Category Archives: Inside NTSB

Get it Right: Addressing the Timeliness of NTSB Investigations

By Acting Chairman Bruce Landsberg

There was once a saying in the news media business to “get it first, get it right, but first get it right.” The NTSB strives to get it right above all, but we recognize that timeliness is essential, too. One of my goals even before joining the Board was to see if aviation crash processing time could be reduced on the less complex events. After all, the whole point of accident investigation is to become educated on what went wrong and get the word out as soon as possible to avoid a similar scenario.

But at the NTSB, it’s not all black and white. I want to take this opportunity to clear up some common misconceptions about how the agency functions and describe our process for those unfamiliar with its intricacies.

Congress requires us to evaluate all aviation accidents in the United States as well as significant accidents in all modes of transportation—rail, pipeline, highway, marine, and hazardous materials (how we determine what’s “significant” is a topic for another blog). Given this mandate, our resources are divided. Out of around 400 NTSB staff, only 45 accident field investigators are assigned to aviation. However, although we are required to investigate every civil aviation accident in the United States, as well as those occurring outside the country when they involve US-made equipment, that doesn’t mean we send an investigator to every crash. Often, it’s sufficient for an investigator to just interview a surviving pilot over the phone. In many cases, the Federal Aviation Administration (FAA) sends someone from its local office to an incident and shares the on-scene data with us.

Sometimes, though, an accident is more complex, and a deeper dive is required. For example, vital electronic data can be extracted from avionics, phones, or tablets that aren’t too damaged. Often that can be done in the field, but some devices must be sent to the NTSB lab in Washington, DC, for more thorough examination. There, our technicians painstakingly recover what they can, but—remember—they’re receiving devices from accident scenes in all the other transportation modes as well. The backlog can get lengthy. The lab must also decipher information from voice recorders (if any), vehicle monitors, onboard and external cameras, and metallurgical specimens, and conduct sound spectrum analysis, among other things, from every mode.

Sometimes, despite hours or days of lab effort, no data survives, which makes determining probable cause much more difficult. That’s why our 2021–2022 Most Wanted List of Transportation Safety Improvements includes “Install Crash-Resistant Recorders and Establish Flight Data Monitoring Programs.” Unbiased and accurate device readouts speed investigations up tremendously compared to relying solely on eyewitnesses, who are far less reliable.

In addition to analyzing all the machine information we can, we also look at the human factors present in an accident. We send toxicology samples to the FAA’s medical lab in Oklahoma City for analysis. Autopsy data must be gathered from local medical examiners, whose schedules don’t always align with ours. In a perfect world all this back-end analysis could be completed quickly, but reality intrudes. Factors such as staffing in other state and local government entities, the sheer number of reports the agency is juggling at a time, and yes, inefficiency, can drag things out. Those situations are not always within NTSB control.

Still, many reports frankly took too long to complete, and the average time to complete reports has increased over the years. Recognizing these delays, in 2019, staff in our Office of Aviation Safety began assessing our report process to see if we could streamline it in any way we can control. The effort produced significant improvements, and the early results are encouraging. From March 2020 to March 2021, about 1,100 investigations were initiated, and about 1,500 were completed. This doesn’t include several hundred foreign investigations in which the NTSB participates every year. This contrasts favorably with the prior year, where from 2019 to March 2020, about 1,320 aviation investigations were initiated, and about 1,150 were completed, not including foreign investigations.

Naturally, everyone wants everything faster. Going forward, the less complex cases we investigate are being scaled to finish in 6 months or so, while the more complicated ones will continue to take longer—sometimes much longer. Although we recognize the importance of timeliness in our investigations, we strive for a level of accuracy that ensures we’ve left no stone unturned.

As we revamp our investigation report process to get accurate information out more quickly, I think the public will appreciate the result. But, like most things, the process is a work in progress. We will never sacrifice precision for speed, but rest assured that we’re taking a hard look to see how we can get lifesaving information out more efficiently. We all look forward to seeing the progress the agency makes as we implement new strategies.

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

By Member Jennifer Homendy

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

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

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

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

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

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

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

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

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

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

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

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

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

Where the Action is in Safety

By Dolline Hatchett, Director, Office of Safety Recommendations and Communications

As the Director of the NTSB’s Office of Safety Recommendations and Communications (SRC), I lead a group that is focused on getting the whole story of accident investigations to the public. When there is a transportation disaster, my group is on scene alongside the frontline investigators, recording B-roll (video imagery of the accident site), and helping prepare NTSB spokespeople for on-scene press conferences.

But that’s just the leading edge of the investigation—and of our communications responsibility. For major investigations, we also focus attention on the public Board meeting. And, equally important but often overlooked, we help craft safety recommendations and advocate for them to be enacted, following up with recipients—sometimes for years—to see the job through.

My division’s mission runs the gamut, from fine points of grammar and usage to getting the right information out so that the people who need it have access to it. And lately, I’ve been thinking about how our language affects how we think—and what we do—about safety.

The Chairman of the NTSB has said that safety is not something that you can get or own, it’s something that you do, day after day. How does that relate to how we talk and write about safety? Well, if safety is something that we do, it’s not safety the noun (or the modifiers safe or safely). At heart, safety is a verb: to save.

To save lives. To save people from injury, and to save property and the environment from damage. How do we do this? By identifying hazards and mitigating risk (more action words—things we do to save ourselves, others, and our world!).

Why is this important? I notice too often that things that we do “for safety” are easily waved off. They’re thought of as things we do just in case something unlikely happens, but that cost time and money for the usual case when those measures aren’t needed. But the unlikely occurrence is out there, ready to happen, if that procedure isn’t followed or that safe design fails. We can’t be lax about safety, even if the likelihood of something going wrong is very low.

Those who are not deeply passionate about safety might dismissively explain that a feature is “for safety.” Think about the last automobile commercial you saw. I’m certain you heard something like “safety features” mentioned as flashy footage of that new car raced around coastline curves. I bet you weren’t thinking at all about what that term—safety features—even meant. It wasn’t made out to be as important as the car’s horsepower or built-in infotainment system. But what if the commercial narrator used a different term? Would you pay more attention if the narrator said, “To save your life, this vehicle is equipped with . . .” before summarizing the car’s safety features?

As you may have concluded, I truly appreciate the power of verbs—as far as language goes, they’re where the action is, where the rubber meets the road. By the same token, safety recommendations are where the rubber meets the road in the NTSB’s mission to improve safety. They’re about actions that can be taken to save people from death or injury, or to save property or the environment.

For example, although we recommend and advocate for transportation operators to use safety management systems (SMSs), implementing an SMS means starting and continuing a process. Although this process does include documents (safety policy), it does not begin and end there. A company must also do safety every day. Complying with rules is a good foundation, but to move ahead in a safety journey, we need the verb to save, which means making an ongoing, active effort. What does it mean to continually save in all that we do? It means following all the safety rules, of course, as a first step. But it also means continually scanning the horizon for the next hazard, to save lives, save others or ourselves from injuries, and save property and the environment from damage. This continual vigilance aligns with the proactive, recurring feedback necessary for a successful SMS.

We can all take a page from the safety professional’s book and forget safety the noun. Especially in today’s environment, safety is not something that we get or own. It’s something that we do, and continue to do, every day.

Safety is, by all rights, a verb. It calls for action. Make safety something you do, and keep doing it.

Attributes of a Healthy Safety Culture

By Chairman Robert L. Sumwalt

I recently wrote a series of social media messages about attributes of a healthy safety culture. I received some interesting feedback and cross-talk from organizational safety leaders, so I wanted to make the collected messages available in PDF form for this blog’s readers.

Attributes of a Healthy Safety Culture

Click on any of the attributes listed below to read the original messages.

I hope that, after viewing these messages, readers look around their operations, note where an attribute is lacking from their organization’s safety culture, and consider whether the shortcoming presents an opportunity for improvement. As widely known expert on organizational accidents James Reason said, “There are no final victories in the struggle for safety.”

While writing these messages, I realized again how integrally enmeshed personal and organizational responsibility are in the safety journey. The active error committed by one employee might not have been committed by another, but the same employee who committed the error might not have done so in another organization. Furthermore, in addition to individuals, an organization might be at the root of an accident.

Continuous safety improvement takes both conscientiousness and boldness to voluntarily identify what might go wrong and to think through the “what ifs” on the way to mitigating risk. It’s a tall order, and my hat is always off to those who accept the challenge—our safety professionals.

I hope that these musings will be of value to you and your colleagues as you move forward in your safety journey!

Safe Skies for Africa Ends, but the Safety Journey Continues

By: Nicholas Worrell, Chief, Office of Safety Advocacy

August 2019 Safe Skies for Africa symposium, Lagos, Nigeria
NTSB staff and attendees at the Safe Skies for Africa symposium in Lagos, Nigeria

After 21 years, the Safe Skies for Africa (SSFA) program officially came to an end last week at a symposium in Lagos, Nigeria. The program was established in 1998 in part to increase direct commercial air service between the United States and Africa, which was minimal at the time. Administered by the US Department of Transportation and funded by the US State Department, the SSFA program has accomplished many of its original objectives since inception, including improving the safety and security of aviation on the African continent. Over a dozen symposia and workshops have been held over the life of the program, and we organized past SSFA symposia with the South Africa Civil Aviation Authority and Kenya’s Air Accident Investigation Department. This year’s event was hosted by the Air Investigation Bureau-Nigeria (AIB-N), who also sent a team of accident investigators and industry representative to participate.

Former NTSB Managing Director (and program pioneer) Dennis Jones spent nearly 20 years in the SSFA program, participating in accident investigations, conducting workshops, helping improve accident investigation programs, and training investigators. In his opinion, the Safe Skies program has done what it was created to do. At the outset of the program, few African airlines and hardly any US airlines were flying to Africa, even though it’s the world’s second-largest continent. Today, two US carriers provide direct service to Africa, and six African countries (Egypt, Ethiopia, South Africa, Morocco, Cape Verde, and Kenya) have direct routes to the United States.

Along with increased US commercial air service to Africa, air investigation quality has improved, resulting in a lower accident rate and greater safety in commercial aviation in Africa. Many African nations now have their own accident investigation agencies, and some are even developing multimodal agencies based on the NTSB model.

We were honored to again join other NTSB communications specialists and experts, as well as former NTSB Managing Director Dennis Jones, for the final symposium. The symposium focused on the following topics:

  • The NTSB’s background and history
  • Emerging aviation safety issues
  • The investigative process and human factors
  • Accident classification and substantial damage
  • Helicopter operations
  • The challenges of providing family assistance
  • Effective safety advocacy: creating positive change in transportation safety

Our team shared lessons learned from NTSB accident investigations, as well as strategies to help our international counterparts take steps in their own aviation safety journey. The AIB-N participants were focused and receptive to our presentations, and the event was bittersweet as we parted ways with old colleagues and brought the program to a close.

Although the SSFA program has resulted in many improvements over its 21 years, more remains to be done. Safe and reliable aviation connects people all over the world, in more ways than you may realize. Aircraft components, engines, and airframes come from manufacturers all over the world. The airplanes they comprise might be flown by airlines in any country. We are all stakeholders in aviation safety, regardless of what continent we inhabit.

We look forward to more programs like SSFA that will advance international collaboration on aviation safety issues. I’m confident that new safety ambassadors will follow in the footsteps of those who participated in the SSFA program, and I look forward to working with the pioneers who participate in these programs going forward.

For our blogs on the other NTSB SSFA symposia in South Africa and Kenya, please see links below:

https://safetycompass.wordpress.com/2018/08/09/ntsb-supports-safe-skies-for-africa-initiative/

https://safetycompass.wordpress.com/2018/10/01/another-step-toward-safer-skies-in-africa/