(InvestigateTV) — With her house decorated for her son’s first birthday party, Mary Hummer was feeling the joyful anticipation of a family celebration when a morning update on the TV broke through the happy chaos in their home.
The report detailed a horrific plane crash in Lexington, Kentucky. Knowing her brother, Charlie Lykins, had been in town settling the sale of a family cabin, the news set off immediate concern for Hummer and her husband.
“He just said, ‘You better call Karen [his wife] and see where he is,’” she recalled.
The call confirmed the news that would shatter the family. Lykins, a husband and father of two young children was gone — one of 49 victims of the 2006 crash of Comair Flight 5191.
“It’s something unexpected. You can’t prepare for it,” Hummer said.
Suddenly Hummer and her family were part of a tragic club, connected by the unique grief that only those mourning someone killed in an aviation crash can feel. It’s a fellowship that seeks answers, looking for causes to help make sense of the tragedies and actions to prevent anyone else from joining their ranks.
However, an InvestigateTV analysis of recommendations made by the National Transportation Safety Board following aviation disasters found the agency guidance designed to improve safety can sit in limbo for years, with some critical suggestions never adopted, even as additional deadly accidents occur.
Experts say those receiving these recommendations, particularly other government agencies, must balance competing priorities and limited resources — and determine whether the presumed safety benefit outweighs the often expensive process of implementing them.
As the survivors of aviation disasters shoulder their grief, NTSB investigators pick up the physical pieces. They dig through evidence, conduct interviews and analyze data to understand the series of seemingly small decisions, malfunctions or mistakes that led to disaster.
“Every incident isn’t one thing. There’s a whole chain of things that lead up to the accident,” said John Goglia, a former member of the NTSB, which is mandated by Congress to independently investigate all aviation incidents and accidents across the country.
When those investigations uncover mistakes, design flaws or gaps in oversight the NTSB believes are of broad enough concern, the agency will issue recommendations — often to other federal agencies such as the Federal Aviation Administration — suggesting changes or additions to regulations or policy.
InvestigateTV found that while most of these directives are eventually adopted, many are never put in place.
Hundreds of others spend years in bureaucratic limbo as federal agencies debate whether the safety benefits outweigh any added costs or challenges.
“We have several hundred recommendations open for aviation,” current NTSB board member Todd Inman said at a news conference in the days following the January midair collision between a military helicopter and a regional passenger jet at Ronald Reagan Washington National Airport.
Inman, who joined the board in March 2024 but has previously worked for the U.S. Department of Transportation, gave an emotional account of his conversations with the loved ones of those aboard the doomed flight from Wichita, Kansas — and how they had focused his frustrations about the need to heed the NTSB’s safety concerns.
“We’re dealing with tragedy, but we need to improve safety,” he said. “You want to do something about it? Adopt the recommendations of the NTSB. You’ll save lives. I don’t want to have to meet with another set of parents like that again. It’s not fair. It could be your family.
The recent crashes in Washington, D.C., Philadelphia and other cities have only resurfaced the pain and anxiety for families including the Hummers.
In August 2006, Hummer’s brother, Charlie Lykins, was on board Comair Flight 5191 when it crashed during its attempted takeoff. According to NTSB records, the Bombardier regional jet lined up on the wrong runway — one that was too short to allow for the aircraft to get off the ground.
After reaching a groundspeed of roughly 157 miles per hour, the plane crashed into a wooded area, the impact and resulting fire killing the 47 passengers and two members of the flight crew. The first officer survived but was hospitalized for nearly four months.
As she and her family mourned, Hummer said she followed the investigation into the crash closely, in part because it helped her to process her grief, but also because she thinks that, given he was a pilot himself, that’s what Lykins would have wanted.
“He was the one who was always researching other crashes and why small planes crashed,” she said. “He would be at the airport all the time and watching other planes coming and going, and he was just very interested in safety and flying.”
The NTSB determined the crash was caused by the pilots’ failure to realize they were on the wrong runway, in part because both the crew and the single air traffic controller were distracted while the flight was taxiing.
Learning the details of what went wrong was painful, Hummer said, but necessary.
“I think there’s nothing that you can do that’s more important than figuring out why it happened, and don’t let it happen again,” she said.
Her perspective echoes the words once emblazoned on the entrance of NTSB’s training center in Virginia and that current board member Inman recited following the crash above the Potomac: “From tragedy, we draw knowledge to improve the safety of us all.”
But by law, while the NTSB is in charge of drawing out that knowledge through its investigations, the responsibility for implementing safety improvements is in the hands of other agencies — often the FAA.
In many ways, the NTSB and the FAA are estranged bureaucratic siblings, both emerging from the Civil Aeronautics Authority in the mid-20th century and while the NTSB is an independent agency, budget limitations require controversially-close work with the FAA when it comes to accident investigations.
“We’re very fortunate that the FAA and the NTSB really work to coordinate,” said Randy Babbitt, a former FAA administrator. “They do completely different things, but they work together so that they come up with the best answers and hopefully corrections so that things won’t happen again.”
InvestigateTV, along with our partners at the Arnolt Center for Investigative Journalism at Indiana University, analyzed data from the NTSB’s catalogue of safety recommendations dating back to 2000. In that time, our analysis found the NTSB has issued 1,396 of its 1,752 total aviation safety recommendations specifically to the FAA.
Over the last 25 years, InvestigateTV discovered nearly 25% of the NTSB’S recommendations made to the FAA were marked by the NTSB as “Closed – Unacceptable Action” or were noted as having been superseded by a new recommendation following a subsequent crash.
Similarly, roughly 1 in 3 of the 187 open recommendations to the FAA are marked “Open – Unacceptable Response,” indicating the NTSB is not satisfied with the FAA’s answers or action to date.
Fifteen of those recommendations have been outstanding for more than a decade — including one that was made following the “Miracle on the Hudson” in which Captain Chesley Burnett “Sully” Sullenberger famously landed an Airbus A320 on the Hudson River.
Following the Comair disaster in 2006, the NTSB issued 11 safety recommendations to the FAA aimed at improving flight deck procedures, runway markings and air traffic control management, most of which were implemented.
However, two recommendations — including one urging the FAA to require all types of commercial aircraft be equipped with technology that would alert pilots to ground conflicts such as lining up the wrong runway — were closed without a resolution acceptable to the NTSB, because while the FAA implemented these changes for commercial airlines, the requirements were not extended to other types of for-hire flights.
Those types of aviation enterprises — and the numerous recommendations the FAA has declined to implement regarding them — have been of significant concern for the NTSB for years.
In July 2024, the NTSB completed a two-year investigation into Federal Aviation Regulation Part 135, issuing three new recommendations and reiterating two others.
One of those, “Safety Recommendation A-16-34,” which asks the FAA to require flight data recording devices and monitoring for all Part 135 operations, has been on the books since 2016 and reiterated five times.
In the years since the deadly Akron, Ohio crash that sparked A-16-34, InvestigateTV found at least 19 people have died in subsequent accidents that led the NTSB to reiterate its concerns — including as the 2020 helicopter crash that killed NBA All-Star Kobe Bryant, his 13-year-old daughter and seven others.
InvestigateTV sent multiple requests over the course of several months to the FAA asking for an interview, but those requests were denied, the agency sending instead an emailed statement:
“The FAA and NTSB share the same goal of continually improving aviation safety. The FAA takes NTSB recommendations seriously and agrees with the vast majority.”
Correspondence between the NTSB and FAA regarding recommendations such as the ones following the deadly Akron crash illustrate how the two agencies are often diametrically opposed on one major factor: cost.
“You don’t just throw out a new rule, there’s a process you go through,” said Babbitt, the former FAA administrator.
Where the NTSB has the liberty to make any recommendations it sees fit, the FAA is legally bound by the federal regulatory process, Babbitt explained.
“Any rule that is proposed by the FAA has to go by the [Office of Management and Budget],” he said. “It has to have a cost-benefit analysis.”
Since 1998, federal agencies have been required to conduct an analysis of the potential monetary costs of a new regulation if the rule would have an annual effect of $200 million or more.
“The way the laws are set in this country when you pass regulatory issues, they have to be cost-effective and have this cost-benefit analysis,” Babbitt said. “The NTSB is not under those restraints.”
InvestigateTV reviewed the correspondence text for aviation recommendations to the FAA where the NTSB has categorized the response as “unacceptable,” and found references to cost-benefit analysis in at least 29. The word “cost” shows up in 90.
For the loved ones like Hummer who are left with missed milestones and empty chairs at family celebrations, it’s a frustrating concept to reconcile.
“It’s hard to even put it in a parallel,” she said, “because there isn’t any amount of money that we wouldn’t give to have him back, you know?”
Babbitt said he understands, having met with grieving families just as Inman, the NTSB board member, described following the crash at DCA.
“I get the emotional side of it. You’re up close to, right there with the heartstrings, the aftermath and the families. I mean, it’s horrible. It’s absolutely horrible.”
He said he recognizes Inman’s and the NTSB’s frustration, and the pain families feel, especially if a tragedy occurs that may have been preventable if certain things were in place.
“But it’s not for lack of wanting to do it,” he said. “It’s the, the system that is built to protect it — sometimes those protections slow you down.”
Tyler Spence, Mari McComish, Yang Chao, Carson Johnson, and Alexis Carvajal with the Arnolt Center for Investigative Reporting at Indiana University contributed to the research for this report.
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