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ACT TO END DEADLY DISTRACTIONS

Distracted(NoCall).jpg

By Acting Chairman Robert Sumwalt

Distracted driving kills, on average, nine people every day on our highways and injures even more. Every day, families are left to grieve the loss of a loved one killed in a highway crash, their lives suddenly in disarray. These preventable tragedies must stop. We must all do our part and take action so that families no longer lose loved ones to a preventable death.

Often, the families and friends left behind after a fatal car crash become survivor advocates, turning their tragedy into action. This week, we will be hosting some of these survivor advocates at our second distraction roundtable, Act to End Deadly Distractions. We will be teaming with Stopdistractions.org, DRIVE SMART Virginia, and the National Safety Council to host this discussion.

I’m excited to facilitate this event, which is designed to focus on survivor advocates’ experiences of what has worked and what hasn’t in their fight against distracted driving. Above all, this roundtable is designed to facilitate effective action. The survivor advocate community will be exploring ways to act in their own towns and states to “move the needle” toward zero distracted driving deaths.

Our first distraction roundtable brought together experts to dive into what we know and don’t know about the science of distraction. At that event one fact became clear: distracted driving is taking lives. According to one market research company, since 2007, the percentage of Americans ages 13 and older with smartphones went from 6% to more than 80%. Although there have always been distractions competing with our focus on driving, these devices are especially addictive and, despite what we tell ourselves, we cannot safely or effectively multitask. To turn the tide will take a change in culture, especially in attitudes about portable electronic devices.

Experience with other causes of highway deaths shows that the science alone will not be enough to stop tragedy. Nor will awareness efforts. Heightened awareness, the right laws and policies, and tough enforcement all must play a role. The NTSB often makes recommendations aimed at changing safety culture within a company or even within a whole industry. We have recommended that states pass legislation to ban drivers from nonemergency use of portable electronic devices. We can’t “recommend” a way to change the minds and behavior of a whole nation of drivers, so we’re facilitating a conversation among survivor advocates and experts in awareness campaigns and in state houses.

We hope that you’ll join us. The roundtable begins at 9:00 am, April 26, in the NTSB Board Room and Conference Center, 429 L’Enfant Plaza, SW, Washington, DC. The event is convenient to the L’Enfant Plaza Metro station. You can also watch the event live at http://ntsb.capitolconnection.org/ and comment via Twitter @NTSB using #Act2EndDD.

 

The New Pipeline Rule I Waited Half a Career to See

By Charles Koval

One night, a couple feet underground outside an American home, the gas flowing in a service line began to escape through a puncture adjacent to a newly installed mailbox. A man and woman inside the home were watching the news. Their children were playing. Then, suddenly, without warning . . . nothing happened.

A simple and inexpensive device called an excess flow valve (EFV) kicked in, stopping the gas flow. There was no explosion, no fire, no injury or loss of life.

As a petroleum engineer and pipeline specialist for the NTSB, I know that the most important pipeline safety advance in recent decades has been the establishment of the national one-call 811 number. But EFVs may be the next most important life-saver, especially for homeowners.

Diagram of how an excess flow valve functionsGas companies install an EFV in a service pipeline where it meets the main line. The EFV shuts off the gas flow in the service line when it exceeds the normal flow rate; excess flow often indicates that gas is escaping the service line through a puncture or sever, potentially leading to an explosion or fire.

I’ve been working a long time to encourage the progress that came to fruition late last year regarding EFVs. The Pipeline and Hazardous Materials Safety Administration (PHMSA) quietly completed an important achievement and, in the process, closed an NTSB recommendation. PHMSA issued a rule expanding the use of EFVs to new or renewed service lines leading to almost all small commercial businesses and multi-residence buildings.

It’s taken decades to achieve this result. In all, the NTSB has made 24 safety recommendations related to EFVs.

When I came to the NTSB in 1990, the agency had already been endorsing EFVs for 20 years, beginning with recommending a shutoff valve after research that came out of a 1970 safety study.

I worked on accident after accident that may have been prevented by EFVs. Most of my work between 1990 and 1994 involved single-family residences, but many multi-residence accidents were just as horrible, if not worse. The incidents occurred in large cities like Tulsa, Oklahoma, and St. Paul, Minnesota, and in smaller towns like St. Cloud, Minnesota; Montezuma, Indiana; and Cliffwood Beach, New Jersey. I can still remember my first NTSB supervisor expressing exasperation that this simple and elegant solution was not in wider use.

Then came June 9, 1994. At about 6:45 that evening, a 2-inch-diameter steel gas service line that had been exposed during excavation separated at a compression coupling about 5 feet from the north wall of John T. Gross Towers, an 8-story retirement home. The escaping gas flowed underground toward Gross Towers, passed through openings in the building foundation, entered the mechanical room through the floor vents, and migrated to other floors.

A resident smelled the gas, as did a workman onsite, who told his foreman. The foreman called the gas company and the housing authority, then had other employees locate and shut off the gas line valve inside the towers. But at 6:58 p.m., the built-up natural gas in the building ignited and exploded; a second explosion followed 5 minutes later. The accident killed one person and injured 66—and it could have been much worse. Many residents were not in the building on the early summer evening of the disaster.

A humble EFV could have shut off the gas flow into Gross Towers. After the explosion, the NTSB recommended that PHMSA’s predecessor agency require that all gas distribution operators inform all customers of the availability of EFVs. After many years, the agency did so. Meanwhile, fatal accidents continued—all potentially preventable with EFVs.

Then, in 1998, the NTSB was called to the site of an explosion and fire at a single-family home in South Riding, Virginia.

A man, woman, and their two children were spending their first night together in their new home. The family retired at about 10:30—the children to the upper level of the house, and, because not all of their furniture had arrived, the parents to the first-floor study. Shortly after midnight, the house exploded and was engulfed in flames. The children were thrown out of the house and onto the lawn, suffering minor injuries. The parents fell into the basement as the first floor collapsed. The father was able to crawl to safety, badly burned; the mother did not escape and died as a result of her injuries.

Again, an EFV could have prevented the tragedy.

Following this accident, the NTSB recommended that PHMSA require EFVs in all new and renewed gas service lines, regardless of customer classification, when operating conditions were compatible with readily available valves. PHMSA first required only that single-family homeowners be notified of the availability of the valve and be allowed to pay for it themselves. Then, in 2009, PHMSA changed the rule, requiring EFVs to be installed on almost all new and renewed service pipelines to single family homes.[1] Finally, on October 14, 2016, PHMSA expanded the safety requirement to include most new and renewed service pipelines for multi-residential and commercial applications, closing one chapter in EFV history—and with it, an outstanding NTSB recommendation.

My first NTSB supervisor is no longer with us, but even years ago, he could imagine the broad use of EFVs that he did not live to see. Sometimes it takes a long time to normalize safety. Too often, it takes a highly visible accident—or several of them—to draw attention to a problem. Solutions often come a little bit at a time, or a long time afterward, without any fanfare.

But for now, and well into the future, for many businesses and homes nationwide, if a service line fails, nothing will happen. These homes and businesses are a little safer today because PHMSA and the gas industry acted on NTSB’s EFV recommendations.

 

Charles Koval is a Petroleum Engineer and Pipeline Specialist in the NTSB Office of Railroad, Pipeline and Hazardous Materials.

 

[1] The service line does not need an EFV if it: 1. does not operate at or above 10 psig all year, 2. has previously had contaminates, 3. could interfere with necessary operation or maintenance activities, or 4. is not commercially available to the operator.

Don’t Press the Envelope

By Mike Folkerts

Loss of control in flight—when a pilot fails to maintain or regain control of an aircraft—is the leading cause of general aviation fatalities. From 2011 to 2015, nearly half of all fatal fixed-wing accidents in the United States involved pilots losing control of their aircraft, resulting in 819 fatalities. Far too many NTSB investigations have shown how a loss of aircraft attitude control is often preceded by the loss of a pilot’s mental attitude control.

April 27, 2013, Piper PA-28R-180 airplane crash near Norfolk, Nebraska.
April 27, 2013, Piper PA-28R-180 airplane crash near Norfolk, Nebraska.

In the fatal accidents that I have investigated, this loss of mental control seems to be a conscious decision by the pilot to “press the envelope”—a term made famous in the 1983 film The Right Stuff, an adaptation of Tom Wolfe’s best‑selling book about the military test pilots who became Project Mercury astronauts. As the United States sought to achieve supersonic flight and put a human on the moon, these test pilots pressed the envelope, pushing the boundaries of both aircraft and human performance. Their efforts were based on national objectives and security, and many of these aviators paid the ultimate price in that pursuit.

Unfortunately, in far too many general aviation accidents, pilots choose to press the envelope for relatively minor (and often selfish) reasons, like “pressing the weather” to get home for dinner, flying at low altitude or maneuvering aggressively for an extra boost of adrenaline, or “pressing a known aircraft issue” to get a job done. Although a “git-r-done” attitude is certainly commendable, pilots too often forget to trust the little voice inside that warns them to steer clear of unwarranted risks, or they fail to guard against the temptation to make extreme efforts to please or impress others. General aviation flying very rarely requires the need to press the envelope, and pressing far too often ends in a tragic loss of control.

The NTSB is so concerned with this phenomenon that, for the last 3 years, we have placed “Prevent Loss of Control in Flight in General Aviation” on our Most Wanted List of transportation safety improvements to help bring attention to the issue. Last week, NTSB Board Member Earl Weener even attended the Sun ‘n Fun International Fly-In—one of the world’s largest general aviation enthusiasts’ training events—to talk to pilots about the dangers of losing control.

Whatever a pilot’s motivation may be for wanting to press the envelope, in general aviation, it’s not worth risking loss of control. Never underestimate the connection between mental attitude and aircraft attitude.

Mike Folkerts is an aviation safety investigator in the NTSB Office of Aviation Safety.

 

NTSB: 50 Years of Asking “Why?”

By Acting Chairman Robert L. Sumwalt

NTSB 50th Anniversary commemerative emblemFifty years ago, on April 1, 1967, the National Transportation Safety Board (NTSB) came into existence, helping to fulfill President Lyndon B. Johnson’s pledge to ensure the safety of Americans on land, sea, and air.

In 1966, Johnson recommended the creation of a single Department of Transportation (DOT), bringing together the functions of many far-flung agencies. He also urged

…that there be created under the Secretary of Transportation a National Transportation Safety Board independent of the operating units of the Department. The sole function of this Board will be the safety of our travelers. It will review investigations of accidents to seek their causes. It will determine compliance with safety standards. It will examine the adequacy of the safety standards themselves… I consider the functions of this Board so important that I am requesting authority from Congress to name five Presidential appointees as its members.

. . .

No function of the new agency—no responsibility of its Secretary—will be more important than safety.

Indeed, between March 2, 1966, and the NTSB’s birth the following year, there was a spate of disastrous commercial aviation crashes, either on US soil or involving US-built aircraft, together taking the lives of hundreds of passengers. This was not extremely unusual for this era; sometimes multiple fatal aviation accidents happened during the same month.

At the same time, the roads were full of automobiles that could never be sold under today’s safety standards. Most cars had no seat belts, and those that did generally had them in the front seat only. Air bags and child safety seats had not made their way into production. Drunk driving laws and enforcement were permissive, and even with far fewer cars on the roads, there were far more crash deaths.

Before the NTSB, major accidents in aviation were investigated by a section of the Civil Aeronautics Board, or CAB. Accidents in other modes of transportation might be investigated by a special subcommittee or jury, but there was no agency to coordinate these efforts or to collect the various findings and analyze them.

The written testimony of government officials in favor of creating the NTSB put it this way: “There is no single official in the entire Government who is in a position to identify, study, and propose solutions to transportation problems.”

The NTSB was established to ask “why?” when an accident happened, and to ask “why not?” Why not improve regulations, training, or a certain aspect of the vehicle or the environment? Even in its infancy, NTSB reports included, as they do today, recommendations to prevent future accidents, often pointing industry and regulators toward a safer future. Although action on NTSB recommendations is purely voluntary, more than 80% of our recommendations are acted upon favorably.

However, like the CAB investigators of its immediate predecessor in aviation, the NTSB initially was part of a larger agency that also concerned itself with operations and regulations. Although NTSB independence has been spelled out since its inception, the Board still came under the purview of the Secretary of Transportation. This arrangement put the NTSB in the position of investigating actions of its own parent agency and its constituent modal administrations. In 1974, Congress passed the Independent Safety Board Act of 1974, which, effective April 1, 1975, made the NTSB independent of the DOT, removing any concern that the regulator was, effectively, investigating itself.

Since our inception, we can point to numerous improvements that the NTSB has recommended as the result of accident and crash investigations in aviation, marine, highway, railroad, and pipeline transportation. The NTSB’s work throughout our 50-year history is responsible for the transformational improvements that make transportation safer for all of us today. But, by design, we can only take partial credit for any such improvement. We have no authority to regulate: only to recommend.

So, in celebrating our 50th anniversary, we also celebrate those who read our investigations and recommendations, agreed with us, and made the improvements happen, as well as those who made things not happen. Together, we avoided preventable accidents. We saved lives that didn’t have to be lost in the first place. We kept property intact that did not have to be damaged, and prevented injuries that didn’t need to be sustained (and the medical costs and loss of productivity that go with them).

The transportation industry is focused on a future with zero accidents. The men and women of the NTSB are committed to this vision and will continue to investigate accidents and to make recommendations that will help future generations enjoy an era free from transportation accidents.

As new technologies and transportation fields come into existence—from autonomous vehicles to commercial space launches, and beyond—we look forward to the next 50 years of transportation safety improvements.

Women of the NTSB

By Robert L. Sumwalt

As Women’s History Month draws to a close, we at the NTSB reflect on the thousands of women who have made a profound impact on transportation—at the NTSB and in the public, private, and nonprofit sectors. The contributions women have made to advance transportation safety, currently and throughout America’s history, are immeasurable and indispensable.

This weekend will mark the 50th anniversary of the NTSB opening its doors, and women have played key roles in the agency since its inception. In 1969, Isabel Burgess was nominated to be the first female Board member. In 1974, Mary Wallace (“Wally”) Funk became the first woman given the official title of Air Safety Investigator at the Board. Throughout the NTSB’s history, there have been seven female Board Members and three female Chairmen of the Board. Kay Bailey (later Kay Bailey Hutchison), once Vice Chairman of the Board, went on to become a US senator from Texas, where she served as the ranking member on the Senate Commerce, Science, and Transportation Committee. On a personal note, I had the pleasure of serving with our former Chairman, Debbie Hersman, who is now president and CEO of the National Safety Council.

Today, women make up 40% of the staff at the NTSB. There are 22 women working specifically on aviation safety issues. Nineteen women are in leadership roles as Member, directors, deputy directors, and supervisors.

The number of great accomplishments achieved by women at the NTSB and in the transportation industry is too great to attempt to tally. Women have been essential fibers in the fabric of the NTSB since day one, and they continue to make essential contributions. In addition to the women included in our administrative, human resources, and other support teams, the women who serve the NTSB as accident investigators, technical writers and editors, recommendation specialists, safety advocates, transportation disaster assistance specialists, recorder specialists, chemists, attorneys, and engineers ensure that the mission of this agency is fulfilled, day in and day out.

This month, and every month, the NTSB honors women in transportation and all the contributions they have made—and will continue to make—both within and outside the agency.

The Black Box

Bella Dinh-Zarr, PhD, MPH, Vice Chairman

The famous “black box.”

Mosaic image of data recorders for the Most Wanted List issue are Expand Recorder Use to Enhance SafetyReporters always ask us about it during high-profile aviation and rail investigations. After the sinking of the El Faro cargo ship during Hurricane Joaquin, the news media closely followed the recovery of the voyage data recorder, which was located in about 15,000 feet of water.

The black box, which is usually orange with reflective tape to make it easier to locate in wreckage, can be critical to our investigations at the NTSB. These devices can withstand enormous impact forces, intense temperatures, and the extreme pressures of ocean depths. Recorders capture a range of useful data, from crewmembers’ actions and conversations to vehicle parameters. We use these data to help identify the cause of an accident and to make recommendations to prevent such accidents from happening in the future. Industry can also use this information to make transportation safer.

We analyze recorder information in all modes of transportation. We transcribe audio from cockpit voice recorders and extract information from flight data recorders on aircraft. We review voyage data recorders that provide ship data, bridge audio, and radar images on vessels. We assess information from event recorders and forward- and inward-facing video recorders on trains. We analyze a variety of recorders and cameras that provide performance information on highway vehicles. No matter what type of recorder we encounter, we are required by law to protect the information obtained for our investigations.

Although the NTSB uses recorders to learn from one tragedy to prevent future ones, industry and operators can install recorders and develop programs to learn lessons from normal operations.

The NTSB urges the transportation industry to install recorders in their vehicles, vessels, trains, and aircraft, and to assess the data collected from them to prevent accidents and assess operator performance. Industry can use information from data, audio, and video recorders to identify issues of operational weakness or noncompliance with procedures. Airlines use the data they gather in everyday line operations through flight operational quality assurance (FOQA) programs to prevent accidents from occurring in the first place. Although most large aircraft are already required to have flight data and cockpit voice recorders, we have also recommended that they have cockpit video recording systems, and we have recommended that certain small aircraft that are not required to have recorders be required to carry recording devices that capture data. For smaller aircraft, recorders can provide crucial accident data, and they can also be a vital part of flight data management programs.

We appreciate the special value of data from video recorders, and that’s why many of our recent recommendations to regulators and operators propose that video recorders be installed to capture operator and crew behavior. Currently, investigators have no access to the visual information from an accident sequence. Although we can piece together key events in an airplane accident from cockpit audio and flight data, with video we have access to nonverbal communications and cockpit instrument manipulation. In fact, our NTSB scientists have even written software that reads needle positions and creates valuable data tables based on cockpit images! Reconstructing the accident sequence without video evidence requires additional time and effort—possibly delaying critical safety improvements.

What can be learned when inward-facing video is available? The answer is apparent from our 2014 investigation of the mid-air breakup of SpaceShipTwo during a test flight. SpaceShipTwo was equipped with data recorders, including video recorders to document the flight test. Because of those video images, the NTSB was able to identify quickly (by the second day of the on-scene investigation) that the co-pilot moved a lever at an inappropriate time, which ultimately resulted in the crash.

It is indisputable that we can make transportation safer by using information obtained from recorders. That’s why “Expand Recorder Use to Enhance Safety” is on the NTSB’s Most Wanted List of transportation safety improvements. And that’s why we urge transportation operators to install this important safety technology as soon as possible.

Tools of the Trade: Drones for the 21st Century Investigator

By Bill English

Throughout its history, the NTSB has prided itself on staying on the cutting edge of transportation technology. One of the most revolutionary changes ever to come about in aviation is the recent explosive growth—in number and capability—of unmanned aircraft systems (UASs), or drones. Last year, the number of registered UASs exceeded the number of manned aircraft. Nothing has drawn as much attention in aviation as the UAS revolution.

CBP MQ-9 crash near Nogales, Arizona, in 2006
CBP MQ-9 crash near Nogales, Arizona, in 2006

This phenomenon didn’t surprise us at the NTSB. Our first occasion to investigate a UAS accident came in 2006, with the crash of a Customs and Border Protection Predator-B MQ-9 near Nogales, Arizona. That investigation gave us a glimpse into the future of civil commercial drone use. In 2008, we held a public forum on UASs. Soon after, we officially acknowledged that UASs represented an expansion of the aviation world that we needed to thoroughly understand.

My entry into the world of UASs began with a side task: learn enough to update Title 49 USC Part 830. We published a revised regulation in August 2010, clarifying the NTSB’s role in investigating UAS accidents. The revision remains valid today, even with all the changes in the industry, and so far, civil, nonhobbyist UASs have a very good record: at the time of this writing, they have caused zero serious injuries and resulted in zero confirmed collisions.

NTSB in vestigators using a UAS to inspect an inflight breakup
Using a UAS to inspect an inflight breakup

The NTSB began experimenting with small UAS (sUAS) technology that could support on-scene accident investigation in 2013. By 2015, we had taken the first real steps toward using UASs to support multimodal accident documentation, obtaining authorization to research sUAS methods and to fly in the DC Special Flight Rules Area, and we began test flights. In early 2016, we started the process of obtaining a public agency Certificate of Authorization (COA) and also began procedures to expedite access to controlled airspace. In April, we made our first flights over an accident site under the COA.

We kept up with the quickly expanding rules for flying small UASs. The FAA published the sUAS Part 107 regulation in August 2016, and we were one of the first in line for a Part 107 certificate. Since then, we’ve developed Federal Flight Program documentation and procedures, conducted more deployments, and obtained our “flagship” drone, a DJI Inspire.

Overhead image of accident site taken by UAS.
With photogrammetry, an orthomosaic can be created in less than an hour.

As we started to gather information and gain experience with drones, we quickly realized that sUASs and their associated technology—small, high-resolution cameras and processing software—would be great tools for NTSB investigations. One such use of this technology is photogrammetry, which, using pixels from multiple photos of an object or area, creates a 3-D model or an orthomosaic (a map with geographical coordinates throughout). We know the value of aerial photographs; there is hardly a major NTSB accident report without an aerial image in it. But with a drone, we can now take high-quality photos, our investigators can specify the most important points of view, and we can immediately review the results. We can re-fly an approach path to view witness marks or runway alignment and quickly obtain high-quality photos of hard-to-access areas (for example, a plane crash into a building that our investigators cannot safely enter).

3-D model of a collapsed rail terminal
3-D model of a collapsed rail terminal

Photogrammetry, especially when it’s enabled by digital GPS-referenced photos, is the real game changer. Gone are the days of hunting through dozens of photos for just the right point of view, or scribbling down a few GPS points and hoping you took the right measurements. Orthomosaic maps and 3-D models let you go back for whatever you need. Our team continues to deploy to accident sites in aviation and rail, and we can now can deploy a drone to an accident site on request—with our COA approval, we can even get the OK to fly in controlled airspace within hours—and our photogrammetry-trained staff continues to grow. Every time we document an accident site, we learn more and get better at using the equipment and techniques.

NTSB investigators involved in photogrammetry training
Photogrammetry training

We intend to keep growing the UAS program and the ability to bring in external partners. Building this program has had an unanticipated side benefit: To operate the drone, which is an aircraft by all definitions, we developed a flight program following the Interagency Committee for Aviation Policy template. Now, anyone who wants to be involved in any aspect of flight operation—whether it be by putting together safety and operational procedures, developing training and standardization, or carrying out safety reporting/SMS activities—has a way to participate in our own little flight department!

NTSB investigators use a UAS for a high-elevation search
High-elevation search

As we grow in our knowledge of UASs, we’re able to maintain our high investigative standards in an expanding segment of aviation and improve our investigative techniques, giving our investigators an opportunity for hands-on experience.

Bill English is an Investigator-in-Charge in the NTSB’s Major Investigations Division and leads the UAS program. He is a current CFI-I who holds an FAA remote pilot certificate and a graduate certificate in geospatial intelligence.