A Beautiful Mind; A Tragic Loss

By Robert L. Sumwalt

CIOT-Infographics_1I spend a fair amount of time on airline flights these days. I usually spend most of that time working and catching up on reading. Late last month, however, I did something I rarely do – I watched an inflight movie. The movie, 2001’s “A Beautiful Mind,” starred Russell Crowe as Dr. John Nash, widely regarded as one of the greatest mathematicians of the 20th Century.

The movie depicted many of Nash’s struggles with mental illness and how he overcame those struggles to be awarded the Nobel Prize for Economics in 1994. The last scene showed Nash and his wife, Alicia, departing the ceremony with happy words scrolling across the screen: “John and Alicia Nash live in Princeton, New Jersey. John keeps regular office hours in the Mathematics Department. He still walks to campus every day.”

Despite the movie’s happy ending, the real-life story did not end so happily. On May 24, 2015, just a few days before I watched the movie, John and Alicia Nash were killed in an automobile crash. The NTSB is not involved with the investigation of this crash, but according to news reports, they were sitting in the back seat of a taxi when another car ran into their vehicle. Neither John nor Alicia were wearing a seat belt; tragically, they were ejected from the vehicle and died at the scene. The taxi driver was treated for non-life threatening injuries.

The question that came to my mind was, “Why would someone so brilliant make such a devastating decision — not to wear a seatbelt?” Perhaps there’s a false sense of security when it comes to riding in the back seat, especially in taxis. CBS News recently featured a story, however, which should dispel any false beliefs about not needing to wear seat belts in the back seat.

The Insurance Institute for Highway Safety (IIHS) teamed with Children’s Hospital of Philadelphia to examine the characteristics of back seat safety. Among the report’s findings was that “the risk of serious injury was nearly 8 times higher among unrestrained rear-row occupants as compared with those using restraints.”

With numbers like that, each of us — mathematical genius and layperson alike – can understand why it is important to wear seat belts, even in the back seat. Make sure every occupant is buckled up when getting on the road.


Member Robert SumwaltRobert L. Sumwalt has been a Member of the NTSB since 2006. He is a frequent contributor to the blog.

ESC for Heaviest Trucks and Buses: A Great First Step Toward Saving Lives

Photo of Indianapolis, IN, rollover crash of combination vehicle.
Indianapolis, IN, rollover crash of combination vehicle.

By Robert Molloy

The NTSB has long urged that trucks and buses be equipped with electronic stability control (ESC) to help prevent and mitigate crashes. ESC automatically helps drivers maintain directional control when they cannot steer and brake quickly enough on their own. We are pleased that the National Highway Traffic Safety Administration (NHTSA) released a final rule earlier this month—FMVSS No. 136that will help drivers of large vehicles do just that.

The new rule requires ESC systems on heavy trucks and large buses with weight ratings over 26,000 pounds, and NHTSA is beginning the process of expanding the requirement to include medium-sized vehicles between 10,000 and 26,000 pounds.

The rule covers vehicles such as the truck-tractor cargo tank semitrailer involved in the 2009 Indianapolis, Indiana, crash.

In that crash, the driver of the combination unit, which was loaded with 9,000 gallons of liquefied petroleum gas, went through a guardrail and collided with the support structure of an interstate overpass. The truck driver had been negotiating a left curve in the right lane on the connection ramp, which consisted of two southbound lanes, when the combination unit began to encroach upon the left lane, occupied by a passenger car. The truck driver responded by oversteering clockwise, causing the combination unit to veer to the right and travel onto the paved right shoulder. The driver’s excessive, rapid, evasive steering caused the cargo tank semitrailer to roll over and separate from the truck-tractor. A large explosion followed the crash, and five people were seriously injured.

The NTSB determined that the rollover might have been prevented had the truck been equipped with an ESC system. As a result of this investigation, the NTSB issued two recommendations requiring ESC on all commercial vehicles.

The new rule is a good first step. Applying the rule to all vehicles over 10,000 pounds is difficult, as hydraulic ESC systems for commercial vehicles are just beginning to be deployed. However, until ESC is expanded to cover commercial vehicles below 26,000 pounds, we may still see crashes such as the one NTSB investigated in Dolan Springs, Arizona. In that crash, a medium-size tour bus with a weight rating of 19,500 pounds was traveling on a four-lane divided highway when it started moving to the left and out of its lane at about 70 mph. The driver steered sharply back to the right, crossing both lanes and entering the right shoulder. The driver overcorrected to the left, again crossing both lanes. The bus entered a median and rolled all the way over before coming to rest on its side. As a result, seven passengers died and nine others were injured.

As vehicle safety technologies continue to be developed, ESC becomes all the more important. ESC is a necessary component of, and serves as a platform for, other life-saving technologies such as collision avoidance systems that include autonomous emergency braking (AEB). According to our Special Investigation Report (SIR) on The Use of Forward CAS to Prevent and Mitigate Rear-End Crashes, the full benefits of AEB for commercial vehicles can be achieved only when such a braking system is installed on vehicles also equipped with ESC. Equipping commercial vehicles with both AEB and ESC would be an effective countermeasure against rear-end collisions.

NHTSA estimates the new ESC rule—which will be rolled out in stages over the next four years—will prevent as many as 1,759 crashes, 649 injuries, and 49 deaths each year. When it becomes expanded to smaller vehicles, even more lives will be saved.

Robert Molloy, PhD, is the Acting Director of the NTSB’s Office of Highway Safety.

Perfect Storm

By Rachel Smith

MITAGS Simulator (photo provided by MITAGS)
MITAGS Simulator (photo provided by MITAGS)

The “perfect storm” overcomes us. Our ship rocks back and forth. Fog sets in obscuring our vision of the passing ships. We navigate the channels based only on our radar and control systems. Panic is beginning to set in. But, then I remember, this is a simulation.

I relocated to Washington, DC to be a student trainee for the summer with the National Transportation Safety Board (NTSB). I recently had the opportunity to visit the Maritime Institute of Technology and Graduate Studies (MITAGS) campus in Baltimore, Maryland with NTSB’s Vice Chairman Bella Dinh-Zarr and Tracy Murrell, Director, Office of Marine Safety. MITAGS is a vocational training center for individuals seeking to enter the maritime profession and for professional mariners seeking to advance their careers. This visit was particularly special to me, because I am from Florida and have grown up around beautiful water ways and beaches. Marine safety is vital, because it helps to protect people, marine life, animals and our precious natural resources.

The technology MITAGS has available allows students to experience challenging scenarios in the safety of a classroom setting. The ship handling simulation scenario we experienced is one of many MITAGS can recreate to prepare their students. MITAGS’ staff showed us the inner workings of their simulations. In addition to the ship handling simulator, MITAGS also has a 300° tug simulator.

After a presentation about MITAGS we made our way to the ship handling simulator’s wheelhouse, and the environment suddenly began to change to mimic that of a ship. The narrow hallway leads to a steep staircase and soon the wheelhouse came into view. The wheelhouse is equipped with navigational technology that would be on a fully equipped ship. There is a small table to lay out navigational material, and even a reading lamp to account for the dim lighting. Every detail makes you feel as though you are sailing through, in our case, the Port of Baltimore.

Surrounding the wheelhouse is a nearly three story tall 360° screen, which the instructor controls from an adjacent room. The instructor has controls to adjust your location, the weather, ship length and the cargo you are carrying. The instructor is also able to control the ships that are sailing in your view. For an extra layer of challenge during our simulation, we were faced with a burning ship on our port side. To monitor the student’s progress, the instructor is also equipped with devices that show every action the student takes to maneuver and monitor the ship, as well as streaming video feed of the wheelhouse.

MITAGS combines high education standards with rigorous simulation exposure and assessment, to equip their students with the tools to safely and successfully navigate their maritime careers. With more than 120 courses, MITAGS allows for specialized training in various areas. They have courses covering a range of disciplines from upgrading to the Chief Mate or Master’s level, continuing education for Tug and Barge, and everything in between.

My experience in a controlled simulation was only a small glimpse at the challenges mariners can potentially face during their time at sea. Although, you may not be maneuvering a ship this summer, remember to be safe as you enjoy your summer time on the water. Always be prepared for inclement weather, because you never know when the “perfect storm” could set in.


Rachel Smith is an intern with the NTSB

A Sobering Experience

By Vice Chairman Bella Dinh-Zarr

Photo of Chairman Hart and Vice Chairman Dinh-Zarr at a  sobriety checkpointLast Friday, Chairman Hart and I, along with several NTSB investigators, observed a sobriety checkpoint in Lanham, Maryland. The checkpoint, which searches for alcohol-impaired drivers, was run by the Special Operations Division of the Prince George’s County, Maryland, Police Department (PGPD). 

For those who challenge the need for such an event, let me remind you: more than 10,000 people die each year from crashes involving alcohol-impaired drivers. For one of our investigators on hand that evening, retired P.G. County police officer Kenny Bragg, the checkpoint brought home to him one experience that changed him forever. He told me about the trauma of having to knock on a stranger’s door to tell them that a loved one had died after a crash involving alcohol. Sobriety checkpoints are meant to stop another family from having to experience such a tragedy.

And, I can relate.

When I was 9 years old in early 1981, the station wagon my mom was driving was struck by a drunk driver. My brother and I were in the back seat and fortunately, perhaps because we had been fighting, my mom made us wear our seat belts. My brother and I weren’t hurt in the crash, but my mom was injured even though she had her seatbelt on. The drunk driver who ran into us lived in my town and was known to both my family and the police, but he was never charged.

In those days, more than 20,000 people per year were dying in crashes involving alcohol-impaired drivers. Mothers Against Drunk Driving had just begun to bring the issue of drunk driving into the national spotlight.

Since then, we have learned a lot about the impact of drinking and driving. All over the country, High Visibility Enforcement (HVE) efforts, which include the use of sobriety checkpoints, have helped significantly reduce impaired driving crashes. Well-implemented sobriety checkpoint programs have been shown to reduce alcohol-related fatal and injury crashes by about 20 percent in the communities where they are used.

This past Friday night, after the officers safely secured the checkpoint area with overhead lighting and safety cones, and officers took their positions on the line, I watched as vehicles began moving through. Within a few minutes, an officer identified a driver he believed to be impaired. It turned out, he was right! The officer conducted a field sobriety test and the driver took an alcohol breath test (breathalyzer test). His preliminary reading was .10 BAC; over the legal .08 BAC limit. 

I observed hundreds of drivers passing through. And, because of the efforts of the PGPD, 12 people were detained and their sobriety evaluated. Although 4 of the 12 were actually arrested, all 12 were found to have some level of impairment and were taken off the road. Who knows what could have happened if they had remained on the road? Maybe someone would have become a victim like my mother or, perhaps worse, like the victims Kenny visited.

Getting drunk drivers off the road is critically important, but it’s even more important to ensure that individuals who drink don’t get behind the wheel in the first place. Improvements in impaired driving laws and stronger law enforcement have had an important impact. Since 1981, we’ve seen the number of impaired driving deaths reduced by half, and our attitudes about drunk driving have changed greatly.

But more work needs to be done. That is why ending substance impairment in transportation is on the NTSB Most Wanted List of safety improvements, and why we are pushing for wider implementation of countermeasures we know will reduce drunk-driving crashes and fatalities.

As I watched the excellent work done by the PGPD, the road safety advocate in me recognized the long-term value of their efforts. But that 9-year-old little girl in me simply thought, “Thank you – somebody’s mom got home safely tonight.”

Safety Shouldn’t Be a Luxury Feature

Accident scene in Paynes Praire, FLMotor vehicle crashes are the leading cause of death for children and the second leading cause of accidental death for adults, claiming more than 30,000 lives annually. Now the good news: That toll is down from more than 50,000 deaths every year from 1966–1973, even though today there are far more drivers on the road.

This reduction in fatalities is in large part due to the single greatest lifesaving technology available to each of us in the event of a crash: the seat belt. Since 1975, seat belts have saved more than 317,645 lives.

Through advances in safety and technology, we’ve seen the development of air bags, a supplemental safety device, providing an additional level of protection for a driver or passenger correctly restrained using a seat belt. Since 1987, frontal air bags have saved nearly 40,000 lives.

Today, seat belts and air bags are available as standard safety equipment in all passenger vehicles.

Yet in 2012 alone, more than 1.7 million rear-end crashes killed more than 1,700 people and injured 500,000 on American roads. And more than 80% of those deaths and injuries might have been prevented or mitigated with another technology: collision avoidance systems.

This week, the NTSB released a Special Investigation Report, The Use of Forward Collision Avoidance Systems to Prevent and Mitigate Rear-End Crashes.

The lag in making collision avoidance systems standard equipment in all new vehicles is creating an unacceptable safety gap, leading to preventable deaths and injuries. Only 4 of 684 passenger vehicle models in 2014 included a complete forward collision avoidance system as a standard feature. The rest don’t offer it, or make you pay for it as an option. Often, it is packaged with luxury items.

You don’t have to buy leather seats to get the benefit of a safety belt. You don’t have to buy a moon-roof to get airbags.

You shouldn’t have to buy a luxury vehicle or a luxury option package to get a complete collision avoidance system.

Our report recommends that vehicle manufacturers include these systems on new vehicles as standard equipment. We also recommend that NHTSA develop ratings for collision avoidance systems, disclose the ratings for each vehicle on the window sticker, and include these ratings in its 5-star safety rating scale.

The NTSB issued its first recommendation on such technologies in 1995. But until now, progress has been limited. One problem is that even better technologies always seem to be on the horizon. But as Mark Twain put it, “Continuous improvement is better than delayed perfection.”

The time to improve the safety of our passenger vehicles and commercial fleets is now.

The full report includes the conclusions of the research and recommendations to the National Highway Traffic Safety Administration and to passenger vehicle, truck-tractor, motorcoach, and single-unit truck manufacturers.

We also issued a related Safety Alert,  Addressing Deadly Rear-End Crashes.

The Importance of Procedural Compliance

By Roger Cox

Image of crashed UPS cargo flight in Birmingham, ALThe August 14, 2013, crash of UPS flight 1354 in Birmingham, Alabama, was one of several recent accidents that involved crew deviations from standard procedures (often referred to as standard operating procedures—SOPs). The Asiana 214 accident in San Francisco in 2013 could have been avoided by closer adherence to standard procedures. Procedural non-compliance is also strongly implicated in several other recent accidents, including two wrong airport landings in 2014, still under investigation.

When I reviewed the facts of the UPS investigation, I was reminded of the familiar feeling I got when I was an airline captain planning and briefing an approach under potentially adverse circumstances. When things were not working out like I expected, I wondered if I was being set up for failure. My caution flags went up. Today, I ask myself how I would have felt and reacted, given what developed during the Birmingham approach.

Being a bit high on descent is allowed and pretty common, but it can throw your planning off. Going to a shorter runway than expected—and one not equipped with an instrument landing system—is another common complication. Having to conduct an unfamiliar non-precision approach at night, in the weather, just adds to the difficulty. The preflight and current weather information said the airport at Birmingham was essentially operating under visual flight rules, with good visibility and a 1,000 foot ceiling—but, alas, these were not the conditions. Finally, due to the proximity to the airport, software versions installed, and high descent rate, the automatic altitude callouts and terrain warnings—provided by protective systems we have come to expect in state-of-the-art airliners—weren’t enabled or were not as effective in alerting the crew to the seriousness of their situation. Yes, I thought, this situation was a set up for failure.

What should be a crew’s first defense against such adverse or unexpected situations? In my mind, it is adherence to standard procedures.

When crews develop the habit pattern of following checklists, doing briefings, and making callouts every time, they begin to do these things reflexively, even when they are stressed, distracted, and tired. The NTSB found that, while the crew adhered to good SOPs during preflight, climb and cruise, they made several critical errors and omissions during the approach that should have been caught if they had carefully and precisely followed procedures.

When a fatal accident occurs, everyone at the affected airline feels the pain. Pilots in particular feel it because they not only have had long friendships with the lost crew but they share a kind of kinship earned through common joys and hardships related to piloting. As they face the fact that they cannot undo what has happened, they ask how can we undo a similar tragedy in the future.

I hope the pilots who read the NTSB report on the UPS accident and watch the video released this week highlighting the issues that led to the UPS crash will take them in the spirit they were intended. Our goal always is to find a safer way in the future. To that end, I ask that we pilots recommit to standardization. In 2015, one of the NTSB’s Most Wanted List priorities is to Strengthen Procedural Compliance. This means: follow your SOPs. If you think one of your procedures is inappropriate or unwise, ask your company to consider changing it, but until they do, follow it and potentially avoid a catastrophic incident.

Roger Cox is a Senior Aviation Safety Investigator in the NTSB Office of Aviation Safety.

Hot Tires, High Risk… and How to Have a Tire-Safer Summer

Photo of the accident van.
NTSB investigated a hot summer tire blowout crash in July 2001 in Randleman, North Carolina. A 15-passenger van overturned on the highway, killing 1 person and injuring 12 others.

By Amy Terrone, Safety Advocacy Division

When you drive on hot roads at highway speeds your tires get hot. And when your tires get hot, you’re at greater risk for a blowout and potentially a crash. Fortunately, there are ways you can head off the risk before heading off to the beach.

How many times have we driven by a family in a minivan on the side of the road changing their tire in 98-degree weather? Being stranded is no fun, but it can be much worse. Tire blowouts can also lead to a loss of vehicle control and a crash.

According to data collected by the National Highway Traffic Safety Administration (NHTSA), the summer months of June–August are associated with the highest number of tire-related fatal crashes.

Why the increase in crashes during the summer? A variety of reasons, such as more teen drivers on the road and vacationers navigating unfamiliar congested highways. But another cause is tire blowouts.

Hot tires can lead to blowouts, especially if the tires are underinflated.

NHTSA estimates that tire failure causes about 11,000 crashes a year, leading to more than 600 deaths and about 19,000 injuries. A common cause of tire failure is underinflated tires. Underinflation also leads to sluggish handling, longer stopping distances, and increased stress on tire components. If you need to be reminded of how dangerous a tire blowout can be, check out this video.

Memorial weekend is the unofficial start of the summer season. It also kicks off National Tire Safety Week (May 24-30), a week established 14 years ago by the Rubber Manufacturers Association to remind consumers about the importance of tire safety (see Be Tire Smart—Play Your PART). Being safe on the roads means regularly checking tire air pressure, alignment, and tread, and rotating tires.

The NTSB has investigated a number of tire failure crashes, including several in recent years, so we know first-hand the dangers of underinflated and poorly maintained tires. In honor of Tire Safety Week and the start of the summer season, the NTSB released a Safety Alert today outlining how tire registration and periodic maintenance can reduce the risk of crashes.

Please, as you embark on this summer of fun, take a moment to check your tires before loading the car with your camping gear, suitcases, fishing rods, and coolers. It’s a simple act that could save you money and time down the road, and it could also save your life…and that’s no hot air.

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