FBI Setting an Example and Raising the Bar

By Chairman Christopher A. Hart

Chairman Hart with FBI Aviation personnelKudos to the Federal Bureau of Investigation, which is proactively applying the lessons that the NTSB learned from the crash of a helicopter operated by the state of Alaska. The kudos are because our recommendations from that crash were to the states, the District of Columbia, and Puerto Rico, as well as the FAA — but not to the FBI. The Bureau’s action is a model of a safety ethic that we hope all helicopter operators will adopt: All operators can learn from others’ mishaps.

After the NTSB investigated the March 30, 2013 crash of an Alaska Department of Public Safety helicopter, we made recommendations that, if implemented, can help prevent future accidents.

More specifically, we recommended that public (i.e., government) operators that conduct search-and-rescue (SAR) operations develop and implement flight risk evaluation programs that take into account current weather conditions and flight-risk decision‑making. The recommendations also address training in flight risk evaluation, night vision googles, simulators, and safety management.

That’s what we do – investigate accidents, determine what caused them, and then make recommendations to those who can learn lessons from the accident to improve the safety of their operations. We did not, however, send these recommendations to the FBI. Thus, I was very pleasantly surprised when I received a letter from the FBI’s aviation program explaining the actions the Bureau had taken implementing NTSB’s recommendations. As a result of our recommendations, the FBI conducted a self-assessment of its policies, procedures, and operational performances. They found many of their programs to be operationally effective, but the FBI emphasized their need to always “improve and adopt.”

For example, the FBI is aggressively pursuing our recommendations concerning the training of non-pilot crewmembers, implementing scenario-based simulation training, and implementing external audits every three years. Furthermore, the FBI has added new aviation goals for the 2015 year. This will include the development and implementation of a formal Crew Resource Management program, considerations of scenario-based inadvertent IMC training, and developing policies on external audit programs.

The FBI, which conducts air operations similar to those of the recommendation recipients, moved admirably and with great purpose after they reviewed our recommendations. The FBI learned of the impending issuance of the six safety recommendations and responded to us regarding the actions they had already taken, as well as those they planned to take, to implement them.

On behalf of the NTSB, I am pleased to acknowledge the new steps that the FBI aviation program has taken. This is an excellent example of government working together to improve safety. The FBI can take pride in its outreach to be aware of these recommendations, its attention to these safety issues, and its willingness to step up and take action.

#PlanAhead for Drive Safely Work Week

By Vice Chairman T. Bella Dinh-Zarr, PhD, MPH

Logo for 2015 Drive Safely Work Week (DSWW)Every day millions of us drive ourselves to work. And for most of us, the idea that we may not arrive safely isn’t even a thought as we leave home. But, we should remember that our drive to and from work (perhaps with stops at schools along the way if we have children) is likely the most dangerous activity we engage in every day.

In 2013, more than 32,000 people were killed and an estimated 2,313,000 people were injured on U.S. roads. That means that an average of 90 people die in motor vehicle crashes every day — one fatality every 16 minutes.

My training is in public health and prevention is at the core of good public health practice. Motor vehicle crashes are a leading cause of death for all ages, exacting an especially tragic toll among children. But we can help beat this “epidemic on wheels” through prevention.   And the workplace is a great place to start.

Each year, The Network of Employers for Traffic Safety (NETS) champions Drive Safely Work Week. This year’s Drive Safely Work Week campaign highlights the importance of planning to safe driving, whether you’re planning the route you’ll take, identifying a designated sober driver, or making time to practice with your teen driver. To help us stay safe on the roads, this year’s campaign features a daily area of emphasis:

  • Monday: Remember to take time to plan the journey—even those trips that feel routine;
  • Tuesday: Prepare for driving situations that take you into unfamiliar areas;
  • Wednesday: Take precautions to ensure you’re driving with a clear head (this includes ensuring that you don’t drive drowsy, distracted, or impaired by any type of drug or medication, licit or illicit, prescription or over-the-counter);
  • Thursday: Learn to navigate the changes we all experience as we age and how they may affect driving;
  • Friday: Think through ways to plan ahead for driving situations that involve family members (such as ensuring children are in age-appropriate restraints and providing plenty of behind-the-wheel training for novice drivers).

Likewise, many of the topics on NTSB’s Most Wanted List of Transportation Safety Improvements focus on ways to help get us to work safely.

  • Reducing distracted driving: More than 3,000 died in distracted driving crashes because someone failed to plan ahead and find a safe place to pull over before engaging in distracting behavior behind the wheel.
  • Ensuring medical fitness to drive: As we enter the fall season, consider the warnings on the allergy and cold medications you are taking. If your medication warns about effects like drowsiness, sleepiness or difficulty with coordination, it’s not safe to drive. If your cold medication warns against operating heavy machinery, yes, your motor vehicle qualifies!
  • Ending substance-impaired driving: 10,000 children, mothers, fathers, sisters, brothers, friends, and coworkers were killed when a driver failed to plan ahead and designate a sober driver to get them home.

The NTSB Most Wanted List issue areas, and the daily areas provided by NETS, are a good start.

Preventing motor vehicle crashes will take a cultural shift encompassing attitudes and behavior. That’s why the NTSB is pleased to join with so many others to support Drive Safely Work Week, a nearly 20 year effort of NETS, to ensure that we all #PlanAhead and make it to work (and back home) safely. Together, we can help save many of the 32,000 lives lost in motor vehicle crashes each year. Let’s #PlanAhead during Drive Safely Work Week – and all year long.

Drive Safely Work Week 2015 is October 5-9. Visit the NETS website for a free Drive Safely Work Week toolkit and to get more information for yourself, your co-workers, and your organization.

Weighing the Benefits of Weigh Stations

By Amy Terrone

Have you ever driven by a weigh station on the side of the highway and wondered what happens to all those trucks that enter that parallel roadway?

And why do some trucks get to whiz by, while others crawl into the station?

NTSB Highway investigators at a weigh station in Boise, ID
NTSB Highway Investigators Mike Fox (L) and Dave Pereira (R) talk with a CMV officer at a Boise weigh station.

I learned the answer to these questions recently when I joined NTSB highway investigators for a tour of one of Idaho’s busiest weigh stations. This visit was sponsored by the Idaho State Police (ISP) commercial motor vehicle enforcement team, which works closely with the Idaho Transportation Department, the lead agency for size and weight and encompasses the Port of Entry Inspectors and weigh stations. The ISP is the lead agency for safety; they inspect commercial trucks for safety violations and put them out of service if they aren’t complying with state and federal regulations.

Several NTSB Highway Safety Investigators and I were attending the Commercial Vehicle Safety Alliance (CVSA) annual conference in Boise, Idaho, last week when the ISP presented us with an opportunity to view the live operations at one of their weigh stations. (The outgoing CVSA president is an ISP major.)

The CVSA conference brings together commercial vehicle truck inspectors (mainly law enforcement), truck and motorcoach fleet owners, regulatory agencies, and other commercial motor vehicle safety advocates around the nation to discuss the latest safety innovations, regulatory requirements, and inspection tactics for commercial motor vehicles.

It turns out that trucks which have been pre-screened and which have a current good safety record, similar to the TSA pre-check for airline passengers, can skip specific roadside weigh stations. Idaho uses a bypass system called NORPASS. With about 30 commercial motor vehicle enforcement officers covering the whole state of Idaho, the goal is not to spend time focusing on the truck drivers/operators who are making the commitment to operate safely and follow regulations.

Those drivers who don’t participate in NORPASS must come in to be…yes, weighed. If the loaded truck weighs more than 80,000 pounds, give or take, then the driver may be asked to pull over and unload.

Why do we care about weight? Because too much weight can tear up the roadway, creating a safety hazard for all drivers. Plus — and the NTSB has seen this in our investigations — overweight trucks can cause additional damage if involved in crashes.

But other information can come out of these weigh station stops.

The weigh station manager showed us how information pops up on their screens as trucks come through that indicates the trucks weight, height, safety score and paper credentials, i.e. registration, taxes, and any out-of-service violations or suspensions. 

ISP commercial motor vehicle officers onsite may also conduct a random inspection. If such an inspection uncovers serious violations, then the truck, the driver, or both may be placed “out of service” — meaning they can’t continue to operate until the unsafe condition has been corrected.

What happens if a truck without the NORPASS transponder runs the station? Commercial motor vehicle enforcement officers chase them down. 

The station manager shows NTSB staff their weight-tracking system.
The station manager shows NTSB staff their weight-tracking system.

I was impressed by how smoothly the operation ran at the Boise weigh station. There was a separate lane for “regulars” so to speak who traverse the station daily or at least multiple times weekly. A person sits behind the window and watches every truck going through, carefully noting the license plate, VIN, and other identifying vehicle information.

With “Strengthening Commercial Trucking Safety” on the NTSB’s Most Wanted List of safety critical improvements, it was important for NTSB to be at the CVSA conference and tour sites such as this roadside weigh station. More than 4,000 people die each year as a result of truck crashes, and truck crashes have been on the rise. Our visit to the ISP weigh station gave us a first-hand look at the work being done to combat this truck safety problem and how information obtained from them can provide us with valuable information in our crash investigations.

Like many of us on the roads, I didn’t know all that was happening inside these non-descript buildings on the side of the road. The men and women who staff them are our eyes and ears on the roads – looking for bad trucks and bad drivers. And, ultimately, the work they do is a critical component of the highway safety process that will help reduce crashes, along with injuries and fatalities on our roadways.

Amy Terrone is a Writer-Editor in the NTSB Office of Highway Safety.

Industry Outreach: Keeping our Finger on the Pulse

By Christopher A. Hart

The transportation of goods and people almost always succeeds without anything going wrong. In those rare cases where something does go wrong, however, the NTSB steps in to investigate. We make recommendations aimed at preventing a similar recurrence and we promote—or advocate—for the implementation of our recommendations.

To inform our investigations and make thoughtful recommendations, it is critical for us to understand how it all works at the operator level. We are trying to spend more time learning from those who manage the business of transportation without mishaps so that we won’t have to spend as much time investigating crashes that could have been prevented.

Chairman Hart with NTSB Colorado Regional staffLast week, NTSB staff and I visited seven transportation organizations in Kansas and my native Colorado to promote NTSB views on safety and, perhaps most importantly, to learn about how they implement safety into their day-to-day operations.

I was pleased to discover many safety processes in place that were recommended by NTSB. We had informative discussions about how to approach safety proactively in order to prevent the kind of catastrophic accidents we investigate. Fortunately, most that we talk to in the industry, it seems, are taking crash prevention seriously.

For more than 80 years, Jeppesen has been helping aviation professionals worldwide reach their destinations safely and efficiently. They offer an array of informational products, services, and software—not only to their air transportation partners, but also to a growing line-up of sea and land transportation partners.

I was given an overview of their digital technology products, toured their customer support center, and learned about their electronic data-driven charting applications.

The NTSB has seen how bringing new technology to bear to enhance transportation safety can yield great benefits. Jeppesen takes pride in safety, and that was apparent during my visit.

Sierra Nevada Corporation works in the commercial space sector, an area of keen interest for the NTSB, and the next frontier for transportation safety. As the commercial space sector grows, we continue to grow in our knowledge of the industry.

I received an overview of the corporation and of Sierra Nevada’s view of the space systems business, small satellite manufacturing, and space technologies manufacturing. Our hosts also shared information on their new spacecraft, its Engineering Test Article, Flight Simulator, Vehicle Avionics Integration Laboratory, and Flight Integration Control Lab.

It was an eye-opening look at one of the many companies working in the commercial space sector, and I was impressed by this industry’s willingness to collaborate. Commercial space operators are now learning, as did their aviation counterparts before them, that when it comes to safety, companies must share and collaborate on new safety approaches — even as they compete in other aspects of their business. 

Chairman Hart at Air Methods CorporationWe have issued several recent recommendations over the years regarding emergency medical service operations, so I was excited to tour Air Methods Corporation, one of the nation’s largest operators of air medical transport.

I learned about its Helicopter Air Ambulance program, and toured the Completion Center, Operational Control Center, Technical Services, and United Rotorcraft, Operations, Maintenance and Clinical facility — all play a critical role in the safety of their helicopter operations.

As I spoke to future helicopter pilots and medical trainees at Air Methods, I took the opportunity to help encourage their culture of safety, as they face the many challenges that are inherent in their business, by sharing with them our passion for transportation safety.

I grew up in a Denver with few mass transit options, so it was a pleasure to see the expansion of rail, light rail, and bus operations in my hometown through the Denver RTD FasTracks program. As I toured the east rail line and the 225 rail line, it occurred to me how important it was for Denver’s FasTracks to pursue a proactive approach to make Mass Transit Safer –an NTSB Most Wanted List issue area this year – which I was pleased to see them emphasize.

Chairman Hart at UPS in ColoradoI also visited with leaders from the Colorado Motor Carriers Association (CMCA), a non-profit organization that has provided support for Colorado’s trucking industry for more than 75 years, and with multimodal shipping giant UPS, in Denver, CO.

Both groups were eager to discuss ways to Strengthen Commercial Trucking Safety, another item on NTSB’s Most Wanted List of critical safety improvements this year.

I learned about the distinctive features of the new UPS 2015 Kenworth truck-tractor. The truck is equipped with some of the most advanced safety systems for heavy-duty trucks, which include the latest in collision avoidance, collision mitigation, and stability-control technologies. Making collision avoidance systems standard in commercial vehicles is a recent NTSB recommendation, the result of a special investigation report released in May.

I was impressed by the extent of driver training that many commercial drivers undergo; however, the large size of commercial trucks — and, consequently, the damage they can cause in any crash — makes it imperative to continuously look for ways to improve commercial trucking.

All of these transportation giants share a common goal: continually look for ways to improve safety. To succeed, they must continue to take a proactive approach to safety, and, like all those organizations committed to safety and protecting lives, they must be both bold and humble.

Humble — because even an organization with the best safety record can have a major accident tomorrow—and bold — because anticipating and preventing accidents are the best ways to move safety forward.

Chin Up…and Avoid Distraction!

By Vice Chairman T. Bella Dinh-Zarr, PhD, MPH

Vice Chairman Dinh-Zarr at the 3rd Annual Virginia Distracted Driving SummitLast week, I attended the 3rd Annual Virginia Distracted Driving Summit to share ideas, gather information, and learn about best practices related to the issue of distraction. It was an honor to be among these advocates and researchers, who are continually working on efforts to reduce the dangerous – and unhealthy – practice of distracted driving.

NTSB has been battling distraction for several years; it has been a contributing cause of accidents in all modes of transportation. The issue is on our Most Wanted List of transportation safety improvements and has been for the past few years. This issue is important to me, the NTSB, and the millions of people who share our roads.

My training is in public health and prevention is the cornerstone of this field. Public health professionals believe almost everything – from diseases to distraction – can be prevented if we can just figure out the cause and disseminate the treatment, whether that treatment is a vaccine or a behavior modification.

To prevent distraction, the culture of safety in the United States and across the world must be changed. Most people don’t think of being distracted as unhealthy. They think of it as simply a part of life. But it is unhealthy.

It is becoming harder and harder to disconnect from technology, because we have the means to stay connected with what’s going on each and every second of the day. Since the advent of the automobile, we have had to deal with the issue of distraction. Drivers felt distracted by windshield wipers, by the radio, by their passengers, and by many other things. Distraction is a complex issue and a difficult topic to tackle because its study (and its prevention) encompasses many factors – the road, the vehicle, and the person. There are so many ways we can tackle this problem – work environment, laws and enforcement, behavior change, technology, safety culture, to name a few. It is also an issue that has affected many people, including myself.

In late 1996, in Houston, I was involved in a crash caused by a distracted driver. It was a morning I’ll never forget.

I was driving down Almeda Road in Houston, Texas, on my way to the Texas Medical Center to turn in my thesis for my Master’s degree in public health, when a distracted driver coming out of the dry cleaners attempted to cross the road and crashed into my vehicle and another vehicle, sending me and another woman to the emergency room.

Because of that crash, I had six months of physical therapy due to injuries to my neck, shoulder, and back. These areas still flare up today.

Why was the gentleman distracted that day? Because he was trying to adjust the radio. When I later learned that I was enduring hours of painful physical therapy every week because someone was adjusting his radio, I was mad. And there are many families today who are mad, but they have found a way to channel those emotions towards efforts to reduce distractions in transportation. At the Summit, I had the honor of meeting some of these families who have become strong advocates against distracted driving.

Looking back, I realize just how lucky I was that day in Houston – lucky because the crash was not as severe as it could have been and lucky because the first responders were there quickly.

I walk or ride my bicycle almost every day – taking turns with my husband to take our son to school or pick him up. Lately, I’ve been hearing the young people in my neighborhood say “chin up” to people who are walking on the sidewalk with their heads down absorbed in their electronic devices. My 7-year-old son loves that saying, and, when we are on our bikes waiting to cross a street, he has even tried to say it to people in their car at a stop who have their heads down.

Chin up – it is a reminder to people to lift their heads, disconnect from whatever the distraction might be, and pay attention to the world around them when sharing a sidewalk or the roads. Chin up – it is also a reminder to traffic safety researchers and advocates to keep up the important work of finding the best, evidence-based interventions and then implementing them widely to keep our communities safe.

Chin up and disconnect from those deadly distractions. Chin up to save lives and prevent injuries.

Child Passenger Safety Week: Protecting our Future

By Stephanie D. Shaw

In 1996, nearly 20 years ago, the National Transportation Safety Board asked the states to strengthen their child passenger safety laws to make sure that all children are properly restrained in a child safety seat or booster seat and that they ride in the back seats of cars.

The NTSB cited 1994 data that said that more than half of children fatally injured in motor vehicle crashes (647 out of 1,203) were unrestrained. They were twice as likely to die as restrained children.

Had they lived, those 647 children would be adults today. They would be working their first real jobs, or like my son who was born in 1996, they would be going back to school for the fall semester. Some would be raising children of their own.

How much has changed?

Motor vehicle crashes are still a leading cause of death for children age 4 and the second leading cause of death for children age 3 and every age 5 through 14. On average, 3 children are killed and more than 400 are injured in traffic crashes every day. In 2013, 307 children died completely unrestrained in motor vehicle crashes.

NHTSA Child Car Safety infographicThey didn’t have to. Car seats, booster seats, and seat belts, used effectively, save lives. Car seats are 71 percent effective in reducing the risk of death to infants and 54 percent effective for children between the ages of 1 and 4.

As a volunteer Child Passenger Safety technician I’ve been trained on how to install all varieties of seats in many types of passenger vehicles.

But even more importantly, I’m a mom – and one day, I want to be a grandmother. And perhaps the single most important thing I can do to make that happen is to make sure that my daughters, ages 5 and 10, are riding in properly installed car seats and booster seats—just as my son did.

As a technician, I walk parents and caregivers through the process of installing their car seats. I demonstrate how to use all their features. I send parents away capable of ensuring that the seat stays properly installed, and armed with the knowledge to provide the maximum safety benefit every time they drive their children somewhere.

And as a safety advocate, I share these tips with as many parents as I can:

  • Children need to be in car seats or booster seats until they fit an adult seat belt properly. Seat belts are designed to protect adults and do not properly fit children until they are at least 4’9” tall.
  • Keep your children in a rear-facing car seat for as long as possible – at least until age 2.
  • Keep your children in a forward-facing car seat with a harness until they reach the maximum height or weight limit for the seat.
  • All children should ride properly restrained in the back seat.
  • If you’re flying, don’t check your car seat like you do your luggage! Even in a plane, children are at risk if they aren’t properly secure in their own seat using a car seat or seat belt.

In communities all across the country, child passenger safety technicians and advocates like me are working to ensure that parents and caregivers are correctly using the right passenger restraints for the children in their care, whether that is a rear- or forward-facing car seat, booster seat, or a seat belt.

If you’re concerned that you may not be using your seat correctly or have questions about the seat your child should be using, I encourage you to find a free hands-on event near you.

Your children – and grandchildren – are counting on you.

Saturday, September 19, is National Seat Check Saturday, to find an event in your community visit http://www.safekids.org/events.

Stephanie Shaw is a Safety Advocate in the NTSB Office of Communications.

The Cranbury Crash Proves the Need for Better Collision Technologies

By Dr. Ensar Becic

Damage to Walmart truck involved in the Cranbury, NJ accident.In August, we concluded an investigation of a fatal rear-end crash that occurred in Cranbury, New Jersey, in which the striking vehicle (truck-tractor combination vehicle) was equipped with an older model collision warning system (CWS). This system did not prevent the crash, and our investigation found no evidence that the system alerted the driver of the impending collision.

Even if the warning had alerted, it would not have come in time to prevent the crash. The good news is that current generation forward collision avoidance systems (CAS ) — a CWS is just one type of CAS technology — detect crashes sooner and with more accuracy.

In May, we released a report recommending passenger and commercial vehicle manufacturers install collision warning and autonomous emergency braking systems as standard equipment in all new vehicles. The report also urged the National Highway Transportation Safety Administration to expand or develop protocols for the assessment of forward collision avoidance systems in passenger and commercial vehicles.

Why is continued evaluation of technologies important? So that we don’t have crashes like the one we saw in Cranbury.

Whether a crash is prevented — or the extent to which it is mitigated — depends on the speed of the vehicles involved and the quality of the CAS in use. These issues must be considered when developing and evaluating the effectiveness of forward CAS in all vehicle types.

Let’s take a closer look at the Cranbury crash. The truck-tractor was traveling at 65 mph when approaching a line of nearly stopped vehicles — an extreme rear-end crash scenario. The truck-tractor was equipped with a CWS, which was designed to warn a driver about 2.5–3 seconds prior to a collision. Our accident reconstruction revealed that the driver of the truck-tractor steered 1.5–2 seconds before impacting the vehicle ahead, an avoidance maneuver. Although the maneuver came very late, it likely mitigated the severity of the crash.

The truck driver involved in the crash was extremely fatigued, and we found no evidence that a warning was presented. A fully alert driver would have noticed the slowed traffic well before the onset of a warning; however, drivers aren’t always fully alert.

Would a properly functioning CWS effectively warn even a rested driver in time to avoid the crash completely? Sadly, in the Cranbury accident, not much would have changed.

While it is possible that the truck driver did receive a warning — which prompted him to steer at the very last moment — it is also clear that the 3-second warning would not have been sufficient to prevent this extreme crash. Even if this truck had been equipped with the new generation of these systems, many of which have a longer warning time, it still would have been difficult to completely prevent this crash. But the damage caused by the crash might have been further mitigated.

Preventing crashes involving vehicles traveling at high speeds is very challenging. But even mitigation of such crashes can make a difference between a fatality and an injury.

Developing forward collision avoidance systems that can prevent all rear-end crashes is a lofty goal, but through continuous technological advancements and research, and more demanding regulatory standards, it is possible.

The NTSB has recommended to the National Highway Traffic Safety Administration that it achieve this goal. In the meantime, we can reap the incremental benefits along the way: fewer crashes, fewer deaths, and less severe injuries.

We should never give up on pursuing technologies that save lives.

Ensar Becic, Ph.D., is a project manager and human performance investigator in the NTSB Office of Highway Safety.