In this episode of Behind-the-Scene @NTSB, we talk with Nicholas Worrell, Chief of Safety Advocacy and Chris O’Neil, Chief of Media Relations, in the NTSB Office of Safety Recommendations and Communications, about the NTSB Most Wanted List.
Earlier this week we announced our 2019–2020 Most Wanted List of transportation safety improvements. The Most Wanted List (MWL) was developed from safety recommendations that we’ve issued but that haven’t been acted on acceptably.
In 2017, the last year for which we have complete numbers, 38,958 people died in transportation accidents and incidents in the United States—that’s 107 per day (or, about the capacity of the room in the National Press Building where we unveiled the MWL). These losses are unacceptable and, most often, completely preventable.
At the MWL unveiling, we shared the lessons we’ve learned from far too many transportation tragedies, and we reemphasized the actions that should be taken on the related recommendations we’ve made to prevent similar accidents and crashes. The 2019–2020 MWL promotes several specific safety recommendations that can—and should—be implemented during the next 2 years. It also features broad, longstanding safety issues that continue to threaten the traveling public.
Distractions come in all forms, and anything that takes a driver’s or operator’s attention away from the task at hand is potentially dangerous. Personal electronic devices are now commonplace, and distractions from these devices are a growing problem that must be curbed.
Each year, more than 10,000 people die in highway crashes related to alcohol impairment. This does not account for highway deaths due to impairment by drugs other than alcohol. As the face of impairment continues to change, we must keep up with new developments while continuing to fight against an old nemesis—drinking and driving.
Our investigations have shown that moving ethanol by rail and crude oil by pipeline can be unnecessarily hazardous. These essential commodities must be conveyed in a manner that ensures the safety of those who are transporting it as well as those in the communities it passes through.
One year ago today, NTSB investigators were on scene in Cayce, South Carolina, investigating a collision between an Amtrak train and a CSX freight train. Like the 149 other rail accidents we have investigated over the years, this accident was preventable with positive train control (PTC).
PTC has been mandated by Congress, but there has been delay after delay in fully implementing the life-saving technology. Each day that we go without PTC, we risk another PTC‑preventable accident.
Speed kills. It contributes to more than 10,000 deaths each year on our nation’s roadways. It’s a factor in nearly one-third of all highway crash deaths—about the same proportion as alcohol.
Yet, there is little stigma to speeding, and we underuse speeding enforcement tools. If we are to reduce speeding-related crashes, we must combine education, enforcement, and technology together in a comprehensive strategy.
“Part 135” aircraft flight operations include services such as medical flights and on-demand charter flights. Although many Part 135 flights operate with very high levels of safety, our accident investigations have highlighted that Part 135 operations aren’t required to meet some of the stringent safety regulations that are required for scheduled air carriers operating under Part 121 (such as scheduled airline flights). Our recommendations in this area seek to provide Part 135 passengers more of the safety benefits Part 121 passengers enjoy.
Collision avoidance systems can prevent and mitigate the severity of crashes. In fact, collision avoidance systems could potentially save more than 1,000 lives each year that would otherwise be lost in rear-end collisions.
We support the broader adoption of collision avoidance systems, including their inclusion as standard equipment in all newly manufactured vehicles.
It is estimated that fatigue played a role in 90,000 highway crashes in 2015. But this problem goes beyond highway transportation; we have investigated accidents in all transportation modes that involve fatigue. We have 42 outstanding safety recommendations related to this widespread and life-threatening issue.
We have repeatedly investigated fatal accidents in which a transportation operator was fatigued due to undiagnosed or improperly treated obstructive sleep apnea (OSA), and we have repeatedly called for OSA screening. The Federal Railroad Administration and the Federal Motor Carrier Safety Administration initiated rulemaking to require such screening, but rescinded it in August 2017.
This inaction is unacceptable. Until we have robust requirements for OSA screening and treatment for operators, people will continue to die.
Our investigations have shown that occupant protection systems must be improved to protect passengers in an accident or crash. In school buses, for example, compartmentalization alone isn’t enough to protect passengers in rollover crashes. In severe side-impact crashes and high-speed rollovers, three-point restraints provide additional protection. We believe all new school buses should be equipped with lap/shoulder belts. Motorcoach occupants will benefit from window glazing and improved roof strength, and greater crashworthiness standards are needed for passenger rail cars, as well.
Our Most Wanted List is data-driven, based on the results of our investigations of tragic, senseless, and often preventable deaths. Our recommendations, if acted upon, will result in safer transportation and save countless lives.
We’ve issued a call to action. Although any member of our five-person Board can speak on these issues and testify by invitation to legislatures and to Congress, we have no power of our own to act. We are counting on industry, advocates, the safety community, and government regulators to implement these recommendations, and quickly. We are counting on you!
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.
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.
One enduring image of the fight against forest fires, like those that devastated California last year, is of a large airplane flying low and dropping red fire retardant. These firefighting air tankers are invaluable, and they operate in extreme environments.
Over the years, we’ve investigated several accidents involving firefighting aircraft, identifying issues and making recommendations to ensure the safety of these important assets. For example, in 1994, we investigated an accident in which a retired Air Force Lockheed C-130A Hercules, which had been converted into a firefighting airplane and was under contract to the US Forest Service (USFS), crashed while battling a fire in the Tehachapi Mountains near Pearblossom, California, killing all three flight crewmembers. In June 2002, another retired Air Force Lockheed C-130A Hercules, also converted into a firefighting aircraft and under contract to the USFS, crashed while dropping fire retardant near Walker, California, killing the three flight crewmembers onboard. Just a month later, a retired Navy Consolidated Vultee P4Y-2 Privateer, again under contract to the USFS to fight forest fires, crashed while maneuvering to deliver fire retardant near Estes Park, Colorado, killing both flight crewmembers. We determined that the probable cause in each of these accidents was in‑flight structural failure due to fatigue cracking in the wings, and we concluded that maintenance procedures had been inadequate to detect the cracking.
Firefighting operations inherently involve frequent and high-magnitude low-level maneuvers with high acceleration loads and high levels of atmospheric turbulence. A 1974 NASA study found that, at that time, firefighting airplanes experienced maneuver load factors between 2.0 and 2.4—almost a thousand times more than those of aircraft flown as airliners. The NASA study concluded that, because the maneuver loading in firefighting airplanes was so severe relative to the design loads, the aircraft should be expected to have a shortened structural life. Repeated and high‑magnitude maneuvers and exposure to a turbulent environment are part of firefighting service, and these operational factors hasten fatigue cracking and increase the growth rate of cracking once it starts.
Aerial firefighting is an intrinsically high-risk operation; however, the risk of in‑flight structural failure is not an unavoidable hazard; rather, fatigue cracking and accelerated crack propagation should be addressed with thorough maintenance programs based on the missions flown. Aircraft maintenance programs, which are typically developed by airplane manufacturers, usually point out highly stressed parts that should be inspected for signs of fatigue cracking, and they give guidance on how often these parts should be inspected. When specifying a maintenance program, manufacturers typically consider the expected loads that an airplane will encounter; however, in the past, for many aircraft used in firefighting operations, very little, if any, ongoing technical and engineering support was available because the manufacturer no longer existed or did not support the airplane, or the military no longer operated that type of aircraft. The maintenance and inspection programs being used for the firefighting aircraft mentioned above did not account for the advanced age and the more severe stresses of the firefighting operating environment.
As a result of our investigations, we issued safety recommendations to the USFS to hire appropriate technical personnel to oversee their airtanker programs, improve maintenance programs for firefighting airplanes and to require its contractors to use these programs. The USFS responded promptly and effectively, substantially improving the safety of its firefighting operations. The USFS hired a team to build out its Airworthiness Branch, to lead their effort to comply with the NTSB recommendations, and with this staff of engineers and technicians made needed revisions to the contracting, oversight, and operations of the USFS program using airplanes to fight forest fires. The agency hired aircraft engineering companies that performed in‑depth stress analyses on the firefighting airplanes in operation. The results were used to improve maintenance programs by identifying parts of the aircraft structure in need of continuing inspections and proposed the time and use intervals needed between inspections to prevent fatigue cracks from developing into catastrophic structural failures. The USFS also outfitted firefighting aircraft (tankers as well as helicopters and lead aircraft) with equipment that measures and records the actual flight loads experienced while fighting forest fires, then used that data to further improve the inspection program for airplanes in use and to develop programs for new types of airplanes being introduced to fight forest fires.
Clint Crookshanks, an NTSB aviation structural engineer and aircraft accident investigator who worked on these airtanker accidents, helped the USFS review its contractors’ maintenance and inspection program documents and provided advice on how they could better address our recommendations. On November 5, 2010, the USFS issued its first iteration of a Special Mission Airworthiness Assurance Guide for Aerial Firefighting and Natural Resource Aircraft, which contained the method, schedule, and standards for ensuring the airworthiness of firefighting aircraft. The USFS has revised the guide twice since then, with the latest revision issued on November 6, 2015. The guide now includes standards for USFS aircraft contracts, which are required for all aircraft used in USFS firefighting missions, satisfying our recommendations. Since these improvements were implemented, no aircraft performing aerial firefighting missions for the USFS have experienced an in‑flight structural failure.
We continue to work with the staff at the USFS to improve the safety of firefighting flights. At the beginning of January 2018, Clint attended a meeting in Missoula, Montana, to discuss the current and future large airtankers on contract to the USFS. Our recommendations are still relevant to the USFS and its contract operators and were the basis for most of the discussion at the Missoula meeting. The current USFS contract requirements have ensured that all contractors have effective maintenance and inspection programs that account for the extreme operating environments seen in aerial firefighting. Aircraft providing aerial firefighting services contain equipment that records the loads on the aircraft and even provides an alarm in real-time when a flight’s loads may have overstressed the airplane. In addition, the data recorded is downloaded and supplied to Wichita State University for mission profile development. British Aerospace, which originally manufactured the jet powered BAe 146 and RJ-85 airplanes currently used for USFS firefighting operations, provides technical support for these airplanes’ operators. The US Air Force also provides firefighting service using C-130 airplanes equipped with a Mobile Airborne Firefighting System (MAFFS) to assist the USFS on an as needed basis. The manufacturer of the C-130, Lockheed-Martin, is working with the Air Force to continually monitor and analyze the loads on airplanes used in the firefighting mission.
The importance of keeping these unique aircraft and their crews safe and functional becomes even more evident during every forest fire season. The lessons we’ve learned from our accident investigations have been used to identify needed changes that have made it possible to more reliably and safely fight forest fires from the air and protect life and land.
Jeff Marcus is an Aviation Transportation Safety Specialist in the NTSB Office of Safety Recommendations and Communications. Clint Crookshanks is an aviation structural engineer and aircraft accident investigator in the NTSB Office of Aviation Safety.
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.
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
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.
At the NTSB, we’ve investigated many tragic transportation accidents that could have been prevented with some planning, forethought, and good decision making. As we mark the beginning of the holiday travel season, we want to encourage all Americans to make it their goal to arrive safely at their destinations, so we’ve boiled down some lessons we’ve learned that the traveling public can use.
Fatigue, impairment by alcohol and other drugs, and distraction continue to play major roles in highway crashes. Here’s what you can do:
If your holiday celebrations involve alcohol, ask a friend or family member to be your designated driver, or call a taxi or ridesharing service.
In a crash, seat belts (and proper child restraints) are your best protection. Always make sure that you and all your passengers are buckled up or buckled in!
Don’t take or make calls while driving, even using a hands-free device. Set your navigation system before you start driving. If you’re traveling with others, ask them to navigate.
By Bus or Train
The NTSB has made recommendations to improve passenger rail and motorcoach operations and vehicle crashworthiness, but travelers should know what to do in an emergency.
Pay attention to safety briefings and know where the nearest emergency exit is. If it’s a window or roof hatch, make sure you know how to use it.
If you’re unsure of where the exits are or how to use them, or if you didn’t receive a safety briefing, ask your driver or the train conductor to brief you.
Always use restraints when they’re available!
By Air or Sea
Airline and water travel have become incredibly safe, but these tips can help keep you and your loved ones safe in an emergency.
When flying, make sure that you and your traveling companions have your own seats—even children under age 2.
Don’t forget your child’s car seat. The label will usually tell you whether your child car seat is certified for airplane use; the owner’s manual always has this information.
If you don’t know the rules for using a child’s car seat on your flight, call the airline and ask what you need to know.
Pay close attention to the safety briefing! Airline and marine accidents have become very rare, but you and your family can be safer by being prepared.
Whether you’re on an airplane or a boat, know where to find the nearest flotation device.
No matter how you travel, you deserve the benefits of the lessons we’ve learned through our investigations, but you need to play an active part to take advantage of them. This holiday season, make a commitment to put safety first.
By: Nicholas Worrell, Chief, NTSB Safety Advocacy Division
Driving is a privilege that gives us the freedom to go where we want, when we want, with whom we want. The benefits of driving are especially attractive to teenagers. Driving is a milestone for teens, but with great power and freedom comes great responsibility.
Motor vehicle crashes are the leading cause of death among teenagers; more teens die in crashes than from drug/alcohol abuse, violence, or disease. In 2016, more than 3,600 teenagers died on our highways, a 4 percent increase from 2015. To address these tragic statistics, the third week of October was designated by Congress as National Teen Driver Safety Week. During this week, advocates, government agencies, communities, and educators aim to promote teen driver safety and eliminate a preventable tragic problem. Especially during this week, we all need to come together to keep simple mistakes from impacting the future of our country.
Today, the NTSB joined the National Organizations for Youth Safety (NOYS) and students from Maryland and Virginia high schools for NOYS’ Youth Interactive Traffic Safety Lab. The event provided hands-on activities for students to learn about a variety of driving safety issues—from auto maintenance and work zone navigation to distracted and impaired driving. Traffic safety experts and community leaders spoke with students about what it means to be a “responsible” driver and the very real consequences of complacency. In a pre-event press conference, NTSB’s Kris Poland, PhD; Maryland’s First Lady Yumi Hogan; Maryland Motor Vehicle Administrator Christine Nizer; and NOYS Interim Executive Director April Rai reminded teens that, while motor vehicle crashes are the leading cause of death for teens, these crashes are preventable. One key message to teens: you have the power to change this reality.
Dr. Kris Poland delivers remarks at the NOYS Youth Interactive Traffic Safety Lab press conference
Safety Advocate Stephanie Shaw talks with students about the dangers of drowsy and impaired driving
Kris Poland talks with students about NTSB crash investigations
Teddy Brown uses simulated goggles to demonstrate alcohol impaired and drowsy driving
Students also had the opportunity to talk with NTSB investigators and safety advocates to learn about our crash investigations and the safety recommendations we’ve made to improve safety for all road users—especially our recommendations for preventing teen driving crashes and their resulting injuries and deaths.
While events like the NOYS Safety Lab helps to arm students with some of the tools needed to make the right choice, we need the help of parents, other influencing adults, school officials, local government, and community leaders to help make the biggest impact. Parents, in particular, play a critical role. They should have a meaningful discussion with their new driver about the key components of driving and the thinking behind certain driving decisions. Parents must take time to outline the risks associated with driving, such as distractions, fatigue (due either from lack of sleep or fatiguing medications), other impairments, and speeding. Sometimes, making safety a priority requires establishing new priorities in the household and a shift in “family culture.” The best way to promote safety is to practice safety and treat it seriously through education, discussion, and role modeling.
At the NTSB, we strive every day to advocate safety in the many modes of transportation. Our Most Wanted List of transportation safety improvements is designed to address our most critical safety issues. We are successful when people engage, learn strategies to improve the lives of themselves and those around them, and execute these strategies to save lives and prevent injuries. I urge you to become an advocate—not only this week, but every week—for driving safely.
If you have any questions about teen driving or NTSB advocacy activities in this area, email SafetyAdvocacy@NTSB.gov. We also encourage you to follow us on Twitter @NTSB and Facebook and Instagram @NTSBgov.