Category Archives: Recorders

Too Close for Comfort in San Francisco

By Bruce Landsberg, Vice Chairman

On March 27, 1977, two Boeing 747s collided on a foggy runway in Tenerife, Spain. The crash took 583 lives, marking it as the deadliest aviation accident in history. Although commercial airline safety has made huge strides since then, a disaster potentially twice as deadly as Tenerife was recently averted by only about 13 feet.

In the late evening hours of July 7, 2017, an Air Canada Airbus A320 inbound from Toronto almost collided with four jetliners awaiting take off at San Francisco International airport (SFO). The night was clear and calm, with no weather to obscure the visual approach to Runway 28 Right.

The Air Canada pilots, not realizing the parallel runway (28 Left) was closed, lined up on a nearby taxiway rather than their assigned runway. As the waiting airliners flashed their landing lights to alert the errant Airbus, one of the pilots on the control tower frequency ground broadcast can be heard saying “Where’s this guy going?” and “He’s on the taxiway!” In the last few seconds, the Air Canada crew recognized their error and aborted the landing.  Simultaneously, the tower controller ordered the Airbus to go around.

Upon landing, the captain called the tower to discuss the incident, and then went to bed. It was 3 am by his body clock and he was exhausted. Although he was required to do so as soon as possible, the captain did not inform Air Canada’s dispatcher about the incident until 16 hours later, by which time the aircraft had already departed on a morning flight, resulting in the required 2-hours of cockpit voice recorder (CVR) data being overwritten.

With all the equipment, training, and safety management systems implemented since Tenerife, it’s astonishing how a near miss like this could happen. But as our investigation revealed, a long and intricate chain of events was to blame. We clearly understand now what happened, but, because the CVR data was lost, we only know part of the why.

We made several recommendations to address the safety issues our investigation uncovered. The incident report, which is available at ntsb.gov, should be required reading for pilots of both large and small aircraft. Here are some of the most important takeaways.

Knowing what to expect. Before flight, all pilots are required to check for Notices to Airmen (NOTAMs), which inform them of anything unusual that has recently changed at the departure or arrival airport, as well as navigational outages along the way. In practice, NOTAMs contain dozens of notices of varying importance, such as closed taxiways, wet runways, and small, unlit towers miles from the airport. Information about closed runways, however, is critical.

From a human factors perspective, we found that the presentation of information in the NOTAM the crew received did not effectively convey the information about the runway closure. This Air Canada crew missed two warnings about the closed runway at SFO, first in predeparture, and then via datalink before landing. Had they been aware of the closure, the pilots almost certainly would’ve suspected an unusual airport configuration with changed lighting patterns.

The current NOTAM system lists everything that could, even under the most unlikely circumstance, affect a flight. It lays an unnecessarily heavy burden on individual pilots, crews, and dispatchers to sort through dozens of irrelevant items to find the critical and important ones. When an important item is missed—as is common—and a violation or incident occurs, the pilot is blamed for not finding what amounts to a needle in a haystack.

Further, NOTAMs are published in hard-to-read codes. Using plain language and conventional date and time configuration in both local and universal (UTC) time could go a long way toward making flight safety information easier to understand. The Federal Aviation Administration (FAA) has been aware of the NOTAM problem for more than 15 years. In 2012, Public Law 112-153 (Pilot’s Bill of Rights) gave the FAA 1 year to fix the problem. The incident at SFO makes it clear that there is still much more work to be done. This is a safety issue that calls for urgent action.

The fatigue factor. Fatigue continues to be a recurring factor in accidents and incidents. The Air Canada captain had been awake for 19 hours at the time of the incident. It’s estimated that he awoke around 0800 eastern time (ET); the incident occurred at 0300 ET the following day. The captain was not technically “on duty” that whole time, and, under Canadian regulations for reserve crew members, he still could have been available for duty for another 9 hours.

During postaccident interviews, the captain said he did not make a timely incident report to Air Canada’s dispatch after landing because it was “very late” and he was “very tired.” If the captain is too tired to make a phone call to report an incident, should the rules allow him to fly a challenging night approach with the lives of 139 passengers and crew in the balance? If we expect solid human performance where lives are at stake, fatigue rules need to be based on human factors science. The NTSB has recommended that Canada’s fatigue regulations be modified.

Cockpit voice recorders and beyond. The Airbus’s CVR would have provided much more information on what happened, but it was overwritten during the first flight following the incident (current CVRs are only required to store a minimum of 2 hours of audio). Without the CVR data, we may never understand all the reasons behind the numerous procedural failures, but we know one thing for sure: the CVR would have provided a much better picture of just how this incident came close to being a catastrophic accident.

Cockpit image recording could provide a much richer source of critical information. We initially issued an image recorder recommendation as long ago as 2000.

We have had far more success with image-recording technology in every mode of public transportation except commercial aviation. Some pilot groups are concerned about the flight crew’s right to privacy and that the information gathered will be used punitively. Workplace right to privacy has been extensively debated, but for employees in safety-critical positions, privacy should take a backseat to human life.

Unlike written transcripts, cockpit audio and video recordings are protected by federal law and never released by the NTSB. Likewise, video recordings are protected by law from being released. Over-the-air transmissions, such as communications between a pilot and air traffic controllers, are in the public domain, by definition, but in-cockpit audio and video recordings are protected by the NTSB against public disclosure.

More importantly, image recorder data gathered routinely before an accident will be invaluable in preventing the next tragedy. This approach has been highly effective in flight operational quality assurance (FOQA). This approach may pose some technical challenges, but it will significantly increase safety and accountability.

Learn and forgive. One of the best practices used in aviation is the concept of “just culture,” or nonpunitive corrective action. Most people put their best foot forward and attempt to minimize a critical error when they make one, which is perfectly understandable. Yet, some supervisors want to mete out sanctions to “teach a lesson” or to make an example of a crew. Unless someone is habitually error prone or intentionally ignoring safety procedures, a punitive response is completely inappropriate to critical performance environments in all modes of transportation.

This Air Canada flight crew will almost certainly never make such a mistake again, and my hope is that they will continue to fly to the normal end of their careers.

We gain much more from being introspective rather than judgmental about this incident. We should celebrate when someone confesses a mistake and learns from it. This is one of the key factors in the decades-long decline in commercial aviation’s accident rate. Fortunately, we’ll get another chance to put some fixes in place to make a highly improbable event even less likely to recur. Let’s not squander it.

 

Reduce Fatigue-Related Accidents and Expand Recorder Use to Enhance Safety are topic areas on the NTSB 2017-2018 Most Wanted List.

 

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.

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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.

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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.

 

 

 

Most Wanted List Progress Report: Rail Safety

By: Chairman Robert L. Sumwalt

 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 fourth and final blog of the series.

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Chairman Sumwalt and Robert Hall, Director, NTSB Office of Railroad, Pipeline and Hazardous Materials Investigations talk with attendees at the Most Wanted List midpoint meeting

On November 14, 2017, the day before our Most Wanted List (MWL) progress meeting, we concluded our investigation into the April 2016 Amtrak train derailment in Chester, Pennsylvania. As I offer the closing words of this blog series highlighting the progress made  to address issues on our list, the NTSB is presently investigating the December 2017 Amtrak train derailment in DuPont, Washington, and the February 2018 Amtrak train and CSX freight train collision near Cayce, South Carolina. And, on February 15, I testified before the US Congress regarding the urgency for the industry to fully implement positive train control (PTC) by year’s end. That same day, we also issued three urgent safety recommendations to address findings from our investigations into the Cayce accident and the June 2017 Long Island Rail Road accident in Queens Village, New York.

At our midpoint meeting, I joined members from our Office of Rail, Pipeline, and Hazardous Materials Investigations to lead a discussion on rail safety. While there has been progress with implementing some of the NTSB’s recommendations, the Chester and DuPont derailments and the Cayce collision tragically illustrate that more needs to be done – and quickly!

A deficient safety management system and impairment were factors in the fatal Chester accident. And, like many accidents we’ve investigated, distraction played a role. When the accident occurred, the dispatcher was speaking to his spouse on a landline. We’ve recommended that Amtrak prohibit such calls while dispatchers are on duty and responsible for safe train operations.

The Chester accident also illustrated the fact that drug use by rail workers has been on the rise in recent years, playing a part in seven accidents in the last 3 years and nine accidents in the last decade, compared to only one accident in the prior decade. In the Chester accident, a backhoe operator who was killed had cocaine in his system, and two different opioids were discovered in the track supervisor’s system. During our investigation, the Federal Railroad Administration (FRA) moved quickly to require random urine drug screening for maintenance‑of‑way workers, effective April 2018. Additionally, the Amtrak locomotive engineer tested positive for marijuana, although there was no operational evidence that his prior drug use impaired his performance on the morning of the accident. What it did show, however, is that despite DOT random drug testing requirements for locomotive engineers, such a program did not deter his use of an illicit drug.

Fatigue and medical fitness are other significant MWL issues for rail, and we’re disappointed that the FRA and the Federal Motor Carrier Safety Administration have withdrawn an advanced notice of proposed rulemaking that would’ve supported sleep apnea screening for railroads and for commercial highway carriers. Clearly, there’s still important work to do on these issues.

Regarding another significant MWL issue for rail, strengthen occupant protection, the FRA has made progress toward developing a performance standard for keeping window glazing in place during an accident. Unfortunately, meaningful improvements related to the safety of corner posts, door designs, restraint systems, and locomotive cab crashworthiness have been slow.

The MWL’s safe transport of hazardous materials issue area focuses on transporting energy products in safer tank cars, built to the DOT-117 rather than DOT-111 and CPC 1232 standards. We are pleased to see that the more robust DOT-117 standard is being used for transport of crude oil. Ethanol transport, however, still widely relies on the DOT-111 and CPC 1232 standards. We urge stakeholders to move to using the DOT-117 standard when carrying ethanol as soon as possible, ahead of the mandated deadlines.

There has been little, if any, progress to improve transit safety oversight since we released the current MWL. To exercise effective oversight, the Federal Transit Administration (FTA) must continue to use the authority it gained with the Fixing America’s Surface Transportation Act and Moving Ahead for Progress in the 21st Century Act to promulgate safety rules.

Finally, on the issue of expanding recorder use, the industry is moving forward with installing inward-facing video cameras on passenger trains, which is a step in the right direction. However, we would like to see the FRA move forward on requiring the installation and that the requirement be expanded to include audio recording, and we believe that the freight rule should follow suit. The FTA still has no such requirements for transit rail.

As I offer the last thoughts on our MWL midpoint meeting blog series, I want to thank all those who attended for taking the time to offer suggestions and share their perspectives on the issues affecting the safety of our nation’s transportation system. As we move into the second year of this MWL cycle, I challenge our stakeholders to target one or more recommendations on which they can make measurable progress before this year is over. We all want to have the safest transportation in the world, and it will take us working together to accomplish it.

 

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. 

 

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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.