend hours of discussion and expenses to solve a problem and don’t “DOCUMENT” everything, it will be a huge waste of time and money.

    My experience…:
    Problem: I think this SMS thing is a waste of time, money and I hate meetings and paperwork.

    Discussion: Just like the preamble to an Airworthiness Directive and most Federal Aviation Regulations.
    Arguments Against: Our Air-Taxi only has about a dozen employees in the summer and four in the off-season. We can just tell each other how to do their job. Every dollar in the business needs to go back into the aircraft and paychecks. How can we justify paying for the extra hours of typing everything out, making power points, meetings and just sticking a binder on a shelf to collect dust? Don’t these lazy bureaucrats have anything better to do then harass us about “A Culture of Safety”? “Do they think we’re trying to be dangerous and kill everyone?” “They must not know that killing your costumers is bad for business”. “These bureaucrats get paid to sit around and type all day, why don’t they do the SMS for their own problems?”

    Arguments For: Remember a couple summer ago the van driver ran the engine out of oil? We put a procedure in place that the Van Driver leave the hood open at the end of the day and checks all the fluids and tires each morning. The van has been very reliable every since. That has saved us at least two grand.
    Pilots are required to read and know the Aircraft Flight Manual and the companies General Operations Manual (GOM). Basically, pilots shall follow the Chief Pilot’s written policies. Any changes to the Chief Pilot’s rules must be discussed, approved and put into the GOM. “Yes, that’s just the way all commercial operators are required to operate per regulations and FAA over-site”. So, what is your companies accident record? “We don’t have accidents”. See?, that’s SMS.
    “If this SMS thing works so good, why can’t all the bureaucratic problems be solved by SMS?” They are!! Your Problems are not the FAA’s/NTSB’s problems. They solve their inner office conflicts and management issues with plethora of policies. These bureaucratic organizations hire as many people as their budget allows. Then use SMS to solve their budget crises and request more money to grow even larger. Trust me, SMS is working, Oh boy, it’s working all across every branch of government. The greatest problem each individual bureaucrat is faced with each day is job security, how to work less and get payed more. They resolved these problems by using a “Pyramid Type Scheme”. The more people hired to do their job under them the more they appear important. If you do a simple internet search you’ll find that this practice is well established throughout many government human resource websites. Some people are known to call this climbing of the government totem pole resolving the employee’s problem of security, pay and benefits ‘Socialism’. It’s really just SMS in action.

    Resolve: Don’t worry about everyone else’s problems. Deal with the problems that improve your organization’s operations and the aviation industries’ value. On the wall of the meeting office (break room) big poster reads “FOCUS ON OUR BUSINESS”. We set policy, each meeting discusses problems that are put to print. That are either passed around or posted on the bulletin board at least three days before. Don’t start complaining about something that’s not formally brought up for discussion. We need a chance to review the problems circumstances. Other wise, we can’t give it a fair unbiased argument. Impromptu complaints sometimes comes off like you’re just whining. Whining drags out meetings and resolves absolutely nothing.

    Documentation: To minimize the time spent typing out the meeting notes we use a video/audio device (cell phone). Created a backed-up computer file folder titled SMS. New folder with the date as it’s name has the recording, the typed out problems and resolution that were discussed. The resolutions are dealt with by the person who brought the problem up. They’re in charge of how the agreed upon fix is effectively dealt with. Some resolutions are just a purchase and/or relocation of items. Placards and power points are not necessarily good solutions. On the other hand, videos that new-hires watch have done wonders.

  3. I can’t believe any pilot group would go along with cameras or image recording devices in the cockpit. Pilot groups got conned into voice recorders on the condition that the recordings were only for NTSB accident investigations. Unfortunately civil courtrooms had other ideas. As far as SMS is concerned if it was so great the FAA would have mandated it already. It was mandated for pt121 because of ICAO harmonization, since many airlines fly international. The fact that most pt135 and other passenger carriers don’t kind of tells you something. As someone who has had to deal with SMS, I still think it is just another worthless paperwork exercise that accomplishes nothing. I fly for a pt 135 company that actually does things right and legal. One big tool we use is APG for performance numbers on transport category (jets) planes. Two previous companies I flew transport planes for did not. Ever try to calculate climb gradients using the AFM or POH? The FAA would probably accomplish more by mandating these types of tools for transport category planes than any SMS.

  4. Totally agree with you, John. May as well mention ISBAO while we’re at it. SMS, required for ISBAO certification is one huge waste of resources as is ISBAO itself. I have flown for two very respectable companies that wouldn’t be able to operate worldwide without those programs. It’s just as much as of a smokescreen and therefore useless as a Wyvern or Argus self-made police force that doesn’t do jack but fill their own pockets and have forced the industry to buy into their product. The CEO SMS statement is also part of absolutely nothing but show. I would incriminate myself heavily if I told two unbelievable but real stories about plain violations of personal minimums, safety and plain idiocy while operating “under” ISBOA and/or Wyvern/Argus.

    When I was a younger pilot I would absolutely have hated image recorders, but they will work for sure. We already hold our tongue because of the CVR, and will behave more appropriate with a camera. This will be SO unpopular but highly effective. I’m sure we can all think of accidents that definitely would NOT have happened if the pilots had known they were being video’d. Until a major incident or accident, just as the case with the CVR, nobody is going to replay the previous flight to simply watch a pilot pick his nose or read inappropriate material while flying. I would imagine that back in the lab, when they’re playing the CVR and watch the pilot’s action on camera, you’re already dead anyway.

    Imaging will prevent accidents, I am 100% convinced.

  5. Most 121 pilots I know do their best to fly the way the Airline they work for and the FAA mandate.

    Once the NTSB gets cockpit video records of crashes, the video becomes public record.

    I personally don’t want my family reliving my death over and over in the news on a video. Having a voice recording is bad enough.

    Pilot unions don’t trust Government entity’s to keep the recordings out of public view. Good luck trying to keep us from placing a piece of tape over the camera if the NTSB is successful.

  6. As the chairman of my X-ray department used to say, “There is no end to the good you can do.” I think we can all see where this going: gub’ment bureaucrats and civil trial lawyers giving our performances a public postmortem every time something doesn’t turn out like it should. Perhaps when we get to completely autonomous flights – without pilots – the problem will solve itself.

    • James Wills. “Perhaps when we get to completely autonomous flights – without pilots – the problem will solve itself.“ guessing this quote was sarcasm?

      I think the “Miracle on the Hudson” took care of fully automated flights for a while.

      There are too many scenarios to let a computer completely control all flying aspects.

      How many times do you have to restart a computer or phone to get it to work correctly?

      A fully automated airplane has to work perfectly every flight. The reliability is not there yet. Normally the passengers have no idea that a plane their on has a small maintenance issue on MCO(MEL) but can still fly because the pilots are there for backup.

      We haven’t even started talking about contaminated runways and other things mother nature throws at pilots on a daily basis.

  7. I was a captain for one of the 17 Part 135 carriers using an SMS system. This is a large 135 operator with an excellent marketing program. However, the SMS system was only in place to impress the customers. All part of marketing. Accidents, incidents, maintenance problems were NEVER talked about (not even in recurrent training) for fear of the customers hearing about them. Taboooooo. Example, a pilot was fired for denying boarding to a drunken passenger. Try denying boarding to a drunken fat-cat that thinks he owns you and the airplane! Not all drunks will be user friendly when they are soused beyond reason. The pilot ( a vet who served our country in an F-18) should have been rewarded for his safety decision, but such is not the case. The company contends the pilot was fired because of the way the pilot handled the pax. The truth is the company made an example of the pilot. If the SMS system were working the company would address the drunken passenger issue. When a company is driven by sales and the sales and marketing experts promote “the good time flights” to the passengers, safety becomes secondary. Drunken passengers are a major safety risk. Don’t forget, as the cabin climbs the drunken get drunker. Enuf said. God bless.

  8. A long since forgotten NTSB similar recommendation was that open mike recorders (similar to cockpit voice recorders) be placed above every control position in all ATC facilities. This recommend occurred following the crash of Hughes Air West 706 in June, ’71. The DC9 was climbing our of LAX when it got T-boned by a VFR Marine F4. The event occurred many miles from the radar site, the F4 was a maintenance mess which included having no transponder. We did not see the F4 on radar for that reason and many others. Four persons were at that radar sector when it happened, including me, and the F4 just did not appear on radar. The investigation concluded that to be the case. However….there was also the implication that the four of us were possibly lying and were just covering up. NTSB recommended the open mikes to insure they would catch our “cover up” comments next time. The FAA didn’t buy into that.

  9. I wonder if the NTSB has ever heard about privacy rights?
    In my opinion, even cockpit voice recorders go too far.
    Cockpit cameras would be the icing of the cake of violating a pilot’s dignity.

    • You should check out the rest of the document referenced in this article. A real eye opener if anyone thinks the NTSB cares about privacy rights.

  10. More intrusion?
    But potentially a source of information when CVR and FDR do not work.

    Log ago Transport Canada engineers were constipated about details of new FDR regulations whereas accident investigators wanted recorders that were working before the crash and survived it.

    – no data from PW 707 that was 400 feet low on final to YEG (I forget why recorders did not provide data)
    – CVR of PW314 did not survive smouldering fire (RCMP would not listen to airline people warning them of that probability). Probably would have really helped understand if crew tried hard to contact the Aeradio (FSS) station in Cranbrook (perhaps more use to lawyers).
    – CVR of Coulson Hercules firefighting airplane had been left turned off after training in the US (wing hit a tree after retardant drop).

    OTOH, data from ancilliary devices like Latitude Technologies’ activity reporting system have been helpful when they survived, including in the case of the pilot in SE Asia who learned the fatal way why the shortcut she took was not on the flight plan. (Too little margin for error among the rocks. IIRC Latitude’s memory chip had stored part of her track to the crash site.)

  11. I always come here expecting some compliant fools, but you’re really impressing me today. Maybe because it’s affecting you, your rights or some reasonable expectation of privacy while you pick your nose, I don’t know. Where are you when they tell us all to wear masks that don’t work in a tiny tube full of recycled air huh. Why can’t you just let them record you? You know it’s just for your own good – and they know better than you. They’re experts. heh.

  12. I posted the rules above to SMS now lets give it a spin. The issue is something that can have real world results that we can measure the effectiveness of SMS.

    My complaint: Not enough commenters on AvWeb.
    I believe there should be many times more people as regulars and first time commenters. Over 100 hundred comments per article.

    The only thing that I would add to the rules is start every reply with (Agree: ) or (Disagree: )

    • About 25 years ago when AVWeb was a new website, comments were permitted. It got crazy out of control. Politics had to be expressed with every issue, rudeness, and quantities of responses. AV Web shut the remarks section down.

  13. What Are Aviation Association Members Paying For?

    This is a comment about roles. We all have our job to do. In the United States, the role of the federal government’s National Transportation Safety Board is to recommend safety enhancements. NTSB is not required to subject its recommendations to cost-benefit analysis; the benefits can be completely theoretical and the costs astronomical – that’s not the NTSB’s concern because NTSB has no power to make law, only suggestions.

    The Federal Aviation Administration has the power to make law. Before FAA adopts an NTSB recommendation, it must subject that recommendation to a cost-benefit analysis. Some NTSB recommendations — like SMS For All and Flight Data Recorders For All — have not made the cut despite decades of repetition by NTSB, a fact that NTSB laments without recognizing its significance. The significance is this: SMS For All would cost many operators more than it is worth — so much more that FAA has been willing to take the heat of NTSB’s constant public carping about it rather than face the larger criticism that will result if FAA were to force operators to adopt SMS For All by regulation. If FDRs For All is not in the same bucket, it is only because the cost of hardware has come down substantially in recent years.

    The job of the aircraft operator is to make wise investments to keep the operation safe and thriving. Any operator who perceives value in SMS or FDRs is free to implement them at will; FAA rule-making is required only to force SMS or FDR implementation on operators who perceive too little benefit to justify the cost.

    With the power and resources of multiple federal government agencies, funded by tax dollars, setting the baseline for aviation safety, what is the role of industry associations? One association of aircraft operators responded to NTSB’s latest Most Wanted list with unqualified cheerleading. Shouldn’t industry associations at least call for cost-benefit analysis of SMS For All or FDRs For All as applied to their members?

    Aviation associations are funded by their members. There seems little reason for operators, manufacturers, or suppliers to spend their scarce discretionary resources to buy more of what their tax dollars already pay for. If you love an NTSB recommendation, you don’t need to pay extra to have an organization agree; the government already agrees with you. If you hate an NTSB recommendation, you don’t need to pay extra to have your organization fight you; that seems like a really poor investment.

  14. I doubt anybody will ever read this, the results are very much what is expected and typical. Most every complainer/commenter on any of these aviation sites all talk up “SAFETY”. “I’m ‘Safer’ then you”. The NTSB and FAA come out and say that discussing and resolving safety issues with SMS is an answer. The type of people that comment don’t want to participate in resolution just complaining and judging others. The greatest number of aviation articles are about how ‘other’ people are not safe. The commenters are always better pilots and always wear their ‘mask’. ‘Safety Justice Warriors’ are always shaming others but, won’t participate in making anything better.

    I suspect aviation’s future is reflected in these ‘safety justice warriors’ endless upping of each other. By-the-way, I wrote this while wearing three mask from my basement closet doing everything the TV news person tells me. ‘Safety First’.