TO THE FEDERAL AVIATION ADMINISTRATION: Require retrofit of all cockpit voice recorders (CVR) on all airplanes required to carry both a CVR and a flight data recorder with a CVR capable of recording the last 25 hours of audio. (Supersedes A-18-31)
Safety Issue and Context
This report discusses the January 13, 2023, runway incursion incident involving American Airlines (AAL) flight 106, a Boeing 777-200, and Delta Air Lines (DAL) flight 1943, a Boeing 737-900, at John F. Kennedy International Airport (JFK), Queens, New York. The flight crew of the AAL airplane was instructed to taxi to runway 4L for departure and cross runway 31L; however, the crew crossed runway 4L, where the DAL airplane had just begun its takeoff roll. The local controller cancelled the DAL airplane’s takeoff clearance, and the DAL flight crew rejected the takeoff.
Safety issues discussed in this report include (1) the need for additional risk mitigation strategies to prevent flight crew surface navigation errors that result in runway incursions; (2) the need for a procedural crosscheck that requires flight crews to verbalize the number of a runway they are about to cross as indicated by runway signs; and (3) the lack of flight deck technology to detect potential traffic conflicts. As a result of this investigation, the National Transportation Safety Board issues eight new safety recommendations to the Federal Aviation Administration (FAA), reiterates one previously issued recommendation to the FAA, and supersedes two recommendations.
Response History
January 29, 2026 · Recipient Response · FAA
-From Bryan Bedford, Administrator: Since initiating rulemaking to address these recommendations in 2023, the Federal Aviation Administration (FAA) Reauthorization Act of 2024 (The Act) was signed into law on May 16, 2024. Section 366(a)(1) of The Act states that covered operators may not operate a covered aircraft manufactured later than one year after the enactment date of The Act, unless the aircraft has a CVR installed that retains the last 25 hours of recorded information, using a recorder that meets the standards found in Technical Standard Order C123c, Cockpit Voice Recorder Equipment, or any later revision.
Additionally, Section 366(a)(2) of The Act states a covered operator may not operate a covered aircraft no later than 6 years after the enactment date of The Act, unless such aircraft has a CVR installed that retains the last 25 hours of recorded information using a recorder that meets the standards of Technical Standard Order C123c, Cockpit Voice Recorder Equipment, or any later revision.
Although sections 366(a)(1) and 366(a)(2) are self-enacting, we worked to incorporate their language into the final rule. The Office of the Secretary has approved the text of the final rule, and it is with the Office of Management and Budget to issue in the Federal Register. We believe that the issuance of the final rule will effectively address the safety issues identified in Safety Recommendations A-18-30 and A-24-9.
I anticipate providing an update to this safety recommendation by October 31, 2026.
July 10, 2025 · NTSB Correspondence · FAA
From the Aviation Investigation Report AIR-25-04 “In-Flight Separation of Left Mid Exit Door Plug, Alaska Airlines Flight 1282, Boeing 737 9, N704AL, Portland, Oregon, January 5, 2024” published on July 10, 2025:
2.6.3.2 Need for 25-Hour Cockpit Voice Recorder Installations and Retrofits
In addition, the NTSB has long advocated for requirements for 25-hour CVRs, which would mitigate the risk of a CVR recording being overwritten. In October 2018, we issued Safety Recommendations A-18-30 and -31 based on investigations lacking access to relevant CVR data (NTSB 2018). These investigations included a July 2017 taxiway overflight incident in San Francisco, California, which had significant safety issues. Also, following the previously referenced runway incursion and overflight incident that occurred in Austin, Texas, on February 4, 2023, we reiterated Safety Recommendation A 18 30 and superseded A-18-31 with A-24-9 (NTSB 2024).
The safety recommendations asked the FAA to take the following actions:
Require all newly manufactured airplanes that must have a CVR be fitted with a CVR capable of recording the last 25 hours of audio. (A-18-30)
Require retrofit of all CVRs on all airplanes required to carry both a CVR and a flight data recorder with a CVR capable of recording the last
25 hours of audio. (A-24-9)
In December 2023, the FAA addressed Safety Recommendation A-18-30 by publishing a notice of proposed rulemaking (NPRM) proposing that newly manufactured aircraft be equipped with CVRs capable of recording 25 hours of data. If issued, a final rule based on the NPRM will likely satisfy this recommendation, which is currently classified Open—Acceptable Response. However, ee do not fully support the NPRM because it did not propose a similar requirement to retrofit existing airplanes required to carry a CVR and an FDR, as discussed in Safety Recommendation A-24-9. Accordingly, this recommendation is currently classified Open—Unacceptable Response.
On May 16, 2024, the FAA Reauthorization Act of 2024 became law. The act required 25-hour CVRs for aircraft operated under Part 121, other transport category airplanes that were type certificated with a seating capacity of 30 or more passengers, and cargo derivatives of such airplanes that are operated under other regulations. The act specified that newly manufactured aircraft would be equipped with 25-hour CVRs starting 1 year after the date of the act. Also, the act specified that affected operators were to retrofit their aircraft with a 25-hour CVR no later than 6 years after the date of the act.
May 9, 2025 · NTSB Correspondence · FAA
We are aware that an Aviation Rulemaking Committee (ARC) has been organized and held its first meeting in September 2023. We also understand that you will decide whether to pursue rulemaking after the ARC has completed its work and you have reviewed its recommendations.
In December 2023, the FAA published a notice of proposed rulemaking (NPRM) that proposed that newly manufactured airplanes that are required to carry a CVR have one that records the last 25 hours of audio. In our comments responding to the NPRM, we said the NPRM was responsive to Safety Recommendation A-18-30, but expressed our disappointment that it did not also propose a similar requirement for existing airplanes, as recommended in Safety Recommendation A-18-31. , Because the FAA did not complete responsive action by January 1, 2024, as specified in Safety Recommendation A-18-31, that recommendation was closed and superseded by Safety Recommendation A-24-9.
We are encouraged that the ARC, which was established in response to Safety Recommendation A-18-31, is continuing its work on this safety issue. We remain concerned, however, that this safety issue was first identified in 2018, yet the ARC was only established in 2023. Pending our receipt of your decision regarding whether the FAA intends to pursue rulemaking, the Board has voted to retain the classification of OPEN-- UNACCEPTABLE RESPONSE for Safety Recommendation A-24-9.
September 5, 2024 · Recipient Response · FAA
-From Michael G. Whitaker, Administrator: The FAA organized an Aviation Rulemaking Committee (ARC) that included industry, regulator, and NTSB participation to discuss, prioritize, and provide recommendations addressing the subject matter of this recommendation. The committee had its initial meeting on September 29, 2023, and its efforts continue. Based on recommendations received by the ARC, the FAA will decide on rulemaking related to this topic.
I believe the FAA has effectively addressed Safety Recommendation A-24-2 and considers our actions complete. The FAA will take no further action on this safety recommendation.
I will keep the Board informed of the FAA’s progress on A-24-3 through -9 and anticipate providing an update by August 31, 2025.
June 18, 2024 · NTSB Correspondence · FAA
This letter provides information about the National Transportation Safety Board’s (NTSB) June 6, 2024, report Runway Incursion and Overflight, Southwest Airlines Flight 708, Boeing 737-700, N7827A, and Federal Express Flight 1432, Boeing 767-300, N297FE, Austin, Texas, February 4, 2023, NTSB/AIR-24-02. The details of this incident investigation and the resulting safety recommendations may be found in the attached report, which can also be accessed at http://www.ntsb.gov.
As a result of this investigation, we identified the following safety issues:
• The lack of air traffic control tower and flight deck technology to detect potential conflicts on a taxiway or runway surface
• The need to ensure, especially during low-visibility conditions, that controllers are aware when pilots, after receiving takeoff clearance, might need extra time on the runway
• The lack of training on the AUS airport’s Surface Movement Guidance and Control System plan and low-visibility operations
• The need for low-visibility operations training at all airports
• The need for CVRs with a 25-hour recording capability
Accordingly, the NTSB issues seven new safety recommendations to the FAA. Additional information regarding these recommendations can be found in the noted sections of the report.
• For airports that are certificated under Title 14 Code of Federal Regulations Part 139 and are currently not equipped with airport surface detection equipment, model X or airport surface surveillance capability, implement surface detection equipment that
o tracks the movement of arriving and departing aircraft,
o determines the proximity between those aircraft, and
o provides air traffic controllers with visual and aural cues of surface movements to aid in their decision-making processes. (A-24-10) (See section 2.3.1.)
• Require air traffic controllers to
o advise pilots, through direct communication and automatic terminal information system broadcasts, when visual contact with aircraft operating on taxiways and runways cannot be established or maintained and
o instruct pilots to provide accurate position reports to aid the controller in determining an aircraft’s location in such conditions. (A-24-11) (See section 2.4.)
• Brief all air traffic controllers about the circumstances of this incident, emphasizing the effect that certain conditions might have on a pilot’s ability to begin a takeoff in a timely manner, including
o low-visibility weather conditions, such as fog;
o ambient conditions, such as temperature; and
June 11, 2024 · NTSB Correspondence · FAA
This letter provides information about the National Transportation Safety Board’s (NTSB) May 29, 2024, report Runway Incursion and Rejected Takeoff, American Airlines Flight 106, Boeing 777-200, N754AN, and Delta Air Lines Flight 1943, Boeing 737-900, N914DU (NTSB/AIR-24-01). The details of this accident investigation and the resulting safety recommendations may be found in the attached report, which can also be accessed at http://www.ntsb.gov.
As a result of this investigation, we identified the following safety issues: • the need for a procedural crosscheck that requires flight crews to verbalize the number of a runway they are about to cross as indicated by runway signs; • the lack of flight deck technology to detect potential traffic conflicts on a taxiway or runway surface; • the need for additional risk mitigation strategies to reduce the likelihood that flight crew surface navigation errors result in runway incursions; and • the need for cockpit voice recorders with a 25-hour recording capability. Accordingly, the NTSB makes the following safety recommendations to the FAA.
Additional information regarding these recommendations can be found in the noted sections of the report. • Encourage Title 14 Code of Federal Regulations Part 91K, 135, and 121 operators to incorporate into their standard operating procedures a procedural crosscheck that requires flight crews to verbalize the number of a runway they are about to cross, as indicated by runway signs, unless an installed automated system already provides an aural advisory. (A 24 2) (See section 2.3.1.)
• Encourage Title 14 Code of Federal Regulations Part 121 operators to use their safety management system to identify flight crew surface navigation errors resulting from the performance of concurrent tasks during taxi and develop and implement effective risk mitigation strategies considering human factors principles. (A-24-3) (See
In addition, the act required the FAA, within 3 years of the date of the act, to issue a final rule to update applicable regulations to conform to the CVR retrofit requirement for existing aircraft.
The airplane involved in this accident would not be subject to the proposed rulemaking announced by the FAA in December 2023 but would be subject to the 6 year retrofit requirement in the FAA Reauthorization Act of 2024. Although the statutory requirement for 25-hour CVRs on newly manufactured airplanes is in effect, the FAA has not yet issued a final rule to incorporate this provision into the regulations.
Since the original issuance of our CVR recommendations in 2018, more than 20 of our investigations (including this investigation) have been negatively affected by overwritten CVR data (see table 4).
As the number of events listed in table 4 shows, the potential for data to be overwritten on a 2-hour recorder persists. Thus, the NTSB concludes that the circumstances of this accident and others show that CVRs with a 25-hour recording capability are necessary because valuable information continues to be overwritten on CVRs that are designed to record only 2 hours of audio data. Therefore, the NTSB reiterates Safety Recommendation A-24-9 to the FAA.
Further, the NTSB notes that nearly 18 months have passed since the FAA released the NPRM to require 25-hour CVRs on newly manufactured airplanes, and, as stated previously, although the statutory requirement is in place, the FAA has not yet issued a final rule to incorporate the provision into regulations. Therefore, the NTSB reiterates Safety Recommendation A-18-30.
o surface conditions, such as ice, snow, and other precipitation, as noted in Order 7110.65, Air Traffic Control, paragraph 5 8 4, Departure and Arrival. (A 24-12) (See section 2.4.)
• Amend the Aeronautical Information Manual so that it instructs pilots to inform controllers, before entering an active runway with the intent to depart, when they need time on the runway for any reason before beginning the takeoff roll. (A-24-13) (See section 2.4.)
• Require all airports with a Surface Movement Guidance and Control System plan to ensure that their plans and the associated letters of agreement correspond with each other and the stakeholder duties and responsibilities described in Advisory Circular 120-57, Surface Movement Guidance and Control System. (A-24-14) (See section 2.5.)
• Direct training administrators at airports with a Surface Movement Guidance and Control System plan to require initial and annual refresher training for all stakeholders, including air traffic controllers and airport operations personnel, on the information in the airport’s plan. (A-24-15) (See section 2.5.)
• Require training administrators at all operating air traffic control towers to conduct annual refresher training on low-visibility operations. (A-24-16) (See section 2.5.)
In addition, the NTSB reiterates the following recommendations to the FAA:
• Collaborate with aircraft and avionics manufacturers and software designers to develop the technology for a flight deck system that would provide visual and aural alerts to flight crews of traffic on a runway or taxiway and traffic on approach to land. (A-24-4) (See section 2.3.2.)
• Require that the technology developed in response to Safety Recommendation A-24-4 be installed in all newly certificated transport-category airplanes.
(A-24-5) (See section 2.3.2.)
• Require that existing transport-category airplanes be retrofitted with the technology developed in response to Safety Recommendation A 24-4 (A-24-6) (See section 2.3.2.)
• Require all newly manufactured airplanes that must have a cockpit voice recorder (CVR) be fitted with a CVR capable of recording the last 25 hours of audio. (A-18-30) (See section 2.6.)
• Require retrofit of all cockpit voice recorders (CVR) on all airplanes required to carry both a CVR and a flight data recorder with a CVR capable of recording the last 25 hours of audio. (A-24-9) (See section 2.6.)
The NTSB is vitally interested in these recommendations because they are designed to prevent accidents and save lives. We would appreciate a response within 90 days of the date of this letter, detailing the actions you have taken or intend to take to implement these recommendations. When replying, please refer to the safety recommendations by number (new Safety Recommendations A-24-10 through -16 and reiterated Safety Recommendations A-18-30, A-24-4 through -6, and A-24-9). We encourage you to submit your response to ExecutiveSecretariat@ntsb.gov.
If your reply, including attachments, exceeds 20 megabytes, please e mail us at the same address for instructions on how to send larger documents. Please do not submit both an electronic copy and a hard copy of the same response.
Justification for reiteration of A-24-9 from the report “Runway Incursion and Overflight Southwest Airlines Flight 708, Boeing 737-700, N7827A, and Federal Express Flight 1432, Boeing 767-300, N297FE, Austin, Texas, February 4, 2023,” published 6/18/2024:
2.6 Cockpit Voice Recorder Duration
Because the 2-hour CVR installed on the FedEx airplane was overwritten after the incident, the NTSB was unable to determine when the first officer saw the SWA airplane or how he communicated the need to go around to the captain. (The SWA airplane also had a 2-hour CVR installed.) In October 2018, the NTSB issued Safety Recommendations A-18-30 and -31, which recommended that new and existing airplanes, respectively, be equipped with CVRs that record 25 hours of data to ensure that investigations would not be hindered by the lack of CVR data.
For this incident, a 25-hour CVR would have recorded the above-mentioned information as well as other audio information that was not captured on ATC recordings.
Other NTSB investigations have highlighted the need for 25-hour CVRs. For example, both airplanes involved in the JFK runway incursion had a 2-hour CVR installed, and both CVRs had been overwritten by the time that the NTSB learned about the incident. The final report for the JFK incident reiterated Safety Recommendations A-18-30 and -31 because of the loss of critical information of interest to the investigation, including the content and timing of crew communications, potential distractions, and crew situational awareness.
In addition, postincident interviews of the American Airlines flight crew involved in the JFK incident did not occur until about 1 month after the incident. Because memories can decay or become distorted with time, CVR information was needed to corroborate the crew’s recollections.
The NTSB recognizes that the FAA has taken action to address Safety Recommendation A-18-30 by publishing an NPRM that proposed that newly manufactured aircraft be equipped with CVRs capable of recording 25 hours of data. However, the NTSB did not fully support the NPRM because it did not propose a similar requirement to retrofit existing airplanes required to carry a CVR and an FDR, as
section 2.3
.2.) • Collaborate with aircraft and avionics manufacturers and software designers to develop the technology for a flight deck system that would provide visual and aural alerts to flight crews of traffic on a runway or taxiway and traffic on approach to land. (A-24-4) (See
section 2.3
.3.)
• Require that the technology developed in response to Safety Recommendation A 24 4 be installed in all newly certificated transport-category airplanes. (A 24 5) (See section 2.3.3.) • Require that existing transport-category airplanes be retrofitted with the technology developed in response to Safety Recommendation A 24 4. (A 24 6) (See section 2.3.3.) • Evaluate the effectiveness of the activation logic for the runway status light system considering the circumstances of this incident. (A 24 7) (See sections 1.9.1.1 and 2.4.1.)
• Using the findings of the evaluation conducted in response to Safety Recommendation A 24 7, update the runway status light system activation logic as necessary to improve system effectiveness. (A-24-8) (See sections 1.9.1.1 and 2.4.1.) • Require retrofit of all cockpit voice recorders (CVR) on all airplanes required to carry both a CVR and a flight data recorder with a CVR capable of recording the last 25 hours of audio. (A 24 9) (See sections 1.9.1.2 and 2.6.)
In addition, the NTSB reiterates the following recommendation to the FAA: • Require all newly manufactured airplanes that must have a cockpit voice recorder (CVR) be fitted with a CVR capable of recording the last 25 hours of audio. (A-18-30) In the same report, we also classified the following safety recommendations: • Require, at all airports with scheduled passenger service, a ground movement safety system that will prevent runway incursions; the system should provide a direct warning capability to flight crews. In addition, demonstrate through computer simulations or other means that the system will, in fact, prevent incursions.
(A-00-66) Safety Recommendation A-00-66 is classified Closed—Unacceptable Action/Superseded in section 2.3.3 of the report. This recommendation is superseded by Safety Recommendations A-24-4 through -6. • By January 1, 2024, require retrofit of all cockpit voice recorders (CVR) on all airplanes required to carry both a CVR and a flight data recorder with a CVR capable of recording the last 25 hours of audio. (A-18-31) Safety Recommendation A-18-31 is classified Closed—Unacceptable Action/Superseded in section 2.6 of the report. This recommendation is superseded by A-24-9, which is classified Open—Unacceptable Response.
The NTSB is vitally interested in these recommendations because they are designed to prevent accidents and save lives. We would appreciate a response within 90 days of the date of this letter, detailing the actions you have taken or intend to take to implement these recommendations. When replying, please refer to the safety recommendations by number (Safety Recommendations A-24-2 through -9, reiterated Safety Recommendation A-18-30, and classified Safety Recommendations A-00-66 and A-18-31). We encourage you to submit your response to ExecutiveSecretariat@ntsb.gov.
If your reply, including attachments, exceeds 20 megabytes, please e mail us at the same address for instructions on how to send larger documents. Please do not submit both an electronic copy and a hard copy of the same response. Justification for A-24-9 from report "Runway Incursion and Rejected Takeoff, American Airlines Flight 106, Boeing 777-200, N754AN, and Delta Air Lines Flight 1943, Boeing 737-900, N914DU," May 29, 2024, John F.
Kennedy International Airport, Queens New York: 1.9.1.1 Surface Detection Technology The NTSB issued Safety Recommendation A-00-66 on July 6, 2000.24 The recommendation asked the FAA to do the following: Require, at all airports with scheduled passenger service, a ground movement safety system that will prevent runway incursions; the system should provide a direct warning capability to flight crews. In addition, demonstrate through computer simulations or other means that the system will, in fact, prevent incursions.
On August 25, 2017, the FAA stated that it was continuing to install runway status lights at some larger airports with scheduled passenger service to “provide a direct indication to pilots and vehicle operators when a runway is unsafe for entry, crossing, or departure … reducing the time it takes to alert them of potentially unsafe situations.”
The FAA also stated that runway status light systems require the installation of ASDE-X or the airport surface surveillance capability (ASSC).25 On December 1, 2017, the NTSB stated that the recommendation remained classified as Open—Acceptable Response and expressed interest in learning about the solutions under consideration for airports that would not be receiving a runway status light system. On July 2, 2021, the FAA stated that, of the 35 US airports with ASDE-X and the 8 airports with ASSC, 20 airports had runway status lights.
The FAA also stated that its “Runway Incursion Prevention through Situational Awareness” initiative was working to identify different types of potential surveillance system technologies, including low-cost solutions that are suitable for smaller airports. Additionally, the FAA stated that it was further exploring technologies, including ADS-B In applications that could provide situational awareness and direct alerts to pilots; however, the avionics to implement such a system did not yet exist.
On March 24, 2022, the NTSB stated that it was encouraged to learn that the FAA was exploring viable and affordable technologies that could directly warn flight crews about potential runway incursions given that ASDE-X, ASSC, and runway status light systems might not be practical at all airports. Safety Recommendation A-00-66 remained classified Open—Acceptable Response. On October 13, 2023, the FAA reported that in June 2023 it hosted an industry event to determine how to enhance controller situational awareness of an airport su