ACT TO END DEADLY DISTRACTIONS

By Acting Chairman Robert Sumwalt

Distracted driving kills, on average, nine people every day on our highways and injures even more. Every day, families are left to grieve the loss of a loved one killed in a highway crash, their lives suddenly in disarray. These preventable tragedies must stop. We must all do our part and take action so that families no longer lose loved ones to a preventable death.

Often, the families and friends left behind after a fatal car crash become survivor advocates, turning their tragedy into action. This week, we will be hosting some of these survivor advocates at our second distraction roundtable, Act to End Deadly Distractions. We will be teaming with Stopdistractions.org, DRIVE SMART Virginia, and the National Safety Council to host this discussion.

I’m excited to facilitate this event, which is designed to focus on survivor advocates’ experiences of what has worked and what hasn’t in their fight against distracted driving. Above all, this roundtable is designed to facilitate effective action. The survivor advocate community will be exploring ways to act in their own towns and states to “move the needle” toward zero distracted driving deaths.

Our first distraction roundtable brought together experts to dive into what we know and don’t know about the science of distraction. At that event one fact became clear: distracted driving is taking lives. According to one market research company, since 2007, the percentage of Americans ages 13 and older with smartphones went from 6% to more than 80%. Although there have always been distractions competing with our focus on driving, these devices are especially addictive and, despite what we tell ourselves, we cannot safely or effectively multitask. To turn the tide will take a change in culture, especially in attitudes about portable electronic devices.

Experience with other causes of highway deaths shows that the science alone will not be enough to stop tragedy. Nor will awareness efforts. Heightened awareness, the right laws and policies, and tough enforcement all must play a role. The NTSB often makes recommendations aimed at changing safety culture within a company or even within a whole industry. We have recommended that states pass legislation to ban drivers from nonemergency use of portable electronic devices. We can’t “recommend” a way to change the minds and behavior of a whole nation of drivers, so we’re facilitating a conversation among survivor advocates and experts in awareness campaigns and in state houses.

We hope that you’ll join us. The roundtable begins at 9:00 am, April 26, in the NTSB Board Room and Conference Center, 429 L’Enfant Plaza, SW, Washington, DC. The event is convenient to the L’Enfant Plaza Metro station. You can also watch the event live at http://ntsb.capitolconnection.org/ and comment via Twitter @NTSB using #Act2EndDD.

 

The New Pipeline Rule I Waited Half a Career to See

By Charles Koval

One night, a couple feet underground outside an American home, the gas flowing in a service line began to escape through a puncture adjacent to a newly installed mailbox. A man and woman inside the home were watching the news. Their children were playing. Then, suddenly, without warning . . . nothing happened.

A simple and inexpensive device called an excess flow valve (EFV) kicked in, stopping the gas flow. There was no explosion, no fire, no injury or loss of life.

As a petroleum engineer and pipeline specialist for the NTSB, I know that the most important pipeline safety advance in recent decades has been the establishment of the national one-call 811 number. But EFVs may be the next most important life-saver, especially for homeowners.

Gas companies install an EFV in a service pipeline where it meets the main line. The EFV shuts off the gas flow in the service line when it exceeds the normal flow rate; excess flow often indicates that gas is escaping the service line through a puncture or sever, potentially leading to an explosion or fire.

I’ve been working a long time to encourage the progress that came to fruition late last year regarding EFVs. The Pipeline and Hazardous Materials Safety Administration (PHMSA) quietly completed an important achievement and, in the process, closed an NTSB recommendation. PHMSA issued a rule expanding the use of EFVs to new or renewed service lines leading to almost all small commercial businesses and multi-residence buildings.

It’s taken decades to achieve this result. In all, the NTSB has made 24 safety recommendations related to EFVs.

When I came to the NTSB in 1990, the agency had already been endorsing EFVs for 20 years, beginning with recommending a shutoff valve after research that came out of a 1970 safety study.

I worked on accident after accident that may have been prevented by EFVs. Most of my work between 1990 and 1994 involved single-family residences, but many multi-residence accidents were just as horrible, if not worse. The incidents occurred in large cities like Tulsa, Oklahoma, and St. Paul, Minnesota, and in smaller towns like St. Cloud, Minnesota; Montezuma, Indiana; and Cliffwood Beach, New Jersey. I can still remember my first NTSB supervisor expressing exasperation that this simple and elegant solution was not in wider use.

Then came June 9, 1994. At about 6:45 that evening, a 2-inch-diameter steel gas service line that had been exposed during excavation separated at a compression coupling about 5 feet from the north wall of John T. Gross Towers, an 8-story retirement home. The escaping gas flowed underground toward Gross Towers, passed through openings in the building foundation, entered the mechanical room through the floor vents, and migrated to other floors.

A resident smelled the gas, as did a workman onsite, who told his foreman. The foreman called the gas company and the housing authority, then had other employees locate and shut off the gas line valve inside the towers. But at 6:58 p.m., the built-up natural gas in the building ignited and exploded; a second explosion followed 5 minutes later. The accident killed one person and injured 66—and it could have been much worse. Many residents were not in the building on the early summer evening of the disaster.

A humble EFV could have shut off the gas flow into Gross Towers. After the explosion, the NTSB recommended that PHMSA’s predecessor agency require that all gas distribution operators inform all customers of the availability of EFVs. After many years, the agency did so. Meanwhile, fatal accidents continued—all potentially preventable with EFVs.

Then, in 1998, the NTSB was called to the site of an explosion and fire at a single-family home in South Riding, Virginia.

A man, woman, and their two children were spending their first night together in their new home. The family retired at about 10:30—the children to the upper level of the house, and, because not all of their furniture had arrived, the parents to the first-floor study. Shortly after midnight, the house exploded and was engulfed in flames. The children were thrown out of the house and onto the lawn, suffering minor injuries. The parents fell into the basement as the first floor collapsed. The father was able to crawl to safety, badly burned; the mother did not escape and died as a result of her injuries.

Again, an EFV could have prevented the tragedy.

Following this accident, the NTSB recommended that PHMSA require EFVs in all new and renewed gas service lines, regardless of customer classification, when operating conditions were compatible with readily available valves. PHMSA first required only that single-family homeowners be notified of the availability of the valve and be allowed to pay for it themselves. Then, in 2009, PHMSA changed the rule, requiring EFVs to be installed on almost all new and renewed service pipelines to single family homes.^[1] Finally, on October 14, 2016, PHMSA expanded the safety requirement to include most new and renewed service pipelines for multi-residential and commercial applications, closing one chapter in EFV history—and with it, an outstanding NTSB recommendation.

My first NTSB supervisor is no longer with us, but even years ago, he could imagine the broad use of EFVs that he did not live to see. Sometimes it takes a long time to normalize safety. Too often, it takes a highly visible accident—or several of them—to draw attention to a problem. Solutions often come a little bit at a time, or a long time afterward, without any fanfare.

But for now, and well into the future, for many businesses and homes nationwide, if a service line fails, nothing will happen. These homes and businesses are a little safer today because PHMSA and the gas industry acted on NTSB’s EFV recommendations.

 

Charles Koval is a Petroleum Engineer and Pipeline Specialist in the NTSB Office of Railroad, Pipeline and Hazardous Materials.

 

[1] The service line does not need an EFV if it: 1. does not operate at or above 10 psig all year, 2. has previously had contaminates, 3. could interfere with necessary operation or maintenance activities, or 4. is not commercially available to the operator.

Don’t Press the Envelope

By Mike Folkerts

Loss of control in flight—when a pilot fails to maintain or regain control of an aircraft—is the leading cause of general aviation fatalities. From 2011 to 2015, nearly half of all fatal fixed-wing accidents in the United States involved pilots losing control of their aircraft, resulting in 819 fatalities. Far too many NTSB investigations have shown how a loss of aircraft attitude control is often preceded by the loss of a pilot’s mental attitude control.

April 27, 2013, Piper PA-28R-180 airplane crash near Norfolk, Nebraska.

In the fatal accidents that I have investigated, this loss of mental control seems to be a conscious decision by the pilot to “press the envelope”—a term made famous in the 1983 film The Right Stuff, an adaptation of Tom Wolfe’s best‑selling book about the military test pilots who became Project Mercury astronauts. As the United States sought to achieve supersonic flight and put a human on the moon, these test pilots pressed the envelope, pushing the boundaries of both aircraft and human performance. Their efforts were based on national objectives and security, and many of these aviators paid the ultimate price in that pursuit.

Unfortunately, in far too many general aviation accidents, pilots choose to press the envelope for relatively minor (and often selfish) reasons, like “pressing the weather” to get home for dinner, flying at low altitude or maneuvering aggressively for an extra boost of adrenaline, or “pressing a known aircraft issue” to get a job done. Although a “git-r-done” attitude is certainly commendable, pilots too often forget to trust the little voice inside that warns them to steer clear of unwarranted risks, or they fail to guard against the temptation to make extreme efforts to please or impress others. General aviation flying very rarely requires the need to press the envelope, and pressing far too often ends in a tragic loss of control.

The NTSB is so concerned with this phenomenon that, for the last 3 years, we have placed “Prevent Loss of Control in Flight in General Aviation” on our Most Wanted List of transportation safety improvements to help bring attention to the issue. Last week, NTSB Board Member Earl Weener even attended the Sun ‘n Fun International Fly-In—one of the world’s largest general aviation enthusiasts’ training events—to talk to pilots about the dangers of losing control.

Whatever a pilot’s motivation may be for wanting to press the envelope, in general aviation, it’s not worth risking loss of control. Never underestimate the connection between mental attitude and aircraft attitude.

Mike Folkerts is an aviation safety investigator in the NTSB Office of Aviation Safety.

 

NTSB: 50 Years of Asking “Why?”

By Acting Chairman Robert L. Sumwalt

Fifty years ago, on April 1, 1967, the National Transportation Safety Board (NTSB) came into existence, helping to fulfill President Lyndon B. Johnson’s pledge to ensure the safety of Americans on land, sea, and air.

In 1966, Johnson recommended the creation of a single Department of Transportation (DOT), bringing together the functions of many far-flung agencies. He also urged

…that there be created under the Secretary of Transportation a National Transportation Safety Board independent of the operating units of the Department. The sole function of this Board will be the safety of our travelers. It will review investigations of accidents to seek their causes. It will determine compliance with safety standards. It will examine the adequacy of the safety standards themselves… I consider the functions of this Board so important that I am requesting authority from Congress to name five Presidential appointees as its members.

. . .

No function of the new agency—no responsibility of its Secretary—will be more important than safety.

Indeed, between March 2, 1966, and the NTSB’s birth the following year, there was a spate of disastrous commercial aviation crashes, either on US soil or involving US-built aircraft, together taking the lives of hundreds of passengers. This was not extremely unusual for this era; sometimes multiple fatal aviation accidents happened during the same month.

At the same time, the roads were full of automobiles that could never be sold under today’s safety standards. Most cars had no seat belts, and those that did generally had them in the front seat only. Air bags and child safety seats had not made their way into production. Drunk driving laws and enforcement were permissive, and even with far fewer cars on the roads, there were far more crash deaths.

Before the NTSB, major accidents in aviation were investigated by a section of the Civil Aeronautics Board, or CAB. Accidents in other modes of transportation might be investigated by a special subcommittee or jury, but there was no agency to coordinate these efforts or to collect the various findings and analyze them.

The written testimony of government officials in favor of creating the NTSB put it this way: “There is no single official in the entire Government who is in a position to identify, study, and propose solutions to transportation problems.”

The NTSB was established to ask “why?” when an accident happened, and to ask “why not?” Why not improve regulations, training, or a certain aspect of the vehicle or the environment? Even in its infancy, NTSB reports included, as they do today, recommendations to prevent future accidents, often pointing industry and regulators toward a safer future. Although action on NTSB recommendations is purely voluntary, more than 80% of our recommendations are acted upon favorably.

However, like the CAB investigators of its immediate predecessor in aviation, the NTSB initially was part of a larger agency that also concerned itself with operations and regulations. Although NTSB independence has been spelled out since its inception, the Board still came under the purview of the Secretary of Transportation. This arrangement put the NTSB in the position of investigating actions of its own parent agency and its constituent modal administrations. In 1974, Congress passed the Independent Safety Board Act of 1974, which, effective April 1, 1975, made the NTSB independent of the DOT, removing any concern that the regulator was, effectively, investigating itself.

Since our inception, we can point to numerous improvements that the NTSB has recommended as the result of accident and crash investigations in aviation, marine, highway, railroad, and pipeline transportation. The NTSB’s work throughout our 50-year history is responsible for the transformational improvements that make transportation safer for all of us today. But, by design, we can only take partial credit for any such improvement. We have no authority to regulate: only to recommend.

So, in celebrating our 50^th anniversary, we also celebrate those who read our investigations and recommendations, agreed with us, and made the improvements happen, as well as those who made things not happen. Together, we avoided preventable accidents. We saved lives that didn’t have to be lost in the first place. We kept property intact that did not have to be damaged, and prevented injuries that didn’t need to be sustained (and the medical costs and loss of productivity that go with them).

The transportation industry is focused on a future with zero accidents. The men and women of the NTSB are committed to this vision and will continue to investigate accidents and to make recommendations that will help future generations enjoy an era free from transportation accidents.

As new technologies and transportation fields come into existence—from autonomous vehicles to commercial space launches, and beyond—we look forward to the next 50 years of transportation safety improvements.