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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.

Safely Fueling the Future

By Robert L. Sumwalt

Promote Completion of Rail Safety Initiatives posterOn Wednesday, July 13, the NTSB will host a roundtable discussion comprised of more than two dozen experts from the nation’s railroad industry, including rail-car manufacturers and owners, union representatives, and transportation safety associations. We will be discussing issues that are critical to ensuring the timely implementation of new federal safety standards for rail tank cars that carry flammable liquids.

The transportation of crude oil, ethanol, and other flammable liquids on our nation’s railroads has skyrocketed in the past decade. The most common tank cars used to transport these hazardous materials are specification DOT-111 tank cars (legacy DOT-111) and a newer modified version of these tank cars, called CPC-1232s.

Since 2006, there have been 28 significant accidents in the U.S. and Canada involving flammable liquids transported by rail. These unfortunate events resulted in more than 5 million gallons of crude oil and ethanol spilling. They all involved legacy DOT-111 or CPC-1232 tank cars. NTSB investigations into these kinds of derailments, dating back to 1991, have shown that older general purpose tank cars lack sufficient crashworthiness. The risks are greater when such tank cars are transported in high numbers, as is seen in ethanol and crude oil unit trains.

The NTSB roundtable comes on the heels of the three-year anniversary of a tragic event involving 63 derailed legacy DOT-111 tank cars in Lac Mégantic, Quebec, which spilled 1.6 million gallons of crude oil. That July 6, 2013, accident and subsequent fire killed 47 people and destroyed the town center.

And the 13 tank cars that derailed in Mosier, Oregon, last month, dumping 42,000 gallons of crude oil were CPC-1232 tank cars.

Congress and the Department of Transportation announced last year new federal standards requiring the rail industry to meet tougher safety guidelines. These guidelines included retrofitting legacy tank cars with more robust safety features, and, in the case of new tank cars, building them to standards, known as DOT-117, that require increased puncture resistance and thermal protection in order to significantly reduce the likelihood of product release in a derailment.

The phase-in deadlines for these new tank cars range from 2018 to 2025 for crude oil and ethanol, and 2029 for all other Class 3 flammable liquids.

In our roundtable, we hope to gain deeper insight into the process involved in upgrading the rail industry’s existing tank fleet, as well as learn how all parties involved can overcome existing roadblocks to the successful and timely implementation of the new tank car rules. The safety of our communities, our economy, and the environment is at stake—and we shouldn’t have to wait another decade or more to see improvements.

The roundtable is open to the public and will be streamed via webcast. We’ll pose a number of questions to our experts during the session, and encourage viewers to submit questions in advance by e-mailing them to RailTankCarSafety@ntsb.gov.

Robert Sumwalt is an NTSB Board Member and will facilitate the roundtable discussion

An Apology

I made a statement in an NTSB board meeting this week that offended many. Through this message, I hope to convey my sincerest apologies.

The board meeting was to deliberate on the January 12, 2015, accident involving Washington, DC’s Washington Metropolitan Area Transit Authority (WMATA) subway system. That accident claimed one life and sent many others to local hospitals.

In my remarks, I noted that the NTSB’s investigation of this tragedy found similarities to a WMATA accident that occurred 33 years earlier. Most surprising to me was that WMATA also failed to do a debriefing after the 2015 accident – something I felt was a lost learning opportunity for them. I then stated: “To me, these things show that WMATA has had a severe learning disability. Quite simply, they haven’t been willing to learn from prior events.” I then quoted Peter Senge, author of a book on organizational learning: “Learning disabilities are tragic in children, but they are fatal in organizations.”

While I don’t mind taking organizations such as WMATA to task for their failings and oversights, I never intended to offend anyone with learning disabilities or their families. Looking back on it, it’s now clear to me how my words were offensive. I therefore want to offer my sincerest apology.

Although I was quoting from a book, the words came out of my mouth and I take full responsibility for what I said. The emphasis of the statement was intended to be on the fact that WMATA failed to learn. However, tying that point to children with learning disabilities was wholly insensitive on my part. Clearly, I could have made the point without referring to learning disabilities at all.

As much as I regret the offense I caused to many, I also regret that my comments may reflect poorly on the agency that I represent.

As a government official who often makes public comments, I try to carefully choose my words; this time I failed. I endeavor not to make the same mistake I asserted WMATA was guilty of – failing to learn. I pledge to use this as a powerful learning opportunity.

Robert L. Sumwalt

NTSB Member

Talking Transportation Safety with Black and Hispanic State Legislators

By Nicholas Worrell

Every community is different, but some things are the same. Everybody wants – and rightly expects – to return home safely from work, school, or play.

I recently attended the conferences of the National Hispanic Caucus of State Legislators (NHCSL) and the National Black Caucus of State Legislators (NBCSL) to learn about these legislators’ concerns and to explain the NTSB’s transportation safety recommendations. Much of the work that we do begins with legislators, and to accomplish our goals and objectives we must go where they are.

In my recent blog, Developing Future Safety Advocates: Reaching the Millennials, I discussed educating youth about highway safety. At the NHCSL and NBCSL, I learned about the viewpoints of legislators from two distinct communities, and I had the opportunity to explain how proposed safety measures could benefit their respective communities.

To reach minority communities with safety messages means getting a seat at an already crowded table. The NTSB’s message regarding better education, legislation, and enforcement related to transportation safety, for example, might be lost among news stories emphasizing more contentious issues.

In many cases, these state legislators are pivotal figures in implementing safety recommendations, and many of them are champions of transportation safety in their own communities.

The NHCSL held its annual conference in November, with a focus on improving legislative involvement by and for their constituents in the Hispanic community – the largest and fastest-growing minority in the country, and one that faces particular transportation challenges.

The Centers for Disease Control and Prevention reports that pedestrian death rates are higher for Hispanic males than for all males (3.93 per 100,000, vs. 2.29 for all males). Rates are higher for Hispanic females as well – 1.29 compared with .92 for all females.

Such disparities are not unique to Hispanics; in fact, Native Americans are confronted with even higher pedestrian death statistics. However, factors contributing to these disparities change from community to community.

Among Hispanics, the National Highway Traffic Safety Administration (NHTSA) points to possible contributing factors affecting newer arrivals.

Initially, many walk or ride a bicycle, which puts them at higher risk of a pedestrian or bicyclist motor vehicle injury. Additionally, new arrivals must learn uniquely American rules of the road and driving customs and the meaning of U.S. traffic signs and rules. Language barriers might also affect their level of safety.

So for this group, pedestrian and bicyclist safety is of vital importance.

Last week, I had the opportunity to attend the annual conference of the NBCSL. The theme of the conference was “Leading by Balancing Justice and Opportunities.”

Some of the many discussions at the conference included youth development and education, and community safety issues.

In a 2006 analysis of fatal crashes, the National Highway Traffic Safety Administration found that while Whites, African-Americans, and Hispanics all had about the same chance of dying in a motor-vehicle crash, African-Americans were particularly likely to die in a crash involving a bus.

African-Americans killed in passenger-vehicle crashes were also more prone to be unrestrained.

While this study is older, year after year, the National Occupant Protection Use Survey continues to record that, while seat-belt use by African-Americans is growing, it is still below the national average – and we know that seat belts save lives.

In my view, getting my fellow African-Americans to recognize the importance of using seat belts and child restraints on every trip is a community issue – as is the installation of restraints on school buses, motorcoaches, and medium-sized buses.

The early estimates for 2015 point to a dramatic increase in the number of highway deaths nationwide. Better economic conditions are often cited as fueling more travel, and in turn, more tragedies.

Traveling more increases the chances of a crash. But eliminating impairment, distraction, and fatigue – and improving occupant protection – can turn around the statistics for all of us.

Many states still require stronger legislative action on issues such as these. I also had the opportunity to talk with legislators about other transportation issues, such as rail tank car safety, commercial trucking, and mass transit safety that affect their communities, as well.

For me, attending these conferences was about learning from the legislators and, hopefully, they learned a bit from me about how to improve transportation safety.

The NBCSL conference closed with the question, “are you fit for your job?” It was meant to encourage each of us to look at our medical, mental, and psychological fitness for duty. It gave me an opportunity to also talk about the NTSB campaigns for medical fitness for duty and against impaired driving.

The NTSB’s recommendations have no color and no ethnicity, but they resonate differently for different communities.

It was a privilege to join the conferences of our two largest minority state legislators and to review their special transportation safety challenges. While the mosaic that makes up this great nation is complex, safety has no complexion.

 

Nicholas Worrell is Chief of the Safety Advocacy Division in the NTSB Office of Safety Recommendations and Communications.