Let’s Stop Going the Wrong Way

By Robert Molloy, PhD, Director, NTSB Office of Highway Safety

If you’re driving down a divided highway and see headlights coming right at you, or hear screeching tires and see cars and trucks swerving to get out of your way, it’s probably an indication you’re heading in the wrong direction. Another indicator may be the large signs that read “Wrong Way” and “Do Not Enter.” The signs are always there, yet, unfortunately, they can go unnoticed, with catastrophic results.

“Do Not Enter” and “Wrong Way” signs posted on an exit ramp (Source: New York State DOT)

The NTSB has a long history of investigating collisions involving vehicles traveling the wrong way on high-speed divided highways. Wrong-way crashes occur relatively infrequently, but they are much more likely to result in fatal and serious injuries than any other type of highway crash.

In December 2012, we released a special investigation report looking at the causal factors involved in wrong-way crashes. In that report, we issued 16 safety recommendations aimed at prevention, many of which are still open, awaiting action by highway safety regulatory agencies, automotive industry groups, and states.

As we strive toward safety, we must look at what the trends and data are telling us. Are we heading in the right direction regarding wrong-way crashes? Today, the AAA Foundation for Traffic Safety released a research brief examining fatal wrong-way crashes. It contained alarming statistics that should be a flashing “Wrong Way” warning sign to all of us. The trendline for these crashes is clearly moving in the wrong direction.

The AAA’s analysis shows that, between 2010 and 2018, there were 3,885 deaths resulting from wrong-way driving crashes—an average of 430 deaths per year. This is a 19-percent increase over the 360 fatalities per year found in our analysis of 2004 to 2009 crash data. In total, we have lost a staggering 6,024 precious lives in wrong-way crashes in just 15 years—an unacceptable loss of life, especially when these types of crashes are preventable.

Like our earlier report, AAA’s research found that alcohol impairment plays a large role in wrong‑way crashes. Over 60 percent of wrong-way drivers in fatal crashes are impaired. In May 2013, we published Reaching Zero: Actions to Eliminate Alcohol-Impaired Driving, which includes a comprehensive list of safety recommendations to help eliminate alcohol‑impaired driving. Specific prevention strategies needed to reduce wrong-way crashes include the following:

• Increase high-visibility impaired-driving enforcement, including sobriety checkpoints and saturation patrols, in areas where wrong-way driving movements are most prevalent.
• Accelerate the development of in-vehicle alcohol-detection technologies.
• Require the use of alcohol ignition interlock devices for all individuals convicted of driving-while-impaired offenses.
• Reduce the per-se blood alcohol concentration (BAC) limit to 0.05 or lower for all drivers. Lowering the BAC has been shown to provide a broad deterrent effect.

AAA research also found that older drivers are more at risk of wrong-way driving than their younger counterparts. The NTSB has open recommendations to the states calling on them to develop a comprehensive highway safety program for older drivers that incorporates, at a minimum, the elements of the National Highway Traffic Safety Administration’s Highway Safety Program Guideline No. 13—Older Driver Safety. A successful program includes driver licensing and medical review of at-risk drivers, education for the medical and law enforcement community, and improved roadway design for older driver safety.

The NTSB, AAA, and others have developed a roadmap for preventing wrong-way crashes. It’s about time we do a U-turn and start heading in the right direction. I applaud the AAA Foundation for Traffic Safety for this recent research. We can’t ignore the flashing warning sign that we are going the wrong way toward preventing deadly wrong-way crashes on our highways.

Twelve Years After Colgan 3407, FAA Still Hasn’t Implemented Pilot Records Database

By Chairman Robert Sumwalt

I grew up in the South, and people sometimes say we do things slowly in that part of the country. Whether there’s any validity to that claim, I can’t say with certainty. What I can say with great certainty, however, is that speed isn’t an attribute commonly associated with the Federal Aviation Administration (FAA), an agency within the US Department of Transportation. Below is a sad, but true, example of the glacial pace of the FAA’s rulemaking processes—even in the wake of a congressional mandate to get something done. Perhaps the new secretary of transportation can give a needed boost to this untenable situation.   

On this date 12 years ago—February 12, 2009—while on approach to the Buffalo‑Niagara International Airport in New York, Colgan Air flight 3407, a Bombardier Q-400 turboprop, plunged from the sky. Fifty lives were lost, including that of a man who died when the turboprop crashed into his home.

The NTSB’s year-long investigation revealed that, as the airplane slowed on approach, the captain became startled by the activation of the aircraft’s stall warning system. In response to something that should have been easily dealt with, the captain inappropriately manipulated the elevator controls, forcing the aircraft into its fateful dive. Our investigation found that the captain had a history of piloting performance deficiencies, including having failed several flight tests. Possibly more troubling, he concealed these performance deficiencies from Colgan when he applied for employment.

The Colgan crash was the deadliest US airline disaster in the past 19 years.

In response to this tragedy, the NTSB issued safety recommendations to the FAA to strengthen the way airlines ascertain a pilot applicant’s background, including requiring previous employers to disclose training records and records of any previous failures.

Congress took note of these recommendations and included them in a bill signed into law in August 2010. This law required the FAA to establish a pilot records database (PRD), and stipulated that “before allowing an individual to begin service as a pilot, an air carrier shall access and evaluate . . .  information pertaining to the individual from the pilot records database.” Items required to be entered into the PRD, and considered by hiring airlines, included “training, qualifications, proficiency, or professional competence of the individual, including comments and evaluations made by a check airman . . . any disciplinary action taken with respect to the individual that was not subsequently overturned; and any release from employment or resignation, termination, or disqualification with respect to employment.” Congress appropriated $6 million per year for the next 4 years to help facilitate creation of the PRD—a total of $24 million.

The FAA’s response reminds me of my college’s football team—they get off to a good start, but after scoring on the opening drive, they have difficulty executing for the rest of the game.

In early 2011, the FAA established an aviation rulemaking committee (ARC) to develop recommendations on the best way to implement the PRD. Despite the ARC completing its work and issuing a report to the FAA in July 2011—just 6 months after being tasked with developing recommendations—it wasn’t until September 2015 that the FAA began a phased approach to implementing the PRD.

By July 2016, Congress had become impatient with the FAA’s lack of progress. After all, it had been 6 years since the FAA was required to create the PRD, and there was still no appreciable progress. Congress gave the FAA a new deadline: it mandated the PRD be in place by April 30, 2017.

Unfortunately, April 30, 2017, came and went. Still no PRD. Meanwhile, 40 days after that deadline, a young pilot applied for employment at Atlas Air and was hired shortly thereafter. As with the Colgan Air captain, this pilot concealed his history of performance deficiencies, which deprived Atlas Air the opportunity to fully evaluate his aptitude and competency as a pilot. He struggled with training at Atlas, but after failing his check ride, he was retrained and passed. Tragically, on February 23, 2019, on what should have been a routine cargo flight from Miami to Houston, this pilot, like the Colgan Air captain, encountered something that startled him. He overreacted and put the Boeing 767 into a fatal dive. The commonalities between the Colgan Air crash and the Atlas Air crash are striking: Both pilots had a record of poor performance prior to their employment, both pilots concealed that information when applying for airline employment, and both pilots misapplied the flight controls following events they weren’t expecting. Events that should have been easily corrected. Events that, tragically, led to their aircraft plunging to the ground.

Neither of these sad events was an isolated case. Including these two crashes, the NTSB has investigated 11 air carrier accidents over 3 decades in which pilots with a history of unsatisfactory performance were hired by an airline and then were later involved in an accident attributed to their poor piloting performance.

After years of foot dragging, last March, the FAA provided its first visible indication of moving forward with the PRD, publishing a notice of proposed rulemaking (NPRM) to give the public a glimpse of what the proposed rule may look like—10 years after Congress initially mandated it, and 3 years after the April 2017 deadline that Congress eventually imposed.

The NPRM indicated that the PRD should be implemented sometime this year; however, the NPRM also proposes allowing a 2-year phase-in period. This puts complete implementation somewhere around a 2023 timeframe, assuming this proposed timeline holds. If that’s the case, we will finally have the PRD 14 years after the Colgan Air disaster, 13 years after Congress mandated it, 5 years after the deadline imposed by Congress, and 4 years after the Atlas Air crash.

A crash is a tragedy. It’s even more tragic to see a similar crash happen again and again and not have the regulatory agency responsible for safeguarding the skies take corrective action in a reasonable timeframe. We’re past the point of reasonable, and the traveling public deserves better.

We Can Do Big Things. Just Look at Positive Train Control

By Member Jennifer Homendy

After 50 years of investigation, advocacy, and persistence by the NTSB, positive train control (PTC) is now a reality across the country!

This video highlights the NTSB’s more than 50 year effort in investigating PTC-preventable accidents and advocacy for this life-saving technology.

PTC systems use GPS and other technology to prevent certain train collisions and derailments. It could have been lifesaving in the 154 rail accidents that have killed more than 300 people, and injured more than 6,800 passengers, crewmembers, and track workers in major accidents stretching across the nation, from Darien, Connecticut, in 1969, to Chatsworth, California, in 2008, to Philadelphia, Pennsylvania, in 2015, and DuPont, Washington, in 2017.

But let’s step back and marvel at this real achievement—and the effort it took. Safety improvements are never easy or quick. It took more than 50 years of advocacy by the NTSB and historic action by Congress to make PTC a reality. For many of these years, the NTSB was a lonely voice for safety, pushing for PTC despite opposition from railroads over the price tag and technological hurdles.

I know how tough the battle was because I was there. As staff director for the House subcommittee charged with overseeing rail safety, I played a role in ensuring that any effort to move legislation forward to improve rail safety included the NTSB’s recommendation to implement PTC. When I got to the NTSB, one of my priorities was to ensure that mandate was implemented.

It truly is remarkable in Washington to keep such clear focus on PTC across so many administrations, through so many changes in Congress and at the NTSB.

Earlier this month, I had the honor of moderating a panel of current and former NTSB leaders and staff who recalled the long, bumpy road to PTC implementation. NTSB Chairman Robert Sumwalt and former agency heads Chris Hart, Debbie Hersman, and Jim Hall recalled their own contributions and noted how remarkable the agency’s sheer persistence was in a time of short attention spans and quickly changing priorities.

It was so uplifting to hear their personal reflections of their time on the Board fighting for PTC, and their continued commitment to the agency and its critical safety mission. But it was the staff panel that really defined persistence. Generations of rail investigators and other staff worked every one of the 154 PTC-preventable accidents over the decades, launching to horrific crash scenes only to discover similarities pointing to the same solution: PTC. They spent holidays working. Missed birthdays and anniversaries. Completed their important jobs regardless of on-scene obstacles and personal priorities.

Recording of the January 14, 2021, NTSB live‑streamed discussion about Positive Train Control implementation.

The public doesn’t often see what goes on behind the scenes at accident investigations, after investigations are completed when recommendations need to be implemented, and the tremendous work required to keep those recommendations at the forefront of discussions to improve safety. As stated in the first panel, board members come and go, but it’s the staff that keep these critical safety issues alive. It was truly remarkable and heartwarming to hear their reflections of the agency’s work and how that work has impacted public safety, as well as how it affected them personally. I hope it gave the public a sense of what it takes to stay focused on an issue for five full decades.

Was it worth it? You bet. PTC will save lives.

Other safety improvements have also taken many years to implement. Midair collisions were dramatically reduced by the Traffic Alert and Collision Avoidance System (TCAS). That took decades to put in place. Airliner fuel-tank inerting systems, which addressed fuel tank explosions like the one that brought down TWA Flight 800 in 1996, also took years. And let’s not forget about the long fight for airbags and seat belts in passenger vehicles. All these transportation safety improvements were strongly and relentlessly advocated for by the NTSB.

We can do big things in America. We can save more lives on our rails, in the sky, in communities where pipelines are located, on the water, and on the highway. But major safety improvements like PTC take time, money and, perhaps most of all, incredible perseverance.

Drive Sober And Save Lives This Holiday Season

By Member Tom Chapman

The holiday season is a time of increased impaired-driving crashes. Accordingly, December has been designated National Impaired Driving Prevention Month to draw attention to the 100-percent preventable traffic fatalities and injuries attributed to impaired driving.

In 2018, according to the National Highway Traffic Safety Administration (NHTSA), 10,511 people were killed in vehicle crashes in which at least one driver had a blood alcohol concentration (BAC) level of 0.08 g/dL or higher. That number comprises 29 percent of the 36,560 traffic fatalities that year. In other words, those 10,511 deaths equal about 29 deaths per day, or one death every 50 minutes. These weren’t just numbers, though. They were mothers and fathers, husbands and wives, children, friends, and other loved ones.

Alcohol isn’t the only impairing substance that can increase the risk of a crash; illegal drugs and prescription and over-the-counter medications can be as dangerous as alcohol for a driver. Unlike alcohol impairment, however, the extent to which drugged driving contributes to fatalities and injuries is less well established, but one fact is certain: the prevalence of drug use—and, even more troubling, the use of multiple drugs—while driving is on the rise. Just this month (December 1, 2020), the NTSB held a Board meeting to consider the June 21, 2019, fatal crash involving a pickup truck and a group of motorcyclists in Randolph, New Hampshire. We determined that the probable cause of the crash was the pickup truck driver crossing the centerline and encroaching into the oncoming lane of travel, which occurred because of his impairment from use of multiple drugs. Of the 22 individuals in the motorcycle group (riders and passengers), 7 were killed. An additional 7 were injured.

In October, NHTSA published a report looking at drug and alcohol prevalence in seriously and fatally injured road users before and during the COVID-19 public health emergency. Based on data collected at trauma centers and medical examiners’ offices in five cities, before mid‑March 2020, 51 percent of seriously or fatally injured road users tested positive for at least one of the following: alcohol, cannabinoids (active THC), stimulants, sedatives, opioids, antidepressants, over-the-counter medication, or other drugs. Eighteen percent tested positive in multiple categories. Stay-at-home orders and reduced travel resulting from the pandemic did not, as you might assume, reduce the prevalence of drug use among drivers. According to the same NHTSA study, the proportion of drivers who tested positive for single and multiple substances jumped to 64 percent and 24 percent, respectively, after mid-March 2020.

The NTSB has issued specific recommendations that, if implemented, would save lives, such as requiring all-offender ignition interlocks, .05 (or below) BAC limits, and a national drug testing standard. Our Most Wanted List includes the issue area “End Alcohol and Other Drug Impairment in Transportation,” and several additional recommendations addressing the issue remain open.

During this holiday season more than in years past, we should strive to keep ourselves and our friends and family as safe as possible. Wear a mask. Practice social distancing. Wash your hands. But also, abstain from drinking and driving. Designate a sober driver. Call a taxi or ride-share service. These simple steps can save our lives, as well as the lives of those we love, so we can enjoy many more holiday seasons to come.

Episode 38: Positive Train Control

In this episode of Behind-the-Scene @NTSB, we talk with Member Jennifer Homendy and Tim DePaepe, Railroad Accident Investigator, Office of Railroad, Pipeline and Hazardous Materials Investigations, about Positive Train Control (PTC), NTSB PTC-related investigations and recommendations and other rail safety issues.

Fully Implement Positive Train Control is on the NTSB 2019-2020 Most Wanted List.

Member Homendy’s full bio is available on our website.

For previous podcasts featuring Member Homendy and her blogs related to PTC visit our website.

The full Railroad Accident Reports mentioned during the podcast are also available on our website.

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/