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2019-2020 Most Wanted List Midpoint Review

By Chairman Robert L. Sumwalt

MWL List

What do you call 125 participants in an NTSB Most Wanted List (MWL) mid-point progress meeting, each of whom has their own idea of a transportation safety goal to achieve by the end of the year?

An excellent start.

On February 4, the NTSB hosted attendees from government, industry, and the advocacy community to discuss progress on the 2019-2020 MWL. The conversations were productive and lively, and there was one thing we all agreed on: we need to achieve more in 2020.

Many people believe the NTSB’s work is done when an investigation has been completed, and we’ve determined the probable cause of an accident. But finding out what happened and why it happened is just half the equation.

The second half is arguably the most important part of our investigations: After determining the what and why, we issue safety recommendations aimed at correcting the deficiencies we uncovered, and thus, preventing similar accidents from happening again.

Even then, our work is still not complete. Recommendations must be implemented by their recipients before they begin to save lives. Therefore, part of our work is to highlight these recommendations and advocate for their implementation.

Board members, safety advocates and other NTSB staff are dedicated to fostering the cooperation necessary to ensure those life-saving recommendations are implemented, so the issues can be addressed and ultimately solved.

The MWL was conceived in 1990 and is the NTSB’s premiere advocacy product. It groups together unimplemented safety recommendations under broad topic areas that we refer to as issue areas. Issues placed on the list are selected from safety recommendations and emerging areas, and are based on the magnitude of risk, potential safety benefits, timeliness, and probability of advocacy efforts to bring about change. Simply put, MWL issue areas are those that we believe need the most attention to prevent accidents, reduce injuries, and save lives.

Up until 2017, the MWL was updated annually. That year, we went to a biennial list, with the provision that we conduct a mid-point progress review. And that, of course, is why we gathered on February 4. The purpose of the meeting was to receive input from stakeholders on where the current list is going, what are the impediments to implementing these recommendations, and what we can do better to advocate successful implementation of these recommendations. It was a day for us at the NTSB to listen to input and feedback.

Prior to the midpoint meeting, only 31 NTSB safety recommendations had been implemented out of 268 targeted in this MWL cycle. Implementing these 31 recommendations will make transportation safer by improving pipeline, aviation, railroad, marine, and highway safety. But as attendees of our mid-point evaluation agreed, implementation of these 31 recommendations, while welcome, is just not enough.

Member Jennifer Homendy and Robert Hall, Director of our Office of Railroad, Pipeline, and Hazardous Materials Investigations, guided the breakout session for that mode. Dana Schulze, Director of NTSB’s Office of Aviation Safety and I facilitated the conversations in the aviation breakout session. The marine safety session was headed-up by Morgan Turrell, Deputy Director of our Office of Marine Safety. And finally, Vice Chairman Bruce Landsberg took the highway safety discussion, joined by Rob Molloy, Director of our Office of Highway Safety.

Here are some of the thoughts that our attendees contributed:

  • Support efforts in the states to strengthen traffic safety laws to address issues like speeding, distracted and impaired driving and seat belt use.
  • Not every solution is a regulatory solution; work with industry and advocates to move toward voluntary compliance to get the required change done.
  • Increase and improve data collection.
  • Be proactive rather than reactive—through increased coordination between the NTSB, agencies, and industry.
  • Identify and promote industry best practices; to make change, it helps to see, hear, and learn from others who have accomplished the task.
  • Increase dialogue between the NTSB and industry outside of the context of accidents through preliminary recommendation communication, site visits, and board member meetings.
  • Creating a safety culture (in business) and addressing negative social norms (in public) are perhaps the most critical steps needed to improve transportation safety overall.
  • NTSB can play a key role in bringing all the key players together, promoting dialogue, and encouraging change.

NTSB recommendations, when implemented, can help to prevent unnecessary deaths, injuries, and property damage. The recommendation that is implemented today could be the life that is saved tomorrow. So, the voices of those closest to the battle for implementation—including the attendees at the midpoint progress meeting—are invaluable.

Time will tell how many critical MWL advances can be achieved by year’s end. I hope it’s all of them.

Automation Complacency: Yet Another Distraction Problem

By Vice Chairman Bruce Landsberg

 The NTSB first issued a recommendation to ban the nonemergency use of portable electronic devices (PEDs) while driving in 2011, and the issue area “Eliminate Distractions” remains on the 2019–2020 Most Wanted List of transportation safety improvements. Web browsing, texting, calling (even hands-free)—all these activities significantly increase the chance of a distracted‑driving crash, which is why we’ve recommended banning driver use of PEDs in all states. Most states have prohibited texting and handheld PED use in some form.

The science is clear: our addiction to PEDs is growing exponentially, placing constant connectivity and convenience above driving responsibly and resulting in tens of thousands of completely preventable, and often tragic, crashes. Driving while distracted by a PED is dangerous and it’s completely preventable. Simply, the decision to drive distracted is dumb.

Distraction by PED is becoming the “old” kind of distraction, as automated and semi-automated vehicles enter the roadways. These new technologies are creating a new and equally menacing kind of distraction: automation complacency. Overreliance on these advanced driver assistance technologies lulls drivers into a false sense of security. They trust in the machine and believe that frees them up to text, e-mail, or watch a video. With automation complacency, human nature asserts itself. We evolve to the idea that we will probably never have to intervene when a computer is doing the driving. The mind creates a rule based on positive prior experience; after so many seamless rides in an automated vehicle, we begin to relax our guard.

A tragic illustration of this growing phenomena is the March 18, 2018, fatal crash in Tempe, Arizona, involving a pedestrian and an Uber vehicle with an experimental automated driving system. The Uber’s safety driver was expected to intervene only if needed, a task that required the driver’s full engagement in and focus on the driving task. Instead, in the half hour prior to colliding with and killing the pedestrian, the driver spent more than a third of her time gazing down at the center console, sometimes for as long as 26.5 seconds. The vehicle’s onboard camera recorded the driver watching streamed content on her cell phone through most of the crash sequence.

Tempe, Arizona crash
NTSB investigators on-scene in Tempe, Arizona, examining the Uber automated test vehicle involved in a March 18, 2018 collision with a pedestrian.

Humans are creatures of habit and this driver had traveled this route more than 20 times in the test vehicle with no incident. Simply put, she was bored. She failed to remain vigilant and succumbed to automation complacency, believing the system would detect pedestrians under all circumstances—even when crossing outside of a crosswalk at night. Our investigation of this fatal crash determined that an attentive human driver would have easily avoided the pedestrian.

If it’s hard to convince drivers to stop multitasking while driving a vehicle that is not equipped with an advanced driver assistance technology, then it’s going to be that much harder to convince drivers to stay alert in a highly automated vehicle. The fact is, there is no commercially available vehicle in the United States that is fully autonomous and doesn’t require the driver’s full attention to the driving task.

The companies testing automated vehicles on public roads, the states where these vehicles are tested, and the National Highway Traffic Safety Administration must work to prevent this emerging form of distraction from increasing and placing roadway users at increased risk, particularly vulnerable users such as bicyclists and pedestrians. Now is the time to get ahead of the problem.



Do You Have a Super Bowl Transportation Game Plan?

By Leah Walton, NTSB Safety Advocate

Super Bowl LIV is almost here! Whether you’re a diehard 49ers or Chiefs fan, or you simply watch for the commercials and halftime show, the play clock is just about to hit 0. For many football fans, driving will be part of the game plan both before and after the Super Bowl, regardless of if they’re driving over 3,000 miles to Hard Rock Stadium or simply going across town to a playoff party. Either way, safe transportation plans must be part of every driver’s Super Bowl game plan.

Football is a game driven by statistics. As Chiefs’ Head Coach Andy Reid takes in stats for his Super Bowl game plan, consider these highway safety facts as you prepare your own playbook.

Driving fast with a sport car

So, what should your Super Bowl transportation game plan look like? First, drive sober or designate a sober driver. Recognize that even a moderate amount of alcohol or certain drugs will make driving unsafe. If you don’t have a designated driver, a taxi, public transportation, or rideshare charge will be a minor cost compared to a DUI—or worse. Second, don’t drive fatigued. Immediately after the game and before work the next day, check yourself to see if you are rested enough to drive safely. If you got less than 7 to 9 hours of sleep, recognize the need to take breaks, take a nap, or find another mode of transportation. Third, don’t drive distracted—the postgame highlights, commentary, and selfies can wait until you safely arrive at your destination.

Whether you’re rooting for the 49ers, Chiefs, or simply a good game, make sure you have a designated sober driver in your Super Bowl lineup, and follow this gameday rulebook!



Global Road Safety Leaders of the Future

By Nicholas Worrell, Chief, NTSB Safety Advocacy Division

Last week, the NTSB hosted a group of students from around the world who are studying or pursuing higher education degrees in traffic safety. They came to us through the International Roads Federation (IRF) Fellows Program, which works to develop transportation safety leaders worldwide.

The students were from diverse cultures—Lebanese, Iranian, Japanese, Colombian, Libyan, Mexican, Palestinian, and Brazilian—but they had one thing in common: they were all studying at universities in the United States.

It was an honor to be chosen by the IRF to help develop and grow these fellows. The group got to hear from Jim Ritter, Director of Research and Engineering; Lisandra Garay-Vega, Supervisory Transportation Specialist; David Pereira, Vehicle Factors Investigator; and several of our lab experts.

In transportation safety, we often ask how we can change safety culture? This question applies in one way to organizations, looking at how a company’s culture might influence a driver’s actions of a driver. This kind of safety culture is widely studied but involves only the minority of accidents/crashes. Most crashes involve everyday drivers operating personal motor vehicles. How do we change the safety perspectives of everyday drivers? We start with investing in young leaders like those who joined us during the visit.

In the United States, we lose more than 40,000 lives every year as a result of accidents and crashes in all modes of transportation. Worldwide, according to the World Health Organization, we lose more than 1.35 million people every year on the roads, alone. When it comes to traffic safety, to truly change our safety culture, we must start with the younger generation. We must invest in ways to teach young children how to be safe on the roads long before they get behind the wheel for the first time. And we must invest our time in working with students like the IRF fellows, supporting their efforts to design transportation systems that protect all road users, not just those inside a motor vehicle.

At the NTSB, we strive to encourage and develop young safety leaders—teaching them to build bridges for others to cross, lay stepping stones for others to walk upon and shoulders for them to stand upon. Our core value of excellence goes beyond our central mission of issuing safety recommendations; it also applies to excellence in the service of others. In advocacy, it demands we pass along information to young leaders who will carry the mantel with a goal of safer transportation worldwide. We wish them well and lots of success.


Episode 30: Member Jennifer Homendy

In this episode of Behind-the-Scene @NTSB, Member Jennifer Homendy shares highlights from her first year at NTSB and the transportation safety improvements she hopes are accomplished in 2020. Member Homendy was first featured on the podcast shortly after she began her tenure as the 44th Member of the NTSB in Episode 20.


Member Homendy’s full bio is available here.


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

And find more ways to listen here:

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.