How the Death of Notre Dame Football Coach Knute Rockne Changed Passenger Aviation Safety

Updated: May 31


In 2017 I was asked to write a history of the National Transportation Safety Board (NTSB) for a fiftieth anniversary publication of the Department of Transportation. I discovered a lot of interesting, and sometimes shocking, facts. Here's the article.


The National Transportation Safety Board was established by Congress as an independent agency within the Department of Transportation (DOT) on April 1, 1967. Despite its small size of about 400 staffers, and lack of regulatory control, over the years it has come to have an enormous impact on the transportation safety in the air, on the ground, and on the water in the United States. It is the lead agency in investigating transportation accidents and partners with industry experts, applicable corporations, and state and federal government agencies to establish the facts, circumstances, and probable causes of accidents. Every accident, from the small, such as a hard landing by a student pilot that blows out an airplane’s tire, to the large, such as US Airways Flight1549, the “Miracle on the Hudson,” as well as the 2009 Washington Metro train collision and the 2007 Minnesota I-35W highway bridge collapse are just a few examples of the transportation accidents that fall under the NTSB’s investigative umbrella.


The NTSB’s origins can be traced to the Air Commerce Act of 1926 which empowered the Department of Commerce to regulate private aviation and the budding commercial airline industry. That industry was just twelve years old when, on March 31, 1931, TWA Flight 599, a wooden-winged Fokker F.10 tri-motor airline, departed from Kansas City, Missouri, en route to Los Angeles, California. About 140 miles later, it crashed into a field near Bazaar, Kansas, killing all eight passengers and crew. Among the passengers was legendary University of Notre Dame coach Knute Rockne. The accident shocked the nation, with President Herbert Hoover calling his death a “national loss.”


A contributing factor to the nation’s shock and outrage was a fact that the public was ignorant of a crucial fact about airline travel at the time: it was the most dangerous way to travel. Prior to the Flight 599 accident all Commerce department investigations of airline accidents were kept secret. The resultant investigation led to sweeping reform and improvements in the airline industry and aircraft design. And, from that point on, aircraft accident investigations and reports were made public.


By the 1960s, transportation had grown, advanced, and expanded to such an extent that existing government departments and agencies were being overwhelmed. This led to the creation in 1967 of the cabinet-level Department of Transportation and folding into it existing agencies like the Federal Aviation Administration and adding new agencies like the NTSB.


Though the NTSB is involved in all types of transportation accidents, its highest profile investigations tend to be those involving aircraft accidents. The NTSB was a little more than three-and-a-half months old when it had its first major investigation: a fatal mid-air collision between a twin-engine private airplane and a commercial airliner.


On July 19, 1967, Piedmont Airlines Flight 22, a new Boeing 727-22, part of a major expansion for the airline, took off from the runway of the Asheville Regional Airport in Hendersonville, North Carolina. Because weather was a 2,500-foot ceiling with broken clouds and hazy conditions, the airline was operating under instrument flight rules, or IFR.


Flight 22 was in its takeoff roll in a climbing left turn and reaching 6,000 feetwhen a Cessna 310, also operating under IFR, slammed into its fuselage just aft of the cockpit. Eyewitnesses on the ground reported the collision sounded like a large explosion like that of a jet breaking the sound barrier. The Cessna disintegrated on impact and the Boeing 727 rolled on its back and crashed vertically into a summer camp. Everyone in the two airplanes were killed. Among the passengers was John T. McNaughton, Assistant Secretary of Defense for International Security Affairs and Secretary of Defense Robert McNamara’s closest advisor.

For Boeing, it was the sixth 727 accident and the second-worst involving fatalities (in February 1966, an All Nippon Airways flight crashed into Tokyo Bay, killing 133 passengers and crew). At the time, it was the nation’s ninth worst aviation accident.


A five-member team was formed to investigate. Its members included led by chairman Joseph J. O’Connell, Jr., John H. Reed, Oscar Manuel Laurel, Louis M. Thayer, and Francis H. McAdams.


A lawyer, Mr. O’Connell’s public service began in 1933 when he worked as an attorney in the Public Works Administration. In 1938, he went to the Department of the Treasury, becoming assistant general counsel in 1941 and general counsel in 1944. In 1947, he briefly returned to private practice before being appointed chairman of the civil Aeronautics Board in 1948, serving two years. He was chairman of the board of Lake Central Airlines from 1955 to 1965. In 1967, President Lyndon Johnson called him from private practice and appointed him the NTSB’s first chairman.


John H. Reed would go on to succeed O’Connell as the NTSB’s second chairman. Before that Reed served as a Maine state representative and senator, then its governor. After his service on the NTSB he would go on to become U.S. ambassador to Sri Lanka and the Maldives.

Oscar Manuel Laurel was a Texas state representative and district attorney before being appointed to the NTSB.


Louis M. Thayer was a retired Coast Guard rear admiral who would serve in the NTSB for nine years.


Francis H. McAdams was a U.S. Navy aviator in World War II, after earning his law degree he served as a corporate and trial attorney for Capital Airlines. He was also an attorney-trial examiner, air safety investigator, and later senior trial attorney for the civil Aeronautics Board. He would serve on the NTSB for sixteen years.


On September 5, 1968, the team issued a 56-page report on the accident. It concluded: “The Safety Board determines that the probable cause of this accident was the deviation of the Cessna from its IFR clearance resulting in a flightpath into airspace allocated to the Piedmont Boeing 727. The reason for such deviation cannot be specifically or positively identified. The minimum control procedures utilized by the FAA in the handling of the Cessna were a contributing factor.”


Local historian Paul Houle spent several years studying the accident, eventually publishing an account of his investigation. In response to a petition filed by Houle, citing irregularities and a conflict of interest concern that the NTSB wasn’t fully independent of the FAA as at the time both were a part of the DOT, in 2006 the NTSB agreed to reopen its investigation.


In February 2007, NTSB chairman Mark Rosenker notified Houle that the panel responsible for the new investigation had voted 3-1 that his arguments were unsubstantiated and that the original findings were confirmed.


Questions regarding NTSB impartiality in safety investigations had been raised soon after the board had been formed. Others had pointed out that because accident causation may sometimes involve issues of inadequate oversight by sister DOT agencies like the FAA, how could the NTSB assure the public that its investigations would be both thorough and objective? That concern led Congress to pass the Independent Transportation Safety Board Act of 1974 which separated the NTSB from the DOT and made it a truly independent agency within the federal government.


In 1990, the NTSB took a page out of the FIB’s manual and released its first “Most Wanted Transport Safety Improvements” list. The purpose of the list was to bring public attention to chronic transportation safety problems that relevant departments and agencies knew existed but for a variety of reasons had not addressed. In so doing, the NTSB hoped to nudge the appropriate bureaucracies to act, or, failing that, to harness the power of public opinion to demand appropriate action be taken.


In some cases, like the passing of the Railroad Safety and Improvement Act of 2008, Congress acted, passing legislation that mandated railroads reduce train crew shift schedules and increase the rest time between shifts. In others, like the placing of babies and toddlers in car seat in the back seats of car, the NTSB sought to galvanize public opinion. Regarding safety seats for babies and toddlers, originally parents had them placed on the passenger side of the front seat. It took about twenty years before attitudes changed enough for state laws to be passed mandating that the safety seats be located on the back seat.


The NTSB’s first Most Wanted list contained eighteen recommendations. Heading that list was “Positive Train Separation,” inadequate signaling and braking systems to ensure constant safe distance separation between trains. Later changed to “Positive Train Control Systems,” it remained on the list until 2008. Also on that first list were recommendations to reduce airline crew fatigue, and to improve runway safety.


Runway safety issues continue to be a problem event to this day. For example, on February 15, 2017, actor and vintage airplane enthusiast Harrison Ford piloting his Aviat Husky accidentally overflew a Boeing 737 airliner at John Wayne Airport in Orange County, California. Fortunately, no accident occurred and Ford’s airplane safely landed on a taxiway that ran parallel to the runway.


Since its inception, the NTSB’s list has been divided into two lists, one addressing federal issues and the other for state issues. The NTSB’s 2017-2018 Most Wanted List for Transportation Safety Improvements on the federal level are:

• Loss of Control in Flight in General Aviation (fourth consecutive year)

• Ensure the Safe Shipment of Hazardous Materials

• End Alcohol and Other Drug Impairment in Transportation

• Reduce Fatigue-Related Accidents

• Require Medical Fitness

• Eliminate Distractions

• Strengthen Occupant Protection

• Expand Recorder Use to Enhance Safety.


During its fifty years of existence it has issued more than 14,000 safety recommendations with more than 80 percent of those recommendations being implemented.


On January 15, 2009, US Airways Flight 1549, a two-engine Airbus A320-214, took off from LaGuardia airport in New York City, bound for Charlotte, North Carolina. Three minutes later, as it was climbing to altitude over the Bronx, the Airbus flew through a flock of geese. Some of the geese were ingested by the aircraft’s engines, severely damaging them and causing them to shut down. About four minutes later, pilots Chesley Sullengerger and Jeffrey Skiles successfully ditched the airplane in the Hudson River off midtown Manhattan. Of the 155 people on board, there were 83 injuries, five of them serious, but no fatalities. It was an incident that became famous as the “Miracle on the Hudson,” with one NTSB board member calling it “the most successful ditching in aviation history.”


The NTSB immediately launched an investigation that included bird studies, interviews of crew and passengers, the recovery of the sunken aircraft, recreations of the incident in flight simulators, and public hearings. Almost a year and a half later, on May 4, 2010, it concluded with a 213-page report, that Sullenberger’s decision to ditch in the Hudson River was the correct one.


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