All posts by ntsbgov

In the Driver’s Seat: Counties Can Enhance Transportation Safety

NTSB Member Mark R. Rosekind with Benton County Commissioner Leo Bowman, Chairman of the National Association of Counties’ Transportation Steering Committee after Member Rosekind’s remarks at the annual conference.

By Mark R Rosekind

As trends go, state and local governments are becoming increasingly responsible for many aspects of transportation safety. This includes the 3,077 counties across the United States. On Saturday, I spoke at the National Association of Counties’ (NACo) 77th Annual Conference in Pittsburgh about the NTSB, its investigation process, on-scene activities after an accident, and ways in which to make travel safer in counties across America. It was a great opportunity to familiarize a broad and important cross-section of the nation’s local leaders with the NTSB should a transportation tragedy happen in their area.

NACo is the only national organization representing county government and its meetings provide a unique forum for over 2,000 elected officials to learn more about organizations and issues affecting their counties, network with colleagues, and educate themselves about innovations across the country. Although counties have an array of various responsibilities depending on the state they are in, some duties are universal, especially enhancing transportation safety. While it is the NTSB’s mission to make safety recommendations to prevent accidents from recurring, local leaders know that being prepared for the possibility of a major transportation accident in their county is critical.

I addressed NACo’s Transportation Steering Committee, charged with guiding the organization on diverse matters related to transportation safety; project development and financing; comprehensive transportation planning; highways; public transit; airports; railroads; waterways; and research and development of new modes of transportation. An area that I highlighted was the integrity of our nation’s infrastructure using pipeline safety as an example and focusing on the PG&E San Bruno, California, pipeline explosion and Enbridge Marshall, MIchigan, oil spill. One concrete action for participants: ensure that their first responders know where pipelines are located in their county, what is transported through them, and contacts/actions needed to address a problem.

It was clear from my discussion with NACo members and staff that all counties are feeling the pressure to fill funding gaps, especially in the area of transportation safety. As state and local governments continue efforts to enhance transportation safety, their interests directly intersect the NTSB and its mission. By increasing dialogue, partnerships, and information sharing with community leaders in counties, towns, and cities, everyone will reap tremendous long-term benefits for making America a safer place to travel.


Mark Rosekind, Ph.D., is a Member of the National Transportation Safety Board. He is a frequent contributor to the NTSB blog.

Looking but not seeing

Jackson Hole B-757

By Robert Sumwalt

In June, the Board deliberated a runway overrun involving an American Airlines B-757 at Jackson Hole, WY. Fortunately, about the only thing hurt during the accident were the egos of the two pilots. Setting the stage for the incident were two separate and unrelated mechanical issues: the speedbrake did not automatically deploy, and the thrust reversers did not initially deploy when commanded. Although the speedbrake could have been deployed manually, this was not done – perhaps because both pilots now were engrossed with trying to deploy the thrust reversers.

At the end of the NTSB board meeting, the Board concluded the probable cause of the incident was a “manufacturing defect in a clutch mechanism that prevented the speedbrakes from automatically deploying after touchdown and the captain‘s failure to monitor and extend the speedbrakes manually. Also causal was the failure of the thrust reversers to deploy when initially commanded. Contributing to the incident was the captain‘s failure to confirm speedbrake extension before announcing their deployment and his distraction caused by the thrust reversers’ failure to initially deploy after landing.”

One learning point is that the captain called out “deployed” for the speedbrake and “two in reserve,” without actually verifying their deployed status. The NTSB concluded that “the captain’s erroneous speedbrakes ‘deployed’ callout was likely made in anticipation (not in confirmation) of speedbrake deployment after he observed the speedbrake handle‘s initial movement; after the ‘deployed’ callout was made, both pilots likely presumed that the reliable automatic speedbrakes were functioning normally and focused on the thrust reverser problem.”

In essence, he was looking but not seeing.

I suspect somewhere in my three decades of flying, I probably made the mistake of looking at something but not really seeing what I thought I was looking at.

Have you ever done that?

The NTSB has seen this in other accidents, as well. In the fatal July 2008 runway overrun accident involving a Hawker 800 at Owatonna, MN, the first officer called out “we’re dumped” to indicate the liftdump had deployed upon landing. Although he immediately corrected himself and said “we’re not dumped,” his initial callout was made in anticipation of the liftdump system activating, not by actually verifying it. The NTSB stated “the first officer most likely stated ‘we’re dumped’ as an automatic callout upon landing when he saw the captain move the airbrake handle aft” without actually verifying the deployment of the liftdump system (underlining for emphasis).

Another case of looking but not seeing occurred in 1988 when a Delta 727 crashed following an ill-fated no-flap takeoff attempt at Dallas-Fort Worth. When the second officer called out “flaps” on the taxi checklist, the first officer quickly replied “fifteen, fifteen, green light” – the standard takeoff flap setting for the 727. The physical evidence indicates that the flaps were retracted and not set for takeoff as stated by the first officer. The NTSB found that “because of the repetitive nature of checklist accomplishments, it is not uncommon for crewmembers to fall into a habit of answering to challenges by rote with the normal response without actually observing the appropriate indicator, light or switch… This can be particularly true if the respondent has a mindset that the action necessary to satisfy the indicator checklist has been completed.”

So, what have we learned from these accidents and incidents? Make sure what you are looking at is actually what you are seeing.

What measures can you take to make sure you not falling into the trap of looking but not seeing?


Robert L. Sumwalt was sworn in as the 37th Member of the National Transportation Safety Board on August 21, 2006. He is a frequent contributor to the NTSB blog.

Putting Transit Safety on the Right Track

By Debbie Hersman

On Monday afternoon, I joined U.S. Sen. Barbara Mikulski, D-Md., and members of the Maryland Congressional delegation at the Washington Metro’s Carmen Turner facility to commend the new law that gives the Department of Transportation crucial safety authority.

For years, the NTSB has called for national safety standards for our nation’s transit systems. With this new law, the foundation has been laid and the train is on the track, but the final destination remains miles away.

Through our investigations of transit accidents, we have identified a number of ways to improve transit safety. Our recommendations cover the need for safety regulations governing operations, track, equipment, and signal and train control systems. We have called for crashworthiness standards and improved evacuation and rescue features on rail transit cars. In addition, the NTSB recommends requiring data recorders on transit trains, implementing non-punitive safety reporting programs and instituting hours-of-service limits to ensure transit operators are rested.

Yes, there is work to be done, but it is gratifying to see the law in place and to know that DOT and the Federal Transit Administration are ready to hit the ground running. Administrator Rogoff has embraced the new mandate and articulated a vision to raise the bar on rail transit safety. We look forward to the day when our recommendations are implemented.

Deadlines Matter

By Debbie Hersman

It has been 16 years since the crash of TWA Flight 800. After an exhaustive four-year investigation, the NTSB concluded that the cause of this disaster was a center fuel tank explosion. Image

Among the many findings that came out of the NTSB’s investigation, we recommended that the FAA and manufacturers take steps to reduce the risk of future explosions. At the NTSB, we always stood by those recommendations, even when we were told that it could not be accomplished. In 2008, after many years of delay, the FAA finally produced the fuel tank flammability rule, which requires airlines to retrofit half of their fleets by 2014 and finish by 2017.

Unfortunately, the delays apparently continue. Today we learned that FAA fined the Boeing Company for failing to meet a Dec. 27, 2010, deadline to submit service instructions that would enable airlines to retrofit their fleets and thereby reduce the risk of fuel-tank explosions on Boeing jetliners. 

This is not just some bureaucratic Washington requirement. There are hundreds of U.S.-registered Boeing jetliners flying passengers that are being placed at risk by these delays.  It is critically important that the operators of these aircraft implement the recommended changes. 

Sixteen years is too long to wait to prevent another accident.  Deadlines do matter.

Lessons Learned from NTSB Investigations Addressed in Highway Bill

By Debbie Hersman

At the NTSB, we don’t have the power to pass laws, regulations or issue fines. Our charge is to thoroughly investigate accidents, analyze trends and make our best recommendations on how to make transportation safer.

It is a testament to the great work of the men and women of the NTSB that Congress addressed so many of our safety recommendations in its latest transportation law.

Based on our investigation of several accidents involving the Washington Metropolitan Area Transit Authority as well as a number of accidents around the country where local oversight was lacking, the NTSB recommended increased federal oversight of rail transit following the 2009 collision near Fort Totten. Senator Mikulski and many in the Washington-area delegation made this a priority following several fatal accidents on Metro and at the DOT, Administrator Rogoff of the Federal Transit Administration and Secretary LaHood, have embraced this safety oversight. The new law improves federal oversight of rail transit systems and creates greater accountability among state safety oversight entities.

Bus occupant safety, which is on our “Most Wanted List” and includes a number of long-standing NTSB recommendations, received a boost in the new transportation law. Senator Hutchison worked for many years with her colleagues to advocate for better bus occupant protection through better crashworthiness, safety monitoring standards, and fire suppression measures. The law also improves the safety-fitness rating system of motorcoaches and additional authority for DOT to combat the efforts of poor carriers who try to escape scrutiny by “reincarnating” themselves under new names. Senator Brown and Congressman Lewis deserve credit for their work on bus safety.

Addressing human fatigue has been a perennial issue on our “Most Wanted List.” For over 30 years, the Board has identified fatigue as the primary cause of numerous fatal highway accidents involving large trucks. The law includes the requirement for electronic on-board recorders to be installed on commercial motor vehicles to monitor drivers’ hours of service. This requirement, while controversial and heavily debated, is the only way to really level the playing field when it comes to driver compliance with the law – we routinely see two sets of log books or drivers exceeding legal limits in our investigations. Adoption of this provision will save lives and make our highways safer.

Other NTSB “Most Wanted List” issue areas, teen driver safety, addressing alcohol-impaired driving and motorcycle safety were also addressed in the law. To improve teen driver safety, grants will be provided to states implementing graduated licensing programs and efforts aimed at increasing teen seatbelt use, reducing distracted driving and curbing underage drinking. To help fight alcohol-impaired driving, the law specifies minimum penalties for repeat offenders and authorizes NHTSA to conduct research on in vehicle alcohol-detection technology. The law also provides motorcycle safety grants focused on improving motorcycle training and reducing fatalities.

The law includes many of our recommendations and important changes which, if implemented, will improve safety. Yet, with more than 30,000 fatalities a year, we know there is much more work to be done. At the NTSB, our investigators and analysts will continue evaluating accidents so we can learn important lessons to constantly improve the safety of our roadways and help inform the policymakers that are working to prevent future accidents.