In this episode of Behind-the-Scene @NTSB we talk with Tim LeBaron, Director; Kristi Dunks, Acting Deputy Director for Regional Operations; and Aaron Sauer, Senior Air Safety Investigator, in the Office of Aviation Safety, about their work to improve general aviation safety and the NTSB’s participation in the upcoming EAA AirVenture Oshkosh event. Hear more about our “Fly Like a Pro” presentation theme for this year, the safety messages being shared with the GA community, including our updated Safety Alert on fly-ins and other safety resources, and where you can find Member Mike Graham and NTSB staff throughout the event.
For more information about NTSB at the EAA Air Venture Oshkosh event, visit our webpage.
To learn more about NTSB aviation investigations, and to access investigative reports, visit our investigations webpage.
NTSB Safety Alerts are also available on our website.
By Lorenda Ward, Chief, NTSB Air Carrier and Space Investigations Division
When I read the Chair’s blog, “A Call to Action from Kennedy,” I asked myself, “Are we ready?” Not for commercial space exploration, but for the next commercial space accident investigation.
One of my responsibilities as the chief of the NTSB’s Air Carrier and Space Investigations Division is to ensure that our senior aviation investigators are prepared to respond to a commercial space accident. As the Chair outlined in her blog post, with the growth of commercial space launches and reentries, it is not a matter of “if,” but a matter of when.
What if we get the call today?
The NTSB has done a lot over the last several decades to prepare, including establishing the Quad-Agency Working Group with the Federal Aviation Administration (FAA), NASA, and the US Space Force, to build those important relationships between the agencies before a bad day happens. We meet regularly to discuss lessons learned and best practices from past investigations to ensure we are ready for the next investigation.
We also have a lot of training opportunities for our investigators that are above and beyond just attending industry conferences. Several years ago, I helped create a spacecraft design and systems engineering training course, as well as a commercial space externship program for our investigators to learn about the different space vehicles. We also take part in mishap tabletop exercises where we discuss the NTSB party process with both government and industry organizations. By far though, our best training opportunities have been the “on-the-job training” investigations that we’ve taken part in over the years. These investigations have provided us a great understanding of multiple launch vehicles and systems.
Responding to the Call
I remember leading the last fatal commercial space accident involving Scaled Composite SpaceShipTwo (SS2). I was actually at the site of another commercial space mishap, examining the recovered ordnance, when the SS2 accident occurred. Because of the possibility that cellphone signals could detonate unexploded munitions, our whole team had left our phones on the bus while we were at the storage location.
An FAA investigator who had stayed back came running into the bunker, saying we need to go now. I didn’t ask any questions and it wasn’t until I got back on the bus that I saw my boss had been repeatedly calling me for half an hour.
When I finally talked with my boss, he told me I would be the investigator-in-charge (IIC) of the go-team to investigate the first fatal commercial space launch accident. All the federal investigators (NTSB and FAA) had to work our way back from Wallops Island, Virginia, to DC. I had to keep pulling over to be patched into conference calls, so the commute took a lot longer than usual. At NTSB, we do not take calls while driving as distracted driving is a serious issue on our roadways. We have an agency-wide policy that prohibits staff from using a cell phone while driving. I remember at one point telling management I would never make it back to DC if I had to keep pulling over.
For the next 9 months, my focus was determining what happened to SpaceShipTwo. The accident occurred on October 31, 2014, when SS2 broke up during its fourth rocket-powered test flight and impacted terrain over a 5-mile area near Koehn Dry Lake, California. One test pilot (the co-pilot) was fatally injured, and the other test pilot was seriously injured. SS2, a reusable suborbital rocket, had released from WhiteKnightTwo, the carrier vehicle, about 13 seconds before the breakup. SS2 was destroyed, no one on the ground was injured by the falling debris, and WhiteKnightTwo made an uneventful landing.
Scaled Composites (“Scaled”) was operating SS2 under an experimental permit issued by the FAA Office of Commercial Space Transportation (AST) according to the provisions of 14 Code of Federal Regulations Part 437. The investigation identified several safety issues, to include the lack of human factors guidance for commercial space operators, missed opportunities during the FAA/AST’s evaluations of Scaled Composite’s hazard analyses, FAA/AST granting waivers from regulatory requirements, and an incomplete commercial space flight database for mishap lessons learned. The full report, safety recommendations and docket material, are available on the NTSB investigation page.
What Went Wrong?
The probable cause of the breakup was Scaled Composite’s failure to consider and protect against the possibility that a single human error could result in a catastrophic hazard to the SS2 vehicle. This failure set the stage for the copilot’s premature unlocking of the feather system which led to uncommanded feather extension and the subsequent overload and in-flight breakup of the vehicle. The accident vehicle had onboard video recording (cockpit image recorder) capability and the recording was obtained from a telemetry ground station located in Scaled’s control room at Mojave Airport, Mojave, California. This video was a key part of the investigation, showing cockpit displays and what actions the crew members took.
The Party System
All of our investigations use a party system, meaning that the operator and the regulator will be part of our investigation, at a minimum. For the SpaceShipTwo investigation, we invited Scaled, Virgin Galactic, Butler Parachute Systems, and the FAA to be parties. Scaled built and tested SS2 and had delivered WhiteKnightTwo to Virgin Galactic before the accident. Scaled had planned on transitioning SS2 to Virgin Galactic toward the end of 2014.
At the end of the investigation, a couple of the party members mentioned that when we first arrived on scene, wearing our blue jackets with giant yellow letters, they had no idea what to expect or what they were in for. They thought they were being invaded. For this reason, and others, we like to meet with commercial space operators before an accident, so we can explain the NTSB investigation process before we show up on their doorstep for an accident investigation. That initial reaction turned to one of trust as the investigation progressed. They said they were glad we led the investigation and had learned a lot from us. We, in turn, also learned a lot from all the parties.
Some party members also mentioned that they felt like full participants in the investigation, and that their voices were heard. To that point, the investigation would not have been completed in 9 months if we did not have the professionalism, openness, responsiveness, and willingness of the parties to trust our process.
To return to the question that I asked myself on reading the Chair’s blog: “Are we ready?”
Yes, we are ready. Nobody is more ready. This is what we do: Investigate. Communicate. Advocate.
By Jeff Marcus, Chief, NTSB Safety Recommendations Division
In many states, when using motorized recreational vessels, or engaging in activities like canoeing, kayaking, and standup paddleboarding, operators are not required to attend a boating safety course, obtain a license or certificate, be familiar with the navigation rules (commonly called the “Rules of the Road”), or even demonstrate proficiency in watercraft operation.
In 2016, the NTSB sought to better understand the scope of the issue and determine the safety impact on the nation’s waterways following:
our investigation of a collision between eight kayakers and a New York Waterways ferry,
feedback we received from marine industry representatives, and
concerns about the increase in encounters between commercial and recreational vessels.
We took what we learned and began to develop a safety recommendation report.
In 2017, we published Shared Waterways: Safety of Recreational and Commercial Vessels in the Marine Transportation System, providing our findings as well as recommendations to improve shared waterway safety. We found there is an increased safety risk, especially where confined waterways limit the ability of vessels to maneuver. This is exacerbated not only by the diversity of waterway users but also by differences in their experience, marine knowledge, and boat-handling skills. Moreover, state requirements varied considerably.
At the time of our report, the US Coast Guard estimated that in 2015 only 28 percent of motorized recreational vessel operators were required by state laws to complete a boating safety course or pass an examination of boating safety knowledge. Could you imagine if that were the case when it came to obtaining a private pilot’s license? Clearly, recreational vessel operators need a minimum level of boating safety knowledge to mitigate the various risks associated with the type of vessel being operated.
So, we issued Safety Recommendation M-17-2, which asked the Coast Guard to seek statutory authority to require recreational boat operators to complete a national boating safety course. When we issued this recommendation, we were aware that the Coast Guard had previously sought statutory authority to require recreational boat operators to complete a national standard minimum boating safety education course. As our Shared Waterways report pointed out, at that time, over 70 percent of motorized vessel operators and most nonmotorized vessel operators were still not required to demonstrate minimum boating safety knowledge.
Today, we commend the US Coast Guard for its determined and sustained role in promoting recreational boating safety. Although the Coast Guard has not been granted authority to implement a minimum national standard for boating safety as we’d hoped, it has developed an alternative approach that addresses the safety issue. Instead of saying there was nothing they could do because they didn’t have statutory authority, the Coast Guard developed a solution to address the safety problem. Consistent with congressional direction, the Coast Guard focused on supporting state-led initiatives to develop educational programs and requirements for recreational boaters. Working in partnership with the National Association of State Boating Law Administrators, the states, and various recreational boating stakeholders, the Coast Guard helped develop and update boating education standards. With the Coast Guard’s active support, recreational boating education has greatly improved nationwide. In its latest update to the NTSB, the Coast Guard reported that currently all but five states have mandatory boating safety education.
Safety is a journey, not a destination. Although there is always more to be done, the Coast Guard’s alternative action led to significant improvements in recreational boating safety across the nation and satisfied the intent of our recommendation.
We issue safety recommendations to other federal agencies and transportation stakeholders engaged in all modes: air, highway, rail, marine, and pipeline. Although we may recommend a particular action, there are often alternative solutions that are equally effective in addressing a safety problem that we identify through our investigations. Like sailing into the wind, sometimes a direct path isn’t possible; sometimes you must tack back and forth to make the mark. We encourage our safety recommendation recipients not to give up if our recommended action proves unattainable, and to pursue alternate actions to satisfy the intent of the recommendation. Our goal is to improve transportation safety in any way possible.
We ask all our recommendation recipients to share updates with us on relevant actions they’ve taken to address our concerns. Hearing from them helps us evaluate progress and properly classify the status of recommendations.
Stay safe on the water. Let’s work together as we navigate our way to zero transportation deaths and serious injuries, and safer transportation for all.
By Nicholas Worrell, Chief, NTSB Safety Advocacy Division
On June 25, I had the opportunity to represent the NTSB at the Route 210 “Dignity of Life” Observance in Prince George’s Country, Maryland, where I have spent most of my adult life. Although the observance had tragic roots, it was good to see some attention paid to the toll taken by crashes in this largely Black area.
After the jubilation of Juneteenth, it was a gut-wrenching reminder of one of our greatest remaining inequities as a nation. Statistics show that Blacks and other minority groups are disproportionately likely to die in crashes.
Total crash deaths skyrocketed to an estimate of almost 43,000 in 2021. If we are to reduce the surging totals, we must also be intentional about our efforts in these underprivileged, underserved, and vulnerable communities.
This solemn and dignified gathering was to remember the irreplaceable, individual human beings who have been lost, and continue to be lost, on Maryland Route 210. Eighty people have died in crashes there between 2007 and the present. One of them was the husband of my NTSB colleague Susan Pipkin. At the event, Susan’s daughter, Diamond, said, “He was just thrown from his motorcycle, and it shook our lives,” as she broke into tears. Like bicyclists and pedestrians, motorcycle riders are vulnerable road users and are overrepresented in fatality statistics nationwide.
Every loss on our roads is a tragedy. Every one of these losses is preventable. And, as I said to the families of the victims, every one of their loved ones was an individual, irreplaceable, had dignity and humanity, and deserved to live.
At the NTSB, we investigate crashes in all modes of transportation. We focus on answering one question, the same question that family members also ask after such a tragedy: Why? Unlike victims’ families and loved ones, though, we must be as objective as possible and look at the same question from an investigator’s point of view. We strive to turn our findings into action by issuing safety recommendations. However, we can only recommend changes—lawmakers, industry, and others must act on them.
I have worked enough with victim and survivor advocates to know that these tragedies are not one-time events. The loss persists and reemerges in so many ways: every time they look across the holiday table to the seat their loved one used to take, every time there is a birthday or a wedding anniversary that they used to celebrate, whenever they go to dial a number to share something with someone who is forever disconnected.
As we approach the Fourth of July holiday, a notoriously dangerous time on our nation’s roads, there’s no better time to take stock of how we’re protecting road users in all communities. This means reflecting on all parts of the system, not just on the behaviors of drivers, pedestrians, cyclists, and riders. We must adopt a Safe System Approach that builds in redundancy so that when one part of the system fails, road users don’t lose their lives. We owe all road users nothing less than our determination that one day, Maryland Route 210 will be another safe road in a safe system, one with zero road deaths and zero serious injuries. And we must ensure that we are making equitable safety investments.
We don’t lose 43,000 faceless statistics every year, we lose 43,000 loved ones. They are irreplaceable. They are precious. The lives of those left behind are shaken, forever changed.
The families I met on June 25 are members of a club none of them ever wanted to join. The best way to honor the life of Mr. Pipkin and the lives of countless others who perished on our roads is to close the door to the club forever.
This is the last post in a three-part series examining the safety of vulnerable road users, as new federal data show a rise in traffic deaths among motorcyclists, bicyclists, and pedestrians last year. You can read the first two posts here and here.
I just got back from Helsinki, Finland, where I attended the International Transportation Safety Association’s annual meeting.
I am amazed at the Finn’s approach to road safety, especially their focus on road design and infrastructure that separates and protects pedestrians and bicyclists from each other and road traffic, which has enabled them to achieve a safety feat in their capital city that people in the United States still consider impossible: zero pedestrian deaths.
A Tale of Two Countries
The public health crisis on U.S. roads is devastating and getting worse. People at the greatest risk are vulnerable road users, which includes anyone lacking the protection of a vehicle in the event of a crash, such as bicyclists, motorcyclists, and pedestrians.
In fact, bicyclist deaths were up 5% over 2020 levels, while motorcyclist deaths increased 9% over the same period, according to 2021 estimates recently released by the National Highway Traffic Safety Administration (NHTSA). But the most astonishing take-away is that pedestrian deaths soared 13% to 7,342 lives lost in 2021.
That means, every single day last year, more than 20 families had to plan a funeral because their loved one was killed while walking, running, or rolling on our roads.
It doesn’t have to be this way. It’s not in Finland.
For a fair international comparison, we can look to the estimated 2019 roadway death rate provided by the World Health Organization. Using this apples-to-apples measure, it’s easy to see how much more dangerous our roads are.
For every 100,000 people in each country, less than four died on Finland’s roads in 2019. That’s the same year Finland’s capital of Helsinki recorded zero pedestrian and bicyclist fatalities.
In the U.S.? Over a dozen people died on our roads for every 100,000 — more than triple Finland’s death rate.
Lessons from Helsinki to Hoboken
Many villages, towns, and cities around the world are having incredible success in saving the lives of vulnerable road users, including here in the United States. And they all have one thing in common.
Whether we’re talking about Helsinki or Hoboken, New Jersey (which has achieved zero traffic deaths for four consecutive years!), these communities all embrace the Safe System approach.
Far from a new fad, the Safe System approach derives from the Vision Zero movement in the 1990’s in Sweden, when it was called Vision Zero. It’s a philosophy or way of thinking, not a single action or “quick fix.” The core belief is that even one roadway death or serious injury is too many.
Places that successfully eliminate traffic deaths through the Safe System approach understand that all parts of society share the responsibility for roadway safety:
This includes government workers in agencies at the local, state, and federal levels that design and build our roads — and set and enforce the speed limits.
It includes the people who make life-and-death decisions every day at companies that manufacture vehicles. Decisions like which safety technology comes standard and how to market new features ethically, among others.
It includes emergency responders who arrive on-scene following a crash, from the firefighter to the tow truck driver and everyone in between.
And it includes individual road users, who must make safe choices every time they walk, run, bike, drive, or roll.
The Safe System in Practice
What does a Safe System look like in practice? Here’s how Hoboken and Helsinki are bringing the concepts of safe streets, safe vehicles, safe speeds, safe road users, and post-crash care to life.
One of the biggest opportunities to move the needle on safety across the U.S. lies in safe vehicles. The NTSB has made many recommendations to NHTSA that, once implemented, will save lives by making new cars safer for people outside the vehicle. Here are a few of our recommendations:
Develop test criteria for vehicle designs that reduce injuries to pedestrians, which NTSB has recommended since 2017 — and has been a reality in Europe since 1997.
Test and require new cars to be equipped with technologies that prevent collisions with vulnerable road users, such as pedestrian automated emergency braking. This is something our European counterparts have been doing since 2016, and which we’ve recommended since 2018.
Incentivize vehicle manufacturers and consumers to adopt intelligent speed adaptation systems (ISA) by including ISA in the New Car Assessment Program. Even though NTSB recommended this back in 2017, Europe is again ahead of us: ISA systems in passenger vehicles will be mandatory in the European Union starting next month.
For even more NTSB recommendations aimed at saving the lives of vulnerable road users, check out the NTSB’s special investigation report on pedestrian safety and my earlier post on bicyclist safety.
Zero: A Bold — But Achievable — Goal
If you think Helsinki or Hoboken are outliers when it comes to eliminating roadway deaths, think again.
This interactive map shows places all over the world that have done it — many for several years in a row, including here in the U.S. (You can change the map language to English by clicking the flag in the top-right corner.)
To be sure, zero is a bold goal. But it’s not impossible. The current world leader is Siero, Spain, which has had zero roadway fatalities for over a decade.
That’s a safety record worth celebrating…and stopping at nothing to emulate. The NTSB will continue to push our safety partners at NHTSA, the Federal Motor Carrier Safety Administration, and in state and local governments to implement our recommendations to move our country farther along the road to zero.