Category Archives: Inside NTSB

NTSB’s Role in Marine Accident Investigations

By Captain James Scheffer, Strategic Advisor, NTSB Office of Marine Safety

I’m often asked how the NTSB chooses which marine accidents to investigate, and what role the US Coast Guard (USCG) plays in our investigations. I had the same question when I first joined the NTSB’s Office of Marine Safety more than 20 years ago. The NTSB has specific authority under the United States Code and Code of Federal Regulations to investigate “major marine casualties.” These are accidents involving vessels that result in one or more of the following:

  • The loss of six or more lives.
  • The loss of a mechanically propelled vessel of 100 or more gross tons.
  • Property damage initially estimated as $500,000 or more.
  • Serious threat, as determined by the USCG Commandant and concurred with by the NTSB Chairman, to life, property, or the environment by hazardous materials.

Our authority to investigate covers major marine accidents on US waters or those involving US-flagged vessels worldwide. We also have the authority to investigate casualties involving public (owned by the United States) and nonpublic vessels. In these casualties the threshold is defined by at least one fatality or damages of $75,000 or greater. Our task in these investigations, whether a major marine casualty or a public and non-public casualty, is to determine the probable cause of the accident and identify  safety recommendations that will prevent similar events in the future. We also investigate, independently or with other government agencies, marine accidents in which the United States is a substantially interested state (SIS), according to the International Maritime Organization’s “Code for the Investigation of Marine Casualties and Incidents.”

NTSB investigators about to board El Yunque - sister ship of El Faro

So, where does the USCG fit in? The USCG conducts preliminary investigations of all marine accidents, then notifies us when an accident qualifies as a major marine casualty. Unlike in other modes of transportation, such as aviation, where the NTSB leads the investigation, the USCG typically takes the lead in marine casualty investigations. Under a memorandum of understanding (MOU) between the NTSB and USCG, however, the NTSB may become the lead federal agency for the investigation, depending on the circumstances. This may occur when there is a significant marine accident that is a subset of a major marine casualty and is defined in the MOU as the following:

  • The loss of three or more lives on a commercial passenger vessel.
  • Loss of life or serious injury to 12 or more persons on any commercial vessel.
  • The loss of a mechanically propelled commercial vessel of 1,600 or more gross tons.
  • Any marine casualty with loss of life involving a highway, bridge, railroad, or other shore side structure.
  • Serious threat, as determined by the USCG Commandant and concurred with by the NTSB Chairman, or their designees, to life, property, or the environment by hazardous materials.
  • Significant safety issues, as determined by the Commandant and concurred with by the Chairman, or their designees, relating to Coast Guard marine safety functions.

If a marine casualty meets any of the above significant marine accident criterion the NTSB may elect to be the lead federal investigative agency.

In marine casualties involving a public (federal government) and a non-public vessel, if the vessel is Coast Guard the NTSB must investigate and be the lead federal agency. With casualties involving other public and non-public vessels, in most cases, the NTSB investigates as the lead federal agency.

The Office of Marine Safety typically investigates 30 to 40 marine accidents per year meeting the above criteria, and we do so with a staff of only 21 people, including investigators, writers, support staff and supervisors/managers. To get an overview of the Office of Marine Safety’s work, take a look at our Safer Seas Digest, which can be found on our ntsb.gov website, and summarizes our recent accident investigations and findings.

 

Good News . . . At Last!

By Chairman Robert L. Sumwalt

Let’s face it: the NTSB isn’t an agency that often has good news to report. As an accident investigation agency, we deal with the hard facts regarding terrible shortcomings in our nation’s transportation system. This week, however, I’m pleased to report some good news.

Best Places to Work 2018

On Wednesday, the Partnership for Public Service released its annual “Best Places to Work in the Federal Government” rankings. The overall rankings are determined by the Best Places to Work employee engagement score, which is calculated using a proprietary formula that looks at responses to the US Office of Personnel Management’s Federal Employee Viewpoint Survey. For the third straight year, NTSB ranked among the top 10 small agencies in the Partnership’s Best Places to Work in Federal Government rankings. We maintained our 2017 rank of number 6 out of 29 small agencies (in 2017, 28 small agencies were assessed). I take great pride in working with the fine men and women of the NTSB who allow this agency to be such a great place to work. That said, our goal is to be even better, and our leadership team is committed to making that happen.

The second piece of good news revolves around a very special recognition for one of our senior leaders. Last evening, NTSB Chief Financial Officer Edward Benthall, Jr, received the prestigious Presidential Rank Award (PRA). Two categories of rank awards are available: “Distinguished,” for leaders who achieved sustained extraordinary accomplishments, and “Meritorious,” for leaders who have achieved sustained Edward Benthall - Presidential Rank Awardaccomplishments. Ed joins a list of only 45 other 2018 Distinguished PRA recipients.

Bestowed by the President of the United States, the PRA is one of the highest awards conferred to Career Senior Executive Service (SES), Senior-Level (SL), and Scientific-Professionals (SP) within the federal government. The review process is extensive, and candidates are vetted with a federal background investigation. Names of the finalist are sent to the White House for final selection.

Ed was recognized for his work to safeguard the NTSB’s financial status and stellar reputation. He and his team have worked tirelessly to ensure that, for the 16th consecutive year, the NTSB received a clean (unmodified) financial audit opinion from outside auditors. When I announced to NTSB employees last week that Ed would receive the PRA this year, Ed brought his team front and center to acknowledge their contributions.

What’s amazing to me is that this is the fourth consecutive year that the NTSB has had a Distinguished PRA recipient. Considering that the Distinguished PRA is only bestowed to fewer than 50 employees government-wide each year, and considering that we have only about 20 SES, SL, and SP employees, this record speaks volumes for the fine caliber and dedication of our employees. With leaders like this, it’s no wonder the NTSB is one of the best places to work in the federal government.

Congratulations NTSB, and congratulations Ed!

3D Modeling: A Valuable Investigative Tool

By Michael Bauer

On February 10, 2018, an air tour helicopter descended into a canyon wash and collided with terrain while on approach to land at Quartermaster landing zone in the Grand Canyon near Peach Springs, Arizona. As part of this ongoing investigation, NTSB engineers needed a three-dimensional (3D) digital model of the accident site and surrounding terrain to thoroughly understand the terrain features in the local area. Although the main effort involved the use of a FARO laser scanner to create the 3D model, the NTSB small unmanned aircraft systems (sUAS) team recognized an opportunity to exercise our sUAS imagery-collection capabilities using photogrammetry and sUAS in a challenging environment to support this investigation and allow for a comparison of the data gathered from the two techniques for future investigations.

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Excerpt from Grand Canyon VFR Aeronautical Chart (FAA)

Since 2016, the NTSB has used sUASs, or drones, to create orthomosaic maps of wreckage sites and provide 3D digital models of terrain and vehicles for use by investigators in all transportation modes. Recently, we’ve launched the drone team to rail accidents (including the Hyndman, Pennsylvania, and Alexandria, Virginia derailments) highway crashes (including the Amtrak grade crossing collision with a refuse truck in Crozet, Virginia), and aviation accidents (including the crash of a cargo airplane in Charleston, West Virginia; the rejected takeoff and runway excursion at Willow Run Airport in Ypsilanti, Michigan; and multiple general aviation accidents at sites across the country). None of these missions, however, presented terrain challenges like those in the Grand Canyon.

Because the Grand Canyon is a combination of National Park Service and tribal lands, planning for the mission started weeks in advance. We needed to obtain permission from various tribal and governmental entities to operate a drone within that airspace and the special flight rules area (SFRA). The area is heavily used by numerous helicopter tour operators in the region, so planning involved coordinating with and notifying the various local operators of our intended sUAS mission. Without the support of the Federal Aviation Administration, the Hualapai Nation, the National Park Service, and Papillion Helicopters, this mission wouldn’t have left the ground.

After we received the appropriate approvals, we assembled in Boulder City, Nevada, to load a helicopter for the short trip into the canyon. Unlike other sUAS missions I’ve conducted, the remoteness of the canyon location introduced many challenges. For example, at the site, there were no electrical outlets or a generator, so we needed to plan the mission carefully in advance to ensure that it could be completed within the flight time enabled by the available batteries—recharging was not an option. Also, cellular coverage (including wifi) was nonexistent; thus, we had to access the Internet for the ground station software before departing for the canyon. In addition, when we use the sUAS to map an accident site, we use ground control points (GCPs) that we typically mark with paint. However, out of respect for the sacred land of the Hualapai Nation where the operation took place, we instead used lightweight, removable targets as GCPs. In total, I took 65 pounds of gear into the canyon to support the sUAS operation.

 

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We conducted the sUAS flight early in the morning in light wind conditions suitable for drone flying and low temperatures, which was welcome compared to the triple-digit temperatures expected later in the day. We conducted our flights concurrent with the laser‑scanning effort in the canyon wash. As remote pilot in command (RPIC), I arranged for our helicopter pilot to work with me as the visual observer (VO) for the mission. The VO monitored the local traffic frequency for inbound and outbound traffic and relayed information back to me. During a few flights, I paused the mission to land the drone to ensure safe separation from tour helicopters. We accomplished the mission in just over an hour of sUAS flying time, which included a 12-minute, 10-acre mapping mission. The effort provided a detailed 3D model of the canyon wash for the engineers and stunning visual imagery of the local terrain area. The data are currently being analyzed by investigative staff.

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NTSB sUAS flying in the Grand Canyon

Through this investigation and others, we’ve found that the ability to create 3D models of accident scenes is a valuable tool in the investigator’s tool box. Moreover, the ability of the sUAS to provide the imagery needed for these models in unique, complex environments in a short time and with low acquisition cost will aid our investigators for years to come. The NTSB sUAS team continues to explore the possibilities of sUAS imagery collection within the envelope of safe drone operations to further understand the capabilities and limitations of the technologies as they relate to the agency’s mission.

Michael Bauer is an aerospace engineering investigator in the NTSB Office of Aviation Safety.

Bike to Work Week

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

I don’t know about you, but it seems that every day I see more and more people traveling by bicycle; whether they’re riding for exercise, taking a fun ride with family and friends, or commuting to work. It’s exciting to see a growing population using bicycles to get from place to place. People are also bicycling year-round, in all types of weather, across the United States. As someone with a background in public health, I’m glad to see that The League of American Bicyclists reports that bike riding is an increasing trend. Personally, I always look forward to participating in Bike to Work Week and Bike to Work Day each May during Bike Month.

Bike Week
Member Dinh-Zarr (center) and NTSB colleagues

I love my bike. It isn’t anything fancy, but it gets me where I need to go, and it was even recently featured in the New York Times. My family and I ride our bikes as often as possible. Some of my colleagues at the NTSB (you can see some of us in the photo) have been biking to work for years. Many of us are lucky to live in Bicycle Friendly Communities where it is easy to travel by bicycle around town.

The NTSB is known for investigating every civil aviation accident and significant accidents in other modes of transportation—highway, rail, pipeline, and marine. Our goal is to help people get around—in whatever form of transportation they choose—as safely as possible. One of the tools we use to achieve this goal is the “Most Wanted List” of transportation safety improvements (MWL). Although neither our investigations nor the MWL have a specific focus on bicycles, many of our recommendations and the MWL items can improve safety for bicyclists. For example, when decisions are made with the safety of all road users in mind, such as following NTSB recommendations for a safe systems approach to setting speed limits or lowering the per se BAC limit to 0.05 g/dL to prevent drinking and driving, those of us who ride bicycles are safer. Additionally, when we make roads safe for the most vulnerable users, such as people who walk and bike, everyone benefits.

I encourage anyone curious about commuting by bicycle to give it a try this Bike to Work Week. You’ll be in good company (and if you see one of us from the NTSB on our bikes, be sure to say hello). According to the League of American Bicyclists, many people who participate in the Bike to Work Day promotion for the first time become regular bike commuters! Give it a try—map your route, get your bicycle tuned up, and always remember to wear your helmet!

Introducing “I Am NTSB”

By Chairman Robert L. Sumwalt 

It gives me great pleasure to introduce a new video series, “I Am NTSB.”

As a Board Member and now as Chairman of the NTSB, I’m often called on to describe our transportation safety mission or our investigative process. It’s a never-ending source of inspiration to think that, just maybe, what we do on a given workday will save lives in the future.

But other people ask me a much simpler question. They ask me what it’s like to work at the NTSB.

For me, it’s a dream job. As an airline pilot, and even before, I got to know what the agency did, and I always wanted to be a part of it. But what I knew little about were the people at this agency. It’s my privilege to lead a top-notch staff with diverse backgrounds, skills, and viewpoints. I’m constantly astounded by their many thoughtful ways of looking at things.

That’s why we created this series of video profiles of our employees. Through these video vignettes, viewers will learn a little more about our people and hear how our employees view the NTSB. If you’re one of those people who wonders what it’s like to work here, this video series is for you.

And who knows? Working at the NTSB might be for you, too!

We’ll lead off with Jane Foster, an electronics engineer in our Office of Research and Engineering.

Recognizing Important Women Leaders at NTSB—From Yesterday and Today

By Chairman Robert Sumwalt

March is Women’s History Month, so it’s only appropriate to look at some of the American women who have helped influence and shape today’s transportation system, including those working at the NTSB today.

We have witnessed the extraordinary accomplishments of women like Bessica Raiche, the first female pilot in the United States to make a planned flight, and our very own Member Bella Dinh-Zarr, the first Asian American to become a Board Member at the NTSB. Member Dinh-Zarr has spent years advocating for and promoting safe and sustainable transportation. These women have reached great heights in their careers and are renowned nationwide for their successes.

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Shannon Bennett (left), Sharon Bryson and Dana Schulze

Yet, there are many more women—perhaps not as nationally known but just as important to the NTSB’s critical mission—that we would like to recognize. In celebration of Women’s History Month, we recently sat down with some of the exceptional women who have emerged from the NTSB’s ranks to become leaders in management and safety. They inspire staff every day to work hard to improve transportation safety, sharing NTSB safety messages and encouraging us all to remember our mission to save lives. They are role models for many at the agency—men and women. We asked them to share their thoughts on leadership with staff last week at a special briefing, and we think their lessons are beneficial to all, even those outside our organization. Here’s what they had to say.

Dana Schulze is the deputy director of the NTSB’s Aviation Safety (AS) Office. As second-in-command of AS, she oversees all aviation accident and incident investigations in the United States and those involving US products or operations overseas. More than 50 air safety investigators and supporting staff within AS report directly to her. She approves information AS releases and routinely briefs Congressional staff and industry stakeholders on behalf of our agency. She began her career in the aircraft manufacturing industry as a mechanical engineer and has experience developing, manufacturing, and conducting failure investigations involving aircraft systems. From there, she rose through the NTSB ranks to her current position. She attributes her success to a continuous learning approach and her interest in improving aviation safety. Because of her critical-thinking skills and ability to lead others, she quickly rose to a leadership position at the agency.

According to Schulze, she did not initially set out to join management, but when the opportunity was offered, she recognized that she could add value and be a good fit. She believes a leader should be able to inspire and motivate others. Through integrity, consistency, and transparency, a leader “can instill a balance of vision and practicality,” she says. She says she has been inspired by thought leaders such as Steven Covey. Transportation has long been a male-dominated industry, and Schulze encourages women to get involved with transportation-related STEM programs that interest them, even those outside their comfort zones.

Sharon Bryson is the NTSB’s deputy managing director. She joined the agency more than 20 years ago after a career providing services to military families at Dover Air Force Base. When she arrived at the NTSB, the agency had just been given the responsibility for family assistance by Congress. Bryson took a lead role in setting up the NTSB’s first family assistance program. This program, now called Transportation Disaster Assistance, is still in place today and has served thousands of families over the years. Later, after serving as director of the Office of Safety Recommendations and Communications, Bryson became the agency’s deputy managing director, a position that involves assisting the Managing Director with managing the day-to-day activities of the agency.

According to Bryson, having the opportunity to mentor others and share what she has learned about leadership is very important to her.  She strives daily to engage with staff members and actively highlights their individual abilities, with the goal of seeing them thrive. “A leader is supposed to support and guide,” she says. By recognizing the strengths and weaknesses of the people around her, she puts value in their diverse opinions; there is no room for judgement or negativity. “When all of these are combined, it creates an environment where people feel engaged and encouraged,” she says.

Shannon Bennett came to the NTSB’s Office of General Counsel in June 2010 before becoming an advisory and special assistant to Board Member Dinh-Zarr in June 2015. She comes from a long military history, having enlisted in 1993 as an Air Force ROTC cadet during college, then serving 11 years on active duty as a judge advocate. She continued to serve in the Air Force Reserve and was assigned as a judge advocate in the Office of The Judge Advocate General at the Pentagon. According to Bennett, when she separated from active duty in 2010, she wanted to find a job where, as in the Air Force, she felt that she was serving her country and making a difference in people’s lives. That’s how she wound up at NTSB.

Leadership is “the art of influencing and directing people to accomplish the mission,” Bennett says, quoting the Air Force Pamphlet on Leadership she received as an ROTC cadet. She tries to live by the adage “saw the log in front of you,” meaning, do your very best in every job that’s given to you no matter how big or small, rather than seek the glory of a job you don’t have. Mentoring is also very important to her, and she encourages all leaders to guide others.

As we celebrate Women’s History Month, let’s all take the time to look around us and celebrate the unique and powerful women in our own lives. We are so grateful to have Dana, Sharon, and Shannon as members of our “Women Dream Team,” as well as all the other female employees at the agency who work daily to improve transportation safety and inspire those around them.

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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. 

 

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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.