TSB Special Investigation Recommends Safety Improvements to Commuter,…

​​​​Report studied more than 500 accidents from 2010-2022

WASHINGTON (August 13, 2024) - A special investigation of more than 500 accidents by the National Transportation Safety Board revealed safety vulnerabilities in the sector of commercial aviation that includes commuter air carriers, air tour operators, air ambulance services, on-demand business jet charters and other operations.

The report identified safety issues in aviation operations conducted under Title 14 Code of Federal Regulations Part 135. The NTSB initiated the special investigation in 2022 after a cluster of safety issues emerged from recent investigations of accidents involving Part 135 operators.

The NTSB's analysis of more than 500 fatal and nonfatal Part 135 accidents from 2010 to 2022 resulted in three new safety recommendations being issued to the FAA and two previously issued recommendations being reiterated.

The report did not look at major commercial airlines, which operate under different, more stringent, rules.

Safety issues explored in the report include:

• ​Unsafe loading conditions. Investigators cited four single-engine airplane accidents where unsafe loading conditions were identified. The NTSB said that a requirement mandating flight manifests and weight and balance documentation be recorded for all aircraft operated under Part 135 would help pilots detect and correct unsafe loading conditions. Such a requirement would also provide operators and inspectors the information needed to support proactive, comprehensive assessments to identify any related operational risk areas that may influence improper aircraft loading and mitigate them before an accident occurs.
• Lack of certificated dispatchers for some operations. The report identified 12 accidents in which flight dispatch and operational control were deficient because the personnel responsible for those areas were not certificated flight dispatchers nor did FAA regulations require them to be. The NTSB said that certificated flight dispatchers would expand the safety margins of many Part 135 operations because of improved quality control over functions such as preflight weather, fuel and route planning, active monitoring of conditions along the route of flight and timely notification of emergency response organizations if an aircraft is overdue.
• Flight data monitoring. The report noted that flight data monitoring programs could provide Part 135 operators with objective information on how their pilots conduct flights, and a periodic review of such information could assist operators in detecting and correcting unsafe deviations from company standard operating procedures.

The NTSB also called for needed improvements in the collection and reporting of aircraft accident and flight activity data used to determine accurate accident rates for certain segments of Part 135 on demand operations. The NTSB is pushing for enhancements to data collection so it can better target safety initiatives.

Special Investigation Report AIR-24-03, "Safety and Industry Data Improvements for Part 135 Operations," is available online.