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.

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!

Expand recorder use to enhance safety

Ensure teh safe shipment of hazardous materials

End alcohol and other drug impairment in transportation

Eliminate distractions

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.

Reduce Fatigue-Related Accidents

Improve rail transit safety oversight

Strengthen occupant protection

Require medical fitness for duty

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 21^st 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.  

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.

 

Prevent loss of control in flight in general aviation

Expand recorder use to enhance safety

Ensure teh safe shipment of hazardous materials

Reduce Fatigue-Related Accidents

Strengthen occupant protection

End alcohol and other drug impairment in transportation

Require medical fitness for duty

 

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

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

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

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

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

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

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

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

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

Most Wanted List Progress Report: Highway Safety

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

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

 

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

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

Reduce Fatigue-Related Accidents

Expand recorder use to enhance safety

Strengthen occupant protection

Eliminate distractions

End alcohol and other drug impairment in transportation

Require medical fitness for duty

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.

Most Wanted List Progress Report: Marine Safety

By Member Christopher A. Hart

 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 first blog of the series. 

Member Christopher Hart and Brian Curtis, Director, NTSB Office of Marine Safety at MWL midpoint meeting.

It’s been just over a year since we released our 2017–2018 Most Wanted List (MWL) of transportation safety improvements, so we decided to check in with stakeholders on our collective progress toward addressing these important safety issues. I had the opportunity to join in the discussion with our Office of Marine Safety and representatives from the US Coast Guard (USCG), the American Pilots’ Association, and the Cruise Lines International Association, and I came away encouraged that progress is being made on the issue areas that most affect our Marine safety efforts: expanding recorder use, ending alcohol and drug impairment, requiring medical fitness, and eliminating distractions.

Expanding requirements for voyage data recorders (VDRs) remains of paramount importance to the NTSB, as underscored by the information obtained from the VDR in our recently-completed investigation of the sinking of the El Faro. We certainly appreciate the extensive and sophisticated resources that several government and non-government entities deployed to find the basketball-sized canister containing the data because it proved to be invaluable to our investigation. Operators can also use VDRs to track and monitor vessel and fleet routes, and to help them determine crew training needs. The marine representatives we spoke with at our midpoint meeting are similarly interested in moving forward with VDR requirements, especially as the technology becomes more capable, affordable, and available. We’re hopeful that our recent report on the El Faro sinking will further encourage stakeholders to take action on increasing the installation and use of VDRs.

Ending alcohol and drug impairment is another important issue that we are working with stakeholders to address. The biggest hurdle here, which we discussed at the midpoint meeting with United States Coast Guard (USCG) representatives, seems to be coordinating rulemaking between the military and civilian sectors. Civilian labor unions are reluctant to support some of the recommendations we’ve proposed, largely out of concern for the rights of their members. The USCG continues to work on this issue to coordinate and implement our recommendations aimed at addressing alcohol and drug impairment.

When our conversation turned to a related concern—requiring medical fitness—I was pleased to hear assurances that the USCG is also making progress. Since its last update, the USCG has stood up an office supporting medical fitness issues and now requires medical certificates in addition to piloting credentials.

The final marine issue we discussed at our midpoint meeting was eliminating distractions. The USCG representatives informed us that the Coast Guard has released our safety alert associated with an accident that tackles this issue (SA-059 November 2016), and it intends to continue to follow up on recommendations related to distractions.

Require medical fitness for duty

End alcohol and other drug impairment in transportation

Eliminate distractions

Expand recorder use to enhance safety

We are always eager to hear feedback from our recommendation recipients, and this midpoint meeting was an excellent opportunity for us to make sure we fully understand the issues. We have recommendation specialists in each mode who help facilitate ongoing feedback, help with questions about our recommendation process, and discuss potential solutions.

At this 1-year mark, I’m encouraged and hopeful that we’re making progress on these important safety issues, and I look forward to seeing the NTSB and our recommendation recipients continue to work together to address them.