Category Archives: Fatigue

Most Wanted List Progress Report: Aviation Safety

By Member Earl F. Weener

The NTSB is releasing a series of blogs highlighting the progress the transportation community is making in each mode to advance issues on our 2017-2018 Most Wanted List. This series sheds light on the progress made and what needs to be done going forward to improve transportation safety. This is the third blog of the series.  

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Member Earl Weener and John DeLisi, Director, NTSB Office of Aviation Safety, talk with attendees during the aviation session of the Most Wanted List midpoint meeting

Aviation is one of the safest forms of transportation—largely due to government-industry collaboration efforts such as the Commercial Aviation Safety Team and the General Aviation Joint Steering Committee. We have seen no passenger fatality in the domestic operation of a U.S. airline (Part 121) since 2009, and the accident rate is trending slightly downward in General Aviation-GA (Part 91 and Part 125). While we celebrate the safety gains made across the commercial aviation industry, there is still work to be done across all sectors, especially in GA.

On November 15, the NTSB brought together government, industry, and advocacy representatives from the transportation safety community to get a progress report on our Most Wanted List (MWL) of transportation safety improvements. Aviation Safety Director John DeLisi and I led the aviation portion of the discussion.



We learned that industry is taking the lead to improve safety, and, while some Federal Aviation Administration initiatives have been helpful, more may be needed. Yet the best path to getting NTSB recommendations adopted, most agreed, was encouraging a more aggressive voluntary, collaborative approach to safety.

Our focus on preventing Loss of Control (LOC) In Flight in General Aviation (GA)—the only aviation-specific issue on the MWL—was the primary focus of our conversations. Successfully resolving this problem requires continuing collaboration, which, so far, appears to be occurring widely and effectively. The GAJSC is one organization helping to facilitate this collaborative approach. At the mid-point meeting, we also announced that the NTSB will be collaborating with the FAA, industry associations, flight schools, technology manufacturers, and others in an upcoming April 24, 2018, roundtable on LOC solutions. The number of LOC and fatal LOC accidents are both trending down as of 2016, our last complete year of data. We won’t call that progress yet, but we might look back one day and say that it was.

The changes to Part 23 of the Federal Aviation Regulations reforming small aircraft certification standards have enabled streamlined adoption and installation of new technologies, such as AOA indicators that would prevent LOC, without a lengthy and costly supplemental FAA flight certification. Private industry can now do what it does best: innovate.

We also discussed another MWL issue, Expand Recorder Use to Enhance Safety. In particular, the NTSB would like to see more cockpit cameras, which aid in accident investigations and provide useful data for developing policies/procedures to prevent accidents. However, privacy issues, data protection challenges, and fears of punitive actions by companies appear to still hinder progress in this area.

Just as we have seen tremendous benefits in crash survivability on our highways with the use of seat belts and air bags, the aviation community so too must also recognize the significant safety benefits of enhanced occupant protection systems, such as five-point shoulder harnesses. While helicopter pilots appear to be buckling up, others in GA are not—including passengers. Child restraint systems (“car seats”) should also be used in planes; yet, they widely are not. The NTSB reported at this meeting that we are collecting more data on if/how seat belts are used in our accident investigations.

Progress is being made on the carriage of lithium-ion (LI) batteries. Heat from one battery can propagate to nearby batteries before a fire breaks out, introducing a challenge for fire detection and suppression. However, we expect the FAA to complete testing related to this risk within this MWL cycle. We also await the Pipeline and Hazardous Materials Safety Administration actions to harmonize its regulations with the International Civil Aviation Organization’s technical instructions regarding segregating lithium batteries carried as air cargo from other flammable cargo.

Just before the beginning of this MWL cycle, in 2016, the new flight and duty regulation went into effect, a huge win for managing fatigue in commercial aviation. We continue to fight for the small wins. We still need to apply the same level of safety to cargo flights, but we have seen progress toward applying it to maintenance personnel.

And, in 2017, the FAA communicated that they’ll research the prevalence of impairing drug use – OTC, illicit, and prescription – throughout aviation. Previously, we had studied their presence in pilots in fatal accidents, which revealed an alarming rate of OTC use in fatal accidents. It may be too early to discuss any changes to medical fitness in aviation due to BasicMed. However, one of the related concerns is the loss of flight time data that we previously gathered as part of the medical certification process.

After our progress report meeting, I felt optimistic that the improvements being made, especially by industry, will serve to make aviation even safer. I encourage all stakeholders and the general flying public to consider areas where we still need to make progress. Everyone has a role to play in improving aviation safety—whether you are a pilot, an operator, or sitting in the seats.

Most Wanted List Progress Report: Highway Safety

By Member T. Bella Dinh-Zarr, PhD, MPH, and Robert Molloy, PhD

The NTSB is releasing a series of blogs highlighting the progress the transportation community is making in each mode to advance issues on our 2017–2018 Most Wanted List. This series sheds light on the progress made and what needs to be done going forward to improve transportation safety. This is the second post of the series. 


Member Dinh-Zarr talks with attendees during the highway session of the Most Wanted List midpoint meeting

We’re now midway through the 2017–2018 Most Wanted List cycle, and we’re eager to learn how this year will measure up to previous years. The past 2 years have resulted in an increase in highway traffic fatalities­­—from 32,000 roadway deaths per year in 2014 to more than 37,000 in 2016­­—so clearly, improvements are vital. We checked in with stakeholders on the progress they’re making to address the most pressing issues, and they’ve updated us on their successes and struggles. Here’s where we stand.

Install Collision Avoidance Technologies

Collision avoidance technologies can reduce the number of deaths and injuries on the nation’s roadways now. Today, automatic emergency braking (AEB) and forward collision warning systems already work to reduce rear-end crashes in equipped vehicles, and we’ve been working to encourage industry and vehicle manufacturers to adopt such systems. In 2017, we cohosted a roundtable with the National Safety Council on commercial vehicle (heavy-duty truck) use of advanced collision avoidance technologies and learned that truck manufacturers are beginning to see high customer demand for forward collision avoidance systems on their trucks. During the roundtable, one manufacturer indicated they were making the technologies standard on their trucks, while another mentioned that over 60 percent of their customers purchase vehicles with technology. In addition, the National Highway Traffic Safety Administration (NHTSA) is making progress on evaluation and testing collision avoidance technologies. We continue to advocate for connected vehicle technology because these technologies can further aid in collision avoidance, especially in situations where vehicle resident sensors are weak. Safety should never be considered a barrier to innovation, but rather, an integral component of it.

End Impairment in Transportation

In 2017, we saw progress on reducing alcohol impairment in transportation. Utah became the first state in the nation to pass a law setting a .05 percent blood alcohol content per se limit, and Nebraska and Oklahoma passed all-offender ignition interlock laws. The Federal Motor Carrier Safety Administration (FMCSA) published a final rule establishing the Commercial Driver’s License Drug and Alcohol Clearinghouse, and NHTSA developed training programs addressing the full range of responses to alcohol impairment, from enforcement through adjudication. Yet, we still need more states to strengthen their impaired driving laws and enforcement. We also need improved “place of last drink” (POLD) data to help law enforcement officers deter future violations, and we need better methods to measure impairment by drugs other than alcohol.

Require Medical Fitness, Reduce Fatigue-Related Accidents

In terms of medical fitness, we’ve criticized both the FMCSA and the Federal Railroad Administration because they have withdrawn their advance notice of proposed rulemaking regarding obstructive sleep apnea, which could have led to a rulemaking to address this important issue for people in safety-critical positions. In the highway mode, untreated moderate‑to-severe sleep apnea disqualifies drivers from operating large commercial vehicles because it affects driving safety, yet clear guidance is needed to assist medical examiners in identifying the condition. Nevertheless, the FMCSA has made notable progress by developing a National Registry of Certified Medical Examiners that lists all medical professionals who are qualified to certify drivers. This is a step in the right direction.

The FMCSA took another important step to improve safety when it implemented the electronic logging device (ELD) rule in December 2017. The rule requires the use of technology to automatically track driving and duty time. The NTSB advocated for such devices for many years because they enable better enforcement of hours-of-service regulations and can lead to reductions in drowsy driving among truck and bus drivers.

Eliminate Distractions

Our roundtable earlier this year, “Act to End Deadly Distractions,” brought together survivor advocates and experts throughout industry and government to discuss progress on state laws. We are beginning to see states consider legislation that would completely ban the use of hand-held devices, which highlight manual and visual distraction, but public awareness of the cognitive distraction that can result from hands-free device use remains very low.

Strengthen Occupant Protection

The good news this year on occupant protection is that motorcoaches are now built with lap and shoulder belts for all passenger seating positions. Now we’re focusing on all motorcoach passengers properly using those belts and using them every time they ride. We are urging primary enforcement of seat belt laws for all vehicles, including large buses equipped with belts, at every seating position, and we’re calling for safety briefings on motorcoaches similar to those delivered on commercial flights that explain seat belts and other safety features. As for passenger vehicles, some states, such as Massachusetts and New Hampshire, are considering joining the 34 states that already have primary enforcement of mandatory seat belt laws. Primary enforcement of mandatory seat belt laws is proven to increase seat belt use and, thereby, reduce the number of deaths and injuries on the roads. Regarding motorcycles, we are concerned that some states are repealing their helmet laws, because we know reduced helmet use will lead to more traumatic brain injuries and deaths.

Critical topics that touch on these highway safety issues are speeding and roadway infrastructure. Our recent safety study on speeding establishes what many of us already know but may not always apply: speeding increases the risk and severity of a crash. Here again, along with other safety recommendations, we’ve identified available technologies that can save lives but are not currently in use. The importance of infrastructure was highlighted recently by our highway accident report on a motorcoach collision that killed 2 people and injured 14 others. An unrepaired crash attenuator, an unmarked gore area, and out-of-compliance signage were cited in the report, in addition to the lack of seat belt use by most of the occupants.

Expand Recorder Use

Finally, we continue to urge all large highway vehicles be required to be equipped with recorders that capture a standard set of parameters. Event data recorders are vital investigative tools in every transportation mode—they help us do our job better and faster by providing valuable information after a crash so we can figure out what went wrong and make recommendations that prevent future injuries and deaths. Unfortunately, in crashes involving large trucks or buses, we are often left with limited data from the vehicle about the crash. We learn much more from passenger vehicles in crashes than from trucks and buses because of the standards NHTSA has developed (no such standards exist for trucks or buses). These standards are critical for large-vehicle operators, who can use recorders to train their drivers and increase safety.

The Most Wanted List midpoint mark allows us to reflect as well as plan and set new goals for the upcoming year. Although we have a long way to go to reach zero fatalities on our roadways, the efforts highlighted above, innovative partnerships and strategies, and bold actions to advance our recommendations are what we need to make America’s roadways fatality-free.


Dr. Robert Molloy is the Director of the NTSB’s Office of Highway Safety.

Thank You

SafetyCompassLogoBy Stephanie D. Shaw

We launched Safety Compass in March 2011 to provide you an inside-out view of the investigative and advocacy efforts we’re engaged in and the important safety issues we’re focused on. As we close out 2017, we want to say “thank you” to you, our readers. Thank you for your interest in the work we do and for sharing our safety messages and recommendations for improving transportation safety.

From teens and sleep to drones, autonomous vehicles to our investigative processes, we’ve given you an inside look at the NTSB and highlighted our comprehensive approach to improving transportation safety across all modes and for all people.

To wrap up the year, here’s a list of some of our most popular blogs of 2017:

Last month, we released data revealing that 2,030 more people died in transportation accidents in 2016 than in 2015. Of those fatalities, 95 percent occurred on the nation’s roadways. Many of those deaths were completely preventable! As we approach 2018, we call on each of you to help us reverse the trend of increasing transportation fatalities, especially on our roadways. Continue to read our blog, see the lessons we’ve learned through our investigations, and share the safety recommendations we’ve made to prevent transportation accidents and crashes, deaths, and injuries.

We encourage you to keep up not only with our blogs, but with other NTSB materials. Sign up to be on our Constant Contact list. Follow us on Facebook (@NTSBgov), Instagram (@NTSBgov), LinkedIn (@NTSB), and Twitter (@NTSB). And in case you missed it, we launched a podcast in 2017, too! Check out Behind-the-Scene @NTSB wherever you get your podcasts. If you’d like to suggest a blog topic, e-mail

As 2017 comes to an end, we again extend our gratitude to you for working with us to improve transportation safety. We wish you safe travels this holiday season and in 2018.

How Employers Can Make Our Roads Safer

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

“Safety should not be a competitive advantage.”

That’s the message I keep in mind every time I visit groups that represent employers, like the Network of Employers for Transportation Safety (NETS) which focuses on highway safety, or when I meet with the executives at individual companies, who may use many different modes of transportation for their businesses.

The NTSB is a unique federal agency because we are completely independent. Our agency has one simple but noble purpose: to prevent transportation-related deaths and injuries. We are on call 24 hours a day, 365 days a year, to investigate accidents, assist victims’ families, develop factual records, and recommend changes to make transportation safer. Unlike many government agencies, the NTSB has no regulatory authority, and we have no financial incentives to promote our safety recommendations. Our daily decision-making is guided by our values of integrity, transparency, independence, and excellence. We undertake investigations and make recommendations for the sole purpose of preventing future transportation disasters.

CMVSInfographicEmployers are uniquely positioned to meaningfully advance the recommendations that we make at the NTSB.  Over the years, we’ve issued over 14,000 safety recommendations to over 2,300 recipients, many of which are employers or groups that represent them. We know that if employers voluntarily implement our recommendations, our transportation system will be much safer. We’ve issued business-relevant recommendations related to installing recorder technology, developing fatigue management plans, requiring medical fitness, and many more—most of which are on our Most Wanted List (MWL).

Employers have a responsibility to address transportation safety. Nowhere is this more evident than for employers with vehicle fleets.  Many employers develop policies and procedures to keep their staff safe on the roads because they know that motor vehicle crashes are the leading cause of death among workers in the United States. According to the Bureau of Labor Statistics, from 2003–2015, there were more than 23,000 work-related motor vehicle deaths in the United States. The issues on our MWL, if addressed by employers, can help reduce this unfortunate statistic.

One way employers have helped advance safety—and can continue to do so—is by promoting evidence-based interventions like lowering the illegal BAC (blood alcohol concentration) to .05 (g/dL) or lower and implementing primary seat belt laws in the communities they serve. More than 10,000 people die in alcohol-related crashes every year. We’ve recently received attention because of our efforts to end impaired driving and our recommendation to change BAC laws from .08 to .05 BAC or lower. Many peer-reviewed studies have shown that such a law would prevent impaired‑driving crashes. While commercial drivers already are required to comply with a .04 BAC limit, employers can be an important influence in the lives of their employees, as well as in the communities in which they operate, by educating their employees and spreading the word about the effectiveness of a .05 BAC law.

Safety-conscious employers were some of the first and most vocal supporters of preventing distracted driving, long before distraction was a popular topic. Good companies didn’t just talk about distracted driving, they took action—as I’ve seen firsthand—to educate their employees and to change polices to prevent distracted driving.

American companies with large fleets also have been some of the most vocal supporters of the UN Decade of Action for Road Safety. They have worked hard to support international road safety, and have contributed to nontraditional traffic safety efforts, like helmet campaigns and infrastructure programs that improve the road environment, especially around schools.

Employers should also consider bringing vehicles with collision avoidance technology into their company fleets. Systems such as collision warning and automatic emergency braking help keep drivers safe by mitigating or even preventing crashes. Employers could install onboard vehicle monitoring systems and recording devices, such as cameras, to help monitor driving activity and unsafe practices. These technologies require an investment, but that investment will go a long way toward reducing insurance and workers’ compensation costs—and ultimately toward preventing injuries and saving lives.

There are many employers already considering and incorporating these technologies to improve safety; however, the more who join these industry leaders, the more lives will be saved. We can’t overstate the influence employers have, not just on their employees, but on their employees’ families and on their entire communities. Employer support of safety initiatives can be far-reaching. Companies that make safety a priority tend to have employees who make safety a priority. What employees learn about safety—whether related to distracted, impaired, or fatigued driving, or the value of collision avoidance technologies in vehicles—goes home to their families and spreads beyond to the entire community. Employers already have made a positive difference in many areas of traffic safety and employers will be vital to the effort to achieve zero deaths on our roads.


For more information on motor vehicle safety at work, visit the National Institute for Occupational Safety and Health website:




Inspiring Youth Safety Leaders

By Nicholas Worrell, Chief, NTSB Safety Advocacy Division

As an NTSB safety advocate, I serve the American people by promoting safety improvements that will save lives, prevent injuries, and preserve property on the nation’s roadways. I work to end distracted and impaired driving, and I encourage greater use of seat belts and child restraint systems.

One way I get my advocacy message across is by speaking on safety issues. I recently attended the National Black Caucus of State Legislators (NBCSL) Annual Conference in Indianapolis, Indiana. The theme this year was “Racing Towards the Future: Leading in a Time of Change,” though, from a transportation safety perspective, it seems like the future is racing toward us. We are living in an age when everyone, everywhere is connected by technology. In the span of a decade, smartphones have gone from the hot new item to a staple of modern life. But to avoid tragedies, all of us must keep our hands, eyes, and minds on the road—especially our youth, who lack driving experience.

At the conference, I sat on a panel with NBCSL corporate roundtable (CRT) members to address students from Warren Central High School in Indianapolis. Our goal was to educate, empower, and engage the youth on a variety of topics. From my perspective, their race toward the future, and the future’s race toward them, are both givens; the challenge will be for them to lead during changing times. I spoke to them about the significance of making good decisions that would have a positive impact on their lives in years to come. I stressed to them that motor vehicle crashes are the leading cause of death for teenagers, killing more young people every year than suicide, drugs, violence, and alcohol abuse combined. In the last decade, more than 51,000 people between the ages of 15 and 20 died in traffic crashes. That’s nearly 100 people each week! My message, then, was for these youth to act intentionally; to think about consequences up front. Not only are those good leadership habits, but they’re also excellent safe driving strategies.

Nicholas Worrell with Warren Central High School Principal Rich Shepler and students

I encouraged the audience members to become leaders among their peers. Fatigue, impaired driving, and distracted driving are all factors that can endanger young drivers’ lives. A big part of racing towards the future is bringing about widespread change at a pace that matches other changes coming about—like curbing distracted driving at a clip that keeps up with the developing technology. Keeping up with these changes will take time and commitment, and will require three things: good education and outreach, good laws, and good enforcement.

Nicholas Worrell joins National Black Caucus of State Legislators corporate roundtable members with Warren Central High School students

The race toward the future must be a race on the Road to Zero Fatalities; however, racing toward the future is more than giving teens a driver’s license or a car. As the CRT members discussed at the conference, today’s teens must meet tomorrow’s challenges with values like responsibility, commitment, passion, initiative, focus, action, persistence, growth, character, goals, gratitude, servitude, and courage, among other things. Racing toward the future will require a great deal of toil, and our youth will benefit from applying the lessons learned before them. Along with my colleagues on the panel, I offered my best advice and my own story to help guide them.

In 2016, we lost more than 37,000 lives on our nation’s roads. As we race toward 2018, what changes will we make to help prevent accidents, injuries, and fatalities? What steps can each of us take to prepare our youth for a brighter future? What stepping stones can we lay for students like those at Warren Central High?

Whether you teach students, mentor younger colleagues, or serve as an example to children, younger family members, or your peers, you, too, can lead during a time of change. The future is racing toward us; the time to prepare the next generation is now.

Travelers, Put Safety First this Holiday Season


By Chairman Robert L. Sumwalt

At the NTSB, we’ve investigated many tragic transportation accidents that could have been prevented with some planning, forethought, and good decision making. As we mark the beginning of the holiday travel season, we want to encourage all Americans to make it their goal to arrive safely at their destinations, so we’ve boiled down some lessons we’ve learned that the traveling public can use.

By Car

Fatigue, impairment by alcohol and other drugs, and distraction continue to play major roles in highway crashes. Here’s what you can do:

  • If your holiday celebrations involve alcohol, ask a friend or family member to be your designated driver, or call a taxi or ridesharing service.
  • In a crash, seat belts (and proper child restraints) are your best protection. Always make sure that you and all your passengers are buckled up or buckled in!
  • Make sure to use the right restraint for child passengers, and be sure it’s installed correctly. If you have doubts, ask a Certified Child Passenger Safety Technician.
  • Make sure you’re well rested! A fatigued driver is just as dangerous as one impaired by alcohol or other drugs.
  • Avoid distractions. In this newly released video, survivor-advocates share their stories of personal loss—and the changes they’re working for now:
  • Don’t take or make calls while driving, even using a hands-free device. Set your navigation system before you start driving. If you’re traveling with others, ask them to navigate.

By Bus or Train

The NTSB has made recommendations to improve passenger rail and motorcoach operations and vehicle crashworthiness, but travelers should know what to do in an emergency.

  • Pay attention to safety briefings and know where the nearest emergency exit is. If it’s a window or roof hatch, make sure you know how to use it.
  • If you’re unsure of where the exits are or how to use them, or if you didn’t receive a safety briefing, ask your driver or the train conductor to brief you.
  • Always use restraints when they’re available!

 By Air or Sea

Airline and water travel have become incredibly safe, but these tips can help keep you and your loved ones safe in an emergency.

  • When flying, make sure that you and your traveling companions have your own seats—even children under age 2.
  • Don’t forget your child’s car seat. The label will usually tell you whether your child car seat is certified for airplane use; the owner’s manual always has this information.
  • If you don’t know the rules for using a child’s car seat on your flight, call the airline and ask what you need to know.
  • Pay close attention to the safety briefing! Airline and marine accidents have become very rare, but you and your family can be safer by being prepared.
  • Whether you’re on an airplane or a boat, know where to find the nearest flotation device.

No matter how you travel, you deserve the benefits of the lessons we’ve learned through our investigations, but you need to play an active part to take advantage of them. This holiday season, make a commitment to put safety first.


Thank You for Your Service  

By Nicholas Worrell, Chief, NTSB Safety Advocacy Division

As we honor our veterans this week, I’d first like to acknowledge the many veterans who continue to serve the public here at the NTSB. Thank you for your service. I, too, began my public service in the armed forces as a member of the US Marine Corps. Like many of my NTSB colleagues, my focus then was—and remains—protecting American lives.

And to all American veterans, on behalf of the whole NTSB, thank you for your service. You were ready to stand your post and, if necessary, engage the enemy to protect your country.

A little more than a year ago, I had an opportunity to speak to sailors aboard the USS George Washington about road safety, which, I’ll admit, sounds strange. After all, why do sailors aboard a ship need to hear about road safety? The answer is because today’s military is working hard to stop an epidemic of vehicle crash deaths among its personnel, both off and on duty. For many years, the number of active duty personnel dying in crashes on our roads rivaled the number dying in our wars. Adding in American civilians, we lose over 37,000 Americans on our roads each year. Unintentional roadway injuries are the most likely cause of death for Americans, from childhood through middle age.

USS Washington
Nicholas Worrell talks with sailors about the USS George Washington

On the George Washington, I urged active duty personnel to “stay frosty” (alert) on US roads because, to me, something that kills tens of thousands of Americans a year must be seen as an enemy. This enemy’s three favorite tactics are impairment, distraction, and fatigue. Using the values drilled into me as a Marine—honor, courage, and commitment—I’m working to encourage others to counter these enemy tactics. I’m teaching my fellow citizens that it’s not okay to drink a six‑pack and get on your bike. It’s not okay to take phone calls—handheld or handsfree—while you’re behind the wheel. It’s not okay to drive without any sleep. If you do, you’re as good as collaborating with the enemy.

Body armor and up-armored vehicles keep soldiers and Marines safer, even when they’re in harm’s way. But what keeps you safe from the enemy on the roads at home?

A full FMVSS-218–compliant helmet.

Consistent use of your restraints.

Age-appropriate child car seats.

This is your body armor on the roads; your up-armor for your POV.

For many of us who have transitioned out of the military, our service values still drive us. We know that if there’s an enemy afoot, we are called to confront it. And, for Americans who never wore the uniform, improving road safety can be your chance to serve our country.

This Veterans Day, let’s thank our veterans by keeping each other safe on the roads that they served to defend.