Eyes on The Road, Hands on the Wheel, Mind on One Task

By Nicholas Worrell, Chief, Safety Advocacy Division

On April 3, I represented the National Transportation Safety Board (NTSB) at an event kicking off Distracted Driving Awareness Month and California Teen Driver Safety Week, in Sacramento. I challenged California to lead the nation in acting on NTSB’s 2011 recommendation to ban the nonemergency driver use of portable electronic devices that do not support the driving task. So far, many states have banned driver use of handheld phones, and all but three have banned texting and driving. But none go as far as our recommendation demands.

Sacramento CA - Press Conference
NTSB Chief of Safety Advocacy, Nicholas Worrell (at podium) addresses media at the April 3, 2019, Distracted Driving Awareness Month kick-off event in Sacramento, CA.

Since the Sacramento event, I’ve spoken about the recommendation to radio and television outlets in the Golden State, some with call-in segments, and I’ve read the comments on news websites covering my kickoff remarks. I’ve learned a lot about what most troubles (and impresses) people about the proposal:

  • Many gave examples of their experiences with dangerous distracted driving behavior on the road and supported the safety recommendation.
  • Some pointed out their personal ability to multitask (an ability at odds with the science of distraction).
  • Some disparaged the danger compared to other distractions (eg, people eating or putting on their makeup).
  • Some asked how the law can be enforced. Indeed, this is certainly a challenge, but one that could be addressed with technology, especially if device-makers get on board. California already bans all nonemergency use of these devices for young drivers and bus drivers, so there’s precedent.
  • Finally, many pointed to technology solutions, and I believe that they’re spot-on. In fact, in response to the same crash that spawned our proposed cell phone ban, we also issued a recommendation encouraging the Consumer Electronics Association to work with its members to disable drivers’ cell phones while driving (except for emergency use, and for use in support of the driving task). We would love to have a meaningful dialogue with device manufacturers through the CEA.

Distracted(4).jpgWhen you talk on a cell phone or become engaged with phone operations, your mind is not on the driving task. Have you ever shushed a passenger while you try to decide if you’re at your freeway exit? How about missed a turn or blown past a stopped school bus while having a conversation on your Bluetooth-enabled, hands-free smartphone? It turns out that we can’t really multitask. We slow down as we disengage from one task and engage in another. It even takes us longer to disengage and reengage our visual focus, to say nothing of completing a competing cognitive task. To experience this lag, just run through the first 10 letters of the alphabet out loud as quickly as you can. Then do the same with the numbers 1 to 10. Then try them together: A-1, B-2, and so on. Do you slow down when “multitasking”? Most people do.

People are quick to admit that manual and visual distraction can cause crashes, but few understand that cognitive distraction can be just as significant.

The NTSB believes that California should apply its cell-phone ban for bus drivers and novice drivers to the general driver population. We also believe that California is the perfect state to lead the charge to develop technology that will help end this deadly problem.

As we learn more about the science of distraction and distracted driving, it becomes more and more obvious that, as distractions are eliminated, Californian lives will be saved.

Episode 25 – Adam Gerhardt

In this episode of Behind-the-Scene @ NTSB, we have a conversation with Adam Gerhardt, an Air Safety Investigator in the NTSB Office of Aviation Safety. Adam shares with us how he got interested in aviation and the journey he took to get to the NTSB.

Gerhardt Image

Get the latest episode on Apple Podcasts , on Google PlayStitcher, or your favorite podcast platform.

To catch up on past episodes and to find more ways to listen visit: https://www.blubrry.com/behind_the_scene_ntsb/

If you have questions about the podcast, or ideas for future topics, feel free to email us at SafetyAdvocacy@NTSB.gov

NTSB’s Role in Marine Accident Investigations

By Captain James Scheffer, Strategic Advisor, NTSB Office of Marine Safety

I’m often asked how the NTSB chooses which marine accidents to investigate, and what role the US Coast Guard (USCG) plays in our investigations. I had the same question when I first joined the NTSB’s Office of Marine Safety more than 20 years ago. The NTSB has specific authority under the United States Code and Code of Federal Regulations to investigate “major marine casualties.” These are accidents involving vessels that result in one or more of the following:

  • The loss of six or more lives.
  • The loss of a mechanically propelled vessel of 100 or more gross tons.
  • Property damage initially estimated as $500,000 or more.
  • Serious threat, as determined by the USCG Commandant and concurred with by the NTSB Chairman, to life, property, or the environment by hazardous materials.

Our authority to investigate covers major marine accidents on US waters or those involving US-flagged vessels worldwide. We also have the authority to investigate casualties involving public (owned by the United States) and nonpublic vessels. In these casualties the threshold is defined by at least one fatality or damages of $75,000 or greater. Our task in these investigations, whether a major marine casualty or a public and non-public casualty, is to determine the probable cause of the accident and identify  safety recommendations that will prevent similar events in the future. We also investigate, independently or with other government agencies, marine accidents in which the United States is a substantially interested state (SIS), according to the International Maritime Organization’s “Code for the Investigation of Marine Casualties and Incidents.”

NTSB investigators about to board El Yunque - sister ship of El Faro

So, where does the USCG fit in? The USCG conducts preliminary investigations of all marine accidents, then notifies us when an accident qualifies as a major marine casualty. Unlike in other modes of transportation, such as aviation, where the NTSB leads the investigation, the USCG typically takes the lead in marine casualty investigations. Under a memorandum of understanding (MOU) between the NTSB and USCG, however, the NTSB may become the lead federal agency for the investigation, depending on the circumstances. This may occur when there is a significant marine accident that is a subset of a major marine casualty and is defined in the MOU as the following:

  • The loss of three or more lives on a commercial passenger vessel.
  • Loss of life or serious injury to 12 or more persons on any commercial vessel.
  • The loss of a mechanically propelled commercial vessel of 1,600 or more gross tons.
  • Any marine casualty with loss of life involving a highway, bridge, railroad, or other shore side structure.
  • Serious threat, as determined by the USCG Commandant and concurred with by the NTSB Chairman, or their designees, to life, property, or the environment by hazardous materials.
  • Significant safety issues, as determined by the Commandant and concurred with by the Chairman, or their designees, relating to Coast Guard marine safety functions.

If a marine casualty meets any of the above significant marine accident criterion the NTSB may elect to be the lead federal investigative agency.

In marine casualties involving a public (federal government) and a non-public vessel, if the vessel is Coast Guard the NTSB must investigate and be the lead federal agency. With casualties involving other public and non-public vessels, in most cases, the NTSB investigates as the lead federal agency.

The Office of Marine Safety typically investigates 30 to 40 marine accidents per year meeting the above criteria, and we do so with a staff of only 21 people, including investigators, writers, support staff and supervisors/managers. To get an overview of the Office of Marine Safety’s work, take a look at our Safer Seas Digest, which can be found on our ntsb.gov website, and summarizes our recent accident investigations and findings.

 

Eliminate Distractions

By Vice Chairman Bruce Landsberg

The NTSB has investigated distraction-linked crashes in all modes of transportation. Our 2017 distracted driving roundtable, “Act to End Deadly Distraction,” made one thing very clear:

We don’t feel these losses in a statistical table. We feel them at the dinner table. We also don’t call them “accidents” because they are totally predictable.

More than 100 people die every day on our roads and highways, nine or ten of them per day in distraction-involved crashes alone. More than 1,000 people per day—391,000 in one year—are injured in distraction-involved crashes. And it’s certain that this number is greatly under-counted. Many of these injuries are life-altering, disfiguring and permanently crippling. My apologies for being graphic – but ask anyone who’s been involved whether the distraction that caused the crash was worth it.

Listen to stories told in our 2017 roundtable by survivor advocates. Or, simply ask around. It won’t take long to find someone with a story of a friend, business colleague or loved one lost to a distracted driver.

What too many of these crashes have in common is a portable electronic device – the universal cell phone. When the NTSB made its first recommendation about driver distraction by “wireless telephone” in 2003, cell phones were primarily just that: tools for making voice calls. Although some cell phones had keypads, the word “texting” does not appear in that early report.

In 2011, the NTSB recommended that the states ban non-emergency driver use of all portable electronic devices that did not support the driving task. To date, no state’s laws have gone that far. Why?

And since drivers look to the law for guidance, no state’s drivers have gone so far as to voluntarily stop driving while visually, manually, and/or cognitively distracted. Why?

Now, a second 2011 NTSB safety recommendation is becoming steadily more feasible: Safety Recommendation H-11-47. We recommended that CTIA—the wireless association, and the Consumer Electronics Association, encourage the development of technology that can disable portable electronic devices within reach of the driver when a vehicle is in motion (with the ability to permit emergency use of the device while the vehicle is in motion, and the capability of identifying occupant seating position so that passengers can use their devices).

Unfortunately, the recommendation has not been adopted, despite smartphones and apps that will allow the driver to opt out of calls and texts while driving. So, why hasn’t there been more action on this recommendation?

The best safety solution is always to design out the problem. Rather than just encourage people to do the right thing, don’t give them the opportunity to do the wrong thing… and possibly take a life or maim someone.

Don’t misunderstand, we endorse a solid tech solution, but such a solution won’t work in every situation. It must be a belt-and-suspenders effort, together with the familiar three-legged stool of highway safety (awareness, tough laws, and high-visibility enforcement).

This year many more loved ones will be lost to distraction, but surveys tell us that most people think distracted driving is a bad idea. Until, that is, we have to put our own phone down. Hypocritical? It couldn’t possibly happen to me – I’m too good a driver! The numbers prove otherwise.

Time, tide and tech wait for no man or woman, to coin a phrase. By the end of today a thousand more families will be dealing with tremendous loss and pain.

This month, the NTSB will host its third Roundtable on Distracted Driving: Perspectives from the Trucking Industry. During the roundtable, members of the trucking community, victim advocacy groups, the business community and legislators will come together to discuss the problem of distracted driving and potential countermeasures. We also hope to hear about new efforts to close Safety Recommendation H-11-47.

To kickoff Distracted Driving Awareness Month, on April 3, we will also host, with Impact Teen Drivers and the California Highway Patrol, the Western States Teen Safe Driving Roundtable to talk about the state of teen driving and the proven strategies for preventing teen-driving related crashes.  Now, what are you going to do about it?

When it Comes to Safety, Not All Flights are Created Equal

By Chairman Robert L. Sumwalt

Last week, we officially adopted our final report on the tragic May 15, 2017, crash of a Learjet 35A on a circling approach to Teterboro Airport in New Jersey. The crash took the lives of the two occupants—the aircraft’s pilots. The probable cause of the accident was the pilot‑in‑command’s (PIC’s) attempt to salvage an unstabilized visual approach, which resulted in an aerodynamic stall at low altitude.

The accident airplane’s operator offered on-demand flights under Part 135 of the Federal Aviation Regulations. (The air carriers that most people are more familiar with, which fly regularly scheduled routes, are regulated under Part 121.) The accident flight was a positioning flight subject to Part 91 rules; however, the procedures that the operator used, the pilots’ training, and the Federal Aviation Administration’s (FAA’s) ongoing oversight duties all pertained to Part 135 aviation.

Imagine knowing that some of what was happening on this accident flight was going on in your regularly scheduled air carrier flight. First, the PIC was not flying the airplane until just before the accident, when the second-in-command (SIC) relinquished control, despite the fact that, by the company’s own standard operating procedures (SOPs), the SIC was not experienced enough to be flying. This was only one of many instances during the flight of an SOP violation or the failure to use required SOPs.

Additionally, during initial training, the PIC and the SIC both had difficulty flying circling approaches in a simulator. This Part 135 carrier, however, did not have a program in place to follow up with pilots who had exhibited issues during training. What’s more, despite both pilots’ training problems flying a circling approach, they were teamed together for this flight.

This accident flight was also an example of poor crew resource management (CRM). CRM done well results in SOP adherence and effective communication and workload management. However, during this flight, the captain had to extensively coach the SIC while also fulfilling his pilot monitoring responsibilities. He did neither well. Both pilots lacked situational awareness.

Contributing to the accident was the PIC’s decision to allow an unapproved SIC to act as pilot flying, and the PIC’s inadequate and incomplete preflight planning. Also contributing to the accident was the carrier’s lack of any safety programs that could identify and correct patterns of poor performance and procedural noncompliance, and the FAA’s ineffective safety assurance system procedures, which failed to identify the company’s oversight deficiencies.

In response to this accident, among other things, we recommended that the FAA require Part 135 operators to establish programs to address and correct performance deficiencies, as well as to publish clear guidance for Part 135 operators to create and implement effective CRM training.

This accident illustrates that Part 135 flight crew members don’t always follow the same procedures or exhibit the same discipline as professionals in Part 121 operations. Before the accident at Teterboro, we found that pilot performance either caused or was a major contributing factor in seven major aviation accidents involving Part 135 on‑demand operators between 2000 and 2015. A total of 53 people were killed and 4 were seriously injured in these accidents. This year, we added “Improve the Safety of Part 135 Aircraft Flight Operations” to our Most Wanted List of transportation safety improvements to help draw attention to this problem.

MWL06s_Part135

Many air carriers operating under Part 121 are required to continually seek and identify risks, and once the risk assessment is done, put measures in place to mitigate those risks through safety management systems (SMSs). Conversely, while some Part 135 operators have implemented SMS, most have not.  In response to the Teterboro accident, we reiterated a previous recommendation to the FAA to require that all Part 135 carriers in the United States have an SMS in place.  In Part 121 training, performance deficiencies are required to be followed up on; there’s no such requirement for Part 135 operators to monitor deficiencies in their pilots’ training.

Further, although Part 135 operators, like their Part 121 counterparts, are required to provide CRM training, they receive less thorough guidance on what constitutes effective CRM training. This shortcoming was evident in the Teterboro accident, where the crew did not display good CRM during the accident flight.

I’ve had two very interesting roles in life – being an airline pilot and serving as an NTSB Board Member. While serving as an airline pilot, I was also a member of a flight operational quality assurance (FOQA) team. In that role, I looked at minor procedural deviations in nonaccident flights with the purpose of learning where potential problems were. In this accident, we reiterated previous recommendations to the FAA to require flight data monitoring (FDM) programs to accomplish the same kind of oversight for Part 135 aviation, and that Part 135 operators install the necessary equipment to acquire FDM data.

In my role as an NTSB Board member, I have seen too many cases where accidents occur in part due to procedural noncompliance and lack of professionalism. A pilot might be born with certain aptitudes, but no one is a born professional; it takes work and constant discipline. Professionalism is a mindset that includes hallmarks such as precise checklist use, callouts, and compliance with SOPs and regulations. Those traits were conspicuously absent on this accident flight. And, now as my role as a frequent airline passenger, I’m glad that airlines are required to have SMS programs; I know they make my flights safer.

The NTSB believes that tools such as an effective SMS should be required and used in Part 135 aviation as well as by Part 121 carriers. We hope that including “Improve the Safety of Part 135 Aircraft Flight Operations” on our Most Wanted List for 2019–2020 will encourage action on this issue.

 

Why?

By Nicholas Worrell, Chief, NTSB Safety Advocacy Division

Earlier this month, I had the opportunity to address more than 150 driver educators at the Dori Saves Lives Driver Education Conference, a meeting at which I first spoke in 2015. The conference is named for Dori Slosberg, who died in a 1996 traffic crash along with four other teens. She was only 14.

2019 Dori Slosberg Foundatin Event
Nicholas Worrell, Chief, NTSB Safety Advocacy Division, addresses attendees at the 2019 Dori Saves Lives Driver Education Conference

Today, more than 20 years later, motor vehicle crashes remain the leading cause of death for young people ages 5­–24. That’s why the work of the Dori Slosberg Foundation and others around the nation is so important.

Compared with earlier generations, Millennials are quick to look at the world as they find it and ask why? This is a good habit; you can’t improve in any endeavor—from education, to manufacturing, to transportation safety—without looking at the status quo and asking why things are the way they are.

We know why young drivers are involved in crashes—most often because of inexperience, distraction, speed, and impairment. And we also know that those risky behaviors are often coupled with low seat belt use rates. So why are young drivers getting behind the wheel impaired or driving distracted? How can policy address risks like inexperience and speed in this age group? Some of the most important voices in traffic safety are young survivor advocates who have refined the raw why? of intolerable loss into the thoughtful and lifesaving why? of policy change.

At the conference, I welcomed the last of the millennials to the traffic safety fight in their new roles as young driver educators. I asked them to never stop asking “why,” just as the NTSB never stops asking that same question to determine probable causes of transportation accidents and crashes. And I challenged them to act on the proven solutions that will prevent traffic crashes—comprehensive laws, education, and enforcement.

Last month, we released our 2019­–2020 Most Wanted List, which includes some of these proven solutions.

For previous blogs about outreach to Dori Saves Lives and driver educators, visit:

 

Don’t Rely on the Luck of the Irish for a Safe Ride Home

By: Member Jennifer Homendy

St. Patrick’s Day is a big deal in our house. “Leprechauns” sneak in the night before to raid our kitchen cabinets. Sometimes they write things in green paint on our walls; other times they leave gold coins. And my daughter always tries to catch one in her latest handmade trap (spoiler alert: it’s never happened). This is also one of the busiest weekends of the year for us. My daughter is an Irish dancer, and over St. Patrick’s Day weekend, our schedule is jam packed with parades and multiple performances at local pubs where there’s lots of dancing, drinking, and good ole reveling in Irish culture. What always concerns me, though, is the number of people who walk out of those pubs right into their cars after an afternoon of drinking.

Did you know that nearly 29 people die each day in the United States in alcohol-impaired driving crashes? That’s one person every 50 minutes, or more than 10,000 people a year. Alcohol-impaired driving crashes are 100% preventable. It’s simple. Choose one: drink or drive. Don’t do both.

St. Patricks Day Impaired Driving Image

This Sunday, you may be tempted to think: well, it’s just one drink, or it’s just two. Although the current legal definition of alcohol impairment in 49 states is a blood alcohol concentration of 0.08% (0.05% in Utah, thanks to the efforts of the NTSB), research shows that impairment begins at much lower levels; even small amounts of alcohol affect the brain and human performance behind the wheel.

So, this St. Patrick’s Day, we want you to have fun. And the best way to do that is to have a plan in place before you start to celebrate. Leave the driving to someone who’s sober or take transit, call a cab or a rideshare service, but please don’t drink and drive.

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