Category Archives: Safety Recommendations

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!

The Age of Reason

By Chairman Robert L. Sumwalt

Some scholars play a critical role in founding a whole field of study: Sigmund Freud, in psychology. Noam Chomsky, in linguistics. Albert Einstein, in modern physics. In the field of safety, Dr. James Reason has played such a role. In this field, no single name is better known.

Dr. Reason turns 80 today, and if you’re reading this, it’s possible that you owe your life to his ideas.

NTSB reports have frequently cited Dr. Reason’s work, and I personally quote him liberally in my talks to industry and safety stakeholders.

His contributions to safety have been influential not only in transportation and workplace safety, but also in fields as varied as healthcare, nuclear power, and fraud prevention.

His books include Human Error; Organizational Accidents; Managing the Risks of Organizational Accidents; Organizational Accidents Revisited; The Human Contribution: Unsafe Acts, Accidents, and Heroic Recoveries; and A Life in Error: From Little Slips to Big Disasters.

He views safety as a system, and accidents as the result of any individual’s mistakes in combination with other failings in the system. People are fallible, but that doesn’t make accidents inevitable.

Focusing on a safer system, instead of only an individual’s mistakes, can help diminish individual error (for example, through better training and procedures). More importantly, studying the system reveals much more of “what went wrong” – and will go wrong again if not corrected, because other individuals will make mistakes.

Dr. Reason came up with a handy analogy for his view, called the “Swiss Cheese Model of Accident Causation.” (Just say “Swiss Cheese Model” to a safety or risk management professional, and they’ll probably nod knowingly.)

In this model, layers of protection against an accident, each of which has weaknesses, are visualized as slices of cheese riddled with holes. An accident occurs when the weaknesses, or holes, align.

 

Swiss Chese Model
Swiss cheese model by James Reason published in 2000. Source: https://openi.nlm.nih.gov/detailedresult.php?img=PMC1298298_1472-6963-5-71-1&req=4, open-access, CC Attribution 2.0 Generic

 

We’re all living in the Age of Reason. It’s a good age in which to live, one during which accidental deaths and injuries have been on the decline.

The continuous improvement of safety depends on safety professionals living with what Dr. Reason called a “chronic unease.” The paradox of safety is that the moment we think we’ve arrived, we introduce another hazard: complacency.

However, even in the chronically uneasy profession of safety, we find cause to celebrate every now and then. So, on that note, Happy 80th birthday to Professor Emeritus James Reason, on behalf of safety professionals everywhere—and on behalf of all those he’s saved, from every walk of life.

Alcohol Awareness Month

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

April is Alcohol Awareness Month. First introduced in 1987 by the National Council on Alcoholism and Drug Dependence, Inc., this time is set aside to increase public awareness for alcohol-related issues and to encourage communities to focus on ways to address this public health problem. In 2016, according to the National Highway Traffic Safety Administration (NHTSA), 10,497 people across the United States were killed by drivers with blood alcohol concentrations (BACs) of .08 g/dL or higher. That means that every 50 minutes, a person is killed in an alcohol-impaired crash in the United States.

Impaired Driving PreventableAt the NTSB, we find this tragic and unacceptable, because every one of these crashes is preventable.

Next week, the Lifesavers National Conference on Highway Safety Priorities will take place in San Antonio, Texas. More than 2,000 highway safety professionals from across the United States will gather to meet, learn, and share their proven-effective programs to increase the safety of America’s roadways, including implementing impaired driving prevention programs, improving enforcement strategies, and encouraging legislative changes. I’m especially excited to be attending the conference this year, not only because it’s being hosted in my home state, but also because I will be speaking on a panel focused on lowering the illegal BAC from .08 to .05 percent in states across our nation. A take-home message that I hope all Lifesavers attendees will remember is that a .05 BAC is a broad prevention strategy which deters even drivers with high BACs from getting behind the wheel.

Reducing drinking and driving deaths takes a comprehensive approach, and lowering the illegal BAC limit is just one part of the impaired-driving-prevention equation. Other important solutions can be found below, through our past blogs, safety recommendations, and efforts to address alcohol-impaired driving. With one-third of all traffic fatalities related to impaired driving, and more than 10,000 American lives lost every year, our work is far from over.

We have accomplished a great deal when it comes to reducing alcohol-impaired driving, ChooseOnebut there is much more to be done to save lives and prevent injuries. The way I see it, the solution—this month and every month—is simple: if we separate drinking from driving, we will save lives.

Reaching Zero: Actions to Eliminate Substance-Impaired Driving Forum

Most Wanted List Progress Report: Highway Safety

This Super Bowl Sunday, Don’t Count on a Hail Mary

National Impaired Driving Prevention Month

How Employers Can Make our Roads Safer

Thank You for Your Service

Carrollton, Kentucky, 29 Years Later: So Much Work Still To Do

Alcohol Awareness Month—It’s Time to Separate Drinking from Driving

 

Focus on Distracted Driving

By Chairman Robert Sumwalt

April is Distracted Driving Awareness Month, a time set aside to raise awareness about the dangers surrounding distracted driving. We continue to see far too many crashes in all transportation modes involving cognitive, visual, and manual distraction. Almost every driver has a portable electronic device, and if those devices are used while a person is driving, they pose a significant risk—not only to that driver, but to the public, as well.

Although distraction has always had the potential to interfere with vehicle operation, new technologies have made it easier to become distracted, and therefore easier to become a risk to ourselves or others. William James wrote in 1892 that “All our life, so far as it has definite form, is but a mass of habits.” Today, constant connectivity has become a mass of habits for many. But when it comes to driving, our eyes, minds, and hands should be on the driving task.

Distraction causes thousands of lives to be lost every year on our roads and it contributes to hundreds of thousands of injuries. We began calling for a ban on driver use of portable electronic devices in 2011. See the links below for some of the other steps we’ve taken to raise awareness about distracted driving and facilitate solutions.


Videos

Events

Roundtable: Act to End Deadly Distractions

Roundtable: Disconnect from Deadly Distractions

Forum: Attentive Driving: Countermeasures to Distraction

Blogs

Act to End Distracted Driving: One Life at a Time

Act to End Deadly Distractions

Today’s Actions, Tomorrow’s Consequences

Addressing Dangers on the Roads: This is no April Fools!

Protect Your Business by Protecting Your Employees

Cognitive Distraction and the Hands-Free Device Myth

Deadly Addictions


The ability to multitask is a myth. Humans cannot operate a vehicle while doing other things without risking the safety of themselves and those around them. Hands-free is not risk free—research shows a driver’s level of cognitive distraction is about equal for hands-free or hand-held communication.

Changing attitudes and behavior takes a sustained awareness effort, better laws, and high‑visibility enforcement of those laws. This combined approach has resulted in widespread seat belt use and gains against drunk driving. We’ve begun to make an impact on the distracted driving habit using these techniques, and you can do your part just by disconnecting for the drive.

Refusing to Take “No” for an Answer

By Chairman Robert L. Sumwalt

On July 17, 1996, about 12 minutes after takeoff from John F. Kennedy International Airport, New York, Trans World Airlines (TWA) flight 800 (TWA-800), a Boeing 747-131, crashed in the Atlantic Ocean near East Moriches, New York. The accident killed all 230 people on board, and the airplane was destroyed. The NTSB’s investigation of this accident was the most extensive, complex, and costly air disaster investigation in US history, and was the subject of high public interest and front-page headlines for years.

On August 23, 2000, a little more than 4 years after the crash, the NTSB determined the probable cause to be an explosion of the center wing fuel tank (CWT), resulting from ignition of the flammable fuel/air mixture in the tank. Because multiple potential sources were identified, the singular source of ignition for the explosion could not be determined with certainty, but the likely source was a short circuit outside of the CWT that allowed excessive voltage to enter the vapor-laden fuel tank through the fuel-quantity–indicating system in the CWT.

twa 800 4

On December 13, 1996, while the investigation was still ongoing, the NTSB issued the first of three sets of safety recommendations to the FAA. We based these initial recommendations on early findings of the investigation to address the threat of a fuel tank exploding on an airliner. Two recommendations included the development of design or operational changes to prevent explosive fuel-air mixtures in the fuel tanks—including the development of nitrogen-inerting systems. A nitrogen-inerting system replaces the air in an empty fuel tank with nitrogen, creating an environment in which neither a fire nor an explosion can occur. A total revision to FAA regulations for wiring and maintenance, including those of fuel-quantity–indicating systems, also resulted from our findings in this accident investigation.

The FAA’s initial response to our inerting recommendations was to convene a group of industry experts, who found that the costs of implementing the recommendations was too high to be practical. We disagreed and urged the FAA to consider other options. The FAA tried again, tinkering around the edges of the problem, focusing on the wiring and electrical systems in aging aircraft. We welcomed these improvements but reiterated that the agency was ignoring the core issue—the hazard posed by potentially explosive aircraft fuel tanks. To its credit, the FAA chose to apply some “out of the box” thinking, and, together with Boeing, developed a system on the airplane to address the threat.

That innovative technology, called a molecular sieve, separates air into nitrogen and oxygen, the two primary gases. The oxygen is vented overboard while the nitrogen is used to inert the fuel tank. The FAA performed in-depth analysis of the technology, and Boeing produced several prototype systems for testing and evaluation. These tests showed the system to be effective, have minimal operational challenges, and to be reasonably priced. Boeing began installing these systems on some of the new airplanes it was producing.

On November 23, 2005, the FAA proposed a new regulation that required newly manufactured and in-service airliners to reduce the chances of a catastrophic fuel-tank explosion. A final rule was enacted by in 2008, and 100 percent compliance with the rule became mandatory on December 26th of 2017—21 years after the NTSB first recommended fuel-tank inerting to the FAA.

The enactment of the fuel-tank flammability rule is a major safety improvement, addressing a critical safety problem at the heart of many aviation accidents over 45 years. However, its enactment was clearly far from easy; it took the persistent advocacy of the NTSB and the efforts of FAA and Boeing staff unsatisfied with cursory cost-benefit analyses. It took the commitment of senior management at the FAA and DOT—including the Director of the Certification Service, Associate Administrator of Safety, the FAA Administrator, and the Secretary of Transportation—to implement this needed safety regulation.

The traveling public is safer today because these organizations, working together, refused to take “no” for an answer.

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.

DSC02887
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.  

DSC02888 copy
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.