(The National Transportation Safety Board issued the following on February 18, 2010.)
WASHINGTON, D.C. — The National Transportation Safety Board today issued its 2010 Federal Most Wanted List of Transportation Safety Improvements, adding rail, aviation and marine issues, and updating the status of other issues on the list. At the same time, the Board removed the issue areas dealing with improved protection for school bus passengers and fatigue in the pipeline industry.
“Every one of the hundreds of currently open safety recommendations address concerns that the Safety Board has uncovered in its accident investigations,” NTSB Chairman Deborah A.P. Hersman said. “But the recommendations on the Most Wanted list represent those improvements that can have the widest benefit.”
Besides removing two issue areas on the list, the Board reviewed the remaining 13 issue areas on the list and added two new ones. Each issue area is color coded by the NTSB to designate its action/timeliness: Red for Unacceptable Response; Yellow for Acceptable Response, Progressing Slowly; and Green for Acceptable Response, Progressing in a Timely Manner.
The 2010 Most Wanted list follows.
RAIL
Coming on the heels of several serious transit rail accidents around the country – notably the June 22, 2009, collision on Washington, D.C.’s system that killed 9 persons – the Board added “Improve Transit Railcar Design” to the list.
A railcar’s ability to withstand the dynamic forces of an accident is essential to protecting the vehicle’s occupants. In accident investigations in recent years, the Board has noted telescoping of transit cars that have destroyed or greatly compromised survivable space. Two recommendations are added to the list aimed at improving transit railcar design, and the issue area was given a Yellow designation.
MARINE
The NTSB has long been concerned about the issue of Safety Management Systems (SMS) on board ships, including subsystems such as preventive maintenance. Although the United States Coast Guard has announced that it intends to require SMS for vessels carrying more than 399 passengers, the Board feels this is unacceptable because it does not cover all U.S.-flagged vessels. The NTSB believes that the Coast Guard should require an SMS for all domestic vessels so that the same level of safety is applied to the domestic fleet of vessels as is applied to the international fleet. This new issue area on the list, “Require Safety Management Systems for Domestic Vessels” was given a Red designation.
AVIATION
“Improve Oversight of Pilot Proficiency” – This new issue area added by the Board contains two 2005 recommendations calling on the FAA to require airlines to obtain histories of flight check failures by pilot applicants and to require special training programs for pilots who have demonstrated performance deficiencies. The designation is Red.
“Require Image Recorders” – Although cockpit voice recorders and flight data recorders record sounds and relatively comprehensive airplane data during an emergency, they do not show the critical cockpit environment leading up to the emergency. The Board has requested image recorders for large transport category aircraft and for smaller aircraft that do not otherwise have recording devices. This issue was designated Red.
“Improve the Safety of Emergency Medical Services Flights” – The Board has issued a series of recommendations aimed at improving the safety of this vital service to the public. The FAA has announced it will issue a proposed rule that will address some of these concerns, and the Board has upgraded the designation for this issue from Red to Yellow.
“Improve Runway Safety” – The deadliest accident in aviation history was a runway collision in 1977. Runway accidents and incidents continue to occur, including a fatal regional jet accident in Kentucky in 2006 and an incident last year where an airliner landed on a taxiway in Atlanta. The NTSB has a series of recommendations aimed at preventing such occurrences, including requiring moving map displays in the cockpit, giving immediate warnings to the cockpit of impending incursions, and requiring landing distance assessments with an adequate safety margin for every landing. The designation remains Red.
“Reduce Dangers to Aircraft Flying in Icing Conditions” – An airliner crash in 1994 prompted the NTSB to examine the issue of airframe structural icing and conclude that certification standards have been inadequate. The NTSB continues to believe that the FAA has failed to make adequate progress in this area and has kept the designation at Red.
“Crew Resource Management for Part 135 Carriers” – Federal regulations require Part 121 and Scheduled Part 135 operators to provide pilots with crew resource management training. The NTSB has investigated a number of Part 135 on-demand operators where such training was not provided, and errors by the crew led to accidents. The FAA has proposed to require a form of CRM training for these carriers, and the Board has upgraded the designation from Red to Yellow.
HIGHWAY
“Enhance Protection for School Bus Passengers” – The Board has recommended that the National Highway Traffic Safety Administration devise new standards to protect school bus passengers from being ejected from their seats or the bus during frontal, side or rear-impact accidents. NHTSA has issued a final rule that increases seatback height, and established performance specifications for voluntarily installed seat belts. As a result, the Safety Board has closed the two recommendations in this issue area and removed it from the Most Wanted list.
“Enhance Protection for Motorcoach Passengers” – The Board recommends that motorcoach window emergency exits be redesigned for easy egress, that standards for bus roofs be strengthened, and that new standards be devised to protect motorcoach passengers from being ejected. The designation was downgraded from Yellow to Red, due to the lack of progress on this issue.
“Require Electronic Onboard Data Recorders” – This renamed issue area seeks to improve hours of service monitoring for commercial drivers. The Federal Motor Carrier Safety Administration has proposed limited use of EOBRs, and the Board has therefore kept the designation at Red.
“Improve the Safety of Motor Carrier Operations” – The Board’s recommendation is aimed at preventing motor carriers from operating if they put vehicles with mechanical problems on the road or unqualified drivers behind the wheel. Due to FMCSA’s continuing slow progress on this issue, the designation was downgraded from Yellow to Red.
“Prevent Medically Unqualified Drivers from Operating Commercial Vehicles” – Based on its investigations of accidents involving drivers with serious medical conditions, the NTSB has determined that serious flaws exist in the medical certification process for commercial vehicle drivers. Two of the 8 recommendations in this area – dealing with FMCSA developing a comprehensive medical oversight program that contains several elements – were closed by the Board, and the designation was upgraded from Red to Yellow.
“Prevent Collisions by Using Enhanced Vehicle Safety Technology” – The Safety Board has recommended the use of adaptive cruise control and collision warning technologies to improve highway safety. A Department of Transportation analysis has shown that 48 percent of accidents could be prevented by the use of certain collision warning systems. The designation on this issue remains Yellow.
“Prohibit Cell Phone Use by Motorcoach Drivers” – The Board believes commercial drivers at the wheels of motorcoaches and school buses should be prevented from using cell phones. With some progress being made by the Department of Transportation and FMSCA, the designation remains Yellow.
INTERMODAL
“Reduce Accidents and Incidents Caused by Human Fatigue in the Marine, Aviation and Pipeline Industries” – The Safety Board has long been concerned about the effects of fatigue on persons performing critical functions in all modes of transportation. The Board believes that working hour limits should be based on the latest fatigue research. For both the aviation and marine modes, the Board believes the actions of the FAA and the U.S. Coast Guard are unacceptable, and maintained designations for both at Red.
However, the Board was pleased to report that the Pipeline and Hazardous Materials Safety Administration has published a final rule establishing new bases for managing fatigue in the pipeline industry. The Board called the rule “a significant step forward for an industry that did not previously have any rules governing hours of service” The Board therefore closed the recommendation Acceptable Alternate Action and has removed fatigue in the pipeline industry from the Most Wanted list.
An updated brochure describing each Most Wanted issue area can be accessed at
http://www.ntsb.gov/Recs/brochures/MostWanted_2010.pdf.