Category Archives: Uncategorized

Flatten the Curve Beyond COVID-19

By Leah Walton, NTSB Safety Advocate

When I read the extended nationwide maximum telework order, prolonging the order that started on March 17th, I couldn’t help but think about what impact the COVID-19 preventive measures might have on traffic deaths around the country. Surely, we’ll see a drop in vehicle miles traveled, like we did in the last great recession, but will that give us a false sense of security that traffic safety has improved? The truth is, even though fewer people are driving, and we might see a drop in traffic fatalities in 2020 due to social distancing and stay-at-home orders, risky driving behaviors persist. On one hand, I’ve seen reports of drivers using the emptier-than-normal freeways as their personal racetracks, and on the other, I’ve seen reports of significantly lower drunk driving arrests in the month of March.

It’s encouraging to see so many people following state orders to implement social distancing and staying at home—if there are fewer people on the roads, there is less risk for vehicle-related injuries, which keeps people out of hospitals, allowing hospital workers to focus on the influx of coronavirus patients. However, this causes me to wonder: if people can be convinced to stay home to avoid contracting a dangerous and sometimes deadly virus, could they also be convinced to designate a sober driver or drive their vehicle at posted speeds? After all, those are lifesaving behaviors, as well.

 

As a transportation safety advocate, I know that motor vehicle crashes are a serious threat to public health in the United States. In 2018, 36,560 people were killed in traffic crashes. The Insurance Information Institute estimates that 1,894,000 people were injured in traffic crashes in the same year. According to NHTSA, 94 percent of all serious traffic crashes are the result of human error; or, in other words, they’re caused by a driver’s choices. We should not let the stress of COVID-19 lower our guard on safe driving practices. Remaining vigilant behind the wheel is critical now more than ever with children home from school, often playing outside, riding bikes in the streets. More people are out walking; sometimes in the street to practice social distancing of other pedestrians.

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The CDC has been promoting thorough handwashing procedures and the importance of covering a cough and sanitizing surfaces to prevent the spread of COVID-19. But did you know that the CDC also promotes motor vehicle safety behaviors like driving sober, buckling up, and not driving distracted?

We are extremely troubled by the increasing number of deaths and cases across our country related to COVID-19. Doctors, scientists, and public health professionals are all searching for a cure or a vaccine to eliminate this virus as quickly as possible. At the NTSB, we’re incredibly grateful for all those professionals—including those transporting vital supplies around the country. If Americans can choose to stay home to help slow the spread of COVID-19, imagine the impact we could have if everyone chose to make the safest driving choices for ourselves and our fellow road users. We have the power to flatten the curve of traffic deaths by making safe choices every day.

Automated Vehicles and Distraction: Lessons Learned from Mt. View

By Robert Molloy, PhD, Director, NTSB Office of Highway Safety

The National Transportation Safety Board (NTSB) met on February 25 to consider the 2018 collision of a Tesla Model X, operating with partial driving automation, with a damaged crash attenuator in Mountain View, California. The car steered out of its travel lane and into a gore area, where it collided with the damaged highway safety hardware. The driver didn’t notice the errant path the vehicle had taken because he was interacting with a game application on his work phone.

March 23, 2018, crash of a Tesla in Mountain View, California
Northbound view of the crash scene before the Tesla was engulfed in flames. (Source: witness S. Engleman)

It was a tragic event for both the driver and his loved ones, and the tragedy was compounded because the event was utterly preventable. In this crash, the driver behaved as if his partially automated vehicle were self-driving when it wasn’t. The driver’s resulting distraction, tragically, led to his death. But it’s rare that a crash is the result of a single factor. At the NTSB,  we try to identify all the factors contributing to a crash so we can propose multiple methods to prevent a similar crash in the future. The NTSB doesn’t apportion blame or liability; we look for ways to prevent the next occurrence.

In this crash, we identified or reiterated several ways to prevent a similar tragedy:

  • Because drivers using portable electronic devices while driving often crash, we recommended that device manufacturers find a way to lock people out of their devices while they’re driving.
  • Because “Autopilot,” Tesla’s automated vehicle control suite, is only designed for certain conditions, we reiterated our recommendation to disable it when those conditions are not met.
  • Because Tesla’s proxy measure for driver engagement—torque on the steering wheel—was previously found ineffective, we reiterated a recommendation that Tesla find an effective measure of driver engagement.
  • Because this vehicle crashed into objects that it “did not detect, and [were] not designed to detect,” (a crash attenuator) we recommended that the National Highway Traffic Safety Administration (NHTSA) rate collision avoidance systems under its 5-star rating program, incorporating such objects into its assessment.
  • Because we found that misuse of Tesla’s automation was foreseeable, we recommended that NHTSA evaluate Tesla Autopilot-equipped vehicles to determine if the system’s operating limitations, foreseeability of driver misuse, and ability to operate the vehicle outside the intended operational design domain pose an unreasonable risk to safety, and to ensure that Tesla takes corrective action if safety defects are identified.
  • Because the crash attenuator that the Tesla crashed into had not been repaired, and because lane markings were worn in the area of the crash, we made recommendations to state agencies responsible for maintaining highway infrastructure.
  • Because Apple, the driver’s employer, had no distracted driving policy, we recommended that it adopt one.
  • Because many other companies also don’t have such a policy, and because transportation accidents are a leading cause of workplace injury and death, we recommended that the Occupational Safety and Health Administration review and revise its distracted driving initiatives and add new enforcement strategies.
  • Because it is important to have ready access to data that fits defined parameters to assess crashes involving automated vehicle control, we reiterated recommendations to require standardized data reporting, including incidents, crashes, and vehicle miles traveled, with such systems enabled. This recommendation would also allow the NTSB and NHTSA to evaluate real data on the safety of level 2 automation, not just industry claims.

When we investigate a crash, we aren’t looking for a driver, a company, or an agency to blame; we’re looking for all the ways the next crash can be prevented. When prevention is the goal, those drivers, companies, and agencies are often happy to help make the changes needed to ensure safety. We hope all parties will heed the lessons learned from this tragic crash and take the steps we’ve recommended to increase the safety of the traveling public.

 

Our Transportation Safety Wish List

By Chairman Robert L. Sumwalt

Every 2 years, the NTSB puts together a wish list, called our Most Wanted List (MWL) of transportation safety improvements. It comprises recommendations ripe for action by their recipients, which, if acted on, will bring safety benefits to all Americans.

Our wish list is not like some other traditional holiday wish lists. For one thing, we’re not asking who’s naughty and who’s nice; the stakes are too high for that. Regardless of whether you’re naughty or nice, you deserve access to safe transportation. Another difference is that a safety wish list is about things that transportation interests—government, industry, and others—are supposed to provide. Our list includes safety items that should “come standard,” not ones that we hope we’ll receive if we’re all really, really good travelers this year.

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That being said, it’s still nice to see some “wishes” checked off our list this year, even if American travelers had every right to expect them. For instance, we recently acceptably closed the following recommendations to the Long Island Rail Road (LIRR) and the Metro-North Railroad, both part of New York’s Metropolitan Transit Authority:

  • Safety Recommendation R-14-65, which asked the LIRR to screen and evaluate employees in safety-sensitive positions for sleep disorders, then treat those who tested positive.
  • Safety Recommendations R-14-62 and R-14-64, which asked Metro-North to revise medical protocols and provide its employees in safety-sensitive positions a list of medications that engineers and conductors must avoid.
  • Safety Recommendation R-17-9(to Metro-North) and R-17-10 (to a number of railroads, including Metro-North), which sought risk assessment and mitigation strategies at grade crossings with third-rail systems at or near the crossings. (Safety Recommendation R‑17‑10 remains classified “open” overall because other recipients have not yet completed action on it.)

What else can we scratch off our list?

In November, we closed Safety Recommendations P-18-5, -6, and -8 acceptably. These recommendations called for the management-of-change process to be used to identify natural gas system threats, and for professional engineers to be included in the engineering plan and constructability review processes as well as in public utility engineering drawings in Massachusetts.

In September, we closed Safety Recommendations P-18-1-7, and -9 acceptably. These recommendations called for improved inspection programs, better records and documentation of natural gas systems, and procedures to mitigate risks identified during management-of-change operations.

In July, we announced the closure of eight MWL-related recommendations. Four (P‑17‑3H‑15‑20, A-09-92, and H-09-18) were closed with acceptable action taken, one (P‑18‑3 ) was closed with acceptable alternate action taken, and one (M-16-28) was closed with a status of “exceeds recommended action.”

  • P-17-3 called for Colonial Pipeline Company to address pipeline dent repairs and leak detection.
  • P-18-3 called on Honeywell to address an issue with incorrectly installed mechanical tapping tee assemblies.
  • H-15-20, to the National Limousine Association, addressed the need for passenger safety briefings about seat belt use in limousines.
  • H-09-18, to the Federal Motor Carrier Safety Administration (FMCSA), addressed access to positive drug and alcohol test results and refusal determinations.
  • A-09-92, to the Federal Aviation Administration, addressed the need for the helicopter emergency medical services to use the Aviation Digital Data Service Weather Tool as an official weather product.
  • M-16-28, issued to the Passenger Vessel Association, called for a variety of actions to improve the safety of amphibious passenger vehicle operations, applying lessons learned in two amphibious passenger vehicle crashes.

As in most years, we did not get most of what we wished for on behalf of the traveling public; Even though these are safety measures the public is supposed to be able to count on, we understand. Many of our wish list items take a long time to achieve. These items, too numerous to name here, remain open.

Sometimes a recommendation, such as R‑04-7, is superseded by a subsequently issued recommendation (in this case, R-19-1).

And sadly, other recommendations must be closed unacceptably, such as H-12-29, issued to the FMCSA. This recommendation asked the FMCSA to establish an ongoing program to mitigate the risk of driver fatigue. That was one “gift” the traveling public really needed this year but did not receive.

Our 2019­–2020 Most Wanted List includes the following broad items:

We celebrate the actions that have been taken this year to improve safety, but there’s plenty left to wish for. Take a look at our website for more information on the MWL and some of the recommendations still on our wish list.

Happy holidays, and may you receive everything you want (and need!) for the new year.

Making the Right Choice this Holiday Season

By Leah Walton, NTSB Safety Advocate

 “On behalf of all of us at the NTSB, I offer our sincerest condolences to the families and friends of the individuals who lost their lives in this crash. Our entire purpose for being here today is to learn from tragic events like this, so that they can be prevented in the future.”

Chairman Robert Sumwalt speaks these words, or some variation of them, with grave sincerity in his opening statement at every Board meeting, and, as we hit the height of this holiday season, I can’t help but reflect on the Chairman’s words, the accident reports I’ve read, and the survivors I’ve met. As families and friends gather to celebrate, socialize, and look back on the year that’s coming to a close, many will also be missing a loved one, some for an agonizing first time.

Regardless of whether they’re experiencing the first holiday season without their loved one or the twenty-first, I imagine this time of year is especially painful for those who have lost someone suddenly in a transportation accident or crash; particularly a crash that was preventable.

Many of the fatal highway crashes we investigate are the result of human error. In 2018, 10,511 of those human errors were the result of alcohol-impaired driving, which—not surprisingly—tends to spike during this season of parties and revelry.

Imagine that—10,511 families are missing loved ones at their holiday celebrations this year due to a human error that is 100% preventable.

Impaired Driving Preventable

At the NTSB, we issue safety recommendations that, if implemented, could prevent transportation tragedies from reoccurring. Our safety recommendations call for bold actions; that’s the only way we’re going to get to zero deaths on our nation’s roadways. We’ve called for actions like:

Like many large problems, though, a comprehensive solution is needed to make real change. When it comes to impaired driving, a massive culture shift is required. We need to adjust our ideas about driving after drinking and take that option off the table, because when we say impaired driving crashes are 100% preventable, it really is that simple. Choose to drink or choose to drive. But never do both.

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This holiday season, as you enjoy coming together with your loved ones, please take a moment to consider those dealing with the pain of an empty seat at their table because of an impaired driver. If your plans include alcohol, make the choice to let someone else do the driving. Keep yourself, your loved ones, and your fellow travelers safe to celebrate again next year and for many years to come.

Ensuring the Safety of School Bus Transportation

By Vice Chairman Bruce Landsberg

Fact: Students are safer riding to and from school and school activities on a school bus than in the family car, and far safer than they would be riding in a car with a teenage driver. There should be no doubt that everything possible is being done to keep children safe on school buses. On commercial aircraft, a flight attendant’s primary responsibility is safety and so it is with school bus drivers, whether at the wheel or leading an evacuation.

But emotional response to tragedies like the one described below, may influence some parents to believe that it’s safer for them— or, worse yet, their teenage drivers — to drive their children to school.

NTSB recently completed an investigation of the December 12, 2017, school bus fire in Oakland, Iowa, that took the life of the driver and one student passenger. The driver entered a private driveway to pick up his first passenger of the morning. As he did routinely, he backed across the gravel road behind the driveway but on this day the rear wheels dropped into a ditch and the bus became stuck, its exhaust pipe wedged into an embankment. As the driver attempted to free the bus, the turbocharger overheated and a fire began in the engine compartment, engulfing the bus several minutes later.

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School bus at final rest in ditch (Source: Pottawattamie County Sheriff’s Office)

None of the doors were blocked so the driver and his single passenger had ample time to exit. It appears that the student was attempting to help the driver escape and they were both overcome with smoke. Sadly, this driver had mobility challenges although he held a valid medical certificate. He used a cane or a walker and was scheduled for surgery two days after the accident.

The Iowa Administrative Code specifies that drivers must be physically able to help ill or injured passengers off the bus. Additionally, an employer can (and should) evaluate a driver’s ability to assist in an evacuation. This driver, simply, was unfit and could not perform the emergency duties required of him. What’s more, the school district knew the driver was unfit for duty, but he was allowed to continue driving. The transportation supervisor, the school principal, and his coworkers all knew of his physical impairment. The Riverside Community School District had the knowledge it needed to act, yet it did not. In fact, in recent years, it had gone so far as to do away with physical performance tests for drivers.

As a result of this crash, NTSB issued and reiterated recommendations which, if acted upon, will result in landmark changes to school bus safety. All new and in‑service school buses should be equipped or retrofitted with fire-suppression systems. Fire-resistant material should separate bus occupants from the engine to ensure that no hazardous gas or flame can pass from the engine compartment, and revise existing standards flammability of interior materials. More robust physical performance testing and maintaining complete records will help to ensure school bus drivers are fit for duty.

The state of Iowa was encouraged to establish a driver safety hotline so anyone could report drivers that may be unfit for the job. Finally, we recommended that every bus driver receive at least annual training on emergency procedures, including evacuation and use of the onboard 911 button. They should demonstrate the ability to operate all exits and assist students off the bus. Likewise, all student riders should be trained on emergency procedures and evacuation – regularly.

We reiterated a recommendation to the National Highway Traffic Safety Administration to adopt new federal fire safety standards for flammability of interior materials that reflect nearly a half-century of progress. It’s well past time for them to act. Fortunately, school bus manufacturers have adopted flammability resistance test procedures that are more stringent than the federal standards; however, stronger federal standards are important to setting a consistent high bar for school bus fire safety. Get it done!

Students are safest when riding the bus, not the family car. Drivers must be medically and physically fit. Buses should be equipped with critical life-saving technology. School districts should review their policies and ensure compliance of equipment, safety training and driver fitness – NO exceptions. Parents should be asking school districts if they comply. Our children deserve that!

The full investigation report for the Oakland, Iowa, school bus fire is available here.

For more information on NTSB school bus investigations and safety recommendations visit www.ntsb.gov/schoolbuses.

 

 

 

 

 

Don’t Get Grounded: Med Form Accuracy Matters

By Vice Chairman Bruce Landsberg

“Always tell the truth. It will confound your enemies and amaze your friends.” This almost direct quote from Mark Twain is essential advice for pilots who are coming up for a medical certificate renewal, initial application, or going for BasicMed.

The online medical form 8500.8, as well as BasicMed form 8700-2, is perilous for the careless and those inclined to “stretch” the truth. MedExpress has lots of fine print, but it’s critical that pilots read and understand what it says, particularly question 18v, which asks “Have you EVER in your LIFE . . .,” and proceeds to list every possible way a driver could have encountered law enforcement relative to impaired driving, including drunk driving, being arrested without conviction, paying a fine, receiving suspension or administrative action, attending a rehab program or an education program—anything.

The Federal Aviation Administration (FAA) has a special investigation division in Oklahoma City whose sole function is to cross check medical applications with the National Driver Register (NDR). They’re very good at ferreting out any indiscretion, and even a slight fabrication can cost you every certificate you have. When you submit the paperwork, either for a medical certificate or BasicMed, you give the FAA permission to look you up in the NDR.

Let’s look at an example. A pilot provides an incorrect answer on the form, accidentally or not, then attests that everything on the form is true. A medical certificate is issued or, in the case of basic medical, the doctor maintains a record and one is provided to the pilot. Several months later, the Oklahoma City team checks the NDR, finds a record relating to the pilot, and sends a letter asking the pilot for information. A letter of revocation may follow, which the pilot may then appeal to an NTSB administrative law judge; however, as codified in Title 49 Code of Federal Regulations (CFR) Part 67.403(c), inaccuracies on an airman medical application form are grounds for possible revocation of any and all FAA certificates, including those for which no medical is required (for example, ground instructor, A & P, AI, etc.). NTSB is required to follow both law and precedent so FAA’s revocation may not be easy to overturn unless there has been an error.

Now, let’s rewind to when the pilot is initially filling out the form. Say the pilot truthfully reports that he had an alcohol- or drug-related driving event, whether 20 years ago or last month. The FAA will ask some additional questions and will likely require additional documentation. Depending on the circumstances, such as length of time since the event, number of events, and level of impairment, the incident may not amount to much. If it’s a recent event, chances are good that there will be some additional hoops to go through and some delay in getting back in the air, but it’s unlikely that there will be a revocation action. Yes, it will take some time and money to work through the process, but nothing like what happens if a pilot tries to sneak through without reporting the event. It’s imperative to remember, also, that once you have reported an incident, you must report it on every subsequent medical application.

If an impairment incident occurs between medical exams, you should report it immediately. Title 49 CFR 61.15 states that you have 60 days after a law enforcement encounter involving alcohol or drugs to self-report to the FAA. Failure to make that report can result in suspension of your medical certificate.

For aviation medical examiners and personal physicians: please personally coach your applicants very carefully on these points. A false answer on the medical application could ground them permanently, while a truthful answer will likely result in some temporary delay before medical certification.

It’s in everyone’s interest to follow these rules to protect the public and to keep aviation out of the court of public opinion. The fine print on your medical forms matters! Don’t let a careless mistake—or a purposeful lie—keep you grounded.

Speeding: Just Because You Can, Doesn’t Mean You Should

By Member Jennifer Homendy

Every day I drive to work on one of the busiest freeways in the country. That freeway has a posted speed limit of 55-65 miles per hour. I am amazed how many drivers disregard the posted speed limit and use the freeway as their opportunity to drive like they are in the Indy 500.

Many people speed because they are trying to make it to their destination sooner. But here’s the thing – according to AAA, on a 30-mile trip, you would only arrive 8 minutes sooner driving at 75 miles per hour (a dangerous, and rarely posted speed limit) than you would driving 55 miles per hour.

Saving 8 minutes on a trip isn’t worth the increased risk of taking a life. On average, 10,000 people die every year in speeding-related traffic crashes, according to the National Highway Traffic Safety Administration.

In 2017, the NTSB released a Safety Study, “Reducing Speeding-Related Crashes Involving Passenger Vehicles” which examined the trends in speeding-related passenger vehicle crashes and identified proven and promising countermeasures to prevent these crashes. We issued 19 safety recommendations which, if implemented, will prevent future crashes and save lives.

One of those safety recommendations was issued to the Federal Highway Administration. We recommended that they remove guidance to states to set speed limits within 5 miles per hour of what 85% of the traffic is travelling at, which only leads to ever-increasing speed limits. Since the mid-1990s, we have watched more and more states increase their speed limits up to 80-85 miles per hour. Just because 85% of traffic is flowing at 80 miles per hour, doesn’t mean speed limits should be set at that speed! At this rate, in 10 years, we could see states increasing their speed limits to 90 miles per hour!

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Speeding increases the likelihood of being involved in a crash and intensifies the severity of injuries sustained in a crash. According to the World Health Organization, vehicle occupants involved in a crash with an impact speed of 50 mph are 20 times more likely to die than had the vehicle been traveling at 20 mph. Additionally, the impact of vehicle speed in urban areas where there are more vulnerable road users like pedestrians and bicyclists is even more serious.

Now, you might be thinking, Member Homendy, I’m not the Federal Highway Administration, I can’t implement this recommendation. That is true. What you can do is drive the posted speed limit and you can talk to your friends and family about doing that too. And if you’re a parent of a young driver, demonstrate and talk to them about safe driving behaviors and especially about speed limits.

Across the country, states have raised and are considering raising speed limits on their roads to dangerous levels. And many of those decisions are based on the 85th percentile speed of free-flowing traffic. We shouldn’t base decisions about speed limits on behaviors we know are dangerous. Higher speeds create the opportunity for even more fatal crashes.

 

The issue of speeding is highlighted on our 2019–2020 Most Wanted List of transportation safety improvements (Implement a Comprehensive Strategy to Reduce Speeding-Related Crashes).