Category Archives: Events

Another Step Toward Safer Skies in Africa

By Dennis Jones, NTSB Managing Director

In my recent blog post, I talked about the NTSB’s visit to South Africa as part of the US Department of Transportation’s Safe Skies for Africa (SSFA) program. Last week, the NTSB team returned to Africa—this time, to the east African nation of Kenya—in continued support of the SSFA program, the aviation safety capacity-building initiative that includes collaboration between African countries and several US government agencies. In Kenya, as in South Africa, we once again shared investigative lessons learned with more than 150 air safety investigators, aviation trainers and operators, government officials, and safety advocates from Kenya and countries in the surrounding region.

Blog Image 1

I was particularly excited about this trip because I first traveled to Kenya for accident investigation purposes 20 years ago, and later, based in the capital city of Nairobi, I worked to implement the NTSB’s SSFA program responsibilities. The goal of the SSFA program in Kenya was to help the country achieve FAA Category 1 status and pave the way for direct scheduled commercial air service between the United States and Kenya. The NTSB’s contribution toward this goal was to help Kenya’s accident investigation program meet international standards in accordance with the provisions of the International Civil Aviation Organization’s (ICAO’s) Annex 13. Our activities included working with the Air Accident Investigation Division of Kenya (AAID) to develop its program, which included on-the-job investigator training; establishing policy, procedures, and practices for the organization; and producing memoranda of understanding between AAID and other domestic government agencies. The NTSB partnered with ICAO as part of the SSFA program to conduct aircraft accident investigation workshops throughout Africa; the first such event was held in Nairobi in 2007.

It took some time but, thanks to Kenya’s painstaking and diligent efforts, and the assistance provided by the SSFA program, Kenya achieved an FAA Category 1 rating in February 2017. Consequently, US and Kenya air carriers can now, with the approval of their respective regulatory agencies, travel between the two countries. Kenya Airways, Kenya’s national carrier, will launch its inaugural flight to the United States, destined to JFK International Airport in New York, in October 2018.

Although Kenya’s government is focused on improving aviation safety, the country—and, more broadly, the continent—still faces challenges that the region’s stakeholders are dedicated to overcoming. General aviation (GA) safety issues have been formidable in the region, just as they are in the United States, and we sought to share some of our experience addressing this issue. Further, through the SSFA initiative, NTSB representatives have recognized other modal transportation safety issues and safety advocacy opportunities for future consideration as the agency formulates its international scope of activities.

After accompanying the NTSB team to South Africa last month, I was fully confident in its ability to conduct the workshop in Nairobi. The team was composed of professionals representative of the superb workforce at the NTSB, and they delivered powerful presentations sharing lessons learned.

Shamicka Fulson, a program manager in the Office of the Managing Director, coordinated the development of the workshops in South Africa and Kenya. She delivered opening remarks and provided an overview of the agency and the SSFA program to begin the workshop in Nairobi.

Clint Crookshanks, an aerospace engineer in the Office of Aviation Safety, facilitated a workshop related to identifying common aviation safety lexicon. He reviewed different accident case studies with the audience and discussed ways to interpret the generalized and vague definitions often found in aviation investigations, such as “substantial damage to aircraft,” or the distinction between an “accident” and an “incident.”

Luke Schiada, Deputy Chief of Aviation Safety for the Eastern Region, presented accident case studies that highlighted international cooperation. Luke told the audience that he believed “international cooperation is, in large part, about building relationships and trust.” He stressed the importance of interacting with and learning from the collective knowledge and experiences of participants in settings like the SSFA workshops. I can’t agree more; after all, we can’t improve within unless we are willing and able to learn from without. Even sharing enables learning and growth.

Dennis Hogenson, Deputy Regional Chief of Aviation Safety for the Western Pacific Region, focused on GA safety improvements. He pointed out that, like Africa, the United States is seeing a high incidence of GA crashes. He told his audience that, while airline accidents have become rare, GA accidents account for most aviation fatalities. In many of our GA accident investigations, we’ve discovered that pilots didn’t have the adequate knowledge, skills, or recurrent training to fly safely. Dennis encouraged his African counterparts to initiate more training and increase awareness of technology that can help prevent these tragedies; this is something we continue to strive to do in the United States via our Most Wanted List issue addressing loss-of-control in flight.

Nicholas Worrell, Chief of the Safety Advocacy Division in the Office of Safety Blog Image 2.jpgRecommendations and Communications, urged attendees—most of whom were investigators—to go beyond investigations to see real improvements in safety. The work doesn’t end with the report findings issued after the investigation; the work to improve safety just begins, he said. African safety organizations need to develop advocacy efforts and strategies to ensure their safety recommendations are implemented. Nick encouraged the audience to look to some of Kenya’s most notable leaders, like Jomo Kenyatta, political activist and Kenya’s first president, and Wangari Maathai, Nobel Peace Prize winner, both of whom saw a need for and executed effective advocacy to improve laws, policies, and practices.

The goal of our visit to Kenya was to continue fostering the development of a safer aviation transportation system in East Africa. It is integral to our mission at the NTSB to share globally what we have learned from 51 years of safety investigations. As the NTSB team supporting the SSFA program has shown, improving transportation safety is a collaborative process that doesn’t end at our borders.

Pedestrian Safety: An NTSB Special Investigation Report

By Member T. Bella Dinh-Zarr, PhD, MPH

 5,987. That’s the number of pedestrians who died on our roadways in 2016. That’s 16 people every day across our country. But because these tragedies happen one by one, pedestrian deaths often fail to receive national attention. But as an agency dedicated to preventing transportation deaths and injuries, we know that must change.

In 2016, we held a public forum to address pedestrian safety. Experts from around the country discussed the data we need to better understand the risks, technology that could prevent vehicles from hitting people, and highway designs that offer safer roads or paths for pedestrians. Since that initial public meeting, we have conducted more than a dozen investigations into pedestrian deaths in order to gain insight into how we can prevent these deaths from happening.

Although the pedestrian crashes we investigated were not meant to be representative of nationwide data, the circumstances around the crashes were not unique—a child walking to school, an older man taking an evening walk around his neighborhood at dusk, a man walking his dog after lunch, a woman crossing a crowded city street, another leaving a bar at night. In most of the cases, the pedestrians were in crosswalks at intersections, and many occurred where speed limits were posted for 25­–30 mph.

Historically, the NTSB has focused highway investigations on vehicle-to-vehicle collisions. But, having watched the trendline of pedestrian fatalities increasing steadily over the past 10 years, we are now calling attention to the problem of pedestrian safety. After all, although we may not all be drivers, we are all pedestrians. As communities embrace the goal of eliminating highway fatalities, preventing pedestrian crashes must be a top priority.

Tomorrow, September 25, 2018, the NTSB will examine the issue of pedestrian safety during a public Board meeting, beginning at 9:00 am. NTSB staff will present recommendations intended to improve pedestrian safety, and afterward, we will release the investigations, the special report, a supplemental data analysis report, and directions to a website that will allow people to examine the history of pedestrian fatalities in their own communities. In addition to being open to the public, the meeting will be webcast for interested parties who cannot attend in person.

Details of the investigations conducted in support of our pedestrian special investigation report will be available after the Board meeting on our NEW Pedestrian Safety page at the NTSB website: www.ntsb.gov/pedestrians.

Ten Years Later: Remembering Chatsworth With Action

By  Member Jennifer Homendy

Ten years ago today, September 12, 2008, a Metrolink commuter train filled with passengers in Chatsworth, California, collided head-on with a Union Pacific freight train. The collision took the lives of 25 people and injured 102 others. The cause: A texting engineer. A human operator making a human error.

On this 10th anniversary, we offer our condolences to all those who lost loved ones or were injured in the Chatsworth tragedy.

 

Photo of the Collision of Metrolink Train 111 With
Union Pacific

Although I was not a Member of the National Transportation Safety Board at that time, I was working tirelessly as the Staff Director of the Subcommittee on Railroads, Pipelines, and Hazardous Materials in the U.S. House of Representatives to mandate implementation of technology, called positive train control (PTC), which could have prevented the Chatsworth accident from occurring.

PTC is designed to automatically stop a train when a human operator fails to. Human error is the leading cause of all train accidents. Frustratingly, the NTSB has been recommending that railroads implement PTC to address human error-caused accidents for nearly 50 years.

In the wake of the Chatsworth collision and a number of others investigated by the NTSB, Congress passed the Rail Safety Improvement Act of 2008, which required freight, intercity passenger, and commuter railroads to implement PTC by the end of 2015. As the deadline approached, Congress extended it to 2018, with the possibility of further extensions until 2020. Now, as the new deadline approaches, PTC is still not fully implemented.

We know from railroad reports to the Federal Railroad Administration, the agency charged with regulating the railroads, that PTC is operational on only a small fraction of the railroad network.

Accidents, however, continue to occur. Since 2008, the NTSB has investigated 22 accidents that could have been prevented by PTC. Together, these accidents have resulted in 29 deaths, more than 500 injuries, and more than $190 million in property damage.

Tomorrow, Chairman Sumwalt will testify on Capitol Hill regarding the need to finish the job without further delay. Regrettably, nothing that the NTSB does can turn back the clock and change a tragic outcome; we can only urge that others be spared such an outcome in the future.

As the newest Member of the NTSB, I will continue to advocate for full implementation of PTC and for the safety recommendations we made as a result of the Chatsworth crash so that a similar tragedy is prevented in the future.

In the meantime, there is something you can do as we remember Chatsworth: eliminate distractions while operating a vehicle. Distraction continues to play a significant role in accidents.

Distracted driving kills thousands and injures hundreds of thousands every year. On the railroads, PTC is an effective backstop in case an operator is distracted, fatigued, impaired, or otherwise unable to take the right action. But operators must still adhere to strict procedures to minimize the chance of an accident.

On the highways, collision avoidance systems—forward collision warning systems and automatic emergency braking—are beginning to play a similar role to PTC. We think that these systems should be on every car, and we are working toward that outcome. But even without a collision avoidance system, you can take control by doing the right thing. Don’t send a text, make a call, or update your social media while driving. Strict laws aimed at preventing the use of portable electronic devices while driving and high-visibility enforcement can help, but ultimately, it’s up to each driver to drive attentively.

As we mark the 10th anniversary of the Chatsworth collision, we still have a long way to go to ensure the same kind of accident doesn’t happen again. But there are things we can do. We can insist railroads complete PTC implementation on all their tracks. We can choose vehicles with collision avoidance systems, and we can refuse to drive distracted.

Fatal collisions don’t end on impact; they echo through communities for years after the moment of a crash. But there can be hope as well as mourning in the echoes—hope for change that will prevent future tragedies. It will take all of us in transportation—professionals and the general public—to ensure the lessons learned from the Chatsworth tragedy result in that change.

 

The Value of Video

By Jennifer Morrison, NTSB Investigator-in-Charge, Office of Highway Safety

 On January 19, 2016, a Greyhound bus with 22 people on board was traveling on a California interstate in the dark in moderate-to-heavy wind and rain. The driver intended to take the left exit, en route to the next stop in San Jose, but instead crashed the bus head-on into the end of a concrete barrier. The bus jumped the barrier and rotated onto its side. Two passengers were ejected and died; the driver and 13 passengers were injured.

The crash occurred at 6:37 in the morning, after the driver had been on duty, commuting to his route and driving the bus, for about 12 hours. Tempting as it was to assume this crash resulted from driver fatigue, our investigation soon revealed that other factors were at play.

HWY16MH005_prelim[1]
Final rest position of bus and remains of REACT 350 crash attenuator base
When I arrived on scene with the rest of the “go team,” we discovered that the highway interchange where the crash occurred had four through lanes, two right exit lanes, and a single left exit lane. When the driver moved the bus left to what he thought was the left exit lane, he instead unintentionally entered a 990-foot-long unmarked gore area that separated the through lanes from the left exit lane. The gore area ended at the concrete barrier where the crash occurred. The crash attenuator at the end of the barrier likely absorbed some crash energy, but it was not designed to redirect a large commercial vehicle like a Greyhound bus.

What was interesting about the crash attenuator was that it had been hit before; our investigation found that damage from the previous impact had ripped the reflective sheeting off its face. Records showed that the California Department of Transportation had placed temporary barricades but had never finished the repair.

Fortunately for our investigation, the bus, like most of Greyhound’s buses now, was equipped with a video camera system. Video recovered from the bus showed that the temporary barricades had blown over, possibly in the wind and rain that morning. As we watched the forward-facing and inward-facing videos, the scene became clear: the driver was attentive as he signaled and moved into the gore area, interpreting it to be a travel lane. At 1 second before impact, a dark black barrel (the first part of the crash attenuator) appeared in the middle of the “lane” (see Figure 1). There was no reflective sheeting on its face, and there were no temporary barricades set up to identify the hazard.

Without the video camera system onboard the bus, it would’ve been impossible to know that the barricades had blown over prior to the crash, rather than simply been displaced by the event. Without the video evidence, it would have been easy to assume that the driver was just too tired or otherwise distracted by fatigue to see the warning. But the video showed clearly and indisputably the events leading up to the crash.

greyhound video
Still image of onboard video at 1 second prior to impact.

Onboard video systems provide investigators and fleet owners with the invaluable, unbiased evidence to interpret—and work to prevent—crashes like this one. That’s why we’ve strongly recommended they be installed on all highway vehicles for decades. We even emphasize the importance of these systems on our Most Wanted List of transportation safety improvements. This crash illustrates why this technology is important, and we continue to urge operators to install it across their fleets.

NTSB Most Wanted List of Transportation Safety Improvements 2017-2018

To learn more about this issue, join us Thursday, September 13 at 2 PM EST, for our “Reducing CMV Crashes Through the Use of Video Recorders webinar.” In our 1-hr webinar, NTSB Member Bella Dinh-Zarr, investigators and recorder analysts from the Office of Highway Safety and Office of Research and Engineering, along with commercial fleet owners representing the truck and bus industries, will discuss why and how their organizations use video recorders to improve safety. NTSB investigators will provide an in-depth discussion into the Greyhound crash discussed in this blog and will also highlight a truck case study. For more details or to register, visit this link.

 

 

 

Working for Safety

By Robert L. Sumwalt, Chairman

 Labor Day and Memorial Day both have specific relevance that can be lost in seasonal associations. The meaning of Memorial Day as a time to honor those lost in our nation’s wars can be eclipsed by its unofficial role as the “kickoff day” for summer. Similarly, all too often, we think of Labor Day only as summer’s end rather than as a commemoration of the contributions of the nation’s working men and women.

This Labor Day, I’d like to take a moment to express my appreciation for the men and women who work every day in transportation, doing everything right so that there’s not an accident for the NTSB to investigate.

TranspWorker_ThankYou2

From owner-operators of long-haul trucks to employees of the biggest trucking companies; from captains of small fishing boats to employees of the biggest cruise lines and marine cargo companies; from air-tour operators to airline pilots and cabin crews; and throughout railroad and pipeline transportation, safe transportation depends on the dedication and hard work of the people on the front lines: individual transportation workers.

At the NTSB, we investigate what goes wrong in transportation. In each accident, we look at the human, the machine, and the environment. When we find a lapse in any of those areas, we look for ways to eliminate the opportunity for error. Meanwhile, day in and day out, good men and women go to work every day and do everything right. We don’t investigate the truck that stayed on the road because its conscientious drivers got plenty of sleep, or the ship that didn’t run aground because its captain and crew were well-trained and attentive. We’ll never hold a Board meeting to discuss one of the millions of safe airline flights every year, or to talk about the pipeline operators and railroad employees who found the safety defect among thousands of miles of rail or pipe before it caused an accident.

Although technology and design innovations have greatly improved transportation safety, we haven’t yet managed to eliminate everything that can go wrong in transportation. That’s why we depend so heavily on the nation’s transportation workers, who face rigorous rules and laws, to ensure safety. Commercial truckers and pilots log their rest and duty time to prevent fatigue. While the general driving public is subjected to a .08-percent blood alcohol content (BAC) legal limit, for commercial drivers, the limit is already .04 percent. And then there are all the safety procedures these professionals are required to know—and follow—throughout their commercial transportation careers.

The majority of our nation’s transportation professionals meet these high standards and are intent on preventing transportation tragedies. As Chairman of the NTSB and a member of the traveling public, I want to express my appreciation for all those transportation workers who are quietly doing things right, day in and day out.

Professor James Reason once said that safety professionals live with a “chronic unease.” Safety is a matter of constantly searching out the unassessed hazard, the unmitigated risk. Transportation operators at every level embrace this difficult challenge every day. On this Labor Day, I gratefully tip my hat to each one of you who takes safety seriously.

 

National Aviation Day

By Chairman Robert L. Sumwalt

Sunday, August 19 is National Aviation Day. It’s a day to celebrate more than a century of innovation and progress in aviation, certainly, but August 19 is also the birthday of a bicycle-maker—albeit one more famous for his contributions to aviation.

National Aviation Day.jpgAugust 19 was chosen to be National Aviation Day in honor of Orville Wright’s birthday while Wright was still alive to enjoy the honor. (Wilbur Wright had passed away in 1912, less than a decade after their landmark flight near Kitty Hawk, North Carolina.) There’s a lesson in how the Wright brothers came to play their pivotal role in the story of aviation, and it’s especially worth mentioning on this day.

Wilbur was an early adopter of what was called the “ordinary” bicycle—a contraption with a high front wheel and a seat many feet off the ground. There had been earlier bicycles without the high wheel, but also without gears; the high wheel was necessary to get better performance out of limited muscle power.

The “safety bicycle” added gears, enabling good performance without using a high front wheel. It had two advantages: a center of gravity that was lower and rear of the front axle, and a shorter distance for the rider to fall. The popularity of pedaling exploded, and the Wright brothers saw a niche. From their shop in Dayton, Ohio, they began repairing, then renting, selling, and manufacturing bicycles—and, of course, tinkering with improvements.

Meanwhile, both were drawn to news of attempts at powered flight. Unlike other aviation pioneers, however, Wilbur and Orville insisted on three-axis control, using wing warping (deforming the shape of the wing) to control roll. Some competitors didn’t believe that a pilot could respond quickly enough to mechanically control all the required surfaces, but Orville and Wilbur had tested their concepts thoroughly (another advantage over some competitors). Through glider testing, they learned that an airplane could be controlled on all three axes and, in the bicycle trade, the Wright brothers had learned firsthand how innovation and safety could go hand-in-hand, providing control even when a platform seemed unstable.

It is an understatement to say that aircraft design has continued to evolve. Wing warping to control roll has given way to ailerons (precursors to amazing potential new technology reminiscent of the Wright brothers’ approach). The elevator has migrated from the front of the airplane to the rear. Wood has given way to aircraft aluminum and composites. Sticks and pulleys have given way to fly-by-wire and automation. But the Wright brothers’ insistence on three-axis control remains a foundational principle in modern powered flight, whether in the airlines or in general aviation. Because Orville and Wilbur Wright dared to believe in full control of all three axes, an industry was born.

Today, certification rules have changed to make it easier than ever to install innovative technology to maintain control of an aircraft. Angle-of-attack indicators and envelope protection are available not only in airliners, but for general aviation craft, as well. However, loss of control in flight continues to be the leading cause of fatal general aviation crashes.

NTSB Most Wanted List of Transportation Safety Improvements 2017-2018
Prevent loss of control in flight in general aviation

Why not celebrate National Aviation Day by reading up on current and innovative training and technology solutions that could eliminate loss of control in flight? You may find yourself surprised by how far aviation has come since the Wright brothers, and by how far there remains to go.

NTSB Supports ‘Safe Skies for Africa’ Program

By Dennis Jones, NTSB Managing Director

Last week, as part of the U.S. Department of Transportation’s Safe Skies for Africa program, I led a team of NTSB investigators and communications specialists to South Africa to share lessons we’ve learned from our accident investigations. The Safe Skies for Africa program, created 20 years ago, aims to improve the safety and security of aviation on the continent. Our team shared some NTSB strategies with our international counterparts to help them achieve similar outcomes in their region.

1
Managing Director, Dennis Jones, talks with attendees at the Safe Skies Symposium in Johannesburg, SA

From my perspective, the Safe Skies program is working. After spending about 20 years in Africa participating in accident investigations, conducting workshops, helping improve accident investigation programs, and training investigators, I’ve seen increased commercial air service between the United States and Africa (for example, there are now US commercial flights to Africa, which wasn’t the case earlier in my career), improved investigation quality, and a reduced rate of accidents involving commercial aircraft.

On this trip, the NTSB team shared a variety of lessons learned from different disciplines. Dennis Hogenson, Western Pacific Region Deputy Regional Chief for Aviation Safety, pointed out that, like Africa, the United States is seeing a high incidence of general aviation (GA) crashes. He told his audience that, while airline accidents have become rare, GA accidents account for most aviation fatalities in the United States. We investigate about 1,500 GA accidents each year; those involving loss of control in flight still result in more than 100 fatalities annually. In many of our GA accident investigations, we’ve discovered that pilots didn’t have the adequate knowledge, skills, or recurrent training to fly safely, particularly in questionable weather conditions, and their inability to appropriately recover from stalls often resulted in deadly accidents. Dennis encouraged his African counterparts to initiate more training and increase awareness of technology, such as angle-of-attack indicators, that can help prevent these tragedies.

Bill Bramble, a human factors investigator, outlined our investigation process and explained how we examine all factors—machine, human, and environment—to understand an accident and make recommendations to prevent it from happening again. Bill highlighted several accidents we investigated in which human factors played a role. But even when a probable cause statement focuses on factors not normally associated with human performance, it’s impossible to totally remove humans from the accident chain.

“Humans designed it, built it, operated it, maintained it, managed it, and regulated it. Human factors are always involved in complex system failures,” Bramble said.

To prevent accidents and improve the safety of air travel in Africa, it’s important that operating aircraft are airworthy, meaning that all structure, systems, and engines are intact and maintained in accordance with the regulations. To emphasize this point, NTSB aerospace engineer, Clint Crookshanks presented a series of case studies discussing airworthiness issues and offered guidance on ways to classify damage to aircraft.

Chihoon “Chich” Shin, an NTSB aerospace engineer, addressed helicopter safety. The number of helicopter operations (emergency medical services, tourist, and law enforcement support) in Africa is increasing, and so is the number of helicopter accidents. Chich presented case studies and highlighted some important safety issues from an engineering perspective.

“The metal doesn’t lie,” Shin said. He called for increased awareness of the safety issues affecting helicopter safety and encouraged action from key stakeholders, such as regulatory agencies and helicopter manufacturers and operators, to help reduce accidents and fatalities. He also touted the importance of crash-resistant recording devices to help investigators determine what happened in a crash and work to prevent it from happening again.

NTSB communications staff emphasized another side of our work in transportation safety. Stephanie Matonek, a transportation disaster assistance specialist, discussed the importance of planning for family assistance after an accident occurs.

“Having a family assistance plan in place, identifying your family assistance partners, and addressing the fundamental concerns for families and survivors that cross all cultures is not only a crucial step but the right thing to do,” she said.

Nicholas Worrell, Chief of the Office of Safety Advocacy, addressed messaging, encouraging attendees to go beyond investigations to teach their safety lessons effectively. He encouraged investigators to raise awareness of the safety issues they uncover to spur action on their recommendations.

Aviation is a global business. Our mission is to make transportation safer the world over by conducting independent accident investigations and advocating for safety improvements. With outreach activities like the one we just completed in Africa, we hope to make aviation safer, not only in Africa, but throughout the world. After all, transportation safety is a global challenge. When safety wins, we all win.

dsc_8283.jpg
NTSB Managing Director and staff with symposium attendees