Addressing Fatigue by Practicing What We Preach

By Debbie Hersman

After more than 40 years of accident investigation, we know the insidious role fatigue plays in transportation accidents. Fatigue affects all aspect of human performance — it reduces reaction time, impairs judgment, degrades memory, and interferes with communication.

The NTSB has long been an advocate for better fatigue management throughout the transportation industry.  We’ve issued almost 200 fatigue-related safety recommendations. Fatigue has been on our Most Wanted List since 1990; addressing human fatigue is on the new Most Wanted List that we announced on June 23.

We decided it was time to practice what we preach. I am pleased to tell you last month we announced a new Fatigue Management Program for the entire agency.  The goal is to enhance job performance, but more importantly, to reduce safety-related risks for our employees on-the-job.

The intent of this program is not to establish specific duty time limits; rather, it will provide guidance that employees need to evaluate whether they might be at risk of impairment due to fatigue, and whether strategies are available to help mitigate this risk.

In the coming months, every employee, myself included, will complete a basic fatigue training course.  Education is the first step to address job-related fatigue.  Knowledgeable employees are more likely to embrace change if they understand and appreciate the effect of fatigue on their work and in their lives.

Life, Liberty, and the Pursuit of Safety

By Mark Rosekind

Enjoy the holiday weekend responsibly. Don't mix alcohol and driving.

Every year on the Fourth of July, we celebrate life, liberty, and the pursuit of happiness with friends and family from across the nation.  As a result, it’s one of the busiest weekends of the year on our roadways. On an average weekend, one-third of all highway deaths involve a driver who is impaired by alcohol.  Unfortunately, during past Fourth of July Weekends, this number increases to 40 percent of all highway fatalities.  

The adverse effects of alcohol, such as slowed reactions, are difficult to detect and people tend to underestimate the extent to which alcohol affects them.  In many cases, drivers do not exhibit the classic signs of extreme drunkenness, and they don’t believe they are drunk.

This Fourth of July, make the appropriate arrangements so that you do not drink and drive.  Ensure that you, your family, and all of those celebrating the Fourth with you are safe, responsible, and able to continue to enjoy the gift of freedom our forefathers made possible for all of us.

Member Mark RosekindMark Rosekind, Ph.D., is a Member of the National Transportation Safety Board. He is a frequent contributor to the NTSB blog.

Celebrate on the Water and Be Safe!

By Debbie Hersman

Always wear a PFD while on the water.

Philadelphians recognized the first 4th of July anniversary with a spontaneous celebration. Almost 100 years later, on June 28, 1870, Congress made Independence Day a federal holiday. This year, many of us will spend time with family and friends over the July 4th weekend at our nation’s rivers, lakes or the seashore.  Unfortunately, our investigators know that many accidents occur during high exposure times when the volume of traffic is increased and people are celebrating.

When it comes to accidents on the water, nothing is more crucial to survivability, especially for children, than wearing a lifejacket or personal flotation device (PFD).  Unfortunately, far too many people leave their PFDs in the storage compartment of their boats.  In 2010, almost three-fourths of all fatal boating accident victims drowned, and 88 percent of those individuals were not wearing a life jacket.  Boater education is another effective way of staying safe.  Congratulations to the state of Nebraska for strengthening its law to require all boaters to take a safety course.

Here are some quick reminders to keep in mind while you are on the water this weekend:

  • Use a life jacket when aboard a recreational boat and be sure that children always wear life jackets. 
  • Complete a recreational boating safety course approved by your state.
  • Review tips on how to dock, use, and operate your watercraft, and make sure your boat maintenance is up to date.
  • Don’t put yourself or others at risk by boating while intoxicated.
  • Refresh your memory about about aids to navigation before entering the water.
  • Lastly, have fun

For valuable resources, information, and education about boating safety and PDFs visit

Technology Drives Safety Improvements on the Road

By Debbie Hersman

The Jetsons Flying Car, from the Hanna-Barbera cartoonAs a child, I watched The Jetsons, that futuristic family with a robot maid named Rosie, an oven that instantly produced a fully cooked dinner on demand, and an automated flying car that often saved George from his own absent-mindedness.  Rosie and the oven were nice conveniences, but the flying car kept the Jetsons safer.

Today, years later, I’m in Michigan touring the proving grounds of the Big Three automakers and other manufacturers in the automotive world.  I am seeing firsthand the technology that may bring us closer to the Jetsons’ flying car and help make driving safer.  Things like adaptive cruise control, collision warning systems, blind spot detection, and lane departure warning systems can alert drivers to dangers they do not recognize.  Some technologies, such as active braking and ESC, can even help compensate for a driver’s inability to identify stopped traffic ahead or negotiate a sharp curve while moving too fast, which can lead to a deadly rollover.

The automotive industry has made many advances in passenger vehicle safety.  Especially encouraging is the fact that some of the technology is also being tested on large trucks, buses, and other commercial vehicles.  Too often, the NTSB investigates accidents in which these technologies, if installed on large trucks, could have prevented a tragedy on the highway.

Just like George Jetson, we will all make mistakes.  While new automotive technologies are designed to assist the driver, rather than replace the driver, if they are widely deployed across the fleet, they have the potential to drive down the number of fatalities on our highways by bridging the gap between the human, the environment, and the machine.

It’s Not Always a Smoking Hole

By Debbie Hersman

Delta Airlines 757

Last week, the NTSB sent a team of investigators to Atlanta to investigate a Delta Air Lines Boeing 757 that experienced an engine fire shortly after take-off.  The captain, who noticed the problem just as the airplane climbed past 3,000 feet, made a successful single-engine landing and the 170 passengers evacuated via the airplane’s emergency slides. 

Most people associate the NTSB with catastrophic plane crashes—ones where numerous people are killed and the aircraft is destroyed.  Photos of our investigators at accident scenes that are  referred to as “smoking holes” are becoming rare when it comes to commercial operations  Fortunately, the event in Atlanta last week was far from a tragic scenario.  In fact, when the evacuation was completed, there were only three minor injuries. 

So, why did NTSB send a team to Atlanta?  Commercial carriers must report to the NTSB any uncontained failures or fires like this one. Our investigators want to find out what happened with that engine so that in the future, they won’t have to investigate the same kind of failure resulting in a smoking hole.  Right now, we have no idea what we will find.  The engine fire may have been the consequence of a design flaw, a manufacturing glitch, or a maintenance discrepancy that could occur again.  And, another occurrence may not end as well.

Our investigators routinely investigate these kinds of events.  Right now, we are investigating why an Airbus 320 experienced an electrical failure in the cockpit right after take-off from New Orleans in April. We are also looking at a Boeing 757 that ran off the runway in Jackson Hole last December.  Neither of these events resulted in fatalities or catastrophic aircraft damage, but they still have a very important safety story to tell.  These investigations are the best ones we do, because they keep us from being called to another smoking hole.

John Nance’s Insights on Safety and Independence

By Robert Sumwalt

John Nance

This week we were proud to welcome renowned author and aviation commentator John J. Nance to Washington as part of our NTSB Speakers Series.  Millions of Americans instantly recognize Mr. Nance through his role as an aviation analyst for ABC News and Good Morning America.  In his role as a bestselling author, however, Mr. Nance has also built a longstanding relationship with the NTSB, researching many aviation disasters using NTSB investigative reports and statistics.

In his lecture, Mr. Nance touched on the roots of the NTSB as an independent federal agency – an independence, he argued, that was critical to furthering key aviation safety concepts, such as crew resource management.  According to Mr. Nance, many of these concepts are now finding application in other industries – most notably, healthcare.  With his wife, Kathleen Bartholomew, a registered nurse, Mr. Nance lectures around the country on how hospitals and healthcare providers can improve patient service by adopting many of the very safety systems pioneered by the aviation industry.

Mr. Nance painted a fascinating picture of how far our system of air travel has come in recent decades, and the significant role that the NTSB has played in advancing its safety.

Member Robert Sumwalt Robert L. Sumwalt has been a Member of the NTSB since 2006. He is a frequent contributor to the blog.

Remembering the Lessons Learned from the Red Line Accident

By Debbie Hersman

Two years ago today, nine people lost their lives when two Washington, DC, Metro trains collided. In our accident report issued a year after the crash, the NTSB cited the failure of track circuit as the probable cause of the accident. But just as troubling as that failure was, our investigation also revealed a systemic breakdown of safety management at all levels at Metro.

Safety management is essential in transportation organizations. A robust safety management system, or SMS, helps organizations identify deficiencies and address them before they result in an accident. In addition, the discipline and standardization of an SMS sets the stage for a positive safety culture, in which employees are encouraged, even rewarded, for providing essential safety-related information. Such a safety culture would have made a huge difference at Metro.

Today is the anniversary of a very sad day for those who lost family and friends in the accident near Fort Totten and it reminds us that we cannot forget the lessons learned in the aftermath of that tragedy. Although more work needs to be done, General Manager Richard Sarles and the new Metro Board of Directors have committed to implementing all of the NTSB’s recommendations. We look forward to the day when that happens.

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