Our Transportation Safety Wish List

By Chairman Robert L. Sumwalt

Every 2 years, the NTSB puts together a wish list, called our Most Wanted List (MWL) of transportation safety improvements. It comprises recommendations ripe for action by their recipients, which, if acted on, will bring safety benefits to all Americans.

Our wish list is not like some other traditional holiday wish lists. For one thing, we’re not asking who’s naughty and who’s nice; the stakes are too high for that. Regardless of whether you’re naughty or nice, you deserve access to safe transportation. Another difference is that a safety wish list is about things that transportation interests—government, industry, and others—are supposed to provide. Our list includes safety items that should “come standard,” not ones that we hope we’ll receive if we’re all really, really good travelers this year.


That being said, it’s still nice to see some “wishes” checked off our list this year, even if American travelers had every right to expect them. For instance, we recently acceptably closed the following recommendations to the Long Island Rail Road (LIRR) and the Metro-North Railroad, both part of New York’s Metropolitan Transit Authority:

  • Safety Recommendation R-14-65, which asked the LIRR to screen and evaluate employees in safety-sensitive positions for sleep disorders, then treat those who tested positive.
  • Safety Recommendations R-14-62 and R-14-64, which asked Metro-North to revise medical protocols and provide its employees in safety-sensitive positions a list of medications that engineers and conductors must avoid.
  • Safety Recommendation R-17-9(to Metro-North) and R-17-10 (to a number of railroads, including Metro-North), which sought risk assessment and mitigation strategies at grade crossings with third-rail systems at or near the crossings. (Safety Recommendation R‑17‑10 remains classified “open” overall because other recipients have not yet completed action on it.)

What else can we scratch off our list?

In November, we closed Safety Recommendations P-18-5, -6, and -8 acceptably. These recommendations called for the management-of-change process to be used to identify natural gas system threats, and for professional engineers to be included in the engineering plan and constructability review processes as well as in public utility engineering drawings in Massachusetts.

In September, we closed Safety Recommendations P-18-1-7, and -9 acceptably. These recommendations called for improved inspection programs, better records and documentation of natural gas systems, and procedures to mitigate risks identified during management-of-change operations.

In July, we announced the closure of eight MWL-related recommendations. Four (P‑17‑3H‑15‑20, A-09-92, and H-09-18) were closed with acceptable action taken, one (P‑18‑3 ) was closed with acceptable alternate action taken, and one (M-16-28) was closed with a status of “exceeds recommended action.”

  • P-17-3 called for Colonial Pipeline Company to address pipeline dent repairs and leak detection.
  • P-18-3 called on Honeywell to address an issue with incorrectly installed mechanical tapping tee assemblies.
  • H-15-20, to the National Limousine Association, addressed the need for passenger safety briefings about seat belt use in limousines.
  • H-09-18, to the Federal Motor Carrier Safety Administration (FMCSA), addressed access to positive drug and alcohol test results and refusal determinations.
  • A-09-92, to the Federal Aviation Administration, addressed the need for the helicopter emergency medical services to use the Aviation Digital Data Service Weather Tool as an official weather product.
  • M-16-28, issued to the Passenger Vessel Association, called for a variety of actions to improve the safety of amphibious passenger vehicle operations, applying lessons learned in two amphibious passenger vehicle crashes.

As in most years, we did not get most of what we wished for on behalf of the traveling public; Even though these are safety measures the public is supposed to be able to count on, we understand. Many of our wish list items take a long time to achieve. These items, too numerous to name here, remain open.

Sometimes a recommendation, such as R‑04-7, is superseded by a subsequently issued recommendation (in this case, R-19-1).

And sadly, other recommendations must be closed unacceptably, such as H-12-29, issued to the FMCSA. This recommendation asked the FMCSA to establish an ongoing program to mitigate the risk of driver fatigue. That was one “gift” the traveling public really needed this year but did not receive.

Our 2019­–2020 Most Wanted List includes the following broad items:

We celebrate the actions that have been taken this year to improve safety, but there’s plenty left to wish for. Take a look at our website for more information on the MWL and some of the recommendations still on our wish list.

Happy holidays, and may you receive everything you want (and need!) for the new year.

Making the Right Choice this Holiday Season

By Leah Walton, NTSB Safety Advocate

 “On behalf of all of us at the NTSB, I offer our sincerest condolences to the families and friends of the individuals who lost their lives in this crash. Our entire purpose for being here today is to learn from tragic events like this, so that they can be prevented in the future.”

Chairman Robert Sumwalt speaks these words, or some variation of them, with grave sincerity in his opening statement at every Board meeting, and, as we hit the height of this holiday season, I can’t help but reflect on the Chairman’s words, the accident reports I’ve read, and the survivors I’ve met. As families and friends gather to celebrate, socialize, and look back on the year that’s coming to a close, many will also be missing a loved one, some for an agonizing first time.

Regardless of whether they’re experiencing the first holiday season without their loved one or the twenty-first, I imagine this time of year is especially painful for those who have lost someone suddenly in a transportation accident or crash; particularly a crash that was preventable.

Many of the fatal highway crashes we investigate are the result of human error. In 2018, 10,511 of those human errors were the result of alcohol-impaired driving, which—not surprisingly—tends to spike during this season of parties and revelry.

Imagine that—10,511 families are missing loved ones at their holiday celebrations this year due to a human error that is 100% preventable.

Impaired Driving Preventable

At the NTSB, we issue safety recommendations that, if implemented, could prevent transportation tragedies from reoccurring. Our safety recommendations call for bold actions; that’s the only way we’re going to get to zero deaths on our nation’s roadways. We’ve called for actions like:

Like many large problems, though, a comprehensive solution is needed to make real change. When it comes to impaired driving, a massive culture shift is required. We need to adjust our ideas about driving after drinking and take that option off the table, because when we say impaired driving crashes are 100% preventable, it really is that simple. Choose to drink or choose to drive. But never do both.


This holiday season, as you enjoy coming together with your loved ones, please take a moment to consider those dealing with the pain of an empty seat at their table because of an impaired driver. If your plans include alcohol, make the choice to let someone else do the driving. Keep yourself, your loved ones, and your fellow travelers safe to celebrate again next year and for many years to come.

Ensuring the Safety of School Bus Transportation

By Vice Chairman Bruce Landsberg

Fact: Students are safer riding to and from school and school activities on a school bus than in the family car, and far safer than they would be riding in a car with a teenage driver. There should be no doubt that everything possible is being done to keep children safe on school buses. On commercial aircraft, a flight attendant’s primary responsibility is safety and so it is with school bus drivers, whether at the wheel or leading an evacuation.

But emotional response to tragedies like the one described below, may influence some parents to believe that it’s safer for them— or, worse yet, their teenage drivers — to drive their children to school.

NTSB recently completed an investigation of the December 12, 2017, school bus fire in Oakland, Iowa, that took the life of the driver and one student passenger. The driver entered a private driveway to pick up his first passenger of the morning. As he did routinely, he backed across the gravel road behind the driveway but on this day the rear wheels dropped into a ditch and the bus became stuck, its exhaust pipe wedged into an embankment. As the driver attempted to free the bus, the turbocharger overheated and a fire began in the engine compartment, engulfing the bus several minutes later.

School bus at final rest in ditch (Source: Pottawattamie County Sheriff’s Office)

None of the doors were blocked so the driver and his single passenger had ample time to exit. It appears that the student was attempting to help the driver escape and they were both overcome with smoke. Sadly, this driver had mobility challenges although he held a valid medical certificate. He used a cane or a walker and was scheduled for surgery two days after the accident.

The Iowa Administrative Code specifies that drivers must be physically able to help ill or injured passengers off the bus. Additionally, an employer can (and should) evaluate a driver’s ability to assist in an evacuation. This driver, simply, was unfit and could not perform the emergency duties required of him. What’s more, the school district knew the driver was unfit for duty, but he was allowed to continue driving. The transportation supervisor, the school principal, and his coworkers all knew of his physical impairment. The Riverside Community School District had the knowledge it needed to act, yet it did not. In fact, in recent years, it had gone so far as to do away with physical performance tests for drivers.

As a result of this crash, NTSB issued and reiterated recommendations which, if acted upon, will result in landmark changes to school bus safety. All new and in‑service school buses should be equipped or retrofitted with fire-suppression systems. Fire-resistant material should separate bus occupants from the engine to ensure that no hazardous gas or flame can pass from the engine compartment, and revise existing standards flammability of interior materials. More robust physical performance testing and maintaining complete records will help to ensure school bus drivers are fit for duty.

The state of Iowa was encouraged to establish a driver safety hotline so anyone could report drivers that may be unfit for the job. Finally, we recommended that every bus driver receive at least annual training on emergency procedures, including evacuation and use of the onboard 911 button. They should demonstrate the ability to operate all exits and assist students off the bus. Likewise, all student riders should be trained on emergency procedures and evacuation – regularly.

We reiterated a recommendation to the National Highway Traffic Safety Administration to adopt new federal fire safety standards for flammability of interior materials that reflect nearly a half-century of progress. It’s well past time for them to act. Fortunately, school bus manufacturers have adopted flammability resistance test procedures that are more stringent than the federal standards; however, stronger federal standards are important to setting a consistent high bar for school bus fire safety. Get it done!

Students are safest when riding the bus, not the family car. Drivers must be medically and physically fit. Buses should be equipped with critical life-saving technology. School districts should review their policies and ensure compliance of equipment, safety training and driver fitness – NO exceptions. Parents should be asking school districts if they comply. Our children deserve that!

The full investigation report for the Oakland, Iowa, school bus fire is available here.

For more information on NTSB school bus investigations and safety recommendations visit www.ntsb.gov/schoolbuses.






Toward a Brighter Future

By Nicholas Worrell, Chief, NTSB Safety Advocacy

As Chief of the NTSB’s Safety Advocacy Division, I firmly believe in taking time to visit with young and novice drivers and promoting safe driving habits in line with the NTSB’s safety advocacy goals. Last week, I addressed students at Stranahan High School in Fort Lauderdale, Florida, during the National Black Caucus of State Legislators (NBCSL) Annual Conference.

Each year, the conference features a visit by Corporate Round Table (CRT) members to a local high school. There, team members engage high school juniors and seniors, educating and empowering them to pursue professional development, foster individual strengths, and strive for excellence.

In this photo taken December 4, 2019, Nicholas Worrell, Chief, NTSB Safety Advocacy Division (top right) is pictured with students from Stranahan High School and National Black Caucus of State Legislators Corporate Round Table members.

The NBCSL’s CRT has a rich history of working with schools across the country to provide high school students with essential insights and knowledge about careers and professional development. CRT members have long positively impacted the youth with whom they work. The theme for this year’s CRT visit was “L.E.A.D: Leadership, Excellence, Attitude, Determination.” Team members discussed the importance of leadership today, and the importance of cultivating leadership skills necessary to succeed tomorrow.

But, as I told the students at Stranahan High School, what’s most basic to all these aspirational goals is to live long enough to build that bright future for themselves and others.

My part in the presentation was to make the young audience aware of the many dangers and challenges they may face on the road, and to arm them with the right driving habits to actually arrive at adulthood. Just as youth must first make it safely to adulthood to have the chance to tackle the leadership challenges to which they aspire, they must also learn to lead themselves before they can successfully lead others. As John C. Maxwell once wrote, “A leader is one who knows the way, shows the way, and goes the way.” The first step in the leadership journey is self-leadership.

That goes double for making our roads a safer place for all.

In 2018, more than 36,000 people died in traffic crashes. For young people like those I talked to last week, the best chance to stay alive to adulthood is to not be involved in a traffic crash, either as a driver, passenger, pedestrian, cyclist, or motorcyclist. The deadly effect of traffic crashes on teenage lives will only change when our culture around road safety changes, and the only way that shift can take place is if we each personally embody the change we wish to see in the world.

Driving sober, disconnecting from our phones and other devices, buckling up, and obeying the speed limit are all simple—and safe—practices. However, making the right choice consistently takes integrity (doing the right thing even when nobody is watching). In road safety, knowing the way is not always the hard part. The ability to consistently go the way, and to show others the way, separates leaders from followers.

Holding ourselves accountable for our conduct on the road is the first step toward the cultural shift we need to ensure our nation’s youth make it to adulthood to fulfill their goals.

For previous blogs on the NBCSL school visits, see the links below:




Episode 29: Tempe, Arizona, Uber Vehicle and Pedestrian Crash

In this episode of Behind-the-Scene @NTSB, Highway Crash Investigators, Ensar Becic and Mike Fox, talk about the 2018 collision between a vehicle controlled by a developmental automated driving system and a pedestrian in Tempe, Arizona. We explore the findings and safety recommendations that came out of the investigation, as well as the strengths and limitations of automated vehicles and how it impacts highway safety and the importance of safety management systems.

To learn more about the NTSB investigation of the Tempe, Arizona, crash, visit: https://ntsb.gov/news/press-releases/Pages/nr20190423.aspx


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

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