NTSB Safety Compass Blog: Recent Episodes
None
By Office of Member J. Todd Inman
One of the primary functions of the National Transportation Safety Board (NTSB) is to advocate for safe transportation practices and for the safety recommendations issued by the Board. At the end of July, NTSB Board Member J. Todd Inman took his first advocacy trip as a Board member to Alaska. Although he had heard about the unique operating landscape that is Alaska, nothing can quite prepare you for gravel runway landings and helping unload 800 lbs of motor oil from the side of a Cessna Caravan.
Member Inman (center), Clint Johnson (left), and Andrew Giacini (right) unloading cargo in Kongiganak, AK.Member Inman, Special Assistant Andrew Giacini, and Confidential Assistant Olivia Marcus visited the NTSB’s Alaska Region office in Anchorage, Alaska, which is the agency’s lead office for investigating aviation accidents in Alaska and Hawaii and contributes to the NTSB’s stakeholder outreach and advocacy efforts.
One thing was clear from the visit—the NTSB’s Alaska Region has exceptional people dedicated to improving aviation safety, with years of aerospace experience and a true desire to be a part of the Alaska and Hawaii communities. The dedicated work of Clint Johnson, Alaska Region Chief, and his team is deeply valued by both the NTSB and the local community, highlighting the need for strong relationships in this unique and expansive state.
On the first day of Member Inman’s arrival in Alaska, two of four investigators from Clint’s team, Stacia Joyce and Mark Ward, launched to Hawaii in response to a fatal helicopter accident off the coast of Kekaha that claimed three lives and required an underwater aircraft recovery effort. As Member Inman realized immediately after coming to the NTSB, the reality of the job is that you are always on call, and the NTSB’s professionals are dedicated to the mission.
Member Inman was grateful for the time he spent with the other two Alaska Region investigators, Millicent Hill and Mitchell Rasmussen, both of whom joined the NTSB with aviation backgrounds and sought out the opportunity to improve aviation safety in Alaska.
The visit to the regional office and the ensuing travel around the region were enlightening, offering a firsthand look at how vital aviation is to the remote and rural areas of Alaska and how Alaskan aviators work to maintain a safe system, even under the most challenging conditions.
Outreach Meetings
Alaska Air Carriers Association, Alaska Airmen’s Association, Congressional Staff, and the Federal Aviation Administration
During the 4 days of the team’s visit to Alaska, they, along with Clint and the Alaska office staff, had an opportunity to meet with Alaska’s aviation stakeholder communities, district staff from Alaska’s congressional offices, and the Federal Aviation Administration’s (FAA’s) Alaska Regional Deputy Administrator.
These conversations underscored the critical role aviation plays in connecting communities across the vast and rugged Alaskan landscape along with the challenges of safe flight in Alaska, and how the NTSB can support safety initiatives in the state. Member Inman wanted to learn about the successes and impediments to the ongoing FAA Alaska Aviation Safety Initiative that was started when he served as chief of staff for the US Department of Transportation (DOT) and stemmed from an NTSB roundtable in September 2019 on Part 135 operations in Alaska and a recommendation the NTSB issued to the FAA in February 2020 to implement a safety-focused working group that would consider Alaska’s safety needs in the FAA’s work.
One of the highlights for the NTSB was unveiling the agency’s new US Civil Aviation Accident Dashboard to the Alaska Air Carrier Association and others. There was widespread agreement that the dashboard could be an extremely valuable tool to display a general overview of accidents while also providing a way to refine the data to analyze Alaska trends or those of specific categories of operators. Everyone was excited to hear about future enhancements that are coming through the NTSB’s Data Technology Modernization Fund.
Member Inman further discussed the agency’s focus on improving our collection, protection, and use of data, as was highlighted in the NTSB’s recent special investigation report, Safety and Industry Data Improvements for Part 135 Operations, and demonstrated by the recent hiring of a chief data officer, Warren Randolph.
A Unique Postal Route Experience
One of the most eye-opening experiences for the team was flying a postal route from Bethel, Alaska, to the villages of Kongiganak (Kong) and Kwigillingok (Kwig). Unlike the image that normally comes to mind of coupons sliding through the door and Amazon packages tucked behind a bush, this journey revealed the vital role that aviation plays in these isolated communities. Here, air carriers are not just delivering letters but essential supplies like medications, food, and motor oil. The stark reality of this reliance on air transport underscored its role in sustaining daily life in the Alaskan Yukon. It also brought to light the significant challenges that come with building and sustaining aviation infrastructure, dealing with dynamic weather conditions, and maintaining situational awareness in the cockpit.
Member Inman (right) and Grant Aviation Pilot and Check Airman, Travis (left).Alaska State Troopers
The NTSB relies on the contributions of many partners and parties, and nowhere is this more evident than in Alaska. Alaska State Troopers maintain and operate a fleet of over 50 aircraft in support of their first responder, search-and-rescue, and other functions. Their mission often includes supporting the NTSB’s investigations. It’s because of partners like these that the NTSB can study accidents, identify causes, and improve safety throughout the transportation system.
Member Inman (right), Alaska State Trooper Pilot and Aviation Program Coordinator Michael Cook (left).In discussing their own operations, the troopers echoed the comments of other stakeholders on the difficulties that come with aviating in such a unique landscape. Member Inman and his staff valued seeing the troopers’ operations and hearing about their regular missions, thanking them for their continued support of the NTSB.
Anchorage International Airport and UPS Operations Member Inman’s team also visited Ted Stevens Anchorage International Airport (ANC), where they observed the airport’s operations and learned about their safety, emergency response, and expansion plans. This visit highlighted how even larger aircraft and infrastructure operators need to mitigate the elevated safety risks in Alaska. Member Inman enjoyed learning more about what it takes for ANC to never close due to snow, as seen in the show “Ice Airport Alaska” (which was just signed for another season— so tune in!).
Member Inman (right), David Hinshaw (bottom left), and Clint Johnson (top left) in UPS’s 747 full-flight simulator.Additionally, UPS showcased its cargo operations at ANC—a base for over 700 UPS pilots—and gave the entire NTSB team the opportunity to experience a “flight” on one of its full-flight 747 simulators that mimics a typical cargo route for their pilots. UPS has two full-motion simulators in Anchorage that are actively used for training 7 days a week. This hands-on experience provided valuable insights into the logistics and challenges of delivering and transferring goods in a region characterized by its harsh weather conditions and serving both international and domestic shippers.
There is More Work to Be Done—Addressing Weather-Related Challenges
A recurring theme throughout the visit was the significant impact of weather on aviation safety in Alaska, particularly the challenges Alaskan aviators face accessing and using reliable weather data in flight planning and while en route. The need for improved usable weather data, advanced equipment, and robust infrastructure and maintenance was evident in every discussion. Improving weather forecasting and related support systems is crucial for making flying safer and more consistent, especially in Alaska’s most remote and hard-to-reach areas.
The time Member Inman and his team spent with the NTSB’s Alaska regional office and so many aviation professionals illustrated Alaskans’ resilience. Member Inman was reassured to see individuals and organizations working tirelessly to keep the state connected and functioning safely. The entire team left with a stronger understanding of the hazards that present themselves to all aviators and a commitment to supporting efforts that improve safety and provide for a way of life in Alaska.
Thank you to everyone who made this first advocacy trip a success and to those working every day in Alaska to continually improve aviation safety. Your efforts are making a difference in the lives of many.
Member Inman (center), Andrew Giacini (left), and Olivia Marcus (right) in Bethel with the
Cessna Caravan they took on the postal route to Kwig and Kong.
By Sophia Peerzada, Safety Advocate
The NTSB published a safety research report in 2022 on micromobility recommending that states begin tracking and collecting data on crashes involving e-scooters and e-bikes. New York was listening. The state’s governor recently signed into law Senate Bill 9419 requiring accidents involving e-scooters and e-bikes to be reported.
In recent years, the use of e-scooters and e-bikes as forms of transportation has skyrocketed across the country. A major finding of our micromobility report was just how little data is available to understand the scope of injuries and fatalities associated with the use of e-scooters and e-bikes.
“We conducted the study to understand the risks associated with micromobility devices and recommend safety improvements,” says Brittany Rawlinson, PhD, who authored the report. “Unfortunately, the popularity of these devices grew so rapidly that crash reporting infrastructure wasn’t prepared to track them.”
Our safety research report made the following recommendations to the states to improve data collection:
- Add e-scooter and e-bike device codes to police crash data and guidance.
- Standardize e-bike-specific coding in injury surveillance data and guidance.
- Collect e-scooter and e-bike trip data to assess injury and fatality risk.
“The best way for our agency to improve the safety of the public’s use of micromobility vehicles is to have comprehensive evidence of the hazards that exist and what increases the risk of those hazards resulting in injuries and fatalities,” says Rawlinson. “We can only do that with better data collection.” New York has passed other laws in recent years that encourage the widespread use of micromobility devices in the state, but the passage of Senate Bill 9419 signals that it’s turning its attention to their safe use on its streets. NTSB’s Advocacy and Government Affairs teams will use this win in New York to continue to encourage other states to follow suit.
In a new episode of our Behind the Scene @NTSB podcast, we talk with Ellen Lee, Project Manager and Brian Bragonier, Investigator, both in the Office of Highway Safety, about the January 29, 2022, multi-vehicle collision in North Las Vegas, Nevada.
The NTSB final report for the investigation we discussed is available on our website.
The recording of the NTSB Board meeting for the investigation is available on our YouTube channel.
To learn more about the Safe System Approach, recordings of each installment of the NTSB Safe System Approach Roundtable series are available on our YouTube channel.
Subscribe to the podcast on Apple Podcasts or your favorite podcast platform.
And find more ways to listen here: https://www.blubrry.com/behind_the_scene_ntsb/
By Anthony Lam, Transportation Safety Specialist, Office of Safety Recommendations and Communications
As the much-anticipated EAA AirVenture Oshkosh 2024 approaches, the NTSB wants to remind all attendees, particularly pilots, to prioritize safety above all else. The unique environment of major fly-in events like AirVenture brings specific challenges that require heightened awareness and preparation. Here are some key safety topics every pilot should prioritize to ensure a safe and enjoyable event.
Preflight Preparation
Ensure your aircraft is in top condition. Conduct thorough preflight inspections and address any maintenance issues well before departure. Plan your route meticulously, considering alternate airports and contingencies. Be familiar with the airspace, arrival, and departure procedures specific to Oshkosh. Check out EAA’s “Flying In” resources guide to help plan your arrival.
Reviewing NOTAMs
Federal Aviation Administration (FAA) notices to airmen (NOTAMs) for fly-in events contain essential information on operational procedures, arrival and departure routes, and communication protocols. Thoroughly review and understand these NOTAMs, including the 32-page AirVenture 2024 NOTAM, before your flight. This knowledge is crucial to navigating the event’s unique operational environment safely.
Physical and Mental Preparedness for Dynamic Environments
Fly-in events can create pressure for pilots to perform, sometimes leading to decisions outside their comfort zones. Be mentally prepared for a challenging environment and avoid pushing beyond your—or your aircraft’s—limits. If an approach feels unsafe, don’t hesitate to go around. Ensure you are well-rested before the flight. Fatigue can significantly impair judgment and reaction times. Stay hydrated and nourished to maintain optimal cognitive and physical performance during the flight.
Environmental Awareness
Stay updated on weather conditions ahead of time. Be prepared to delay, alter your arrival or departure, or even cancel your fly-in plans if weather conditions deteriorate past your comfort zone. There will always be another fly-in event.
Radio Discipline
With the high density of air traffic, maintaining radio discipline is essential. Monitor the published frequency well in advance, and remember acknowledgement of air traffic control (ATC) instructions is done by rocking of the wings. If you absolutely need to use the radio, keep communications clear and concise. Listen to ATC communications from prior EAA AirVenture Oshkosh events from publicly available sources like YouTube to know what to expect. These can help alleviate communications congestion and ensure that critical instructions from ATC are heard and understood by all pilots in the area.
Runway Separation and Working with ATC
Fly-in events allow for reduced runway separation standards, sometimes as little as 1,500 feet between aircraft. This, combined with minimized radio communications and shared control of arrival and departure aircraft, requires pilots to be extra vigilant. Keep radio traffic to a minimum, follow ATC instructions precisely, and be prepared for dynamic changes. If at any point you are unsure or uncomfortable with an instruction, communicate this to ATC and prioritize flying your aircraft safely. If uncomfortable with any ATC instructions, remember it is safer to execute a go-around than to risk an accident.
Briefing Passengers
Ensure that all passengers are aware of what to expect during the flight, particularly during arrival and departure. Involve them in safety by asking them to help watch for other aircraft. This not only increases overall safety with extra pairs of eyes but also helps keep everyone engaged and informed.
Stall/Spin Awareness
High-density traffic and special flight procedures can increase the risk of stall/spin accidents. These incidents often occur when pilots are focused on complying with ATC instructions and lose control of their aircraft. To prevent stalls, avoid flying too slowly, using excessive bank angles, or overshooting the runway during turns from downwind to base leg or from base leg to final. Regularly practice slow flight, go-arounds, short-field landings, and stall recovery techniques with a qualified instructor to stay sharp. Remember, the priorities are clear: aviate, navigate, communicate.
Knowing Your Limitations
Understand both your personal and your aircraft’s limitations. Practice key maneuvers before the event to build confidence and proficiency. Use flight simulators to practice arrivals, departures, and emergency procedures in a controlled environment to stay mentally prepared. Recognizing your limits and preparing accordingly can prevent accidents caused by overextending capabilities.
Postflight Review
After your flight, conduct a debriefing to evaluate what went well and what could be improved. Share your experiences with fellow pilots to collectively enhance safety practices.
EAA AirVenture Oshkosh 2024 promises to be an exciting event for aviation enthusiasts and pilots alike. By staying vigilant and prioritizing safety, you can help ensure that this event is memorable for all the right reasons. The NTSB encourages all attendees who are flying in to review these safety reminders and enjoy a safe and successful AirVenture experience.
For more information on staying safe during your upcoming AirVenture fly-in, explore the following additional resources:
- NTSB Safety Alert SA-053 – Arriving at a Major Fly-in Event?
- NTSB’s Aviation Investigation Search
- NTSB’s Accident Docket Search
Sophia Peerzada, Safety Advocate
May is National Bicycle Safety Month. For some, bicycling is a primary mode of transportation. For others, it may be a hobby or simply a way of getting outdoors and moving their bodies. No matter the case, all bicyclists should feel safe riding around their communities.
Unfortunately, many of the statistics surrounding bicycle safety in the United States are dire. According to the National Safety Council, more than 850 bicyclists were killed in motor-vehicle crashes in 2021.
My home state of Florida has led the nation in bicyclist deaths for the last 5 years. To put it into perspective, 197 bicyclists died in crashes on Florida roadways in 2021. This means that roughly 23 percent—more than 1 in 5—of the nation’s bicyclist fatalities occurred in Florida that year. These numbers continue to rise as estimates from the Florida Highway Safety and Motor Vehicles department show that 227 bicyclists died and an additional 7,897 were injured as a result of crashes in 2023.
As a lifelong Floridian, I know too well how commonplace it is for a simple bike ride to turn into a trip to the emergency room. My brother, who, incidentally, is an urban planner concerned with roadway safety, still lives in Florida and is an avid bicyclist. Knowing the statistics both nationwide and statewide, of course, I worry about his safety. At the same time, though, I am hopeful that positive change in bicycle safety is imminent.
The data gives us a clear understanding of the risk factors most often associated with bicycle crashes. According to the National Highway Traffic Safety Administration, roadway location, land use, vehicle type, lighting conditions, and time of day all play a role in fatality rates. Safety advocates everywhere, from the federal to hyperlocal level, are using this information to champion bicycle safety improvements across the United States.
For example, the Washington Area Bicyclist Association is a Washington, DC-based organization that focuses on empowering bicyclists and holds regular events promoting bike safety at the local level. I had the pleasure of attending the organization’s “walk & learn” event in March. The 1-mile route showcased some of DC’s bicyclist infrastructure while “quizzing” attendees on local traffic laws. Educational events like these go a long way in promoting bicycle safety through tangible experiences.
Furthermore, as a safety advocate with the National Transportation Safety Board (NTSB), I get a firsthand look at the work being done at the federal level to improve bicycle safety. In 2019, we published a safety research report, titled Bicyclist Safety on US Roadways: Crash Risks and Countermeasures, which highlights safety issues, presents findings, and lists safety recommendations that would mitigate bicycle crashes.
Bicycle safety is part of the larger Vision Zero movement, which is “a strategy to eliminate all traffic fatalities and severe injuries, while increasing safe, healthy, equitable mobility for all.” The NTSB is a strong proponent of the Safe System Approach as a means of achieving Vision Zero, and Chair Jennifer Homendy has hosted a series of virtual roundtables on the topic.
Bicyclists everywhere have the right to feel safe in their communities, no matter their reason for bicycling. We have the stories and data to advocate for necessary change, and we must continue to push for safer roads until we reach zero fatalities and injuries.
Anthony Lam, NTSB Transportation Safety Specialist, Office of Safety Recommendations and Communications
Have you considered the strategies, tactics, and tools you use to connect with Asian American and Native Hawaiian/Pacific Islander (AANHPI) communities? Are your messages effectively reaching your target audiences? The NTSB recently hosted a webinar in celebration of AANHPI Month, featuring five expert panelists that each shared specific insights related to reaching AANHPI audiences. The session explored challenges like addressing the inherent differences in communication styles and community interactions within Asian communities. Here are highlights from each of the speakers.
Leah Reish, MPH, CPH, CPST, Traffic Safety Data Analyst, NHTSA
Leah Reish, a traffic safety data analyst at the National Highway Traffic Safety Administration (NHTSA), presented updated race and ethnicity data concerning traffic safety from 2017 to 2021. Her analysis covered occupant and nonoccupant fatalities and behavioral factors, like alcohol impairment and speeding. She also provided insights into restraint use. Reish highlighted variations in fatality rates among different ethnic groups, emphasizing the need for targeted safety measures and thorough data collection to address specific community needs.
Adam Ungson, Communications Specialist, Multicultural, ICF NEXT
Adam Ungson, Multicultural Communications Specialist with ICF NEXT, discussed diversity within Asian American communities, stressing that the demographic encompasses a vast range of cultures, languages, and socioeconomic statuses. He shared strategies for effective communication, emphasizing the importance of cultural competence, tailored messaging, and using digital platforms familiar to the community. Ungson also warned against stereotypes that might affect how safety messages are received.
Marilyn Cachola Lucey, MA, National Director of Community Development for Asian Pacific Islander American Public Affairs
Marilyn Cachola Lucey focused on community engagement and empowerment, detailing how her organization fosters leadership and civic participation among Asian Americans. She argued for culturally sensitive messaging that reflects the community’s values and concerns, advocating for participation in policymaking to ensure that safety messages and programs are effective and inclusive.
C.Y. David Yang, President and Executive Director, AAA Foundation for Traffic Safety
C.Y. David Yang from the AAA Foundation for Traffic Safety shared research on how behavioral changes and technological advancements can improve road safety. He suggested that understanding community-specific behaviors and preferences is crucial for designing effective safety interventions. His talk also covered the impact of community engagement in promoting safety and the importance of culturally relevant messaging.
Anthony Lam, NTSB Transportation Safety Specialist
Drawing from my experiences living in Asia for nearly two decades, I emphasized respect for cultural norms and the use of relevant media platforms to engage AANHPI communities. I shared insights into generational differences in media consumption and the effectiveness of community-specific interventions. I also talked about my approach to safety messaging, which focuses on cultural respect and leveraging community networks to enhance the impact of safety campaigns. Like my co-presenters, I reiterated the importance of cultural competence and social etiquette for building strong relationships with AANHPI audiences.
To sum up, the webinar provided valuable insights into the unique dynamics of communicating safety messages to AANHPI communities. Each presenter highlighted the importance of culturally tailored approaches that respect and understand the diverse cultural backgrounds within these groups. As we continue to develop and refine our strategies, the key takeaways from this webinar will guide our efforts to enhance safety outreach and ensure that our messages not only reach every segment of this diverse community, but resonate with its members as well. Embracing these principles of engagement will ultimately reduce traffic risks and foster a safer environment for all.
This webinar was part five in our “Communicating and Connecting Safety Messages with Underserved Communities” series, which supports Executive Order 13985: Advancing Racial Equity and Support for Underserved Communities Through the Federal Government. Panelists discussed the challenges these communities have in common and ways to authentically engage with them through safety messaging.
Anthony Lam, NTSB Transportation Safety Specialist, Office of Safety Recommendations and Communications
In a significant move toward enhancing aviation safety, the Federal Aviation Administration (FAA) recently mandated safety management systems (SMSs) for Part 135 operators, Part 91.147 air tour operators, and certain aircraft manufacturers. This ruling comes in response to the pressing need for proactive safety measures in revenue passenger-carrying operations. The NTSB swiftly responded to this development in a recent press release, commending the FAA for its decisive action while also stressing the need for further measures to ensure comprehensive protection for all passengers.
The journey toward this milestone ruling has been marked by the NTSB’s longstanding advocacy for SMS implementation in revenue passenger-carrying operations. The NTSB made its first aviation safety recommendation on SMS in 2007. This recommendation led the FAA to require commercial air carriers (Part 121) to implement an SMS. The agency’s ongoing advocacy for these systems in other revenue passenger-carrying operations is evidenced by six open safety recommendations to the FAA regarding SMS between 2016 and 2022, namely:
- A-16-36: Require all Part 135 operators to establish safety management system programs.
- A-19-28: Require all commercial air tour operators, regardless of their operating rule, to implement a safety management system.
- A-21-13: Require SMSs for the revenue passenger-carrying operations addressed in Safety Recommendations A-21-9 and -10.
- A-21-14: For the revenue passenger-carrying operations addressed in Safety Recommendations A-21-9 and -10, provide ongoing oversight of each operator’s SMS once established.
- A-21-48: Require organizations that design, manufacture, and maintain aircraft to establish a safety management system.
- A-22-15: Develop guidance for small operators for scaling a safety management system that includes methods and techniques for implementation and specific examples applicable to several operational sectors, including air tours.
The NTSB hosted a panel discussion, “Improving the Safety of Part 135 Operations,” in 2020Additionally, NTSB advocacy events and initiatives on SMS, such as our 2020 Part 135 safety panel discussion, 2021 NTSB blog post, and 2023 SMS virtual roundtable on the importance of implementing SMS in small to midsized aviation operations further underscore our dedication to promoting SMS in other aviation sectors. These advocacy events and initiatives, among others, highlight the critical role of proactive safety measures in aviation operations and underscore the NTSB’s dedication to promoting SMS in the aviation sector.
The NTSB hosted a virtual roundtable in 2023 to discuss the importance of implementing SMS in small to midsized aviation operationsThe NTSB’s advocacy efforts, including the aforementioned events and initiatives, have played a crucial role in raising awareness and driving action toward SMS implementation in revenue passenger-carrying operations. These initiatives have paved the way for the FAA’s recent mandate, demonstrating the power of collaborative efforts in advancing aviation safety standards.
As we celebrate this milestone, it is imperative to acknowledge the collective efforts of all stakeholders involved. Moving forward, continued collaboration and proactive measures will be essential to addressing evolving risks and ensuring the comprehensive protection of passengers and crews alike. Together, we will continue to build a safer sky for all.
Anthony Lam, NTSB Transportation Safety Specialist, Office of Safety Recommendations and Communications
Attendees stepped into the world of road safety innovation and collaboration at last week’s Lifesavers Conference 2024 in Denver, Colorado. Each year, experts, advocates, and policymakers convene at Lifesavers to tackle pressing issues shaping the future of safer roadways. From combating impaired driving to ensuring equitable access to cutting-edge vehicle technology, NTSB staff presented and moderated a variety of workshops that offered invaluable insights and strategies for creating a safer tomorrow.
NTSB staff at 2024 Lifesavers Conference exhibit boothNTSB Transportation Research Analyst Dr. Ryan Smith’s presentation, “The Oral Fluids Factor: Roadside & Evidential Testing to Reduce Drug-impaired Driving,” shed light on the rising interest in using oral fluid testing in roadside and evidential testing for drug impairment. With the landscape of cannabis legalization evolving and concerns about drugged driving escalating, the timing couldn’t be more crucial. Attendees gained insights into the nuances between preliminary and evidential testing, the mechanics of roadside testing, and the outcomes from states already implementing oral fluid testing. Discussions encompassed emerging challenges such as detecting novel drugs, ongoing research, and legal hurdles faced by states.
In 2022, we released a safety research report titled, Alcohol, Other Drug, and Multiple Drug Use Among Drivers, which found oral fluid is a valuable—but underused—biological specimen for detecting drug use by drivers. The report also recommended states modify their impaired-driving laws, if they have not already, to allow for oral fluid drug testing. Smith pointed this out in his presentation, adding, “It [oral fluid testing] can play a key role in supporting the enforcement of impaired-driving laws.”
Dr. Ryan Smith, Transportation Research Analyst, Office of Research and EngineeringSmith also organized and moderated the session, “Brave New World in Cannabis Detection,” which brought together leading-edge researchers in the field of cannabis detection. Cannabis impairment is a critical issue, and researchers discussed novel ways that cannabis use can be detected in drivers. In his opening remarks, Smith stated: “More than half of the US population now lives in a state where cannabis has been legalized. Recent NTSB research demonstrates the high prevalence of cannabis use among drivers, second in prevalence only to alcohol. Effective methods for detecting signs of cannabis impairment are critical for getting impaired drivers off our nation’s roadways.”
NTSB Office of Highway Safety Program Manager Ellen Lee gave a presentation on the dangers of speeding titled, “Not so Fast & Furious – Channeling Our Energy to Prevent Speed-related Fatalities,” which highlighted the urgent need to address speed-related fatalities through a comprehensive approach. Lee talked about the NTSB’s recent recommendations from our investigation of a crash in North Las Vegas, Nevada, where speeding and speeding recidivism were key.
Ellen Lee, Program Manager, Office of Highway SafetyLee emphasized our findings that the driver in the crash was impaired and had received seven recent speeding offenses in the 5 years before the crash. “Despite repeated law enforcement actions, the driver’s record was inaccurate (showing only one speeding violation) and local courts treated this driver as a new offender for each violation,” Lee said.
Drawing from NTSB crash investigations and real-world examples, attendees learned about effective countermeasures and community engagement strategies. From leveraging data insights to advocating for vehicle safety technologies and infrastructure enhancements, the workshop underscored the importance of collaboration to curb excessive speed and protect lives on the road.
NTSB Safety Advocate Leah Walton moderated a thought-provoking discussion in her session, “A Safe System Approach to Address Impaired Driving” exploring where and how impaired driving fits into the five pillars of the Safe System Approach. Walton and her panel explored the multifaceted challenges posed by impaired driving, particularly concerning polysubstance impairment. Attendees gained a deeper understanding of the prevalence and risks associated with this behavior, along with potential policy interventions and enforcement strategies.
Leah Walton, Safety Advocate, Office of Safety Recommendations and CommunicationsIn Walton’s opening remarks, she emphasized, “We cannot have a safe system while impaired driving is killing over 13,000 people a year. To achieve zero fatalities, we must expand our view of impaired-driving prevention through the Safe System lens.” With an emphasis on partnership-building at both the state and national levels, the workshop provided a roadmap for stakeholders to tackle impaired driving head-on and enhance road safety.
Stephanie Shaw, NTSB Management Analysis Officer, moderated the session, “Safety for All: How Vehicle Technology Addresses Underserved Populations.” Exploring design considerations, benefits, and challenges, attendees learned ways to extend these advancements to underserved populations. Shaw emphasized the importance of building a system that guarantees safe transportation for all who use it, regardless of socioeconomic status or mode of travel, whether it be personal vehicle, bike, walking, rolling, hailing a rideshare or an autonomous shuttle service, or taking public transportation. This sentiment encapsulated the overarching theme of inclusivity and accessibility discussed throughout the workshop.
Stephanie Shaw, Management Analysis Officer, Office of Railroad, Pipeline, and Hazardous Materials InvestigationsThe Lifesavers Conference serves as a catalyst for meaningful dialogue and collaboration in advancing road safety initiatives. By harnessing innovation, data-driven approaches, and community engagement, attendees are empowered to drive tangible change and create safer roads for everyone. We hope to continue these important dialogues at next year’s Lifesavers Conference in Long Beach, California!
By Sophia Peerzada, Safety Advocate
On March 28th, I moderated a webinar titled “Traffic Safety Through a Public Health Lens.” This joint effort between the NTSB and the American Public Health Association (APHA) ahead of National Public Health Week highlighted traffic safety as a public health issue.
This topic is very important to me as a transportation safety advocate with a degree in public health. When I was studying for my Master of Public Health degree at the University of South Florida, I was the only student in my program (that I knew of) who was interested in traffic safety. I was motivated by the Tampa Bay region’s regrettably high rates of traffic-related fatalities, and the perceptible imbalance of safety interventions along socioeconomic lines. I also knew the statistics nationwide: each year, 43,000 people die on US roadways. I thought, of course this is a public health issue—people are getting hurt and dying on our roads each day!
Since joining the NTSB in November 2023, I have had the pleasure of meeting folks who bring a public health mindset to transportation safety. In fact, the NTSB itself plays a significant role in public health by identifying transportation safety issues and issuing recommendations to make travel safer for the public.
Prior to the webinar, I connected with former NTSB Vice Chair T. Bella Dinh-Zarr, who notably referred to traffic fatalities as an “epidemic on wheels.” Of course, I was thrilled when Dr. Dinh-Zarr and public health colleagues Dr. Kathleen Carlson, Dr. David Ederer, and Dr. Mighty Fine agreed to be panelists on this first-of-its-kind webinar.
Each panelist brought an invaluable perspective to the conversation.
Dr. Carlson, a professor of epidemiology at the Oregon Health and Science University-Portland State University School of Public Health and core investigator at the Portland VA, opened the event with a review of injury epidemiology. She explained that “public health takes a scientific approach to a public health problem” as it seeks to identify the problem’s cause and develop strategies for preventing it from happening again.
Dr. Ederer, an epidemiologist at the CDC’s Physical Activity and Health Branch, followed with a presentation on the Safe Systems Pyramid and how public health principles can be applied to engineering. His presentation underscored the need to apply traffic safety interventions systematically to improve population health.
Dr. Dinh-Zarr, Senior Advisor at FIA Foundation and the Traffic Injury Research Foundation, built upon Dr. Carlson’s and Dr. Ederer’s presentations by providing concrete examples of how the public health lens has been applied to traffic safety efforts. She highlighted the NTSB’s investigation process as an example of taking a public health approach to preventing the recurrence of traffic-related injuries and fatalities.
Finally, Dr. Fine, associate executive director of the APHA’s Division of Public Health Policy & Practice, rounded out the panel by emphasizing the need to apply a health equity perspective to all traffic safety efforts. He urged traffic safety practitioners to ensure that interventions are inclusive, accessible, and culturally relevant.
Overall, it was a wonderful and much-needed discussion that I am certain each attendee walked away from having learned something new. Dr. Ederer said it best in his presentation: “Public health is a way of describing and solving problems.” Given that, I think all of us in the traffic safety space are public health practitioners.
You can view the full webinar recording here: https://youtu.be/DMNxSFNANeI?si=FDR2BhF6vZXdJDut..
By NTSB Safety Advocacy Division
Last week, NTSB Board Member Thomas Chapman and agency staff spoke at the Safe Mobility Conference, hosted by the AAA Foundation for Traffic Safety in collaboration with the University of North Carolina Chapel Hill. Attendees came from throughout government, industry, academia, the research community, advocacy, and other key stakeholder groups. Students and professionals alike were welcome.
The NTSB delegation discussed the agency’s investigations, recommendations, and experiences advocating for traffic safety improvements. In the closing plenary, Member Chapman capped off the NTSB’s presentations, discussing how to learn from NTSB investigations to turn the vision of zero traffic deaths into reality.
Amplifying Victims’ VoicesNTSB Chief of Safety Advocacy Nicholas Worrell set the tone with opening remarks, and Dr. Ryan Smith, of NTSB’s Office of Research and Engineering, led the discussion that followed about incorporating testimonials from victims of traffic crashes into transportation safety campaigns.
Worrell highlighted successes from both the aviation and road safety worlds, and Smith encouraged victim advocates and researchers to explore how the advocacy and research communities can more effectively work together to improve transportation safety. Both focused on the role and importance of firsthand stories in raising awareness, creating political will and public demand for change, and changing driver behavior.
Safe Speeds for a Safe Transportation SystemNTSB Senior Advisor Ivan Cheung updated conference attendees regarding progress on safety recommendations issued from our 2017 speeding report. Speeding is about as prevalent as alcohol in fatal crashes, and the NTSB is committed to finding solutions.
“Speeding increases the likelihood of being involved in a crash and intensifies the severity of injuries sustained by all road users in a crash. Slow down—your life or the life of your loved ones depend on it, the lives of shared road users depends on it,” Cheung told attendees.
Building a Healthy Traffic Safety CultureNTSB Safety Advocate Bryan Delaney presented on engaging youth and teen drivers in roadway safety. Delaney explained the role of mentorship and advocacy in bringing youth into traffic safety initiatives and creating a positive youth traffic safety culture.
“Engaging youth and teen drivers in traffic safety efforts will increase the effectiveness of interventions,” Delaney said. “Put youth at the head of the table, not in the seat to the side, and they engage. Empowerment leads to ownership.”
Member Chapman: Moving from Vision to RealityDuring the closing plenary, Member Thomas Chapman discussed NTSB investigations, recommendations, and positions. He stressed that attendees could learn from NTSB investigations in all modes to turn the vision of zero traffic deaths into reality.
“I am a big believer in the Safe System approach,” Member Chapman said.
Later, he described new and reiterated NTSB recommendations to the National Highway Traffic Safety Administration (NHTSA) springing from crashes in Avenal, California, and North Las Vegas, Nevada. We called on to NHTSA to:
- require all new vehicles be equipped with passive vehicle-integrated alcohol impairment detection systems and/or advanced driver monitoring systems;
- incentivize adoption of intelligent speed assistance systems that would prevent speed-related crashes;
- require, as standard equipment in all new vehicles, intelligent speed assistance systems that, at a minimum, warn the driver when the vehicle exceeds the speed limit;
- develop guidelines to assist states in implementing pilot intelligent speed assistance interlock programs for high-risk drivers who speed.
The conference boasted 3 interactive workshops and 3 plenary sessions, as well as 8 technical sessions featuring experts in topics such as the Safe System approach, traffic safety culture, and more. Attendees had opportunities to network, as well as to learn from new traffic safety research with a goal of moving the needle on road safety.
By Nicholas Worrell,
Chief, Safety Advocacy Division
NTSB Office of Safety Recommendations and Communications
Recently, members of the Prince George’s County, Maryland, government reached out to the NTSB Safety Advocacy Division to participate in a week of public safety community meetings.
The goal of this countywide listening tour was to learn about constituents’ concerns surrounding public safety and health. County officials called on the NTSB because of our advocacy in road safety and the worrying trends they’ve seen in the county’s road fatalities. In these sessions, community members identified health, human services, and public safety concerns and worked toward solutions.
County Government to Residents: We’re Listening
To gather a diverse perspectives, three events took place over the course of a week. Safety Advocate Leah Walton and I participated as facilitators to capture feedback and lead discussions on traffic safety concerns. Although very similar concerns surfaced in each event, each segment of the county had its own perspective.
Themes that emerged in all sessions were:
- Traffic safety
- Crime
- Youth engagement
- Mental health/homelessness
An NTSB presence helped give the traffic safety topic a seat at the table. Focusing on traffic safety concerns, Leah and I were able to provide a deeper dive into road safety issues. We discussed the road fatality statistics; shared NTSB safety recommendations around setting speeds, distraction, and impaired driving; and directed folks to NTSB.gov for more information. What was great about the sessions is that participants were not only able to share the problem areas in their community, but, through facilitation, they were also able to arrive at insights on several aspects of each issue, like the following:
- Root causes of the problems
- Effects of doing nothing
- Possible solutions
- Outcomes for those solutions
In traffic safety specifically, residents were concerned with:
- Lack of accessible and reliable public transportation
- Speeding
- Lack of enforcement
- Potholes
- Lack of speed cameras
- Lack of driver education
- Distractions
- Accountability
- Road infrastructure
- Impaired driving
Residents expressed concern that if the traffic safety problem wasn’t addressed, fatalities, insurance rates, and economic cost (including lost wages) would all continue to increase. They urged government officials to assess speed cameras and other traffic control devices, improve and repair road infrastructure, increase sobriety checkpoints, and enhance parking enforcement. Residents envisioned these improvements leading to safer citizens, improved mortality rates, and reduced crashes, injuries, and fatalities.
The energized exchanges that occurred during these local listening sessions showed us that the NTSB’s traffic safety concerns align with those of the local community. It was advocacy at its best, and proved the maxim, “All advocacy is local.”
The Advocate’s Takeaway
Advocates know that to connect with the community, to inspire citizens to act as advocates, they must begin by hearing the community’s voice.
To us, this meant that facilitating these sessions was our chance to hear and learn this community’s language. We knew that if we, authentically, put them first, we could not only see the problem through their eyes, but we could also see them as part of the solution. This brought to mind what Nelson Mandela famously said: “If you talk to a man in a language he understands, that goes to his head. If you talk to him in his language, that goes to his heart.”
Through these community events, the NTSB was able to provide valuable information about traffic safety statistics, potential solutions, and behavior changes that the participants could not only implement themselves, but could advocate to their family, friends, neighbors, and other community members. In short, in these sessions, participants became safety messengers as much as community leaders providing feedback to their county leaders.
Ultimately, this is the goal of the NTSB Safety Advocacy team—to inspire behavior change, to improve safety, and to motivate individuals to become community advocates for our recommendations and safety improvements.
Thank you to Councilmember Wanika Fisher, Chair of the County’s Health, Human Services, and Public Safety Committee; Committee Vice Chair Sydney J. Harrison; and County Council Member Calvin S. Hawkins for inviting us to take part in these valuable listening sessions, to learn from and educate citizens, and to help further transportation safety.
In this episode of Behind-the-Scene @NTSB we talk with NTSB Office of Railroad, Pipeline and Hazardous Materials Investigations’ HazMat Branch about their work to improve transportation safety.
To read some of the investigative reports discussed in this episode, visit our webpage.
Subscribe to the podcast on Apple Podcasts, Google Play, Stitcher, or your favorite podcast platform.
And find more ways to listen here: https://www.blubrry.com/behind_the_scene_ntsb/.
By Stephanie Matonek, NTSB Transportation Disaster Assistance Specialist
Today, the third International Day Commemorating Air Crash Victims and their Families, we join with survivors in remembering those they have lost.
Three years ago, the International Civil Aviation Organization (ICAO), in cooperation with the Air Crash Victims’ Families’ Federation International (ACVFFI), designated February 20 the International Day Commemorating Air Crash Victims and Their Families. This observance was established to ensure we never forget about the victims and their families, or the unimaginable journey these families faced in the aftermath of an aviation disaster.
In the United States, the NTSB’s Family Assistance program was established in part by the tireless efforts of survivors and family members advocating for change after experiencing loss and suffering from aviation disasters in the 80s and early 90s. Today, the NTSB’s Transportation Disaster Assistance (TDA) team continues this important work to ensure survivors and families are provided information, resources, and support after a disaster, no matter what mode of transportation it occurs in. Yet the TDA team that is responsible for this program cannot do this work alone. Over the decades since the NTSB’s family assistance program began, the partnerships we have made with organizations and agencies from around the world and involved in providing family assistance after transportation disasters have become an integral part of our existence. In fact, our team today is continuously reminded how important and valuable these partnerships are to ensuring we meet the fundamental needs of survivors and families when tragedy strikes.
One partnership in particular has been vital to the NTSB’s family assistance program since its inception: the American Red Cross. At the request of the TDA team, the Red Cross provides direct care and support to hundreds of families and survivors yearly. These efforts can be seen during NTSB public events, through direct requests by those TDA assists, and on-scene at accidents that NTSB investigates.
Today we remember each and every air crash victim we have lost, and their families. And we extend our appreciation to our family assistance partners that help us ensure that those who are affected most, survivors and families, get the care and support they need, no matter where or when a disaster occurs.
In this episode of Behind-the-Scene @NTSB, we talk with staff from the Office of Marine Safety, the Office of Railroad, Pipeline, and Hazardous Materials Investigations, and the Office of Research and Engineering, about the investigation of the 2021 Anchor Strike of Underwater Pipeline and Eventual Crude Oil Release in San Pedro Bay off the coast of Huntington Beach, CA.
For full details on this investigation, including a recording of the Board Meeting, visit our webpage.
Subscribe to the podcast on Apple Podcasts, Google Play, Stitcher, or your favorite podcast platform.
And find more ways to listen here: https://www.blubrry.com/behind_the_scene_ntsb/.
“Yes, And” Approach Also Retains Familiar Excel TablesBy NTSB Safety Advocacy Team
Before reading any further, start exploring this dashboard. Addictive, right? If you care about aviation accidents, the NTSB’s dashboards get the statistics to you in an interactive format that always seems to have another layer to discover.
If you use the NTSB’s static accident spreadsheets in Excel, you can keep using them. But you’re getting less information, with less control, than is available to you through the agency’s data dashboards. Many users grab the same data regularly to populate legacy products, but if you want to see the data from many points of view with more control, check out the data dashboards.
In the new US Civil Aviation Accident Dashboard, for example, you can customize a range of years, see the data on a map, and filter by accident details for Part 121, Part 135, and general aviation (GA) flights. Familiar Excel tables, such as Accidents by Defining Events and Phases of Flight, are still available, but the dashboard lets you further customize the selected data dynamically by operation type, injury level, and state, delivering many more possible data views than the tables provide.
Screen capture of the NTSB US Civil Aviation Summary DashboardHistorically, the NTSB Office of Research and Engineering’s Safety Research Division provided the annual census first as a printed book, and then as an annually updated set of Excel spreadsheets, and now, finally, as a dashboard. Additional GA data is also available in the new format. (And, because it was our first dashboard, the division created a video tutorial providing instructions for working with it.)
“We rolled out the GA dashboard for Oshkosh (EAA Airventure),” says Senior Aviation Accident Analyst Nathan Doble, who made the annual US Civil Aviation data available and interactive in dashboard form. “We recognized that this is a new capability for many of our users, so we wanted to provide training and solicit their feedback.”
Chief Data Scientist Loren Groff adds the team was conscientious about enhancing customer experience. “We took a ‘Yes And . . .’ approach with all of the dashboards. We’ll give you that familiar government document and we’ll also give you the new dashboard version with so much more control by the user.”
“Then there is the state-by-state, monthly breakdown,” Groff explains. “We had a congressional requirement to report accidents in Alaska monthly. The NTSB data analytics team thought, if we’re doing it for Alaska, why not do it for all the states?” (The monthly data are actually updated daily and organized by year and month.)
You can bring up a list of accidents covered in all of the dashboards, which in turn link to accident reports, and plot the accidents on a map. For GA accidents, you can see what types of findings and what recommendations the NTSB has issued in connection with accidents that meet the users’ filters.
Screen capture of the General Aviation (GA) DashboardGroff, Doble, and the Safety Research Division are taking the agency’s accident data from static tables to powerful interactive dashboards defined by the user, and in the process offering increased content and capabilities. Stay tuned as the NTSB’s dashboard capabilities continue to grow.
By Nicholas Worrell, Chief of NTSB Safety Advocacy Division
On November 28, I moderated a discussion at the Pearl-Cohn School in Nashville, Tennessee, during the National Black Caucus of State Legislators (NBCSL’s) 47th Annual Conference Corporate Roundtable (CRT) School Visit. The CRT represents small and large companies, associations, and nonprofit organizations.
The NBCSL is a group of black representatives in state legislatures who are united by their roots in the black community. They work to pass laws that will make life better for all and meet occasionally to ensure that the voices of those in black communities are included in legislative decisions. They also strive to lay steppingstones for the future generations of black leaders. We at the NTSB recognize the significance of equipping and empowering the next generation of leaders.
NBCSL Corporate Roundtable School Visit at Pearl-Cohen High SchoolThe theme of the NBCSL conference was “The Future is Now: Meeting Challenges and Creating Opportunities.”
There is an urgency to the phrase, “The future is now,” and nowhere is that urgency more obvious than in the safety of teens in the face of one of their biggest threats: motor vehicle injuries and death. Their future—potentially spanning so many years—is all too likely to be cut short, now, in traffic violence. Participants were surprised to learn that we lose 43,000 lives on our roads yearly, and that the fatality rate is disproportionately high among both black Americans and teen drivers.
As I told the young people in the audience, their futures are on the line each time they take the wheel, ride as passengers, or even cross the street as pedestrians or share the road as cyclists or motorcyclists. The deadly effect of traffic crashes on teenage lives will only change when our culture around road safety changes.
Driving sober, disconnecting from our phones and other devices, buckling up, and obeying the speed limit are all simple—and safe—practices. However, making the right choice consistently takes integrity (doing the right thing even when nobody is watching). In road safety, knowing the way is not always the hard part. You have to go the way too.
I have long worked with the NBCSL to highlight the NTSB’s many state-level transportation safety recommendations. Our outreach to the NBCSL is in the same spirit as the NTSB’s current webinar series, Reaching Underserved Communities (ntsb.gov): a connection between the affected community and the people who are working on solutions.
NTSB Safety Advocacy Chief Nicholas Worrell moderating the Corporate RoundtableAlthough the day focused on more than just transportation, the students asked intelligent questions, both on how traffic violence affects their community and on how they might parlay a passion for safety into a future career. In addition to making the youth aware of the NTSB and the greater federal government as career destinations, I was able to interact with NBCSL state legislators, the people who make the laws that govern our roads. And I also put in a good word for the NTSB as a workplace to aspire to.
The November 28 program helped each attendee concentrate on their own ability to grow and change the world, rather than focus on the obstacles in their way. To hear that many were interested in working for transportation safety was an additional bonus.
I felt confident that the NBCSL’s conference would motivate young attendees to strive to build the world they want to live in, rising to meet the challenges and eagerly pursuing leadership opportunities. And now that I’ve made them aware of some opportunities at the NTSB, many may consider putting their energy into making transportation safer throughout their communities and the entire country.
By Jeff Marcus, Chief, NTSB Safety Recommendations Division
From the Wright brothers’ first flight on December 17, 1903, to today, aviation has made remarkable progress. The affordability, speed, capacity, comfort, and, most importantly, safety of flight have all improved to the point that flying is one of the safest modes of transportation.
But that safety has been hard won. In honor of National Aviation History Month, let’s reflect on how the aviation industry and Congressional action have evolved to further transportation safety.
The Early Days of Flying
Although most people are familiar with the Wright brothers, who did the research and development that produced the first airplane, many are unfamiliar with other important visionaries, such as Otto Lilienthal and Samuel Langley.
Otto Lilienthal with glider, 1895
Photo credit: Library of CongressKarl Wilhelm “Otto” Lilienthal was a German pioneer of aviation who made the first successful flights with gliders, making the idea of a heavier-than-air machine a reality. His flight attempts in 1891 are seen as the beginning of human flight. Lilienthal made over 2,000 flights in self-designed gliders until his death on August 9, 1896, when he was unable to regain control after his glider stalled. Falling from about 50 ft, he broke his neck and died the next day. At the time of his death, Lilienthal’s total lifetime flying time was about 5 hours. The Wright brothers later cited Lilienthal’s death as the point when their serious interest in flight research began.
Samuel Langley’s Experimental Tandem Biplane on the Potomac River, 1896
Photo credit: Library of CongressAnother early aviation pioneer was Samuel Langley. In addition to being an American aviation innovator, Langley was the third secretary of the Smithsonian Institution. His first aviation success came on May 6, 1896, when his unpiloted, steam-powered, fixed-wing aircraft, weighing 25 pounds, made two flights—one 2,300 ft and the other 3,300 ft—after a catapult launch from a boat on the Potomac River. He followed that on November 11, 1896, with an improved aircraft model that flew more than 5,000 feet. In 1898, based on the success of his models, Langley received grants of $50,000 from the War Department and $20,000 from the Smithsonian to develop a piloted airplane.
Langley gave up on the project after two crashes on take-off on October 7 and December 8, 1903 (just a few days before the Wright brothers’ successful flight). The Smithsonian displayed Langley’s device as the first human-carrying airplane in the world capable of sustained free flight, triggering a decades-long feud with Orville Wright.
The first aviation fatality in a powered aircraft crash came on September 17, 1908, when, during a demonstration flight for the War Department in hopes of getting a military contract for their invention, Orville Wright crashed his aircraft, injured himself, and killed his passenger, Signal Corp Lieutenant Thomas Selfridge.
Lt. Selfridge & Mr. Wright stepping into the Wright airplane at Ft. Myer, 9/17/1908
Photo credit: Library of CongressThe Wright Flyer flew four circles around Fort Myer at an altitude of 150 feet. Halfway through the fifth, the right propeller broke, creating a vibration. The damaged propeller hit a guy-wire bracing the rear vertical rudder. The wire tore out of its fastening allowing the rudder to swivel to the horizontal sending the Flyer into a nosedive.
Wright cut the engine and glided to about 75 feet, but then the aircraft descended nose-down into the ground. Wright and Selfridge were thrown forward, and Selfridge struck one of the wooden uprights of the framework, fracturing the base of his skull. He died 3 hours later without regaining consciousness. Wright suffered severe injuries and was hospitalized for 7 weeks.
Despite the setback, aviation continued to develop worldwide, and on January 1, 1914, the St. Petersburg-Tampa Airboat Line became the world’s first scheduled airline. The airline provided service between St. Petersburg, Florida, and neighboring Tampa—a distance of about 23 miles with a travel time of 23 minutes (compared to 2 hours by boat). A one-way fare was $5.00 (approximately $130 in 2020 dollars), and flights rarely exceeded an altitude of 5 feet. The service terminated on May 5, 1914.
The Birth of Commercial Aviation
During the 1920s, airlines began to offer regular commercial air service. The were 24 fatal commercial airline crashes over 1926 and 1927, 16 in 1928. In 1929, which remains the worst year on record, there were 51 fatal crashes, about 1 for every 1,000,000 miles flown. In today’s world, this rate would result in 7,000 fatal airline accidents per year, or about 20 every day.
Partly in reaction to this accident rate, Congress passed the Air Commerce Act, which President Calvin Coolidge signed into law on May 20, 1926. The act established federal control over civil aviation by making the secretary of commerce responsible for improving air commerce by designating and establishing airways; establishing, operating, and maintaining aids to air navigation (but not airports); sponsoring and conducting research and development to improve such aids; licensing pilots; issuing airworthiness certificates for aircraft and major aircraft components; and investigating accidents.
On March 31, 1931, a Fokker F-10A operated by Transcontinental and Western Air (which evolved to become TWA) crashed near Bazaar, Kansas, after the wooden structure of one wing failed in flight. The crash killed eight people, including Notre Dame football coach Knute Rockne. The investigation found that the wooden wing became moist over time, causing the glue connecting the wing to the body to weaken, allowing the wing to separate. At the time, the investigation was publicly criticized for its secret nature. This crash brought about significant changes in the airplane industry, and was of cultural significance, given the death of Rockne and the public perception of aircraft safety. This accident, which killed a well-known public figure and the secretive nature of the investigation brought public attention to learning from accident investigations to prevent such disasters in the future. The intense public interest forced the Department of Commerce to make the results of aircraft accident investigations more transparent.
The investigation of the Bazaar, Kansas, crash resulted in a public expectation that the US government would objectively investigate crashes and publicly release its findings. In 1934, the Air Commerce Act was amended to require that reports on probable causes of fatal aircraft crashes be made public and banned the use of such reports and related evidence in court proceedings.
On May 6, 1935, a Douglas DC-2 operated by TWA crashed near Atlanta, Missouri. Its pilots were trying to make an emergency landing before their fuel ran out. The crash killed five, including Senator Bronson M. Cutting of New Mexico. Public debate and criticism over the cause of the accident showed the need for an independent investigative body.
Investigators from the Bureau of Air Commerce concluded that several factors led to the crash, including communications malfunctions, darkness, inaccurate weather forecasts, worsening weather at the destination airport, and errors in judgment, both from the airline dispatchers and the flight crew. They also found TWA in violation of several aviation regulations. Senator Cutting’s death drove Congress to investigate the Bureau of Air Commerce’s management of civil aviation. Senator Royal S. Copeland established a special subcommittee that harshly criticized the bureau in a report. Partly as a result, in 1938, President Franklin Roosevelt signed the Civil Aeronautics Act of 1938, which transferred federal responsibilities for nonmilitary aviation from the Bureau of Air Commerce to a new, independent agency: the Civil Aeronautics Authority.
Focus on Safety
On June 30, 1940, the Civil Aeronautic Authority was split into the Civil Aeronautics Administration (CAA) and the Civil Aeronautics Board (CAB). The CAA area of responsibility was air traffic control, safety programs, and airway development. The CAB focused on safety rulemaking, accident investigation, and economic regulation of the airlines.
During the 1950s, airline travel expanded. A midair collision on June 30, 1956, between a TWA Super Constellation and a United Air Lines DC-7 over the Grand Canyon killed all 128 occupants of the two airplanes. The collision occurred while the airliners were flying under visual flight rules in uncongested airspace. The accident showed that, even though US air traffic had more than doubled since the end of World War II, little had been done to expand the air traffic control system or to increase safeguards against midair collisions. This accident led directly to the Federal Aviation Act of 1958, which President Dwight Eisenhower signed on August 23, 1958. The law created the Federal Aviation Agency and led to the creation of the air traffic control system as we know it today.
Air traffic control booth with staff at Washington National Airport, Arlington, Virginia, 1958
Photo credit: Library of CongressOn October 15, 1966, President Lyndon Johnson signed the Department of Transportation (DOT) Act, which created the new cabinet-level department with five major agencies, including the Federal Aviation Administration. The DOT Act also created, within the DOT, an independent National Transportation Safety Board (NTSB) with authority to investigate accidents in all modes of transportation. The new DOT began operations on April 1, 1967.
President Lyndon Johnson signs the Department of Transportation Act
that created the NTSB, 1966
Source: NTSB.govIn 1974, Congress made the NTSB completely independent of the DOT with the Independent Safety Board Act of 1974, which also prohibits the use of any portion of an NTSB report as evidence in a lawsuit related to matters discussed in the report and, with few restrictive exceptions, bars discovery, admittance into evidence, and public release of transcripts or recordings of a “cockpit or surface vehicle . . . voice or video recorder,” if not made public by the NTSB. In 1996, the Aviation Disaster Family Assistance Act expanded the role of the NTSB to include coordinating victim and family assistance following a major aviation accident.
The history of aviation, and the remarkable safety enjoyed today, are the result of the detailed aviation accident investigations throughout the years. And that work continues at the NTSB today, because we know that, from tragedy, we draw knowledge to improve the safety of us all.
Jeff Marcus, Chief of the Safety Recommendations Division, is retiring from federal service on December 29 after 43 years.
By Nicholas Worrell, Chief, NTSB Safety Advocacy Division
Sunday, November 19, is the World Day of Remembrance for Road Traffic Victims. Every year on this day, people around the world honor the memories of crash victims. All of us at the NTSB want to express our condolences to those who have lost loved ones to motor vehicle crashes.
The NTSB works tirelessly to discover the cause of a crash and issue recommendations to prevent future crashes. From tragedy, we identify and advocate for improvements that move us toward a safer transportation system.
It can be said that much of the NTSB’s function is to remember, as we fight for the implementation of our safety recommendations even long after a crash. We remember crashes. We remember the recommendations that stemmed from them. And we never forget recommendations just because they have not yet been acted upon or because too much time has passed.
Similarly, victim advocates–those who have lost loved ones to senseless crashes–are often at the forefront of safety improvements, driven on by the memory of those they lost.
One of the better known and longest-tenured advocacy organizations, Mothers Against Drunk Driving, grew from a mother who lost her daughter to a national movement of victim advocates who support one another and work tirelessly to prevent future impaired-driving tragedies.
The In One Instant Teen Safe Driving Program was founded after a mother escorted her daughter to the funerals of three friends who were killed in car crashes. In One Instant has been implemented in more than 4,000 schools in all 50 states and educates young drivers on the risks associated with distracted, impaired, and reckless driving.
In 2017, the NTSB hosted the Act2End Distracted Driving Roundtable, which gave a voice to victim advocates impacted by distracted driving. Advocates spoke about turning their personal tragedies into effective advocacy efforts to prevent others from going through what they have endured.
It is not unusual for the NTSB to find itself supported by victim advocates in our quest for action on our safety recommendations. This goes beyond NTSB-hosted roundtables and webinars to our testimony in state legislatures about changes to the rules of the road. Why? Because, like the NTSB, these advocates remember, and they will not stop fighting for change until the highway deaths stop.
You don’t have to be personally affected by a crash to mark the World Day of Remembrance in your thoughts and in your actions. This World Day of Remembrance, commit to redoubling your attention to safe driving. To drive distracted, fatigued, or impaired is to forget the danger and impact our decisions can have on families, friends, and our communities.
Remembrance is not only an honorable response to tragedy, but a sacred duty to protect each other from future crashes and loss of life. Before you get behind the wheel, make sure you’re rested and sober. Put the phone away. Don’t speed. Remember that your life, and the lives of others, can be changed irrevocably by just one bad driving decision.
Remember those lost to protect the future of loved ones still with us.
Action Needed Now to Prevent Future Injuries and Accidents
By Jana Price, PhD, NTSB National Resource Specialist
In 2021, the National Transportation Safety Board (NTSB) published a safety research report about preventing turbulence-related injuries. We found that turbulence was involved in more than a third (38%) of Part 121 air carrier accidents between 2009 and 2018. The NTSB report included 24 recommendations aimed at reducing the incidence of turbulence accidents and associated injuries.
The good news for travelers is that wearing a seat belt while flying virtually eliminates the risk of being injured if an airplane experiences turbulence. Our research found that passengers accounted for just 21% of those who were seriously injured due to turbulence, and nearly all of those passengers were unbelted when the turbulence occurred.
When turbulence occurs, it’s usually flight attendants who suffer. Flight attendants accounted for 79% of all seriously injured occupants in the turbulence-related accidents we studied. These injuries often occur as flight attendants prepare the cabin for landing; that is, when the seat belt sign is typically illuminated for passengers. In our 2021 report, the NTSB concluded that having flight attendants seated with their seat belts fastened earlier in the descent phase of flight would reduce the rate of flight attendant injuries due to turbulence (and, consequently, the rate of turbulence-related accidents overall). Our report recommended that the Federal Aviation Administration (FAA) revise the turbulence guidance it provides to airlines, including revisions concerning the phases of flight and associated altitudes at which flight attendants should be secured in their seats. However, 2 years later, the FAA has not yet acted on this recommendation.
The NTSB is not the first to recommend that flight attendants be seated and buckled in altitudes where turbulence risk is higher. More than 20 years ago, the Commercial Aviation Safety Team, a government-industry working group, recommended a policy to remain seated from takeoff to cruise and from 20,000 feet until landing. However, such a policy was never widely adopted, and serious injuries from turbulence under 20,000 feet have continued to occur. Since the NTSB turbulence safety research report was published in August 2021, as shown in the table, there have been 30 air carrier accidents involving turbulence. Reports are completed and publicly available for 11 of those accidents, and more than half of them involve flight attendants who were seriously injured when the airplane experienced turbulence at or below 20,000 feet. The following are examples of these accidents.
Part 121 air carrier accidents involving turbulence between August 2021 and September 2023. See the list of turbulence-related Part 121 air carrier accidents since 2008.* On August 21, 2021, as American Airlines flight 2760 descended to land in Chicago, Illinois, the aircraft encountered turbulence at 7,000 feet. A flight attendant who had been walking through the aisle to prepare for landing fell to her knees because of the turbulence and fractured her kneecap. * On August 19, 2022, as United Airlines flight 1400 descended to land in Columbus, Ohio, the aircraft encountered turbulence at 10,000 feet. A flight attendant in the rear of the aircraft fell and fractured her ankle. * On August 29, 2022, as Delta Air Lines flight 2968 descended to land in Detroit, Michigan, at approximately 20,000 feet, the flight began to experience turbulence. A flight attendant was thrown into a galley counter, fracturing her rib. * On September 1, 2022, as United Airlines flight 1675 descended to land in Denver, Colorado, below 13,000 feet, the aircraft encountered turbulence as the flight attendants were taking their seats. A flight attendant placed her hand on the jump seat to lower it when severe turbulence occurred, causing her to fracture her hand. * On September 4, 2022, as Delta Air Lines flight 673 descended to land in New York City, at 13,000 feet, the aircraft encountered turbulence, which caused a flight attendant to fall and subsequently break her foot. * On November 10, 2022, as American Airlines flight 2548 descended to land in Miami, Florida, at 18,000 feet, the aircraft encountered unexpected turbulence. As a result, a flight attendant in the aft galley was thrown to the floor and fractured her spine. * On February 16, 2023, as Spirit Airlines flight 641 descended to land in New Orleans, Louisiana, at 7,000 feet, the aircraft encountered turbulence. Three flight attendants fell to the floor. One flight attendant fractured her ankle. The other two flight attendants received medical treatment for minor injuries.
In each of these cases, the seat belt sign was illuminated, and the passengers were belted. In some cases, the flight crew knew turbulence was possible during the descent and communicated this to one or more flight attendants, but the flight attendants were not seated in time. In other cases, the turbulence was unexpected. However, in every case described here, if there had been a policy for flight attendants to be seated and belted at 20,000 feet, these serious injuries would likely have been prevented.
Flight attendants spend their careers working to keep us safe. Our 2021 safety research report concluded that asking flight attendants to be seated earlier during the descent phase of flight could reduce serious injuries and accidents related to turbulence. The FAA has not made updating its guidance in this area a priority, but the agency must do so to avoid serious injuries that are entirely preventable.
By Bryan Delaney, NTSB Safety Advocate
Since 2007, Teen Driver Safety Week has emphasized safe driving practices among young drivers and fostered important conversations on the future of teen driver safety.
The National Transportation Safety Board (NTSB) has long advocated for teen and young driver safety. This includes directly encouraging teen drivers to use their seat belts, put their phones away while driving, always drive sober, avoid drowsy driving, limit the number of passengers in the car, and follow the speed limit.
The NTSB also issues recommendations to states to improve their laws, whether specifically for teen drivers (for example, by enacting strong graduated drivers licensing laws) or for all drivers (such as enforcing a .05 g/dL blood alcohol concentration limit and strong seat belt laws).
In addition to teen driver responsibility and changes to laws that will make driving safer for teens, advanced driver safety technologies are shaping the future of teen driver safety.
According to a recent Insurance Institute for Highway Safety (IIHS) study, crash avoidance features and teen-specific vehicle technologies have the potential to prevent or mitigate up to 75% of fatal crashes involving teen drivers. But that potential depends on properly using this technology.
Below is a guide to the functions and safety benefits for collision avoidance technologies that are widely available in vehicles today.
Adaptive Cruise Control: Adaptive Cruise Control helps your vehicle maintain a safe following distance from the vehicle in front of it by automatically adjusting your car’s speed. This technology helps reduce the likelihood of rear-end collisions, a common crash scenario among teen drivers.
Lane-Keeping Assist: Lane-Keeping Assist uses cameras and sensors to monitor lane markings and automatically provide steering assistance to keep the vehicle in the lane.
Forward Collision Warning: Forward Collision Warning systems use sensors to monitor your vehicle’s speed and the speed and distance of the vehicle in front of you and sends alerts of a potential crash.
Automatic Emergency Braking: Automatic Emergency Braking takes Forward Collision Warning to the next level by automatically applying the brakes to avoid or mitigate a crash.
Pedestrian Automatic Emergency Braking:Pedestrian automatic emergency braking systems are designed to initiate an automatic braking sequence to avoid a forward crash with a pedestrian or bicyclist.
Blind Spot Warning: Blind Spot Warning systems alert drivers with visual or haptic warnings during lane changes if a vehicle is detected in an adjacent lane.
Adaptive Headlights:Adaptive Headlights improve lighting to changing roadway conditions, such as a curve, to improve visibility on the road. Because nighttime driving is particularly risky for teen drivers, adaptive headlights can improve driving conditions for inexperienced drivers. As collision avoidance technology becomes more broadly accepted and evolves, getting the best safety benefit from the technology for the newest drivers remains critical to teen driver safety. During Teen Driver Safety Week, we encourage parents and their teens to understand the driver assistance technologies in their vehicles and learn how to properly use them to improve safety.
By Bryan Delaney, NTSB Safety Advocate
NTSB recorder specialist listens to and transcribes audio from a Cockpit Voice Recorder (CVR) in the CVR Listening Room.If you watch the news coverage of a plane crash, you will very likely see investigators wearing the iconic blue jacket with “NTSB” written in bright yellow on the back. On scene, these investigators evaluate the wreckage and locate the flight recorders or “black boxes,” which contain essential information about the accident. Investigators transport the recovered flight recorders, the cockpit voice recorder (CVR) and the flight data recorder (FDR), to the NTSB headquarters in Washington, DC, where engineers use state-of-the-art technology and equipment within our Vehicle Recorder Lab to review the device’s content.
Throughout the year, the Vehicle Recorder Lab receives on average more than 400 electronic devices to examine. The experts within this lab play an important role in determining the probable cause of accidents in all modes of transportation. Most of the devices the Vehicle Recorder Lab receives are not CVRs and FDRs, which are designed to survive and accident, but other electronic devices that are no longer functioning and often require use of our Chip Recovery Lab.
Few get the opportunity to go inside our Vehicle Recorder Lab, see the technology we use, or meet the people behind the scenes whose electronic forensics skills help determine the probable cause of accidents. Let’s take a virtual look inside the lab.
A flight data recorder inserted into the Data Extraction Rack.Arrival to the “Dirty Room”
Once a recorder arrives at NTSB headquarters, engineers take it to the lab’s “Dirty Room,” so called because of the condition of many of the electronic devices that arrive at the lab (damaged and usually covered with debris). First, the condition of the evidence as it arrived in the lab is documented and photographed. Engineers then perform any mechanical work needed to access the internal components of a damaged device. This can involve using cutting wheels, shears, and even hammers and pry bars. The devices are disassembled then transferred to other rooms and labs that have more specialized equipment to conduct closer inspections.
Engineer evaluates an Electronic Flight Information System (EFIS) from a recent crash investigation in the dirty room.Microelectronics Lab
In the Microelectronics Lab, engineers inspect the electronic devices to determine if they contain information that can be downloaded and analyzed, if they require further detailed repair and recovery, or if they are damaged beyond recovery. Sometimes devices arrive relatively undamaged and can be downloaded using a manufacturer’s standard procedure, but often the devices are severely damaged by fire, impact, and/or liquid immersion and are no longer functional. In the Microelectronics Lab, engineers can use methods that include working down to the individual chip level to extract data while minimizing the possibility of data loss.
An active workstation within the Microelectronics Lab used to test
and probe electronic devices.Visual Inspection Microscopes
An initial visual inspection is performed using digital and optical microscopes. The condition of the integrated circuits and other essential electronic components inside each device are evaluated and documented. Engineers identify areas of concern on circuit boards and electronic components such as broken connections, cracked components, or signs of corrosion. Once engineers ensure any damage to the memory chips have been repaired, a transplant of the memory chip can be conducted to a working device, or in some cases, the memory chip can be read directly.
X-Ray & CT Scanner
An x-ray taken from the lab’s x-ray scanner. Here, a microSD card from a device involved in an accident is examined for potential damage.If engineers identify any concerns during the visual examination, they will transfer the memory device to the X-ray scanner to identify any potential internal issues on the memory devices. Under certain circumstances, a computed tomography (CT) scanner is also used to construct a 3D view of the component for further inspection. Once reviewed, engineers use the NTSB’s vast array of chip recovery tools to collect data.
Engineer uses equipment at a work station in the Microelectronics Lab.FDR Laboratory
Once engineers have completed the initial inspection and documentation of the recorders, they bring the device to the FDR lab to process the raw recording into a format that can be used to help understand the circumstances of an accident.
A shelf unit housing nearly every known type
of flight data recorder.
These surrogate recorders are known as “Golden Chassis”.Golden Chassis
A pristine example of nearly every FDR model ever used in modern aircraft can be found in the lab. These “surrogates” are used as a resource and reference when extracting data from heavily damaged recorders. These reference models are referred to in the accident investigation community as “Golden Chassis.” Engineers transfer the physical memory device from the damaged recorder to the golden chassis to facilitate data downloads.
Data Extraction Rack
The data extraction rack powers undamaged or repaired flight recorders and serves as a method to interface with the manufacturer’s software to download data. Each FDR will contain at least 25 hours of parametric data and each CVR will contain 2 hours of cockpit audio for investigators to review and use to help determine what might have happened during a crash.
FDR Recovery
Once an FDR is downloaded, engineers process the raw and extracted data—such as altitude, airspeed, and heading—to engineering data. Engineers then validate and
plot the data, showing a visual representation of the parameters recorded. This can be time consuming as newer aircraft frequently record hundreds, if not over a thousand, parameters. Technical specialists that are parties to the investigation (designated organizations or companies that are invited to assist the NTSB investigation) may assist NTSB recorder lab engineers at this stage.
Engineer inserts surrogate flight data recorder into the Data Extraction Rack.CVR Recovery
The lab has listening rooms to allow investigators and select party members to review the cockpit audio recordings. The recorder specialist and any party members on the CVR audio group review the entire recording and transcribe the pertinent portions of the recording (or the entire recording). By federal law, the original recording is never released by the NTSB and party members participating in the group sign non-disclosure agreements. The CVR audio group produces a transcript of summary of the recording and other investigators will typically work from the transcript or summary.
A recorder specialist reviews recorder audio and transcribes pertinent content in
the CVR Listening Room.In Conclusion
Extracting information from a new or damaged electronic recording device is often an arduous process, requiring superior technical and analytical skills. NTSB Recorder Lab engineers recognize the importance and gravity of their work and strive to provide the most accurate information for investigations. When we know what caused an accident, we can issue recommendations to those who can affect the change needed to make sure a similar accident doesn’t occur again. Retrieving the important recorded information from vehicles involved in a crash allows us to pinpoint issues and to make sure we’re addressing the right safety concerns, to make the best recommendations to improve transportation safety for everyone.
For more information, visit our Office of Research and Engineering page.
A previously released podcast episode featuring staff from the Vehicle Recorders lab is available here.
By Paul Stancil, NTSB Senior Hazardous Materials Accident Investigator
I wonder what Don Ross, the Transportation Safety Board of Canada (TSB) investigator-in-charge, might have said to commemorate the 10th anniversary of the train derailment that occurred in Lac‑Mégantic, Quebec: a tragedy that claimed 47 lives, forced about 2,000 people to evacuate, and destroyed 40 buildings and 53 vehicles. It was my somber privilege to lead a team of NTSB investigators to that devastating accident scene to assist the TSB.
Sadly, Don passed in 2019. But I am certain that he would have expressed gratitude for the dedication and personal sacrifices of his team members who, despite the massive scale of the task before them, organized quickly to get the job done. And I know he’d talk about how the appreciation and trust offered by families of the victims kept them going.
I wish I were visiting the accident scene with my friend Don to reflect on the enormous impact of this event. I’d tell him that he and his team didn’t just set the standard for how investigations of this magnitude should be done; the lessons they uncovered are still saving lives across Canada and the United States.
Lac-Mégantic town center, July 7, 2013. Courtesy: Transportation Safety Board of Canada.What Happened
The events that led to this derailment began on July 5, 2013, at 10:50 p.m. local time, when Montreal, Maine & Atlantic Railway (MMA) freight train MMA-002 enroute from Montréal, Quebec, to Saint John, New Brunswick, Canada, via Brownville Junction, Maine, came to rest at a crew change point near Nantes, Quebec. The track had a descending grade toward the town of Lac-Mégantic. The train was carrying volatile Bakken petroleum crude oil, a flammable liquid, that originated from New Town, North Dakota, destined for an oil refinery in Saint John, New Brunswick. The train was composed of five head-end locomotives, a special‑purpose caboose equipped to remotely control the locomotives, one loaded boxcar used as a buffer car, and 72 DOT-111 general service tank cars.
The train was operated by a single locomotive engineer, who left the lead locomotive idling after setting hand brakes on the locomotive consist and buffer car (seven cars in total). The locomotive engineer reported to the MMA rail traffic controller located in Bangor, Maine, that he had experienced mechanical difficulty with the lead locomotive throughout the trip and excessive smoke was coming from the engine. The engineer and rail traffic controller agreed the condition would likely settle on its own and the performance issues could be dealt with the next morning. The locomotive engineer then departed the area, leaving the idling lead locomotive and train unattended on the mainline track.
About 11:40 p.m., a local resident reported a fire on the idling locomotive. The fire department responded, and the MMA dispatched an employee to assist the fire department personnel. About midnight, the responders activated the emergency fuel cut-off switch to shut down the locomotive and extinguished the fire. The fire department and MMA personnel then departed the location, leaving the train unattended.
With no locomotive running, the air in the train’s brake system slowly began to deplete, resulting in a reduction in the retarding force holding the train in place. Shortly before 1:00 a.m. on July 6, 2013, the unattended train started to move, and it gathered speed, rolling uncontrolled for 7.2 miles down the descending grade into Lac‑Mégantic. The train reached a speed of about 65 mph as it entered the center of Lac‑Mégantic, where 63 loaded crude oil tank cars derailed on a curve and caught fire.
To this day, the Lac-Mégantic derailment remains the worst dangerous goods railroading disaster in Canadian history. At least 60 of the 63 derailed DOT-111 tank cars released about 1.6 million gallons of crude oil. Some of the spilled oil ignited immediately and engulfed the derailed tank cars, resulting in cascading fires and explosions. More than 26,000 gallons of the released crude oil entered Mégantic Lake and the Chaudière River. The fire wasn’t extinguished until around noon on July 7, 2013.
Rail Car Safety at the Forefront
I was preparing for an NTSB investigative hearing on another derailment with hazardous material release when I first learned about Lac‑Mégantic. Before we knew the details, I found myself hoping that the Lac-Mégantic train was not composed of many DOT-111 tank cars.
Based on our own experience with train derailments going back to the 1990s, my NTSB colleagues and I knew that this type of tank car performed poorly in an accident. Between 2007 and 2012, alone, there were several derailments with major flammable liquids releases and fires involving DOT-111 tank cars.
- New Brighton, Pennsylvania: 23 derailed DOT-111 cars lost over 485,000 gallons of denatured ethanol on October 20, 2006.
- Cherry Valley, Illinois: 19 DOT-111 tank cars carrying ethanol derailed on June 19, 2009, killing one person and injuring seven others who were stopped in automobiles at a grade crossing. We concluded that enhanced tank head and shell puncture-resistance systems such as head shields, tank jackets, and increased shell thicknesses could have significantly reduced the severity of the accident.
- Arcadia, Ohio: 33 derailed DOT-111 tank cars released about 786,000 gallons of ethanol on February 6, 2011.
- Tiskilwa, Illinois: 10 DOT-111 tank cars derailed, resulting in fire, energetic rupture of several tank cars, and the release of 162,000 gallons of ethanol on October 7, 2011.
- Columbus, Ohio: Three derailed DOT-111 tank cars released about 53,000 gallons of ethanol on July 11, 2012; one of the derailed tank cars experienced energetic rupture.
- Plevna, Montana: Five of 18 derailed DOT-111 tank cars carrying ethanol caught fire on August 5, 2012, resulting in explosions.
Sadly, the degree of urgency for immediate regulatory action following these accidents was not commensurate with the potential for harm.
Recognizing the growing problem, however, the Association of American Railroads (AAR) Tank Car Committee had begun an effort in July 2009 to improve the accident survivability of DOT-111 tank cars transporting petroleum crude oil, ethanol, and ethanol/gasoline mixtures. Thus, in the absence of any new federal regulatory requirements, builders began producing new “CPC-1232” tank cars that used thicker steel for greater tank head and shell strength.
Several days after the Lac-Mégantic derailment, our worst fears at the NTSB were confirmed: all 63 of the derailed tank cars were DOT‑111s.
An Incredible Partnership
Given our history of safety recommendations citing safety deficiencies in DOT-111 tank cars and our newly acquired ability to laser scan tank cars, the TSB soon reached out to the NTSB to assist in its investigation. That is how I came to lead a team of five NTSB investigators to Lac-Mégantic, where we helped examine the derailed tank cars. A sixth NTSB investigator deployed to the oil shipment’s point of origin in North Dakota.
As a result of our collaborative examination of the derailed tank cars, we found that the train was solely composed of “legacy” DOT‑111s that incorporated basic 1950s technology for general service. The TSB determined that 94% of the derailed cars were breached in some way. Further, more than half of the shell-breaching damages were equal in size to the car’s diameter, which resulted in massive instant loss of product.
NTSB investigators adjust laser scanning equipment next to a damaged tank car in Lac-Mégantic, July 25, 2013.During this investigation, we also discovered that railroads were not required to conduct analyses to ensure safe transport routes for flammable liquids, a requirement that did apply to other high-hazard materials.
Because the MMA had not ensured response resources would be available to remove a potential crude oil discharge of this size, Canadian authorities were left to complete the cleanup. We found a loophole in US federal regulations that established a comprehensive oil spill response planning threshold for a single tank size that was greater than any currently in use. In other words, had this derailment occurred in the United States, the rail carrier’s lack of oil-spill planning would have required the federal government to initiate removal actions using the Oil Spill Liability Trust Fund to pay for the costs.
Finally, the shipper in North Dakota had incorrectly classified the crude oil as a Packing Group III material, meaning it presented the lowest degree of danger in transportation. However, TSB’s testing found that the crude oil should have been assigned to the more hazardous Packing Group II. Not only could misclassification affect the type of tank car used to ship the hazardous material; it also could have affected other safety provisions, such as outage requirements, operational controls, and safety and security planning for the train. The misclassification also could have hampered emergency responders’ ability to correctly understand the hazards associated with a shipment.
Impact on Tank Car Design
In January 2014, the TSB and the NTSB, in unprecedented action, jointly issued safety recommendations to remedy deficiencies that impacted the safety of rail operations both in Canada and the United States. Our recommendations were coordinated in recognition of the cross-border nature of hazardous materials rail shipments. This approach proved to be a call to action for improving the safety of operating freight trains that later came to be known as high-hazard flammable trains. Our combined voice was also beneficial for eliminating confusion about what had to be done.
Within 2 months of the Lac-Mégantic accident, the Pipeline and Hazardous Materials Safety Administration (PHMSA) addressed four of our safety recommendations dealing with improving tank car standards and improving the availability of hazardous materials information to emergency responders.[1] Other freight rail safety improvements soon followed.
- January 2014: Transport Canada proposes a new standard for DOT-111 tank cars that included thicker steel, top fittings protection, and head shields.
- April 2014: Transport Canada orders the least crash-resistant DOT-111 tank cars removed from service; the NTSB holds a Rail Safety Forum on the Transportation of Crude Oil and Ethanol in response to the 16 significant derailments in the United States and Canada which, combined, were responsible for 48 deaths and 281 derailed DOT-111 tank cars that released 2.8 million gallons of crude oil and 2 million gallons of ethanol.
- August 2014: Citing Lac-Mégantic as justification, PHMSA considers a new specification DOT-117 tank car, which, among other things, would be required to have a thicker shell than the CPC-1232 tank car, full head shields, and tank jackets with thermal protection system.[2]
- Early 2015: A spate of fiery derailments fuels public outcry over so-called “bomb trains.”
- April 2015: the NTSB recommends that all new and existing tank cars used to transport flammable liquids be equipped with thermal protection systems and appropriately sized pressure relief devices. We also recommended an aggressive milestone schedule for replacement or retrofitting legacy DOT-111 and CPC-1232 tank cars and a publicly available reporting system for its progress.
- May 2015: PHMSA imposes restrictions on high-hazard flammable trains, ensures proper classification of unrefined petroleum products, and codifies new tank car design standards for DOT-117 tank cars. Transport Canada harmonizes Canadian regulations to reflect the new tank car design standards.
- December 2015: President Obama signs the Fixing America’s Surface Transportation Act of 2015 (FAST Act) into law, which instructs the Secretary of Transportation to make specific regulatory amendments to tank car design standards and establishes a phase-out schedule.
- August 2016: PHMSA codifies the FAST Act mandates by requiring newly manufactured DOT-117 and retrofitted tank cars meeting DOT specification 117R to be equipped with a thermal protection blanket and top fittings protection.
The Work Ahead
According to the latest AAR figures, more than 92,900 tank cars in the North American fleet meet DOT-117 specifications, while about 33,600 total DOT-111 and CPC-1232 tank cars remain to be retrofitted or phased out of flammable liquids service.[3]
As we have watched the flammable liquids fleet transition away from DOT-111 tank cars in recent years, there have been fewer derailments of high-hazard flammable trains. Although declining accident numbers could certainly be due to a significant decrease in petroleum crude oil shipments since 2014, a steady volume of ethanol continues to fill between 300,000 and 400,000 carloads per year.
However, thanks in large part to increased puncture resistance, service equipment protection, and thermal protection systems, there has not been a single death or serious injury, nor a single instance of energetic fireball release or boiling liquid expanding vapor explosion (BLEVE) involving a derailed specification DOT-117 tank car transporting flammable liquids. The Lac-Mégantic investigation has remained the cornerstone for these safety improvements.
Nevertheless, there continue to be incidents and near-misses; more work is needed to improve rail tank car safety. For example, recent derailments have revealed vulnerabilities in the thermal performance of gasket materials, hinged and bolted manways, and service equipment. This includes the following four derailments with hazmat release that the NTSB is currently investigating:
- The January 8, 2022, derailment of a high-hazard flammable train in Oklaunion, Texas, in which 28 derailed DOT-117J tank cars released almost 602,000 gallons of ethanol, largely due thermal damage of manway gaskets and other service equipment.
- The February 3, 2023, train derailment with hazardous material release and fires that occurred in East Palestine, Ohio, in which a mixed freight train derailed 11 tank cars carrying hazardous materials, including three DOT-111 tank cars that were punctured and released flammable and combustible materials that ignited. The resulting thermal damage to other tank cars carrying vinyl chloride prompted a controversial vent-and-burn action that released toxic combustion products into the surrounding community.
- The March 30, 2023, derailment of a mixed freight train in Raymond, Minnesota, including 10 DOT-117J tank cars carrying ethanol, some of which was released from two punctured tank cars and ignited and caused thermal damage to manway gaskets in other tank cars.
- The June 24, 2023, freight train derailment in Reed Point, Montana, in which nine DOT-111 tank cars carrying hazardous materials derailed from a bridge and came to rest in the Yellowstone River, where they released molten sulfur and asphalt petroleum liquid into the river.
Thinking back on those lost in the Lac-Mégantic tragedy, I can’t help but remember something Don once told me: “I think it is fair to say that no one can be fully prepared for this.” That may be true, yet Don and the TSB team more than rose to meet the occasion. And we are all safer for it.
[1] Safety Recommendations R-12-5, R-12-6, R-12-7, and R-07-4 (reiterated).
[2] 79 Federal Register 45016 (August 1, 2014)
[3] North American Flammable Liquid Tank Car Fleet: Status Report, 4th Quarter 2022, (Association of American Railroads, April 2023).
By Dana Schulze, NTSB Managing Director
The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant events in railroad, transit, highway, marine, pipeline, and commercial space. We determine the probable causes of the accidents and events we investigate and issue safety recommendations aimed at preventing future occurrences.
The agency’s investigative and technical staff are recognized for their forensic safety expertise, and with support from the agency’s professional staff, the NTSB is the premier safety investigation organization in the world. In total, the NTSB has conducted more than 153,000 aviation-related investigations and thousands of highway, transit, marine, rail, pipeline, and commercial space investigations, resulting in more than 15,300 safety recommendations. As a result, the NTSB has had a significant and far-reaching impact improving transportation safety for all, with 80% of our recommendations being addressed.
We’ve been getting the job done, even though our budget and workforce has remained relatively flat for the past 20 years. That’s until the 15th Chair of the NTSB, Jennifer Homendy, was sworn in on Aug. 15, 2021.
From her first day, Chair Homendy immediately began implementing her vision of putting mission first, building our agency’s staffing and infrastructure to equip us to better meet the transportation safety challenges we face, including today’s accidents and significant events and those coming in the very near future from emerging technologies like autonomous vehicles and commercial space.
Growing our Workforce
Her first step: fund the agency to grow our workforce. Chair Homendy understood that the agency could not effectively operate with the same number of people that we had in 1997, given the growing complexities of the transportation systems we investigate. Working with leadership across the agency, the Chair secured needed funding increases in fiscal years (FYs) 2022 and 2023, prioritizing recruitment of a diverse and talented workforce, starting with hiring the agency’s first chief human capital officer and supporting a hiring surge.
Under Homendy’s leadership, our workforce has rebounded from an all-time low of 397 employees in August 2019 to its current 419 dedicated professionals. The NTSB workforce is expected to grow to 435 employees by the end of September.
Chair Homendy and Office of Aviation Air Traffic Control TeamChair Homendy routinely swears in new staff as they are welcomed into the agency by our senior leaders. Just this week, the Chair gave the oath of office to a returning NTSB employee joining our Office of Research and Engineering and new members of the Air Traffic Control Team within the Office of Aviation Safety. That division is now fully staffed for the first time in 7 years.
We also have Chair Homendy to thank for successfully asking the Office of Personnel Management to grant us direct-hire authority, which has sped up the hiring process and enabled us to identify and hire the right talent, for the right job, faster.
Getting Up to Speed Quickly
With so many new hires, agency leaders are focused on ensuring all staff have the skills to succeed. Staff now have access to a Career Development Roadmap with a curated list of educational resources in emerging technology, leadership, project management, data analytics, and many other areas critical to our mission success. We’ve developed and launched a multimodal drone program, including new drones and training for drone operators.
We even launched a new mentoring program in 2023 to connect our seasoned veterans with our newest members to help transfer their knowledge, skills, and expertise. We kicked the program off with a speed mentoring event featuring female leaders across the agency during Women’s History Month.
Women’s History Month Mentoring EventWe’re also investing in our infrastructure, prioritizing funding to acquire long-overdue enhanced IT tools and digital capabilities to improve the customer experience of both staff and those seeking information from the NTSB. This will be supported by the $16.2 million Technology Modernization Fund loan recently awarded to our agency, thanks to an agencywide team led by the Office of Chief Information Officer (CIO) in coordination with the Office of Managing Director, the Office of the Chief Financial Officer, and the Office of Human Capital Management and Training.
If you’ve met Jennifer Homendy, you know she’s a people person. She’s always out there building relationships in big and small ways, internally and with external stakeholders. Our recent ice cream social, co-hosted by the agency’s staff-led Diversity and Inclusion Council (“the DIAC”) and my office, is one example of the Chair’s efforts. The social was a great opportunity to break down our organizational silos, help our new staff feel welcome, and assure everyone that we’re all focused on the same core mission, no matter what your role, as part of Team NTSB.
Driving Change with Data
Ensuring our agency leaders have the data they need to make critical decisions, improve our operations, and swiftly answer data calls from Congress and the public has been a top priority for Chair Homendy.
As a result, the NTSB now has a formal Data Program and Data Strategy Plan. We’ve also hired a chief data officer, who will join our agency in early FY 2024. Already, with the help of our chief data scientist and CIO, our data infrastructure has grown to allow staff use dashboards and data visualization tools to help analyze the agency’s work, identify trouble spots and bottlenecks, and make changes to improve efficiency.
The proof of success from our data-driven change and larger workforce is in the numbers. Over the past 2 years, thanks to staff’s incredible work, we’ve reduced our backlog of 442 incomplete investigations over 2 years old to almost zero, and the average time to complete an investigation has decreased across every mode of transportation we investigate. Now, that’s measurable progress!
Rightsizing our Budget
Growth and operational improvements come at a cost—a fact not lost on Chair Homendy. For the past 2 years, the Chair has been on Capitol Hill knocking on doors and speaking to everyone who will listen about why our agency’s budget needs to be rightsized.
She has also spent the past 2 years proving to Congress that this agency is responsive and nimble, and that we’re improving our operational efficiency. All her efforts to grow our staff, reduce our investigation backlog, and better serve and represent our customers are paying off.
For FY 2024, the House Appropriations Committee approved a $145-million budget for our agency. If granted, it would be the first significant NTSB funding increase since the mid-1990s. The new funding has long been needed to continue to grow the agency’s size and capabilities so we can more effectively accomplish our critical safety mission.
We look forward to entering the new fiscal year energized, better staffed, and prepared to meet new challenges, with a new group of NTSB employees ready to join in our critical mission to make transportation safer for all.
By Leah Walton, NTSB Safety Advocate The 2023-2024 school year is upon us, and parents all over the country are preparing to send their students back to school. In the rush to gather back-to-school supplies, it’s easy to lose sight of what “back to school” means at the basic, literal level. Your student is going … Continue reading Back to School – Safely! →
By Vice Chair Bruce Landsberg On July 7 Gov. Mike Parson signed the Siddens Bening Hands Free Law, prohibiting the use of portable electronic devices while driving, making Missouri the 49th state with some form of texting ban. The District of Columbia also bans texting and driving. As the nation battles the rising number of … Continue reading Missouri Bans Texting While Driving, Only Montana Remains →
In this episode of Behind-the-Scene @NTSB, we talk with staff from our Vehicle Recorders Division, in the Office of Research and Engineering, about the work they do to support transportation safety investigations, and how they contribute to the mission of the NTSB. For more information about NTSB job opportunities, visit our webpage. To learn more about … Continue reading EPISODE 55: NTSB VEHICLE RECORDERS DIVISION →
By Chair Jennifer Homendy
NOW is the time to break barriers for women in aviation.
I shared this call to action with lawmakers earlier this month when I testified before the U.S. House of Representatives Committee on Transportation and Infrastructure (T&I) — a body I’m proud to have served for nearly 15 years in my pre-NTSB days.
It was the T&I Committee’s first hearing as it prepares to work on the Federal Aviation Administration (FAA) reauthorization bill. In the words of Chairman Sam Graves, the bill is an unmissable opportunity to enhance “America’s gold standard in aviation safety.”
Make no mistake: the lack of diversity in U.S. aviation is a safety issue, which is why I’m so glad Congressman Rudy Yakym asked me about it.
The State of Women in Aviation
I’m only the fourth woman to serve as NTSB Chair since the agency was established in 1967 — 55 years ago.
Unfortunately, my story isn’t unique; women are underrepresented across transportation in every mode and nearly every job category, especially in roles that tend to pay more, such as upper management and highly technical positions.
Aviation is no exception, where the data are startling: women hold less than 8% of FAA-issued pilot certificates.
Things are improving, but not fast enough. In fact, the share of commercial pilot certificates held by women is increasing at a rate of approximately 1% a DECADE. That’s unacceptably slow progress.
There’s also an unacceptable lack of ethnic and racial diversity among U.S. pilots, 94% of whom are white…and less than 0.5% of whom are Black women.
Other roles in aviation show a similar trend when it comes to gender diversity. Women represent 19.7% of dispatchers, 16.8% of air traffic controllers, 3% of aviation CEOs, and less than 3% of maintenance technicians. I could go on.
The System-Level Change We Need
What’s keeping women out of the control towers, off the tarmac, and everywhere in between — and what can we do about it?
The Women in Aviation Advisory Board (WIAAB) set out to answer these questions. Convened by Congress, the board’s charge was to develop recommendations and strategies to support female students and aviators to pursue a career in aviation.
The board concluded its work last year with a groundbreaking report, whose findings are best understood with an example.
Let’s use a hypothetical young woman who dreams of flying when she grows up.
I’ll call her “Lexi.”
Barriers to Entry
Lexi will face significant barriers to entering aviation at all stages of her life — and they present sooner than you might think.
As one survey revealed, more than half (54%) of women in aviation cited childhood exposure to the field as a positive influence on their decision to pursue an aviation career.
Conversely, 70% of women outside the industry say they never considered aviation. The most common reason they cited? A lack of familiarity with aviation-related opportunities.
In other words, exposing young kids to aviation is a powerful step we can take toward our diversity goals.
That means Lexi is more likely to become a pilot if someone exposes her to it before she’s 10 years old.
As Lexi grows up, society will send her powerful messages about who “belongs” in aviation. The WIAAB report points out, “During the secondary school years (ages 11–18), girls continue to be subjected to gender-limiting stereotypes and face bias and harassment for behaving outside of societal norms.”
Without intervention, repeated exposure to such negative messages can end Lexi’s aviation career before it even begins.
Barriers to Retention
Getting more women to enter aviation is only half the battle; we need to ensure they stay once they get there. Let’s assume Lexi is one of them.
Lexi is now a young adult. She’s completed her studies, graduated at the top of her class, and earned her pilot’s certificate. She’s thrilled to accept an offer to work as a commercial pilot.
At her new job, Lexi quickly makes a group of friends: 9 other women in aviation who defied the odds to be there. They “made it.”
The heartbreaking truth is that 6 of those 10 women will consider leaving aviation before long. Chances are, it’ll include Lexi.
What could possibly force Lexi and five of her colleagues from a job they’ve each dreamed about since childhood…one they worked incredibly hard to get?
In short: implicit bias discrimination, lack of career opportunities, and lack of flexibility and work-life balance. That’s what the WIAAB report shows.
The report also reveals chilling statistics on the prevalence of sexual harassment. Among women in aviation:
- 71% report experiencing sexual harassment at work or in an aviation setting.
- 68% of flight attendants experienced sexual harassment during their flying career.
- 51% who reported or complained about sexual harassment experienced retaliation.
- 62% say sexual harassment remains a significant problem in the aviation industry.
- 81% say they’ve witnessed sexual harassment in the workplace.
It’s not right and it’s not safe — for anyone.
The Safety Implications
Keep these statics in mind. Now, consider this line from NASA’s Safety Culture Model, which was developed following the 1986 Challenger disaster: “No one should ever be afraid to speak up; it could save a life.”
How could a woman like Lexi feel safe speaking up if she’s being harassed at work? And retaliated against for reporting it?
It’s clear that our aviation safety culture is falling short on NASA’s measure.
The Royal Aeronautical Society makes the case succinctly: “Without an inclusive environment, there can be no guarantee of safety.”
Fortunately, the opposite is also true: an inclusive culture can make everyone safer.
That’s why the WIABB recommends interventions like creating an industry-wide reporting system on gender bias. Imagine for just a moment what that could do to attract women to careers in aviation and ensure they stay. It’d be game-changing.
Now imagine ALL 55 of the WIAAB recommendations are implemented — it would transform aviation.
THAT’s how we create a more inclusive aviation culture, one that attracts and retains people from all walks of life…one that makes our skies safer for everyone.
We also need to give credit where it’s due. Many in the aviation industry are taking proactive steps that are also having a tremendous positive effect. For example, several commercial airlines have launched pilot training academies to diversify their applicant pool, efforts that I applaud!
The next step, as I see it, would be for the entire industry and labor to combine efforts. Such an action could supercharge progress toward our diversity goals. It would also allow industry and labor to defray the costs associated with investing in tomorrow’s aviation workforce…an investment from which we all benefit.
A Personal Take
I want a different future for women in aviation. Women like Lexi…whose aviation career, I’ll now admit, isn’t hypothetical.
Lexi is my daughter.
Lexi speaking at the 2022 Women in Aviation International ConferenceThough she’s now 15 years old, Lexi has known for years that she wants to be an aerospace engineer when she grows up. She even spoke about her passion for flying at last year’s Women in Aviation International Conference. I’m incredibly proud of her.
I have no doubt that my daughter will make her aviation dreams come true. And yet, I worry about the culture she’ll encounter once she gets there, and not just because I’m her mom — but because a more inclusive aviation culture will make everyone safer. I also think about the other little girls who never know that aviation is a viable dream in the first place.
Luckily, the Women in Aviation Advisory Board has provided us with a “flight plan for the future,” which gets at the root causes of our diversity problem.
Let’s get to work. Our “gold standard” of aviation safety depends on it.
In this episode of Behind-the-Scene @NTSB we talk with Senior Air Traffic Control Investigator Betty Koschig and Senior Aviation Accident Analyst Allison Diaz in the Office of Aviation Safety, about their work to improve aviation safety and the NTSB’s participation in the upcoming Women in Aviation International conference. Hear more about opportunities to work at the NTSB and our efforts to advance aviation safety and support women in aviation.
For more information about NTSB job opportunities, visit our webpage.
To learn more about NTSB’s Office of Aviation Safety, visit the office’s webpage.
Subscribe to the podcast on Apple Podcasts, Google Play, Stitcher, or your favorite podcast platform.
And find more ways to listen here: https://www.blubrry.com/behind_the_scene_ntsb/
By Elias Kontanis, Chief, Transportation Disaster Assistance Division
Last year, for the first time, the international aviation community observed February 20th as the International Day Commemorating Air Crash Victims and Families. This year, on the second annual observance, we join in reflecting on the lives lost in aviation accidents as well as on the vigilance needed to ensure safety remains the priority in aviation.
As important as it is to commemorate, it is imperative that we also commit—commit to ensuring our programs effectively address the concerns of accident survivors and families and provide the information and support needed after tragedy happens.
The NTSB conducts its investigations with the goal of preventing future accidents. We do this work so that no other families must experience the painful loss or injury of loved ones due to transportation accidents. Our objective is, first and foremost, accident prevention. We maintain a steadfast commitment to this because we believe that the only acceptable number of deaths and serious injuries in all modes of transportation is zero.
With our commitment to transportation safety, we also have a commitment to support families by offering information about the NTSB’s investigative process, addressing their questions about the specific accident investigation involving their loved ones, and offering information about other services that may be available. The NTSB’s family assistance team does this every day, not only for aviation accidents but for all transportation accidents involving fatalities investigated by the NTSB. In 2022, our seven-member team provided support for 868 investigations, interacting with 3,480 accident survivors and family members.
The NTSB’s commitment to supporting transportation accident survivors and their family members is long-standing, spanning over 25 years. In that time, we have established some basic yet enduring principles:
- An independent and transparent safety investigation, with a focus on enhancing safety and not assigning blame or liability, is essential to the success of family assistance. Transparency and honesty fosters confidence.
- Rapport and credibility must be established with family members by communicating realistic expectations about the investigation and other aspects of the response. This includes clearly and appropriately communicating limits to the information and services available.
- A well-designed family assistance plan should be flexible and scalable. Rigid constructs break when they encounter an unanticipated force, but when the plan is flexible, it will bend and spring back to its original form when a stressor is applied.
- The entity responsible for coordinating the response should use a unified command concept of operations, enabling organizations to work together without giving up authority, responsibility, or accountability.
- A comprehensive response requires collaboration from multiple government agencies and nongovernmental organizations. Participating entities should focus on the fundamental concerns of families within the boundaries of their mandate and capabilities.
The International Civil Aviation Organization (ICAO) has spearheaded several initiatives to promote these principles among contracting states (that is, countries) by developing a 3-day course designed to provide governments, aircraft and airport operators, and other stakeholders the foundational knowledge to develop family assistance plans. Most recently, the European Civil Aviation Conference and the ICAO European and North Atlantic Regional Office have also jointly organized a workshop on assistance to aircraft accident victims and their families, which is scheduled for February 20, 2023, in Milan, Italy. This workshop will bring together representatives from several countries, family associations, and other stakeholders to share best practices.
Family assistance needs to be an organizational priority, ingrained in the culture and mindset of an entity engaging in this work. More than regulations, policies, standard operating procedures, or checklists, family assistance is about listening to and learning from those affected by disaster. Ultimately, family assistance is about caring for our fellow human beings and treating them with dignity and compassion, the same way we would expect to be treated when faced with an unexpected injury or loss of a loved one.
We stand with our international colleagues in honor of this solemn day, commemorating the lives lost and the families who faced such unimaginable tragedy, and we will not forget our commitments to them in the work we do.
By James Scheffer, Strategic Advisor, NTSB Office of Marine Safety
It’s been 40 years since the large bulk carrier SS Marine Electric tragically sank on February 12, 1983, off the Virginia coast. Nearly all aboard—31 of 34 souls—were lost. But I remember the events of that tragic day as if they happened yesterday.
On that day, I was the 34-year-old captain of the 661-foot, 34,700-DWT lube oil tanker Tropic Sun, the first vessel to respond to the Marine Electric’s early morning distress call.
On February 11, a nor’easter formed off Cape Hatteras and the Virginia coast. On land, the storm was responsible for a blizzard that set snowfall records in several eastern seaboard cities and blanketed Washington, D.C., in up to 30 inches of snow. At sea, it generated 50–60 knot winds and 30–40-foot seas.
On the evening of February 11, while on the bridge, I heard the Ocean City Coast Guard Station side of a VHF radio telephone call to the Marine Electric. The Coast Guard was acknowledging that the Marine Electric had pumps going and was telling the crew to keep the Coast Guard informed if they needed help.
Meanwhile, the Tropic Sun was rolling, the bow slamming into the swells and seas shipping across the main deck—not unusual conditions for a loaded tanker during a nor’easter. Again and again, water covered the deck; again and again, the deck emerged after each wave. We took that for granted. It was normal in a storm.
I tried—but failed—to get some sleep. The Tropic Sun was three hours from Cape Henlopen, Delaware, and another from our discharge terminal at Marcus Hook, Pennsylvania.
At 0315, the radio telegraph auto alarm went off on the bridge. The SOS was from the Marine Electric, which was taking on water and readying its lifeboats for abandoning ship. The crew needed help as soon as possible.
The Marine Electric was more than 35 miles from us. I changed course and informed the local Coast Guard station that we were responding to the SOS. On our way south to render aid, we saw an unwelcome sight, one that still makes me shake my head: vessels that must have heard the Marine Electric’s SOS sailing in the opposite direction.
When we got within a dozen miles of the Marine Electric’s last position, our hearts sank. There was no sign of the bulk carrier on radar. Before daybreak the sea was full of blinking strobe lights, which we recognized as the lights on lifejackets.
I maneuvered the ship in heavy seas to a full stop alongside more than 20 possible survivors floating in the water around 0540. At the time, the water temperature was 39F with an air temp of 34F. They were unresponsive to our calls in the dark/early morning and eerily peaceful, all dressed in winter gear and lifejackets. By all appearances, the Marine Electric‘s open lifeboats had failed to keep them out of the water and alive.
My own vessel carried the same style of open lifeboat.
The Coast Guard requested that I launch our lifeboats to retrieve the potential survivors, but I refused because of the strong winds and heavy sea conditions. The chief mate and I would not put our crew in harm’s way in the same type of open lifeboats that had so abjectly failed the crew of the Marine Electric. At the request of the Coast Guard, I agreed to stay in the area following a search pattern for any missing crewmembers. The Coast Guard thanked us for our efforts, and we resumed our voyage at dusk on February 12.
Later, while discharging cargo at Marcus Hook, some of the Tropic Sun’s crewmembers discussed buying their own survival suits, but then thought of another solution, which I gladly forwarded to management: a request for survival suits for all onboard. Within two trips (28 days), the vessel was outfitted with survival suits, the first ship to be so outfitted in our eight-ship ocean fleet. These suits, also known as immersion suits, are used without a life jacket when abandoning ship in cold conditions.
On July 18, while the investigation of the sinking was in progress, the NTSB recommended that the Coast Guard require immersion suits be provided for crewmembers, scientific personnel, and industrial workers on vessels that operate in waters below 60°F. The NTSB also made a companion recommendation to Marine Transport Lines, which operated the Marine Electric, as well as to industry groups to recommend their members also provide the suits. The suits became mandatory the following year.
The NTSB determined that the probable cause of the capsizing and sinking of the US bulk carrier Marine Electric was the flooding of several forward compartments as the result of an undetermined structural failure. The lack of thermal protection [survival suits] in the water was one of the factors contributing to the loss of life in the tragedy.
As a result of the Marine Electric’s sinking, the Coast Guard’s inspections improved, and many World War II-era (and older) vessels were scrapped. The Marine Electric tragedy also resulted in the creation of the Coast Guard’s rescue swimmer program.
The Marine Electric as seen underway before its capsizing and sinking on Feb. 12, 1983 (Photo: U.S. Coast Guard)I sailed for over 24 years with the Sun Marine Department, mostly on coastwise voyages on the east and west coast, with the occasional foreign voyage. I sailed as a captain for over 16 years without any casualties or pollution events. The night the Marine Electric was lost served as a constant reminder to me to respect the power of the sea.
Over the past 26-plus years, I have investigated dozens of accidents and supervised more than 200 accident investigations as Chief of Investigations and Chief of Product Development in the Office of Marine Safety at the NTSB. And since then, we have seen the emergence of technologies and innovations that, combined with survival suits, could have helped prevent such tragedies, such as personal locator beacons.
However, I will never forget the night the Marine Electric sank, and neither will the other members of the Tropic Sun’s crew. While events in our lives have sent each of us forward on our separate courses, whenever we meet, our conversations converge on that evening 40 years ago.
This anniversary has passed, but the memory of those 31 mariners will not.
Those of us aboard the Tropic Sun fared far better that night; however, our similarities to the crew that was lost drove home two points about losses at sea. First, if we are telling the story, we are the fortunate ones. And second, nothing is more important than taking fortune out of the equation by making life at sea safer.
By Morgan Turrell, Director of the Office of Marine Safety
New Year’s Eve is a time of celebration and remembrance. Three years ago, on December 31, 2019, as the new year was being rung in across the lower 48 states, a tragedy was playing out in icy Alaskan waters. The fishing vessel Scandies Rose, with seven crew members aboard, encountered severe icing conditions and high winds and waves as it transited from Kodiak to fishing grounds in the Bering Sea. The crabber tried to make it to Sutwik Island to shelter from the storm; however, because of the weight of the topside ice that had accumulated on the vessel and the force of the winds and waves, the Scandies Rose capsized and sank before reaching safety.
Two crewmembers managed to climb out of the capsized ship and swim to a life raft, where they were tossed about for 4 hours in 50‑mph freezing winds and 30-foot seas. Search-and-rescue (SAR) operations, hampered by the poor weather conditions and unsure of the survivors’ location, struggled to find them. Eventually, a Coast Guard helicopter rescued the two crewmembers, but the remaining five were never found.
Our investigation into this accident found that the Scandies Rose’s emergency position indicating radio beacon (EPIRB) failed to provide a position after crewmembers were forced to abandon the vessel. The crew was left without a means of communicating with SAR personnel, who, going off the EPIRB information, were searching in the wrong area. As a result of this situation, we reiterated a 2017 recommendation (M‑17-45) to require mariners to have personal locator beacons (PLBs). This recommendation asks the Coast Guard to require that all personnel employed on vessels in coastal, Great Lakes, and ocean service be provided with a PLB. Unfortunately, this recommendation is still open.
Rescue helicopter search area for Scandies Rose based off position passed in error. (Courtesy: Coast Guard)A PLB is a personal electronic device that transmits a survivor’s location on or in the water to the Search and Rescue Satellite-Aided Tracking system during an emergency. It’s designed to be carried in a person’s life vest (or elsewhere on their body) and manually activated when the wearer is in distress. PLBs continuously update a survivor’s location.
The Scandies Rose is one of several notable marine casualties the NSTB has investigated in the last 5 years involving mariners lost at sea in which PLBs could have made a difference. These casualties highlight the critical safety need for PLBs to aid in SAR operations at sea. We’ve been recommending that all mariners use PLBs since our investigation of the October 2015 sinking of the cargo ship El Faro, which sank in the Atlantic Ocean about 40 nautical miles northeast of Acklins and Crooked Island, Bahamas, after sailing directly into the path of Hurricane Joaquin. The entire crew of 33 aboard perished.
Three days after the El Faro’s sinking, searchers spotted the remains of one El Faro crewmember in an immersion suit. It’s unclear when the crewmember perished or if any other crewmembers were able to abandon ship; however, had that crewmember, or any others who were able to evacuate, been equipped with a PLB, searchers would have had the essential information to focus rescue efforts. We concluded then that equipping all people onboard a vessel with a PLB would enhance their chances of survival, and, in 2017, we issued safety recommendation M-17-45.
Since the sinking of the El Faro and the Scandies Rose, we have investigated two other marine tragedies that continue to highlight the need for PLBs.
- On November 23, 2020, the Coast Guard received a distress signal about 27 miles from Provincetown, Massachusetts, from the EPIRB registered to the Emmy Rose, an 82-foot-long commercial fishing vessel with four crewmembers aboard. The Coast Guard recovered the EPIRB, but none of the crewmembers were located and are presumed dead. The investigation showed that if any crewmembers had been able to evacuate the vessel, they would have been able to survive up to 22.5 hours in the water with an immersion suit. It’s unlikely that the crew had PLBs; however, had they been able to activate a PLB after abandoning the vessel, SAR crews may have been able to find them.
- On April 13, 2021, the liftboat SEACOR Power capsized off the coast of Port Fourchon, Louisiana, in a severe thunderstorm. Six crewmembers were rescued by the Coast Guard and Good Samaritan vessels, and the bodies of six other fatally injured crewmembers were recovered. Seven crewmembers were never found and are presumed dead. None of the survivors rescued had PLBs or similar satellite emergency notification devices (SENDs), which use commercial satellite systems, nor did they know of anyone else on board who did.
Other marine investigations we’ve conducted have shown how PLBs and SENDs, when voluntarily incorporated into marine operations, likely saved lives. For example, our investigation of the November 10, 2021, fire aboard the fishing vessel Blue Dragon found that SAR controllers were able to correlate location data from multiple emergency beacons. Similarly, our investigation of the July 23, 2016, sinking of the commercial fishing vessel Ambition found that use of the vessel’s SEND prompted an immediate response from the commercial response center when the Coast Guard did not receive the captain’s mayday call.
PLBs are now widely available, relatively inexpensive, and remarkably accurate. Models typically cost $300–$400, and most offer GPS location functionality that can provide SAR operations with a continuously updated location of each person to within 300 feet. PLBs can be equipped with an integrated automatic identification system (AIS) “Man Overboard” alert that, in addition to satellite GPS location, transmits AIS signals for local assistance from nearby vessels.
The NTSB has been advocating for PLBs for many years now. The Coast Guard should require them, but the marine industry doesn’t have to—and shouldn’t—wait for a Coast Guard requirement to make PLBs a common piece of safety equipment on commercial vessels.
This New Year, as we reflect on the third anniversary of the tragic Scandies Rose sinking, we ask mariners and marine operations to make it their new year’s resolution to invest in their crews’ safety by providing PLBs. Without a doubt, a PLB can avoid turning an unfortunate accident or incident into a tragedy on the seas.
—————————————–
For more information on our marine casualty investigations, visit our Office of Marine Safety investigative reports webpage. Also, check out these resources on PLB use from the National Oceanic and Atmospheric Administration (NOAA) and the Federal Communications Commission. Note that for any PLB, mariners should read the manufacturer’s instructions for specific guidance on use and register the device with NOAA prior to use.
In a new episode of our Behind the Scene @NTSB podcast, we talk with Meg Sweeney, Project Manager and Shawn Currie, Motor Carrier Factors Investigator, both in the Office of Highway Safety, about the October 27, 2020, collision between a service truck and school bus in Decatur, Tennessee.
The NTSB final report for the investigation we discussed is available on our website.
To learn more about NTSB school bus-related crash investigations visit our School Bus Safety webpage.
To learn more about the Safe System Approach, recordings of each installment of the NTSB Safe System Approach Roundtable series are available on our YouTube channel.
For information about the NTSB Most Wanted List, visit our website.
Subscribe to the podcast on Apple Podcasts, Google Play, Stitcher, or your favorite podcast platform.
And find more ways to listen here: https://www.blubrry.com/behind_the_scene_ntsb/
By Stephanie Shaw, Acting Chief, NTSB Safety Advocacy Division This week, families and friends will gather to celebrate the Thanksgiving holiday. According to estimates from AAA, nearly 55 million people will travel away from home this year, with about 49 million of them taking to the roads. As we mark the beginning of the holiday … Continue reading Prioritizing Safety This Holiday Travel Season →
By Chair Jennifer Homendy 50 million deaths. Hundreds of millions of injuries. That’s the worldwide cost of traffic violence, in human terms. It’s difficult to comprehend fully, which is why the World Day of Remembrance for Road Traffic Victims is so meaningful. This annual observance provides a time to reflect on the real people behind … Continue reading Honor Traffic Victims with Action →
This week is Drowsy Driving Prevention Week. In a new episode of our Behind-the-Scene @NTSB podcast, we talk with Safety Recommendations Division Chief Jeff Marcus, Human Performance Investigator Dennis Collins, and National Resource Specialist Jana Price, Ph.D., about fatigue and NTSB fatigue-related crash investigations. They also discuss NTSB safety recommendations aimed at mitigating fatigue risk … Continue reading Episode 52: Drowsy Driving Prevention Week →
By Bryan Delaney, NTSB Safety Advocate This week is Teen Driver Safety Week, a time dedicated to raising awareness and seeking solutions to prevent teen driving-related deaths and injuries on the road. The NTSB has long advocated for preventive measures that would address the common factors—distractions, fatigue, impairment, speeding, and lack of seat belt use—contributing … Continue reading Teen Driver Safety Week: Keeping The Next Generation Safe on the Roads →
By Leah Walton, NTSB Safety Advocate In the Spring of this year, I attended the Association of Ignition Interlock Program Administrators (AIIPA) Annual Conference, a gathering of about 130 people all committed to eliminating impaired driving. Attendees included state ignition interlock program administrators, ignition interlock manufacturers, researchers, law enforcement, toxicologists, and representatives from the treatment … Continue reading Help Us Reach Zero: Adopt All-offender Ignition Interlock Laws →
In a new episode of our Behind-the-Scene @NTSB podcast, we talk with Morgan Turrell, Director, Office of Marine Safety about the lessons learned from the 2019 Conception disaster. To learn more about the NTSB Conception investigation, and to access the full investigative report and docket, visit our investigation webpage. For more information about the NTSB Most … Continue reading Episode 51: Conception Investigation →
By Chair Jennifer Homendy Three years ago, I launched with the NTSB Go Team to Santa Barbara, California, to investigate the deadliest U.S. marine accident in decades. On September 2, 2019, the Conception dive boat caught fire in the early morning hours, burned to the waterline, and sank less than 100 feet from shore. Tragically, … Continue reading Time for Action: Passenger Vessel Safety Can’t Wait →
In this episode of Behind-the-Scene @NTSB, we celebrate the 50th episode with NTSB Executive Officer Erik Strickland and Safety Advocacy Division Chief Nicholas Worrell to talk about the genesis for the podcast, reflect on the interviews with Board Members and staff since the podcast was launched in 2017, and look to the future as we … Continue reading Episode 50: NTSB Executive Officer Erik Strickland →
By Stephanie Shaw, NTSB Safety Advocate Like many parents, I send my daughter to school on a school bus because I know that it’s the safest way for her to get to and from school. In fact, students are 70 times more likely to get to school safely when taking the school bus than when traveling by … Continue reading Back-to-School Safety: Keeping Children Safe In and Around the School Bus →
In this episode of Behind-the-Scene @NTSB we talk with Tim LeBaron, Director; Kristi Dunks, Acting Deputy Director for Regional Operations; and Aaron Sauer, Senior Air Safety Investigator, in the Office of Aviation Safety, about their work to improve general aviation safety and the NTSB’s participation in the upcoming EAA AirVenture Oshkosh event. Hear more about … Continue reading Episode 49: EAA Air Venture Oshkosh 2022 →
By Lorenda Ward, Chief, NTSB Air Carrier and Space Investigations Division When I read the Chair’s blog, “A Call to Action from Kennedy,” I asked myself, “Are we ready?” Not for commercial space exploration, but for the next commercial space accident investigation. One of my responsibilities as the chief of the NTSB’s Air Carrier and … Continue reading Ready to Answer the Call →
By Jeff Marcus, Chief, NTSB Safety Recommendations Division In many states, when using motorized recreational vessels, or engaging in activities like canoeing, kayaking, and standup paddleboarding, operators are not required to attend a boating safety course, obtain a license or certificate, be familiar with the navigation rules (commonly called the “Rules of the Road”), or … Continue reading Salute to the US Coast Guard’s Persistence in Improving Recreational Boating Safety →
By Nicholas Worrell, Chief, NTSB Safety Advocacy Division On June 25, I had the opportunity to represent the NTSB at the Route 210 “Dignity of Life” Observance in Prince George’s Country, Maryland, where I have spent most of my adult life. Although the observance had tragic roots, it was good to see some attention paid … Continue reading Remembering the Victims of Maryland Route 210 →
By Chair Jennifer Homendy This is the last post in a three-part series examining the safety of vulnerable road users, as new federal data show a rise in traffic deaths among motorcyclists, bicyclists, and pedestrians last year. You can read the first two posts here and here. I just got back from Helsinki, Finland, where … Continue reading Reaching Zero, from Helsinki to Hoboken →
By Nicholas Worrell, Chief, NTSB Safety Advocacy Division The year 2012 seems not so long ago in some ways, but in other ways, it seems like another age. That was the year of the first International Road Federation (IRF) Caribbean Regional Congress during the UN’s Decade of Action on Road Safety. The group focused that … Continue reading Taking Stock: The IRF Caribbean Regional Congress at 10 →
In this episode of Behind-the-Scene @ NTSB, we have a conversation with James Anderson, the Audio Visual Communication Specialist in the NTSB Office of Safety Recommendations and Communications and the Producer of the NTSB podcast. James shares how he got interested in audio and video production, his career path to the NTSB, and some notable projects he’s worked … Continue reading Episode 48: James Anderson →
By Chair Jennifer Homendy This is the second in a three-part series examining the safety of vulnerable road users, as new federal data show a rise in traffic deaths among motorcyclists, bicyclists, and pedestrians last year. Read the first post. I love nearly everything about bicycles, from riding around Virginia to creating art for the … Continue reading We Need to Change the Bike Safety Conversation →
By Chair Jennifer Homendy This is the first in a three-part series examining the safety of vulnerable road users, as new federal data show a rise in traffic deaths among motorcyclists, bicyclists, and pedestrians last year. When it comes to learning, I’m one of those people who doesn’t just want to read about something — … Continue reading Motorcycle Safety Is Everyone’s Responsibility →
By Chair Jennifer Homendy This week, I visited NASA, Boeing, Blue Origin, and Space-X at Kennedy Space Center (KSC) in Florida. KSC has been a leader in space exploration for over 50 years. The Apollo, Skylab, and Space Shuttle programs took off from there, as did the Hubble Space Telescope, the Mars Rover project, and … Continue reading A Call to Action from Kennedy →
By Member Michael Graham Motor vehicle crashes are a leading cause of death for teens. According to the Centers for Disease Control and Prevention, in 2019, approximately 2,400 teens in the United States aged 13–19 died and about 258,000 were injured in motor vehicle crashes. This means that approximately 7 teens died, and hundreds more … Continue reading Collision-Avoidance Technologies Can Improve Safety for Teen Drivers →
By Chair Jennifer Homendy 42,915 16-year high 10.5-percent increase An early estimate, released this week by the National Highway Traffic Safety Administration (NHTSA), shows 42,915 people—117 people per day—died on the nation’s roads last year. I, for one, am outraged by these needless deaths. Those victims are mothers and fathers, children and grandparents, friends, and … Continue reading Where is the Outrage? Road Users Deserve Better →
By Chair Jennifer Homendy The warmer months are here, which means more time outside for many of us, whether for recreation or to tackle home-improvement projects. Personally, I’m looking forward to running in the mornings, biking in the evenings, and spending weekends digging around in my vegetable garden — but not before taking an important … Continue reading ‘Tis the Season…for Safe Digging →
By Vice Chairman Bruce Landsberg Our recent investigation of the fatal Jan. 5, 2020, multivehicle crash near Mt. Pleasant Township, Pennsylvania, determined that excessive speed played a critical factor. This is a recurring theme in too many highway crash investigations. Between 1967 and 2022, the NTSB has investigated over 50 major crashes in which speed … Continue reading Excessive Speed Continues to Take Too Many Lives →
In this episode of Behind-the-Scene @NTSB, Highway Factors Investigator, Dan Walsh discusses the 2020 multi-vehicle crash investigation near Mt. Pleasant Township, PA, and we explore the safety issues and safety recommendations issued as a result of our investigation. The NTSB final report for the Multivehicle Crash Near Mt. PleasantTownship, Pennsylvania, mentioned in this episode is available on … Continue reading Episode 47: Mt. Pleasant Township, PA Crash Investigation →
By Nicholas Worrell, Chief, NTSB Safety Advocacy Division In August, 2019, I wrote that Safe Skies for Africa was ending, but that the safety journey would go on in Africa, the world’s second-largest and second-most-populous continent. Earlier this month, it was my pleasure to represent the NTSB in a presentation about best practices in safety … Continue reading Improving Safety in the Second-Largest Continent →
By Kathryn Catania, Acting Director, NTSB Office of Safety Recommendations and Communications Since the unveiling a year ago of the 2021-2022 cycle of the NTSB’s Most Wanted List of Transportation Safety Improvements, we have seen increased awareness and discussion of safety items, high levels of engagement from the public, and incremental progress toward implementation of … Continue reading The 2021-2022 MWL After One Year: Noticeable Progress But Few Closed Recommendations →
By Nicholas Worrell, Chief, NTSB Safety Advocacy Division More people are dying in crashes since the pandemic began. Deaths on our roads increased from 36,096 in in 2019 to 38,824 in 2020, and to an estimated 31,720 in the first 9 months of 2021, a further 12% increase. At that rate of increase, fatalities will … Continue reading Kicking off National Distracted Driving Awareness Month →
In this episode of Behind-the-Scene @NTSB, Chair Jennifer Homendy reflects on her NTSB journey so far, her transition from Board Member to Chair, and talks about our Most Wanted List of transportation safety improvements, the Safe System Approach, and what she hopes to see accomplished to improve transportation safety as head of the agency. For … Continue reading Episode 46: Chair Jennifer Homendy →
By Leah Walton, NTSB Safety Advocate I was 21 years old in the year 2000 when I started working in the field of impaired driving prevention, specifically underage drinking prevention. I remember some of my colleagues recalling, “Back in my day, the legal drinking age was 18 years old.” I don’t have that recollection – … Continue reading 40 Years Later: The Safety Impact of the 21 Minimum Legal Drinking Age Law →
By Chair Jennifer Homendy Who will be speaking? The Chair? What’s his name? That’s what I overheard a reporter asking an NTSB employee just a few weeks ago. We were in Pittsburgh, where I was on scene for the agency’s investigation into the collapse of the Fern Hollow Bridge. I couldn’t help myself and … Continue reading Reflections on International Women’s Day →
By Leah Read, NTSB Senior Air Safety Investigator “N555$$, call the tower. N555$$ call the tower…your gear isn’t down!” As a newly minted certified flight instructor (CFI) in the early 90s, I loved reading the latest addition of Flight Training magazine. I’ll never forget reading a funny quip about a pilot who was on final … Continue reading BEFORE LANDING CHECKLIST to Pilot: “Remember me?” →
By Nicholas Worrell, Chief, NTSB Safety Advocacy Division Our stoplight system—red for stop, green for go, and yellow for caution—benefits every motorist in the nation. Yet, most people don’t realize that the system was invented by a Black man whose father was formerly enslaved: Garrett Morgan. A largely self-taught inventor and a hard worker, Morgan … Continue reading Black History Month and Transportation Safety →
By Elias Kontanis, Chief, NTSB Transportation Disaster Assistance Division This year, the International Civil Aviation Organization (ICAO) designated February 20 the International Day Commemorating Air Crash Victims and Families. Although ICAO has addressed various aspects of family assistance for decades, this is the first time a day has been set aside to remember and honor … Continue reading February 20: International Day Commemorating Air Crash Victims and Families →
By Member Tom Chapman This year, the Super Bowl will be played on Sunday, February 13th. Like many Americans, I circled the date on my calendar months ago. It’s a special day to enjoy with family and friends. It’s a day to watch the biggest game of the year while indulging in favorite football fare— … Continue reading The Super Bowl—By the Numbers →
By Chair Jennifer Homendy Blue jackets. Devastating scenes. Calm in the wake of tragedy. This is how many people describe their first impressions of NTSB. It’s not surprising given the international visibility of our on-scene work. But today is all about who you don’t see: the folks who make the agency’s headline-grabbing work possible. I’m … Continue reading Recognizing a Quarter Century of 24/7 Response →
By Chair Jennifer Homendy Adapted from i-Chiefs magazine, originally published Feb 2021 Imagine for a moment that you’re an emergency medical services (EMS) worker. You’re assisting a patient who requires transport to another facility. You decide to request a helicopter air ambulance (HAA). How do you pick the safest HAA operator? In a perfect world, … Continue reading How EMS Workers Can Improve Air Ambulance Safety →
By Member Michael Graham Today, the NTSB released a four-part video series: “V2X: Preserving the Future of Connected-Vehicle Technology.” Vehicle-to-everything (V2X) is one of the most promising life-saving technologies available today. While radars and sensors are limited to line-of-sight and are often impeded by inclement weather, V2X technology uses direct communication between vehicles and with … Continue reading NTSB Video Series Highlights Safety Benefits of Connected-Vehicle Technology, Raises Concern about Future of V2X →
By Jeff Marcus, Chief, NTSB Safety Recommendations Division Forty years ago, on Jan. 13, 1982, a Boeing 737 jetliner crashed into Washington, DC’s 14th Street Bridge and plunged into the freezing Potomac River after departing National Airport during a snowstorm. The crash killed 73 of the 79 people aboard the airplane and 4 people in cars on … Continue reading Remembering Air Florida Flight 90 and the Progress Towards Eliminating Airline Icing Accidents →
By Nicholas Worrell, Chief, NTSB Safety Advocacy Division As 2021 ends, it’s time to reflect on the past 12 months and begin to set goals for the year ahead. After all, as Zig Ziglar once said, “if you aim at nothing, you will hit it every time.” So, let us all aim to improve the … Continue reading A New Year’s Resolution We All Can Make: Prioritize Safety →
By Member Tom Chapman Unlike last year when many holiday gatherings were cancelled due to the pandemic, many of us will return to visiting family and attending holiday parties this year. Some may see this as an opportunity for a 2020 do-over and may overindulge on merriment. The holiday season is a time of increased … Continue reading Drive Sober and Save Lives the Holiday Season →
By Bryan Delaney, NTSB Safety Advocate Motor vehicle crashes are a leading cause of death for teens and, for today’s teens, distraction is a major factor in crash risk. According to the National Highway Traffic Safety Administration (NHTSA), dialing a phone number while operating a vehicle increases a teen’s risk of crash by 6 times, … Continue reading Three Key Strategies to Prevent Teen Distracted-Driving Crashes →
By Member Michael Graham In 2015, the Federal Aviation Administration (FAA) required commercial airlines to develop a comprehensive safety management system (SMS) to improve safety for the flying public. An SMS is an organization-wide system that ensures operators are properly identifying, assessing, and mitigating the conditions that exist for an accident to occur. The FAA, … Continue reading Paying Passengers Deserve Safety on All Flights →
By Chair Jennifer Homendy November 21 is the World Day of Remembrance for Road Traffic Victims. It is a day to honor the 1.3 million lives lost each year around the world in motor vehicle crashes. Today, I urge everyone to take a moment to remember all those who have lost loved ones in crashes, … Continue reading World Day of Remembrance for Road Traffic Victims →
In this episode of Behind-the-Scene @ NTSB, we talk with Mike Fox and Steve Prouty, Highway Crash Investigators, Nathan Doble, Transportation Research Analyst and Brittany Rawlinson, Statistician about the 2021-2022 Most Wanted List safety items Implement a Comprehensive Strategy to Eliminate Speeding-Related Crashes and Protect Vulnerable Road Users through a Safe System Approach. For more information about the … Continue reading EPISODE 45: MOST WANTED LIST – VULNERABLE ROAD USERS AND SPEEDING →
By Member Michael Graham Every day more than 2.6 million miles of pipelines across the United States transport enormous volumes of natural gas and liquid petroleum that provide for the nation’s energy needs. These pipelines crisscross the country under our neighborhoods, homes, and businesses. While, statistically, pipelines are the safest method for energy transportation, the … Continue reading Improve Pipeline Leak Detection and Mitigation →
By Bryan Delaney, NTSB Safety Advocate Last month, as part of Teen Driver Safety Week the NTSB held two virtual roundtables to discuss the state of teen driver safety and graduated driver license laws (GDLs). While the dialogue was robust and yielded many critical insights, these events reminded us that one week isn’t enough to … Continue reading A Look Back on Teen Driver Safety Week 2021 →
October 17-23, 2021 was designated by the National Highway Traffic Safety Administration (NHTSA) as Teen Driver Safety Week, a time dedicated to raising awareness of preventive measures that can be taken to eliminate teen injuries and fatalities on American roadways. In this episode of Behind-the-Scene @ NTSB, State and Local Liaison Steve Blackistone, Chief of the … Continue reading EPISODE 44: TEEN DRIVER SAFETY →
By Bryan Delaney, NTSB Safety Advocate For most teens, receiving the car keys for their first trip alone on the road is a ceremonious moment—one that opens their world to freedom of mobility. For parents and guardians, however, this moment can be nerve-wracking. Unfortunately, the anxiety parents and guardians feel is justifiable, as traffic crashes … Continue reading Teen Driver Safety: Education + Action = Positive Change →
By Mike Hodges, Air Safety Investigator, and Clint Crookshanks, Aerospace Engineer (Structures) When an aircraft crashes, National Transportation Safety Board (NTSB) air safety investigators and aerospace engineers must determine if the event can be classified as an accident or an incident, as defined by Title 49 Code of Federal Regulations (CFR) Part 830. An accident … Continue reading Accident or Incident? Explaining Aircraft Damage Assessment →
In this episode of Behind-the-Scene @ NTSB, we talk with Rob Hall, Director, NTSB Office of Railroad, Pipeline and Hazardous Materials Investigations and Railroad Accident Investigators, Tim DePaepe and Joe Gordon, about the 2021-2022 Most Wanted List safety item Improve Rail Worker Safety. To learn more about the NTSB Most Wanted List and the Improve Rail Worker Safety item, … Continue reading Episode 43: Improve Rail Worker Safety →
By Member Tom Chapman The Federal Railroad Administration (FRA) and the railroad industry have recently implemented new protections to make rail passenger travel and hazardous materials transportation safer. That’s great news. However, the NTSB anticipates more accidents involving passengers and the public until our safety recommendations regarding rail worker safety are implemented. Members of train … Continue reading Improve Rail Worker Safety →
By Member Tom Chapman Each year, Operation Lifesaver, Inc., spearheads Rail Safety Week. For 2021, Rail Safety Week runs from September 20 through 26. Operation Lifesaver and its safety partners across North America, including the NTSB, use this annual event to educate and empower the public to make safe decisions around trains and tracks and … Continue reading RAIL SAFETY WEEK 2021 →
By Bryan Delaney, NTSB Safety Advocate Motor vehicle crashes continue to be a leading cause of death for American teens. As new teen drivers are tossed the keys to their first car, it’s important for peers, parents, guardians, and other influential individuals to encourage safe driving habits that will last a lifetime. These habits can … Continue reading Fostering Teen Driver Safety Through Policy, Advocacy and Technology →
By Chair Jennifer Homendy Two years ago today, a preventable tragedy became one of the worst maritime events in US history. At about 3:14 a.m. on September 2, 2019, the U.S. Coast Guard (USCG) received a distress call from the Conception, a 75-foot-long small passenger vessel operated by Truth Aquatics, Inc. The Labor Day fire … Continue reading Two-years Later: Conception Tragedy Still a Reminder that More Should Be Done to Improve Passenger Vessel Safety →
By Jeff Marcus, Chief, NTSB Safety Recommendations Division Fifteen years ago today, on August 27, 2006, Comair flight 5191, a Bombardier CL-600-2B19, lined up on the wrong runway and crashed during takeoff from Blue Grass Airport, Lexington, Kentucky (LEX), killing 49 people, including the captain and flight attendant. The first officer, who was seriously injured, … Continue reading Comair 5191 Crash Led to Air Traffic Control Changes →
In this episode of Behind-the-Scene @NTSB, NTSB Managing Director, Sharon Bryson and Frank Hilldrup, Chief Technical Advisor for International Affairs, NTSB Office of Aviation Safety, talk about the July 17, 1996, TWA flight 800 accident. We discuss what happened, the findings and safety recommendations that came out of the investigation, its tremendous impact on aviation … Continue reading Episode 42: TWA Flight 800 →
By Member Michael Graham Motor vehicle crashes are a leading cause of death and injuries in the United States. Early estimates for 2020 show that more than 38,000 people lost their lives in traffic crashes on our nation’s roads. These preventable tragedies are often due to driver mistakes and poor decisions—speeding or driving while impaired, … Continue reading It’s Time to Require Collision-Avoidance and Connected-Vehicle Technologies on all Vehicles →
By Stephanie Shaw, NTSB Safety Advocate As parents, caregivers, teachers, school administrators, and school transportation safety professionals prepare for the return to school the health and safety of our children is the highest priority. This school year, back to school preparation for our children looks very different and it’s easy to forget about transportation safety … Continue reading Back-to-School Transportation Safety →
By Acting Chairman Bruce Landsberg Most people are familiar with the nightly news image of NTSB investigators at the scene of an accident, searching for the “black (orange) box.” The flight data recorder (FDR), which records aircraft control inputs and operational conditions, and the cockpit voice recorder (CVR), which records pilot conversations, are at the … Continue reading Accident Data for Investigations, Routine Flight Data for Prevention →
By Acting Chairman Bruce Landsberg There was once a saying in the news media business to “get it first, get it right, but first get it right.” The NTSB strives to get it right above all, but we recognize that timeliness is essential, too. One of my goals even before joining the Board was to … Continue reading Get it Right: Addressing the Timeliness of NTSB Investigations →
By Leah Walton, NTSB Safety Advocate Twenty years ago, in the summer of 2001, I began my work to end alcohol-impaired driving at the Minnesota State Office of Mothers Against Drunk Driving. Over these 20 years, although so much has changed and there’s much to celebrate, we still have so much work to do. What … Continue reading Preventing Alcohol-Impaired Driving: We All Are Part of the Solution →
By Chairman Robert L. Sumwalt I guess it all started on an overcast day in 1973, when I found myself on the scene of a fatal aviation crash for the first time. I had heard of the crash on my car radio, and, as a curious 17‑year-old, I decided to find the crash location. Once … Continue reading I Lived My Dream: Looking Back on 15 years at NTSB →
In this episode of Behind-the-Scene @NTSB, Chairman Robert L. Sumwalt reflects on his time at the NTSB, from his first day on the job, to how he’s feeling about his last day as Chairman. He also shares memorable moments during his 15 years at NTSB and some of the leadership lessons he’s learned along the way. Chairman … Continue reading Episode 41: Chairman Robert Sumwalt →
By Chairman Robert L. Sumwalt Speeding kills about the same number of Americans as drinking and driving, yet garners far less attention. We’ve included “Implement a Comprehensive Strategy to Eliminate Speeding-Related Crashes” on our 2021–2022 Most Wanted List of Transportation Safety Improvements because we know that speeding significantly impacts safety on the country’s roads, and … Continue reading Speeding: Comprehensive Changes Needed to Save Lives →
By Member Thomas Chapman Impaired driving, in some form or another, has been on every NTSB Most Wanted List since its inception in 1990. And with more than 10,000 impaired-driving deaths each year, it’s hard to imagine ever removing it. We have made safety recommendations about impaired driving prevention since 1968.Yet the problem persists. Part … Continue reading Prevent Alcohol- and Other Drug-Impaired Driving →
May has been designated by the National Highway Traffic Safety Administration as National Motorcycle Safety Awareness Month, to help motorists understand standard motorcycle driving behaviors and learn how to drive safely around motorcycles on our roadways. In this episode of Behind-the-Scene @ NTSB, NTSB Highway Crash Investigators Kenny Bragg and Mike Fox discuss our investigation of … Continue reading Episode 40: Motorcycle safety month →
May 22-28, 2021, has been designated as National Safe Boating Week, which kicks off a yearlong campaign promoting the importance of wearing a life jacket. In this episode of Behind-the-Scene @ NTSB, we talk with Morgan Turrell, Director, NTSB Office of Marine Safety, about the 2021-2022 Most Wanted List safety item Improve Passenger and Fishing Vessel … Continue reading Episode 39: Marine Safety →
By Chairman Robert L. Sumwalt May 22–28 is National Safe Boating Week, calling to mind well known campaigns against boating while intoxicated, distracted operations, and promoting proper use of life jackets on watercraft. But the present NTSB Most Wanted List puts a special emphasis on a lesser-known issue: the safety of passenger vessels and commercial … Continue reading Improving Passenger and Fishing Vessel Safety →
By Member Thomas Chapman An estimated 42,000 traffic deaths occurred in 2020. This is an alarming number. From 2014 to 2019, overall traffic fatalities increased by 10 percent. Over the same period, however, annual traffic deaths among vulnerable road users (pedestrians, bicyclists, and motorcyclists) jumped from 9,935 to 12,062— a 21 percent increase. If you … Continue reading A Safe System Approach to Traffic Safety Roundtable →
By Vice Chairman Bruce Landsberg April is National Distracted Driving Awareness Month, and we launched our 2021–2022 Most Wanted List of Transportation Safety Improvements on April 6. It seemed only natural that we begin our Most Wanted List blog series with the item, “Eliminate Distracted Driving.” Crashes involving distracted drivers killed 3,142 people in 2019—up … Continue reading Eliminate Distracted Driving →
By Robert Molloy, PhD, Director, NTSB Office of Highway Safety If you’re driving down a divided highway and see headlights coming right at you, or hear screeching tires and see cars and trucks swerving to get out of your way, it’s probably an indication you’re heading in the wrong direction. Another indicator may be the … Continue reading Let’s Stop Going the Wrong Way →
By Chairman Robert Sumwalt I grew up in the South, and people sometimes say we do things slowly in that part of the country. Whether there’s any validity to that claim, I can’t say with certainty. What I can say with great certainty, however, is that speed isn’t an attribute commonly associated with the Federal … Continue reading Twelve Years After Colgan 3407, FAA Still Hasn’t Implemented Pilot Records Database →
By Member Jennifer Homendy After 50 years of investigation, advocacy, and persistence by the NTSB, positive train control (PTC) is now a reality across the country! PTC systems use GPS and other technology to prevent certain train collisions and derailments. It could have been lifesaving in the 154 rail accidents that have killed more than … Continue reading We Can Do Big Things. Just Look at Positive Train Control →
By Member Tom Chapman The holiday season is a time of increased impaired-driving crashes. Accordingly, December has been designated National Impaired Driving Prevention Month to draw attention to the 100-percent preventable traffic fatalities and injuries attributed to impaired driving. In 2018, according to the National Highway Traffic Safety Administration (NHTSA), 10,511 people were killed in … Continue reading Drive Sober And Save Lives This Holiday Season →
In this episode of Behind-the-Scene @NTSB, we talk with Member Jennifer Homendy and Tim DePaepe, Railroad Accident Investigator, Office of Railroad, Pipeline and Hazardous Materials Investigations, about Positive Train Control (PTC), NTSB PTC-related investigations and recommendations and other rail safety issues. Fully Implement Positive Train Control is on the NTSB 2019-2020 Most Wanted List. Member Homendy’s full bio … Continue reading Episode 38: Positive Train Control →
By Chairman Robert Sumwalt It’s been quite a year! This time last year, none of us had heard of COVID-19. It’s still difficult to process the profound effect that this crisis has had, and continues to have, on people’s lives and on society. At the NTSB, we understand all too well the duality of a … Continue reading Resilience in a Time of Crisis: NTSB Employees Shine Despite Uncertainty →
Shaun Williams, Senior Aviation Accident Investigator, and Amy Terrone, Safety Advocate Ever paid for a helicopter tour over a scenic spot, like the islands of Hawaii or the Grand Canyon? Ever needed an emergency medical flight to a hospital or known someone who has? Ever joined the company CEO on a chartered flight to visit … Continue reading The Safety of ‘Part 135’ Flights—Why Should You Care? →
By Member Tom Chapman Is it possible to have a sleep disorder and not know it? From personal experience, I can tell you the answer is yes. A few years ago, my doctor told me that I was at risk for obstructive sleep apnea (OSA), which is a sleep disorder involving episodes of airway obstruction … Continue reading Screening Commercial Motor Vehicle Drivers for Obstructive Sleep Apnea Can Save Lives →
By Member Jennifer Homendy When you think of common ways drivers are distracted on the road, you probably think of talking or texting on mobile devices, eating, reading, or perhaps even putting on makeup or shaving. It’s easy to recognize that these risky behaviors are distractions. There are even laws on the books in several … Continue reading It’s Past Time to Think About Cognitive Distraction →
The blog was co-authored by: Bruce Landsberg, Vice-Chairman, National Transportation Safety Board Lorraine Martin, President & CEO, National Safety Council By now, we all should be aware of the deadly consequences of distracted driving. Yet, driving while distracted by cell phone use has become too common an occurrence on the nation’s roads. This must stop. … Continue reading Joining Forces on Distracted Driving →
By Nicholas Worrell, Chief, NTSB Safety Advocacy Division Sunday, November 15, is the World Day of Remembrance for Road Traffic Victims. I’ve known many of you who have lost loved ones this way, and I’ve worked alongside many survivor advocates for years. Along with the courage and strength I’ve seen among these survivors, it’s plain to me that … Continue reading World Day of Remembrance for Road Traffic Victims →
By Robert Molloy, PhD, Director, NTSB Office of Highway Safety As we wrap up Drowsy Driving Prevention week, I want to remind drivers about the importance of getting adequate rest before operating their car, truck, or bus. Drowsy Driving Prevention Week (November 1–8) was established by the National Sleep Foundation to draw attention to the … Continue reading Drowsy Driving Prevention Week →
October has been designated by the National Highway Traffic Safety Administration as National Pedestrian Safety Month, with the goal of increasing awareness about pedestrian safety, and reminding drivers and walkers that staying safe is a shared responsibility. In this episode of Behind-the-Scene @ NTSB, Member Tom Chapman, his Special Assistant Ivan Cheung, and Senior Highway … Continue reading EPISODE 37: PEDESTRIAN SAFETY →
October 2020 has been designated Distracted Driving Awareness Month. This national effort focuses on ways to change driver behavior through legislation, enforcement and education. In this episode of Behind-the-Scene @ NTSB, we have a conversation with Vice Chairman Bruce Landsberg and Senior Highway Safety Investigator Don Karol talk about NTSB crash investigations involving distraction, the decisions … Continue reading Episode 36: DISTRACTED DRIVING AWARENESS MONTH →
By Vice Chairman Bruce Landsberg This blog will be short and, to some, a bit brutal. To mark the start of Distracted Driving Awareness Month, let’s have a talk. You’ve heard all this before but stay with me for just a moment. Can we just stop? Can we just stop killing and seriously injuring innocent … Continue reading Perform a Death-Defying Act Without Lifting a Finger! →
By Dolline Hatchett, Director, Office of Safety Recommendations and Communications As the Director of the NTSB’s Office of Safety Recommendations and Communications (SRC), I lead a group that is focused on getting the whole story of accident investigations to the public. When there is a transportation disaster, my group is on scene alongside the frontline … Continue reading Where the Action is in Safety →
By Michelle Watters, MD, PhD, MPH As the weather gets colder and using your aircraft’s cabin heater becomes more of a necessity than a luxury, there’s no better time to start thinking about a plan for handling carbon monoxide. Commonly called the “silent killer,” carbon monoxide is best known as the cause of household poisonings … Continue reading General Aviation’s Silent Killer in the Sky →
By Member Jennifer Homendy Today kicks off Operation Lifesaver’s 2020 Rail Safety Week in North America. In normal years, Operation Lifesaver and its partners hold events across the country to educate the public on rail safety issues and promote safe actions around railroad tracks. Those efforts will be focused on virtual outreach this year. This … Continue reading Rail Safety Week 2020 →
In this episode of Behind-the-Scene @NTSB, Member Michael Graham and Highway Investigators Michele Beckjord and Meg Sweeney share lessons learned from our school-transportation-related crash investigations and discuss why school buses are the safest form of transportation for students. For more information about NTSB school transportation-related investigations, safety recommendations and presentations, visit the NTSB School Bus … Continue reading Episode 35: School Transportation Safety →
By Member Jennifer Homendy Today marks 10 years since the devastating natural gas pipeline rupture that shattered a residential neighborhood in San Bruno, California. The September 9, 2010, explosion destroyed 38 homes and damaged 70 others. Even worse, 8 people were killed, 10 people sustained serious injuries, and many others suffered minor injuries. The Accident … Continue reading San Bruno Victims and Their Families Deserve Long-Overdue Action →
By Leah Walton, NTSB Safety Advocate Labor Day, the annual celebration of U.S. workforce achievements, will be unique in many ways for Americans workers this year. Because of the COVID-19 pandemic, many establishments have significantly reduced their workforces or even closed entirely. At the same time, workers deemed essential have put their lives on the … Continue reading A Labor Day #SafetyReminder →
By Member Jennifer Homendy December 31, 2020—not only will it be the last day of an incredibly challenging year that I think we’ll all be happy to put behind us, it’s also a significant day for railroad safety. It’s the final deadline for all 41 railroads to fully implement Positive Train Control (PTC). It’s been … Continue reading Arriving Soon: Fully Implemented Positive Train Control →
By Member Jennifer Homendy This Saturday marks the 10th anniversary of one of the largest and most expensive inland oil spills in our nation’s history. At 5:58 p.m. on July 25, 2010, a 30-inch diameter pipeline owned and operated by Enbridge ruptured, releasing nearly a million gallons of heavy crude oil into Talmadge Creek, which … Continue reading Remembering Marshall, Michigan →
By Aaron Sauer and Michael Folkerts, NTSB Air Safety Investigators In normal times, many NTSB staff—including investigators and Board members—would be participating at the world’s largest general aviation (GA) event this week: Experimental Aircraft Association’s (EAA’s) AirVenture 2020. The event is held annually in late July in Oshkosh, Wisconsin, and features hundreds of seminars, presentations, … Continue reading EAA AirVenture is Off, but Our Focus on Summer Flying Safety Remains →
By Vice Chairman Bruce Landsberg Would you get tired after driving for 8 hours straight? What about after driving up to 11 hours, even with a short rest break? Suppose your vehicle weighed 80,000 pounds and was 80 feet long—would that require just a bit more alertness and finesse than the family car? Trucks are … Continue reading New Hours-of-Service Rule Relaxes Critical Safety Regulations →
By Member Jennifer Homendy In my senior year of college I worked part-time as a “hot walker” for a trainer at a racehorse track. One afternoon, a coworker asked if I wanted to leave for lunch and grab a sandwich at a local deli. The last thing I remember before the crash was getting in … Continue reading Fatal Distraction: The Dangers When our Eyes Aren’t Faithful to the Road →
By Member Thomas Chapman This has been a year of continuous and unexpected events. Never did I expect that just two months after being confirmed as the 46th Board Member of the NTSB, I would be sent home to quarantine and physically distance from my new colleagues – and for a period now approaching 5 … Continue reading Let’s Make This Independence Day Memorable with ZERO Impaired Driving Crashes →
By Dolline Hatchett, Director, NTSB Office of Safety Recommendations and Communications COVID-19 has affected every American, and the NTSB has adapted to respond to the effects of the pandemic. As the agency’s Director of Safety Recommendations and Communications (SRC), I know how important it is to keep the industry, elected officials, and the advocacy community … Continue reading This July 4, Travel Safely—Don’t Put Unnecessary Strain on First Responders and Hospital Staff →
In this episode of the Behind-the-Scene @NTSB podcast, NTSB Office of Highway Safety Director Rob Molloy, PhD, and Deputy Director Kris Poland, PhD, discuss their journeys to the NTSB and current work. Hear their views on the increase in speed-related crashes, current NTSB highway investigations, new safety recommendations related to vehicle automation, and much more. … Continue reading Episode 34: Highway Safety →
By Member Jennifer Homendy Crash-protected flight recording systems, such as cockpit voice recorders (CVRs) and flight data recorders (FDRs), often called “black boxes,” are required on most commercial aircraft by the Federal Aviation Administration (FAA). CVRs record sounds like engine noises and pilots’ voices in aircraft cockpits. FDRs record important data on a plane’s operating … Continue reading FAA Must Take Action on Recorder Safety Recommendations →
By Member Jennifer Homendy It seems like it should be obvious that you should never gamble with safety, but, for some reason, people often do when it comes to trains. Last spring, I visited our regional office in Alaska, and on the way to a meeting, I stopped along the road near Turnagain Arm. Just … Continue reading When it Comes Down to You and a Train, You Won’t Win! →
By: Nicholas Worrell, Chief, Office of Safety Advocacy We recently announced the launch of a new #SafetyReminder campaign to provide the traveling public with a few friendly reminders as unprecedented stay-at-home restrictions are eased and we slowly resume air, rail, road, and marine travel. During this return to “normalcy,” we’re especially concerned about young drivers. … Continue reading Teen Drivers: Don’t Take Your Return to the Road for Granted →
In this episode of Behind-the-Scene @NTSB, Chairman Robert L. Sumwalt talks about NTSB’s communications, leadership, and operations during this period especially as it relates to our mission. Chairman Sumwalt also discusses how the agency is maximizing the use of virtual platforms to support its day-to-day operations and shares important transportation safety reminders as the nation … Continue reading Episode 33: Chairman Robert Sumwalt →
By Chris O’Neil, Chief, NTSB Media Relations May is Motorcycle Safety Awareness Month and, although the number of motorcyclists killed in crashes dropped again in 2018, motorcycle riders remain overrepresented in overall highway traffic deaths. In fact, according to the National Highway Traffic Safety Administration, per miles traveled, motorcyclists are 28 times more likely to … Continue reading Motorcycle Safety: Your Mindset Makes All the Difference →
In this episode of Behind-the-Scene @NTSB, Member Thomas Chapman talks about his journey to the NTSB, his work before joining the Board and what he hopes to accomplish as an NTSB Board member. Member Chapman’s full bio is available here. Get the latest episode on Apple Podcasts , on Google Play, Stitcher, or your favorite podcast platform. And find … Continue reading Episode 32: Member Thomas Chapman →
By Nicholas Worrell, Chief, Office of Safety Advocacy Normally this time of year, the transportation safety advocacy world would be buzzing with annual calendared campaigns, like these more well-known ones in the highway safety world: • Global Youth Traffic Safety Month • Motorcycle Awareness Month • 100 Deadliest Days of Summer • NHTSA’s “Click it … Continue reading Returning to Travel with Safety on the Mind →
In this episode of Behind-the-Scene @NTSB, Member Michael Graham talks about his journey to the NTSB, his work before joining the Board and what he hopes to accomplish as an NTSB Board member. Member Graham’s full bio is available here. Get the latest episode on Apple Podcasts , on Google Play, Stitcher, or your … Continue reading Episode 31: Member Michael Graham →
By Member Michael Graham I recently participated in my first NTSB Board meeting as a member. We deliberated the findings of a crash involving a Tesla that drove into a gore area and struck a crash attenuator on a highway in Mountain View, California, killing the driver. Although this investigation was focused on level 2 … Continue reading Incentivizing Implementation of Collision Avoidance Technology through NCAP →
By Member Jennifer Homendy This past week, law enforcement officials across the United States, including in Indiana, Minnesota, and Virginia, took to social media to express their concern about the increased number of motorists speeding on the nation’s currently less-crowded roads. In Minnesota, Governor Tim Walz reported that state officials have seen a “troubling surge” … Continue reading Open Roads are not a Reason to Speed →
By Leah Walton, NTSB Safety Advocate When I read the extended nationwide maximum telework order, prolonging the order that started on March 17th, I couldn’t help but think about what impact the COVID-19 preventive measures might have on traffic deaths around the country. Surely, we’ll see a drop in vehicle miles traveled, like we did … Continue reading Flatten the Curve Beyond COVID-19 →
By Mike Fox, NTSB Highway Crash Investigator I’ve spent more than 25 years of my professional career in and around trucking, and I want to take a minute to highlight this industry. Having been a terminal manager, an FMCSA investigator, and a now an NTSB investigator, I’ve seen hundreds of fleet operations, and I understand … Continue reading Keeping Those Wheels—and the Country—Rolling →
By Jeff Marcus, Chief, NTSB Safety Recommendations Division Forty-three years ago, on March 27, 1977, two Boeing 747s, KLM flight 4805 and Pan Am flight 1736, collided on a runway at Los Rodeos Airport in Tenerife, Canary Islands, killing 583 people. It was the single greatest loss of life in aviation accident history. The crash … Continue reading Remembering Tenerife →
By Member Jennifer L. Homendy For the past few weeks, I’ve woken up every morning to a text message from the Virginia Railway Express (VRE) updating riders on its continued service and modified schedule. It’s hard not to think of all the VRE and Amtrak locomotive engineers and conductors that I’ve come to recognize (or … Continue reading Ensuring Transportation Safety, Even During a Crisis →
By Chairman Robert L. Sumwalt What do you get when you cross a transportation-related life-saving mission with some of the best people in the federal government? The National Transportation Safety Board, of course! And that is no April Fool’s joke. On this day 53 years ago, the NTSB was formed by an act of Congress. … Continue reading A Tribute to NTSB Employees →
By Chairman Robert L. Sumwalt I recently wrote a series of social media messages about attributes of a healthy safety culture. I received some interesting feedback and cross-talk from organizational safety leaders, so I wanted to make the collected messages available in PDF form for this blog’s readers. Click on any of the attributes listed below … Continue reading Attributes of a Healthy Safety Culture →
By Robert Molloy, PhD, Director, NTSB Office of Highway Safety The National Transportation Safety Board (NTSB) met on February 25 to consider the 2018 collision of a Tesla Model X, operating with partial driving automation, with a damaged crash attenuator in Mountain View, California. The car steered out of its travel lane and into a … Continue reading Automated Vehicles and Distraction: Lessons Learned from Mt. View →
By Member Jennifer Homendy Last fall, the National Transportation Safety Board released a report that made safety recommendations meant to improve safety for an important and growing segment of users on our roadways – bicyclists. The report issued 12 new safety recommendations and reiterated 10 safety recommendations. Through NTSB’s 50+ years of accident investigation experience, we’ve … Continue reading A Comprehensive Approach to Bicycle Safety →
By Chairman Robert L. Sumwalt What do you call 125 participants in an NTSB Most Wanted List (MWL) mid-point progress meeting, each of whom has their own idea of a transportation safety goal to achieve by the end of the year? An excellent start. On February 4, the NTSB hosted attendees from government, industry, and … Continue reading 2019-2020 Most Wanted List Midpoint Review →
By Vice Chairman Bruce Landsberg The NTSB first issued a recommendation to ban the nonemergency use of portable electronic devices (PEDs) while driving in 2011, and the issue area “Eliminate Distractions” remains on the 2019–2020 Most Wanted List of transportation safety improvements. Web browsing, texting, calling (even hands-free)—all these activities significantly increase the chance of … Continue reading Automation Complacency: Yet Another Distraction Problem →
By Leah Walton, NTSB Safety Advocate Super Bowl LIV is almost here! Whether you’re a diehard 49ers or Chiefs fan, or you simply watch for the commercials and halftime show, the play clock is just about to hit 0. For many football fans, driving will be part of the game plan both before and after … Continue reading Do You Have a Super Bowl Transportation Game Plan? →
By Nicholas Worrell, Chief, NTSB Safety Advocacy Division Last week, the NTSB hosted a group of students from around the world who are studying or pursuing higher education degrees in traffic safety. They came to us through the International Roads Federation (IRF) Fellows Program, which works to develop transportation safety leaders worldwide. The students were … Continue reading Global Road Safety Leaders of the Future →
In this episode of Behind-the-Scene @NTSB, Member Jennifer Homendy shares highlights from her first year at NTSB and the transportation safety improvements she hopes are accomplished in 2020. Member Homendy was first featured on the podcast shortly after she began her tenure as the 44th Member of the NTSB in Episode 20. Member Homendy’s … Continue reading Episode 30: Member Jennifer Homendy →
By Chairman Robert L. Sumwalt Every 2 years, the NTSB puts together a wish list, called our Most Wanted List (MWL) of transportation safety improvements. It comprises recommendations ripe for action by their recipients, which, if acted on, will bring safety benefits to all Americans. Our wish list is not like some other traditional holiday … Continue reading Our Transportation Safety Wish List →
By Leah Walton, NTSB Safety Advocate “On behalf of all of us at the NTSB, I offer our sincerest condolences to the families and friends of the individuals who lost their lives in this crash. Our entire purpose for being here today is to learn from tragic events like this, so that they can be … Continue reading Making the Right Choice this Holiday Season →
By Vice Chairman Bruce Landsberg Fact: Students are safer riding to and from school and school activities on a school bus than in the family car, and far safer than they would be riding in a car with a teenage driver. There should be no doubt that everything possible is being done to keep children … Continue reading Ensuring the Safety of School Bus Transportation →
By Nicholas Worrell, Chief, NTSB Safety Advocacy As Chief of the NTSB’s Safety Advocacy Division, I firmly believe in taking time to visit with young and novice drivers and promoting safe driving habits in line with the NTSB’s safety advocacy goals. Last week, I addressed students at Stranahan High School in Fort Lauderdale, Florida, during … Continue reading Toward a Brighter Future →
In this episode of Behind-the-Scene @NTSB, Highway Crash Investigators, Ensar Becic and Mike Fox, talk about the 2018 collision between a vehicle controlled by a developmental automated driving system and a pedestrian in Tempe, Arizona. We explore the findings and safety recommendations that came out of the investigation, as well as the strengths and limitations … Continue reading Episode 29: Tempe, Arizona, Uber Vehicle and Pedestrian Crash →
At the NTSB, we determine the cause of transportation crashes and accidents, and issue safety recommendations that, if implemented, could save lives and minimize injuries. Unfortunately, we see far too many tragedies that could have been easily prevented. As we head into the holiday season, Vice Chairman Bruce Landsberg and Member Jennifer Homendy share some … Continue reading Safe Travels This Holiday Season →
By Vice Chairman Bruce Landsberg Are you one of the hundreds of thousands of people who use a cell phone every day while driving? It’s so convenient, but it’s also potentially deadly. Thousands of people across the nation will lose their lives this year to this preventable public health problem. Tens of thousands more will … Continue reading Distracted Driving →
This week is National School Bus Safety Week. The theme this year is “My School Bus, The Safest Form of Student Transportation.” School Bus Safety Week is a public education program hosted by the National Association of Pupil Transportation, National School Transportation Association and the National Association of State Directors of Pupil Transportation Services, designed … Continue reading Episode 28: School Bus Safety Week →
By Member Jennifer Homendy In 2017, 37,133 people died on our nation’s roadways in preventable crashes. One way to prevent or mitigate these tragedies is by implementing proven and effective vehicle technologies, such as collision-avoidance systems. We know these systems can save lives, and our current Most Wanted List includes “Implementing Collision Avoidance Systems in … Continue reading The New Car Assessment Program →
By Nicholas Worrell, Chief, NTSB Safety Advocacy Division In today’s world, distractions are everywhere. From the electronic device in our hands to the infotainment options built into our vehicles, we are surrounded by hundreds of things vying for our attention every day. Even if we try to block out these distractions, despite our best efforts, … Continue reading The State of Distracted Driving in Missouri →
By Chairman Robert Sumwalt On September 6, in Anchorage, Alaska, I facilitated a first-of-a-kind roundtable of industry operators, government officials, educators, and aviation associations. Troubled by investigations into too many crashes involving Part 135 flight operations (which include air medical service, air taxi, air tours, charter, and on-demand flights) in Alaska, we called together some … Continue reading Roundtable Discussion Yields Key Insights, Critical Actions Needed for Improving Safety of Part 135 Flight Operations in Alaska →
By Vice Chairman Bruce Landsberg Trucks move the economy, and they do a superb job. One- and two-day delivery wouldn’t be possible without the nation’s truck army. But when trucks are involved in a crash, the results are often disastrous. How do we make trucking even safer? I recently spoke to the National Private Truck … Continue reading Safe Trucking is Good Business →
This week is Rail Safety Week. The theme this year, “Stop Track Tragedies,” provides an opportunity to raise awareness of the need for rail safety education and calls attention to ways to stay safe near highway-rail grade crossings and railroad rights-of-way. In this episode of Behind-the-Scene @NTSB, we talk with Member Jennifer Homendy and Ruben … Continue reading Episode 27: Rail Safety Week →
By Jeff Marcus, Chief, NTSB Safety Recommendations Division This past Sunday, August 25, 2019, Captain Al Haynes died a week shy of his 88th birthday. Captain Haynes was a remarkable pilot who, 30 years ago last month, brought United Airlines flight 232 to an emergency landing in Sioux City, Iowa, with no means of control … Continue reading Remembering Captain Al Haynes →
By Stephanie Shaw, NTSB Safety Advocate It’s nearing the end of August. Gone are the days of lounging by the pool or on the beach, or running around and playing outside. Soon, crowds of children will be waiting on the street corner for their school bus to arrive. It’s almost Labor Day, and the back-to-school … Continue reading Heading Back to School Safely →
By: Nicholas Worrell, Chief, Office of Safety Advocacy After 21 years, the Safe Skies for Africa (SSFA) program officially came to an end last week at a symposium in Lagos, Nigeria. The program was established in 1998 in part to increase direct commercial air service between the United States and Africa, which was minimal at … Continue reading Safe Skies for Africa Ends, but the Safety Journey Continues →
By Chairman Robert L. Sumwalt Last week, I kicked off Safe and Sound Week—an Occupational Safety and Health Administration initiative—with this video message. In the video, I reminded NTSB employees that one of the things our agency does is meet with victims’ family members on perhaps on the worst day of their lives. I told … Continue reading Safe and Sound at Work →
By Member Jennifer Homendy Exactly 50 years ago today, two Penn Central commuter trains collided in Darien, Connecticut. Four people died and 43 others were injured. The collision led to our first recommendation related to positive train control (PTC). Today, I joined Senator Richard Blumenthal at a commemoration of the accident in New Haven. The … Continue reading PTC, 50 Years After Darien →
By Vice Chairman Bruce Landsberg “Always tell the truth. It will confound your enemies and amaze your friends.” This almost direct quote from Mark Twain is essential advice for pilots who are coming up for a medical certificate renewal, initial application, or going for BasicMed. The online medical form 8500.8, as well as BasicMed form … Continue reading Don’t Get Grounded: Med Form Accuracy Matters →
By Member Jennifer Homendy Every day I drive to work on one of the busiest freeways in the country. That freeway has a posted speed limit of 55-65 miles per hour. I am amazed how many drivers disregard the posted speed limit and use the freeway as their opportunity to drive like they are in … Continue reading Speeding: Just Because You Can, Doesn’t Mean You Should →
By Aaron Sauer, NTSB Senior Air Safety Investigator, and Amy Terrone, NTSB Safety Advocate Loss of control and midair accidents, drones in accident investigations, startle effects and distraction, general aviation safety trends, and survivor stories (oh my!)—these are just a few of the topics NTSB staff will present at this year’s Experimental Aircraft Association AirVenture … Continue reading Oshkosh AirVenture 2019: Raise the Bar of Your Safety Culture →
By Leah Walton, NTSB Safety Advocate When I started my career with Mothers Against Drunk Driving 20 years ago, I never imagined I would still be advocating to eliminate impaired driving in 2019. I wasn’t so naïve to believe we’d have flying cars by now, but I did think that, surely in 20 years, Americans … Continue reading Don’t Drive High This 4th of July →
By Stephanie Shaw, NTSB Safety Advocate My youngest son is 16 and a newly licensed driver. He’s had his license for about 4 months. Statistically, as a driver, the cards are stacked against him. For young drivers like him, the first 6 months of unsupervised driving are the most dangerous. As a mom, I’m terrified. … Continue reading Deadly Days of Summer →
By Nicholas Worrell, Chief, NTSB Safety Advocacy Division Author and leadership expert John Maxwell once said, “Everything rises and falls on leadership.” Leadership is at the core of all we do, whether it’s in our professional organizations, community groups, or personal lives. Success depends on sound leadership. Earlier this week, I represented the NTSB to … Continue reading Developing Future Safety Leaders →
In this episode of Behind-the-Scene @NTSB, we talk with Rachel Gunaratnam, a Hazardous Materials Accident Investigator in the NTSB Office or Railroad, Pipeline and Hazardous Materials Investigations and Frank Zakar, a Senior Metallurgist in the NTSB Office of Research and Engineering, about the natural gas-fueled explosion, on August 10, 2016, in Silver Spring, Maryland. Rachel … Continue reading Episode 26 – Silver Spring, Maryland, Apartment Building Explosion Investigation →
By Lorenda Ward, Sr. Investigator-In-Charge, NTSB Office of Aviation Safety As an investigator-in-charge (IIC) at the National Transportation Safety Board (NTSB), part of my job is to launch to aviation accident scenes. When my team and I arrive at the scene of an accident, we come prepared to uncover the sequence of events that led … Continue reading Why We Care When Things Go Right →
By Mike Hodges, Air Safety Investigator, NTSB Office of Aviation Safety On August 9, 2008, a privately-owned Cessna 182E airplane was reported overdue near Juneau, Alaska. The NTSB immediately started monitoring search efforts being conducted by the US Coast Guard, the Alaska State Troopers, the Civil Air Patrol, and a host of good Samaritans. The … Continue reading When an Aircraft Goes Missing →
By Member Jennifer Homendy Today marks the 20th anniversary of the Olympic Pipe Line rupture in Bellingham, Washington, which resulted in the release of about 237,000 gallons of gasoline into a creek that flowed through Whatcom Falls Park. Sometime after the rupture, the gasoline ignited and burned about 1.5 miles along the creek. Two 10-year-old … Continue reading Remember Bellingham →
By Chris O’Neil, Chief, Media Relations Division May is Motorcycle Safety Awareness Month As a motorcyclist, I know there’s a lot that goes into being a safe rider. There’s training and experience that help build and sharpen our riding skills. There’s equipment designed to help us avoid crashes and equipment designed to protect us when … Continue reading Got Plans? →
By Member Jennifer Homendy On May 10, 1869, 150 years ago today, a golden spike was driven home at Promontory Summit, in what was then the Utah Territory, by Central Pacific Railroad President Leland Stanford. This momentous event joined the Central Pacific and Union Pacific Railroads, completing the first transcontinental railroad, just 7 years after … Continue reading The Golden Spike at 150 →
By Nicholas Worrell, Chief, Safety Advocacy Division Around the world, about 1.25 million people lose their lives every year in motor vehicle crashes. That’s roughly the entire population of Dallas, Texas. Others—20–50 million—are injured or disabled. That’s about the equivalent of injuring everybody in a medium-sized country, like Spain (46 million) or Ukraine (44 million). … Continue reading Global Road Safety Week →
By Member Jennifer Homendy The United States continues to be one of the world’s leaders in drunk-driving deaths. One of the reasons for this shameful distinction is that US drivers are allowed to operate motor vehicles with more alcohol in their system than is permitted in most other countries. One state in the nation is … Continue reading Drink or Drive—Pick One →
By Nicholas Worrell, Chief, Safety Advocacy Division On April 3, I represented the National Transportation Safety Board (NTSB) at an event kicking off Distracted Driving Awareness Month and California Teen Driver Safety Week, in Sacramento. I challenged California to lead the nation in acting on NTSB’s 2011 recommendation to ban the nonemergency driver use of … Continue reading Eyes on The Road, Hands on the Wheel, Mind on One Task →
In this episode of Behind-the-Scene @ NTSB, we have a conversation with Adam Gerhardt, an Air Safety Investigator in the NTSB Office of Aviation Safety. Adam shares with us how he got interested in aviation and the journey he took to get to the NTSB. Get the latest episode on Apple Podcasts , on Google Play, Stitcher, or your favorite podcast platform. To … Continue reading Episode 25 – Adam Gerhardt →
By Captain James Scheffer, Strategic Advisor, NTSB Office of Marine Safety I’m often asked how the NTSB chooses which marine accidents to investigate, and what role the US Coast Guard (USCG) plays in our investigations. I had the same question when I first joined the NTSB’s Office of Marine Safety more than 20 years ago. … Continue reading NTSB’s Role in Marine Accident Investigations →
By Vice Chairman Bruce Landsberg The NTSB has investigated distraction-linked crashes in all modes of transportation. Our 2017 distracted driving roundtable, “Act to End Deadly Distraction,” made one thing very clear: We don’t feel these losses in a statistical table. We feel them at the dinner table. We also don’t call them “accidents” because they … Continue reading Eliminate Distractions →
By Chairman Robert L. Sumwalt Last week, we officially adopted our final report on the tragic May 15, 2017, crash of a Learjet 35A on a circling approach to Teterboro Airport in New Jersey. The crash took the lives of the two occupants—the aircraft’s pilots. The probable cause of the accident was the pilot‑in‑command’s (PIC’s) attempt … Continue reading When it Comes to Safety, Not All Flights are Created Equal →
By Nicholas Worrell, Chief, NTSB Safety Advocacy Division Earlier this month, I had the opportunity to address more than 150 driver educators at the Dori Saves Lives Driver Education Conference, a meeting at which I first spoke in 2015. The conference is named for Dori Slosberg, who died in a 1996 traffic crash along with … Continue reading Why? →
By: Member Jennifer Homendy St. Patrick’s Day is a big deal in our house. “Leprechauns” sneak in the night before to raid our kitchen cabinets. Sometimes they write things in green paint on our walls; other times they leave gold coins. And my daughter always tries to catch one in her latest handmade trap (spoiler … Continue reading Don’t Rely on the Luck of the Irish for a Safe Ride Home →
By Chairman Robert Sumwalt Yesterday, the NTSB issued a press release about our ongoing assistance to the Ethiopian Aircraft Accident Investigation Bureau in its investigation into the crash of Ethiopian Airlines flight 302. Under the provisions of Annex 13 to the Convention on International Civil Aviation—or simply, Annex 13—Ethiopian authorities are responsible for investigating the … Continue reading Ethiopia Airlines Flight 302, Annex 13, and the NTSB’s International Mission →
This week is Sleep Awareness Week. The theme this year, “Begin with Sleep,” highlights the importance of good sleep health for individuals to best achieve their personal, family, and professional goals. In this episode of Behind-the-Scene @NTSB, we talk with Mary Pat McKay, MD, MPH, Chief Medical Officer; Jana Price, PhD, Senior Human Performance Investigator, … Continue reading Episode 24: Sleep Awareness Week →
By Vice Chairman Bruce Landsberg Traffic crashes that claim the lives of one, two, . . . maybe even five people don’t seem that severe. Would there be more urgency to address highway safety if per-crash fatalities were higher? Suppose a family member or a friend was the one killed or injured? Typically, it’s not … Continue reading Most Highway Crashes Are Not Accidents →
In this episode of Behind-the-Scene @ NTSB, we have a conversation with Vice Chairman Bruce Landsberg. Vice Chairman Landsberg shares with us his passion for safety education and training, his past work to improve aviation safety and the path he has taken to become an NTSB Board Member. Get the latest episode on Apple Podcasts , … Continue reading Episode 23 – Vice Chairman Bruce Landsberg →
In this episode of Behind-the-Scene @NTSB, we talk with Nicholas Worrell, Chief of Safety Advocacy and Chris O’Neil, Chief of Media Relations, in the NTSB Office of Safety Recommendations and Communications, about the NTSB Most Wanted List. To learn more about the NTSB Most Wanted List visit: www.ntsb.gov/mostwanted Get the latest episode … Continue reading Episode 22 – NTSB 2019-2020 Most Wanted List →
By Chairman Robert L. Sumwalt Earlier this week we announced our 2019–2020 Most Wanted List of transportation safety improvements. The Most Wanted List (MWL) was developed from safety recommendations that we’ve issued but that haven’t been acted on acceptably. In 2017, the last year for which we have complete numbers, 38,958 people died in transportation … Continue reading 2019–2020 Most Wanted List →
In this episode of Behind-the-Scene @NTSB, we talk with Kenny Bragg and Rafael Marshall, Senior Human Performance Investigators, in the NTSB Office of Highway, about the collision of a pickup truck and medium-size bus, on March 29, 2017, near Concan, Texas. Kenny and Rafael talk about the circumstances of the crash, the probable cause, and … Continue reading Episode 21 – Concan, Texas Investigation →
By Chairman Robert L. Sumwalt Let’s face it: the NTSB isn’t an agency that often has good news to report. As an accident investigation agency, we deal with the hard facts regarding terrible shortcomings in our nation’s transportation system. This week, however, I’m pleased to report some good news. On Wednesday, the Partnership for Public … Continue reading Good News . . . At Last! →
In this episode of Behind-the-Scene @ NTSB, we have a conversation with Board Member Jennifer Homendy. Member Homendy shares with us her passion for transportation safety, her past work to improve rail, pipeline, and hazardous materials safety and the path she has taken to become an NTSB Board Member. Get the latest episode on … Continue reading Episode 20 – Member Jennifer Homendy →
In this episode of Behind-the-Scene @NTSB, we talk with Chairman Robert Sumwalt about Thanksgiving holiday travel and ways to keep you and your loved ones safe whether traveling by air, land, or sea. To learn more about the NTSB investigation of the gas explosions and fire in Lawrence, Massachusetts, visit: https://ntsb.gov/investigations/Pages/pld18mr003.aspx. Get the latest episode … Continue reading Episode 19 – Chairman Sumwalt →
By Chairman Robert L. Sumwalt
Every year, I hear that the holiday season has gotten too long—that holiday music, commercials, and sales begin too early. Traditionally, the season starts on Thanksgiving, the fourth Thursday of November.
I think the season should actually start even earlier this year—on the third Sunday in November, World Day of Remembrance for Road Traffic Victims. Why? Because to truly give thanks for what we have, we have to imagine losing it. Around the world, about 1.3 million people lose their lives in automobile crashes every year; 20 to 50 million more survive a crash with injuries, many of which are life-altering. Here in the United States, annual traffic deaths number around 37,000—more than 100 a day—and a motor vehicle crash is the single most likely way for a teen to die.
If you’ve lost somebody to a crash, you probably need no special reminder. Your loved one will be missed at the holiday dinner table, on the way to the home of a friend or out-of-town relative, and throughout the holidays. But for the rest of us, the Day of Remembrance is a time to think of those needlessly lost on our roads.
I encourage us all to go beyond remembering those lost in highway crashes, to thinking of victims of transportation accidents in all modes who won’t be joining family and friends this holiday season. Before we give thanks next Thursday, let’s take a moment to remember those who have been lost, and then take steps to make our own holiday travel safer.
By Car
Fatigue, impairment by alcohol and other drugs, and distraction continue to play major roles in highway crashes. Here’s what you can do to keep yourself and those around you safe on the road.
- If your holiday celebrations involve alcohol, ask a friend or family member to be your designated driver, or call a taxi or ridesharing service.
- In a crash, seat belts (and proper child restraints) are your best protection. Always make sure that you and all of your passengers are buckled up or buckled in!
- Make sure to use the right restraint for child passengers, and be sure it’s installed correctly. If you have doubts, ask a Certified Child Passenger Safety Technician.
- Make sure you’re well rested! A fatigued driver is just as dangerous as one impaired by alcohol or other drugs.
- Avoid distractions. In this video, survivor-advocates share their stories of personal loss—and the changes they’re working for now.
- Don’t take or make calls while driving, even using a hands-free device. Set your navigation system before you start driving. If you’re traveling with others, ask them to navigate.
By Bus or Train
We’ve made recommendations to regulators and industry to improve passenger rail and motorcoach operations and vehicle crashworthiness, but travelers should know what to do in an emergency.
- Pay attention to safety briefings and know where the nearest emergency exit is. If it’s a window or roof hatch, make sure you know how to use it.
- If you’re unsure of where the exits are or how to use them, or if you didn’t receive a safety briefing, ask your driver or train conductor to brief you.
- Always use restraints when they’re available!
By Air or Sea
Airline and water travel have become incredibly safe, but these tips can help keep you and your loved ones safe in an emergency.
- When flying, make sure that you and your traveling companions have your own seats—even children under age 2.
- Don’t forget your child’s car seat. The label will usually tell you whether your child car seat is certified for airplane use; the owner’s manual always has this information.
- If you don’t know the rules for using a child’s car seat on your flight, call the airline and ask what you need to know.
- Pay close attention to the safety briefing! Airline and marine accidents have become very rare, but you and your family can be safer by being prepared.
- Whether you’re on an airplane or a boat, know where to find the nearest flotation device.
This holiday season, no matter how you plan to get where you’re going, remember that, for many, this time of year is a time of loss. Honor survivors and remember traffic crash victims by doing your best to make sure you—and those around you—make only happy memories on your holiday travels.
In this episode of Behind-the-Scene @NTSB, we talk with Mike Hiller, Railroad Accident Investigator, Joe Gordon, Rail Safety Investigator, and Paul Stancil, Hazardous Materials Accident Investigator, in the NTSB Office of Railroad, Pipeline and Hazardous Materials Investigations, about the derailment of a Union Pacific Railroad ethanol train, on March 10, 2017, near Graettinger, Iowa.
https://safetycompass.files.wordpress.com/2018/11/leah-walton-and-stephanie-shaw-interview-paul-stancil-joe-gordon-and-mike-hiller_mixdown.mp3
To learn more about the NTSB investigation of the Graettinger, Iowa train derailment visit: https://ntsb.gov/investigations/Pages/2017-graettinger-ia.aspx.
Get the latest episode on Apple Podcasts , on Google Play, Stitcher, or your favorite podcast platform.
And find more ways to listen here: https://www.blubrry.com/behind_the_scene_ntsb/
It’s been one year since we launched our Behind-the-Scene @NTSB podcast. As we reflect on the last year and the 16 episodes we’ve shared with listeners so far, we decided to sit down and talk with our podcast host, Erik Strickland.
In this episode of Behind-the-Scene @NTSB, Erik Strickland, a transportation safety specialist in the NTSB Office of Safety Recommendations and Communications shares with us his transportation journey from Mothers Against Drunk Driving (MADD), to NTSB Safety Advocate and now Senior Advisor to NTSB Member Jennifer Homendy.
https://media.blubrry.com/behind_the_scene_ntsb/safetycompass.files.wordpress.com/2018/11/leah-walton-and-stephanie-shaw-interview-erik-strickland-1.mp3
Get the latest episode on Apple Podcasts , on Google Play, Stitcher, or your favorite podcast platform.
And find more ways to listen here: https://www.blubrry.com/behind_the_scene_ntsb/
By Bruce Landsberg, Vice Chairman
On March 27, 1977, two Boeing 747s collided on a foggy runway in Tenerife, Spain. The crash took 583 lives, marking it as the deadliest aviation accident in history. Although commercial airline safety has made huge strides since then, a disaster potentially twice as deadly as Tenerife was recently averted by only about 13 feet.
In the late evening hours of July 7, 2017, an Air Canada Airbus A320 inbound from Toronto almost collided with four jetliners awaiting take off at San Francisco International airport (SFO). The night was clear and calm, with no weather to obscure the visual approach to Runway 28 Right.
The Air Canada pilots, not realizing the parallel runway (28 Left) was closed, lined up on a nearby taxiway rather than their assigned runway. As the waiting airliners flashed their landing lights to alert the errant Airbus, one of the pilots on the control tower frequency ground broadcast can be heard saying “Where’s this guy going?” and “He’s on the taxiway!” In the last few seconds, the Air Canada crew recognized their error and aborted the landing. Simultaneously, the tower controller ordered the Airbus to go around.
Upon landing, the captain called the tower to discuss the incident, and then went to bed. It was 3 am by his body clock and he was exhausted. Although he was required to do so as soon as possible, the captain did not inform Air Canada’s dispatcher about the incident until 16 hours later, by which time the aircraft had already departed on a morning flight, resulting in the required 2-hours of cockpit voice recorder (CVR) data being overwritten.
With all the equipment, training, and safety management systems implemented since Tenerife, it’s astonishing how a near miss like this could happen. But as our investigation revealed, a long and intricate chain of events was to blame. We clearly understand now what happened, but, because the CVR data was lost, we only know part of the why.
We made several recommendations to address the safety issues our investigation uncovered. The incident report, which is available at ntsb.gov, should be required reading for pilots of both large and small aircraft. Here are some of the most important takeaways.
Knowing what to expect. Before flight, all pilots are required to check for Notices to Airmen (NOTAMs), which inform them of anything unusual that has recently changed at the departure or arrival airport, as well as navigational outages along the way. In practice, NOTAMs contain dozens of notices of varying importance, such as closed taxiways, wet runways, and small, unlit towers miles from the airport. Information about closed runways, however, is critical.
From a human factors perspective, we found that the presentation of information in the NOTAM the crew received did not effectively convey the information about the runway closure. This Air Canada crew missed two warnings about the closed runway at SFO, first in predeparture, and then via datalink before landing. Had they been aware of the closure, the pilots almost certainly would’ve suspected an unusual airport configuration with changed lighting patterns.
The current NOTAM system lists everything that could, even under the most unlikely circumstance, affect a flight. It lays an unnecessarily heavy burden on individual pilots, crews, and dispatchers to sort through dozens of irrelevant items to find the critical and important ones. When an important item is missed—as is common—and a violation or incident occurs, the pilot is blamed for not finding what amounts to a needle in a haystack.
Further, NOTAMs are published in hard-to-read codes. Using plain language and conventional date and time configuration in both local and universal (UTC) time could go a long way toward making flight safety information easier to understand. The Federal Aviation Administration (FAA) has been aware of the NOTAM problem for more than 15 years. In 2012, Public Law 112-153 (Pilot’s Bill of Rights) gave the FAA 1 year to fix the problem. The incident at SFO makes it clear that there is still much more work to be done. This is a safety issue that calls for urgent action.
The fatigue factor. Fatigue continues to be a recurring factor in accidents and incidents. The Air Canada captain had been awake for 19 hours at the time of the incident. It’s estimated that he awoke around 0800 eastern time (ET); the incident occurred at 0300 ET the following day. The captain was not technically “on duty” that whole time, and, under Canadian regulations for reserve crew members, he still could have been available for duty for another 9 hours.
During postaccident interviews, the captain said he did not make a timely incident report to Air Canada’s dispatch after landing because it was “very late” and he was “very tired.” If the captain is too tired to make a phone call to report an incident, should the rules allow him to fly a challenging night approach with the lives of 139 passengers and crew in the balance? If we expect solid human performance where lives are at stake, fatigue rules need to be based on human factors science. The NTSB has recommended that Canada’s fatigue regulations be modified.
Cockpit voice recorders and beyond. The Airbus’s CVR would have provided much more information on what happened, but it was overwritten during the first flight following the incident (current CVRs are only required to store a minimum of 2 hours of audio). Without the CVR data, we may never understand all the reasons behind the numerous procedural failures, but we know one thing for sure: the CVR would have provided a much better picture of just how this incident came close to being a catastrophic accident.
Cockpit image recording could provide a much richer source of critical information. We initially issued an image recorder recommendation as long ago as 2000.
We have had far more success with image-recording technology in every mode of public transportation except commercial aviation. Some pilot groups are concerned about the flight crew’s right to privacy and that the information gathered will be used punitively. Workplace right to privacy has been extensively debated, but for employees in safety-critical positions, privacy should take a backseat to human life.
Unlike written transcripts, cockpit audio and video recordings are protected by federal law and never released by the NTSB. Likewise, video recordings are protected by law from being released. Over-the-air transmissions, such as communications between a pilot and air traffic controllers, are in the public domain, by definition, but in-cockpit audio and video recordings are protected by the NTSB against public disclosure.
More importantly, image recorder data gathered routinely before an accident will be invaluable in preventing the next tragedy. This approach has been highly effective in flight operational quality assurance (FOQA). This approach may pose some technical challenges, but it will significantly increase safety and accountability.
Learn and forgive. One of the best practices used in aviation is the concept of “just culture,” or nonpunitive corrective action. Most people put their best foot forward and attempt to minimize a critical error when they make one, which is perfectly understandable. Yet, some supervisors want to mete out sanctions to “teach a lesson” or to make an example of a crew. Unless someone is habitually error prone or intentionally ignoring safety procedures, a punitive response is completely inappropriate to critical performance environments in all modes of transportation.
This Air Canada flight crew will almost certainly never make such a mistake again, and my hope is that they will continue to fly to the normal end of their careers.
We gain much more from being introspective rather than judgmental about this incident. We should celebrate when someone confesses a mistake and learns from it. This is one of the key factors in the decades-long decline in commercial aviation’s accident rate. Fortunately, we’ll get another chance to put some fixes in place to make a highly improbable event even less likely to recur. Let’s not squander it.
Reduce Fatigue-Related Accidents and Expand Recorder Use to Enhance Safety are topic areas on the NTSB 2017-2018 Most Wanted List.
In this episode of Behind-the-Scene @NTSB, we chat with Gloria Noguera the Administrative Officer in the NTSB Office of Railroad, Pipeline and Hazardous Materials Investigations. Gloria shares with us her transportation journey from Colombia, South America, to an FAA control tower in New Jersey, and now at the NTSB.
https://safetycompass.files.wordpress.com/2018/10/2018-07-12-erik-strickland-interviews-gloria-noguera.mp3
Get the latest episode on Apple Podcasts , on Google Play, Stitcher, or your favorite podcast platform.
And find more ways to listen here: https://www.blubrry.com/behind_the_scene_ntsb/
By Amy Terrone, NTSB Safety Advocate
My morning commute into work is often delayed because of a crash. If you live and work in the Washington, DC, area, you know that we have some of the worst, most congested rush-hour traffic in the country, which means a bunch of tired, irritated drivers are on the road at the same time—perfect conditions for a crash. As I passed by one such crash scene recently, I wondered how the driver ended up in that situation. My guess is that he or she was distracted by a cellphone or was traveling too close to the car ahead in the stop-and-go lineup. Unfortunately, these things happen every day.
But did you know that there’s already technology out there that can prevent these types of crashes? Automatic emergency braking, or AEB, is available on many vehicles and is increasingly becoming standard—not just an option included with a luxury package. In fact, 22 automakers have agreed to install AEB as a standard feature by 2022. AEB is designed to address the large number of rear-end crashes in which drivers do not apply the brakes, or fail to apply enough braking power to avoid or mitigate a crash. AEB systems use sensors, such as radar, cameras, and lasers, to detect an imminent crash, warn the driver, and, if the driver does not take sufficient action, engage the brakes.
Forward collision warning, part of the collision avoidance system paired with AEB, helps you react to an imminent crash. It alerts you to the vehicle ahead so that you reengage with what’s happening on the road and apply the brakes.
We’ve promoted the benefits of collision avoidance technologies—also known as advanced driver assistance technologies—since 1995. In particular, we’ve advocated for forward collision avoidance systems featuring AEB and forward collision warning, and we’ve issued recommendations to require such technologies in all vehicle types—not just the ones you and I drive, but big rigs and big buses, as well. Collision avoidance technologies also include other technologies to help a driver avoid a crash, such as blind-spot monitoring/detection, lane-departure assist/warning, and rear-cross traffic alert. We’ve made implementing and using collision avoidance technologies a focus of our Most Wanted List for several years now.
Technology can compensate for human behavior and human mistakes. Ideally, all humans should remain focused on the roadway 100 percent of the time; however, that’s not realistic. Distraction, impairment, fatigue, speeding, and wrong decisions are all preventable, but they still occur. That’s where collision avoidance technologies come in. Technology can play a key role in reducing the nearly 40,000 deaths that result from human error on our roadways each year.
In 2001 and again in 2015, we released a special report assessing the efficacy of collision avoidance systems and their ability to reduce crashes. A key finding of the 2015 report was that many of the approximately 1.7 million rear-end crashes that occurred on our nation’s roadways in 2012—which killed 1,700 people—could have been mitigated or even prevented by collision avoidance technologies.
Of course, to get the biggest benefit from these technologies, drivers need to understand what they do. Dealers and rental car agencies play a role in educating consumers when we buy or rent a car, but, ultimately, it’s our responsibility to research the technology, request it, and learn how to use it.
Myriad resources can help you ensure you’re equipping yourself with every possible means to prevent a crash, and our Safety Alert regarding rear-end crashes encourages you to do your homework. Two good places to start are the National Safety Council’s My Car Does What website and the National Highway Traffic Safety Administration’s (NHTSA’s) SaferCar website. The Insurance Institute for Highway Safety also announced that it will soon unveil a consumer rating system for advanced driver assistance systems. But, the most often overlooked resource about new collision avoidance technology is your vehicle manufacturer’s website or owner’s manual (yeah, the one you leave in your glove compartment to collect cobwebs). When you’re car shopping, don’t hesitate to ask your salesperson about a car’s safety technology and ask for a demonstration.
The NTSB has recommended that NHTSA rate collision avoidance technologies as part of its 5‑star safety ratings (NHTSA currently recommends certain driver-assist technologies), and advertise the ratings on new-car window stickers. Until then, it’s up to us, the consumers, to do our research.
The technology to prevent common types of crashes is here today and is proven to save lives. So, what are you waiting for?
By Member T. Bella Dinh-Zarr, PhD, MPH
This summer, I had the opportunity to observe men and women training to be law enforcement officers. Part of their training included 40 hours focused specifically on executing a standardized field sobriety test (SFST).
The SFST is a series of assessments an officer performs during a traffic stop to determine if a driver is impaired. I was surprised to learn how the SFST also helps officers detect drivers who are impaired by drugs other than alcohol. When an officer encounters a subject who he believes to be impaired, his first response will be to evaluate his physical condition by administering a SFST. Although all the clues for impairment which are analyzed in the SFST are for alcohol, there are similarities in impairment by some of the 7 different drug classes. Additionally, the presence of some impairment clues and the absence of others can be a strong indicator of drug impairment. For instance, a subject who displays nystagmus (uncontrollable twitching of the eyes) from alcohol impairment will also present an inability to maintain balance. With some drug classes, there will be a high degree of nystagmus, but their balance may not be affected to the same degree. The same goes with the strong odor of alcohol. If a subject is obviously impaired but has no odor of alcohol about their breath, drug impairment may have an influence. When officers administer an SFST to a suspected drug-impaired driver, the results often identify the need for a drug recognition expert (DRE) to evaluate the driver for physical signs of drug impairment.
Trainees learn about the effects of alcohol on the body and the visual cues to look for when they suspect a driver is impaired, as well as how to determine the likelihood of impairment so they have probable cause to administer an impairment test. In addition to the SFST training, officers spend hours learning how to document impaired driving arrests and how to present evidence of such arrests in court.
To effectively practice these skills, trainees conduct the SFST on live subjects who have consumed varying amounts of alcohol in a controlled environment (a law-enforcement training facility; subjects are driven home by law enforcement officers afterward). Volunteers are given measured amounts of alcohol over the course of 4 hours prior to the mock SFST, and then are given a breath test to document their breath alcohol concentration (BrAC) as the evaluation begins. SFST instructors observe trainees as they evaluate subjects and offer real-time feedback and suggestions for improvement. By using live subjects, trainees witness how variably alcohol consumption can present in individuals.
A law enforcement trainee conducts the SFST on a live subject that has consumed alcohol I spent some time with the live subjects, all of whom were impaired, before their evaluations. All subjects had a BrAC of 0.08 percent or higher and, had they been behind the wheel, would have been subject to arrest. The SFST instructor showed me the documented BAC levels of the subjects. While all of the subjects were at or above 0.08, they were each keenly aware that they were in no condition to drive. They were unsteady on their feet, reacted slowly to orders, and struggled to follow directions given by the trainees. I couldn’t tell which subjects had higher BACs than others, but just knowing that some were close to or just above the “legal limit,” I would not be comfortable sharing the road with any of them.
When the evaluations started, I got to be one of the (sober) subjects evaluated by the trainees. I received the same set of questions and was given the same tests as the impaired subjects. The SFST is incredibly thorough, and officers determine the likelihood of impairment by scoring the elements of the test based on how the subject performs. I was asked questions such as, “Where are you coming from?” “Have you had anything to drink tonight?” “Are you on any medications or do you have any medical conditions that I should be aware of?” From there, I was asked to walk a certain number of steps, heel to toe, counting each step out loud; to stand on one foot with my arms at my sides and balance, and to track a pen that the trainee moved in front of my face from side to side. The test is designed to evaluate a person’s ability to complete simultaneous tasks—an ability that is hindered by impairment. What I learned later is that each part of the test helps the officer gather data about the subject—slurred speech, an alcohol odor, impaired coordination, and atypical eye movement are all signs of impairment. Subjects who score in or above a certain range on the test are considered to have a positive likelihood of impairment.
Member Dinh-Zarr undergoes the SFST I learned two things through this test. First, I struggle with balancing on one foot, even when I’m sober! Second, the trainees are taught this protocol very thoroughly; they are instructed to take their time and not rush any element of the test. They need to be very deliberate because officers cannot administer a breath test unless they positively detect impairment.
End Alcohol and Other Drug Impairment in Transportation is on our Most Wanted List of transportation safety improvements. Specifically, we recommend that all states lower their per se BAC limit from 0.08 percent to 0.05 percent or lower. Observing this SFST training exercise reaffirms my belief in the NTSB’s position on this recommendation. A 0.08 percent BAC illegal limit is far too high. At .05, drivers have difficulty with vision, coordination, and steering, even if they may not realize it. In fact, in 2016, approximately 1,400 people were killed by drivers with a BAC of 0.01–0.07 percent.
Driver BAC’s from fatal crashes in 2016. Drivers are not considered legally impaired before 0.08 BAC, but 1,400 people were killed by drivers that had between 0.01 and 0.07 BAC in 2016. In addition to calling on states to lower their legal BAC limit, we also recommend increased high-visibility enforcement, such as sobriety checkpoints, which allow law enforcement officers to screen a high number of drivers in a short amount of time for potential impairment. All of these safety recommendations are not intended to increase arrests. In fact. they may decrease the number of arrests because they deter many impaired people from even getting behind the wheel in the first place. That is true prevention!
Our 2013 report, “Reaching Zero: Actions to Eliminate Alcohol-Impaired Driving” includes a series of recommendations to combat impaired driving. We believe that implementing a combination of a lower BAC legal limit, increased or high-visibility enforcement, and mandatory ignition interlock devices for all DUI offenders can reduce the number of impaired drivers on our roadways. Our goal is to eliminate impaired driving by convincing people to separate drinking or drugging from driving.
I’d like to thank all law enforcement officers who conduct SFSTs and remove alcohol-impaired drivers from our roadways. It may not seem as glamourous as other aspects of their job, but they are making our nation safer with this important work. These trained professionals help keep our roads safe and prevent families from losing a loved one to an impaired driving crash. It’s up to the rest of us to do our part to reach zero.
In this episode of Behind-the-Scene @NTSB, we chat with some of our summer interns—Keely, a junior at Virginia Tech; Lauren, a junior at Embry-Riddle Aeronautical University; Tim, a senior at the University of Maryland & Alexander, a junior at the University of Michigan. They’ll share how they discovered opportunities at the NTSB and what they learned about transportation safety and our agency’s role in improving it.
http://media.blubrry.com/behind_the_scene_ntsb/safetycompass.files.wordpress.com/2018/10/2018-08-07-erik-strickland-interviews-the-interns.mp3%20_blank%20rel=noopenerhttp://media.blubrry.com/behind_the_scene_ntsb/safetycompass.files.wordpress.com/2018/10/2018-08-07-erik-strickland-interviews-the-interns.mp3
Get the latest episode on Apple Podcasts , on Google Play, Stitcher, or your favorite podcast platform.
And find more ways to listen here: https://www.blubrry.com/behind_the_scene_ntsb/
By Dennis Jones, NTSB Managing Director
In my recent blog post, I talked about the NTSB’s visit to South Africa as part of the US Department of Transportation’s Safe Skies for Africa (SSFA) program. Last week, the NTSB team returned to Africa—this time, to the east African nation of Kenya—in continued support of the SSFA program, the aviation safety capacity-building initiative that includes collaboration between African countries and several US government agencies. In Kenya, as in South Africa, we once again shared investigative lessons learned with more than 150 air safety investigators, aviation trainers and operators, government officials, and safety advocates from Kenya and countries in the surrounding region.
I was particularly excited about this trip because I first traveled to Kenya for accident investigation purposes 20 years ago, and later, based in the capital city of Nairobi, I worked to implement the NTSB’s SSFA program responsibilities. The goal of the SSFA program in Kenya was to help the country achieve FAA Category 1 status and pave the way for direct scheduled commercial air service between the United States and Kenya. The NTSB’s contribution toward this goal was to help Kenya’s accident investigation program meet international standards in accordance with the provisions of the International Civil Aviation Organization’s (ICAO’s) Annex 13. Our activities included working with the Air Accident Investigation Division of Kenya (AAID) to develop its program, which included on-the-job investigator training; establishing policy, procedures, and practices for the organization; and producing memoranda of understanding between AAID and other domestic government agencies. The NTSB partnered with ICAO as part of the SSFA program to conduct aircraft accident investigation workshops throughout Africa; the first such event was held in Nairobi in 2007.
It took some time but, thanks to Kenya’s painstaking and diligent efforts, and the assistance provided by the SSFA program, Kenya achieved an FAA Category 1 rating in February 2017. Consequently, US and Kenya air carriers can now, with the approval of their respective regulatory agencies, travel between the two countries. Kenya Airways, Kenya’s national carrier, will launch its inaugural flight to the United States, destined to JFK International Airport in New York, in October 2018.
Although Kenya’s government is focused on improving aviation safety, the country—and, more broadly, the continent—still faces challenges that the region’s stakeholders are dedicated to overcoming. General aviation (GA) safety issues have been formidable in the region, just as they are in the United States, and we sought to share some of our experience addressing this issue. Further, through the SSFA initiative, NTSB representatives have recognized other modal transportation safety issues and safety advocacy opportunities for future consideration as the agency formulates its international scope of activities.
After accompanying the NTSB team to South Africa last month, I was fully confident in its ability to conduct the workshop in Nairobi. The team was composed of professionals representative of the superb workforce at the NTSB, and they delivered powerful presentations sharing lessons learned.
Shamicka Fulson, a program manager in the Office of the Managing Director, coordinated the development of the workshops in South Africa and Kenya. She delivered opening remarks and provided an overview of the agency and the SSFA program to begin the workshop in Nairobi.
Clint Crookshanks, an aerospace engineer in the Office of Aviation Safety, facilitated a workshop related to identifying common aviation safety lexicon. He reviewed different accident case studies with the audience and discussed ways to interpret the generalized and vague definitions often found in aviation investigations, such as “substantial damage to aircraft,” or the distinction between an “accident” and an “incident.”
Luke Schiada, Deputy Chief of Aviation Safety for the Eastern Region, presented accident case studies that highlighted international cooperation. Luke told the audience that he believed “international cooperation is, in large part, about building relationships and trust.” He stressed the importance of interacting with and learning from the collective knowledge and experiences of participants in settings like the SSFA workshops. I can’t agree more; after all, we can’t improve within unless we are willing and able to learn from without. Even sharing enables learning and growth.
Dennis Hogenson, Deputy Regional Chief of Aviation Safety for the Western Pacific Region, focused on GA safety improvements. He pointed out that, like Africa, the United States is seeing a high incidence of GA crashes. He told his audience that, while airline accidents have become rare, GA accidents account for most aviation fatalities. In many of our GA accident investigations, we’ve discovered that pilots didn’t have the adequate knowledge, skills, or recurrent training to fly safely. Dennis encouraged his African counterparts to initiate more training and increase awareness of technology that can help prevent these tragedies; this is something we continue to strive to do in the United States via our Most Wanted List issue addressing loss-of-control in flight.
Nicholas Worrell, Chief of the Safety Advocacy Division in the Office of Safety Recommendations and Communications, urged attendees—most of whom were investigators—to go beyond investigations to see real improvements in safety. The work doesn’t end with the report findings issued after the investigation; the work to improve safety just begins, he said. African safety organizations need to develop advocacy efforts and strategies to ensure their safety recommendations are implemented. Nick encouraged the audience to look to some of Kenya’s most notable leaders, like Jomo Kenyatta, political activist and Kenya’s first president, and Wangari Maathai, Nobel Peace Prize winner, both of whom saw a need for and executed effective advocacy to improve laws, policies, and practices.
The goal of our visit to Kenya was to continue fostering the development of a safer aviation transportation system in East Africa. It is integral to our mission at the NTSB to share globally what we have learned from 51 years of safety investigations. As the NTSB team supporting the SSFA program has shown, improving transportation safety is a collaborative process that doesn’t end at our borders.
By Member T. Bella Dinh-Zarr, PhD, MPH
5,987. That’s the number of pedestrians who died on our roadways in 2016. That’s 16 people every day across our country. But because these tragedies happen one by one, pedestrian deaths often fail to receive national attention. But as an agency dedicated to preventing transportation deaths and injuries, we know that must change.
In 2016, we held a public forum to address pedestrian safety. Experts from around the country discussed the data we need to better understand the risks, technology that could prevent vehicles from hitting people, and highway designs that offer safer roads or paths for pedestrians. Since that initial public meeting, we have conducted more than a dozen investigations into pedestrian deaths in order to gain insight into how we can prevent these deaths from happening.
Although the pedestrian crashes we investigated were not meant to be representative of nationwide data, the circumstances around the crashes were not unique—a child walking to school, an older man taking an evening walk around his neighborhood at dusk, a man walking his dog after lunch, a woman crossing a crowded city street, another leaving a bar at night. In most of the cases, the pedestrians were in crosswalks at intersections, and many occurred where speed limits were posted for 25–30 mph.
Historically, the NTSB has focused highway investigations on vehicle-to-vehicle collisions. But, having watched the trendline of pedestrian fatalities increasing steadily over the past 10 years, we are now calling attention to the problem of pedestrian safety. After all, although we may not all be drivers, we are all pedestrians. As communities embrace the goal of eliminating highway fatalities, preventing pedestrian crashes must be a top priority.
Tomorrow, September 25, 2018, the NTSB will examine the issue of pedestrian safety during a public Board meeting, beginning at 9:00 am. NTSB staff will present recommendations intended to improve pedestrian safety, and afterward, we will release the investigations, the special report, a supplemental data analysis report, and directions to a website that will allow people to examine the history of pedestrian fatalities in their own communities. In addition to being open to the public, the meeting will be webcast for interested parties who cannot attend in person.
Details of the investigations conducted in support of our pedestrian special investigation report will be available after the Board meeting on our NEW Pedestrian Safety page at the NTSB website: www.ntsb.gov/pedestrians.
By Nicholas Worrell, Chief, Safety Advocacy Division
Parents and teens, please read this blog together (not while you’re driving!).
When you hear “distracted driving,” you probably immediately think of the endless “don’t text and drive” campaigns across the nation each year. This is not without good reason—texting and driving is certainly one of the deadliest forms of distraction. Reading or responding to a text takes your eyes from the road for 5 seconds. If you’re traveling at 55 mph, that’s enough time to drive the entire length of a football field.
Today’s teens have grown up with near-constant access to social media. Some teens text and drive, even though they acknowledge it’s dangerous. According to a recent AAA poll, 94% of teen drivers acknowledge the dangers of texting and driving, but 35% admitted to doing it anyway. Modern teens are often inseparable from their phones. It’s hard to think of a scenario in which a teen isn’t pulling out a device to text, take a selfie, or access social media. Most of the time, this is a minor annoyance to those competing for a teen’s attention, but this habit playing out behind the wheel could kill someone.
Distracted driving can be as deadly as driving impaired—the law supports this fact. New laws are being implemented across the nation to curb distracted driving; for example, an Oregon law that went into effect July 1st punishes distracted drivers with consequences akin to those incurred by DUI offenders. And, like many of the other topics we’ve covered in our Back-to-School Safety Series—impairment, drowsy driving, and seat belts—“Eliminate Distractions” is on our Most Wanted List of transportation safety improvements.
But what many fail to realize is that distracted driving is more harmful for teens than DUI—teens who text and drive are involved in 6 times more car accidents than their drunk‑driving counterparts, making it statistically even more dangerous to drive distracted than to drink and drive (and that’s saying something, considering the common knowledge that drinking and driving is an often fatal, horrible idea). Distracted driving kills more teens than drunk driving. A 20-year-old’s reaction time while talking on a cell phone is equal to the reaction time of 70-year-old. Texting while driving increases crash risk 23 times over for drivers of all ages. Texting while driving now accounts for 1.6 million crashes a year—that’s 25% of all car crashes. It’s a bigger issue than a few typed words on a little cell phone screen would seem.
As we mentioned in our introductory blog, if children grow up watching their parents drive distracted without major incident, they’ll see the danger as slight and the behavior as acceptable. But what your children don’t know is that whether it’s the first time or the fiftieth, at any moment the statistics can catch up to you. The good news is that 62 percent of teens say they don’t text and drive when their parents remind them not to—so, starting now, remind your kids about the dangers of distracted driving, and then practice what you preach.
Take a moment now and talk about it. Make a family rule on distraction and hold each other accountable.
By Member Jennifer Homendy
Ten years ago today, September 12, 2008, a Metrolink commuter train filled with passengers in Chatsworth, California, collided head-on with a Union Pacific freight train. The collision took the lives of 25 people and injured 102 others. The cause: A texting engineer. A human operator making a human error.
On this 10th anniversary, we offer our condolences to all those who lost loved ones or were injured in the Chatsworth tragedy.
Although I was not a Member of the National Transportation Safety Board at that time, I was working tirelessly as the Staff Director of the Subcommittee on Railroads, Pipelines, and Hazardous Materials in the U.S. House of Representatives to mandate implementation of technology, called positive train control (PTC), which could have prevented the Chatsworth accident from occurring.
PTC is designed to automatically stop a train when a human operator fails to. Human error is the leading cause of all train accidents. Frustratingly, the NTSB has been recommending that railroads implement PTC to address human error-caused accidents for nearly 50 years.
In the wake of the Chatsworth collision and a number of others investigated by the NTSB, Congress passed the Rail Safety Improvement Act of 2008, which required freight, intercity passenger, and commuter railroads to implement PTC by the end of 2015. As the deadline approached, Congress extended it to 2018, with the possibility of further extensions until 2020. Now, as the new deadline approaches, PTC is still not fully implemented.
We know from railroad reports to the Federal Railroad Administration, the agency charged with regulating the railroads, that PTC is operational on only a small fraction of the railroad network.
Accidents, however, continue to occur. Since 2008, the NTSB has investigated 22 accidents that could have been prevented by PTC. Together, these accidents have resulted in 29 deaths, more than 500 injuries, and more than $190 million in property damage.
Tomorrow, Chairman Sumwalt will testify on Capitol Hill regarding the need to finish the job without further delay. Regrettably, nothing that the NTSB does can turn back the clock and change a tragic outcome; we can only urge that others be spared such an outcome in the future.
As the newest Member of the NTSB, I will continue to advocate for full implementation of PTC and for the safety recommendations we made as a result of the Chatsworth crash so that a similar tragedy is prevented in the future.
In the meantime, there is something you can do as we remember Chatsworth: eliminate distractions while operating a vehicle. Distraction continues to play a significant role in accidents.
Distracted driving kills thousands and injures hundreds of thousands every year. On the railroads, PTC is an effective backstop in case an operator is distracted, fatigued, impaired, or otherwise unable to take the right action. But operators must still adhere to strict procedures to minimize the chance of an accident.
On the highways, collision avoidance systems—forward collision warning systems and automatic emergency braking—are beginning to play a similar role to PTC. We think that these systems should be on every car, and we are working toward that outcome. But even without a collision avoidance system, you can take control by doing the right thing. Don’t send a text, make a call, or update your social media while driving. Strict laws aimed at preventing the use of portable electronic devices while driving and high-visibility enforcement can help, but ultimately, it’s up to each driver to drive attentively.
As we mark the 10th anniversary of the Chatsworth collision, we still have a long way to go to ensure the same kind of accident doesn’t happen again. But there are things we can do. We can insist railroads complete PTC implementation on all their tracks. We can choose vehicles with collision avoidance systems, and we can refuse to drive distracted.
Fatal collisions don’t end on impact; they echo through communities for years after the moment of a crash. But there can be hope as well as mourning in the echoes—hope for change that will prevent future tragedies. It will take all of us in transportation—professionals and the general public—to ensure the lessons learned from the Chatsworth tragedy result in that change.