Excessive Speed Continues to Take Too Many Lives

By Vice Chairman Bruce Landsberg 

Our recent investigation of the fatal Jan. 5, 2020, multivehicle crash near Mt. Pleasant Township, Pennsylvania, determined that excessive speed played a critical factor. This is a recurring theme in too many highway crash investigations. Between 1967 and 2022, the NTSB has investigated over 50 major crashes in which speed was cited as a safety issue, a cause of the crash, or a contributing factor. And that represents just the tip of the iceberg, given the NTSB selectively investigates highway crashes. We have made numerous safety recommendations prioritizing safety technology, legislation, and education to prevent speed-related crashes and save lives. 

​​​In this photo, the final rest positions of all vehicles involved in crash below the curve on westbound Pennsylvania Turnpike. (Photo courtesy of the Pennsylvania State Police. Graphic overlay by NTSB.)​

The Mt. Pleasant Township investigation and resulting recommendations point out the importance of technology, such as automated speed safety cameras, to limit highway crashes. Safety-focused legislation is also needed to develop performance standards for advanced speed-limiting technology in heavy vehicles. We need education initiatives to inform drivers about the circumstances of the Mt. Pleasant Township crash; the importance of following the Federal Motor Carrier Safety Administration’s guidance on engine retarders, “Motorcoach Brake Systems and Safety Technologies”; and the need to incorporate the guidance into their members’ training and manuals.

The changes proposed to the Commonwealth of Pennsylvania are applicable to all states as they strive to improve safety on their roads and highways: 

• Allow speed safety cameras to be used outside of active work zones. (H-22-7)

Safety cameras are a reliable supplement to traditional enforcement. When properly implemented, they offer fair and equitable speeding enforcement. They should not, however, be used as a revenue source for non-safety-related projects, and drivers should be notified about when and where cameras are in use. Where photo enforcement has been used in construction and school zones, the numbers of crashes, injuries, and fatalities have all decreased markedly!

• Implement the use of variable speed limit signs or other similar technology to adjust speeds in real-time based on weather and road conditions. (H-22-8)

Dynamic speed limits will help drivers adapt to changing road conditions. What’s suitable for dry pavement and light traffic is too fast for heavy traffic and contaminated road surfaces. Well-documented stopping distance tests on wet and icy roads have proved that point consistently. Reduced visibility is deadly, and there have been several massive crashes recently where drivers were unable to see stopped or slowed vehicles ahead of them. One-size speed limits do not fit all conditions or vehicles! 

• Evaluate the applicability and use of the 85th percentile speed input variable in both of your tools, USLIMITS2 and the National Cooperative Highway Research Program 966, for setting appropriate speed limits to reduce serious and fatal injuries. (H-22-2) 

The 85th percentile is defined as “the speed at or below which 85 percent of all vehicles are observed to travel under free-flowing conditions past a monitored point.” This may not be the safest and most effective way to engineer safety into our roadways. Crash history and the presence of vulnerable road users should also be considered when setting speed limits.

For decades, excessive speed has been a factor in about one-third of all motor vehicle crashes. The NTSB added “Implement a Comprehensive Strategy to Eliminate Speeding-Related Crashes” to the Most Wanted List of Transportation Safety Improvements in 2019. Speeding increases the likelihood and severity of crashes. The physics of reaction time, stopping distance, and impact forces are sadly proven every single day—dozens of times.

State and federal government officials, safety advocates, and drivers have critical roles in preventing speed-related crashes. The safety recommendations outlined in the Mt. Pleasant Township crash investigation and in our 2017 safety study, Reducing Speeding-Related Crashes Involving Passenger Vehicles should be implemented in your state. Take action and slow down. Your life and the lives of your loved ones depend on it.

Check out the latest Behind-the-Scene @NTSB podcast episode for more information about the Mt. Pleasant Township, PA crash and investigation. Listen now: https://safetycompass.wordpress.com/?p=5820

Accident Data for Investigations, Routine Flight Data for Prevention

By Acting Chairman Bruce Landsberg

Most people are familiar with the nightly news image of NTSB investigators at the scene of an accident, searching for the “black (orange) box.” The flight data recorder (FDR), which records aircraft control inputs and operational conditions, and the cockpit voice recorder (CVR), which records pilot conversations, are at the heart of modern aviation accident investigations on all airline aircraft. The devices have helped to improve the safety of airline operations tremendously. They are used, of course, in crash investigations but most airlines also use them routinely to monitor pilot and aircraft performance and correct problems before they result in a crash.  

However, these devices designed to help in investigations are not required or used in most air-taxi or charter operations. For example, no recording equipment was installed in 86 percent of the turbine-powered aircraft involved in fatal accidents between 2005 and 2017. As a result, valuable information was missing to fully understand what happened and to prevent a crash from happening in the first place if the operator had used the predictive approach that the systems provide.

We believe recorders and analysis of their data before a crash offer tremendous safety benefits. That’s one reason why Install Crash-Resistant Recorders and Establish Flight Data Monitoring Programs is on the NTSB’s Most Wanted List of Transportation Safety Improvements (MWL).  

Cockpit Image Recorders

Even after an FDR and CVR are analyzed, investigators still don’t know for sure how the flight crew interacted with the aircraft systems or what visibility was like inside or outside the cockpit. Even the most modern flight data recorders leave some questions unanswered. That’s where a cockpit image recorder (CIR) can be useful. For more than 20 years, the NTSB has called for CIRs in addition to FDRs and CVRs. The images CIRs provide could quickly reveal a pilot’s actions without ambiguity. Some in the industry claim that it’s an invasion of privacy or that video will be used by the media for sensationalist purposes. Federal law prevents the release of CVR or CIR data except in transcript form and there has never been a breach of that trust! Please note that most other modes of commercial transportation (trucks, busses, railroads and marine) have already installed this equipment and are reaping the benefits.

A  CIR was vital to our investigation of the in-flight breakup of Scaled Composite’s SpaceShipTwo over California in 2014. Cockpit images show a test pilot inadvertently deploying a feature called the “feather,” (similar to a thrust reverser) which led to the in-flight breakup. Without a CIR, the investigation would have taken months, or years, to evaluate the wreckage and understand if the feather lock mechanism mechanically failed or was deployed as a result of a crew action.  

Too many investigations have been hindered by a lack of CIRs. For example, had the Atlas Air Inc. flight 3591, a Boeing 767-375BCF, that crashed near Houston in 2019 been equipped with a crash-resistant image recording system investigators might have had relevant information about the data available to the flight crew and the flight crew’s actions during the accident flight. This information would have been critical in determining what happened and while there’s a very plausible idea of what happened some uncertainty of precise causal factors remains.

Recorders should be able to survive crash dynamics that include impact, submersion or fire. In the 2019 Sikorsky helicopter crash in Calabasas, California, visual cues associated with the adverse weather and the pilot’s focus of attention could not be conclusively determined because the helicopter wasn’t equipped with a CIR. A crash-resistant flight recorder system with audio and image functions could have provided valuable information to possibly identify additional safety issues and prevent a similar crash in the future.

Flight Data Recorders and Monitoring Programs

As an investigative agency, NTSB has a vested interest in recorders because they yield essential evidence, that can often be used to prevent future crashes. Required flight data monitors (FDMs) and FDM programs like Flight Operations Quality Assurance (FOQA) at the airlines have improved safety through the analysis of data collected by these recorders. Other segments of commercial aviation, like corporate and on-demand charter operations, could similarly benefit from FDMs and FDM programs.

On May 15, 2017, a Learjet 35A departed controlled flight while on a circling approach to Teterboro Airport in New Jersey impacting a commercial building and parking lot. Both pilots died.  The investigation again identified the need for FDM programs (and supporting recording devices) for 14 CFR Part 135 operators. The operator lacked safety programs that would have enabled it to identify and correct poor performance and procedural noncompliance which was the primary cause of the crash. Without an FDM program, the operator couldn’t identify the flight crew’s prior deviations from policy and procedures and had no way to determine if previous operations were conducted properly.

The NTSB has long recognized the value of FDM programs for Part 135 operators, having first issued a safety recommendation for data recording devices and monitoring programs for helicopter air ambulance operators in 2009. FDM programs typically involve the use of an onboard device capable of recording various flight parameters. Periodic routine review of the recorded data enables an operator to identify deviations from procedures and observe potential safety issues. Data reviews help a company take proactive measures and corrective action BEFORE a crash occurs. FDM should be integrated into safety management systems (SMS), another pillar of safety in modern aviation. Read more about SMSs on our MWL webpage.

Flight crews are an asset to every operator, who clearly has a vested interest in the safety and performance of the flight crew. Therefore, an FDM program should never be used in a punitive way, but rather to identify and correct safety issues.

Expanding Aviation Lessons for Safety

Through decades of accident investigations, many of which were aided by key evidence gleaned from recorders, airline travel in the United States has become extraordinarily safe. But to keep this strong safety record going, and to make progress elsewhere in aviation through lessons learned, it is essential to install recorders on an even broader scale appropriate to the activity. Devices built to survive a crash and supplemented with FDM programs, will enable operators to identify deviations and safety concerns prior to an accident.

Operators don’t need to wait for government mandates to install them; they can realize the safety benefits of this technology today and just one crash prevented will be highly cost effective for that operator and certainly for the people involved! The fact that an operator, without an FDM program and an effective SMS, hasn’t had a crash as we’ve seen too many times, doesn’t mean that they were good, merely lucky.

Get it Right: Addressing the Timeliness of NTSB Investigations

By Acting Chairman Bruce Landsberg

There was once a saying in the news media business to “get it first, get it right, but first get it right.” The NTSB strives to get it right above all, but we recognize that timeliness is essential, too. One of my goals even before joining the Board was to see if aviation crash processing time could be reduced on the less complex events. After all, the whole point of accident investigation is to become educated on what went wrong and get the word out as soon as possible to avoid a similar scenario.

But at the NTSB, it’s not all black and white. I want to take this opportunity to clear up some common misconceptions about how the agency functions and describe our process for those unfamiliar with its intricacies.

Congress requires us to evaluate all aviation accidents in the United States as well as significant accidents in all modes of transportation—rail, pipeline, highway, marine, and hazardous materials (how we determine what’s “significant” is a topic for another blog). Given this mandate, our resources are divided. Out of around 400 NTSB staff, only 45 accident field investigators are assigned to aviation. However, although we are required to investigate every civil aviation accident in the United States, as well as those occurring outside the country when they involve US-made equipment, that doesn’t mean we send an investigator to every crash. Often, it’s sufficient for an investigator to just interview a surviving pilot over the phone. In many cases, the Federal Aviation Administration (FAA) sends someone from its local office to an incident and shares the on-scene data with us.

Sometimes, though, an accident is more complex, and a deeper dive is required. For example, vital electronic data can be extracted from avionics, phones, or tablets that aren’t too damaged. Often that can be done in the field, but some devices must be sent to the NTSB lab in Washington, DC, for more thorough examination. There, our technicians painstakingly recover what they can, but—remember—they’re receiving devices from accident scenes in all the other transportation modes as well. The backlog can get lengthy. The lab must also decipher information from voice recorders (if any), vehicle monitors, onboard and external cameras, and metallurgical specimens, and conduct sound spectrum analysis, among other things, from every mode.

Sometimes, despite hours or days of lab effort, no data survives, which makes determining probable cause much more difficult. That’s why our 2021–2022 Most Wanted List of Transportation Safety Improvements includes “Install Crash-Resistant Recorders and Establish Flight Data Monitoring Programs.” Unbiased and accurate device readouts speed investigations up tremendously compared to relying solely on eyewitnesses, who are far less reliable.

In addition to analyzing all the machine information we can, we also look at the human factors present in an accident. We send toxicology samples to the FAA’s medical lab in Oklahoma City for analysis. Autopsy data must be gathered from local medical examiners, whose schedules don’t always align with ours. In a perfect world all this back-end analysis could be completed quickly, but reality intrudes. Factors such as staffing in other state and local government entities, the sheer number of reports the agency is juggling at a time, and yes, inefficiency, can drag things out. Those situations are not always within NTSB control.

Still, many reports frankly took too long to complete, and the average time to complete reports has increased over the years. Recognizing these delays, in 2019, staff in our Office of Aviation Safety began assessing our report process to see if we could streamline it in any way we can control. The effort produced significant improvements, and the early results are encouraging. From March 2020 to March 2021, about 1,100 investigations were initiated, and about 1,500 were completed. This doesn’t include several hundred foreign investigations in which the NTSB participates every year. This contrasts favorably with the prior year, where from 2019 to March 2020, about 1,320 aviation investigations were initiated, and about 1,150 were completed, not including foreign investigations.

Naturally, everyone wants everything faster. Going forward, the less complex cases we investigate are being scaled to finish in 6 months or so, while the more complicated ones will continue to take longer—sometimes much longer. Although we recognize the importance of timeliness in our investigations, we strive for a level of accuracy that ensures we’ve left no stone unturned.

As we revamp our investigation report process to get accurate information out more quickly, I think the public will appreciate the result. But, like most things, the process is a work in progress. We will never sacrifice precision for speed, but rest assured that we’re taking a hard look to see how we can get lifesaving information out more efficiently. We all look forward to seeing the progress the agency makes as we implement new strategies.

Eliminate Distracted Driving

By Vice Chairman Bruce Landsberg

April is National Distracted Driving Awareness Month, and we launched our 2021–2022 Most Wanted List of Transportation Safety Improvements on April 6. It seemed only natural that we begin our Most Wanted List blog series with the item, “Eliminate Distracted Driving.”

Crashes involving distracted drivers killed 3,142 people in 2019—up nearly 10 percent from the year before. A staggering 400,000 people were injured, some seriously and permanently. These numbers are certainly significantly under-reported, given police don’t always examine phone records after a crash and, although the problem of distraction is not new, the potential for distracted driving has increased exponentially with the introduction of personal electronic devices (PEDs). With an estimated 294 million smartphone users in the United States, our phones and other PEDs are a constant temptation for nearly all drivers. Our PEDs continually demand our attention, and our brains reward us for responding to their demands.

Although awareness is the first step in avoiding your own distracted-driving crash, we don’t believe awareness alone is enough to eliminate the problem. In many respects, driving distracted is the same as driving while impaired by drugs or alcohol—each is a behavioral choice that can result in death and life-altering injuries, not only to the perpetrators, but to many innocent people, as well. Solving the problem will require not only raising awareness and educating the public, but also enacting laws and implementing high-visibility enforcement.

We have investigated numerous distracted-driving crashes where PED use and distraction, in general, had tragic consequences. For example, on August 5, 2010, in Gray Summit, Missouri, a truck-tractor was traveling slowly or had stopped behind traffic on Interstate 44. A pickup truck merged from the left to the right lane and struck the rear of the tractor, initiating the first in a series of three collisions. The pickup truck driver was texting and driving.

Two school buses approached the collision site: a lead bus carrying 23 passengers and a following bus with 31 passengers. The driver of the lead bus became excessively focused on a motorcoach that had pulled over onto the shoulder, and the lead bus struck the rear of the pickup truck, pushing it forward and overturning it onto the back of the tractor. Moments later, the second school bus struck the right rear of the lead bus.

Gray Summit crash scene, showing Volvo tractor and lead school bus. GMC
pickup is located between the two vehicles. The
following school bus is located at right rear of photo. (Courtesy of Boles Fire Protection District)

As a result of this crash, the driver of the pickup and one passenger seated in the rear of the lead school bus were killed. A total of 35 passengers from both buses, the two bus drivers, and the driver of the tractor sustained injuries ranging from minor to serious.

Education is critical to prevent distracted driving, particularly because there are still many myths out there about it. For example, drivers—and legislators—must understand that hands-free is notrisk free. People who would not dream of texting and driving or talking on a handheld phone while driving still take their chances when it comes to hands-free conversations. This purely mental aspect of distraction is called “cognitive distraction.” Additionally, many drivers believe they are good “multitaskers” and exempt from the dangers of distracted driving. The truth is humans can only focus on one task at a time. You can drive or you can use a PED, but you can’t do both safely. Look at this way: your brain is only a single-core processor, and there are no upgrades available.

There’s a big disconnect between the facts and many drivers’ actions. Drivers need to disconnect from devices while driving, except when using them for navigation. All phones have a do-not-disturb feature that can be enabled while you drive—use it!

It can take some drivers a long time to change their minds about risky driving behavior, despite mountains of evidence that a driving behavior is unsafe. In fact, some never do. And what about when drivers do change their behavior and choose not to drive distracted? All other drivers must make the same choice for the issue to totally disappear, because, unfortunately, even the most conscientious driver has limited ability to respond to the risks careless drivers expose them to. Passengers, and even people outside a vehicle, are relatively powerless against “the other guy.”

That’s why, in addition to awareness and education, we also need the right laws and enforcement to make real progress, just like we’ve done to address other risky driving behaviors in the past.

That’s why, in addition to education, we need legislation to combat this problem. Our recommendations, if acted upon, can further protect all road users—whether inside a vehicle or out—against distracted drivers by building attentive driving into the law. Banning texting while driving is a start. Texting is manually, visually, and cognitively distracting. We also support bans on handheld phone use while driving. Although we strive for bans on all nonemergency PED use that don’t support the driving task, and, as mentioned, even though hands-free isn’t risk-free, banning handheld phone use is a step in the right direction. We also believe that distracted driving should be the target of high-visibility enforcement, like impaired driving and seat belt use are.

There are those who believe it’s their right to use their phones whenever, however. But consider the risk-reward tradeoff—death, permanent injury to you or someone else, massive legal struggles, and for what? To tell someone what you had for lunch? To discuss a business deal? To text your spouse a reminder to pick up the dry cleaning? Think about it. Maybe you think you’re immune to the dangers of distracted driving. Maybe you think this message is geared toward all the other drivers on the road. Maybe you think the science doesn’t apply to you. Tens of thousands of similarly self-assured distracted drivers have thought the same and gotten it horribly—and irrevocably—wrong!

“Eliminate Distracted Driving” is on our 2021–2022 Most Wanted List because insisting on attentive driving will reduce injuries and save lives, pure and simple. Make the choice to drive attentively and encourage others to do the same. If that doesn’t feel like enough, consider supporting one of the many distracted driving advocacy groups that are working to eliminate this problem. When driving, no distraction is worth the risk.

NTSB Investigations involving Distracted Drivers

• Collision Between a Sport Utility Vehicle Operating with Partial Driving Automation and a Crash Attenuator, Mountain View, CA (March 2018)
• Collapse of the Interstate 5 Skagit River Bridge Following a Strike by an Oversize Combination Vehicle, Mt. Vernon, WA (May 2013)
• Multivehicle Collision Interstate 44 Eastbound, Gray Summit, MO (August 2010)    

Joining Forces on Distracted Driving

The blog was co-authored by:

Bruce Landsberg, Vice-Chairman, National Transportation Safety Board

Lorraine Martin, President & CEO, National Safety Council

By now, we all should be aware of the deadly consequences of distracted driving. Yet, driving while distracted by cell phone use has become too common an occurrence on the nation’s roads. This must stop.

It has been nearly a decade since the National Transportation Safety Board (NTSB) called on the states and the District of Columbia to enact laws that prohibit the non-emergency use of cell phones by all drivers. It has been more than a decade since the National Safety Council (NSC) became the first nongovernment organization to call for a total cell phone use ban for all drivers. Yet, tragically, no state has implemented this life-saving measure. 

Between 2011 and 2018, the National Highway Traffic Safety Administration reported that 25,926 people were killed and an estimated 2.4 million more were injured in distraction-affected crashes. While these numbers are staggering, we know that they don’t accurately reflect how big a problem distracted driving is because distracted driving-related crashes are, in fact, greatly underreported.

“Eliminate Distractions” is on the NTSB’s 2019-2020 Most Wanted List of Transportation Safety Improvements. We are calling on states, operators and industry, vehicle manufacturers, and the driving public to take action.

Together, NTSB and NSC have joined forces to urge the following immediate actions:

States: Enact laws that prohibit all cell phone use while driving—yes, even hands free. Laws must send a clear message to drivers that there is no safe way to use a phone while driving.

Employers: Establish strong transportation and driving policies that prohibit cell phone use by employees – no calls, no social media, no texts, no email while driving. The most effective safe driving policies go beyond merely prohibiting all cell phone use to include activities such as using infotainment systems while driving. Policies should also prohibit employees from contacting other employees when you know they will be driving. (Employers don’t have to wait for a state law to tell you to do this; be a leader in safe practices.)

Drivers (you and me!): Use your phone’s “do not disturb” feature. Place your phone out of reach or simply turn your phone off until you reach your destination. No call, no text, no update is worth your life or the life of someone else.

Manufacturers of portable electronic devices: Develop a distracted driving lock-out mechanism or application for portable electronic devices that will automatically disable any driver-distracting functions when a vehicle is in motion, but allows the device to be used in an emergency.

The NTSB and NSC are committed to eliminating preventable crashes caused by cell phone use. The research is clear: we cannot safely multitask behind the wheel. So, when you choose to drive distracted, you don’t just pose a risk to yourself, you are a risk to the safety of the others you share the road with.

October was National Distracted Driving Awareness Month, but we need to focus on this issue all year. We will continue in our fight and efforts to end the preventable crashes, injuries and fatalities caused by distracted driving. Join us in this commitment by acting responsibly and making attentive, distraction-free driving your goal when behind the wheel. We are aware of the problem; now let’s take action to prevent any more needless tragedies.