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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

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.

Improving Medical Standards for Railroaders

By Dr. Mary Pat McKay

Photo of Tank car shoved through the bumping post (right), into the building, and through the back wall (left).
Tank car shoved through the bumping post (right), into the building, and through the back wall (left).

On August 7, 2014, a certified locomotive engineer was operating a locomotive to push train cars into a warehouse railroad loading dock in Arden, Nevada. Although the conductor, who was standing on the ground, told the engineer to push the train three-car lengths and then stop, the train continued moving forward—first through a bumping post and then through the wall of the warehouse. Thankfully, no one was injured.

Our investigation revealed the engineer was known to have epilepsy (also known as recurrent seizures) since 1992. He told the Union Pacific Railroad (UP) about his epilepsy when he was hired in 2003. Although the engineer had an observed seizure at work in 2008, it did not happen while he was operating a train and he was back to full working status by April, 2009.

The engineer told NTSB investigators he believed he blacked out immediately before the accident. Evidence from the event-data recorder indicated that during the accident, the throttle was moved repeatedly when the train should have stopped. During the engineer’s follow‑up medical evaluation, an abnormal focus of electrical activity was found in his brain. We concluded that the probable cause of the accident was the engineer’s failure to stop the train before it collided with the bumping post and the inside wall of the building because he was incapacitated by a seizure (See: The Rail Accident Brief RAB1507).

UP followed all required medical regulations when the engineer was hired and when he was allowed to return to work after his 2008 on-the-job seizure. Although the engineer had chronic back pain and had filled prescriptions for high doses of narcotic medication nearly every month for several years prior to the accident, UP did not ask him about his use of medications after his 2003 pre-employment physical because there were no regulations requiring it. Despite the engineer’s prescription narcotic medication, his post accident urine toxicology test came back negative.

According to the current Federal Railroad Administration (FRA) regulations, a locomotive engineer with epilepsy—or any other medical condition that causes intermittent episodes of unresponsiveness—may operate a train on any railroad in the United States. In fact, the only occupational medical evaluation required by the FRA for engineers is to have a vision and hearing test every 3 years. Also, although locomotive engineers may not possess controlled substances while at work, they may take any type of prescription medications as long as the prescribing physician knows that the engineer operates trains. The trains these engineers could operate include those carrying crude oil and hazardous materials through highly populated areas and those carrying passengers.

For comparison, pilots (including most recreational pilots), merchant mariners, and commercial drivers must regularly pass a medical evaluation that includes a review of their medical history, evaluation of their current medications, measurement of their vital signs, and a physical examination before they can operate in their modes of transportation. In addition, in virtually every other transportation mode, medical standards include a list of medical conditions and medications that an operator may neither have nor use to qualify for work.

Because of a series of railroad accidents where a medical condition or its treatment contributed to the probable cause, for 15 years the NTSB has been recommending that the FRA enhance the medical evaluation of railroad employees in safety-sensitive positions (primarily engineers and conductors). The most recent recommendations include requiring a review of their medical history, evaluation of their current medications, measurement of their vital signs, and a physical examination before working in safety-sensitive positions—just like other commercial transportation operators. Over the years, the FRA has held meetings on medical requirements, but has not reported any success in addressing these NTSB safety recommendations, which remain in unacceptable status. As a result, the NTSB determined that the FRA’s failure to establish medical certification standards, other than the hearing and vision tests, contributed to the cause of the accident in Arden, Nevada. Without action by the FRA, such accidents will continue to occur.

Fortunately, no deaths or injuries resulted from this particular accident but that was pure luck. Until railroad engineers and conductors are required to meet the same medical standards as operators in other transportation modes, these sorts of accidents will continue to happen. Hopefully, the next one won’t lead to deaths, injuries, or an environmental catastrophe.

Dr. McKay is the NTSB’s Chief Medical Officer.

A Week 40 Years in the Making

By Bella Dinh-Zarr, PhD, MPH, Vice Chairman of NTSB

Last week is one I won’t forget: it marked the 40th anniversary of the day my family—and many other Vietnamese American families—first set foot on American soil.

Vice Chairman Dinh-Zarr with Chairman Hart, Member Sumwalt and Member Weener at the Board Meeting to discuss the Chicago Transit Authority passenger train accident.
Vice Chairman Dinh-Zarr with Chairman Hart, Member Sumwalt and Member Weener at the Board Meeting to discuss the Chicago Transit Authority passenger train accident.

My parents, my three older brothers, and I were on an American airplane out of Saigon’s Tan Son Nhat Airport in late April 1975, thanks to the help of my dad’s American friends and fellow physicians. We landed safely first in Guam, then Camp Pendleton, and finally in Texas, to begin our life in the United States. We didn’t bring much in the way of luggage, but we did bring a great deal of commitment to public service and gratitude for our new home.

My father, a physician, and my mother, a nurse, instilled in their four kids a deep gratitude for the opportunities we were given in the United States. My three brothers chose to serve others as surgeons, saving lives. My path to public service has been slightly different. I am honored to have been appointed as Member and Vice Chairman of the National Transportation Safety Board (NTSB). I am proud to be the first Asian American to serve as a Board Member, but I am even prouder of the fact that there are other Asian Americans at the NTSB making valuable contributions to our country. (I would be remiss if I didn’t mention that this week, coincidentally, is Public Service Recognition Week, and May is Asian American Pacific Islander Heritage Month.)

With so many milestones, perhaps it is fitting that last week also marked both my first Board Meeting at the NTSB and my first “launch” to an accident investigation. First, with Chairman Christopher Hart, Member Robert Sumwalt, and Member Earl Weener, I was pleased to discuss the final report of the March 2014 accident involving a Chicago Transit Authority passenger train. The recommendations resulting from that meeting will, if acted upon, improve safety by reducing the chance that mass transit train systems will have fatigued operators and design flaws.

Vice Chairman Bella Dinh-Zarr with Member Earl Weener and NTSB Go-Team in Roswell, NM accident site.
Vice Chairman Bella Dinh-Zarr with Member Earl Weener and NTSB Go-Team in Roswell, NM accident site.

Then, at the conclusion of the Board Meeting, I quickly gathered my “go bag” (containing safety vest, hard hat, boots, and other safety gear) to accompany Member Weener on my first launch to a site near Roswell, New Mexico, where two freight trains had collided head on. Sadly, one person died at the scene and another person was seriously injured. I was struck by the powerful forces of two trains colliding, the sheer dedication and technical expertise of investigators and staff, and the productive collaboration of local and state authorities for the benefit of safety. To see the destruction at the crash site reinforced even further the need to do everything in our power to prevent these accidents from happening in the first place. As Member Weener, a long-time Board Member and the principal spokesperson at the scene, said, “Our mission is to understand not just what happened, but why it happened, and to recommend changes to prevent it from happening again.”

This noble mission of the NTSB is one I plan to keep in the forefront of my mind as I serve my term. I look forward to using what I have learned this past week, and in the weeks to come, to do everything I can to advance transportation safety and prevent deaths and injuries. Forty years after setting foot on American soil, it is the least I can do for the country that has given me—and my fellow Vietnamese Americans—so much.


Teens Doing Their Part in The Fight For Road Safety

By Nicholas Worrell

Every day teens get behind the wheel for the first time. And seemingly every day, new portable electronic devices come on the market, adding to the possibility of driver distraction.

Nicholas Worrell with attendees at the Dori Slosberg Foundation’s Teen Driving SummitThis was one of the messages I carried to young people from across Florida on March 11 at the Dori Slosberg Foundation’s Teen Driving Summit in Tallahassee.

I emphasized that motor vehicle accidents are the number-one killer of youth ages 15-19. In the last decade, nationwide, we have lost more than 50,000 teenagers in motor vehicle crashes. That’s the 15-19 year-old population of Tallahassee, Florida – plus three additional similar cities.

Substance-impaired, fatigued, and distracted driving all contribute to this state of affairs. In the past decade, portable electronic devices have proliferated, presenting new ways to take the driver’s attention off the road. I told these young drivers that one step toward safer roads must be to Disconnect from Deadly Distractions.

Not all distractions are new: Rambunctious passengers, eating fast food behind the wheel, and gawking at extraneous sights outside the vehicle can distract drivers as well. But new hand-held, hands-free, and in-vehicle electronics have exploded in popularity, posing new hazards for all drivers, particularly young drivers.

I told the audience that while they are connected to the world like no generation before, this ubiquitous connectivity – when it is not related to the driving task – can take lives. But I also stressed that outside of the vehicle, this same connectivity may give new safety advocates new ways to spread the word about safer driving. They can instantly share potentially life-saving knowledge with vast informal networks of like-minded teens.

One such piece of information I shared is that drivers can be cognitively distracted even when their eyes are on the road and their hands are on the wheel. Hands-free is not risk free; even hands-free cell phone calls introduce cognitive distraction. I shared some examples and some other information with the audience, and then encouraged them to share the information.

Today’s adults remember a time before smart-phones. It falls on us to model responsible behavior to our kids, by disconnecting from deadly distractions while driving. It is our job to teach the next generation of drivers that the only thing they should connect to while driving is the driving task.

By the same token, the next generation shares in the challenge of making alert driving a cultural norm. Every driver should be well-rested, unimpaired by drugs or alcohol, and focused on the driving task.

Such a cultural change will take a protracted, concerted effort. It will take our youth speaking up when they see a peer driving unsafely in any way, and it will take adults modeling safe driving behavior.

The road to zero highway deaths is a long one, perhaps generations-long. Education, laws, and high-visibility enforcement all have their place in “reaching zero.” But with teens like the ones I met in Florida on-board, I believe it can be done.