Making Rail Transit Safer – In Our Own Backyard

By Mark Rosekind, PhD

Memb er Rosekind at the unveiling of the new WMATA train carsSummer in Washington and the city’s bustling Metrorail transit system is packed with tourists, interns, and the usual daily commuters including those I work with at the NTSB. It seems a fitting time to focus on rail transit safety, one of the agency’s Most Wanted List items of national transportation safety priorities.

Last week, I spoke to a gathering of the American Public Transportation Association’s (APTA) transit board members on what the NTSB does and how its recommendations enhance the traveling public’s safety.

I used the opportunity to highlight a success story from the agency’s own hometown, where a horrible tragedy and the NTSB’s Recommendations from that tragedy have helped make the nation’s second busiest rapid transit system, the Washington Metropolitan Area Transit Authority’s (WMATA) “Metro,” safer than ever. To quote former NTSB Chairman Deborah Hersman, “[It] has gone from worst to first” in safety.

The NTSB just recently closed three Recommendations issued in the aftermath of the 2009 Fort Totten Metro collision in which a lead rail car struck a stopped train. Nine people were killed and 52 were injured. Metro has worked hard to improve from that sad day and there is more good news. Of the 16 new Recommendations that came from that crash, the transit authority is setting its sights to close the remaining ones involing longer-term projects – such as replacement of Metro’s entire 1000-series fleet with new, safer 7000-series railcars. The first 7000-series trains are expected to enter service late this year and I recently rode one still under trials.

It was an eye-opening experience. These new railcars will provide Metro riders with some of the latest innovations in protection and safety. They are designed for greater crashworthiness and increased durability with advancements in technology that will help prevent future tragedies like the Ft. Totten crash.

The NTSB has made a total of 29 safety Recommendations to WMATA over the years and only five remain to be closed including the 7000-series railcar replacement. This is a noteworthy achievement and reflects the benefits of having a willing, conscientious transportation operator that can take the NTSB’s Recommendations and use them as a roadmap for greater safety. In the five years since Fort Totten, Metro has improved safety on multiple fronts…railcars…infrastructure…organizational culture. It is good to see and more remains to be done, because we never want to have another crash like Ft. Totten occur, but also because this is the transit system that serves all Americans in the nation’s capital, visitors, tourists, interns, and the general public. It must serve as a model for the country and the world. That begins with safety.


Mark Rosekind, Ph.D., is a Member of the National Transportation Safety Board. He is a frequent contributor to the NTSB blog.

Eliminating Substance-Impaired Driving: It Takes a Community

By Christopher A. Hart

Chairman Hart with the Rooneys Last week, in Columbus, Ohio, I had the opportunity to shine the spotlight on the problems of alcohol-impaired driving in a press conference, along with an opportunity in a research summit to address the problems of drug-impaired driving.

In the press conference, I expressed the NTSB’s support for Annie’s law, House Bill 469, which strengthens Ohio’s ignition interlock policies. Named for Anna Louise Rooney, the legislation, sponsored by State Representatives Gary Scherer and Terry Johnson, is a positive step toward eliminating alcohol-impaired driving. Certified ignition interlocks are crucial to curbing this public health problem because they force DWI offenders to prove that they are not alcohol-impaired before their cars can start.

During this press conference, I had the opportunity to witness the courage and strength of the Rooney family. Just over a year after losing their daughter, the Rooneys stood before the group and talked about their memories of Annie. I was struck by the stark reality that any one of us could be in a similar position. That’s why advocacy efforts like these are more than just a speech; it’s about helping to save lives, lives that could include you, me, or a loved one.

More than twenty states have enacted legislation that mandates that all DWI offenders have a certified ignition interlock installed in their vehicle. According to one estimate by the Insurance Institute for Highway Safety, if all drivers who had a prior alcohol-impaired driving conviction within the last three years used a zero-B.A.C interlock ignition, 1,100 lives would have been saved. Research over the last two decades has found that ignition interlocks reduce recidivism among DWI offenders by as much as 62-75 percent. With these facts in mind, the NTSB continues to work towards all fifty states adopting stricter interlock ignition laws. We hope that Annie’s law will motivate other states to take action.

The next day, I spoke at the Ohio Teen DUID Research Summit hosted by RADD and the Office of National Drug Control Policy. The summit brought top academics and government agencies together to discuss how we can address teenage drug-impaired driving. In my remarks, I focused on NTSB’s concerns with DUID (driving under the influence of drugs) and outlined some ways to address the problem.

It will take improvements in three areas: education, legislation, and enforcement. Better education will give drivers, including teenage drivers, a more thorough understanding of the dangers of drug-impaired driving. Stronger legislation is needed to deter all forms of substance-impaired driving, not just alcohol-impaired driving. Improved enforcement will remove offenders from the roadway before they become a danger to themselves or others. According to the 2011 National Survey of Drug Use and Health, one in eight young drivers between the age of 18-25 report using drugs while driving; we can’t wait until drug-impaired driving is as prevalent as alcohol-impaired driving before we take action to end DUID.

My trip to Ohio showed that positive steps can be taken to reach our goal of eliminating substance-impaired driving. Annie’s Law is an excellent example of lawmakers working towards making our roads safer. The NTSB commends Ohio for getting serious about ignition interlocks. I was honored to participate in the Ohio Teen DUID Research Summit and invigorated to see so many experts come together to tackle the problem of teenage DUID.

If we continue to enact strong legislation and come together to exchange ideas, we can reach zero substance-impaired driving deaths sooner rather than later.

A Transportation Safety Need . . . 25 Years Later

By Christopher A. Hart  

On July 19, 1989, the unthinkable happened –fragments from an uncontained engine explosion took out all three independent hydraulic systems of a DC-10 traveling from Denver to Chicago, rendering all flight controls ineffective. Then an amazing thing happened – despite this catastrophic event, the pilots and emergency responders were able to save 185 [1] of the 296 people on board when the plane crashed in Sioux City, Iowa. The NTSB’s investigation of this accident led to 25 recommendations and advancements in aviation safety, including research on non-destructive inspection techniques for rotating engine parts and reliability of flight controls. Twenty-five years later, however, one issue that remains unaddressed is the issue of allowing lap-held infants.

For more than 30 years, the NTSB has investigated aircraft accidents involving unrestrained children and has issued safety recommendations asking the FAA to require that children under age 2 be appropriately secured in a child restraint. Unlike when they are riding in a car, children under age 2 on an airplane are permitted to travel unrestrained. However, adults may not be able to maintain a secure hold on a lap-held child during turbulence or survivable accidents, as appears to have been the case with this united flight. Preventable deaths and injuries have occurred in children under age 2 who were unrestrained.

We issued our most recent recommendation addressing this concern following the investigation of the March 22, 2009, crash of a private plane carrying a pilot and 13 passengers in Butte, Montana. The plane was equipped with only 10 seats; however, the investigation determined that some seats were occupied by two passengers. We asked the FAA to mandate child seats for all passengers, including those in general aviation aircraft. In response to this and previous recommendations, the FAA has encouraged, but not required, parents to use appropriate restraints for children under 2, on the basis of their concerns that parents may choose to drive to their destination instead of flying if they are required to purchase another seat for their infants, but the likelihood of death or injury is greater from driving than from flying.

Meanwhile, the problem remains. Earlier this year, a United Airlines flight encountered severe turbulence while flying from Denver to Billings, Montana. While it’s not uncommon to hear reports of planes encountering turbulence and passengers being jostled around in their seats, what was particularly concerning about this incident was that a baby who was traveling on a parent’s lap received minor injuries.

The safety of infants and children on aircraft was discussed at the 38th Session of the International Civil Aviation Organization (ICAO) General Assembly, held in September 2013. The Assembly identified the need for recommended practices encouraging air operators to use child restraint devices appropriate to each child’s size and weight, as well as guidance for regulations related to child restraints and the use of different types of devices. The NTSB is supporting ICAO’s efforts by providing an advisor to the ICAO Cabin Safety Working Group. This group is focusing on the importance of developing guidance material to assist ICAO member states and operators to implement the use of child restraint system and enhance safety of infants and children on board aircraft in an internationally harmonized manner.

Parents want to keep their children as safe as possible. When parents drive, they look to state laws for guidance on how to properly restrain our children; when they fly, they look to the FAA or airline to determine how to best restrain our children during flight. Unfortunately, the laws and regulations for flying with our children don’t always reflect what is best or safest. The NTSB has long recommended and advocated for children to be properly secured in a restraint appropriate for their size, whether flying or driving.

On that fateful day twenty-five years ago, United Airlines Flight 232 approached Sioux City airport at over 240 miles per hour. What the pilots were able to accomplish was remarkable. The fact that the parents of two lap children couldn’t hold on to their babies, however, was not surprising. Another passenger found one of the babies and was able to get her out of the plane; the other infant did not survive. Lap babies rarely die in airplane crashes, but those statistics are little comfort the families that have suffered such a loss.

After pursuing this issue for decades, we are very disappointed that there has been little progress. We are encouraged, however, that ICAO has begun discussing the issue, and we hope that those activities will bear fruit in the foreseeable future.


[1] One passenger survived the initial crash, but died 31 days later. For the purposes of the NTSB report, this passenger’s injuries were classified as “serious.”

Sleep Apnea: Why Everyone Who Travels Is at Risk

By Mark Rosekind, PhD

A man asleep while drivingThe NTSB has long sounded the alarm on the subject of obstructive sleep apnea (OSA), its adverse effect on sleep quality, and the significant safety risks associated with human fatigue in transportation operations. For over 40 years, the NTSB has identified fatigue as a problem and OSA as one of its several causes. It is a common fatigue-inducing medical disorder that affects pilots, drivers, captains, and conductors. This stealth impairment affects transportation safety in every mode and it often remains undiagnosed. It places everyone in the traveling public at risk and I recently had the opportunity to discuss sleep apnea and transportation safety on ABC’s Nightline.

The NTSB has issued more than 200 safety recommendations on fatigue and it was on our Most Wanted List of critical transportation safety issues from 1990 to 2011. Take, for example, NTSB recommendations with extensive background on OSA resulting from a 2008 incident in which a go! Airlines captain and first officer fell asleep and flew past their destination airport in Hilo, Hawaii. Excessive daytime sleepiness due to fatigue resulting from the captain’s undiagnosed sleep apnea contributed to the incident.

Three of the NTSB recommendations apply specifically to OSA, and the critical issue of diagnosis and treatment. Although these particular recommendations are specific to this aviation incident, they have tremendous applicability to every other form of transportation and call for:

  1. getting at an early stage specific information about any previous diagnosis of obstructive sleep apnea and the presence of specific risk factors for that disorder;
  2. implementing a program to identify those at high risk for obstructive sleep apnea and requiring that high risk individuals provide evidence of having been appropriately evaluated and, if treatment is needed, effectively treated for that disorder before being granted permission to operate; and
  3. developing and disseminating guidance for operators, employers, and physicians regarding the identification and treatment of individuals at high risk of obstructive sleep apnea, emphasizing that operators who have obstructive sleep apnea – effectively treated – are routinely approved to continue their job.

The problem of undiagnosed sleep disorders such as OSA has received some attention in aviation as well as commercial trucking, but the chronic issue has applicability throughout transportation.

Because sleep apnea leads to excessive daytime fatigue, increases the risk of accidents, impairs cognitive skills, substantially elevates the likelihood of critical errors and falling asleep, and because many individuals who have the disorder do not know they have it, the NTSB has been eminently clear in specific recommendations on identifying and treating the disorder to ensure the safety of the traveling public. With treatment, sleep can be improved, OSA symptoms reduced, and adverse effects reversed, leading to a return to normal and safe operations. It is a priority that this agency cannot ignore.


Mark Rosekind, Ph.D., is a Member of the National Transportation Safety Board. He is a frequent contributor to the NTSB blog.

Beach Reading

By Tracy Murrell

One year ago, on July 1, 2013, two young women were seriously injured while parasailing in Panama City Beach, Florida. Their towline broke in high winds, sending their canopy on a terrifying, unconparasailingreporttrolled flight into the concrete face of a beachfront condominium, before they finally fell onto the roof of a parked car.

What started as a chance to enjoy an hour of the thrill, adventure, and panoramic views of parasailing, resulted in many months of painful recovery from serious injuries.

The NTSB has released a special investigation report focused on parasailing safety, and a safety alert to operators of parasailing businesses.

Three to five million Americans enjoy parasailing every year and the majority of those experiences end without incident. But when something does go wrong, the consequences can be deadly. The NTSB Special Investigation Report looked at accidents in parasailing, and what can be done to prevent them in the future.

As Acting Chairman Christopher A. Hart said,

“An afternoon of parasailing can have tragic results if something as simple as a weak towline, strong winds, or a worn harness causes a serious accident. It is crucial that operators are competent and aware of all the risks associated with parasailing.”

Right now, no federal regulations or guidelines establish specific training or certification requirements for parasailing operators, and with the exception of a few states, there is no requirement to suspend operations in bad weather.

The NTSB’s experience is that voluntary standards are only as good as those operators who choose to use them. Inevitably, some operators cut corners on safety to save on costs. But establishing a single standard of safety levels the playing field for those safety-conscious operators.

In the report, the NTSB makes recommendations to the United States Coast Guard and the Federal Aviation Administration to bridge the regulatory gap. We also recommend that the National Association of State Boating Law Administrators draft a model act as a basis for state legislation.

In the safety alert, we spell out what operators of parasailing businesses can do now to raise the level of safety in their operations.

If you’re an operator of a parasailing business, we urge you to read the alert. Replace equipment as appropriate. And, if you have any doubt about weather or any other factor described in the alert, err on the side of caution.

If you’re planning to parasail this weekend, don’t put your safety solely in the hands of others.

Before you parasail, do your homework. Research the company, ask questions and be curious. Be aware of the weather forecast and look at the equipment your operator is using. Simple things like frayed ropes may be easy to spot.

And don’t hesitate to ask the operators of the parasailing business you use whether they’ve seen the report and safety alert. If they have not, urge them to review it.

Because safety never takes a holiday.


Tracy Murrell is Director of NTSB’s Office of Marine Safety.

NTSB’s Role in the Freedom of Information

By Joy White

Declaration of IndependenceTomorrow, many of us will gather to celebrate Independence Day, the first step our nation took to becoming a democracy. In signing the Freedom of Information Act (FOIA) on July 4, 1966, President Lyndon Johnson said, “This legislation springs from one of our most essential principles: a democracy works best when the people have all the information that the security of the nation will permit.”

FOIA gives everyone rights to a federal agency’s records upon request. It is a law that keeps citizens in the know about their government. Under FOIA, agencies must disclose any information that is requested unless the information is protected from public disclosure. As part of the Executive Branch, the National Transportation Safety Board is mandated by Congress to make those records available to the public as appropriate. The fact is that our compliance with FOIA is an important component of our mission, Independently Advancing Transportation Safety, and our core values of transparency, accountability, integrity, diversity, and inclusion.

I started at the NTSB in 1993 working in the Office of Research and Engineering. As I reflect on my tenure here at the NTSB and the moment I began to understand the accident investigation process, I remember the first accident in which I had an opportunity to provide assistance—the crash of US Flight 427 in Aliquippa, Pennsylvania on September 8, 1994, where the entire aircraft was destroyed and no one survived. I was part of a group that had the daunting task of sorting through wreckage, personal affects, and meeting with families of the victims and other parties involved in the investigation. Little did I know that a few years later, I would move to an office to process and train other personnel to process FOIA requests. It is because of my experience working this and other accident investigations that I have an understanding for why investigators collect so much information.

What does it take to process a FOIA request for the NTSB? As you may imagine, most of those requests address our accident investigations, and our investigators are very thorough. They collect massive amounts of records, maintenance documents, licensing and certification documents, notes, audio/videotapes, photographs, as well as information from other agencies who were a party to the investigation. When forwarded to the FOIA team (my colleague Tamara Crawford and myself), we meticulously review thousands of pages to eliminate duplicates, identify sensitive and non-releasable information, and apply redactions.

To enlighten you on just how complicated a FOIA request can be, we must review all documents from 1 to over 10,000 pages submitted by our investigators, including large maps, charts, graphs, notes, thousands of photographs, and animations. We also have to assess whether exemptions preventing release would apply. In some cases, we create a log to keep track of all investigative materials received.

As a part of the FOIA team since 1997, I can say that we have come a long way when it comes to granting the public access to our records. It is our responsibility at the NTSB to serve the general public and provide openness to our investigative process. Our files are now maintained electronically, and we have purchased FOIA tracking software that helps with the redaction process and tracking the requesters. Just in Fiscal Year 2013, we received over 450 FOIA requests, most of which were the very complicated “any and all” requests; with only two FOIA analysts, electronic tools are invaluable! We have also established a Public Access Link to provide requesters with the benefit of tracking their individual request. Proactive policy changes have been made to include posting frequently requested accident documents online.

The overall goal of the NTSB FOIA process is to improve accountability and transparency. Efforts are continually being made to enhance the process and maintain the success of the program in serving the American people. In 1822, President James Madison stated, “A popular Government without popular information or the means of acquiring it, is but a Prologue to a Farce or a Tragedy or perhaps both. Knowledge will forever govern ignorance, and a people who mean to be their own Governors, must arm themselves with the power knowledge gives.” I think FOIA is in keeping with those principles so well-articulated by President Madison.


Joy White is a FOIA Specialist in NTSB’s Records Management Division

From Bad to Worse: Kids and Impaired Driving Crashes

By Danielle Roeber

dontdrinkanddriveGetting together with family and friends on Independence Day is a tradition. And with this July 4th falling on a Friday, a lot of people will be on the roads to enjoy a long weekend. At this time of year, it’s not uncommon to hear messages about celebrating safely and not driving after drinking. As we prepare to travel, I want to bring to your attention something that may not be as well-known. According to an article released last month in Pediatrics,of those children who died in impaired driving crashes in the last decade, 65 percent were riding with the impaired driver. And the median blood alcohol concentration of the impaired drivers was 0.15, almost twice the legal limit.

What could be worse than adults driving under the influence of alcohol or drugs with children in the vehicle? As it turns out, those kids are also unlikely to be restrained by seat belts or child safety seats, putting them at even greater risk of injury or death in the event of a crash. In those cases where researchers could determine restraint use, 61 percent of the children killed while riding with an impaired driver were not restrained. Meanwhile, 71 percent of those impaired drivers survived the crash and had to live with the consequences. How might the use of a child seat or a seat belt have made a difference?

It gets even worse. A similar analysis was released in 2000 in the Journal of the American Medical Association. The researchers examined child passenger deaths from 1985-1996 and found eerily similar results; 64 percent of those child passengers killed in impaired driving crashes were riding with the impaired driver. And again, many of those child passengers who died were unrestrained.

What will it take to keep impaired drivers from putting children at risk? Increasing restraint use is certainly critical. Another intervention worth considering is mandating ignition interlocks for all individuals convicted of driving while impaired (DWI); many of the impaired drivers who were transporting children had prior DWI convictions. You don’t have to wait for a law, however. If you plan to drink this weekend or anytime in the future, make a plan for how you will get you and your family home safely. Make sure anyone transporting your children understands the risks and doesn’t get behind the wheel after drinking. No one should have to pay for someone’s decision to drive impaired, least of all our children.


Danielle Roeber is the Safety Advocacy Division Chief in NTSB’s Office of Communications

 

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