Buzzed Driving is Drunk Driving – Time to Walk the Talk

By Kenny Bragg

In 2016, 10,497 motor vehicle crash fatalities involved drivers with a blood alcohol concentration (BAC) of 0.08 g/dL or higher; that means almost 3 of every 10 lives lost on our highways involved impairment. What’s more, every life lost as a result of alcohol-impaired driving could have been saved, because deaths resulting from impaired driving are 100% preventable when the driver chooses to call a cab, hand the keys to a sober friend, or take public transportation to get home.

I’m a retired police officer, and, during my time in the traffic enforcement division, I encountered countless impaired drivers and investigated numerous impaired-driving crashes.  I evaluated and arrested drivers impaired at all BAC levels.

ChooseOne

The current per se BAC limit of 0.08 percent gives the public a false belief that lower BACs are safe when, in reality, impairment begins with the first drink. Many drivers don’t realize that even low levels of alcohol can degrade skills and increase crash risk. This is why, 5 years ago, the National Transportation Safety Board (NTSB) recommended that states decrease legal per se BAC levels to 0.05 percent—or even lower. “End Alcohol and Other Drug Impairment in Transportation” is one item on the NTSB’s Most Wanted List of transportation safety improvements. This list, released biennially, includes transportation safety goals that have a strong chance of being achieved if given a good, hard push by the NTSB, likeminded organizations, and states. We believe that the bold move to lower the legal per se BAC limit will save lives and decrease the number of highway deaths each year.

Many ad campaigns remind us that “buzzed driving is drunk driving,” but how can we support that message with laws and enforcement? About 100 countries around the world already have a .05 BAC law. In fact, although people consume more alcohol, per capita, in countries with .05 BAC laws, they are less likely to die from impaired driving. In 2012, Alberta, Canada, passed an administrative penalty law that imposes tougher sanctions on drivers with BACs of .05 to .08 percent. Between July 1, 2012, and December 31, 2013, Alberta saw a decline in alcohol-related fatalities compared to the same period in each of the previous 5 years.

Some advocates support a .05 limit but believe we should focus only on solutions targeting high-BAC drivers, or on emerging technology that prevents impaired drivers from operating a vehicle. However, a .05 BAC law is a broad deterrent that decreases the number of impaired drivers on the road at all BAC levels—high and low. Along with alcohol interlocks and enhanced enforcement efforts—which we have also recommended—a .05 BAC limit would help prevent drivers with high BACs from getting behind the wheel.

Many peer-reviewed studies demonstrate that lowering the legal BAC limit would indeed prevent impaired-driving crashes, and, according to a AAA Foundation survey, 63% of Americans would support a .05 BAC law. However, only one US state has taken the bold step to pass such a lifesaving law, which would encourage people to find other forms of transportation when they’ve been drinking. Utah passed a 0.05 BAC law in 2017, which will go into effect on December 30, 2018.

Some opponents argue that lowering the per se BAC level will be too complicated, and that law enforcement will struggle to accurately evaluate lower BAC levels during field sobriety tests. I was an active law enforcement officer when the legal per se BAC level was lowered from 0.10 to 0.08.  As with the current recommendation to lower the legal BAC, opponents predicted that lowering the BAC to .08 would result in arrests that were un-prosecutable, and that responsible drinkers would be unjustly punished. However, once the law was implemented, agencies actually experienced a decline in arrests at all BAC levels.

In these days of advanced technology and connectivity, if you have a phone, you have a sober ride. There is no excuse for driving after drinking.

Impaired Driving Preventable

Kenny Bragg is a Senior Human Performance Highway Investigator for the NTSB. He is a retired accident reconstruction investigator from the Prince George’s County Police Department (MD).

 

 

Part 135 Flight Data Monitoring: The Best Way to Ensure Pilots Fly Safely

By John DeLisi, Director, Office of Aviation Safety

 

On November 10, 2015, a Hawker 700A operating as a Part 135 charter flight crashed on approach to Akron Fulton International Airport in Akron, Ohio. The crash killed 9 people. During our investigation, we learned that the first officer was flying the airplane, although it was company practice for the captain to fly charter flights. We also discovered that the crew did not complete the approach briefing or make the many callouts required during approach. Additionally, the flight crew did not configure the airplane properly, the approach was unstabilized, and the flight descended below the minimum descent altitude without the runway in sight.

Akron, Ohio
NTSB investigators at the scene of the crash of a Hawker 125-700 into an apartment building in Akron, Ohio

How could this happen? Wasn’t the flight crew trained to follow standard operating procedures (SOPs)? (Yes, they were.) Didn’t they know when to lower the flaps? (Yes, they did.) Yet, weren’t they flying the airplane contrary to the way they were trained? (Yes, they were.)

The crew ignored, forgot, or improvised their company’s SOPs and the airplane’s flight manual information. Even more disconcerting was that, upon our review of the cockpit voice recorder (CVR), it appeared that this type of haphazard approach was fairly routine for them. How could that be?

The NTSB investigators discovered that no one at the company was monitoring—or had ever monitored—the way this crew flew the airplane. Because the airplane was not equipped with a flight data recorder, a quick access recorder, or any type of data monitoring device, the operator had no insight into what was happening inside the cockpit or how this crew was flying its airplane. The fact was that this crew was able to fly an airplane carrying passengers in an unsafe, noncompliant manner, which ultimately led to tragic consequences. If the operator had better insight into the behavior of its flight crew and had taken the appropriate actions, this accident may have been prevented.

That is a lesson learned the hard way—and we have seen similar such situations in several accidents the NTSB has investigated in recent years.

It’s time to be proactive about aviation safety and accident prevention! The NTSB believes flight data monitoring (FDM) programs for Part 135 operators—which includes charter flights, air tours, air ambulance flights, and cargo flights—is one answer to this problem.

An FDM program can help an operator identify issues with pilot performance, such as noncompliance with SOPs, and can lead to mitigations that will prevent future accidents. Too many Part 135 operations occur in which the operator has no means to determine if the flight was being flown safely. An FDM program can help companies identify deficiencies early on and address patterns of nonstandard crew performance. Most importantly, with an FDM program, pilots will know that their performance is being monitored. As a result of the Akron investigation, the NTSB recommended that the Federal Aviation Administration (FAA) require all Part 135 operators to install flight data recording devices. But it’s not enough to just capture the data; we also recommend that operators establish an FDM program to use the data to correct unsafe practices. The FAA has yet to act.

But some Part 135 flight operators aren’t waiting for FAA mandates; they have already made the investment in such a proactive safety program—and with great success. One operator I read about started an FDM program recently and is having success using the data in a nonpunitive fashion to monitor approaches. With this critical data at its fingertips, the operator is attempting to identify instances of incorrect aircraft configuration or exceedances of stabilized approach parameters. Designated line pilots assess the data captured in the FDM program to determine if further follow up is needed.

Another Part 135 operator involved in an accident near Togiak, Alaska, investigated by the NTSB recently made the commitment to equip every airplane in its fleet with a flight data recorder. The operator told us the data will “further enable [the company] to review compliance with company procedures through data analysis, similar to a Part 121 operation.”

Togniak, AK
NTSB Member Earl F. Weener (center), Director of the Office of Aviation Safety, John DeLisi (right) and Loren Groff (left), Senior Research Analyst in the NTSB’s Office of Research and Engineering served as the board of inquiry for an investigative hearing held in Anchorage as part of the ongoing investigation of the crash of flight 3153 near Togiak, Alaska

Kudos to both these operators for learning from past lessons and committing to a culture of safety.

Last year, a Learjet that was being repositioned following a charter flight crashed on approach to an airport in Teterboro, New Jersey. Both crewmembers died. While the final NTSB report on this accident has not yet been released, our analysis of the CVR revealed that the first officer, who was not permitted by the company to fly the airplane, was, in fact, flying the airplane. During this flight, the captain was attempting to coach the first officer. The first officer flew a circling approach; however, when the airplane was one mile from the runway, the circling maneuver had not yet begun. The first officer gave the controls to the captain, who proceeded to bank the airplane so steeply that the tower controller said the wings were “almost perpendicular to the ground” just prior to impact.

It comes as no surprise that the performance of this flight crew was not being monitored by any FDM program.

Isn’t it time to make passenger-flying operations safer? We see this type of program on major commercial Part 121 airlines, so why not on Part 135 aircraft? After all, flight data monitoring is the best way to ensure pilots are flying safely and passengers reach their destinations.

Understanding the Dangers: Motorcycle Safety Advocacy

By Nicholas Worrell, Chief, Safety Advocacy Division

MAMMay is Motorcycle Safety Awareness month and, for those of us who don’t have the privilege of riding year-round, the season is upon us. You may have heard that new data from the state highway safety offices show that motorcyclist fatalities were down 5.6% in 2017—a difference of 296 lives—which the Governors Highway Safety Association estimates means about 4,990 people were killed on motorcycles last year.

All of us in roadway safety have a common mission and goal: To reduce crashes, injuries, and fatalities on the roads. Motorcycles are disproportionately represented in fatality statistics, and the NTSB has long been concerned with motorcycle safety.

In 2007, we issued Safety Recommendation H-07-39, calling on states and territories to require that all riders wear an FMVSS 218-compliant helmet while on a motorcycle. Although wearing a helmet is a rider’s best protection in the event of a crash, currently only 16 states have motorcycle helmet laws. Several others that once had helmet laws have repealed them.

Repealing a helmet law is like taking the seat belts back out of cars and selling them at roadside stands to those drivers who want one. It’s making the road user’s best protection optional. Riders are 29 times more likely than car occupants to die in a crash; they should be required to use the best possible protection.

There are many other instances where we’ve emphasized the importance of motorcycle safety.

We continue to advocate for motorcycle safety by testifying before state legislators, educating the public, and working with advocacy groups to raise awareness about the issue. And we’ll continue to do so until we reach zero rider fatalities.

I’ve heard people say that a helmet law or a seat belt law takes away their freedom. ButMotorcycle Image I’ve also heard people say a helmet or a seat belt saved their life. So, if you’re a cager, please buckle up, every seat, every trip; or, if you’re a rider, put on that FMVSS-218­–compliant helmet, because I’ve seen what people look like after a crash when they haven’t made that choice and I don’t want that to happen to you.

Personally, I like having a reminder written into the law (and backed up by a hefty penalty), because when the sun is shining, and the weather is fine, sometimes I want to feel as free as possible. But the laws of physics are the same on all days, and they can’t be repealed. I’m thankful for helmet laws, just like seat belt laws; I’m glad they’re there, helping shape my habits. Helmet laws reinforce lifesaving habits that all riders benefit from.

During this Motorcycle Safety Awareness month and Memorial Day weekend, many messages deserve to be spread—Ride your own ride. Don’t ride impaired or fatigued. Share the road. But, when all else fails, the one message you don’t want to miss is “wear a helmet,” whether the law in your state requires it or not.

Bike to Work Week

By Member T. Bella Dinh-Zarr, PhD, MPH

I don’t know about you, but it seems that every day I see more and more people traveling by bicycle; whether they’re riding for exercise, taking a fun ride with family and friends, or commuting to work. It’s exciting to see a growing population using bicycles to get from place to place. People are also bicycling year-round, in all types of weather, across the United States. As someone with a background in public health, I’m glad to see that The League of American Bicyclists reports that bike riding is an increasing trend. Personally, I always look forward to participating in Bike to Work Week and Bike to Work Day each May during Bike Month.

Bike Week
Member Dinh-Zarr (center) and NTSB colleagues

I love my bike. It isn’t anything fancy, but it gets me where I need to go, and it was even recently featured in the New York Times. My family and I ride our bikes as often as possible. Some of my colleagues at the NTSB (you can see some of us in the photo) have been biking to work for years. Many of us are lucky to live in Bicycle Friendly Communities where it is easy to travel by bicycle around town.

The NTSB is known for investigating every civil aviation accident and significant accidents in other modes of transportation—highway, rail, pipeline, and marine. Our goal is to help people get around—in whatever form of transportation they choose—as safely as possible. One of the tools we use to achieve this goal is the “Most Wanted List” of transportation safety improvements (MWL). Although neither our investigations nor the MWL have a specific focus on bicycles, many of our recommendations and the MWL items can improve safety for bicyclists. For example, when decisions are made with the safety of all road users in mind, such as following NTSB recommendations for a safe systems approach to setting speed limits or lowering the per se BAC limit to 0.05 g/dL to prevent drinking and driving, those of us who ride bicycles are safer. Additionally, when we make roads safe for the most vulnerable users, such as people who walk and bike, everyone benefits.

I encourage anyone curious about commuting by bicycle to give it a try this Bike to Work Week. You’ll be in good company (and if you see one of us from the NTSB on our bikes, be sure to say hello). According to the League of American Bicyclists, many people who participate in the Bike to Work Day promotion for the first time become regular bike commuters! Give it a try—map your route, get your bicycle tuned up, and always remember to wear your helmet!

Roundtable Discussion About Loss of Control in Flight Yields Some Important Ideas

By Chairman Robert L. Sumwalt

On April 23, I had the privilege of moderating an important roundtable discussion on preventing loss of control (LOC) in flight in general aviation (GA), the leading factor of general aviation accidents and an issue on our Most Wanted List. LOC involves the unintended departure from flight and can be caused by several factors, including distraction, complacency, weather, or poor energy management.

IMG_8676 (1) Full Group
NTSB Chairman Sumwalt and Member Weener with LOC roundtable participants

 

I can say unequivocally that the NTSB LOC roundtable event—held in our Board Room and Conference Center at our Washington, DC, headquarters and webcast live—was a resounding success. We achieved what we aimed to do: bring together leading experts in government, industry, and academia to identify training and cockpit technology solutions that could make a difference, as well as dig into the challenges of implementing these solutions.

And I was thrilled to hear that about 1,000 pilots and GA enthusiasts watched our discussion, with many receiving FAA WINGS credit.

At our event, we saw an honest, open sharing of ideas among GA safety experts, as well as a willingness to collaborate to address and overcome the challenges associated with this problem, which is the cause of nearly 40 percent of all fixed-wing general aviation crashes. The 18 industry and government participants included a NASA astronaut, a world-famous aerobatics champion and trainer, GA associations, tech companies, the Federal Aviation Administration, as well as our own investigators and Board Member Earl Weener. I was also thrilled to welcome to our roundtable two bright young minds, Thomas Baron and Justin Zhou—high school students from Virginia. Baron and Zhou (Remora Systems) won the Experimental Aircraft Association’s Founder’s Innovation Prize for a product they developed for pilots to help avoid LOC. Their fresh, Generation Z perspectives on this issue enhanced our discussions.

The NTSB’s Director of the Office of Aviation Safety John DeLisi kicked off our discussion with these experts by reminding us that more than 1,500 people have died in the last 10 years due to loss of control and that “we are here to save lives.”

 

Our roundtable experts—all leaders in their organizations—discussed both the challenges and solutions to reducing LOC accidents, especially in the area of training and technology. I will recap just some of their key insights:

 On Training . . .

  • Address pilot weaknesses and skills requirements; pilots should always continue to improve their skills.
  • Reward pilots for additional training taken and ratings achieved, and incentivize new instructors to make sure pilots are taught correctly.
  • Teach students the importance of maintaining situational awareness during their initial training. The first 10 hours that new pilots spend with instructors can be some of the most important training time.
  • Recognize that technology is not a substitute for basic stick skills, nor should it compensate for poor training.
  • Incorporate more realistic scenarios into flight training regarding stalls. Ensure pilots have the confidence to do stall recovery.
  • Train for the startle factor so it doesn’t happen at low altitudes. The stall warning might be too late to recover.

 On Technology . . .

  • Find a responsible role for cockpit technology; it can make a big impact on safety.
  • Continue to responsibly innovate.
  • Reduce angle of attack (AOA); this is the key to recovery. AOA indicators can help.
  • Continue to quickly certify new technologies in a variety of plane types.

Other ideas . . .

  • Use data to improve GA safety; data monitoring programs can help us standardize safety.
  • Establish mechanisms where industry and government can continue to collaborate to collectively find solutions.
  • Recognize that regulation and mandates aren’t always the answer; education and outreach may be a better approach.
  • Utilize pilot social networks and type clubs to learn and grow.
  • Get involved in working groups; study best practices and incorporate outcomes.
  • Be aware of the limits of the airplane; pilots should not fear the capabilities of their planes.
  • Change the way we do outreach. Unifying around a single topic like LOC helps.

The statistics are trending in a good direction, thanks to the FAA’s and industry’s efforts to address LOC. However, from NTSB accident investigations, we know that much more can—and should—be done to accelerate the improvements in training and technology, because one death for what is largely a preventable problem is one too many.

For more information on the LOC roundtable, including the topics covered, participant’s list, and our LOC resources, see our events page.

 

Global Perspectives on Youth Traffic Safety

By Nicholas Worrell, Chief, Safety Advocacy Division

May is Global Youth Traffic Safety Month, a time where communities come together to bring more awareness to safety issues impacting teens on the road. GYTSM, which began as National Youth Traffic Safety Month, was expanded to support the United Nations’ 2007 Global Road Safety Week, because teen driving crashes are a worldwide safety problem requiring global solutions.

Last month, I had the opportunity to travel to London to address an audience concerned about young driver safety. Although the United Kingdom has far fewer road deaths per capita than the United States, the country loses more teen drivers than drivers in any other age group each year.

My hosts were interested in hearing the perspective of a US safety advocate as they consider implementing a graduated driver licensing (GDL) system. Just as the United Kingdom has much to teach us on many roadway safety topics, we have much to share about GDLs and factors that combine with them to make them even more effective. For example, in 1993, the NTSB recommended keeping young drivers off the road at certain times, particularly from midnight to 5 a.m. In 2002, we recommended that:

  • a supervising adult driver be 21 or older;
  • states that did not already have a three-stage graduated licensing system implement one; and
  • states with a GDL program prohibit young drivers from carrying more than one teen passenger without adult supervision.

And it wasn’t just the NTSB that was looking at GDL systems and their effect on teen drivers. By 2011, researchers associated with the National Institutes of Health found that GDL laws reduce crashes among drivers 16 and 17 years old by 8 to 14 percent. They also found GDL laws to be most effective in combination with at least five of these seven factors:

  1. A minimum age of 16 for a learner’s permit
  2. A mandatory waiting period of at least 6 months before a driver with a learner’s permit can apply for a provisional license
  3. A requirement for 50 to 100 hours of supervised driving
  4. A minimum age of 17 for a provisional license
  5. Restrictions on driving at night
  6. A limit on the number of teenage passengers allowed in a car
  7. A minimum age of 18 for a full license

US states are often called “laboratories of policy.” This is a grim prospect when it comes to setting a single, high safety standard, but, as I told my hosts in London, it also allows researchers to review what works best and where we can still improve. Opportunities to share lessons learned across national borders are another important tool in combatting roadway deaths and injuries.

According to the World Health Organization, 1.25 million people die each year around the world in traffic crashes. Road traffic injuries are the leading cause of death among people age 15 and 24 years old. In the fight against roadway deaths and injuries, our youngest and most vulnerable drivers are counting on us to help them emerge victorious, not only during Global Youth Traffic Safety Month, but every day. Until roadways around the world are safe for them, our work will continue.

My British counterparts are committed to winning this war with us. And we agree that, as Sir Winston Churchill once said, we shall never surrender.

 

 

The Age of Reason

By Chairman Robert L. Sumwalt

Some scholars play a critical role in founding a whole field of study: Sigmund Freud, in psychology. Noam Chomsky, in linguistics. Albert Einstein, in modern physics. In the field of safety, Dr. James Reason has played such a role. In this field, no single name is better known.

Dr. Reason turns 80 today, and if you’re reading this, it’s possible that you owe your life to his ideas.

NTSB reports have frequently cited Dr. Reason’s work, and I personally quote him liberally in my talks to industry and safety stakeholders.

His contributions to safety have been influential not only in transportation and workplace safety, but also in fields as varied as healthcare, nuclear power, and fraud prevention.

His books include Human Error; Organizational Accidents; Managing the Risks of Organizational Accidents; Organizational Accidents Revisited; The Human Contribution: Unsafe Acts, Accidents, and Heroic Recoveries; and A Life in Error: From Little Slips to Big Disasters.

He views safety as a system, and accidents as the result of any individual’s mistakes in combination with other failings in the system. People are fallible, but that doesn’t make accidents inevitable.

Focusing on a safer system, instead of only an individual’s mistakes, can help diminish individual error (for example, through better training and procedures). More importantly, studying the system reveals much more of “what went wrong” – and will go wrong again if not corrected, because other individuals will make mistakes.

Dr. Reason came up with a handy analogy for his view, called the “Swiss Cheese Model of Accident Causation.” (Just say “Swiss Cheese Model” to a safety or risk management professional, and they’ll probably nod knowingly.)

In this model, layers of protection against an accident, each of which has weaknesses, are visualized as slices of cheese riddled with holes. An accident occurs when the weaknesses, or holes, align.

 

Swiss Chese Model
Swiss cheese model by James Reason published in 2000. Source: https://openi.nlm.nih.gov/detailedresult.php?img=PMC1298298_1472-6963-5-71-1&req=4, open-access, CC Attribution 2.0 Generic

 

We’re all living in the Age of Reason. It’s a good age in which to live, one during which accidental deaths and injuries have been on the decline.

The continuous improvement of safety depends on safety professionals living with what Dr. Reason called a “chronic unease.” The paradox of safety is that the moment we think we’ve arrived, we introduce another hazard: complacency.

However, even in the chronically uneasy profession of safety, we find cause to celebrate every now and then. So, on that note, Happy 80th birthday to Professor Emeritus James Reason, on behalf of safety professionals everywhere—and on behalf of all those he’s saved, from every walk of life.

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