NTSB: 50 Years of Advancing Safety by Faircount Media Group

THE NATIONAL TRANSPORTATION SAFETY BOARD 50 Years of Advancing Safety

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THE NATIONAL TRANSPORTATION SAFETY BOARD 50 Years of Advancing Safety

Table of Contents INTERVIEWS Webster “Dan” Todd.................................................................................14 NTSB Chairman, 1976-1978 Marion C. Blakey.......................................................................................26 NTSB Chairman, 2001-2002 Ellen Engleman Conners..........................................................................38 NTSB Chairman, 2003-2005 Mark Rosenker..........................................................................................50 NTSB Chairman, 2006-2008 Deborah A.P. Hersman.............................................................................68 NTSB Chairman, 2009-2013

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A History of the National Transportation Safety Board.......................6 By Dwight Jon Zimmerman NTSB Organization...................................................................................10 Promoting Safety.......................................................................................22 By Craig Collins The NTSB’s Most Wanted: Greasing the Gears of Change..................30 By Craig Collins Walk the Scene..........................................................................................42 The Accident Investigation Process By Eric Tegler Families and Fundamentals.....................................................................60 Transportation Disaster Assistance By Jan Tegler The Office of Administrative Law Judges...............................................74 The NTSB Training Center........................................................................78 By J.R. Wilson

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For both the public and the workers who keep this country moving, the NTSB plays a vital role in investigating accidents. Only through comprehensive investigation into the causes of each catastrophic accident can we move forward toward prevention. In this regard, the research and advocacy of the NTSB is vital to protecting our workforce and the public. is government agency’s success at reducing accidents demonstrates the vital role of government oversight in protecting the lives of American citizens. e combination of technical expertise and tenacity as well as independence from outside interference is the hallmark of the agency. We should not forget the hardship faced by investigators who respond to the scene of a devastating accident or have to piece together the details of a terrible chemical spill. ese dedicated researchers deserve our appreciation and support for the diﬃcult work they do. e success of this government agency in reducing chemical accidents, boat and plane disasters, roadway crashes and railway accidents is a testament to America’s leadership and commitment to safety. erefore, on behalf of the working women and men of the International Union, UAW we are proud to congratulate the NTSB on its 50th year of leading America and the world in accident prevention. Dennis Williams President

Gary Casteel Secretary-Treasurer

Vice Presidents Cindy Estrada, Norwood Jewell, Jimmy Settles

THE NATIONAL TRANSPORTATION SAFETY BOARD 50 Years of Advancing Safety Published by Faircount Media Group 4915 W. Cypress Street Tampa, FL 33607 Tel: 813.639.1900 www.defensemedianetwork.com www.faircount.com EDITORIAL Editor in Chief: Chuck Oldham Managing Editor: Ana E. Lopez Editor: Rhonda Carpenter Contributing Writers: Craig Collins, Eric Tegler Jan Tegler, J.R. Wilson, Dwight Jon Zimmerman DESIGN AND PRODUCTION Art Director: Robin K. McDowall Designer: Daniel Mrgan Ad Traffic Manager: Rebecca Laborde ADVERTISING Ad Sales Manager: Art Dubuc III Account Executives: Chris Day Brandon Fields, Patrick Pruitt OPERATIONS AND ADMINISTRATION Chief Operating Officer: Lawrence Roberts VP, Business Development: Robin Jobson Business Development: Damion Harte Financial Controller: Robert John Thorne Chief Information Officer: John Madden Business Analytics Manager: Colin Davidson FAIRCOUNT MEDIA GROUP Publisher, North America: Ross Jobson

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A History of the National Transportation Safety Board By Dwight Jon Zimmerman

The NTSB’s origins can be traced to the Air Commerce Act of 1926, which empowered the Department of Commerce to regulate private aviation and investigate air accidents. The department created the Aeronautics Branch to handle these new responsibilities. The act also charged the Department of Commerce with fostering air commerce, particularly the budding commercial airline industry. Just shy of five years later, on March 31, 1931, TWA Flight 599, a wooden-winged Fokker F.10 tri-motor airplane, departed from Kansas City, Missouri, en route to Los Angeles, California. About 140 miles later,

it crashed into a field near Bazaar, Kansas, killing all eight passengers and crew. Among the passengers was legendary University of Notre Dame coach Knute Rockne. The tragic death of such a revered man shocked the country President Herbert Hoover called his death “a national loss.” Prior to the Flight 599 accident, all Aeronautics Branch investigations and reports of aviation accidents were kept secret and not publicly commented upon. However, the public’s interest in this crash was intense, and mourning Americans wanted answers. In response to the heightened scrutiny, Aeronautics Branch investigators made

public statements about first one possible cause of the accident – which upon further investigation was disproved – then another (again disproved), followed a few days later by more inaccurate statements. Confidence in the Aeronautics Branch to competently investigate and reach conclusions uninfluenced by relationships with the airline industry was low. As a result, when the Air Commerce Act was amended in 1934, it required that accident reports be made public. That same year, the Aeronautics Branch was renamed the Bureau of Air Commerce. So it was the newly dubbed Bureau that came under scrutiny when

Library of Congress photo

The National Transportation Safety Board (NTSB) was established by Congress as an independent agency within the Department of Transportation (DOT) on April 1, 1967, to investigate transportation accidents and issue safety recommendations based on its findings, with the aim of preventing future accidents. With a workforce of 430, the NTSB investigates all civil aviation accidents in the United States as well as significant railroad, highway, maritime, and pipeline accidents, and over the years it has come to have an enormous impact on transportation safety in the air, on the ground, and on the water in the United States. Though it does not have any regulatory authority to address safety issues it uncovers, an overwhelming majority of its safety recommendations – approximately 80 percent of 14,500 to date – have been adopted, changing the transportation habits and practices of the nation.

AP Photo

the 1935 crash of a TWA DC-2 in Missouri that killed New Mexico Sen. Bronson M. Cutting – the majority of the blame for which the Bureau, in its accident report, laid on the airline – prompted a congressional investigation into air traffic safety and the Bureau’s operations. Congress determined that the Bureau of Air Commerce – which was tasked with both promoting commerce through aviation and investigating accidents, even if government entities or prominent American companies were found to be at fault – had questionably close relationships with airlines and manufacturers and was reluctant to admit when its own rules and procedures might have contributing to an accident. The need for an independent investigative body was clear. Passage of the Civil Aeronautics Act in 1938 created the Civil Aeronautics Authority and within it the Air Safety Board, an independent group that would conduct investigations of aviation accidents and suggest ways to prevent accidents going forward. Shortly after, in 1940, President Franklin D. Roosevelt split the Civil Aeronautics Authority into the Civil Aeronautics Administration (CAA) and the Civil Aeronautics Board (CAB), both part of the Department of Commerce. Accident investigation duties fell under the purview of

OPPOSITE PAGE: Legendary Notre Dame football coach Knute Rockne. Rockne’s death and the investigation into the airplane crash in which he was killed prompted increased transparency in aviation accident investigations. ABOVE: Fire and ambulance workers search through wreckage for bodies after a Piedmont Airlines jet crashed in a wooded area near Hendersonville, North Carolina, July 19, 1967. The NTSB investigation that followed was the first major investigation begun after the new agency took effect.

the Bureau of Safety within the CAB, which functioned independently. The advent of jet travel, coupled with a series of mid-air collisions in the 1950s – including a highly publicized one over the Grand Canyon in 1956 – prompted passage of the Federal Aviation Act of 1958. The act established the Federal Aviation Agency to regulate aviation, ensure the safety and efficiency of national airspace, oversee air traffic control, and develop airways. It became the new home of the CAB, which maintained accident investigation duties. By the 1960s, transportation and its technology had grown, advanced, and expanded to such an extent that existing government departments and agencies were being overwhelmed. This led to the creation in 1967 of the Cabinet-level Department of Transportation (DOT). Existing transportation-related agencies such as the Federal Railroad Administration, the Federal Highway Administration, and the Federal Aviation Agency – renamed the Federal Aviation Administration (FAA) – folded into DOT. Likewise, the safety promotion and accident investigation responsibilities of the

separate modal agencies were consolidated in a single new organization: the National Transportation Safety Board. The NTSB was established as an independent agency effective April 1, 1967, placed within DOT solely for administrative purposes. It would henceforth investigate aviation, highway, maritime, and pipeline accidents, as well as accidents involving transportation of hazardous materials. The NTSB was a little more than threeand-a-half months old when it started the first major investigation begun under the new agency: a fatal mid-air collision between a twin-engine private airplane and a commercial airliner. On July 19, 1967, Piedmont Airlines Flight 22, a new Boeing 727-22, took off from the runway of the Asheville Regional Airport in Hendersonville, North Carolina. Because weather was a 2,500-foot ceiling with broken clouds and hazy conditions, the airline was operating under instrument flight rules, or IFR. Flight 22 was in its takeoff roll in a climbing left turn and reaching 6,000 feet when a Cessna 310, also operating under IFR, slammed into its fuselage just aft of

the cockpit. Eyewitnesses on the ground reported the collision sounded like a large explosion, like that of a jet breaking the sound barrier. The Cessna disintegrated on impact and the Boeing 727 rolled on its back and crashed vertically into a summer camp. Everyone in the two airplanes was killed, with no fatalities suffered on the ground. Among the passengers was Assistant Secretary of Defense for International Security Affairs John T. McNaughton, Secretary of Defense Robert McNamara’s closest adviser. A five-member NTSB team led by Chairman Joseph J. O’Connell, Jr. was formed to investigate. Members included John H. Reed, Oscar Manuel Laurel, Louis M. Thayer, and Francis H. McAdams. A lawyer, O’Connell’s public service began in 1933, when he worked as an attorney in the Public Works Administration. In 1938, he went to the Department of the Treasury, becoming assistant general counsel in 1941 and general counsel in 1944. In 1947, he briefly returned to private practice before being appointed chairman of the CAB in 1948, where he served for two years. He was chairman of the board of Lake Central Airlines from 1955 to 1965. In 1967, President Lyndon Johnson called him from private practice and appointed him the NTSB’s first chairman. Reed would succeed O’Connell as the NTSB’s second chairman. Before that, Reed served as a Maine state representative and

senator, as well as the state’s governor. After his service on the NTSB, he would go on to become U.S. ambassador to Sri Lanka and the Maldives. Laurel was a Texas state representative and district attorney before being appointed to the NTSB. Thayer was a retired Coast Guard rear admiral who would serve in the NTSB for nine years. McAdams was a U.S. Navy aviator in World War II. After earning his law degree, he served as a corporate and trial attorney for Capital Airlines. He was also an attorneytrial examiner, air safety investigator, and later senior trial attorney for the CAB. He would serve on the NTSB for 16 years. On Sept. 5, 1968, following completion of its investigation, the team issued a 56-page report on the accident. It concluded: “The Safety Board determines that the probable cause of this accident was the deviation of the Cessna from its IFR clearance, resulting in a flight path into airspace allocated to the Piedmont Boeing 727. The reason for such deviation cannot be specifically or positively identified. The minimum control procedures utilized by the FAA in the handling of the Cessna were a contributing factor.” The same questions regarding impartiality in safety investigations that had been raised with previous agencies tasked with investigation duties were raised again soon after the NTSB was formed. The point was made that accident causation might sometimes involve issues of inadequate oversight by sister DOT agencies like the FAA, and in such cases, how could the NTSB assure the public that its investigations would be both thorough and objective? That concern led Congress to pass the Independent Safety Board Act of 1974, which separated the NTSB from DOT and

made it a truly independent agency within the federal government. It now reports directly to Congress. While the mandate to conduct thorough and objective accident investigations is likely the best known of the NTSB’s responsibilities, its duty to advocate and promote the safety recommendations that emerge from its investigations and safety studies is just as important. In 1990, the NTSB released its first “Most Wanted List” of transportation safety improvements. The purpose of the list was to prioritize and bring public attention to chronic transportation safety problems that for a variety of reasons had not been resolved. In so doing, the NTSB hoped to nudge the appropriate bureaucracies to act, or, failing that, to harness the power of public opinion to demand appropriate action be taken. The NTSB’s first Most Wanted List contained 18 recommendations, among them calls to reduce airline crew fatigue and to improve runway safety. Heading the list was “Positive Train Separation,” signaling and braking systems to ensure constant safe distance separation between trains. Later changed to “Positive Train Control Systems,” it remained on the list until 2008, when Congress passed the Rail Safety Improvement Act in response to several significant rail accidents between 2002 and 2008. The legislation requires implementation of positive train control on the nation’s railroads in addition to other safety measures.

Library of Congress photos

LEFT: President Lyndon B. Johnson signed the Department of Transportation Act of 1966, enacted April 1, 1967, that created the Department of Transportation (DOT) and the National Transportation Safety Board. RIGHT: President Gerald Ford signed the Independent Safety Board Act of 1974, which made the NTSB a completely independent agency separate from DOT.

NTSB photos

ABOVE LEFT: An NTSB accident report photo of wreckage from the crash of Valujet Airlines Flight 592 on May 11, 1996. Several commercial aviation accidents in the late ‘80s to mid ‘90s highlighted the lack of support for the families of aviation accident victims and prompted passage of the Aviation Disaster Family Assistance Act and the subsequent development of the NTSB’s disaster assistance role. ABOVE: An aerial view of the accident scene of the collision of a Metrolink train with a Union Pacific train in Chatsworth, California, Sept. 12, 2008. The NTSB’s aviation disaster assistance duty was expanded to include certain accidents in other modes – including rail – shortly after the Chatsworth accident. LEFT: Transportation Disaster Assistance Specialist Max Green presents on planning and preparedness at the NTSB Training Center during a three-day training course about family assistance programs. The NTSB Training Center provides a space to train NTSB employees and to share its investigative and disaster assistance expertise with the wider transportation community.

A series of commercial aviation accidents in the late ’80s through the mid ’90s highlighted the lack of support for victims’ loved ones in the wake of these transportation disasters. The 1996 crash of TWA Flight 800 into a New York neighborhood shortly after takeoff, and that accident’s aftermath, spurred Congress to bestow upon the NTSB a new responsibility: assisting victims of transportation accidents and their families. The Aviation Disaster Family Assistance Act of 1996 requires the NTSB to coordinate federal, state, local, volunteer, and air carrier disaster response resources to ensure there is a compassionate and efficient framework in place to provide information and support services to those affected by aviation accidents. This disaster assistance

role was expanded to include accidents in other modes starting with the Rail Passenger Disaster Family Assistance Act of 2008. In November 2000, the NTSB announced that it would break ground on the NTSB Academy, a space dedicated both to training that would increase NTSB employees’ skills and to making its investigative and disaster assistance expertise more readily available to the wider transportation community. Located on George Washington University’s campus in Virginia and adjacent to the DOT’s National Crash Analysis Center, the facility opened in September 2003. It changed its name in 2006 to the NTSB Training Center to better reflect its internal training activities.

In the 50 years since it was established, the NTSB has investigated more than 145,000 aviation accidents and thousands of surface transportation accidents. With the majority of its resulting safety recommendations accepted, it has undoubtedly made the movement of people and commerce safer in all transportation modes. Thanks to its record of objectivity and impartiality in its investigations and the thoroughness and transparency of its reports, the NTSB has earned the respect, admiration, and trust of the American public. Given its experience and reputation, the NTSB recognizes the many transportation challenges ahead and will continue to work hard to keep American transportation and infrastructure safe.

NTSB Organization The National Transportation Safety Board (NTSB) is led in its mission by a Board of five members, each appointed by the president and confirmed by the Senate to serve five-year terms. The president also nominates two of the five members to serve as chairman and vice chairman, each with a two-year term. The chairman must be separately confirmed by the Senate. The vice chairman serves as acting chairman when there is no designated chairman. The offices that make up the NTSB report to the chairman. They are: the Office of the Chief Financial Officer; the Office of the General Counsel; the Office of Safety Recommendations and Communications; the Office of Equal Employment Opportunity, Diversity, and Inclusion; and the Office of the Managing Director. The current Board members are: Chairman Robert L. Sumwalt, Christopher A. Hart, Earl F. Weener, Ph.D., and T. Bella Dinh-Zarr, Ph.D. There is one vacancy. The Office of the Chief Financial Officer The Office of the Chief Financial Officer develops the budget requests for the Board that are submitted to Congress and to the Office of Management and Budget and manages the NTSB’s financial resources. Additionally, the office oversees the agency property and inventory control programs, analyzes the fee structure for services the NTSB provides on a reimbursable basis, prepares financial statements required by the Accountability of Tax Dollars Act, and ensures compliance with the Federal Managers’ Financial Integrity Act. The Office of the General Counsel The Office of the General Counsel supports the activities of the NTSB by providing legal advice, assistance, and representation. It determines the agency’s legal policy. The office ensures that the NTSB and its activities comply with applicable laws and regulations, and prevents the use of certain Board products in civil litigation by upholding statutory prohibitions against it.

The NTSB’s ethics officials are part of the Office of the General Counsel. The Office of Safety Recommendations and Communications The Office of Safety Recommendations and Communications ensures that the NTSB’s mission and strategic positions and information about its activities are accurately communicated to Congress, state and local governments, the loved ones of those involved in transportation disasters, the media, and the public. Six divisions carry out the duties of this office: • The Media Relations Division serves as the NTSB’s point of contact for media. • The Division of Government Affairs manages responses to inquiries about NTSB’s mission from Congress and other government entities. • The Safety Advocacy Division develops and implements advocacy programs – including the Most Wanted List – to draw attention to and build support for its safety recommendations.

• The Transportation Disaster Assistance Division carries out the Board’s mandate to facilitate assistance for victims of transportation accidents and their families. • The Safety Recommendations Division ensures that the agency issues appropriate and effective safety recommendations and tracks the status of recommendations at the state, federal, and industry levels. It also tracks the acceptance rate of NTSB’s recommendations. • The Digital Services Division manages NTSB’s digital media presence, programs, and online engagement with the public and stakeholders to share information about the agency, its products, and its safety messages. The Office of Equal Employment Opportunity, Diversity, and Inclusion The Office of Equal Employment Opportunity, Diversity, and Inclusion (EEODI) is responsible for overall leadership and management of the NTSB’s equal employment opportunity, diversity, and inclusion program. EEODI works to eliminate barriers to equal employment opportunity, resolve workplace conflicts, and implement diversity and inclusion awareness activities and training to ensure that all members of the NTSB workforce feel valued and motivated to perform their jobs advancing transportation safety in a diverse, inclusive workplace. The Office of the Managing Director The Office of the Managing Director is responsible for the overall leadership, direction, and performance of the NTSB. As such, it assists the chairman in carrying out the role’s executive and administration functions, oversees the day-to-day operation of the agency, coordinates activities of NTSB staff, develops strategies to achieve operating plan objectives, manages volunteer activities, and handles interagency coordination.

NATIONAL TRANSPORTATION SAFETY BOARD

Member

Vice Chairman

Chairman

Member

Office of the Chief Financial Officer

Office of the General Counsel

Office of the Managing Director

Office of Safety Recommendations and Communications

Office of Equal Employment Oppournity, Diversity and Inclusion

Office of Research and Engineering

Office of Railroad, Pipeline and Hazardous Materials

Office of Aviation Safety

Office of Highway Safety

Office of Marine Safety

Office of the Chief Information Officer

Office of Administration

Office of Administrative Law Judges

NTSB graphic

Additionally, the office manages the NTSB Training Center. The Office of the Managing Director encompasses eight offices and two divisions, described below. The Office of Research and Engineering Technical support to accident investigations is provided by the Office of Research and Engineering through four divisions (described below). The office also conducts safety studies in all transportation modes. • The Safety Research Division prepares safety reports based on analyses of transportation accident data, which are used to determine factors common to a series of events and to identify safety improvements or evaluate the worth of transportation-related devices or policy. Additionally, the division provides statistical expertise to support the NTSB’s analytical projects. • The Vehicle Performance Division provides specialized mechanical and aeronautical engineering, biomechanics, and accident reconstruction support for investigations. It uses computational and visualization technology to create accurate time-motion histories, computer simulations, and video animations of accident scenarios, and it determines vehicle and occupant motion as well as the causes of that motion.

• The Vehicle Recorder Division extracts, formats, and analyzes data from a range of recording devices, including aircraft flight data and cockpit voice recorders, recorders in locomotives, large ships, and highway vehicles, and other electronic devices with nonvolatile memory. It can work with both damaged and undamaged recorders. The division also examines electronic audio and video information recorded from aircraft, ship, train, support communication systems, and personal electronic devices. • The Materials Laboratory Division’s materials engineers examine wreckage and parts from accidents in all transportation modes. Division staff perform engineering and scientific analyses to determine if the performance of materials and structures in accident conditions is related to the cause or severity of an accident. • Medical Investigation Staff advise the Board on biomedical aspects of investigations, including pathology, toxicology, human performance, and biomechanics. The Office of Railroad, Pipeline, and Hazardous Materials Investigations As its name suggests, the Office of Railroad, Pipeline, and Hazardous Materials

Investigations carries out investigations into accidents involving railroads, pipelines, and the transportation of hazardous materials. The safety recommendations that result from these investigations are issued by the NTSB to federal and state regulatory agencies, industry and safety standards organizations, carriers and pipeline operators, equipment and container manufacturers, producers and shippers of hazardous materials, and emergency response organizations. There are four divisions in the office: • The Railroad Division conducts investigations of passenger railroad, freight railroad, and commuter rail transit system accidents, which often involve collision or derailment. Some such accidents result in the release of hazardous materials. • The Pipeline and Hazardous Materials Division handles investigations of accidents involving the transport of hazardous liquids through pipeline systems as well as accidents in which the release of hazardous material threatens public safety. The division investigates accidents in all modes of transportation, as hazardous material may be moved via rail tank cars, highway cargo tanks, and smaller nonbulk packaging. • The Human Performance and Survival Factors Division’s human performance investigator examines the performance of persons whose actions may have caused or contributed to an accident. The division’s survival factors investigator examines factors such as safety procedures, crashworthiness, equipment design, emergency response, and emergency procedures training that affect the survival of people involved in accidents. • The Report Development Division drafts and edits investigation reports, safety recommendation letters, and special investigation reports. The Office of Aviation Safety The Office of Aviation Safety investigates domestic aviation accidents and incidents involving civil air carrier, commuter, air taxi aircraft, general aviation and certain public-use aircraft. The office participates in investigations of major airline accidents

in foreign countries when U.S. carriers and/or U.S.-manufactured or -designed equipment is involved, according to U.S. obligations stated in International Civil Aviation Organization agreements. The office proposes probable causes of accidents and incidents and develops safety recommendations with the aim of preventing similar future accidents or incidents. The Office of Highway Safety Significant highway crashes that highlight national safety issues, generate strong public interest, or are likely to diminish public confidence in highway transportation safety are investigated by the Office of Highway Safety. The office also works to identify common safety risks or underlying causes of crashes by conducting studies on trends that emerge from its crash investigations and from other research. The office has two divisions: • The Investigations Division comprises investigators with expertise in human performance, highway factors, vehicle factors, survival factors, and commercial motor carrier operations, distributed among three investigative teams. • The Report Development Division researches national highway safety issues and oversees development of accident reports and safety recommendations. The division manages public hearings held during ongoing accident investigations. It also raises public awareness by managing forums and other settings that bring attention to highway safety issues. The Office of Marine Safety It is the responsibility of the Office of Marine Safety to investigate major marine accidents on or under the navigable waters, internal waters, or the territorial sea of the United States as well as accidents involving U.S.-flagged vessels worldwide with the aim of determining probable cause and developing safety recommendations to prevent similar accidents in the future. Additionally, the Office of Marine Safety investigates accidents involving U.S. public vessels and non-public vessels, accidents that may involve U.S. Coast Guard (USCG) marine safety functions, and may

investigate – either independently or with another government – marine accidents in which the United States is a party of substantial interest. Recurring accidents, such as those related to recreational boating safety, and catastrophic accidents on U.S. waters may also come under investigation by the Office of Marine Safety. The office is involved in both U.S. and international groups dedicated to improving marine investigations and promoting maritime safety. The Office of the Chief Information Officer Four divisions and one program area carry out the Office of the Chief Information Officer’s duty to provide strategic direction and operational support for NTSB information systems and to develop and distribute programs and products for use by the Board and the public. • The Computer Services Division provides help desk support for a range of computer-related issues, including setup, repair, network connectivity, and software installations and upgrades, and network engineering support for account administration, email, internet access, and backup/recovery and security. • The Systems Support Division develops, distributes, and maintains NTSBspecific applications such as accident data collection, storage, analysis, and dissemination and management of systems for accident records, safety recommendations, correspondence, Freedom of Information Act (FOIA) requests, and general administration. The division also supports program offices with database administration services. • The Records Management Division manages the NTSB archives of accident investigation files, reports, and other agency records. It provides general records management oversight, fulfills public requests for information, provides training for its Docket Management System, and monitors privacy and confidentiality of data and information. • The Enterprise Architecture Division defines how – in business and in technology terms – the NTSB currently

operates, how it plans to operate in the future, and how it intends to invest in technology to make the transition to its future operations. • The Information Technology (IT) Security Program ensures that the NTSB is in compliance with IT security requirements put in place by the Federal Information Security Management Act of 2002. The Office of Administration The Office of Administration manages infrastructure and support activities for the NTSB. Four divisions – Administrative Operations and Security, Acquisition and Lease Management, Human Resources, and Safety – handle those duties, which range from human resources management, labor relations, and occupational safety and health to facilities management and support, acquisitions and lease management, physical inventory, and shipping and receiving. The Office of Administrative Law Judges The Office of Administrative Law Judges fulfills the NTSB’s role as a “court of appeals” for airmen, mechanics, or mariners who have been the subject of certificate action taken by the Federal Aviation Administration (FAA) or the USCG. Four NTSB administrative law judges hear and consider appeals filed with the Board and issue initial decisions. The judges also adjudicate claims for fees and expenses incurred from FAA certificate and civil penalty actions. The Strategic Management Program This division is responsible for strategic planning; performance management and evaluation; operating plans, the agency’s annual report to Congress, internal audits and reviews, Government Accountability Office liaison activity and support; and the communications survey. The Quality Assurance Division This division oversees notation process and quality assurance, correspondence management, and modal office product coordination. NTSB organization information sourced from www.ntsb.gov.

INTERVIEW:

Webster “Dan”Todd NTSB Chairman, 1976-1978 By Ana E. Lopez

Webster “Dan” Todd was the third chairman of the National Transportation Safety Board (NTSB). Appointed to the position by President Gerald Ford not long after the NTSB gained its independence from the Department of Transportation, Todd endeavored during his two years as chairman to firmly establish and make known the agency’s autonomy in both the ranks of the NTSB and in all those – in government and industry – who interacted with it. In the years leading to his NTSB service, Todd bought – and then rebuilt – a small New Jersey airport and started a commuter airline. He also served in several government positions, among them special assistant to the chair of the Civil Aeronautics Board, deputy special assistant to President Richard Nixon, and Inspector General of Foreign Assistance in the State Department. He returned to the private sector after his time at the NTSB, and held senior-level executive positions with such organizations as Frontier Airlines, the Air Line Pilots Association, and the Aircraft Owners and Pilots Association. Todd is a commercial pilot, a U.S. Coast Guard licensed captain, a certified mountain search and rescue pilot, and a firefighter.

Before you entered public service you were quite involved professionally in the aviation field. I read that you were a partner in a couple of different aviation companies, and started a commuter airline and owned an airport, is that correct? Webster “Dan” Todd: I did. I started out as a fixed base operator in a small leased airport in New Jersey. And it didn’t take me very long to figure out that leased airports weren’t the best way to try to make a living. So I bought out the operation in Princeton, New Jersey, bought enough land adjacent to the airport, redesigned the airport, and built a new airport in Princeton, which opened in 1964. … At Princeton, we started a scheduled commuter back in the days when there weren’t

that many. I’ve always considered us one of the four or five operations that founded the whole third tier scheduled system – with the help of United Airlines, I might add. United Airlines was a huge supporter of feed collection through the scheduled air taxis. … So I had the airlines, I had the fixed base operation, I had a couple of flight schools. I started General Aviation Engineering, which dealt with small GA [general aviation] airports. I also served as chairman of the Scheduling Committee of the National Air Taxi conference, and held a couple of other offices in membership organizations around the country. So I was pretty well versed. I won’t say I had a lot of 121 airline experience. On the ground side, I’m an A&P mechanic. I’m a farmer. I ran a lot of the

NTSB investigators Ron Kaminski and Steve Prouty document the scene at a highway/railroad grade crossing accident in White Marsh, Maryland. On-grade crossings posed a safety risk during Webster “Dan” Todd’s term as NTSB chairman in the mid ‘70s and continue to be an issue today.

NTSB photo

equipment in building these airports. I knew the road systems very well. I had some familiarity with railroads because my father had something to do with the railroads. I didn’t know anything about big maritime. I knew little boats, but I didn’t know maritime. I didn’t know anything about pipelines, which the NTSB had. So I was pretty comfortable with three of the five industries that were our clients. I had a lot of learning to do with maritime and pipeline. So it was a pretty good fit. And I think the real reason that I was selected to be chairman was because I started in Washington as special assistant to the chairman of the Civil Aeronautics Board in 1969, where I handled the Hill for Chairman [Secor D.] Browne. I got to know most of the aviation and substantive committee and appropriations committee staffers and members. Secor was very well regarded on the Hill and that rubbed off on me. You became chairman of the NTSB after the Transportation Safety Act went into effect and made the NTSB separate from the Department of Transportation. What were some of the particular challenges you faced as chairman during that transition? The first challenge was the technical side of the administrative separation. The government, as you probably are well aware, is an amorphous mass. You try and find structure but it’s way too easy to obfuscate to the point of being paralyzed. So, I felt my first job was to make sense out of the administration of the Board and set it up for a life of its own, which it never had. There was no culture. There was no history – the history was always looking over your shoulder to see who is going to tell you you can’t do it. That mindset, you can’t

But the second priority was establishing the political credibility, because nobody on the Hill respected the Board as an entity, because it was not the Board – it was controlled by the Secretary of Transportation or it was controlled by the administrator of the FAA. … You need the credibility of the Board, the political management.

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erase that by just saying, “Hurray, we’re independent!” You’ve got to erase that by concrete action that reestablishes the credibility of the agency in and of itself. And that allows you to develop your own culture. That was the first thing. But the second priority was establishing the political credibility, because nobody on the Hill respected the Board as an entity, because it was not the Board – it was controlled by the Secretary of Transportation or it was controlled by the administrator of the FAA. … You need the credibility of the Board, the political management. This is really important. The political management, the National Transportation Safety Board and its operations, are presumed to be neutral. They are presumed to be a fact-finding and analytical agency, that is not – not – subject to outside influence. And in the last couple of years before I got there, lawyers from various entities would have ex parte communications with the chairman and change language in Board reports. Now that’s outrageous. That’s just not acceptable. And those kinds of things had to be stopped. And thank God, you know, my

reputation is I don’t care about the job, I’m going to do what is right. I very quickly got into it with one of the major aerospace providers who knew about the issue [of a] report on an accident, and these fellows didn’t like it. So their corporate counsel was skiing in Switzerland. They flew him from Switzerland the day before we were going to release the report. He called me up and he said, “I’m going to come to a meeting.” I said fine. He comes to the meeting with me, and I had included Fritz Puls, who was my general counsel, and Harry Zink, who was my administrative assistant. He said, “What are they doing here?” I said, “I’m sorry, if you think I’m going to sit in a room with you alone, you’re nuts.” “Well,” he said, “that’s the way we do it.” I said, “It ain’t the way we do it anymore.” He proceeded to tell me what language I had to change in the report. And I took his hat and sailed it out the door. And sent him out after it. But that kind of stuff was a regular occurrence. And that had to stop. The third thing that needed attention was the field offices. The field officers and the more senior

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The process was the same.They all had a suitcase packed. And when it’s decided that a Go Team has to go to the accident, for whatever reason, whatever threshold it crosses that requires the Go Team ... then the senior staff member will be a senior field investigator (IIC) in that discipline. Washington staff felt – and I think this is probably a feeling that’s pretty common in government agencies – that merit was not the only basis upon which promotions were given and assignments were handed out. And that’s a pretty sticky tar baby. And it’s very hard to say it was or it wasn’t. But if the perception is there, who cares what the facts are? You’ve got to deal with the perception. So … that required a lot of time expenditure on my part, just visiting, visiting, visiting, and doing more than a chairman normally would have done. For example, the first accident I ever went to was an Alaska Air 727 that had a landing incident in Ketchikan. A guy came in a little hot. He got on the brakes and the airplane hydroplaned, and the rubber in the tires reverted, causing it to slide off the end of the runway. The flight crew did an amazing job. There was a ravine – there used to be a ravine – right off that end of the runway at Ketchikan, and it crumpled up the airplane. There was only one fatality. I said to the member who was assigned to the Go Team, “When are you leaving for Alaska?” He said, “Well, I’m not going to Alaska.” I said, “Wait a minute, we have a 727 off the end of the runway with a fatality.” He said, “Well it’s only one fatality. That’s not important enough.” I thought to myself, “Jesus H. Christ. What is going through these guys’ minds?” Well, Robin [Martin, an assistant] and I, we thumbed our way to Seattle, spent the night in the airport in Seattle, thumbed our way to Anchorage, somehow got down to Ketchikan and handled it ... with the Go Team. And the word was, “Did you hear the chairman went to Ketchikan? We better pay attention here.” By the way, that accident led to significant redesign of the reversers on the 727, so you never know at the beginning where you will end up. You mentioned Go Teams. And I understand that’s part of the investigation process today – the Go Teams, the Party System, requirements for media briefings, etc. Was that the same accident investigation process when you were chairman? Has it stayed unchanged from the earliest days of NTSB? Yes. [With] the Go Teams, there is a rotating suitcase amongst the members. If I went, I don’t go next time. If you go next time … The process was the same. They all had a suitcase packed. And when it’s decided that a Go Team has to go to the accident, for whatever reason, whatever threshold it crosses that requires the Go Team ... then the senior staff member will be a senior field investigator (IIC) in that discipline. In other words, it’ll be a pipeline guy if it’s a pipeline accident. It’ll be a railroad guy if it’s a railroad accident, and so on up the line. And then, when I was there, each group had their specialists. If it was a significant event (Tenerife aviation accident, Wenatchee tank car explosion), usually a member of the Public Information Office went as well. And you’d look at the initial information that was available and you put on the Go Team people who have expertise in all the identified stuff. Now if you went through the process, you might find you needed more or less, or didn’t need this person or didn’t need that person. But that came after you had a chance to think about the whole thing.

And there are a couple of things about investigations that you have to realize and make allowance for. First of all, eyewitnesses are the most unreliable witnesses in the world. That’s not an individual criticism. It’s a human fact that unless you’re trained, highly trained, you can’t remember anything that you see in great and less detail to be helpful. And often you remember things that aren’t true. And that’s not because you’re crazy. It’s because you don’t have a background to absorb the information, and analyze it, and process it. … The second fact to understand, which is kind of sad in a way, if the situation is in a populated area, securing the wreckage is really tough because we are a society of collectors. Most people will say, “I found something over here and I don’t know what it is.” So somebody should – will – go mark it, and stake it, and write it down, and take a picture, and know that it is part of an elevator, know it is part of the wheel brake on a tank car or whatever. But a lot of stuff just disappears. And sometimes a small thing can make a difference. So securing the accident site is really important. And that goes for all of the people who think they are going to be parties, if they think they are going to be parties and they send somebody to the accident site. For the member and the IIC, the two most difficult things are securing the site, and keeping people out of there that have no business being there, particularly if they happen to be uninvited. Let’s take an accident. I don’t care what discipline you are under. If it’s a railroad accident, the IIC is going to want people from the railroad company there. He wants to ask them – they’re going to see things – and say, “How could this happen?” But he doesn’t want the lawyer there – he wants the guy who changed the switch. So you’ve got to keep all those people out. And that is tough. That is really tough. What were some of the most pressing safety issues that the NTSB was trying to get addressed while you were chairman? Aviation was the designated engineering representative process whereby the FAA certificated new airplanes, one. And, two, was the air traffic control system,

The big issue with maritime was, and still is, I believe, the fact that there is no international standard for language. the management. And again, you have to go back to time frame. When I became chairman, the causal factor in most accidents shifted from mechanics to human factors. So if I’m pleased with anything that I did, I was there … when the Board made the transition to human factors, and cockpit resource management, and human ergonomics in the train engine cab – chemical impairment in the urban mass transit. I mean, I don’t think we had an urban mass transit accident that wasn’t either caused or exacerbated by the operators who were not there. For whatever reason. With the pipelines, it was One Call. One Call was sort of an embryonic idea back in the ’70s. And we firmly believed then and believe now that if you call before you dig, you’re going to cut the intrusive actions to almost nothing. And people get in a hurry and they don’t call. And that’s when they dig up 600-volt electrical lines. In the railroads, [it was] impenetrable head shields on super tank cars. And that’s gone away now. The railroads have finally said, “Well, we can’t make any money if we have to put these on the cars.” So now we’ve got super tankers full of corrosive and hazardous materials without head shields. And maybe they’ve got some engineering cure or magic wand that they wave every time there is a derailment that keeps a tank car from being pierced, but I don’t … see what it is. On highway safety, the big issue in highways and railroads was separated crossings. The number of railroad and highway intersections that were on grade was cut significantly. But it’s expensive to do that, it’s expensive to maintain that. And in my state of Montana, five years after I left the Board, I watched two separated grade crossings be put into on-grade crossings because it was cheaper. … On-grade crossings are just absurd. You can’t fix them all. I understand that. But you surely shouldn’t create any new ones.

The big issue with maritime was, and still is, I believe, the fact that there is no international standard for language. You can have a Panamanian registration with a British bridge crew, and a Portuguese deck crew, and a Chinese engine crew. And if something goes wrong, they can’t talk to each other. Can you imagine a super tanker or one of these big container ships where the guys who are making it go don’t speak the same language as the people that are asking it to go? And handling the cargo, can’t speak to anybody because there is no common [language]? It’s just bizarre. It’s better now, but it is still a big problem. I understand you have a commercial license as well and you’re a certified flight instructor. So clearly aviation has been a part of your life, probably your whole life! What impact has the work of the NTSB had on you personally as a pilot over the years as far as regulations that have been put in place because of recommendations that the NTSB made, for example? The NTSB has worked very closely with the FAA on flight time duty time, on ergonomics in the cockpit, on certification procedures that deal with human factors. It’s all little stuff. But it adds up to a cumulative factor that is pretty massive. I think the Board does a very good job of keeping the system honest. And I don’t say that lightly, and I’m not pointing the finger at anybody. I’m just saying that the economic pressures today are way worse than they were when I was chairman. And what’s

at stake if something goes wrong is way worse than when I was chairman, by quantum factors. … And the U.S. Safety Board is not alone – the Canadians are magnificent, the Brits are magnificent, the Aussies aren’t bad, the French are okay – but the rest of the world doesn’t have the resources or capacity to do the kind of work that the Safety Board has done. … The staff finds a lot of things to make recommendations on that are not yet accidental. And that work falls into the studies that [they do]. They are very good at that. The studies that they do are not theoretical. What would you say is your best memory of your time at the NTSB? I think it’s a couple of things, they’re thrown together. One, … it was kind of a wonderment in the whole atmosphere for me personally – and therefore the necessary homework and self-education – to say things that people would take seriously. [It] was a great intellectual challenge. The product, however, made the hard work worthwhile. The staff was terrific – very professional, patient, thorough to the point of absurdity. … It’s a tough business – I don’t know how you do it if you can’t have a giggle or two. And that spirit … you don’t see that in a lot of places, particularly in the government. When you’re really excited about what you’re doing, the whole idea of keeping more people alive and eliminating stupid stuff, regulations that don’t make any sense at all ... every day we did a little bit of something that did good. I think that was it. The idea of doing good is good.

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Promoting Safety By Craig Collins

The work the National Transportation Safety Board (NTSB) does is driven by the belief that no mishap is purely accidental; every investigation performed by the NTSB over the past 50 years has revealed actions that could have been taken to prevent misfortune. But the resources and expertise poured into the NTSB’s accident investigations aren’t aimed at assigning blame. They’re aimed squarely at the Board’s mission, which is one of the simplest and purest among government agencies: to prevent accidents and save lives. Probably the most important products delivered by the NTSB are the safety recommendations that arise from its investigations. The Board is unusual for a government agency in that recommendation is as far as it can go to compel change. Because it has no formal authority to regulate the transportation industry, its potency relies on its reputation for thoroughness, accuracy, timeliness, and independence. In its first five decades, the NTSB has issued more than 14,500 safety recommendations to more than 2,500 recipients. In April 2017, for example, the NTSB produced an accident report examining the fatal crash of a floatplane operated by a company in Ketchikan, Alaska, one of several commercial operators flying cruise ship passengers on sightseeing tours from Alaskan ports of call. The crash happened on June 25, 2015, when a de Havilland DHC3 Otter, on a return flight from Misty Fjords National Monument in what the NTSB report determined to be “deteriorating weather conditions,” slammed into a mountainside about 20 miles northeast of Ketchikan, killing the pilot and eight cruise ship passengers. When NTSB investigators delved into the circumstances leading up to this

accident, they discovered a confluence of several factors, both human and technical, both direct and indirect. One of the most important contributors, they found, was a competitive company culture that tacitly promoted flying in bad weather and selecting more dangerous routes – shorter routes over terrain, rather than longer routes along the fjords – to get passengers back to their cruise liners on time. More conservative operators, who cancelled flights rather than take passengers up in bad weather, were punished with a loss of revenue, as were companies that returned passengers after the cruise ships’ scheduled departure: When this happened, the companies had to pay to get the passengers to the next port of call. In its accident report, the NTSB conveyed nine new safety recommendations to the Federal Aviation Administration (FAA), the agency with regulatory authority, and one recommendation to Cruise Lines International Association, the cruise industry’s trade organization in North America. The recommendations covered both human and cultural factors, including special operating rules, training programs, and best practices for the Ketchikan air tour industry, as well as technical factors – specifically,

providing more effective terrain awareness and warning systems (TAWS) – to prevent such accidents from happening in the future. The timing of the NTSB’s safety recommendations is left to the judgment of Board members. If they determine recommendations can make a difference before an accident report is finalized, they may issue them earlier in the investigatory process. One of the most noteworthy historical examples of this occurred in 1996, after TWA Flight 800, a Boeing 747 passenger aircraft, exploded over the Atlantic Ocean shortly after takeoff from John F. Kennedy International Airport, killing all 230 people on board. Early in its investigation, the NTSB determined that an explosion in the center fuel tank had caused the aircraft to break apart, and it issued recommendations aimed at eliminating explosive vapors in airliner fuel tanks. The recommendations were issued in 1996, four years before the NTSB completed its final report on the TWA 800 accident. Often an accident investigation will reveal issues that have already been raised in previous reports, and the Board may reiterate certain recommendations. In the report on the crash near Ketchikan, for example, it reiterated recommendations that the FAA require safety management system programs, and flight data recorders and cockpit voice recorders in new and existing aircraft similar to the plane involved in the accident. SAFETY STUDIES AND SPECIAL INVESTIGATIONS Much of the NTSB’s work is reactive; its recommendations are most often formulated in response to events that have already happened. Because its mission is the prevention of accidents, the NTSB has taken steps to be as proactive as possible –

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ABOVE AND BELOW: NTSB investigators Brice Banning and Clint Crookshanks (below) examine the wreckage of a de Havilland DHC-3 sightseeing plane (above) that crashed into a mountain near Ketchikan, Alaska, on June 25, 2015. In the course of its investigation into the accident, the NTSB identified several factors that contributed to the crash, and in its report, it issued 10 new safety recommendations.

to examine and get ahead of issues arising in transportation. The NTSB develops and publishes a list of emerging issues annually, and often makes these issues the focus of public events such as hearings, forums, and seminars. In April 2017, after a series of small plane crashes in the New York metropolitan area, Sen. Chuck Schumer arranged for the NTSB to conduct a general aviation pilot training seminar later in the year. The NTSB’s enabling legislation also mandates that it “carry out special studies and investigations about transportation safety.” This mandate comprises a proactive safety agenda, empowering the NTSB to identify safety issues and develop safety recommendations through the analysis of issues beyond the scope of a single event. One of the NTSB’s primary tools for accident prevention has been the safety study – a multi-year examination of particular issues, including the effectiveness of or need for government activity to reduce transportation losses; technical components of a transportation system; accident data

analysis; or historical development of transportation safety improvements. Safety studies result in the issuance of a narrative report on the facts, along with conclusions and any applicable recommendations. One of the Board’s

most recently published safety studies, for example, was an examination of the Coast Guard’s Vessel Traffic Service (VTS) System, the maritime analogue to the U.S. air traffic control system. The report, issued in September 2016, detailed 14 conclusions

and 21 recommendations aimed at further reducing the risk of collisions, allisions, and groundings involving vessels operating within the operating areas of the Coast Guard’s 12 VTS centers. Likewise, the NTSB sometimes undertakes special investigations, informationgathering efforts aimed at supporting safety studies or examining issues or problems identified in one or more accident investigations. In April 2017, the NTSB released a special investigation report calling for changes in training and protocols for pilots, air traffic controllers, and others in the aviation community who might do more to prevent weather-related aviation accidents and incidents – specifically, to improve the creation and dissemination of pilot weather reports, or PIREPs. After months of studying the circumstances of 16 weather-related plane crashes that happened between March 2012 and December 2015, the NTSB made safety recommendations to the FAA, the National Weather Service, the National Air Traffic

technological shift in light aircraft avionics that had occurred over the last decade. Using prospective data collection, NTSB investigators identified several challenges associated with this rapid shift from conventional instruments to electronic “flyby-wire” technology and digital displays. The study resulted in six recommendations to the FAA related to equipment-specific training and simulation and reporting requirements. NTSB safety recommendations typically target public and private organizations, rather than individuals. In the strictest sense, an NTSB safety recommendation is a letter addressed to the organization(s), public or private, best able to address the relevant safety issues. This makes sense, as recommendations are viewed by the NTSB as a starting point, rather than as an end in themselves. The NTSB’s mission is fulfilled when its recommendations have been accepted and become standard practice, whether voluntarily or through legislation or regulation. Every year, the NTSB issues an average of 280 safety recommendations, and when public or private measures are taken as a result, they’re often incremental. Today, NTSB’s efforts to promote safety go far beyond this starting point – and increasingly, in the 21st century, the agency has adopted strategies and tactics to extend the reach of its messages to people throughout the United States. BROADCASTING SAFETY: OUTREACH AND SOCIAL MEDIA The NTSB’s traditional form of direct communication has been, and continues to be, the Safety Alert: a recommendation or recommendations targeting individuals – pilots, mechanics, mariners, railroad engineers, drivers, recreational boaters,

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Controllers Association, Aircraft Owners and Pilots Association Air Safety Institute, Aviation Accreditation Board International, National Association of Flight Instructors, Society of Aviation and Flight Educators, and the Cargo Airline Association. Safety studies and special investigations provide an important complement to the NTSB’s accident investigation activity. In 2012, Joseph Kolly, then-director of NTSB’s Office of Research and Engineering, and Loren Groff, then a National Resource Specialist in the Office of Research and Engineering, published a technical paper for the International Society of Air Safety Investigators in which they offered examples of how NTSB safety studies can expand safety analysis – first, by including evidence of risks derived from aggregate analyses of previous events and existing circumstances. Safety studies, in particular, enable the NTSB to seek out secondary information sources and reveal previously unidentified safety hazards and risk mitigation measures. Directed safety studies can collect and analyze operational data for comparison and risk analysis. As an example, Kolly and Groff cited a 2005 NTSB study that examined weather-related aviation accidents. By using a “case-control” methodology common among public health researchers, NTSB investigators compared accident and non-accident flights in order to identify the risk factors that could predict weather-related accidents. As Kolly and Groff pointed out, the NTSB, in most cases, uses safety studies to more thoroughly understand the safety issues identified in its accident investigations, but it has also used safety studies to discover and analyze new and emerging issues. In March 2010, for example, it released “Introduction of Glass Cockpit Avionics into Light Aircraft,” an examination of the dramatic

NTSB photo

LEFT: Dr. Joseph Kolly, then director of the Office of Research and Engineering, identifies components of the battery that caught fire in the Japan Airlines B-787 incident during a media briefing held Jan. 24, 2013. Kolly and his colleague, Loren Groff, published a paper in 2012 describing how NTSB safety studies can expand safety analysis. The agency’s safety studies and special investigations are an important complement to its accident investigations in advancing transportation safety. BELOW: One of the NTSB’s most recently published safety studies examined the Coast Guard’s Vessel Traffic Service (VTS) System.

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LEFT: NTSB Board member (then vice chairman) T. Bella Dinh-Zarr, far left, joined safety advocates, legislators, educators, and youth to kick off Bike to School Day and Global Youth Traffic Safety Month. In-person events are another way that the NTSB works to spread its safety messages. BELOW: The NTSB has embraced the use of social media to engage and inform the public and media. In the winter of 2010-2011, the NTSB established its own YouTube channel.

motorcyclists, and others – who can take preventive measures and reduce accident risk. A Safety Alert takes the form of a brief bulletin featuring three items: • A statement of the problem or problems. A recent Safety Alert about railroad signal visibility, for example, revealed confusion resulting from the combination of newer LED signals and older incandescent signals at control points: The brighter LED signals could mask the older ones, a problem that worsened with proximity and created the potential for confusion. • Related accident(s): An explanation of one or more incidents in which the problem has resulted in an accident. • An itemized list of the steps individuals can take to reduce the safety risks associated with the problem.

The internet, of course, has made the distribution of these Safety Alerts much easier; all are collected on the NTSB website, along with several related safety videos, and accessible via links on the web pages of government and private partners. Another important publication available on the NTSB website is Spotlight, the Board’s safety advocacy newsletter, released three times a year and detailing its efforts to promote safety – particularly of the items on its Most Wanted List (see “The NTSB’s Most Wanted,” p.30) – among state and federal legislatures, businesses, safety advocates, and the general public. The advent of social media has meant the NTSB doesn’t need to simply drive internet users to the NTSB site: The agency has extended its reach with social media and other tools. In the winter of 2010-2011,

for example, it launched a Twitter account (@NTSB) and a YouTube channel (NTSBgov). The @NTSB Twitter stream, which engages audiences with information about a variety of issues and the work of the NTSB, now has more than 128,000 followers, and the videos on its YouTube channel have garnered more than 7.2 million views and more than 14,700 subscribers. In July 2016, the NTSB added a second Twitter handle – @NTSB_ Newsroom – dedicated to relaying its most newsworthy information to make it easier for families and the media to quickly find accurate and timely information in the wake of a transportation disaster. The NTSB also uses @NTSB_Newsroom to provide information about its investigations. The handle has gone from zero to more than 8,300 followers in the year since it has been active. Virtually everything the NTSB produces – investigation reports, studies, alerts, videos, tweets, and public service announcements – can also be accessed from the NTSB’s Facebook page (@NTSBgov). A visit to this page offers a look at just how busily the NTSB’s people are working to spread the word about transportation safety. While it enjoys an increasing online presence, the agency still relies on the human touch. On the agency’s Facebook page, you’ll see Board members and other NTSB safety experts traveling the country tirelessly, in a kind of safety barnstorming tour: delivering speeches, hosting seminars, entertaining schoolchildren, lobbying lawmakers, and launching new safety initiatives. It’s a relentless nationwide effort – much bigger than a single accident – aimed at saving lives and avoiding accidents everywhere, all the time, in all modes of American transportation.

INTERVIEW:

Marion C. Blakey NTSB Chairman, 2001-2002 By Ana E. Lopez

Marion C. Blakey has had a long and distinguished career in transportation. She served as administrator of the Department of Transportation’s National Highway Traffic Safety Administration from 1992 to 1993, then finished out the ’90s as a public affairs consultant focusing on transportation issues and traffic safety. In September 2001, Blakey was appointed by President George W. Bush and confirmed by the Senate as chairman of the National Transportation Safety Board, the first woman to hold the position. In addition to serving as the on-scene Board member and NTSB spokesperson in the wake of several major accidents, including the crash of American Airlines Flight 587 in November 2001, Blakey worked to improve the Board’s accident reporting process, increase responsiveness to its safety recommendations, and promote safety in all transportation modes. Blakey left the NTSB when she was tapped to lead the Federal Aviation Administration (FAA), where she served as administrator for five years (2002-2007). After eight years as chief executive of the Aerospace Industries Association (2007-2015), Blakey joined Rolls-Royce North America Inc. (RRNA) in 2015 as president and chief executive officer. In this role, Blakey also serves as chairman of the RollsRoyce North America Holdings Inc. Board. Born in Gadsden, Alabama, Blakey received her bachelor’s degree with honors in international studies from Mary Washington College of the University of Virginia. She is a member of Phi Beta Kappa, a fellow in the Royal Aeronautical Society, and has received numerous honorary degrees and awards, including the National Aeronautic Association’s Wright Brothers Memorial Trophy in 2013.

How did you first become interested in transportation safety? Marion C. Blakey: Well … I always wore my seat belt when I was a child. Does that count? But seriously, I can’t think of a more compelling and fascinating area in which to work. I have been a safety advocate for all modes of transportation going back to my days as administrator for the National Highway Traffic Safety Administration during President George H.W. Bush’s administration. And, I came into that position because I was in the field of communications and advocacy. What’s the connection? The vast majority of transportation accidents can be attributed to

human error, and if you can raise awareness and alter people’s behavior, it changes the equation. So, I had an interest in transportation safety and, more importantly, felt that I could make a difference. If you can effectively communicate with pilots, drivers, and the public, then you can help alter behaviors and ultimately have a huge impact. You stepped into the role of NTSB chairman a little more than two weeks after September 11. Can you speak to the effect that 9/11 had on subsequent NTSB accident investigations? How did you handle being at the helm of the NTSB with a perhaps

Photo courtesy of Rolls-Royce North America Inc.

newfound need to consider terrorism as a possible cause of an accident? Well, it was a challenging time in our nation’s history to be sure. And just a short time later, we had another tragic accident: the crash of American Airlines Flight 587. All 260 souls on board that flight died when the plane went down shortly after takeoff into the Belle Harbor neighborhood of Queens, New York. So soon after the tragedy of 9/11, the immediate suspicion was another terrorist attack. The public was very afraid. And I would have to say the urgency to confirm or, in the case of Flight 587, rule out terrorism was an effect from 9/11. As investigators arrive on an accident scene today, the possibility of it being terroristrelated is considered now more than ever. The NTSB’s responsibility to provide assistance to families of aviation accident victims was relatively new when you became chairman. Was that process fairly well established by the time you took the lead? What changes

or efficiencies were implemented during your NTSB tenure? You are right: The Family Assistance Act was relatively new when I arrived. This became a priority of mine, continuing to ensure that families and survivors were treated with dignity and respect. And I must point out that we had a very seasoned, professional, and empathetic team who somehow managed to support families at all three sites following 9/11. During my tenure, we aligned with transportation companies (especially in commercial aviation and rail) to ensure they all had established victim’s assistance programs in place. Also, the Family Affairs Office developed courses that were held at the NTSB Academy [now the NTSB Training Center] with transportation companies, first responders, and media outlets for continuing education. Both the NTSB and stakeholders have found this to be very helpful.

The vast majority of transportation accidents can be attributed to human error, and if you can raise awareness and alter people’s behavior, it changes the equation.

You were at the helm of the Safety Board as much of the groundwork was being laid for the NTSB Academy. Can

What I have learned over the years is that managing in demanding technical environments requires you to rely on a strong team of experts, specialists, and engineering talent as the basis of reaching conclusions.

you describe what the vision was for the academy and the steps taken during your chairmanship to make that vision a reality? First, I have to give credit to former Congressman Frank Wolf of Virginia. He was responsible for a lot of the work that led to the academy being established and funded. The initial vision of the NTSB Academy was to help train and educate members of the emergency response community on the proper protocols and techniques necessary to improve the quality of accident investigation. This was to be done through a combination of instruction – critical thinking, sharing of best practices, etc. – and practical training. Keeping in mind the NTSB takes the lead in the investigations, there was also a goal of improving the collaboration of the various players involved in an investigation, such as NTSB investigators, first responders, responsible parties, and the media. All of these groups have a role in an investigation and need to work together for the best results. With everyone working together and understanding the situation, we can ensure an accurate flow of information. I imagine your public affairs background was great preparation for the communications responsibilities you had as NTSB chairman, e.g. testifying before Congress, addressing Americans and the media in

What was the biggest challenge you faced as NTSB chairman? What do you think was your most important accomplishment? First and foremost the priority is to help survivors and the families of the victims. But then putting together the proper team to investigate the root cause has always been critical, and bringing the findings to both the authorities and the public. Since I became the chairman post-9/11, many things changed in how we conducted the early investigative phases of the incident. It became clear the Board needed to be more closely aligned with the Justice Department and the FBI in determining as quickly as possible if the accident was terrorism and which agency would take the lead. Beyond the challenges of 9/11, I also made it a priority to advocate for a greater focus on the NTSB’s Most Wanted List and not just with the federal agencies, but also with the state governors and their legislatures. What was the transition from NTSB chairman to FAA administrator like? Do you think your experience at the NTSB had an effect on how you, as FAA administrator, considered safety recommendations issued to the FAA by the NTSB?

NASA photo by Jeff Caplan

NTSB employee Brian Murphy (second from right) updates NTSB Chairman Marion C. Blakey on the investigation of the tail fin and rudder from American Airlines Flight 587 at Langley Research Center on Feb. 11, 2002. Also pictured are (left to right) Jim Starnes, a senior engineer in Langley’s Structures and Materials Competency; Carol Carmody, vice chairman of the NTSB; George Black of the NTSB; and David Mandell, Blakey’s counsel. Langley was selected to help in the investigation because of its expertise in composite materials.

the wake of transportation accidents, etc., but what degree of technical expertise was necessary for your role as chairman? What was that learning curve like? Technical expertise is certainly a critically important element in investigating and analyzing an accident. That being said, in-depth technical expertise doesn’t necessarily need to reside with the chairman. The technical knowledge base is grounded in a lot of disciplines and modes of transportation, and it would be hard to find sufficient technical background in any one person. What I have learned over the years is that managing in demanding technical environments requires you to rely on a strong team of experts, specialists, and engineering talent as the basis of reaching conclusions. You of course have to do a lot of homework on a technical level. But, at the root of it, good management and strong judgment grounded in the facts makes all the difference.

Being at the helm of the NTSB gave me a greater understanding of the forensics behind accident investigations and a high degree of respect for the agency’s methodology and recommendations. Being at the helm of the NTSB gave me a greater understanding of the forensics behind accident investigations and a high degree of respect for the agency’s methodology and recommendations. However, at the same time, at the FAA you are conscious of the fact that the NTSB is not required to do any cost-benefit analysis. So, when I read some of the letters that I had signed as administrator of the NTSB addressed to the FAA administrator, I was acutely aware of that juxtaposition. At the FAA, I had a responsibility to weigh the benefits of public safety and at the same time the cost involved to achieve the best public outcome. In your experience, what is the main reason that companies or organizations or government agencies don’t always implement NTSB safety recommendations? What do you feel is the most effective way to persuade those companies, organizations, or government agencies to implement NTSB safety recommendations? Well, I would point to a couple of reasons: one being technical feasibility and the other being the cost versus offsetting benefits. Some recommendations are much easier to implement than others. For instance, if the recommendation addresses a change in a flight procedure in lieu of a redesign, it is much easier for the company to address the problem. Everyone wants safety. But companies must also consider the R & D costs and whether they can change the design in new assembly or would they have to retrofit existing manufactured items. For example, after the TWA 800 center fuel tank explosion, the FAA Tech Center developed a fuel inerting system that the FAA and carriers agreed was a key safety measure and it was implemented. In the long run, the safety benefits far outweighed the costs.

Photo courtesy of Rolls-Royce North America Inc.

What lessons learned did you take from your time as chairman of the NTSB to your later positions as FAA administrator, as chief executive of the Aerospace Industries Association, and now as president and CEO of Rolls-Royce North America? All of these positions have required taking informed positions and advocating them effectively to achieve a desired outcome. Maintaining strong lines of communication through the media and key stakeholders, so should something happen, you are able to manage the flow of information to dispel rumors and get accurate data out early in the process. Allowing the uninformed to control the narrative erodes the traveling public’s trust. What do you think is the most serious threat to transportation safety today, and what can be done about it? All of us agree that the United States has the safest aviation system in the world, but we always have room to do better. Security problems and terrorism continue to be major threats to our system, and we have to do all we can to protect the safety of the flying public. I would add one other thing, and I certainly wouldn’t classify it as a threat, but more of a challenge – that is the impact of technology. In the coming years, we will see incredible advances that have the potential to significantly influence transportation. For example, we are seeing a lot of advances in the world of autonomy – in cars and ships now, but how soon will we be talking about autonomous flight? These and other technologies will have a profound role in shaping travel. It’s going to be exciting to be sure. But regulating these technologies to ensure safety will certainly be a challenge.

The NTSB’s Most Wanted: Greasing the Gears of Change By Craig Collins

After a couple of decades of work, the NTSB recognized that the number and variety of specific recommendations resulting from its accident investigations might dilute its most important messages. In 1990, it released its first Most Wanted List of transportation improvements to generate awareness and support for what it saw as the most significant changes – legislative, regulatory, industrial, and cultural – that could be implemented to prevent accidents and save lives. In its earliest forms, the Most Wanted List contained items that differed very little from the recommendations resulting from NTSB investigations. For the most part, Most Wanted items represented recurrent concerns, usually specific to certain modes of transportation – for example, the NTSB’s first two Most Wanted Lists included “Ground Proximity Warning Systems in Commuter Aircraft,” a recommendation based on a number of “controlled flight into terrain” (CFIT) accidents among smaller planes. The Federal Aviation Administration (FAA) had required all large turbine and turbojet airplanes to install ground proximity warning systems (GPWS) in 1974, but there were no such requirements for smaller planes. The NTSB knows well that the gears of change move slowly. It was 2000 when the

FAA amended its operating rules to require all U.S. turbine-powered airplanes with six or more passenger seats to be equipped with an approved GPWS. When change does happen, it often falls short of what the NTSB recommends; one of the Board’s first Most Wanted items, “Mandatory Seat Belt Use in Automobiles, Vans and Light Trucks,” has been mostly, if imperfectly, fulfilled: 49 states now require seat belts for adults in motor vehicles, and all 50 states and the District of Columbia have

separate child restraint laws, but these laws vary greatly in age requirements, penalties, whether a law is “primary” (a driver can be stopped and ticketed for not wearing a seat belt) or “secondary” (a driver can only be cited if he/she has already been cited for a primary violation such as speeding), and in whether the mandate applies to backseat passengers. Nevertheless, the positive changes in U.S. transportation laws, regulations, and best practices over the past two-and-a-half decades have been measurable, and often related to issues, such as seat belt requirements, prioritized by the NTSB. To the Board, the Most Wanted List is an expression of the most urgent issues confronting the transportation sector, the problems that, once solved, will bring the greatest benefit to the public. Last fall, the NTSB’s then-chairman, Christopher Hart, called the Most Wanted List “our roadmap from lessons learned to lives saved.” Over time, the Most Wanted List has changed considerably, not only in its content, but also in its format; issues became less tied to specific modes of transportation and

NTSB Board member Christopher Hart (then chairman, at podium) unveiled the NTSB’s 2016 Most Wanted List at a press event in Washington, D.C. At his side were, from left, Board member (now chairman) Robert Sumwalt, Board member (then vice chairman) T. Bella Dinh-Zarr, and Board member Earl Weener. The Most Wanted List highlights safety issues identified from the NTSB’s accident investigations to increase awareness about the issues and promote recommended safety solutions.

NTSB photo

The National Transportation Safety Board (NTSB) estimates that over its 50-year history, it has issued more than 14,500 safety recommendations to more than 2,300 recipients, but the NTSB has never measured its effectiveness in such terms. It’s an advisory board, with no regulatory authority over the transportation industry or individuals, so its power to effect change lies not in the amount of its recommendations, but in their persuasiveness.

more indicative of general concerns. In 2011, the NTSB reduced the number of issues on the list to 10, with the intent to make it more streamlined and representative of general concerns. An item on the 2010 list, for example – “Prohibit Cell Phone Use by Motorcoach Drivers” – has since morphed into an encapsulation of the overarching problem throughout transportation: “Eliminate Distractions.” The current 2017-2018 Most Wanted List, unveiled in November 2016, reflects another change, in recognition of the time it takes to advocate and make progress on issues that, in some cases, have presented challenges for many years: For the first time, the NTSB is issuing its list every two years, rather than annually. In its announcement of the new list, the NTSB said, “The change allows more time for the transportation industry, safety advocates, regulatory agencies and individuals to effect the changes necessary to address the 10 issues on the Most Wanted List.”

Most Wanted List includes recommendations aimed at identifying and mitigating the causes of operator fatigue, at both the company and individual levels. Increase Implementation of Collision Avoidance Technologies The NTSB’s early emphasis on aircraft GPWS and positive train separation has evolved to embrace emerging collision avoidance technologies in all modes of transport, such as lane departure warning systems, automatic braking systems, electronic stability control, or blindspot detectors for motor vehicles. These innovations hold great promise. A 2015 study by the University of Michigan Transportation Research Institute found that these new technologies reduced crashes by as much as 19 percent among large motor carriers.

THE NTSB’S 2017-2018 MOST WANTED LIST

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Reduce Fatigue-related Accidents Fatigue – which impairs a person’s ability to stay alert and attentive to the task of controlling a vehicle safely – has appeared on every Most Wanted List since 1990, and the NTSB has issued more than 200 safety recommendations addressing fatigue-related problems across all modes of transportation. Fatigue remains an emphasis for NTSB because it remains a significant factor in transportation accidents in all modes: aviation, highway, rail, and marine. Of the major investigations conducted by the NTSB from 2001 to 2012, nearly 20 percent identified fatigue as a probable cause, contributing factor, or finding. The

While the Surface Transportation Extension Act of 2015 fulfilled a long-held Most Wanted item, mandating positive train control systems to be installed by railroads by 2018, it also allows railroads to apply for extensions – which the NTSB urges them not to do. “Safety delayed,” the agency wrote, “is safety denied.” Strengthen Occupant Protection This item urges changes that are both behavioral and technological. As the NTSB points out, children under 2 years of age are not required to be restrained in their own seat on an airplane, and airline passenger safety risks are further increased by inadequate evacuation procedures. On the highways, more than half the people killed in vehicle accidents were unrestrained in 2015, despite seat belt laws in nearly all the states. When an Amtrak passenger train derailed in Philadelphia that year, eight passengers were killed and 185 were

taken to the hospital after many were ejected through windows that had become dislodged, or dropped from their seats after their rail cars overturned. The NTSB’s recommendations in this area are aimed at increasing use of existing restraint systems, and better design and implementation of systems that preserve survivable space and ensure ease of evacuation. Expand Recorder Use to Enhance Safety Data, audio, and video recorders can help capture and store critical information that can help investigators to determine the cause of accidents – and more important, they help companies and operators take preventive steps, such as establishing safety management strategies and training programs. Recording systems are now available for vehicles in every mode of transportation, and while many operators have implemented them, or are in the process of implementing, many are slow to do so without regulatory requirements.

Prevent Loss of Control in Flight in General Aviation While on the decrease, small airplane accidents involving inflight loss of control (LOC) still occur at a high rate relative to aviation accidents overall. Nearly half of all general aviation accidents are caused

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by inflight LOC. From 2008 to 2014, LOC accidents killed 1,194 people.

medically fit for duty before they operate a vehicle.” Improve Rail Transit Safety Oversight Rail transit remains relatively safe, but incidents over the last several years, including two fatal accidents involving Washington Area Metropolitan Transit Authority (WMATA) trains, revealed – despite warnings from the Federal Transit Administration – insufficient oversight by the regional organization assigned to the

There are many potential causes of inflight LOC, and one of the most common is a stall caused by an abnormal attitude, or angle of attack (AOA). A plane is most vulnerable to LOC in three flight phases: climbing, maneuvering, and approaching a landing. NTSB’s recommendations for pilots include better training on how to eliminate distraction, avoid stalls, and manage weather-related issues (such as wing icing and microbursts); the Board also urges the installation of technologies, such as AOA indicators, that can help pilots during busier phases of flight.

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Require Medical Fitness The NTSB cites several accidents in the past decade that were caused directly by medical conditions, such as color vision deficiency, obstructive sleep apnea, or seizure disorder. While medical certification systems exist for all modes of transportation, certification requirements vary. For example, while the NTSB has found sleep apnea to be a factor in multiple accidents, most transportation modes still lack a screening process for the condition. The NTSB’s goal in adding medical fitness to its Most Wanted List is not to discriminate among safety professionals, but to “ensure safety-critical professionals are

Insurance survey admitted to surfing the Web while driving, up from 13 percent in 2009. In 2010, a barge under tow ran over a tour boat on the Delaware River, killing two passengers, when the tugboat lookout was talking on his cell phone. The NTSB’s recommendations are aimed at promoting a vigorous public education campaign for operators and safety-critical professionals, as well as expanded regulations prohibiting the personal use of electronic devices while operating a vehicle. End Alcohol and Other Drug Impairment in Transportation The NTSB has long issued alcohol- and drug-related safety recommendations, and in recent years, the use of over-the-counter (OTC), prescription, and illicit drugs has increased in the United States. The NTSB is tracking an increase in the use of all drugs by aircraft pilots, including those killed in accidents. In 2014, a roadside survey conducted by the National Highway Traffic

task. As mass transit ridership increases at a rate greater than the nation’s population, the NTSB contends that the existing scheme of oversight, in which such organizations receive certification by state safety oversight agencies, may be insufficient for creating and enforcing safety standards and accountability. Eliminate Distractions This is another problem that exists for operators in every mode of transportation: In 2014, the NTSB investigated a general aviation accident that happened because the pilot was updating a Facebook post. A fatal 2011 helicopter crash occurred after the pilot, distracted by texting on a cell phone, failed to notice the helicopter had run out of fuel. In 2015, 30 percent of the drivers who responded to a State Farm

Safety Administration (NHTSA) found that nearly 1 in 4 drivers tested positive for at least one drug that could affect safety. Studies of drivers and pilots indicate dramatic increases in marijuana use over the past several years. The NTSB believes states should lower the legal blood alcohol content (BAC) level from 0.08 to 0.05, given the evidence of impairment. For other drugs – and particularly for marijuana – the relationship between the amount consumed and crash risk remains poorly understood. The NTSB urges states to increase the collection, documentation, and reporting of driver breath and blood test results for alcohol and drugs after crashes, and new laws specific to the operation of vehicles while under the influence of certain drugs. As always, the Board encourages collaboration

among advocacy groups, industry, and the public to increase awareness of drug and alcohol impairment and its effects on vehicle operation.

At the 2017 SafeRail Congress, NTSB Board member Christopher Hart shared how oversight and technology can improve safety on rail systems.

personal electronic devices, and other consumer products. Fires started by lithium batteries have destroyed three U.S. cargo planes, killing the crews of two. As the FAA points out, it can now be assumed that every passenger on a commercial flight is carrying at least one of these batteries, and the NTSB has released related safety recommendations to the FAA and the Pipeline and Hazardous Materials Safety Administration. In rail transit, an emerging issue has been the increasing transport of crude oil. About 9,500 tank cars of crude oil were shipped on Class 1 railroads in 2009; five years later the number had increased to 500,000. Given such an increase, it isn’t surprising that the amount of crude oil spilled from rail transport in 2013 – 1.5 million gallons – was more than was spilled in the previous 37 years of railroad incidents combined. To address the problem, the NTSB recommends specific upgrades and replacements for existing tank cars; improvements to railroad operation; and robust emergency response to mitigate damage. A more complete discussion of the NTSB’s 2017-2018 Most Wanted List items is available online at www.ntsb.gov/ mostwanted.

THE NTSB ROAD SHOW In many ways, it’s never been easier to spread the word about what NTSB experts see as the nation’s most crucial transportation safety issues. Social media tools such as Facebook, Twitter, and Safety Compass, the official blog of the NTSB chair, extend the Board’s reach and allow it to connect with an unprecedented number of people. In March, for example, the Board hosted a Twitter chat to help promote the release of the agency’s Safety Alert on teen drowsy driving. But today’s public sphere is a noisy one; the NTSB’s messages compete with countless others for attention. Perhaps the most important work the NTSB does is in creating opportunities to connect with people and deliver its messages the old-fashioned way: face-to-face, in meetings, speeches, seminars, and other public events. The NTSB’s campaigns create as many opportunities as possible to meet people and make progress on its Most Wanted List of transportation improvements, and many of these events are highlighted in the NTSB’s periodic newsletter, Spotlight, which offers an updated progress report on the Most Wanted List.

The spring 2017 issue of Spotlight presented an intriguing snapshot of recent NTSB efforts: • In New Orleans, Board member Christopher Hart met with the board of directors of the National Automobile Dealers Association at their centennial conference, urging implementation and training in the use of collisionavoidance technologies. • In Washington, D.C., NTSB Chairman Robert Sumwalt moderated a Distracted Driving Roundtable in collaboration with Stopdistractions.org, the National Safety Council, and DRIVE SMART Virginia, an exchange designed to inspire and improve coordination among advocates. • At the 2017 SafeRail Congress in Washington, D.C., Hart explained to attendees how technologies such as positive train control and appropriate oversight can improve rail safety. • In Puyallup, Washington, at the Northwest Aviation Conference and Trade Show, Board member Earl Weener delivered the keynote address, highlighting the Board’s

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Ensure the Safe Shipment of Hazardous Materials While the NTSB has expanded this item to encompass the safe transport of all hazardous chemicals, this Most Wanted change is rooted in two significant issues that have emerged in recent years. The first is aviation cargo fires involving lithiumion batteries, the power source common to laptop computers, cordless power tools,

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NTSB Board member (now chairman) Robert Sumwalt speaks about the dangers of distracted driving at the Texas State Capitol.

recommendations for preventing loss of control in flight in general aviation – a message he also took to events in Florida and Kansas. • In St. Louis, highway safety investigator Mike Laponte shared key lessons from recent motorcoach crashes at the United Motorcoach Association’s Annual Motorcoach Expo. Several Most Wanted changes, including occupant protection, recorders, impairment, and fatigue, were discussed. Meanwhile, Board members and investigators were delivering reports and testimony to state legislatures in Arizona, Texas, Maryland, Delaware, and New York, aimed at strengthening safety laws and regulations. Like the Americans they work to protect, the NTSB’s people are constantly in motion, and they know their work to improve

the safety of American transportation will never be finished – a fact acknowledged by Hart when he announced the release of the 2017-2018 Most Wanted List at the National Press Club in November 2016. “Safety,” he

said, “is not a destination, but a continuing journey, and our efforts to improve safety must never stop. It takes a concerted and continuing effort by industry, government, and private citizens to save lives.”

INTERVIEW:

Ellen Engleman Conners NTSB Chairman, 2003-2005 By Ana E. Lopez

Ellen Engleman Conners joined the National Transportation Safety Board as chairman in March 2003 during the George W. Bush administration. After her chairmanship came to a close two years later in March 2005, she remained on the Board as an NTSB member until her resignation in May 2006. In the two years that she was chairman, the number of open or non-implemented safety recommendations dropped to its lowest number since 1975. She represented the NTSB in national media – as the member on scene for several accidents, including the Staten Island Ferry crash in 2003 and the capsizing of the Lady D in Baltimore in 2004 – and before Congress, and oversaw the opening of the NTSB Academy’s doors. Engleman Conners’ appointment to the NTSB was neither her first nor her last position in government. Currently, she is deputy director of governmental and public affairs for the U.S. Coast Guard, part of the Department of Homeland Security. Additional government service includes serving as administrator of the Research and Special Programs Administration at the U.S. Department of Transportation (DOT), as the deputy bureau chief of enforcement at the Federal Communications Commission, and as director of external relations for the NASA Johnson Space Center (JSC). She also served as a public affairs officer (PAO) in the U.S. Navy Reserves (1999-2008) for the Chief of Naval Information (CHINFO) at the Pentagon. In the private sector, Engleman Conners was president and CEO of Electricore, Inc., a research consortium for advanced technology

research and development for hybrid electric drive and alternative energy; CEO of the Indiana Realtors Association, a 20,000-member association; director of corporate and government affairs for Direct Relief International; and governmental affairs executive and public affairs manager for GTE North, Inc. (now Verizon). She is an active community volunteer and has served on numerous boards of directors for community organizations. Engleman Conners has a Juris Doctor from Indiana University, a master of public administration from Harvard University (MPA), and her Bachelor of Arts degree in English and communication media from Indiana University. She is a member of the Indiana Bar and received accreditation (APR) from the Public Relations Society of America.

Prior to serving as chairman of the NTSB, you were the administrator of the Research and Special Programs Administration at the Department of Transportation and oversaw some transportation safety offices – the Office of Pipeline Safety and the Office of Hazardous Material Safety. Did you have any interaction with the NTSB in your role at DOT? How did your experience at DOT inform your work with the NTSB? Ellen Engleman Conners: When I became administrator of Research and Special Programs at the U.S. Department of Transportation, I was concerned to learn that the Office of Pipeline Safety was the recipient of multiple safety recommendations and was on the NTSB Most Wanted List – the annual list of highlighted open safety recommendations. I worked hard to address these issues,

opening up a dialogue with the NTSB and continuously highlighting the importance of responding to safety recommendations to our staff and stakeholders. This dialogue, augmented by my experience at the Department of Transportation, was instrumental in my awareness and understanding of the importance of safety in all modes of transportation – aviation, rail, highways, pipelines, hazmat transport, and waterways.

During your time as NTSB chairman, the number of open safety recommendations dropped to under 1,000 – the lowest it had been in 30 years. Can you describe the factors that made such a reduction in open or unimplemented recommendations possible?

AP Photo/M. Spencer Green

While issuing safety recommendations raises awareness, the NTSB’s bully pulpit does not include regulatory or policing authority. I felt strongly that our safety advocacy would be increased by introducing a level of accountability within the NTSB to ensure that there was active “follow up” with the recipients of NTSB safety recommendations to verify the status of the open recommendations. We found that many of the safety recommendations had been addressed – but not reported back to the NTSB. Others were partially addressed or perhaps an alternative response was appropriate. By instituting a more robust dialogue, we were able to both clean up the record where appropriate, as well as raise awareness with the recipients that we “meant what we said.” According to the 2003 NTSB Annual Report, “In FY 2003, 255 recommendations were closed – 90 percent of them satisfactorily.” What of the other 10 percent? In what status other than “satisfactorily” can recommendations be closed? Some safety recommendations may no longer be relevant as the intended recipient, in the case of a small business for example, was no longer viable. Others may have been issued broadly across multiple states and considered “open” because there hadn’t been a 100 percent response by all of the recipient states. Your Safety With a Team (SWAT) approach to addressing the challenge of lingering open safety recommendations entailed working closely with Department of Transportation

National Transportation Safety Board member Ellen Engleman Conners discusses an accident involving a Southwest Airlines Boeing 737 Friday, Dec. 9, 2005, at Midway Airport in Chicago. The jetliner, trying to land in heavy snow, slid off the runway, crashed through a boundary fence, and slid out into the street, hitting one car and pinning another beneath it. A child in one of the vehicles was killed.

entities to draft the recommendations that would be issued, and it did draw some criticism. For an independent agency like the NTSB, how difficult is it to walk the line between constructive collaboration that can potentially advance safety and maintaining enough distance to ensure complete impartiality? The NTSB is an independent agency and ensures that its ultimate goal is safety. The Safety With a Team approach did not thwart the independence of the NTSB. There are two separate issues here. Addressing safety recommendations that have already been issued can be facilitated by dialogue with the recipient of these safety recommendations: “Do you understand what the NTSB is recommending? Can you address it? Why or why not? Do you have an alternative response that will still meet the intended goals of the recommendation?” That is a separate process from when the NTSB conducts an independent accident investigation and develops proposed safety recommendation(s) from the results.

All accident investigations are challenging – and, as each life matters, any accident that results in loss of life is equally important. and safety recommendations would have immediacy in their impact on safety in public transportation on our waterways. You embraced the use of new media during your chairmanship – the beginning of streaming public hearings online happened on your watch. What effects from this increased media presence did you observe or experience? What effect did it have on the work of NTSB? The majority of NTSB accident investigation hearings were held in Washington, D.C., at the NTSB headquarters. My decision to webcast the Board meetings, develop multi-language websites, and establish new external communication products was focused on two issues: first, to ensure that family members and friends of any who had been lost in an accident would have the opportunity to view the hearings if they were unable to attend in person and provide access to additional information. Secondly, it was important for the public, as well as state and local government officials, safety stakeholders, and advocacy groups, to have increased access and awareness about NTSB investigations, hearings, and safety recommendations. An outcome of this decision provided better access to everyone – including the media.

You were the on-scene spokesperson for the NTSB’s investigation of two marine accidents: the 2003 Staten Island Ferry crash and the 2004 sinking of the Lady D water taxi in Baltimore. What are some of the challenges particular to marine accident investigations? All accident investigations are challenging – and, as each life matters, any accident that results in loss of life is equally important. I often would say, “out of tragedy, good must come” – not should or may come, but that good must come. It was important to me that by learning the cause(s) of the event, our resulting safety recommendations would save lives in the future. Both the Staten Island Ferry and Lady D accidents involved waterway transportation – and thus the lessons learned

The NTSB Academy (now known as the NTSB Training Center) opened while you were chairman. What impact did it have on the capabilities of the NTSB workforce while you were on the Board? The NTSB Academy [was created to focus on] teaching and sharing transportation safety so that future lives could be saved. The extensive experience and expertise of the NTSB staff was a valuable asset that could be used to support safety in all transportation modes. The NTSB accident investigation process and the NTSB’s body of knowledge forged from decades of accident investigation experience needed an outlet to offer this knowledge to industry, other safety organizations, transportation professionals, and emergency personnel. The NTSB Academy provided the ability to offer training classes and host safety symposia on a national and international basis. Initial attendance consisted of 1,000 students from 25 countries. The NTSB Academy also received certification for continuing education credits. The co-location of the reconstruction of TWA 800 provided a somber reminder of the importance of lessons learned. What was the biggest challenge you faced as NTSB chairman? What do you think was your most important accomplishment? It was a privilege to serve as both chairman and member of the National Transportation Safety Board. The professionals who work at the NTSB are dedicated to making a difference through their safety investigations and safety advocacy. While the NTSB may most commonly be known for its role in aviation safety, my role as chairman brought a safety advocacy focus on all modes of transportation safety, including pipeline, hazmat transportation, rail, marine, and highway.

NASA photo by Jeff Caplan

U.S. Coast Guard photo

How did strategies to advocate for transportation safety at the national level differ from those at the state and local level during your time at the NTSB? Safety advocacy is most effective when you can work at all levels of government. Within states, for example, there is the opportunity to testify in support of state safety legislative initiatives and work with state elected officials. On a national level, our advocacy role often partnered with national safety stakeholders and advocacy groups.

Walk the Scene The Accident Investigation Process By Eric Tegler

One of the most important steps in any accident investigation is a deceptively simple one. “Just walking through the scene to get an idea of what we’re dealing with – the big picture. That’s important,” National Transporation Safety Board (NTSB) Chairman Robert Sumwalt confided. “We’re not necessarily there on day one picking up pieces and measuring things. That’s basically the first step.” Each year, the NTSB investigates, on average, 1,300 aviation accidents and incidents, 22 highway crashes, nine rail accidents, three pipeline or hazardous materials accidents, and 30 maritime accidents. There are guidelines and procedures for investigating accidents, but since no two are the same, they are not absolute. Accident investigations are deliberative, collaborative, and they vary in size, scope, and public attention. While there’s a definite framework for investigation, there’s room to move inside it, Sumwalt pointed out. And there are a couple of other popular misconceptions he’d like to address. “When we’re on scene, we’re there to collect the perishable evidence. We’re really not there to solve the accident while on scene.” The public’s logical desire for timely answers and standard media coverage of accidents – which typically dissipates once a scene has been cleared – are the likely sources of this misperception, but they overlook the fact that NTSB accident investigations run a far longer course. “A lot of people think that when we pack up and leave a scene, it’s the end of the investigation,” Sumwalt said. “I like to say it’s quite the opposite. It’s just the beginning of the investigation.” THE LAUNCH When an accident takes place, you might imagine that authorities in the geography where it occurred swiftly notify the NTSB of the incident. You’d be largely correct, but you’d be mistaken if you imagine that such notification would be the first the Board hears of an accident.

In actuality, the NTSB most often learns about accidents the same way we do – by watching or reading the news. At its Washington, D.C. headquarters, the Board maintains a media watch room with feeds from all the major news gathering organizations, continuously staffed by Board personnel throughout the year. The Board doesn’t launch investigators based solely on media reports, but news monitoring gives NTSB staff a “heads up,” advance warning that investigators may soon need to get moving. When an accident has taken place, the decision to send individual investigators or a team of investigators largely hinges on the NTSB’s jurisdiction as well as the scope, complexities, and issues surrounding the accident. In the case of aviation accidents, dispatch of NTSB investigators is automatic. “We have jurisdiction over all civil aviation accidents,” Sumwalt explained. “As long as any transportation accident is within our jurisdiction, we don’t need to be invited to send representatives.” That aviation jurisdiction occasionally extends to military aircraft, but only in circumstances where they are involved with a civilian aircraft, as in a mid-air collision. The majority of rail and energy pipeline accidents falls within the Board’s jurisdiction as well, and it actively coordinates with both the Federal Railroad Administration (FRA) and the federal Pipeline and Hazardous Materials Safety Administration (PHMSA). However, since its role in investigating such accidents is less widely known, the Board is sometimes forced to explain to small operators and some local police, fire, and governments that it does hold the authority to investigate rail and pipeline accidents. The NTSB has the authority to investigate any highway crash it selects, and, when it does investigate a crash, it

NTSB photo

NTSB investigators walk the site where a Union Pacific freight train derailed on March 10, 2017, in Graettinger, Iowa. Investigators at accident scenes work to document sites and collect perishable evidence.

will work in conjunction with the state where it took place. In cases where criminal activity is suspected, other agencies may take part. Criminal investigation is not within the NTSB’s remit. Past precedent has established that where crime has been confirmed in a transportation tragedy, the FBI becomes the lead federal investigative body, with the Board providing support. “It’s important that we have a good working relationship with all of these entities,” Sumwalt stressed. When an accident has unfolded, its specifics determine the type of investigatory response from the NTSB. Most of the aviation accidents are general aviation accidents that involve smaller aircraft

and have zero to two fatalities. In those instances, the Board will usually send one of its regional investigators. The Board has four regional offices: Eastern, located in Ashburn, Virginia; Central, located in Denver, Colorado; Western Pacific, located in Seattle, Washington; and Alaska, located in Anchorage, Alaska. Investigators usually sortie from the investigative office nearest the accident, but demand for investigators or logistics may dictate sending an investigator from an adjoining region. If the accident is proximate to their location, investigators take ground transportation. If not, regional investigators (or larger Go Teams from the Board’s Washington, D.C. headquarters) travel by commercial airliner or government aircraft, depending on circumstances and availability. In some cases, a Federal Aviation Administration (FAA) aircraft will be used to transport some members of a Go

Team investigating a significant accident to an airport near the scene, but the return flights are commercial. “Some locations aren’t easy to get to,” Sumwalt acknowledged. “We like to get there in the most expeditious and economical manner possible, though sometimes those things are conflicting. We get there however needed to meet the accident investigation needs.” Getting there brushes on another common misperception of NTSB accident investigations. While the Board’s investigators must be on scene in a timely fashion, they need not necessarily arrive in the shortest possible time. “We want to be there as quickly as possible, but we’re not first responders,” Sumwalt pointed out. “A lot of people misconstrue that. For example, the [2015] Amtrak accident in Philadelphia happened shortly after 9 o’clock in the evening. Most of the Go Team traveled in the next morning. We

NTSB photo NJ Transit Police photo by Detective Laquan Hudson

ABOVE: Board member Robert Sumwalt, now chairman of the NTSB, briefs the media after the derailment of Amtrak Train No. 188 in Philadelphia, Pennsylvania, in 2015. The NTSB keeps the public informed in the wake of transportation accidents by responsibly releasing information as investigators get it. Often the investigator-incharge (IIC) handles press communications, but when it seems an accident will draw increased media attention, a Board member may serve as the on-scene spokesperson to ensure the IIC can work the investigation. RIGHT: James Southworth, IIC for the NTSB’s investigation of the Sept. 29, 2016 crash of NJ Transit’s Pascack Valley Line Train No. 1614, receives the lead car’s video recorder in an antistatic bag from NTSB investigator Michael Hiller on Oct. 4, 2016. The recorder was transported to an NTSB laboratory in Washington, D.C., for its data to be analyzed as part of the NTSB’s investigation to identify probable cause in the accident.

know that local law enforcement officials are going to preserve the perishable evidence.” Whether assigned to a regional office or to the headquarters, NTSB investigators are hired based on their expertise in particular disciplines. Their specialties range from operations, structures, and power plants to systems, weather, human performance, and survival factors. Most have previous accident investigation experience with backgrounds tied to aircraft, rail, and engine manufacturers. Many have military aircraft accident investigation experience or come from another agency like FRA.

After training, new investigators may work regionally or be assigned to a D.C.-based Go Team. Go Teams can number from three or four to more than a dozen specialists who travel to a site together. Go Teams are on call for seven-day periods, typically from 5 p.m. Monday to the following Monday evening. ON SCENE Upon reaching the site of an accident, individual investigators or teams will seek to ascertain the “big picture” Sumwalt mentioned. They’ll typically talk with first responders to gain an understanding of

the incident and the scene, determine if the scene is safe for the NTSB investigators to enter, then walk through it and document it with photographs. Collecting perishable information is a priority given that weather, materials degradation, or the need to clear the scene for safety or logistical reasons may preclude obtaining it later. The need to get things moving again does weigh on investigators, Sumwalt acknowledged, but the pressure is limited and investigators typically have their work done quickly in any case. Average on-scene time may be 48 hours to a week. Some investigators may leave early while

others stay. For example, information from train data recorders can be read on site while aircraft data recorders are sent back to Washington. After surveying the scene and talking with first responders, investigators typically hold a first-day organizational meeting if the investigation involves multiple personnel. Where a Go Team is involved, an investigatorin-charge (IIC), a senior investigator with years of NTSB and industry experience, will lead it. Each additional Go Team investigator is a specialist responsible for a defined portion of the accident investigation. At the meeting, all investigative parties gather, go over their initial information, divide into working groups for each area of expertise, and the IIC explains the Party System, in which the NTSB designates outside organizations or companies that can provide relevant expertise as parties to its investigations (and only individuals from those parties who can provide needed technical or specialized expertise to the Board are allowed to take part). Working groups are led by Go Team specialists. For example, in the case of an aviation accident, structures, power plant, systems, survival factors, and weather groups would number among those included. Each working group encompasses the relevant experts or parties from outside the NTSB. In the aviation accident example, Boeing would likely be in the structures group while Pratt & Whitney or GE would have a representative

in the power plant group. Airline and pilots’ union representatives would reside within an operations group or human factors group. The collected outside experts work within the Party System, which bolsters the Board’s own resources, speeds discovery, and provides an additional layer of transparency. Each evening, there’s a progress meeting wherein each working group reports its findings for the day and its plans for the next. “It’s all very open,” Sumwalt said. “Everyone hears what the other groups are doing so that they can plan their activities around that information.” The Party System also improves communication, efficiency, and timeliness, he said. “When people are literally at the same table with us, we can say, ‘We need the pilot training records,’ and the party which has those is right there. The next thing we know, we’ve got those records on our desk. It’s an efficient way to get things done.” Sumwalt joined the NTSB Board as vice chairman in 2006. His previous career was spent as an airline pilot, including 24 years with Piedmont Airlines and US Airways, accumulating more than 14,000 flight hours. He also worked with NTSB investigators as an outside investigator through the Party System. “I fully recognized that everyone had their own interest,” he says of the parties that comprise working groups. “I believe that in that process, everybody’s looking over each

other’s shoulders and in so doing, we leave no stone unturned. If you have the Air Line Pilots Association looking over the manufacturer’s shoulder, and they’re all looking over the FAA’s shoulders, it keeps everyone honest.” As an example, Sumwalt recalled an accident in April 2011 when a 6-foot hole opened in the fuselage of a Southwest Airlines Boeing 737-300 cruising at 37,000 feet. As the airliner depressurized, the aircrew declared an emergency, successfully landing in Yuma, Arizona. “The Go Team arrived the next day, a Saturday. That night, we had our organizational meeting – when all parties get together and say, ‘This is what we’re going to do and here’s how we’ll do it.’ Boeing was at the table, and they said that, along with our staff, they’d identified structural problems with the airplane that [originated] at the factory. “They traced it all the way back to the manufacture of the fuselage. By Sunday, Boeing was working on a fix, and by Monday, they’d issued a service bulletin. Southwest was also in the discussions. They grounded that particular model until they could conduct inspections. The FAA was at the table as well, and on Tuesday, they mandated the service bulletin Boeing had put out. That’s how the Party System works. When there are deficiencies, they can be identified and corrected with the right people immediately.” As the IIC (and working groups if the investigation is larger) gathers data on site, he/she has another responsibility: working with the press. “We have a need to be transparent,” Sumwalt said. “The public is entitled to know that the government is conducting an honest, competent, thorough, independent investigation.” The need to inform the public drives NTSB investigators to responsibly release information as they get it. Preliminary “black box” recorder readouts are usually released fairly quickly, whether from the scene or from

NTSB photo

An NTSB Go Team en route to investigate the loss of container ship El Faro in October 2015. Go Teams can number from three to four to more than a dozen specialists who travel to an accident site together.

To Great Lengths NTSB LABORATORIES By Eric Tegler

ccident investigation doesn’t just happen at the accident scene. A critical portion of any investigation unfolds in the National Transportation Safety Board’s (NTSB) laboratories, where experts painstakingly analyze the data, materials, systems, and operations involved in an accident. The NTSB has four major laboratories at its Washington, D.C. headquarters: Vehicle Recorders; Materials; Vehicle Performance; and Safety Research. Each helps tell the story of a particular accident or of trends among accidents. They contribute to an accident investigation’s final report and, in the case of Safety Research, issue stand-alone reports. One of the most recognizable of the NTSB labs is the Vehicle Recorder Laboratory. It downloads recording devices from trains, buses, trucks, ships, and airplanes as well as personal portable devices like cell phones and iPads, even GoPro cameras. As such, it needs a wide array of tools and techniques to extract information from very old devices as well as the newest technologies. From magnetic tape recorders to tiny digital memory chips, the Vehicle Recorder Laboratory maintains a variety of equipment and techniques.

“We go to great lengths to do that,” says Michael Budinski, chief, Materials Laboratory. “We have the ability to remove, evaluate, and repair individual electronic memory chips as well as a host of techniques to gather data from damaged devices.” The Materials Laboratory looks largely at materials’ contribution to failure in elements from ship structures to train components, aircraft engine components, seating, batteries, and much more. The laboratory employs an electron microscope and conducts fractography, chemical analysis, wear and corrosion evaluation to determine effects on various materials. The Vehicle Performance Laboratory employs computational and visualization technology to provide time-motion histories, computer simulations, and video animations of accident scenarios. This group determines vehicle and occupant motion and the underlying causes of that motion. The laboratory also conducts stress modeling of accident components. All of the NTSB’s laboratories participate in the Party System with representatives from various parties (manufacturers, operators, regulators, etc.) present in each. On average, the laboratories issue their factual reports in approximately three to six months, though findings may come out much faster in certain instances.

NTSB member Robert L. Sumwalt (now NTSB chairman) and Sean Dalton of the NTSB’s Office of General Counsel at the scene in Biloxi, Mississippi, of a March 2017 grade crossing collision involving a freight train and a motor coach. When NTSB investigators departed the accident scene, they continued the investigation by traveling to Georgia to inspect the train involved and to Texas to visit the bus operator.

NTSB photo by Peter Knudson

THE ANALYTICAL PHASE the Board’s headquarters. And investigators speak directly to the press. The Board’s preference is to have the lead investigator handle press communications, partly because the media is usually where they are – on scene. In March 2017, a church bus and pickup truck collided on a road in Texas, killing 13. In this instance, the IIC handled communications with the press. “She did a great job with the media,” Sumwalt said. “That’s one end of the spectrum

where the investigator-in-charge will do it. On the other end will be something where we sense there’ll be a lot of media attention, like the Amtrak crash in Philadelphia two years ago. We wanted a Board member there, not because the Board member is a better spokesman, but because feeding the media, meeting with elected officials, and interacting with families becomes a full-time job. We want to free up the investigators to do the investigation.”

When the Board’s investigators leave the scene, they may still be collecting information. After a March 2017 bus accident in Biloxi, Mississippi, in which a bus stuck on a train track was struck by a train, killing four, one group of investigators departed the scene to visit the bus operator in Texas. Another working group went to Georgia to further inspect the train involved and document damage to it once it had reached its final destination. Medical records were collected and additional follow-on information was gathered.

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the public to observe the progress of the investigation. Hearings are usually held within six months of an accident. Additional tests and analysis enter into the final report, which is drafted by Safety Board staff from each working group’s factual reports. The National Transportation Safety Board members then deliberate over the final report in a public Board meeting in Washington, D.C. If the meeting results in the adoption of a major report, an abstract of that report is made available on the NTSB’s website in the “Publications” section. The Board’s conclusions, probable cause, and safety recommendations are rendered in the abstract and the full final report appears several weeks thereafter on the website.

NTSB photos

ABOVE: Then-NTSB Vice Chairman T. Bella Dinh-Zarr listens to a witness on the second day of the NTSB hearing into the Jan. 12, 2015 Washington Metropolitan Area Transit Authority smoke and electrical arcing event at L’Enfant Plaza Station. The NTSB may hold hearings in the course of investigations to gather additional information and to enable the public to observe the investigation progress. BELOW: An NTSB investigator uses a drone to inspect an inflight breakup. Drone technology has become an asset in surveying and documenting accident sites.

These facets of what Sumwalt calls the factual phase give way to the analytical phase, in which the circumstances, possible causes, and other factors are examined. At this point, the outside expertise that the Board has leveraged is separated from the investigation, Sumwalt stressed. “The parties are there to help us during the fact-finding phase. Once we go into the analysis phase, only the NTSB is involved. That’s where the Board takes biases into account and makes its determination.”

The Board’s accident analysis moves forward as each working group chairman, an NTSB staffer, assembles his/her group’s factual report, which is entered with other working group factual reports into a public docket. During this period, the NTSB may hold a public hearing if a major investigation warrants it. Such hearings serve to gather sworn testimony from subpoenaed witnesses on issues identified by the Board during the course of the investigation, and to allow

NOW VERSUS THEN As the NTSB celebrates its 50th anniversary, the question of what has changed in its investigative efforts over time naturally arises. We put the question to Sumwalt, who began following the NTSB while in college in 1974, to gain his insight into what has changed most in the last 25 years. “Technology has changed the way we do business,” he confirmed. “The Board first used GPS in an accident investigation in 1991. Now we use it routinely. We can send photos back to our headquarters via secure channels and look at them in real time. We can use drones now to survey and photodocument wreckage. We have great drone footage from a rail accident in March that will help our investigators figure out which tank cars were where. “Our investigators worked with the Woods Hole Institute to find the voyage data recorder from the El Faro [a cargo ship that sank off the southeastern Bahamas in October 2015]. We had a live feed from Woods’ ROV [remotely operated vehicle] as it searched the ocean floor for those recorders.” Sumwalt added that technology occasionally comes with hiccups of its own, but that it has “fundamentally changed the way our investigators work.” NTSB investigators will continue to adopt technologies that advance their capacity for discovery and analysis, but they’ll also continue to walk the scene.

INTERVIEW:

Mark Rosenker NTSB Chairman, 2006-2008 By Ana E. Lopez

Mark Rosenker joined the National Transportation Safety Board as a Board member and vice chairman in March 2003, when he was unanimously confirmed by the Senate after being nominated by President George W. Bush. He served as NTSB chairman from 2006 to 2008 and was re-nominated by President Bush for another term, and for a year prior to his chairmanship and for a year after, he was acting chairman. He resigned from the Board in August 2009 after President Barack Obama’s new chairman had been confirmed. Rosenker’s tenure at the NTSB spanned several major accident investigations, including the 2007 collapse of the I-35W bridge in Minneapolis, Minnesota; the 2008 crash of a Metrolink train in Chatsworth, California; the 2009 emergency water landing of US Airways Flight 1549 – the “Miracle on the Hudson”; and finally, Colgan Air Flight 3407, which resulted in profound changes in pilot training requirements, in duty day hours, and in the Pilot Records Improvement Act. A number of open safety recommendations were satisfactorily closed on his watch, including positive train control, which is slowly being implemented by the nation’s railroads. He counts the high morale of the NTSB workforce – as evidenced by the NTSB being named a top 10 place to work in the federal government – as an accomplishment of his time with the Board. Prior to his NTSB appointment, Rosenker served as deputy assistant to the president and director of the White House Military Office (2001-2002). He was traveling with President Bush on 9/11. He was managing director of the United Network for Organ Sharing from 1999 to 2001, after spending 23 years at the Electronic Industries Alliance as vice president of public affairs. In the ’70s, Rosenker was involved in transportation safety issues while working for a global public affairs organization, where his clients included the American Safety Belt Council, the Motorcycle Safety Foundation, and the Safety Helmet Council of America. Rosenker is a retired major general of the U.S. Air Force with a 37-year active-duty and Reserve career of service. Today, Rosenker is president of the Transportation Safety Group, which consults on transportation safety issues, and he sits on several corporate boards. He is also the transportation safety analyst for CBS News. Additionally, he is a popular public speaker, and frequently addresses groups about transportation safety and technology.

Your career previous to the NTSB included a lot of public affairs and communications experience, much of it specifically related to transportation. But despite your previous communications and public affairs experience, was there something that you didn’t quite feel prepared for going into the NTSB? Mark Rosenker: Well certainly [with] the investigative aspect of what we do, you have to learn a lot about: one, our process; and two, the various modes that we are dealing in; and three, the technical aspects of the investigation, and the industry that you’re dealing in, whether it is trains, planes, automobiles, ships, or pipelines. … So for the overall depth and breadth of what we do at the NTSB, we must heavily depend, obviously,

upon our professional investigators for the facts. Our business as Board members is to articulate what these investigators are finding, the process that they go through, and ultimately vote on the reports and specifically the probable causes based on the recommendations of the highly experienced, professional investigative staff. The Rail Safety Act passed in 2008, during your time at the NTSB. Among other things, its passage made it possible to remove a couple of items from the Most Wanted List, one of which was implementation of positive train control (PTC), which had been on the list for 18 years. In your opinion, why was such legislation so long in coming, and why do you think it finally did pass when it did?

AP Photo/Lauren Victoria Burke

Then-NTSB Chairman Mark Rosenker answers questions on Jan. 15, 2008, about the investigation of the I-35W bridge collapse in Minneapolis, Minnesota. The bridge collapsed on Aug. 1, 2007.

I think it came as a result of a very serious train wreck [the Metrolink crash in Chatsworth, California, in September 2008]. It was a terrible accident where 25 people died, and [135] were injured. Positive train control would have prevented this accident from happening. It was as a result of an engineer who was texting instead of operating his train solely with focus on doing his job. He missed a signal and collided with another train. The Congress historically is reactive in many, many cases. So [passage of the act] came as a result of this catastrophic train collision combined with the maturity,

if you will, of the actual technology of positive train control. When you add those two issues together, it made it politically compelling for the Congress to pass the Railroad Safety Improvement Act of 2008. [They] included a provision to require the Class I railroads [railroads are classified based on their annual operating revenues; the threshold for Class I railroads is $447,621,226 or more] to implement positive train control, and they gave them seven years to do the work. The Board believed it was a long time and an adequate time to have the railroad industry implement this important technology.

So [passage of the act] came as a result of this catastrophic train collision combined with the maturity, if you will, of the actual technology of positive train control.

Well, [the railroads] chose to, for whatever reasons, slow roll the process. And when it came time for the Congress and the FRA [Federal Railroad Administration] to say, “Hey, you guys haven’t done this, we’re going to start fining you,” the railroads cleverly were able to say, “Well, we certainly don’t want to be in violation of the Railroad Safety Improvement Act. I guess we’re going to have to stop running until we can get PTC put in.” Well, everybody recognized at the Congress that you just can’t do that. You will destroy the economy. So much is carried by the rail industry – not only passengers, but critical freight. So they knew, I think, what they were doing. And at that point, Congress gave them an extension – disappointingly, I might add. But they did. The crash was in September 2008, and I think the act passed in October? Absolutely, that moved very fast. Very, very quickly. And if I remember correctly, I think I testified. I certainly was out there beating the drum for implementation. I was so proud of what the Congress had done, and believed – honestly believed – that the rail industry recognized that when it becomes law they are required to do this. [So] I asked our Board to pull it from the Most Wanted List – because there is a finite number of things [you can include]; you can’t say on your Most Wanted List “Everything!

In 2007, the NTSB concluded its first investigation of an unmanned aircraft accident, and the NTSB issued 22 safety recommendations as a result. As far as new technology goes, is it only after the first accident happens that the NTSB has the opportunity to assess the safety, in a real world setting, of those new technologies? We always like to try to be forward-leaning where we believe we can have impact on all transportation modes. So, although we had not been actively involved in an investigation of a drone, if you will, an unmanned vehicle, we certainly knew they existed and were concerned about how they were going to be used, and the rules and regulations which would surround them. Until we actually investigate something, we don’t know exactly what causes problems. We can surmise, but we don’t know for a fact. In this case, we were able to do this investigation. It was a federal device – I think it was a Customs and Border Protection [CBP] UAV [unmanned aerial vehice] – and we had tremendous cooperation with the CBP. We learned what had happened here, and, as a result, we made recommendations to prevent that kind of accident from happening again, and then to understand what potentially could happen in other instances. What were the most pressing safety issues the NTSB was pushing to have addressed while you were on the Board? Clearly positive train control was one. One issue I was particularly active in was recreational boating safety, to include the use of PFD, personal floatation devices, for children when boats were being operated. I was successful in getting 49 states out of 50, I believe, to finally require that; there are people alive today because of that law.

NTSB photo

Wreckage of a Customs and Border Protection drone that crashed in Arizona in 2006. The accident, which occurred during Rosenker’s tenure, was the first time the NTSB conducted an investigation involving an unmanned aircraft.

All of our recommendations are critical!” You’ve got to pick some. So when you get a victory – what appeared to be a victory at that time, it seemed to me – why would you continue to have it on the Most Wanted List when the Congress passed it? Ultimately [the railroads are] going to do it. They recognize that they can’t continue to get extensions from the Congress forever. And ultimately they’re going to have to comply. And, again, they are doing it, but in a very slow process. Amtrak, as you recall, also brought the issue to light after that terrible accident between Philadelphia and New York [the 2015 derailment of Amtrak Northeast Regional No. 188 in Philadelphia], where clearly positive train control would have prevented that accident, that derailment.

Amtrak, as you recall, also brought the issue to light after that terrible accident between Philadelphia and New York [the 2015 derailment of Amtrak Northeast Regional No. 188 in Philadelphia], where clearly positive train control would have prevented that accident, that derailment.

The collapse of the I-35W bridge in Minnesota happened during your chairmanship, and it was decided that there would be no public hearing in the course of that investigation. And I guess the NTSB drew some criticism for that move. In the course of accident investigations, how do you balance being as transparent as possible with the public with conducting investigations with efficiency and reasonable expediency? We drew some criticism, and part of it was as a result of two of my colleagues believing [a hearing] was necessary to do. [Not needing nor holding a hearing] was the decision that was recommended by the professional investigators: They believed they had pinpointed what had basically created this problem, and it was done with a great deal of modeling and computer analysis. So, we did not believe we were going to get anything from holding a public hearing other than to push the final meeting, which is where you actually determine and announce the probable cause and make recommendations. So three of the five Board members agreed with professional staff that this was not a good use of the Board’s funds or time, and it is best to get the report out as expeditiously as possible if we are going to prevent one of these types of accidents from happening again. Another issue was that this turned out to be a highly political investigation. Democrats and Republicans were publicly arguing with each other on what caused the bridge to fail. Both sides were questioning was this an infrastructure failure caused by lack of

proper maintaince or was it something else. The legislature blamed the governor and the governor blamed the legislature. There was a whole lot of politics going on here. And we believed that all we were going to do if we did hold a public hearing was fan the flames of the politics. Our organization is a nonpolitical organization. Our mission is to find the truth. And our business is a very technical business. The facts, evidence, analysis, and the science that goes into our determination of various technical causes is not political. It’s scientific. It’s factual. The investigators and majority of the Board believed there was nothing that was going to be gained scientifically resulting from a public hearing in this unique case. Traditionally we will do a public hearing when we need to actually get more facts; if we don’t understand the essence of what has happened in an investigation, and a public hearing would help us do that; or to push, for example, potentially other issues which could be important to the case. Based on the technical modeling that we had – the preliminary findings that came from Turner Laboratories, as well as the various other technical organizations that were helping us do this analysis – we found that we pretty much understood what created the problem. And that was a design flaw. Somebody made a mistake in the design, and then others in the process didn’t catch it in the entire history of the bridge. The U 10 gusset plate, which in fact failed, was a half-inch thick, as opposed to an inch. It needed to be an inch. … We were hoping that we could understand the failure by finding a manufacturing flaw rather than a design flaw, meaning that the designer actually called for an inch and the company that made the steel gave him a half-inch. Well, that’s not what happened. It was made exactly to the way it was specified. But we did find out what happened. What happened was this gusset plate – and there were a couple of them – was underdesigned. And it was not a question of if this bridge was coming down; it was when is it coming down. What scared me toward making sure we could expeditiously get this report out was: What happened if another bridge collapsed and people died while we were fooling around with a public hearing? …

CONGRATULATIONS TO THE NTSB FOR 50 YEARS

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Photo courtesy of Mark Rosenker

The last thing I wanted was to be having knowledge of what we believed created the problem and then ignore it for the sake of politics in doing a public hearing, which would have pushed everything back four or five months. Four or five months, in my judgment, was much too long when our investigators and engineers knew what had happened here.

What was the biggest challenge you faced as chairman and what do you think your most important accomplishment was? I think certainly budgeting is always a challenge as a federal organization. We’re a small group. People perceive us as a much larger organization than we are. When I was there, it was about 400 people. The budget was what it was. And we continued to work with what we had in hand. [But] I could have used more professional investigators on the staff. I would have liked to have the ability to shorten the time from the time we actually go on site of an investigation to the time we finish and write the final report. I would have liked to have been able to do that in months rather than in, sometimes, years. But I understand why the process has taken longer. We are doing a much – I believe – a much more thorough, meticulous, comprehensive examination, [because] we have to know more than we did 40 years ago. And that’s simply because there is more technology. There is more advanced science and technology that goes into the various modes of transportation that we didn’t have benefit of 40, 50 years ago. And today we are not the font of all knowledge as it relates to composites, as it relates to advanced electronics and things like that. We have to bring technical experts and appropriate parties in to help us understand how these things work. So it takes longer. When you’re dealing with a much simpler vehicle, well, there are only a few things that could be the problem. When you’re dealing with advanced vehicles, like composites of an airplane, for example, [or] advanced electronics that in many cases could even land the airplane, well, there are more questions to be asked. More things potentially could go wrong. So therefore you have more potential probable causes. So there are lots of things, lots of things, that have to be examined and ruled out to guarantee, and we must be spot on in coming up with probable causes, because the only thing we have at the NTSB is our good reputation and credibility. And speaking of that, did you see the movie Sully [the 2016 film that depicts the emergency water landing of US Airways Flight 1549 by Capt. Chesley “Sully” Sullenberger and the

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ensuing investigation into the accident, and is based on Sullenberger’s book]? I did not see it, actually. I was so disappointed. I know Sully. He’s a good guy. He’s a great aviator and I have great respect for him. But that motion picture was the biggest hour and a half of exaggerations of how we do things at the NTSB, mischaracterizations of how we handled that investigation, truly an inaccurate, nasty portrayal of the investigators and the agenda that they allegedly had. That disturbed and disappointed me and I know it troubled the majority of staff and particularly anyone who was involved in that investigation – I was the chairman during that period of time. And to see that portrayal … it makes us look small, petty, makes us look incompetent, makes us look like we are agenda-driven. It soils our reputation. And, as I say, the only thing we have is our good name and credibility. And if people don’t believe we are telling the truth and we’re doing things for the right reasons, that affects safety and the perception of what we have to say – and as a result affects safety. So I was really disappointed, disturbed, publicly commented on it, and continue to publicly comment on this, and just say it was a disservice. And I recognize that it was a movie. Well, there is the difference between Star Wars, which is totally fabricated, and something which allegedly was supposed to be kind of a docudrama, which is supposed to be based on facts. What in your opinion is the greatest threat to transportation safety today and what can or should be done to address it? Complacency in all of our modes where we think we are ok. We have got to continue to lean forward in all of the modes to guarantee that we don’t have complacency and that we’re always looking to raise the safety bar. And it would be nice to get to perfection, but I’m not convinced we can. But we certainly can do better than we are doing today, because by stretching, by continually trying to get continuous improvement, then we will end up raising the bar, and thereby ultimately prevent accidents; resulting in fewer and fewer

We have got to continue to lean forward in all of the modes to guarantee that we don’t have complacency and that we’re always looking to raise the safety bar. injuries and ultimately fewer and fewer fatalities. Is there anything you’d like to add that maybe I didn’t touch on? This is an incredible agency! I count as one of the great blessings and career accomplishments of my entire life the chance to work with these great people and to ultimately have the privilege to lead them. It was the best job I ever had. I don’t think I could have a better job. I don’t think I could work for an agency that does more for as little cost to the American people as the NTSB. … These people are great people. They are probably some of the best and brightest public servants I have ever come across. And I’ve worked in federal government at various agencies including the White House. And I love the United States Air Force – I spent 37 years as an active and Reserve officer. And I will put these guys up against any and every one of the great people that I have ever had a chance to work with. These folks are second-to-none. One important accomplishment we made is we began to clean up a lot of the long-standing FOIA [Freedom of Information Act] issues. We were able to come up to date. We were able to do a lot with our recommendations and begin to close a significant number of them satisfactorily. We made a lot of improvements to all the transportation modes we cover, from aviation, to highways, to rail, to marine and pipelines. Certainly an important accomplishment was to get our agency, the NTSB, voted by the employees one of the top 10 best places to work in federal government. That happened under my administration. And I am still very proud of that. I think we had a high level of morale. And clearly these people worked absolutely extraordinarily hard, and again, I can’t think of a more important federal agency to work for than the NTSB. These people are the best of the best.

CASE STUDY CASE STUDY CASE STUDY

Safer Routes,OF Quicker Permitting in the Nation’s Capital DISTRICT DEPARTMENT TRANSPORTATION DISTRICT Safer Routes, Quicker Permitting in the Nation’s Capital DISTRICT More than one million people commute throughin Washington, D.C., each work Safer Routes, Quicker Permitting the Nation’s Capital DEPARTMENT OF UnitedDISTRICT States Moreand than million people commute through D.C., each day, 18one million visitors travel to the city eachWashington, year. The mission of thework

DEPARTMENT OF More than million commute through Washington, D.C., each day, and 18one million visitors travel to the(DDOT) city each year. The these mission of thework District Department ofpeople Transportation is to ensure people – as DEPARTMENT OF TRANSPORTATION day, and 18 million visitors travel to theefficiently city each year. The these mission of the– as District Department of Transportation (DDOT) is to ensure people well as goods and information – move and safely with minimal Safer Routes, Quicker Permitting in the Nation’s Capital travel within the district. While DDOT issues thousands of single-haul TRANSPORTATION District Department of Transportation (DDOT) is toand ensure these – as well as goods and – move efficiently safely withpeople minimal adverse impact oninformation residents and theOS/OW environment. More than 1 million people commute through Washington, D.C., each permits for vehicles each year, the process for determining TRANSPORTATION well as goods and – move efficiently and safely with minimal adverse impact oninformation residents and the environment. United States

workday, and 18 million visitors travel to the city each year. The mission the safest route – taking into consideration factors such as the height adverseDDOT’s impact on residents and the efficient environment. Among isofto enable andrestrictions safe mobility of commercial of the District Department of Transportation (DDOT) is to ensuremandates these overpasses and weight for bridges – was manual, and Among DDOT’s mandates is to enable efficient and safe mobility of commercial vehicles traveling in D.C., while mitigating community impacts and people – as well as goods and information – move efficiently and safely therefore cumbersome, costly, and potentiallypreserving error-prone. It also proAmong DDOT’s mandates is to Commercial enable efficient and safe mobility of commercial vehicles traveling in D.C., while mitigating community impacts and infrastructure. vehicles are essential topreserving the delay city, for carriers. with minimal adverse impact on residents and transportation the environment. longed the issuance of permits, causing a lengthy

United States United States

vehicles traveling in D.C., while mitigating impacts and transportation Commercial vehicles are essential topreserving the city, providing goodsinfrastructure. and services to thousandscommunity of residents and businesses every transportation infrastructure. Commercial vehicles are essential to the city, providing goods and services to thousands of residents and businesses every day. However, there are challenges to commercial vehicle routing. The city has Among DDOT’s mandates is to enable efficient and safe mobility of DDOT previously used paper maps to determine routes before switchproviding goods and services toathousands of residents and businesses every day. However, there are challenges to commercial vehicle routing. The city has a diverse mixture of land uses, dense urban environment, and extensive commercial vehicles traveling in D.C., while mitigating community iming to a geographic information system (GIS); but even the district’s day. However, there challenges to commercial vehicle routing. The city has a diverse mixture ofare land uses, a dense urban environment, and extensive transportation infrastructure. pacts and preserving transportation infrastructure. Commercial vehicles GIS required DDOT personnel to manually review routes – segment by a diverse mixture of land uses, a dense urban environment, and extensive transportation infrastructure. are essential to the city, providing goods and services to thousands of segment – checking overpasses, bridges, and more. District officials transportation infrastructure. Washington, D.C., you have really narrow streets,process 68 square and residents and businesses every day. However,“In there are challenges to wheredecided to introduce an automated thatmiles, would conduct the “In Washington, D.C., where you have really narrow streets, 68 square miles, and over a million commuters each day, it can be quite an issue,” said José Colón, commercial vehicle routing. The city has a diverse mixture of land uses, proper checks and balances for safe routing, as well as reduce the “In D.C., where youday, haveit really streets, square overWashington, a million commuters each can benarrow quite an issue,”68 said Josémiles, Colón,and DDOT’s chief information officer. a dense urban environment, and extensive transportation infrastructure. amount of time required to generate a route and thus approve a sinover a million commutersofficer. each day, it can be quite an issue,” said José Colón, DDOT’s chief information “In Washington, D.C., where you have really narrow streets, 68 square gle-haul permit. DDOT’smust chiefalso information officer. withDDOT federal agencies, including U.S. miles, and over a million commuters each day,DDOT it can be quite an coordinate issue,” Toextensively meet this need, selected Hexagon Safetythe & Infrastructure’s DDOT must also coordinate extensively with federal agencies, including the U.S. Secret Service, U.S. Capitol Police, and National Park Service. These factors said José Colón, DDOT’s chief information officer. software for automated route planning and restriction management, DDOT alsoU.S. coordinate extensively with federal agencies, including the U.S. Secretmust Service, Police, and National Park Service. These factors require a distinct setCapitol of rules and regulations to govern the operation of trucks which was integrated with DDOT’s permitting system to offer a seamSecret Service, U.S. Capitol Police, and National Park Service. These factors require a distinct set of rules and regulations to govern the operation of trucks and commercial vehicles. DDOT must also coordinate extensively with federal agencies, including less workflow. The new solution streamlines the routing process to require a distinctvehicles. set of rules and regulations to govern the operation of trucks and commercial the U.S. Secret Service, U.S. Capitol Police, and National Park Service. ensure safety, increase efficiency, and expedite permits for trucking and commercial vehicles. These factors require a distinct set of rules and regulations to govern the operation of trucks and commercial vehicles.

companies.

AUTOMATING THE WORKFLOW AUTOMATING THE WORKFLOW “Before, it was a tedious, cumbersome process,” said Colón. “AutomatTo protect the public and WORKFLOW city limitsure traffic congestion, DDOT are involved AUTOMATING THE ing infrastructure the workflow andand making all the right stakeholders

AUTOMATING THE WORKFLOW Tolimit protect public city infrastructure and limit trafficto congestion, DDOT a the permit for and oversize/overweight (OS/OW) vehicles travel To protect the public and city infrastructure andrequires traffic congestion, really helps to improve the overall process and within makes the us much more To protect the public and city infrastructure and limit trafficto congestion, DDOT requires a permit for oversize/overweight (OS/OW) vehicles travel within the district. While DDOT issues thousands of single-haul permits for OS/OW vehicles DDOT requires a permit for oversize/overweight (OS/OW) vehicles to streamlined, much more efficient.”

requires a permit forissues oversize/overweight (OS/OW) vehicles to for travel within the district. While DDOT thousands of single-haul permits OS/OW vehicles district. While DDOT issues thousands of single-haul permits for OS/OW vehicles

1 “You can only imagine what the return on investment would 1 1 be if we can avoid just one bridge strike a year.”

“This is going to help ensure we are issuing permits at a YDUTS ESAC high confidence level.” MANAGING ROUTES & RESTRICTIONS The solution is delivered to users via a web browser. The system’s restriction management application maintains all permanent restrictions, such as bridges, tunnels, turning radii, signal lights, and overhead clearances, to name a few – all of which could impact the safe routing of an OS/OW load. DDOT permitting agents can also upload additional data on temporary restrictions, such as road closures, construction zones, parade or dignitary routing, or weather/ accident-related restrictions. Carriers can access the system to register their companies; input vehicle and load information and entry, destination, and exit locations; and request permits. The solution’s route planning application streamlines and automates the process – taking into consideration vehicle and load information, cross- referencing against transportation infrastructure data, and factoring in temporary restrictions – before generating the safest route.

AT A GLANCE The Challenge The District Department of Transportation (DDOT) ensures people and goods move efficiently and safely through Washington, D.C. The department requires a permit for oversize/overweight (OS/OW) vehicles to travel within the district. While DDOT issues thousands of single-haul, OS/OW permits each year, the process for determining the safest route was manual, cumbersome, costly, and potentially error-prone. It also delayed the issuance of permits, causing a lengthy delay for carriers.

The Solution

DDOT selected Hexagon Safety & Infrastructure’s software for automated route planning and restriction management, which The routes are then sent for approval to relevant stakeholders, such as was integrated with DDOT’s permitting system for a seamless bridge engineers or district or federal police departments. The system workflow. Carriers can input vehicle, load, and location tracks all approved routes and makes that data available to DDOT for information and request permits. The solution streamlines and later analysis and reporting. Drivers receive detailed maps and driving automates routing, cross-referencing against transportation directions and are alerted if new restrictions arise that would require infrastructure data and restrictions, before generating the safest re-routing. krow hcae ,.C.D ,notgnihsaW hguorht etummoc elpoep noroute. illim eDrivers no nahreceive t eroMdetailed maps and driving directions eht fo noissim ehT .raey hcae ytic eht ot levart srotisivand noiare llimalerted 81 dnifa new ,yadrestrictions arise that would require reBy providing the most suitable route, the system helps prevent bridge sa – elpoep eseht erusne ot si )TODD( noitatropsnarT fo trouting. nemtraBy peensuring D tcirtsithe D most suitable route, the system helps strikes and other actions that could damage infrastructure and impact laminim htiw ylefas dna yltneicfife evom – noitamrofnprevent i dna sbridge doog sstrikes a llewand other actions that could damage public safety. “You can only imagine what the return on investment .tnemnorivne eht dna stnediserinfrastructure no tcapmi eand sreimpact vda public safety. would be if we can avoid just one bridge strike a year,” said Colón.

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It also improves overall traffic congestion by keeping OS/OW vehicles laicremmoc fo ytilibom efas dna tneicfife elbane ot si setadnam s’TODD gnomA off main arterial roads and diverting them to more suitable and safer gnivreserp dna stcapmi ytinummoc gnitagitim elihw ,.C.D ni gnilevart selcihev routes. Overall, the solution ensures permits are issued quickly and ,ytic eht ot laitnesse era selcihev laicremmoC .erutcurtsarfni noitatropsnart safely, which keeps people safer, protects infrastructure, and supports yreve sessenisub dna stnediser fo sdnasuoht ot secivres dna sdoog gnidivorp the needs of carriers.

TCIRTSID FO TNEMTRAPED NOITATROPSNART setatS detinU

sah ytic ehT .gnituor elcihev laicremmoc ot segnellahc era ereht ,revewoH .yad evisnetxe dna ,tnemnorivne nabru esned a ,sesu dnal fo erutxim esrevid a “Part of our agency’s mission is to move goods throughout the district .erutcurtsarfni noitatropsnart safely and efficiently,” said Colón. “This is going to help ensure we are issuing permits at a high confidence level.”

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About Hexagon Safety & Infrastructure .S.U eht gnidulcni ,seicnega laredef htiw ylevisnetxe etanidrooc osla tsum TODD Hexagon Safety & Infrastructure provides mission-critical and busisrotcaf esehT .ecivreS kraP lanoitaN dna ,eciloP lotipaC .S.U ,ecivreS terceS ness-critical solutions to governments and service providers. A global skcurt fo noitarepo eht nrevog ot snoitaluger dna selur fo tes tcnitsid a eriuqer leader, proven innovator, and trusted partner, our software and industry .selcihev laicremmoc dna expertise help improve the lives of millions of people through safer communities, better public services, and more reliable infrastructure.

WOLFKROW EHT GNITAMOTUA

Visit hexagonsafetyinfrastructure.com. Hexagon Safety & Infrastructure is part of Hexagon (Nasdaq StockThe Route Planner application generates a route through the district. On the left are detailed driving directions. In the center is a map with the route location. On the The application generates a route through the holm: HEXAB; Thexagon.com), ODD ,noitsegnaoleading c cfifarglobal t timilprovider dna eruof tcinformation urtsarfni yticrightdisntheamapclegend ilbuwith poptional eRoute htmap tcfeatures ePlanner torandpbase oTmaps. district. On the left are technologies that productivity eht drive nihtiw levart ot sand elcquality ihev )Wacross O/SO(geospatial thgiewrevand o/ezisrevo rof timrep a seriuqer detailed driving directions. In the center is a map with the route location. On the right is the map legend with industrial enterprise selcihevapplications. WO/SO rof stimrep luah-elgnis fo sdnasuoht seussi TODD elihW .tcirtsid optional map features and base maps.

©2017 Intergraph Corporation d/b/a Hexagon Safety & Infrastructure. Hexagon Safety & Infrastructure is part of Hexagon. All rights reserved. Hexagon Safety & Infrastructure and the Hexagon Safety & Infrastructure logo are trademarks of Hexagon or its subsidiaries in 1 and in other countries. 2/17. the United States

About Hexagon Safety & Infrastructure Hexagon Safety & Infrastructure provides mission-critical and business-critical solutions to governments and service providers. A global leader, proven innovator, and trusted partner, our software and industry expertise help improve the lives of millions of people through safer communities,

Families and Fundamentals Transportation Disaster Assistance

By Jan Tegler

When Americans think of the National Transportation Safety Board (NTSB), they most commonly associate it with accident investigation. For most of us, that remote understanding is all we require. But for family members of those who are victims in transportation accidents, the NTSB is much more. It’s a resource for information, understanding, and assistance.

fundamental areas of concern for family members: notification of involvement, victim accounting, access to resources and information, and personal effects management. “Any comprehensive, effective family assistance response will address those four concerns,” Kontanis said. “These things transcend culture, socioeconomic, and religious boundaries. They’re fundamental to all people. But there’s no one organization, agency, or company that’s responsible for every one of those broad concerns.”

President Bill Clinton signs the Aviation Disaster Family Assistance Act of 1996. The legislation charged the NTSB with coordinating disaster assistance resources to meet the needs of family members and survivors in the wake of aviation accidents.

NTSB photo

The NTSB’s Transportation Disaster Assistance (TDA) Division is charged with coordinating the resources of federal, state, and local agencies, transportation carriers, and the American Red Cross to meet the needs of family members and survivors following a transportation accident. It’s a mission born of tragedy. From the late 1980s though the mid-1990s, a series of major accidents in commercial aviation led to growing recognition of the fact that support for those most affected by these disasters – families – was lacking. Appreciation for the problem spiked in July 1996 with the loss of TWA Flight 800 following an in-flight explosion that took the lives of all 230 passengers and crew aboard the Boeing 747. Just three months later, Congress passed the Aviation Disaster Family Assistance Act (ADFAA) of 1996. The creation of the ADFAA was hastened by a number of family groups connected with airline disasters who banded together in the mid-1990s to lobby the NTSB and the Department of Transportation. The legislation created a new responsibility for the NTSB, tasking the agency with crafting an organized, compassionate response for families in the aftermath of aviation accidents that resulted in a major loss of life. Prior to the ADFAA, there was no single rallying point for the families of victims. Interaction with family members fell primarily on the air carriers and NTSB senior management. “Response was disjointed and not well coordinated” between the air carriers and the families of victims, TDA Chief Elias Kontanis explained. “Local response communities didn’t do a fantastic job of communicating with families either, and certainly the NTSB was part of the issue.” The agency stood up a new “Family Affairs Division” to meet the requirements of the ADFAA. The division’s role was to address four

The Family Affairs Division has evolved over time, becoming the Transportation Disaster Assistance Division. The modern title gives an indication of the wider scope of support the division now provides. But it all began with response to legislated accidents.

ABOVE: NTSB transportation disaster assistance (TDA) specialist Elias Kontanis searches through a damaged rail car at an accident site in Fairfield, Connecticut. In 2008, the NTSBâ&#x20AC;&#x2122;s disaster assistance role after aviation accidents was expanded to include certain accidents in other modes of transportation, including rail. BELOW: Kontanis works with a medical examiner representative on an accident scene. NTSB TDA staff coordinate with medicolegal personnel in whose jurisdiction an accident has occurred as part of their disaster assistance duties.

NTSB photos

AVIATION AND RAILWAY ACCIDENTS The Aviation Disaster Family Assistance Act was created with the intention of coordinating family assistance in response to aviation accidents that meet three criteria. First, they must occur in the United States or U.S. territories. Second, they may only include air carriers that have economic authority to operate in the United States issued by the Department of Transportation. Third, an accident must result in a major loss of life. If all three criteria are met, an accident is considered to fall within the ADFAA.

An unidentified woman is consoled aboard a bus reserved for relatives and acquaintances of passengers who were aboard TWA Flight 800 at John F. Kennedy International Airport in New York on July 18, 1996. The crash of TWA Flight 800 highlighted the lack of coordinated support for families in the wake of aviation accidents. The Aviation Disaster Family Assistance Act passed later that year.

fatalities – then we consider the legislation to be in play.” With all criteria satisfied in the wake of a legislated accident, TDA goes into action to respond to the four fundamental concerns of family members and survivors.

AP Photo/Wally Santana

CALL AND RESPONSE

In other words, it’s considered a “legislated accident,” and as such, gives the TDA the authority to coordinate disaster assistance for victims’ family members. Until 2008, aviation accidents were the only kind of transportation accidents to which TDA had formal authority to respond. That year, Congress passed the Rail Passenger Disaster Family Assistance Act (RPDFAA). The RPDFAA gives TDA the authority to provide the same kind of disaster assistance to families as ADFAA. The criteria that must be met are similar. The RPDFAA applies to interstate/intercity passenger rail operators. Currently, only Amtrak, the high-speed rail operator in the U.S. northeastern corridor, meets this requirement. But later this year, All Aboard Florida’s new Brightline high-speed rail service will launch, and its operations will fall under the new legislation.

Kontanis said that TDA is already communicating with Brightline about its obligations under the RPDFAA. The respective acts mirror each other in stipulating that air carriers and rail operators must provide multiple forms of notification, information, and logistics assistance to families, the NTSB and other authorities, and the media. Interestingly, Kontanis noted that neither the ADFAA nor the RPDFAA specifies how the NTSB and air carriers/rail operators are to meet the requirements of the legislation. The acts also left open the question of what constitutes a “major loss of life.” “We appreciate the fact that the death of even one individual is significant to their family,” he emphasized. “The way we’ve interpreted the act in practice is that if there are two or more fatalities resulting from a crash – whether crew, passengers, non-revenue passengers, or ground

“The first thing we do, let’s say if we hear about an aviation accident,” said TDA’s chief, “is ask where it occurred, what the severity of injuries may be, are there fatalities, how many? Does this operator have economic authority?” If the answer to those questions is yes, TDA deems the event a legislated accident. Internal checklists and operating procedures are then triggered and followed to launch a response. In some cases, depending on the magnitude of an event, the division will launch every one of its total of five team members, Kontanis said. “Each of the five team members will engage with the entity we’ve determined they’ll be the primary contact for. One team member will serve as liaison with the air carrier, another liaises with the American Red Cross, a third serves as prime contact with the medical examiner. The next team member liaises with emergency management and first responders, and finally we liaise with our federal partners and our internal investigative staff.” Those interactions broadly outline the responsibilities TDA has in assisting family members and coordinating disaster assistance among federal, state, and local authorities. TDA staff also work side by side with NTSB investigators to provide information regarding the NTSB investigation, one of the four fundamental concerns for families. TDA is responsible for facilitating the recovery and identification of fatally injured passengers by coordinating with the presiding medicolegal jurisdiction

NTSB photo

– the medical examiner or coroner in whose jurisdiction the accident has occurred. As Kontanis explained, aviation accidents can happen anywhere in the United States, near to population centers or in remote locations. Consequently, jurisdictions in the United States vary in their capability to handle a mass fatality or mass casualty incident. “We conduct a gap analysis with the relevant medical examiner or coroner to determine what capabilities they might or might not have on hand to process an event and appropriately recover and identify the dead. We work with our federal partners in order to fill some of those gaps. We have the Department of Health and Human Services, the Armed Forces Medical Examiner, the FBI, and the Department of State to call on. That’s where they come in and support the process.” One of the most important functions TDA provides is its role as a liaison between NTSB investigators and family members. TDA staff act as a clearinghouse for information, keeping family members informed about the varied aspects of an accident investigation and assisting them in understanding investigative activities. This vital communication addresses the “access to resources and information” concern and also aids NTSB investigators.

The NTSB Go Team arrives on the scene of the Amtrak Train No. 188 derailment in Philadelphia, Pennsylvania, in 2015. In the aftermath of the derailment, the Transportation Disaster Assistance (TDA) Division adapted to the needs of the families, visiting them where they were – in hospitals with loved ones – rather than setting up a family assistance center to which families would have to travel.

“Our investigators are there to focus on collecting factual information and assessing its significance so they can take further steps in an investigation,” Kontanis explained. “We’re there to focus on the needs of family members. It’s very difficult for an investigator to do both of those things, especially with a large family group. We allow investigators to focus on what they need to do.” The dissemination of information to family members is a priority and a balancing act. Kontanis said TDA staff consider each accident as a unique event and try to deliver accurate details and information to families in the most efficient, appropriate way. The specifics of an incident “drive the response,” he noted. In some cases where there are multiple family members or multiple families in need of assistance or resources, the division will collaborate with the transportation operator, government agencies, and nongovernmental organizations such as the American Red Cross to establish a Family Assistance Center. “This is a place where family members can congregate,” Kontanis said. “It’s a setting where they can receive formal briefings from various response agencies, whether it’s the

NTSB, the medical examiner, or others. The American Red Cross may be there providing disaster mental health services in the role designated for them by the ADFAA. That’s a classic family assistance model that works well in certain circumstances, typically following mass fatality events.” Because the TDA also responds to a range of aviation and rail accidents, there’s no cookiecutter approach to providing assistance. Both the ADFAA and RPDFAA require air carriers and rail operators to meet a defined set of obligations for family disaster assistance. These can include: notification of involvement for families whose loved ones are victims in an accident; provision of a manifest to the NTSB and TDA, which lists the names of passengers; personal effects management; and assisting with travel/ logistic support for family members when they travel to the site of an accident. But even in cases where air carriers or rail operators are able to meet their obligations for a legislated accident, TDA may have to improvise, Kontanis said. When Amtrak Northeast Regional Train No. 188 crashed in Philadelphia in May 2015, killing eight passengers and injuring more than 200, TDA

staff were confronted with family members and survivors dispersed over a wide area. “Let’s say you have three fatalities and 100 people injured and dispersed among five hospitals. Where will those family members want to be – a family assistance center or with their loved ones in the hospital? Typically they want to be in the hospital with loved ones. We saw that following the Amtrak 188 derailment,” Kontanis said. “We went from hospital to hospital and introduced ourselves to passengers that were admitted and their family members. We provided them with our contact information, briefed them on the investigative process, and initiated a relationship in person as much as we could. For those we miss in person, we follow up with contact information and letters.” As challenging as legislated accidents can be, TDA’s five staff members also encounter many more complexities when addressing accidents not covered by the ADFAA or RPDFAA. NON-LEGISLATED ACCIDENTS The NTSB is responsible for investigating a broad range of accidents. In addition to

aviation and railway incidents, the Board investigates pipeline, hazardous materials, marine, and highway accidents. Given that the agency’s investigative activities go well beyond legislated accidents, TDA has evolved over time to provide family assistance for non-legislated accidents. “We believe that the fundamental concerns I mentioned really apply to anyone who experiences an unexpected loss,” Kontanis explained. “We take the principles we’ve developed from aviation disaster assistance and, when possible, apply them to the other modes of transportation that we investigate.” Just as with aviation and rail disasters, TDA can serve as the primary point of contact with families in non-legislated accidents. TDA staff address family members’ questions about the status of an investigation, explain the investigative process, describe what their interaction with the families will be like going forward, and help them understand the NTSB’s investigative products. For non-legislated accidents, however, the decision to respond and the details of TDA’s response are more complex. Kontanis said his team must evaluate the magnitude of

LONG-TERM ASSISTANCE While TDA is present on scene during the initial aftermath of all legislated accidents and many non-legislated accidents, Kontanis was keen to emphasize that the division never really concludes its cases.

NTSB photo by Nicholas Worrell

An investigator briefs NTSB Board member (then chairman) Christopher Hart and NTSB highway investigator Jennifer Morrison on the damage to a school bus involved in an accident in Chattanooga, Tennessee, on Nov. 21, 2016, in which several passengers were killed. Though it was a non-legislated accident, the NTSB sent a TDA specialist to Chattanooga to ensure that family members’ concerns were addressed.

an event, the number of family members, the family assistance framework that may or may not exist in a local community or with the operator, and the needs of NTSB investigative staff. “If they’d like us there to help them communicate with family members, then we’ll send one or perhaps two team members.” TDA can also act as a resource for response communities, supporting the efforts of operators, local governments, the office of emergency management, police, fire, medical examiners, and the American Red Cross. This is particularly useful in addressing non-legislated accidents, where the transportation operator is not obligated to support family assistance operations. “There was a school bus accident on Nov. 21, 2016, in Chattanooga, Tennessee, that resulted in several fatalities of elementary school children,” Kontanis recalled. “We launched a TDA specialist for Chattanooga to work with the American Red Cross, to work with law enforcement, with the school, and others in a cohesive manner to ensure that the concerns family members had were addressed.” The staff member communicated why the Board was there, what it was there to do, and how that differed from the investigations the local law enforcement agencies were also conducting. In addition, the TDA specialist helped authorities determine which agencies were best suited to address families’ needs and helped families understand the broader context of the response. “We need to understand the limits of agencies and organizations,” Kontanis stressed. “We need to think outside the box sometimes and figure out if one organization cannot support a need, who can? Honestly, there are times when needs cannot be met. It’s just reality. We can’t mandate that organizations do things, especially outside of those legislated areas.”

NTSB investigations are exhaustive endeavors and can last months or, in some cases, longer. Accordingly, TDA remains a source of assistance and understanding for family members throughout the cycle of an investigation and beyond. Victim recovery and identification can be a lengthy process in the wake of some accidents as complex medicolegal efforts proceed. NTSB Board hearings and meetings may also take place during the course of an investigation, months after the accident. TDA staff keep family members apprised of progress and invite them to attend hearings or meetings. They meet with families prior to the start of a hearing or Board meeting, and explain the process and what they can expect to hear. Support for family members doesn’t end, even after the NTSB produces a final report, Kontanis said. “We leave the door open and advise family members when the Board releases a final product and explain the final report to them. Safety recommendations can be associated with those reports, and they may take a

while to go through their life cycle. We keep contact information and tell families they can always reach out to us.” Kontanis added that TDA has interacted with family members for cases that “predate my birth,” doing what it can to obtain and provide information. PREPARING FOR THE FUTURE TDA staff members spend approximately 60 to 70 percent of their time working with family members in post-accident response. But as crucially, TDA specialists go on the road, spending up to 30 percent of their time delivering presentations and doing workshops with transportation operators and local response communities. Kontanis reported that in the first three months of 2017, TDA staff conducted 15 workshops and seminars focused on family assistance across the United States. “It’s not only about response. As critical is making sure we’re prepared and local response communities are prepared and

have proper planning for broad family assistance response.” As mentioned, the division executes its mission with just five staff members. Each manages approximately 30 to 50 cases simultaneously. The majority are aviation accidents, but as TDA extends its assistance to non-legislated accidents, staff are responding to the full range of accidents the NTSB investigates. Looking ahead, Kontanis said his division is wrestling with how to satisfy family members’ needs and expectations as technology evolves, working to strike a balance between timeliness, accuracy, and compassion. “For someone who believes their loved one is on board an airplane or a train that may have been in an accident, information can never come fast enough. But we have a responsibility to deliver accurate information and that can take time. There’s an importance to keeping up with societal expectations and managing our response, but we must constantly keep family members’ fundamental concerns uppermost in our minds.”

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INTERVIEW:

Deborah A.P. Hersman NTSB Chairman, 2009-2013 By Ana E. Lopez

Deborah A.P. Hersman’s career in safety stretches back to a transportation tragedy. A train accident in 1996 in her home state marked her first interaction with the National Transportation Safety Board (NTSB), and focused her drive to help people by endeavoring to improve safety for all. In the years following that accident, Hersman worked on transportation safety legislation as a senior legislative aide to West Virginia Rep. Bob Wise until 1999 and served as a senior advisor to the U.S. Senate Committee on Commerce, Science and Transportation (1999-2004). In 2004, she was appointed as an NTSB Board member by President George W. Bush. In 2009, Hersman began the first of three terms as chairman of the NTSB when she was appointed by President Barack Obama and confirmed by the Senate. In her role as chairman, Hersman was the Board member on scene for more than 25 major transportation accidents, chaired numerous NTSB hearings, forums, and events, and regularly testified before Congress. The sharing of NTSB’s news and information via the agency’s own website and social media channels became more streamlined and effective thanks to policies and guidelines put in place during her tenure. Hersman resigned from the NTSB in 2014 during her third term to take on her current role as president and CEO of the National Safety Council (NSC). Today at the NSC, she continues her mission to improve safety and prevent injuries and loss of life not just in transportation modes, but in homes, workplaces, and communities.

I read that you took flying lessons as a teenager and that you are licensed to drive a motorcycle, so it seems you have a personal interest in different kinds of transportation, but how did you first become interested in transportation as a professional career? Deborah A.P. Hersman: My professional passion for transportation safety began on a snowy winter evening after a deadly collision between an Amtrak and a commuter train outside of Washington, D.C. Tragically, three crewmembers were killed. Even more heartbreaking, a number of their passengers survived the collision, only to perish in the post-crash fire because they couldn’t get out of the burning cars. First responders

and passersby attempted to save them, but because emergency doors and windows wouldn’t open, were inaccessible, or not marked, they watched helplessly as people perished in the blaze. That was in 1996 and I was a young congressional staffer working for a senior member of the House Transportation Committee. When NTSB investigators explained their initial findings to my boss, Congressman Wise, I remember feeling stunned and incredulous, but committed to learning all I could to make sure this would never happen again. That investigation and the fact that the loss-of-life was entirely preventable was a turning point for me.

Then-NTSB Chairman Deborah A.P. Hersman briefs the media on the investigation into an accident on Nov. 30, 2012, where a bridge collapse in Paulsboro, New Jersey, caused a train to derail and release hazardous materials.

NTSB photo

After the crash, through voluntary industry actions, safety legislation, new regulations and better design, the lessons learned were institutionalized across the nation’s transit systems. Today, 50 percent of windows in passenger compartments must be emergency windows, doors must have quick releases, and emergency exits must be clearly marked, not just on the inside, but also on the outside for first responders. There’s no way to know how many lives have been saved … how many injuries prevented … but the NTSB investigation and recommendations coupled with congressional legislation and new FRA [Federal Railroad Administration] regulations made a difference. It was my first exposure to the NTSB, and how they gained knowledge from tragedy to improve safety for all of us. You started out on the legislative side working for Rep. Wise and on the Senate

Committee on Commerce, Science and Transportation. Was it a difficult change for you going from crafting legislation and trying to get things passed to mandate safety changes to then going to the NTSB where you’re advocating and you don’t have a regulatory role? No, because each part of the government has a role to play. The legislation that created the NTSB in the late 1960s became the international model for transportation accident investigations. By designating a separate independent agency, outside of and not beholden to the regulator, the NTSB became the gold standard for similar agencies all around the world. While each part of government has an important role to play, the real value to the public and policymakers is the NTSB as “truth teller.” And while they don’t have authority to compel people to do things, they’re not bound by cost-benefit

There’s no way to know how many lives have been saved … how many injuries prevented … but the NTSB investigation and recommendations coupled with congressional legislation and new FRA regulations made a difference.

analysis, and they can say what they think the right solution is. It may be a solution that isn’t ripe yet. Maybe the technology doesn’t exist. But the NTSB has the ability to say, “You need to create technology that will keep trains from crashing into each other, or for aircraft, you need to design sensing equipment that will tell you your proximity to the ground or give you a wind shear alert.” The NTSB is charged with making recommendations – they have the ability to say what should be done, not necessarily what can be done. And I think that is a very important distinction; it is the difference between endorsing the status quo and changing things for the better. So they are able to aim a little higher, so to speak. That’s right, the NTSB should be the conscience and compass of the transportation industry. They can say, “This is the direction that we need to go. This is the way we should go. And if we want to save lives, this is what needs to be done.” It is up to other people to figure out how to implement those things, and sometimes

they come up with better alternatives, but the NTSB is like the rabbit out in front of the greyhound giving the transportation industry something to chase. It seems like people associate the NTSB with the headline-making accidents: plane crashes, train derailments, pipeline explosions. But everyday accidents caused by distracted driving are a more widespread threat to the public and that doesn’t make those same front-page news headlines. Distracted driving was one of your priority areas while you were NTSB chairman. What strides did you and the NTSB make in addressing this safety issue? And is it an issue you’re still continuing to tackle as part of the Road to Zero Coalition? On my first day as chairman, I announced a policy for all NTSB employees prohibiting the use of cell phones, handheld or hands-free, while operating a vehicle so we would walk the talk. We had identified for many years that plane crashes, train derailments, motor vehicle crashes occurred because people were inattentive or weren’t paying attention. While 95 percent of transportation fatalities occur on our roads, there isn’t a call to action or political scrutiny as when there is a fiery crash or derailment. You are

NTSB photo

Hersman and fellow Board members Robert Sumwalt (right) and Christopher Hart (far left) listen to presentations during an NTSB investigative hearing.

[The NTSB] can say, “This is the direction that we need to go. This is the way we should go. And if we want to save lives, this is what needs to be done.” absolutely right in that while the plane crashes and the train derailments get a lot of attention, there seems to be a cultural novocaine when these deaths occur one or two people at a time. But at the end of the day, those fatalities are every bit as important – and at the end of the day, as in all NTSB investigations, the deaths can and should be prevented. In 2016, there were over 40,000 fatalities on our roadways, yet we have gone for years without a single fatality in commercial aviation [in the United States]. The Road to Zero Coalition has a goal of getting to zero roadway fatalities by 2050. The NTSB is certainly one of those lead partners. They’ve made great recommendations over the last 50 years when it comes to improving highway safety and that continues to this day. But whether it is addressing distracted driving, impaired driving, or even motorcycle helmet use, NTSB recommendations don’t always result in implementation. As a nation, we lag behind our industrialized counterparts. In the last few decades, other countries have made faster progress in reducing fatalities on the roadways. The good news is since our founding in October 2016, more than 350 partner organizations have joined the Road to Zero Coalition on this journey to eliminate highway fatalities. There is great potential for success in this space, similar to the strides made in aviation safety and rail safety. Child passenger safety was another area of focus for you during your time at NTSB. And while the FAA today recommends the use of child restraint systems for infants and small children, it doesn’t require it. Why do you think it is that that regulation doesn’t exist yet? Allowing parents to carry a child under 2 years old in their lap rather than purchasing a seat for them was an arbitrary standard established in the 1950s; it is not grounded

in safety and it continues today without any basis in science. Now all 50 states require children to be appropriately restrained in cars. So they ride to the airport going 50 mph in a car seat, but they get on a plane and are permitted to be unrestrained at 250 mph, while all adults must be buckled up and we secure coffee pots and laptops for safety. It is nonsensical. This situation is so frustrating because we have a system that works really well most of the time, but this inequity and our failure to protect the most vulnerable passengers is one of my greatest disappointments. You spent about 10 years at the NTSB, half of them as chairman. What were the biggest changes you witnessed in the organization itself while you were there? I would say as the world changes, the NTSB has to change. One of the big evolutions during my time at the Board was the proliferation of mobile technology. When I first joined the NTSB in 2004, we were issued pagers. You would have to call in to the Comm Center to find out why they were paging you. When I left the NTSB in 2014, I had transitioned from a pager to a Blackberry to an iPhone in the span of 10 years – that technology in the palm of everyone’s hand was a game changer. Not only was I able to be in constant contact with the team, but when I was on scene, I could take pictures, videos, and I could send emails and text messages. You could use it to identify GPS locations. There was really no end to how much utility the cell phone provided. And it changed how we conducted investigations too –

it streamlined our communications. It allowed for real-time sharing about the things we were learning and what we were seeing. In fact, you didn’t actually have to have meetings at the very end of the day to report back to everybody on what was going on because you could tell them what was happening as it was happening. It also changed how and what we investigated. During that 10-year period, we located crash scenes by working with law enforcement and cell phone providers to triangulate the last known signal locations. We also formalized the process of immediately issuing preservation orders for the records of all electronic devices and we would routinely follow up with subpoenas. And when it comes to the issue of distraction, I cannot tell you how many times people told us they weren’t using their device, only to learn through the records that they were in fact using one. What was your biggest challenge at the NTSB? And what was your greatest accomplishment?

The most significant challenge I faced as chairman was the remaking of how we communicated as a result of the internet, the 24/7 news environment, and connectedness of the world through technology. Cell phones and social media provided an opportunity for any citizen, any bystander, to become a “boots on the ground reporter.” News stations used cell phone video in reports and the public no longer needed to wait for the evening news or for a news crew to arrive on scene for the story to begin to unfold. One of the last plane crashes I responded to was Asiana Airlines Flight 214. It occurred in San Francisco in 2013. And the first information out of the Asiana crash was a Tweet about a plane crashing. Then passengers who were evacuating the airplane were actually using social media to document their experience, as it was happening. It took 30 more minutes for the traditional news media to report the crash. During my tenure we transformed how we communicated about our work. We carefully built a social media presence

Photo courtesy of Deborah A.P. Hersman

Hersman and Investigator-in-Charge Bill English on scene at the crash of Asiana Airlines Flight 214 in San Francisco, California, in 2013. First news of the accident came through social media – a Tweet from one of the passengers.

by creating a Twitter account, a YouTube channel, and developed the necessary operating principles, guidelines, and policies to ensure we could use these channels in an effective way while still preserving the integrity of our work. Once we became actively engaged in the social media world, we started providing real-time updates to the media, the public and other stakeholders about our work. In essence, we became our own media channel. In the past, we would have relied on traditional media to tell the story; through our social media presence, we were able to tell the story ourselves. While we still held daily in-person news briefings, we also streamed them live and videotaped them so that we could post the unedited briefings on our website for all to see. The public could hear exactly what we said. And I’ll tell you, the incidence of getting misquoted really was almost eliminated because we could point to the actual statements. A lot of people felt like what we were doing was something completely different or that we had changed the rules. In fact, we hadn’t really changed what we had been doing – we just changed who got to see what we had been doing. Before, it used to only be the media that would travel to the crash site and listen to our briefings. Now, we were making them available for anyone and everyone. And it wasn’t just people in the U.S. – it was international audiences around the world as well. Everyone got to see how we conducted investigations. We didn’t change how we did our work. We just changed how we shared the information about our work. How much, if at all, do you think aging infrastructure affects transportation safety in the United States? And was this a subject that was discussed much during your time at the NTSB? At the NTSB, typically investigators looked at three things: the human, the machine, and the environment. In the U.S., our transportation infrastructure is the backbone of our nation. We have to invest in it if we are going have strong economic growth and ensure we have a safe system. Aging infrastructure isn’t just about

We carefully built a social media presence by creating a Twitter account, a YouTube channel, and developed the necessary operating principles, guidelines, and policies to ensure we could use these channels in an effective way while still preserving the integrity of our work. when things crumble, but it is a mindset of modernizing and creating a system of safety – including upgrading runways with engineered material arresting systems to prevent overruns or investing in technology in our vehicles that detect objects in our blind spots. Two railroad examples emphasize these points: First, aging infrastructure and a state of good repair were issues at the Washington Metropolitan Area Transit Authority in the Fort Totten investigation. The light rail system was three decades old and the automatic train control system was failing. Warning signs included close calls, failing equipment, and inability to get some replacement parts. Rather than investing, they “tied the shoelaces together” in the face of operational pressures and budget shortfalls. In 2009, two trains collided near Fort Totten, and tragically, lives were lost. In the aftermath, the region undertook a major re-investment program in equipment and maintenance. Second, we must evolve and adapt – that means replacing World War IIera signal systems with a GPS-based system that can keep trains from colliding with one another or going too fast for conditions. For decades, the NTSB recommended implementation of positive train control systems – and while the technology has been available for decades, we do not have full deployment on lines that carry passengers or highly hazardous cargo. I think people take a lot of things for granted. We must invest in our transportation system so that it is safe today, tomorrow, and for the next 50 years.

The Office of Administrative Law Judges Since 1967, the National Transportation Safety Board (NTSB) has served as the “court of appeals” for any airman whenever a certificate action is taken by the administrator of the Federal Aviation Administration (FAA). The NTSB’s Office of Administrative Law Judges is responsible for conducting all formal proceedings arising under the Federal Aviation Act of 1958, as amended. These proceedings involve, primarily, appeals by pilots, navigators, mechanics, dispatchers, air traffic control tower operators, and air carriers from orders of the FAA suspending, revoking, or modifying their certificates for alleged violations of the Federal Aviation Regulations, or for lack of qualification to hold such certificates. Proceedings also involve petitions from applicants denied airman medical or other certification by the FAA administrator, and appeals of certain civil penalty actions initiated by the FAA administrator in which the amount in dispute is less than $50,000. Additionally, this office reviews and decides applications for attorney fees and expenses under the Equal Access to Justice Act from airmen who prevail against the FAA in certain adversarial adjudications. The Board currently has three administrative law judges. A fourth administrative law judge will be appointed in the near future. Two judges are based in the NTSB headquarters building in Washington, D.C., and handle cases in Circuits I and II, which typically involve cases in which hearings will be held in the eastern United States. Another judge was previously assigned to the NTSB’s Arlington, Texas office, but when that office was closed, the judge became a fulltime teleworker from his home in Texas, and he covers Circuit IV, which typically involves cases in which hearings will be held in the central United States. The new administrative law judge will be assigned to the NTSB’s office in Denver, Colorado, and will handle cases in Circuit III,

which involves cases in which hearings typically will be held in the western United States. While Puerto Rico is assigned to Circuit II, cases in Alaska and Hawaii are assigned to judges on a rotational basis. Chief Judge Alfonso J. Montaño joined the NTSB in August 2010 as an administrative law judge. In July 2012, he was appointed chief judge. He had been an administrative law judge since October 1995, serving with the Social Security Administration and the Departmental Appeals Board within the Department of Health and Human Services (HHS). Montaño previously served as a trial attorney in the Civil Division of the U.S. Department of Justice and with the Office of Inspector General for HHS.

NTSB graphic

NTSB Law Judge Circuit Assignments map.

He holds a private pilot certificate and graduated from the New Mexico Highlands University and the University of San Francisco School of Law. Judge William R. Mullins joined the NTSB in January 1989 as an administrative law judge. Prior to that, he served as an administrative law judge with the Occupational Safety and Health Review Commission and also for 15 years as a trial judge in the state of Oklahoma. He retired as a colonel from the U.S. Army Reserves after 30 years. Mullins holds a commercial pilot certificate and is a graduate of Panhandle State University (Goodwell, Oklahoma) and the University of Colorado School of Law. Judge Stephen R. Woody joined the NTSB in August 2012 as an administrative law judge. Before joining the NTSB, he was an administrative law judge with the Social Security Administration, and before that, he served more than 22 years as a judge advocate in the U.S. Air Force, where he held a variety of positions, including as a military judge

presiding over courts-martial. Woody retired as a colonel and is a graduate of West Virginia University and the West Virginia University College of Law. The independence of the NTSB hearing process is protected by the use of the split enforcement model. The FAA takes and prosecutes actions. The NTSB administrative law judges then conduct objective reviews through administrative hearings in air safety proceedings and render initial decisions. The NTSB is wholly independent from the FAA and the Department of Transportation. In reviewing FAA actions, the NTSB is not bound by the FAAâ&#x20AC;&#x2122;s findings. The NTSB administrative law judges conduct a completely impartial and objective review of the evidentiary record. An administrative law judge is an independent, impartial trier of fact in formal hearings similar to that of a trial judge conducting civil trials without a jury. Administrative law judges conduct hearings, develop evidentiary records of those hearings, apply the law to the credible facts, and render decisions. The record of the proceeding includes

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hearing testimony (a transcript of the proceedings), exhibits submitted by the parties to the hearing, and the judge’s decision. The independence of the administrative law judges is also protected by the Administrative Procedure Act of 1946 and the unique Title 5 protection afforded administrative law judges. The cases that are appealed to the NTSB Office of Administrative Law Judges are handled on an emergency basis or a routine basis as designated by the FAA. If a case is designated as an emergency, statutory time deadlines are invoked and the FAA action is effective immediately. The NTSB must fully adjudicate emergency cases in 60 days. In routine or nonemergency cases, the FAA action is stayed by the filing of an appeal and there is no regulatory deadline within which the case has to be fully adjudicated. When an FAA order is appealed to the NTSB, the case is assigned to an administrative law judge for an evidentiary hearing. An advance notice of the formal hearing is issued at least 30 days before the hearing, but as far in advance as 60 days to allow the parties time to prepare for the hearing. The notice given in an emergency hearing, however, can be as little as two weeks, because the Board is required by statute to render a decision in such cases within 60 days of the appeal, and this includes cases in which the administrative law judge’s decision is appealed to the full Board. In formal hearings conducted by the administrative law judges, all parties are given an opportunity to present testimony and documentary evidence, to submit evidence in rebuttal, to conduct crossexaminations, and to make arguments. The Pilot’s Bill of Rights, Public Law No. 112-53, 126 Stat. 1159 (August 3, 2012), requires administrative law judges to apply the Federal Rules of Evidence and Federal Rules of Civil Procedure to air safety proceedings to the extent practicable. The parties may be accompanied, advised, and represented by legal counsel or other qualified representatives. Although it is not required for a respondent or petitioner to have an attorney at a hearing, appeals to the NTSB are formal legal proceedings and the FAA is always

represented by counsel from one of its regional or headquarters offices. The FAA bears the burden of proving the charges alleged in its suspension, revocation, or modification order. The airman or respondent may offer evidence and affirmative defenses in such cases. In cases involving certificate denials, however, it is the airman or petitioner who bears the burden of proof. In the vast majority of cases, the judge issues an oral initial decision at the conclusion of the hearing, but has the option of issuing a written decision. The regulations mandate that the administrative law judge must issue an oral initial decision in emergency cases. This office contracts for court reporters to transcribe all hearings, and a copy of the transcript is provided to each party at our expense. As soon as an appeal is docketed, the assigned administrative law judge issues a prehearing order to provide the parties guidance as to discovery and to focus and narrow the issues for trial. Either party may request evidence and information that will be used at hearing, to including names of witnesses, curriculum vitae of expert witnesses, exhibits, and any other relevant data. Parties may also use legal discovery tools such as depositions, written interrogatories, and requests for admission. Hearings are generally conducted where the alleged incident took place or where the majority of witnesses are located. In special circumstances, however, the location of a hearing can be set or changed to accommodate the convenience of the parties or the witnesses. Hearings can last from several hours to several days. A recent hearing lasted two weeks (10 days). A typical hearing, however, lasts from one to three days. If either the FAA or the airman is dissatisfied with the administrative law judge’s decision, a further appeal may be taken to the NTSB’s full five-member Board. The Board’s review on appeal is based on the record of the proceeding below and on appeal briefs submitted by the parties. The FAA may appeal the decision of the full Board only when the FAA determines that the Board’s decision may have a

significant adverse impact with respect to its aviation safety duties and on the powers designated to be carried out and implemented by the Federal Aviation Act. If the airman is dissatisfied with the full Board’s decision, the airman may petition for review to a United States court of appeal or as provided by the Pilot’s Bill of Rights, to a federal district court. The standard of review in the federal district court is unclear at this point and is evolving through the appeal process. The court of appeals has the power to affirm, modify, or set aside the decision, in whole or in part, or, if the need is determined, to order further proceedings by the Board. The decision of the Court of Appeals is subject to review by the U.S. Supreme Court on writ of certiorari. Section 716 of the Aviation Investment and Reform Act for the 21st Century, Public Law 106-181 (April 5, 2000), expanded the NTSB jurisdiction to include reviews of FAA designations of safety enforcement actions as emergencies that require the order to be effective immediately, upon petition by the affected certificate holder. The Board has delegated this review authority to its administrative law judges. However, in the event of an appeal to the Board from a law judge’s decision on the merits of the emergency or other immediately effective order, the Board may, at its discretion, note in its order disposing of the appeal its views on the law judge’s ruling on the petition, and such views serve as binding precedent in all future cases. The Pilot’s Bill of Rights provides for substantive independent and expedited review by the U.S. district court of any decision by the FAA administrator to make such an order effective immediately. Marine certificate actions are heard first by the United States Coast Guard administrative law judges and may be appealed to the commandant of the USCG. The ruling of the commandant may then be appealed to the full Board of the NTSB. Text adapted from a handbook created by the NTSB Office of Administrative Law Judges.

The NTSB Training Center By J.R. Wilson

The National Transportation Safety Board (NTSB) had been investigating airline and other major transportation accidents for nearly 30 years when a single event – the July 1996 explosion and crash of TWA Flight 800 only moments after takeoff from New York’s John F. Kennedy International Airport – set into motion a chain of events that would significantly affect all future accident investigations. The NTSB spent four years and one month investigating the loss of the Boeing 747-100 and all 230 crew and passengers aboard, meticulously reassembling the aircraft’s wreckage before determining the explosion was caused by vapors in the center wing fuel tank, most likely sparked by a short circuit. During that time, the agency kept the relatives of the victims informed of their progress, ultimately leading some of them to tell Congress “the NTSB should teach people how we did it and use the TWA 800 wreckage as a permanent training aid. And we still use it today,” according to Paul F. Schuda, Ph.D., director of the NTSB Training Center. Congress agreed, and planning for the Training Center – then known as the NTSB Academy – began in 2000, leading to its opening in August 2003 in a special-built facility on the Ashburn, Virginia campus of George Washington University just outside Washington, D.C. The football field-sized lab houses the remains of TWA 800, along with the complete wreckage of a Cessna 208 taken there in May 2004, when it became a secure NTSB resource for active investigations as well as training. “We also have a Bonanza that was in an in-flight breakup, to teach people to look at the structure and what may have failed; a Cessna 210 Centurian that had an in-flight fire; a TH-67 helicopter that lost tail-rotor effectiveness; various jet and piston engines

students can look at; and a controlled-flightinto-terrain Beechcraft Baron, which hit a mountain – students can look at the wings to see if it hit something that caused them to lose control and at the engines to see if they lost power,” Schuda noted. Although the center is used to improve the training and skills of NTSB investigators, it has become a unique source for accident investigation training for the diverse global transportation community. Some classes are limited to NTSB investigators, others who may be directly involved in an investigation, and emergency first responders, but many classes are open to the general public. The center also has formed relationships with a wide range of government agencies and private organizations to help meet their needs as well as to enhance what the NTSB has to offer and gain. Among those partnerships and alliances are: • Airports Council International of North America • Air Transport Association • Armed Forces Institute of Pathology • Aviation Safety Alliance • Civil Aviation Administration of China • FBI • Global Maritime and Transportation School • National Association of State Boating Law Administrators • NASA

• New Jersey State Police • Transportation Safety Institute • Regional Airline Association • Society of Automotive Engineers “Our two-week basic aviation accident investigation class costs about $4,000 per student. That class actually has become pretty popular; both the Army National Guard and U.S. Coast Guard have come to us and we now put on special closed classes for them – three a year for the Coast Guard and twice a year for the National Guard,” said Schuda, a former university organic chemistry professor and commercially rated pilot who spent eight years as an NTSB investigator before becoming the Training Center’s second director in mid-2007. “Those are not open to the public and the syllabus is a little different. The Army, for example, has their own reporting processes and procedures but are very interested in using some of our investigative techniques in combination with their own to get the best possible solution. [Another] set of classes, open only to NTSB employees, is called workforce development. Those include time management, how to conduct meetings – really to increase both the technical and managerial skills of our internal staff.” Nearly all the center’s instructors are current or former NTSB investigators, with roughly one-quarter of all active investigators teaching at least one class each year. For some specialty instruction, such as cognitive interviewing and media relations, outside specialists or noninvestigator NTSB employees are used. From its original three or four classes to 15 to 20 each year now, Schuda estimates that in its 14-year history, the center has taught

AP Photo/J. Scott Applewhite

From left, Matthew Ziemkiewicz, brother of TWA Flight 800 victim Jill Ziemkiewicz, National Transportation Safety Board Chairman Mark Rosenker, Secretary of Transportation Mary E. Peters, and acting FAA Administrator Robert Sturgell view the recovered wreckage of TWA Flight 800 at the NTSB Academy (now the NTSB Training Center) in Virginia on July 16, 2008, as NTSB Research and Engineering Director Vernon Ellingstad, right, gives details. The remains of the aircraft are used by the NTSB for training purposes.

up to 1,300 people in the public classes and another 800 in workforce development courses, although some of those have attended more than one class. The two-week basic course is the only one anywhere near that long. Aside from a rotorcraft accident investigation course that lasts five days and a four-day marine investigation class, most are two or three days and offered once each year. “One is Aviation Investigation 301 – a twoday class – which is mainly geared toward higher-level airline and corporate officials so they have an overall understanding of our process and how we do investigations,” he said. “The other is Transportation Disaster Assistance, which is for how we deal with

family members and is mostly attended by airlines, which are required to have a plan for how to deal with family members after an accident. That became part of our regulations after TWA 800.” While best known for its investigations of aircraft accidents, the NTSB deals with all forms of transportation – and the Training Center is trying to do the same. In addition to the maritime accident investigation course, they have a two-day rail class and are developing a highway course. They also are looking into new areas brought on by rapidly evolving technology, including private space flights. “Our Office of Aviation Safety has a group looking at that. We’ve been involved with an incident a couple of years ago in which

one pilot died in a private flight. Generally, if there is an accident, we go to it. If it happens in space, we will help to investigate, maybe even be in charge of it, but we don’t send people into space – yet. We teach people to look at telemetry, understand launch protocols, etc.,” Schuda explained. “We also started a one-day class on investigating UAV [unmanned aerial vehicle] accidents and using UAVs. It’s a pretty small audience, so we don’t yet offer it every year, but there may be a lot of those flying around in the future. If one hits another aircraft, such as general aviation, we would look at both the aircraft and the drone and its operator – were they operating in the proper airspace, did they have the proper license, which varies according to what you’re doing and where.”

Ideas for changes to current courses or the addition of new ones can come from anyone – students, instructors, investigators, etc. “For all of our classes, the students fill out critique sheets, including asking them what else they would like to see taught. Up-and-coming trends in transportation,

such as safety management systems, have been added in recent years,” he added. “Safety isn’t just the job of the safety manager, but everyone from the CEO down, and it’s important to know how to implement a system to ensure everyone is looking at safety. This year or next, we will

NTSB photos

ABOVE: An NTSB transportation disaster assistance specialist teaches a transportation disaster assistance course at the NTSB Training Center. BELOW: The NTSB Training Center educates not only NTSB personnel but also investigative partners, both domestic and international.

be offering an internal class on that for NTSB employees as part of our workforce development course. “Some things change through time, but most of a class is basic processes and procedures, which don’t change much. One thing that has changed is a higher emphasis on digital forensics – cell phones, security cameras, etc. – in addition to interviewing witnesses. We have a two-day class, in our workforce development course, on digital forensics and what kind of information you can get from a digital camera or cell phone. We work with the FBI and our own NTSB labs on that.” The Training Center is required by law to run on a cost-recovery basis, but not make a profit. With class fees typically $390 per day per student (an amount they have to justify every few years), the Training Center is projected to bring in roughly $1.1 million in 2017, less than the expenses it incurs (utilities, instructors’ time, etc.). The difference is covered as a budget line item in the NTSB base appropriation. “The fees we collect for the classes are called ‘no-year’ money, where it goes into a bank account and, unlike most federal agencies, does not go into the general treasury at the end of the year. We carry it over for day-to-day operations,” Schuda explained. Although new classes have been and continue to be added, the mission of the NTSB Training Center has remained unchanged since its founding. “The purpose of our public classes is to train our investigators and investigative partners, including local law enforcement and emergency responders. We think it is critically important that our investigative partners understand how we do investigations and why our people take the time out of their schedules, at least twice a year, to teach these classes,” Schuda said, adding many who attend are from outside the United States. “In general, they are mostly from other countries’ accident investigative arms, mostly aviation, such as the Transportation Safety Board of Canada. The most popular is our two-week flagship course, which last had about 48 students, a third to half from all over the globe. The major advantage of coming here is almost every instructor is an investigator, which you can’t get anywhere else in the world.”