Episode 2- Member Christopher Hart

In this episode of Behind-the-Scene @ NTSB, we chat with Board Member Christopher Hart. He shares how he got interested in aviation and the path that led to a pilot’s license and law degree. Join us as he shares his unique experience of serving as a Board Member in the 90’s and then again in the 2000’s.

Get the latest episode on Apple Podcasts or on Google Play.

And find more ways to listen here: https://www.blubrry.com/behind_the_scene_ntsb/

Why Teen Driver Safety Week Should be Every Week

By: Nicholas Worrell, Chief, NTSB Safety Advocacy Division

Driving is a privilege that gives us the freedom to go where we want, when we want, with whom we want. The benefits of driving are especially attractive to teenagers. Driving is a milestone for teens, but with great power and freedom comes great responsibility.

Motor vehicle crashes are the leading cause of death among teenagers; more teens die in crashes than from drug/alcohol abuse, violence, or disease. In 2016, more than 3,600 teenagers died on our highways, a 4 percent increase from 2015. To address these tragic statistics, the third week of October was designated by Congress as National Teen Driver Safety Week. During this week, advocates, government agencies, communities, and educators aim to promote teen driver safety and eliminate a preventable tragic problem. Especially during this week, we all need to come together to keep simple mistakes from impacting the future of our country.

Today, the NTSB joined the National Organizations for Youth Safety (NOYS) and students from Maryland and Virginia high schools for NOYS’ Youth Interactive Traffic Safety Lab. The event provided hands-on activities for students to learn about a variety of driving safety issues—from auto maintenance and work zone navigation to distracted and impaired driving. Traffic safety experts and community leaders spoke with students about what it means to be a “responsible” driver and the very real consequences of complacency. In a pre-event press conference, NTSB’s Kris Poland, PhD; Maryland’s First Lady Yumi Hogan; Maryland Motor Vehicle Administrator Christine Nizer; and NOYS Interim Executive Director April Rai reminded teens that, while motor vehicle crashes are the leading cause of death for teens, these crashes are preventable. One key message to teens: you have the power to change this reality.

Students also had the opportunity to talk with NTSB investigators and safety advocates to learn about our crash investigations and the safety recommendations we’ve made to improve safety for all road users—especially our recommendations for preventing teen driving crashes and their resulting injuries and deaths.

While events like the NOYS Safety Lab helps to arm students with some of the tools needed to make the right choice, we need the help of parents, other influencing adults, school officials, local government, and community leaders to help make the biggest impact. Parents, in particular, play a critical role. They should have a meaningful discussion with their new driver about the key components of driving and the thinking behind certain driving decisions. Parents must take time to outline the risks associated with driving, such as distractions, fatigue (due either from lack of sleep or fatiguing medications), other impairments, and speeding. Sometimes, making safety a priority requires establishing new priorities in the household and a shift in “family culture.” The best way to promote safety is to practice safety and treat it seriously through education, discussion, and role modeling.

 At the NTSB, we strive every day to advocate safety in the many modes of transportation. Our Most Wanted List of transportation safety improvements is designed to address our most critical safety issues. We are successful when people engage, learn strategies to improve the lives of themselves and those around them, and execute these strategies to save lives and prevent injuries. I urge you to become an advocate—not only this week, but every week—for driving safely.

 

If you have any questions about teen driving or NTSB advocacy activities in this area, email SafetyAdvocacy@NTSB.gov. We also encourage you to follow us on Twitter @NTSB and Facebook and Instagram @NTSBgov.

 

 

Episode 1- Chairman Robert Sumwalt

In our first “real” episode of Behind-the-Scene @ NTSB, we chat with Chairman Robert Sumwalt and find out what got him interested in aviation. This interest turned into a passion not just for aviation, but for all transportation. We also talk about his views on leadership and how it can apply to creating strong safety systems.

Get the latest episode on Apple Podcasts or on Google Play.

And find more ways to listen here: https://www.blubrry.com/behind_the_scene_ntsb/

 

International Advocacy to Prepare and Prevent

By Nicholas Worrell

I recently had the privilege of speaking in Manchester, England, at the National Safer Roads Partnerships Conference. The United Kingdom has some of the lowest road-user fatality rates in the world. While our annual vehicle miles traveled vary greatly, on a typical day, about 109 road users are killed on America’s roadways, while only 5 Britons lose their lives the same way. But, as I reminded the conference audience, even one fatality is still too many.

This was a unique opportunity to represent the NTSB because the audience was mainly British law enforcement officers, and the British tradition of “policing by consent” was tailor‑made for a prevention-focused discussion. Policing by consent means that, because most people want law and order, the goal should be to prevent crime rather than focus on punishing perpetrators. Our Safety Advocacy Division operates with much the same philosophy, working to prevent transportation accidents by encouraging stakeholders to implement the agency’s recommendations. We also explain road safety to vulnerable populations, such as young drivers, to bring lifesaving information to the traveling public, and we share our findings with colleagues.

We know that, as we face coming challenges in road safety, prevention opportunities abound. Our recent speeding study noted the value of a “safe system” approach, which depends on layers of safety in a given road environment and recognizes preventive uses of technology, such as automated speed enforcement. Our recent investigation into the fatal crash of a partially automated vehicle allowed us to consider the double-edged sword of automation. Our investigations have shown that, as vehicles rely more and more on automated sensors, they also collect more data, which should be gathered in a standard format and reported when vehicles with enabled control systems crash.

The world is changing, crash factors are changing, and our tools are changing. The data that cars themselves can provide about crashes is expanding. As I told the law enforcement officers in Manchester, the NTSB has learned that everything an accident can tell us is worth our attention. We are conscious that every safety lesson learned is worth retelling, both to spur acceptance of our recommendations and to prepare ourselves, our colleagues, and the public for the challenges of a fast-approaching future. By sharing lessons learned across borders, we improve our chances at reaching zero transportation fatalities worldwide.

 

Nicholas Worrell is Chief of the NTSB Safety Advocacy Division.

 

Lessons from Our Runway Incursion Forum

By Member Christopher Hart

On September 19 and 20, the NTSB held a Runway Incursion Forum featuring some of the industry’s foremost runway safety experts. These experts came from far and wide, and from a variety of aviation associations, companies, research organizations, government agencies, and airports. It was a very thought‑provoking event, and I believe we had the right people at the table to address an increasing trend in the most significant (Levels A and B) runway incursion events.

NTSB Runway Incursion Participants
Member Hart and NTSB staff with Runway Incursion Forum participants.

The aviation industry has proven itself to be adept at tackling challenging safety issues. In the early 1990s, the fatal commercial aviation accident rate that had been declining for several decades began to plateau. Many safety experts concluded that further reduction in the rate was unlikely because the plateaued rate was already exemplary. Nonetheless, concerned that the volume of flying was projected to double in the next 15­–20 years—and with it, if the rate remained flat, the number of airline crashes—the industry began an unprecedented voluntary collaborative safety improvement program to further reduce the accident rate. This program was called the Commercial Aviation Safety Team, or CAST. Amazingly, CAST reduced the flat fatality rate by more than 80 percent in only 10 years.

Perhaps the most difficult challenge that we are currently facing regarding runway incursions is pursuing additional remedies in the absence of an accident. The industry is frequently accused of having a “tombstone” mentality: attempting to improve safety only when there’s a major accident. I applaud the efforts of the FAA, the general aviation community, the commercial aviation industry, and the airports, along with the front-line vigilance of the pilots, air traffic controllers, and airport operators who live and breathe this issue every day, to proactively identify ways of driving down the numbers. It’s a sign of this vigilance that they came together out of our common concern about the apparent turnaround from the previous downward trend in A and B incursions.

So, what did we learn from our forum? First and foremost, the staff who organized this event recognized one of the major lessons learned from the CAST collaboration: that everyone who is involved in a problem should be involved in developing the solution. Hence, we invited pilots, air traffic controllers, airport operators, affected industry organizations, and the regulator (the FAA), as well as those who collect and analyze the data­—in other words, everyone who is involved in the problem—to discuss their perspectives on the runway incursion problem.

Each participant emphasized the need for more and better data: data to help us identify the problems, determine what caused them, develop interventions, and determine whether the interventions are accomplishing the desired result. We need to determine how to collect better data, how to analyze the data more effectively, and, pursuing the collaboration concept, how to share the data more effectively, both with peers and with other participants in the system.

Perhaps the most challenging issues that warrant better data are the human factors issues regarding human limitations and vulnerabilities, and determining how humans can interact most effectively with rapidly advancing technologies. There has been considerable progress in understanding human factors in the cockpit, and it was interesting to hear in the forum about the development of a new program that also aims to enhance our understanding of human factors issues that affect air traffic controllers.

Participants at the forum also discussed several exciting new technologies—in the cockpit, in air traffic control facilities, at airports, and in airport ground vehicles—to help increase the situational awareness of pilots, controllers, and vehicle operators. We heard of many activities by the airport community to address “hot spots,” the places on the airport surface where runway incursions are occurring most frequently. These activities include changing procedures, improving training, adding new technologies, and making major capital improvements to modify airport geometry.

NTSB Runway Incursion Forum
Member Hart leads a roundtable discussion during the Runway Incursion Forum.

Runway incursions are increasing amidst a culture that, in the last 15–20 years, has become more sensitized to their potential danger. What is needed is both site‑specific remedies (due to the uniqueness of every airport) and systemic remedies that address the system’s commonalities. Through their presentations and active participation in our forum, it became clear to me that our forum participants refuse to wait for an accident to begin making improvements.

We heard from multiple participants that about 80 percent of runway incursions involve general aviation aircraft. Although the creation of new collaboration networks, such as the General Aviation Joint Steering Committee (GAJSC), is beginning to bring general aviation stakeholders more consistently into the runway incursion prevention conversation, we learned that the effort to bring all stakeholders to the table must continue, which is a challenge because the general aviation community is very broad and multifaceted.

I am optimistic that government, airlines, airports, and others will follow up on the most important directions that we collaboratively identified in the forum, and that they will continue to develop and deploy new solutions to the complex problem of runway incursions.

The full agenda, speaker biographies and a recording of the forum are available at https://go.usa.gov/xRhpC.

Inside the NTSB’s General Aviation Investigative Process

The Nuts and Bolts

By Aaron Sauer

This is the sixth blog in a new series of posts about the NTSB’s general aviation investigative process. This series, written by NTSB staff, explores how medical, mechanical, and general safety issues are examined in our investigations.

 

The public’s image of our agency is often based on the iconic blue and yellow NTSBNTSB Investigators Onscene jacket they see at accident scenes. What’s less well known is that examining and documenting on-scene evidence is just one step in an exhaustive process to gather all available information, determine a cause, and recommend any changes that can prevent similar accidents.

Since 2014, 12 percent of general aviation accidents—about three accidents every week—have involved a power plant malfunction. These malfunctions may include a fuel issue, component failure, or improper maintenance.  As an NTSB air safety investigator, I investigate such mechanical malfunctions, gather the facts of the investigation, and ultimately help determine the probable causes of accidents.

After the on-scene phase of the investigation is complete, the airplane wreckage is often recovered by professional recovery services and stored in a secure location until we determine if further NTSB investigation is needed. When circumstances, such as a large hole in the engine crankcase or the in-flight loss of a propeller, indicate that further examination is necessary, we work with the airframe, engine, and component manufacturers. These entities serve as parties to our investigation, providing technical expertise on their product. If required, we coordinate a follow-up plan to examine the aircraft wreckage in greater detail. At the accident scene or recovery facility, our investigators examining the machine determine the scope of follow-up based on any anomalies discovered.

In some accidents involving a reported loss of engine power, the initial examination (typically a 100-hour inspection) turns up no obvious anomalies. At this point, one of the best and most telling follow-up activities is to attempt an engine test run. Engine test runs may be performed at a recovery facility or at a manufacturer’s facility. A successful engine test run is a critical piece of information that may lead the investigation down another path.

When, upon initial examination, the investigator observes an engine issue consistent with an internal mechanical failure, it’s typical to disassemble the engine at the manufacturer’s facility or the recovery facility under NTSB supervision. Examining an engine at the manufacturing facility often provides the advantage of having available engineering staff, historical data and drawings, and proper test equipment for the engine components.

Once at the manufacturer’s facility, the investigation team (typically including NTSB, FAA, and airframe, engine, and component manufacturer personnel) determines the plan or approved test procedure for the detailed investigation. The scope of the investigation is determined based on the known facts and circumstances of the accident, the condition of the engine and components, and the work required to confirm the failure. It’s important to note that, although the parties work collaboratively, the NTSB has the final say if there is any disagreement in the investigation process.

Engine functional testing, partial disassembly, and full engine disassembly are the most common investigation techniques used to determine the cause of a failure or malfunction. Disassembly helps us identify fractured or broken parts, which are then documented and set aside for even further examination.

Most manufacturers have their own materials laboratory, metallurgists, and engineers. At this point and with the team present, our investigators may elect to use the manufacturer’s material laboratory for a preliminary examination to obtain a quick analysis of the failure mode, then forward the parts to our materials laboratory in Washington, DC, for a detailed metallurgical examination.

Even observers with a solid understanding of our processes beyond the on-scene images might not understand the many ways that NTSB investigations can improve safety. Even when all signs point to a mechanical malfunction, our investigative process still looks at two other factors: human and environment. When an accident involves reported loss of engine power, we gather information about the pilot and aircraft owner—documentation from the scene, aircraft records, and Federal Aviation Administration (FAA) records. We interview witnesses, visit and examine maintenance facilities, and meet with manufacturers. When necessary, we conduct follow-up examinations and interviews. If FAA inspectors handle the initial on-scene observations, we work hard to guarantee that our two agencies communicate effectively.

When the fact-gathering phase of the investigation is complete, our investigators compile all the relevant factual information, complete a detailed factual report, and create a public accident docket. For an engine failure accident, the docket may include engine reports, materials laboratory reports, aircraft records, and historical engine safety information in the form of service bulletins and airworthiness directives.

Many people understand that we may make recommendations at any point during an investigation, but sometimes our investigations also result in other actions to improve safety. For example, depending on the nature of the material failure, an NTSB investigator may work with the FAA or the manufacturer to issue a manufacturer service bulletin, service letter, safety notice, or a potential airworthiness directive. The safety action taken by the FAA or manufacturer depends on the failure’s cause, fleet exposure, and the potential safety awareness benefit of each product.

Over my 17 years as an NTSB investigator, I’ve investigated numerous engine-failure–related accidents that resulted from human error and material failure. Despite the varied causes and outcomes of these accidents, one fact stands out: proper maintenance is the best way to avoid catastrophic consequences. Following manufacturer-recommended maintenance practices and procedures and adhering to basic maintenance principles can prevent accidents.

Remember: SAFETY is NO ACCIDENT!

All accident reports and public accident dockets are available on the NTSB website:  www.ntsb.gov.

 

¿Qué se puede hacer para mejorar la seguridad del transporte de los trabajadores agrícolas migratorios?

Por Jennifer Morrison

Este Domingo pasado marcó el aniversario del choque de carretera más mortífero de la historia de Estados Unidos. Hace cincuenta y cuatro años, el 17 de septiembre de 1963, un autobús improvisado que transportaba 58 trabajadores agrícolas migratorios chocó con un tren de carga cerca de la ciudad de Chualar, California (consulte la figura 1) 32 personas murieron y 25 sufrieron lesiones. Los trabajadores que venían en el autobús estaban regresando de un campo de trabajo después de una jornada de diez horas recolectando apio en el Valle Salinas. Los pasajeros se transportaban en dos bancos largos colocados a lo largo de un camión de plataforma que estaba cubierto con un toldo.

LA Times Headline
Titular e imagen del ejemplar del 18 de septiembre de 1963 de Los Angeles Times. En ese momento se creía que solo 27 personas habían perdido la vida pero el número de víctimas ascendió a 32.

Otro choque mortal de trabajadores agrícolas migrantes ocurrió en la década de 1970. El 15 de enero de 1974, la Junta para la seguridad del transporte nacional (National Transportation Security Board, NTSB) investigó un choque que involucró 46 trabajadores agrícolas migrantes cerca de Blythe, California. Un autobús de trabajadores agrícolas que viajaba por una carretera rural no pudo tomar una curva de la carretera y cayó al fondo de una zanja de desagüe. El autobús quedó apoyado en su lado izquierdo, parcialmente sumergido. Murieron diecinueve de sus ocupantes, incluyendo el chofer. En la mitad del último siglo se han efectuado numerosas mejoras en la seguridad del transporte y sin embargo ocurren choques catastróficos y la seguridad de los trabajadores agrícolas migrantes continúa siendo un problema.

Específicamente, durante el período de ocho meses desde noviembre de 2015 hasta julio de 2016, la NTSB investigó tres choques con numerosas muertes en los cuales 16 personas murieron y otros 57 resultaron lesionados. La mayoría de los fallecidos y lesionados eran trabajadores agrícolas migrantes que se transportaban hacia o desde granjas. La finalidad de nuestra investigación sobre estos choques es conocer sobre estas tragedias y responder la pregunta importante: ¿Qué se puede hacer para mejorar la seguridad del transporte de los trabajadores agrícolas migrantes?

Esta semana la NTSB abrirá el expediente público de 1,125 páginas de información documentando nuestra investigación en curso sobre el choque del 2 de julio de 2016 cerca de St. Marks, Florida. El choque involucró un autobús de trabajadores agrícolas que transportaba más de 30 personas desde una granja en Georgia a Belle Glade, Florida. El autobús no se detuvo en la intersección de la carretera estatal 363 y la autopista US 98, la cual estaba marcada con un cartel de señal de pare y una luz intermitente en rojo de señal de “pare”, y este fue impactado por un vehículo de tipo combinado de semirremolque con tractor de remolque. Después del choque se produjo un incendio y el chofer del camión y tres pasajeros del autobús perecieron (Consulte la figura 2).

El 28 de noviembre de 2017, la NTSB llevará a cabo una reunión pública de la junta para discutir las conclusiones de la investigación del choque de St. Marks, su causa probable y las recomendaciones de seguridad destinadas a prevenir choques futuros.  En la reunión la NTSB también revisará las circunstancias de los choques de Little Rock, Arkansas y Ruther Glen, Virginia (Consulte la figura 2).

Investigation Images
(Parte superior) Autobús y camión involucrados en el choque de St. Marks, Florida en su etapa final (Fuente:  Patrulla de carreteras de Florida). (Parte inferior izquierda)  Autobús involucrado en el choque de Little Rock, Arkansas mostrando la porción de la parte posterior faltante y el techo dañado.  (Parte inferior derecha) Camioneta para 15 pasajeros involucrada en el choque Ruther Glen, Virginia mostrando el techo deformado.

El choque de Little Rock ocurrió el 6 de noviembre de 2015, cuando un autobús que transportaba 20 trabajadores agrícolas desde Michigan a Texas se salió de la Interestatal 40 y chocó con una barrera de concreto.  El choque con la barrera ocasionó que el autobús se montara en el costado de la barrera y el techo del autobús impactara la columna de un puente que apoyaba el viaducto de la autopista. Como resultado del choque, 6 pasajeros del autobús perecieron.

El choque de Ruther Glen ocurrió el 8 de junio de 2016, cuando una camioneta para 15 pasajeros que transportaba 16 ocupantes, la mayoría de los cuales eran trabajadores agrícolas migrantes, se salió de la Interestatal 95. La camioneta se desplazó hacia la derecha por todos los canales de circulación e impactó a otro carro de pasajeros antes de volcarse varias veces.  Seis de los pasajeros de la camioneta salieron impelidos y fallecieron.

Al examinar la supervisión de los transportistas federales y estatales que participan en el transporte de trabajadores agrícolas, los mecanismos de las regulaciones de seguridad, la divulgación y la educación de la comunidad agrícola y las mejores prácticas de los estados individuales, esperamos desarrollar recomendaciones de seguridad para mejorar la seguridad del transporte de los trabajadores agrícolas migratorios y evitar tragedias futuras.

Asista a la reunión del 28 de noviembre de 2017, en persona o mírela en la transmisión por la web donde se tratarán las investigaciones de los choques de St. Marks y otros con las propuestas a la pregunta: ¿Qué se puede hacer para mejorar la seguridad del transporte de los trabajadores agrícolas migratorios?

Jennifer Morrison es una investigadora encargada de la oficina de la NTSB para la seguridad en las carreteras

 

 

 

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