I Lived My Dream: Looking Back on 15 years at NTSB

By Chairman Robert L. Sumwalt

I guess it all started on an overcast day in 1973, when I found myself on the scene of a fatal aviation crash for the first time. I had heard of the crash on my car radio, and, as a curious 17‑year-old, I decided to find the crash location. Once there, I saw the remains of a twin-engine airplane lodged in the bases of the surrounding pine trees. Seeing that accident scene sparked an acute interest within me for accident investigation. In college, I spent copious amounts of time in the government documents library reading NTSB aircraft accident reports. It was then, in the mid-1970s, that I began to dream of becoming an NTSB Board member. Today, as I wrap up 15 years with the agency, serving as Board member, vice chairman, and chairman, I can look back and say I have truly lived that dream.   

Photo of ‘The State’ newspaper article on the 1973 plane crash

I was sworn in as the 37th member of the NTSB in August 2006. Seven days later, I found myself on the scene of another aviation disaster. Comair flight 5191, a regional jet operated as a Delta Connection, crashed just off the departure end of a runway in Lexington, Kentucky. Forty-nine lives were lost that morning after the pilots inexplicitly attempted to take off on a short, closed, unlighted runway. The investigation found that the pilots’ casual attitude during preflight and during the brief taxi, including their engaging in nonpertinent conversation, enabled the crew’s errors. Quite simply, the crew wasn’t paying attention and lost positional awareness. As a result, we issued and reiterated several recommendations to prevent that same type of accident. Today, flights are safer because airline pilots use enhanced procedures to ensure they are aligned with the proper runway before departure, and pilots have electronic maps that provide real-time position information during taxi.

Since the Comair crash, I’ve been on the NTSB Go-Team and served as the Board member on scene for 35 transportation accidents and crashes, and I’ve been involved in the deliberation and determination of probable cause of over 250 accidents and crashes. I’ve met with grieving family members and friends of victims on the worst day of their lives. Through these interactions, the one thing that really stands out to me is just how precious life really is. I’ve often said that we are here to give a voice to those who don’t have a voice—the victims of transportation accidents and their families. I take great solace knowing our work really does make a difference and keeps others from enduring similar tragedies.

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Looking back, I believe there are two things that allow the NTSB to truly be one of the “Best Places to Work in the Federal Government,” as ranked by the Partnership for Public Service: the agency’s mission, and our people.

First, the agency’s mission: Congress charged the NTSB with investigating transportation accidents and crashes, determining their cause, and issuing safety recommendations to prevent similar accidents and crashes, reduce injuries, and save lives. It’s an important calling—taking something tragic and learning from it so others don’t have to endure such a tragedy. Since the NTSB was formed in 1967, we have investigated over 150,000 aviation accidents, along with thousands of highway, marine, rail, pipeline, and hazardous materials accidents and incidents. In that period, we’ve issued over 15,000 safety recommendations, the majority of which have been successfully implemented.  

Our people: Even with a respectable mission, you’re nothing without great people. Fortunately, this is where the NTSB really takes the cake. We’re able to attract and retain dedicated, bright employees who love their work. We actively promote diversity and inclusion, and my hope is that the agency will continue to expand this effort. Our investigators’ passion and determination to find the truth is uplifting. Even throughout the pandemic, although working remotely, NTSB employees found ways to continue delivering our high-quality products. For example, before the pandemic, we had never conducted virtual Board meetings, where we deliberate accident findings, determine the probable cause, and adopt safety recommendations. Even with the challenges of 2020, our employees figured a way to get it done. We held 12 virtual Board meetings in a year, which compares favorably to a normal year of in-person meetings. Although I’ve always had high expectations of the NTSB workforce, I can honestly say that, considering the challenges we all faced during the pandemic, NTSB employees surpassed all expectations.

There are several other qualities that allow the NTSB to be a highly respected federal agency. One of our core values is transparency; we are open and honest with the public about our work. We realize that, when a transportation disaster occurs, the public needs to be assured that the government is conducting an open, competent, and thorough investigation. Therefore, we deliver fact-based information as we learn it. We don’t speculate—just the facts, ma’am. All NTSB Board meetings and hearings are open to the public (literally in person when not in pandemic times, and always via webcast). We post all our accident reports and publications on our website, along with the docket for each accident, which provides reams of background information such as interviews, photos, and technical information that may not be in the final accident report.

When I was sworn in for my first term at the agency in 2006, I told the audience something I had read: “Public service is one of the highest callings in the land. You have the opportunity to make a positive impact on families, communities, states, and sometimes the world.”

I followed up by saying, “I truly believe this statement applies so well to the work of the NTSB. When my term expires, I hope we can look back and say, ‘you know, we—Board members, professional staff, industry, labor, government—we all worked together, and we did make a positive impact.”

Indeed, looking back, I truly believe we have made a difference.

I will very much miss working with the incredibly dedicated men and women of the NTSB. It will be hard to stop referring to the NTSB as “we.” Although I will no longer be part of it, the NTSB will always be part of me. For that privilege, I am forever proud and grateful. I have lived my dream.

Episode 41: Chairman Robert Sumwalt

In this episode of Behind-the-Scene @NTSB, Chairman Robert L. Sumwalt reflects on his time at the NTSB, from his first day on the job, to how he’s feeling about his last day as Chairman. He also shares memorable moments during his 15 years at NTSB and some of the leadership lessons he’s learned along the way.

Chairman Sumwalt’s full bio is available here.

Previously released podcast episodes featuring Chairman Sumwalt are available here.

Get the latest episode on Apple Podcasts , on Google Play, Stitcher, or your favorite podcast platform. And find more ways to listen here: https://www.blubrry.com/behind_the_scene_ntsb/

Speeding: Comprehensive Changes Needed to Save Lives

By Chairman Robert L. Sumwalt

Speeding kills about the same number of Americans as drinking and driving, yet garners far less attention. We’ve included “Implement a Comprehensive Strategy to Eliminate Speeding-Related Crashes” on our 2021–2022 Most Wanted List of Transportation Safety Improvements because we know that speeding significantly impacts safety on the country’s roads, and we think it’s past time for that to change.

About 100,000 people died between 2009 and 2018 because someone was driving faster than the speed limit, or faster than road conditions warranted. That’s around 9,000 to10,000 crash deaths per year, or nearly one in three crash deaths in the United States. Preliminary reports suggest that during the COVID-19 pandemic of 2020, speeding might have been even more prevalent in traffic deaths, despite a drop in vehicle miles traveled.

Speeding can lead to a loss of vehicle control. Faster speeds also increase the severity of injuries once a crash occurs. (If you’re having a hard time imagining this potential destruction, you can watch what happens in a speed-comparison crash test video produced by the Insurance Institute for Highway Safety.) This relationship holds true for all road users, but when vulnerable road users, such as pedestrians, bicyclists, and motorcyclists, are involved in a crash with a vehicle, their chances of being severely injured skyrocket as impact speeds increase. For a pedestrian, the risk of being severely injured goes from 10 percent at an impact speed of 16 mph to 25 percent at 23 mph, 50 percent at 31 mph, 75 percent at 39 mph, and 90 percent at 46 mph.

For drivers, passengers, and vulnerable road users alike, speeding kills.

What can be done?

Speeding deserves to be a nationally recognized road safety issue. Regulators must collaborate with traffic safety stakeholders to develop and implement an ongoing program to increase public awareness of speeding as a national traffic safety issue.

Further, we recognize that posted speed limits aren’t always based on real-world conditions. Present guidance says to set speed limits in speed zones within 5 mph of the 85th percentile speed of free-flowing traffic. But that guidance could lead to higher operating speeds, which would, in turn, result in an even higher 85th percentile speed, and on and on. What’s more, there’s no strong evidence that the 85th percentile speed decreases crash involvement rates; therefore, states should instead adopt an engineering study methodology that places less emphasis on the 85th percentile speed in favor of a more robust approach I that includes additional parameters, such as roadway geometry, crash statistics, and traffic volumes.

We believe that states should amend current laws to remove restrictions on the use of automated speed enforcement. Regulators should update and promote speed enforcement guidelines to reflect the latest enforcement technology and operating practices. For heavy vehicles, including trucks, buses, and motorcoaches, regulators should develop performance standards for advanced speed-limiting technology, such as variable speed limiters and intelligent speed adaptation devices, then require that all newly manufactured heavy vehicles be equipped with them.

At the individual level, drivers should follow the speed limit and slow down during bad weather, when a road is under repair, in poorly lit areas at night, and in other challenging driving conditions.

Finally, we should ​protect vulnerable road users through a Safe System approach—another Most Wanted List safety improvement. You can watch our May 20 roundtable on the Safe System approach on the NTSB YouTube channel.

We have yet to fully understand how the pandemic changed our driving habits as a nation; we have known for some time, however, that the faster a vehicle is going when it strikes something, the greater the energy expended in the crash, and the greater the resulting damage. Setting logical speed limits—and enforcing them—is something that can be done right now to save lives.

We hope that, as drivers return to the roads, regulators use this opportunity to reevaluate speed‑limit guidance, evaluate the effectiveness of current enforcement programs, and assess new speed-limiting technology that can improve safety for all road users.

Learn More

Implement a Comprehensive Strategy to Eliminate Speeding-Related Crashes

Safety Study: Reducing Speeding-Related Crashes Involving Passenger Vehicles | July 2017

Motorcoach Run-Off-the-Road and Collision with Vertical Highway Signpost, Interstate 95 Southbound, New York, NY | March 2011

Protect Vulnerable Road Users through a Safe System Approach

Improving Passenger and Fishing Vessel Safety

By Chairman Robert L. Sumwalt

May 22–28 is National Safe Boating Week, calling to mind well known campaigns against boating while intoxicated, distracted operations, and promoting proper use of life jackets on watercraft. But the present NTSB Most Wanted List puts a special emphasis on a lesser-known issue: the safety of passenger vessels and commercial fishing vessels.

It’s critical to watch out for your own safety and that of your guests on board personal watercraft, but when you step aboard a passenger vessel or go to work on a fishing vessel, somebody else is responsible for the whole range of safety concerns, from having appropriate fire-detection devices to well-maintained lifesaving equipment. We’re working to ensure that marine operators have your safety in mind, in part, by asking the country’s marine transportation regulating authority, the US Coast Guard, to implement our safety recommendations.

Passenger Vessels

Passenger vessels range in size from small charter vessels, such as dive boats and amphibious passenger vessels (DUKW boats or “duck boats”) to large cruise ships operating in international waters. The number of passengers and crew on these types of vessels varies.

Fires can pose a catastrophic threat to passenger vessels, as we saw in the 2019 Conception dive boat accident off the coast of California, in which 34 people died. Our investigations have revealed that crew training and safety regulations for these vessels vary, increasing the risk to passengers and crew. We have investigated 74 fire-related marine accidents since 2010.

To prevent needless deaths and mitigate injuries, passenger vessels should:

• have safety management systems,
• use voyage data recorders, and
• provide adequate fire-detection, extinguishing systems, and available emergency egress options.

Operators should ensure their crews have enhanced training that includes practicing fire drills and learning firefighting techniques. We also need to see existing requirements for roving patrols enforced to ensure passengers are being transported safely.

Additionally, amphibious passenger vehicle operators should instruct passengers that seat belts must not be worn while the vessel/vehicle is operated in the water. Each passenger should visually check to ensure they have unbuckled their belt when the vessel enters the water.

Commercial Fishing

The commercial fishing industry, which remains largely uninspected, is another marine sector of concern. Fishing consistently tops the list of most deadly occupations due, in large part, to challenging work environments, such as poor weather and rough waters. These conditions threaten vessel stability and integrity, which, as we’ve seen in our investigations, can lead to catastrophic results. More than 800 people have died on fishing vessels in the past two decades.

We need new standards to address—and periodically reassess—intact stability, subdivision, and watertight integrity in commercial fishing vessels up to 79 feet long. Many fishing crews aren’t trained in stability management techniques or emergency response, and we have found that many vessels do not have proper life-saving equipment, such as flotation devices and operational search-and-rescue locator devices.

Back on the Water

As more and more people get vaccinated against COVID-19, many Americans are considering travel again, including on personal craft, passenger, and fishing vessels. The NTSB will continue to investigate accidents such as allisions, groundings, sinkings, and vessel fires in which people are injured or lose their lives, vessels are damaged or destroyed, or there is a threat to the environment. These cases are rare, and we hope to make them rarer, but as traffic on our waterways begins to return to pre-pandemic levels, the likelihood of an accident increases.

The dedicated men and women of the US Coast Guard work to improve safety on both passenger and fishing vessels by implementing recommendations that come out of our investigations and studies. We continue to urge the US Coast Guard to act on our passenger and fishing vessel recommendations to make these marine sectors as safe as possible for crews and passengers.

Learn more

Improve Passenger and Fishing Vessel Safety

National Safe Boating Week

Fire Aboard Small Passenger Vessel Conception
Santa Barbara, CA | September 2019

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Sinking of Amphibious Passenger Vessel Stretch Duck 7
Branson, MO | July 2018

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Capsizing and sinking of fishing vessel Destination
George’s Island, AK | February 2017

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Fire aboard Roll-on/Roll-off Passenger Vessel Caribbean Fantasy
Atlantic Ocean, 2 Miles Northwest of San Juan, Puerto Rico | August 2016

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Capsizing and sinking of fishing vessel Christopher’s Joy
Southwest Pass, LA | September 2014

Twelve Years After Colgan 3407, FAA Still Hasn’t Implemented Pilot Records Database

By Chairman Robert Sumwalt

I grew up in the South, and people sometimes say we do things slowly in that part of the country. Whether there’s any validity to that claim, I can’t say with certainty. What I can say with great certainty, however, is that speed isn’t an attribute commonly associated with the Federal Aviation Administration (FAA), an agency within the US Department of Transportation. Below is a sad, but true, example of the glacial pace of the FAA’s rulemaking processes—even in the wake of a congressional mandate to get something done. Perhaps the new secretary of transportation can give a needed boost to this untenable situation.   

On this date 12 years ago—February 12, 2009—while on approach to the Buffalo‑Niagara International Airport in New York, Colgan Air flight 3407, a Bombardier Q-400 turboprop, plunged from the sky. Fifty lives were lost, including that of a man who died when the turboprop crashed into his home.

The NTSB’s year-long investigation revealed that, as the airplane slowed on approach, the captain became startled by the activation of the aircraft’s stall warning system. In response to something that should have been easily dealt with, the captain inappropriately manipulated the elevator controls, forcing the aircraft into its fateful dive. Our investigation found that the captain had a history of piloting performance deficiencies, including having failed several flight tests. Possibly more troubling, he concealed these performance deficiencies from Colgan when he applied for employment.

The Colgan crash was the deadliest US airline disaster in the past 19 years.

In response to this tragedy, the NTSB issued safety recommendations to the FAA to strengthen the way airlines ascertain a pilot applicant’s background, including requiring previous employers to disclose training records and records of any previous failures.

Congress took note of these recommendations and included them in a bill signed into law in August 2010. This law required the FAA to establish a pilot records database (PRD), and stipulated that “before allowing an individual to begin service as a pilot, an air carrier shall access and evaluate . . .  information pertaining to the individual from the pilot records database.” Items required to be entered into the PRD, and considered by hiring airlines, included “training, qualifications, proficiency, or professional competence of the individual, including comments and evaluations made by a check airman . . . any disciplinary action taken with respect to the individual that was not subsequently overturned; and any release from employment or resignation, termination, or disqualification with respect to employment.” Congress appropriated $6 million per year for the next 4 years to help facilitate creation of the PRD—a total of $24 million.

The FAA’s response reminds me of my college’s football team—they get off to a good start, but after scoring on the opening drive, they have difficulty executing for the rest of the game.

In early 2011, the FAA established an aviation rulemaking committee (ARC) to develop recommendations on the best way to implement the PRD. Despite the ARC completing its work and issuing a report to the FAA in July 2011—just 6 months after being tasked with developing recommendations—it wasn’t until September 2015 that the FAA began a phased approach to implementing the PRD.

By July 2016, Congress had become impatient with the FAA’s lack of progress. After all, it had been 6 years since the FAA was required to create the PRD, and there was still no appreciable progress. Congress gave the FAA a new deadline: it mandated the PRD be in place by April 30, 2017.

Unfortunately, April 30, 2017, came and went. Still no PRD. Meanwhile, 40 days after that deadline, a young pilot applied for employment at Atlas Air and was hired shortly thereafter. As with the Colgan Air captain, this pilot concealed his history of performance deficiencies, which deprived Atlas Air the opportunity to fully evaluate his aptitude and competency as a pilot. He struggled with training at Atlas, but after failing his check ride, he was retrained and passed. Tragically, on February 23, 2019, on what should have been a routine cargo flight from Miami to Houston, this pilot, like the Colgan Air captain, encountered something that startled him. He overreacted and put the Boeing 767 into a fatal dive. The commonalities between the Colgan Air crash and the Atlas Air crash are striking: Both pilots had a record of poor performance prior to their employment, both pilots concealed that information when applying for airline employment, and both pilots misapplied the flight controls following events they weren’t expecting. Events that should have been easily corrected. Events that, tragically, led to their aircraft plunging to the ground.

Neither of these sad events was an isolated case. Including these two crashes, the NTSB has investigated 11 air carrier accidents over 3 decades in which pilots with a history of unsatisfactory performance were hired by an airline and then were later involved in an accident attributed to their poor piloting performance.

After years of foot dragging, last March, the FAA provided its first visible indication of moving forward with the PRD, publishing a notice of proposed rulemaking (NPRM) to give the public a glimpse of what the proposed rule may look like—10 years after Congress initially mandated it, and 3 years after the April 2017 deadline that Congress eventually imposed.

The NPRM indicated that the PRD should be implemented sometime this year; however, the NPRM also proposes allowing a 2-year phase-in period. This puts complete implementation somewhere around a 2023 timeframe, assuming this proposed timeline holds. If that’s the case, we will finally have the PRD 14 years after the Colgan Air disaster, 13 years after Congress mandated it, 5 years after the deadline imposed by Congress, and 4 years after the Atlas Air crash.

A crash is a tragedy. It’s even more tragic to see a similar crash happen again and again and not have the regulatory agency responsible for safeguarding the skies take corrective action in a reasonable timeframe. We’re past the point of reasonable, and the traveling public deserves better.