Episode 18 – Graettinger, Iowa Accident Investigation

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.

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/

Episode 17 – Erik Strickland

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.

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/

Too Close for Comfort in San Francisco

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.

 

Episode 16 – Gloria Noguera

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.

Concept

Get the latest episode on Apple Podcasts , on Google PlayStitcher, or your favorite podcast platform.

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

Why You Should Buy a Car with Collision Avoidance Technologies

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.

MWL2017-18_03_collision

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?

Observing an Impaired Driving Enforcement Training

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.
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
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.

.01 - .07 BAC Fatalities
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.

Episode 15 – NTSB Summer Interns

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.

Get the latest episode on Apple Podcasts , on Google PlayStitcher, or your favorite podcast platform.

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

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