Category Archives: Events

A Safe System Approach to Traffic Safety Roundtable

By Member Thomas Chapman

An estimated 42,000 traffic deaths occurred in 2020. This is an alarming number.

From 2014 to 2019, overall traffic fatalities increased by 10 percent.  Over the same period, however, annual traffic deaths among vulnerable road users (pedestrians, bicyclists, and motorcyclists) jumped from 9,935 to 12,062— a 21 percent increase. If you only look at pedestrian and bicyclist deaths, there was a 25 percent increase in fatalities from 2014 to 2019. So, disproportionately, increasing numbers of vulnerable road users are being killed on our roadways. We must do more to reverse this upward trend.

In April, we adopted our 2021–2022 Most Wanted List. The list includes a new safety item, Protect Vulnerable Road Users Through a Safe System Approach. With traffic fatalities trending in the wrong direction, it’s appropriate to evaluate how we approach roadway safety. At the NTSB, we’re focusing our attention on a Safe System approach.

How is a Safe System approach different?

Traditionally, as we have tried to mitigate and prevent crashes by changing individual human behavior, we’ve sought to convert everyone into perfect drivers, pedestrians, bicyclists, and motorcyclists. We try to reduce injury severity by increasing occupant protection and improving crashworthiness. We tend to put roadway safety in the hands of each individual road user, rather than taking a holistic approach. We’ve seen tremendous safety improvements through the years, such as developing safer vehicles, and we have seen a significant decline in motor vehicle occupant deaths over decades. But the overall trend is not downward, especially not for those outside of motor vehicles.

A Safe System approach focuses on injury severity by seeking to eliminate death and serious injury. In exchange, some less severe crashes are more tolerable. Instead of trying to make us all perfect drivers, pedestrians, and cyclists, a Safe System approach assumes that we all make mistakes and emphasizes methods to prevent these mistakes from causing deaths or serious injuries. Human vulnerabilities are accommodated by managing kinetic energy through engineering, design, and policy. We also acknowledge that road safety is a shared responsibility among road users, designers, planners, engineers, corporations, and policy makers.

That’s why, next week, we’re hosting an NTSB MWL Roundtable: A Safe System Approach to Traffic Safety. We recognize the need to educate others about what the Safe System approach is and to emphasize that Safe System—which underpins Vision Zero policies and initiatives—can’t be merely a slogan; it must integrate all proven safety countermeasures. Our virtual roundtable will highlight the key elements of the Safe System approach and will kick off our safety advocacy actions on this issue for the next two years.

What should you expect from the roundtable?

We have a very strong lineup of panelists planned for the event. An expert from Sweden— the birthplace of Vision Zero—will discuss the origin, history, and principles of a Safe System approach. Other panelists will provide national, state, and local perspectives on implementing a Safe System approach, and we’ll discuss the elements of such an approach—safe roads, vehicles, road users, and speed, as well as post-crash care. Member Jennifer Homendy, along with NTSB staff from the offices of Highway Safety and Research and Engineering, will also share their perspectives.

Want to learn more about the roundtable?

Visit our event page, A Safe System Approach to Traffic Safety (ntsb.gov). The event is open to the public. Register for the roundtable. You can also submit a question for the panelists by writing to NTSBSafeSystemRoundtable@ntsb.gov.

EAA AirVenture is Off, but Our Focus on Summer Flying Safety Remains

By Aaron Sauer and Michael Folkerts, NTSB Air Safety Investigators

In normal times, many NTSB staff—including investigators and Board members—would be participating at the world’s largest general aviation (GA) event this week: Experimental Aircraft  Association’s (EAA’s) AirVenture 2020. The event is held annually in late July in Oshkosh, Wisconsin, and features hundreds of seminars, presentations, and workshops—including many delivered by NTSB investigators—focused on safety and current flying trends. Due to the COVID-19 pandemic, the in-person event was canceled this year, and that means we aren’t able to share our NTSB safety messages in person with the throngs of AirVenture eventgoers. So, we’re turning to this platform to highlight some of the lessons learned and safety messages we planned to discuss at AirVenture 2020.

EAA ImageOne speaker slated to join us in a panel discussion was Mike Patey, the pilot of the famous “Draco,” a Pzl Okecie PZL104, that experienced a loss-of-control accident in Reno, Nevada. We determined the probable cause of the accident to be a failure to maintain bank control during takeoff in gusting crosswind conditions, resulting in a loss of control in flight and subsequent impact with terrain. Fortunately, Patey had built a very rugged airplane and took extraordinary steps to make a potential crash survivable, and neither he nor his two passengers were injured. We were pleased that Patey was willing to share his story during our panel discussion, and, even though that panel won’t be taking place, you can head to his YouTube channel to hear him share it. His accident serves as a reminder that, as we take to the air this summer, we need to ensure we’re prepared to mitigate loss-of-control scenarios, especially in the event of stall recovery.

Loss of control in flight in which weather is a key factor remains a significant safety concern for the GA flying community. This safety issue has been featured on the past three iterations of our Most Wanted List of transportation safety improvements (MWL). To mitigate any potential loss-of-control incidents, GA pilots should ask themselves the following before taking to the air:

    • Have I thought about and trained for possible loss-of-control scenarios?
    • Am I proficient and up to date on all aspects of my airplane?
    • Am I aware of risks so I can avoid ending up in a loss-of-control situation?

Flight instructors should also ensure they practice stalls in a variety of scenarios with their students.

Another reason for loss of control involves distractions. Personal electronic devices in the cockpit have become a real and growing threat to safety. Eliminating distractions, not just in aviation, but in all transportation modes, is another issue on our current MWL. We know that pilots involved in GA operations are more susceptible to distraction-related accidents because they are subject to minimal federal regulations, such as the “sterile cockpit” rules seen in commercial airline operations. We believe that all pilots should keep distractions to a minimum, regardless of FAA requirements.

Mike Folkerts and Aaron Sauer talk with guest speaker and acrobatic pilot Patty Wagstaff
Mike Folkerts and Aaron Sauer at EAA AirVenture in 2019 talking to Patty Wagstaff, an NTSB panelist.

Although we could not participate in AirVenture this year to share our safety concerns in person, we urge all pilots to consider the following important safety tips to prevent in-flight loss of control and other avoidable tragedies:

    • Properly train and maintain currency in the aircraft you operate.
    • Maintain proficiency on how to avoid stalls and consider adopting available technologies that provide you with greater awareness, such as angle-of-attack indicators.
    • Take advantage of available commercial trainers, type clubs, and transition training opportunities, as they are an excellent way to improve your knowledge and abilities.
    • Don’t forget about the risks associated with unaddressed maintenance issues. Staying vigilant regarding your aircraft’s airworthiness could be the difference between life and death.
    • Safety restraints can make a difference in the event of an accident. Have your restraints examined by a mechanic or manufacturer to verify that they meet required specifications. Replace the restraint systems if the examination deems it necessary. If your airplane is not equipped with shoulder harnesses, install them if possible. (Note: “Strengthen Occupant Protection” is also an issue area on our current MWL).

We hope to see you at AirVenture next year! For more safety tips, check out our NTSB GA safety alerts here: https://www.ntsb.gov/safety/safety-alerts/Pages/default.aspx.

Teen Drivers: Don’t Take Your Return to the Road for Granted

By: Nicholas Worrell, Chief, Office of Safety Advocacy

We recently announced the launch of a new #SafetyReminder campaign to provide the traveling public with a few friendly reminders as unprecedented stay-at-home restrictions are eased and we slowly resume air, rail, road, and marine travel.

During this return to “normalcy,” we’re especially concerned about young drivers. That’s why we partnered with Students Against Destructive Decisions (SADD) to host a virtual get together to reach out to teen drivers and their parents.

It’s an understatement to say that 2020’s young drivers have seen a lot in a short time. Like the rest of us, teens have done their part to slow the spread of the coronavirus through self-quarantine, protecting both themselves and others. Now that the country is slowly reopening, it’s time to return our focus to what’s most deadly to young drivers and their peers. It’s time to think not only about socially distancing ourselves, but also about isolating our cars from hazards like vulnerable road users, roadside obstacles, and even other cars. It’s time for a reminder about the biggest threat to teens’ lives: traffic crashes.

Parents have always passed the car keys to the next generation with trembling hands, and for good reason. Unintentional injuries are the leading cause of death for every age group between 1 and 44. According to the Centers for Disease Control and Prevention, motor vehicle crashes are the leading cause of fatal injury for people between the ages of 15 and 44. So, when it’s time to return to the road, we all need to be aware of the “danger zones” for young drivers:

  1. Inexperience
  2. Driving with teen passengers
  3. Nighttime driving
  4. Not using seat belts
  5. Distraction
  6. Drowsiness
  7. Impairment
  8. Reckless driving

Although it’s good for young drivers—and their parents—to refresh their knowledge of all the danger zones, they should be aware that our recent isolation may have increased risk in certain danger zone categories. For example, stay-at-home orders have hampered new drivers’ ability to gain experience and start to internalize many of the actions that will become second nature with more time behind the wheel. Any skills even the most seasoned driver had before lockdown will be rusty; that’s compounded for new drivers who have had far less time to practice behind the wheel. Beyond that, young drivers may not weigh risk as carefully as their adult counterparts, and the excitement of getting back on the road may easily manifest as risky behavior.

Here’s another consideration that teens and their parents might overlook: driving with teen passengers not only makes it harder for teen drivers to keep their concentration on the road, but it also flies in the face of social distancing. We understand that it’s been a long time since we’ve gotten together with people outside our homes, and teen drivers are probably the most eager of anyone to reunite with their friends. But reunions don’t belong in the same car, where distraction can be as contagious as a virus. Nothing good is going to come from getting behind the wheel if those reunions involve illegal use of alcohol or other drugs, or they go late into the night, or a driver is running on little sleep.

While distraction from passengers is one risk to avoid, driving while distracted by personal electronic devices—which was deadly before the pandemic—is potentially even deadlier now, given how accustomed we’ve become to practicing virtual contact. The always-connected world that helped us be resilient during this isolating time can also make us vulnerable to danger if we continue that constant connection while behind the wheel. No call, no text, no update, is worth a human life.

Even age-old risky behaviors, like speeding, that have always been a pitfall for young drivers pose an increased danger following isolation. The roads have been emptier for months, and some drivers have taken advantage, driving unimpeded at breakneck speed. Even on nearly empty roads, drivers need to leave the lead foot at home and keep an eye out for those who treat the less-crowded roads like their personal speedways. Most importantly, drivers need to make sure they—and their passengers—are always using seat belts, in case the high-risk driver in the next lane makes a bad decision.

Teens, for all your admirable resilience in the face of today’s challenges, you are still our most vulnerable and inexperienced road users. You’re going to be a great generation of adults before long; let us help make sure you make it there.

Parents and guardians, don’t send your teens back out on the road unprepared. Talk to your teens about the key components of driving and set the example for safe driving. A study by Liberty Mutual and SADD found that parents are setting a poor example for teens by engaging in unsafe driving behaviors, such as texting and driving, and are not listening to their kids’ warnings. Forty-one percent of teens say their parents continue these unsafe behaviors even after their teens ask them to stop, and 28 percent of teens say their parents justify unsafe behavior.  Take a moment to consider how to keep your young drivers safe, how to help them make good choices, and what example you’re setting. Take time to outline the key risks of driving. If you need a reminder, visit the websites of expert organizations like NHTSA and the CDC. And remember: your example is the most powerful instructor. Teens learn by example.

It’s been said that insisting on one’s rights without accepting one’s responsibilities is not freedom but adolescence. As somebody who works in youth safety outreach, I assure you, that’s an insult to today’s adolescents, who have used their voices and actions to demonstrate that they understand the role of conscience, mindfulness, and selfless service. I have no doubt this resilient group—many of whom gave up rites of passage, like prom and in-person graduation, to self-quarantine and protect those around them—can come back to the driving task with a renewed understanding of their profound responsibilities behind the wheel.

Our virtual joint event with SADD will take place on May 27, 2020, and we want to hear from parents and youth about the challenges and successes of returning to the road. We’ll also discuss resources that everyone can use to promote safer driving, whether they’re talking to peers, parents, or teens.

NTSB & SADD Transportation Safety Youth Leader Check-in

Teens, take care as you reenter the roadway. Don’t let your freedom from isolation end in unnecessary injury or death—for you or those around you. I know it will feel amazing to get back to some kind of normal, but don’t let your sacrifices of the past few months be in vain.

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.

 

Remembering Captain Al Haynes

By Jeff Marcus, Chief, NTSB Safety Recommendations Division

This past Sunday, August 25, 2019, Captain Al Haynes died a week shy of his 88th birthday. Captain Haynes was a remarkable pilot who, 30 years ago last month, brought United Airlines flight 232 to an emergency landing in Sioux City, Iowa, with no means of control except the ability to vary the thrust produced by the airplane’s two engines (the DC-10’s third engine had experienced an uncontained engine failure). Although 111 passengers ultimately perished in the accident, the actions of Captain Haynes and the other crewmembers saved the lives of 184 others on the flight.

The sequence of events started when the airplane’s central engine in the tail failed, sending heavy, high-speed shrapnel spraying through the rear of the airplane. The shrapnel cut all three of the airplane’s hydraulic lines and all hydraulic pressure was lost. This left no way for the pilots to control the airplane—at least, no way intentionally designed for that purpose. Hydraulic pressure was needed to move the airplane’s control surfaces and allow it to turn, climb or descend in response to pilot input, and to configure the airplane for landing by extending the flaps.

After the engine failure, the airplane started banking to the right and its nose dropped. The crew tried to stop the bank and bring the nose up, but the airplane did not respond. The only controls that worked were the throttles for the remaining two engines, one on each wing. By varying how much power each engine produced—that is, applying differential thrust—the pilots were able to stop the turn and bring the airplane level.

The plane pulled right, and slowly oscillated vertically in what is called a phugoid cycle, losing approximately 1,500 feet of altitude with each cycle. Among the passengers on the flight was Captain Dennis Fitch, a United pilot and training check airman, who came to the cockpit and offered Captain Haynes any help that he could provide. Captain Haynes welcomed Captain Fitch’s help.

Captain Fitch began to apply differential thrust, and that way, regained some control of the airplane. He was able to minimize the phugoid and gain some directional control, although the airplane could only turn to the right. The decision was made to make an emergency landing at the airport in Sioux City, Iowa.

The crew was able to use differential thrust alone to control the airplane’s direction of travel and descent, and line up the DC-10 with the runway. But, with no hydraulics, the flaps could not be extended. When the DC-10 was designed and approved, the total loss of hydraulic-powered flight controls was considered so unlikely that there was no need to develop and approve a procedure to deal with such a situation. Because flaps control both the minimum required airspeed and sink rate, however, the flight 232 crew could control neither.

Just prior to landing, the airplane was going 220 knots and descending at 1,850 feet per minute, well above the normal targets of 140 knots and a 300-feet-per-minute descent. As the plane touched down, the right wing tip hit the runway first, and the plane began to break up and catch fire, ultimately resulting in the fatalities of 111 people. For 184 others, Captain Haynes and his flight crew are credited with their improbable deliverance from an unlikely accident cause.

In our investigation of this accident, we pointed out that the interaction of the pilots, including the check airman, during the emergency showed the value of crew resource management (CRM – then known as cockpit resource management) training, which had been practiced at United Airlines for a decade. Ten years before the United flight 232 accident, we recommended that CRM training be required for all airline flight crews.

Flight simulator reenactments of the accident airplane’s flight profile carried out as part of our investigation revealed that it was virtually impossible to control all parameters simultaneously needed to land safely at a predetermined point. After observing the performance of a control group of DC-l0-qualified pilots in the simulator, we concluded that Captain Haynes’s damaged DC-10 airplane, although flyable, could not have been successfully landed on a runway after the loss of all hydraulic flight controls, and that, under the circumstances, United flight 232’s flightcrew reacted commendably and beyond reasonable expectations.

But the benefits of CRM training were clear. The flight crew, lead by Captain Haynes, used CRM to deal with a situation considered so unlikely that there were no procedures or training on how to respond. When talking about the accident later, Captain Haynes said, “If I hadn’t used CRM, if we had not let everybody put their input in, it’s a cinch we wouldn’t have made it.”

Although he always denied that he was a hero, Captain Haynes was the right man at the right time for an event considered to be so unlikely that it was virtually impossible. Thirty years after that accident, and mere days after Captain Haynes’s death, we at the NTSB remember how his CRM practice saved over half the people on United flight 232. Aviation is safer the world over thanks to Captain Haynes.