National Transportation Safety Board
Office of Public Affairs
WASHINGTON, D.C. - Citing a serious near collision of two jumbo aircraft in Chicago last July, the National Transportation Safety Board, at a public meeting today, called again for effective action by the FAA to counter the danger posed by potentially catastrophic runway collisions. The Board was reviewing its Most Wanted List of safety improvements, a list that calls for action by federal agencies on the most critical transportation safety issues. In the marine area, the Board welcomed the adoption of new rules by the U.S. Coast Guard that improve procedures for crew drug/alcohol testing after serious accidents, and removed this issue from the Most Wanted List. In its recommendations, the Board had cited 28 major marine investigations dating back to the Exxon Valdez in which mandatory post-accident alcohol and drug testing was not completed. The final Coast Guard rule was issued in December 2005, and seven of the eight recommendations were closed with acceptable action.
Expressing great disappointment at the FAA's continued refusal to take appropriate action, the Board also removed from the list a recommendation that children under two years of age be restrained on airliners for take off and landing and during periods of turbulence.
The NTSB added two new issue areas to the Most Wanted list: Air taxi crew resource management training and school bus occupant safety.
Established in 1990, the Most Wanted List highlights specific recommendations the Board believes would significantly reduce transportation deaths and injuries.
"Our Most Wanted List puts extra pressure on our nation's transportation safety regulators to act more quickly on our recommendations," said NTSB Chairman Mark Rosenker. "We've made progress, but this year's list again shows that there are numerous areas that need improvement and they need improvement now. The Board will continue to push aggressively for implementation of the measures needed to make our safe transportation system even safer."
In addition to pinpointing important safety issues, the Most Wanted List also rates agencies by the timeliness with which they act to implement the recommendations. At today's meeting, the Federal Aviation Administration received five unacceptable timeliness ratings, and the Federal Motor Carrier Safety Administration received two unacceptable timeliness ratings.
Issues on the Most Wanted List:
Runway Incursions -- This issue has been on the Board's list since it's inception in 1990. The FAA completed action on a number of objectives to make ground operation of aircraft safer. However, these incidents continue to occur with alarming frequency. The FAA indicates that during fiscal year 2005 there were 327 incursions, and during 2006 there were 330. A system introduced by the FAA provides warning to air traffic controllers, but not to the flight crews, a fact that severely reduces the amount of time that pilots have to react to an impending incursion. Recommendation: Implement a safety system for ground movement that will ensure the safe movement of airplanes on the ground and provide direct warning capability to the flight crews. Timeliness Classification: Unacceptable.
Fuel/Air Vapors -- Operating transport-category airplanes with flammable fuel/air vapors in fuel tanks presents a risk of explosion that is avoidable. Center wing fuel tank explosions have resulted in 346 fatalities in four accidents since 1989. There also have been several non-fatal fuel tank explosions, the latest of which occurred earlier this year in India. After the TWA 800 accident in 1996, the Board issued both short and long term recommendations to reduce the potential for flammable fuel/air vapors in aircraft fuel tanks. The short-term recommendation was closed in an unacceptable status because the FAA took no action. The FAA has committed to action on the long term recommendation by Fall 2007. Recommendation: Complete rulemaking efforts to preclude the operation of transport-category airplanes with flammable fuel/air vapors in the fuel tank on all aircraft. Timeliness Classification: Acceptable (progressing slowly).
Aircraft Icing -- The consequences of operating an airplane in icing conditions without first having thoroughly demonstrated adequate handling/controllability in those conditions are sufficiently severe that they warrant a thorough certification test program. The FAA has not adopted a systematic and proactive approach to the certification and operational issues of airplane icing. Recommendation: Complete research on aircraft structural icing and continue efforts to revise icing certification criteria, testing requirements, and restrictions on operationsin icing conditions. Evaluate all aircraft certified for flight in icing conditions using the new criteria and standards. Timeliness Classification: Unacceptable.
Audio, Data and Video Recorders -- Investigators must have information rapidly, effectively and efficiently in order to determine the factors related to an accident. Automatic information recording devices, such as Cockpit Voice Recorders (CVRs) and Flight Data Recorders (FDRs) have proven to be very useful in gathering pure factual information. This information results in the development of timely, more precise safety recommendations that are likely to reduce future similar accidents. Recommendation: In addition to adopting a 2-hour CVR requirement, require the retrofit of existing CVR's with an independent power supply, and require that existing FDRs and CVRs be on separate generator busses, with the highest reliable power so that any single electrical failure does not disable both. Require the installation of video recording systems in small and large aircraft. Require the recording of additional needed FDR data for Boeing 737s. Timeliness Classification: Unacceptable.
Crew Resource Management (CRM) Training for Part 135 Flights - Part 121 and scheduled Part 135 operators are required to provide pilots with CRM training in which accidents are reviewed and skills and techniques for effective crew coordination are presented. The Safety Board has investigated several fatal aviation accidents involving Part 135 on-demand operators (air taxis such as that involved in the crash that killed Senator Paul Wellstone in 2002) where the carrier either did not have a CRM program, or the CRM program was much less comprehensive than would be required for a Part 121 carrier. Although the FAA has agreed in principal with the recommendation, no discernable progress has been made. Recommendation: Require that Part 135 on-demand charter operators that conduct dual-pilot operations establish and implement an FAA-approved CRM training program for pilots in accordance with Part 121. Timeliness Classification: Unacceptable.
Reduce Accidents and Incidents Caused by Human Fatigue -- Operating a vehicle without the operator having adequate rest, in any mode of transportation, presents an unnecessary risk to the traveling public. The laws, rules, and regulations governing this aspect of transportation safety are archaic in many cases and are not adequate to address the problem. Recommendation: Establish scientifically based hours-of-service regulations that set limits on hours-of-service, provide predictable work and rest schedules, and consider human sleep and rest requirements. Timeliness Classification: Flightcrews and aviation mechanics: Unacceptable. Professionalmariners and pipeline controllers: Acceptable (progressing slowly). Overall U.S. DOT rating: Acceptable (progressing slowly).
Positive Train Control --The NTSB has a long history of investigating accidents in which crewmembers failed to operate their trains effectively and in accordance with operating rules for a variety of reasons, such as fatigue, sleeping disorders, use of medications, and operator distraction. The Board has advocated the implementation of a system known as positive train control (PTC) that compensates for human error and that incorporates collision avoidance to prevent train collisions. Recommendation: Implement a positive train control system. Timeliness Classification: Acceptable (progressing slowly).
Motor Carrier Operations -- The two most important factors in safe motor carrier operations are the operational status of the vehicles and the performance of the individuals who drive them. If significant problems in these two areas persist, the motor carrier should have its license to operate revoked. The NTSB has called on the Federal Motor Carrier Safety Administration (FMCSA) to implement such an oversight system. Recommendation: Continue efforts to develop a fitness rating system that appropriately recognizes the importance of vehicle and driver factors in measuring the overall safety of a motor carrier's operations. Timeliness Classification: Unacceptable.
Preventing Medically Unqualified Drivers from Operating Commercial Vehicles --Investigations of accidents involving drivers with serious medical conditions has exposed disturbing flaws that exist in the medical certification process of commercial vehicle drivers. These flaws can lead to increased highway fatalities and injuries for commercial vehicle drivers, their passengers, and the motoring public. Recommendation: Continue efforts to develop medical certification procedures that ensure unfit drivers are not allowed behind the wheel of a commercial vehicle. Timeliness Classification: Unacceptable.
Enhance Protection for Motorcoach Passengers -- One of the primary causes of passenger injury in motorcoach accidents occurs when passengers are thrown from their seating areas during an accident. In its 1999 special investigation report on bus crashworthiness, the NTSB concluded that the overall injury risk to occupants in motorcoach accidents involving rollover and ejection may be reduced significantly by retaining the occupant in the seating compartment throughout the collision. The Board asked the National Highway Traffic Safety Administration (NHTSA) to require new motorcoach bus occupant protection systems that retain passengers in their seats. In addition, stronger bus roofs and easy-to-open window emergency exits are needed to enhance safety. Recommendation: Continue efforts to improve motorcoach design, and to address construction and occupant protection issues. Timeliness Classification: Acceptable (progressing
Enhance Protection for School Bus Passengers - In its 1999 special investigation report on bus crashworthiness, the Safety Board found that current compartmentalization, because of its design, does not protect all passengers during lateral impacts with vehicles of large mass and during rollovers. Recommendations: In two years, develop performance standards for school bus occupant protection systems that account for a variety of accident scenarios and, once these standards have been developed, require newly manufactured school buses to have an occupant crash protection system that meets the standards and retains passengers, including those in child safety restraint systems, within the seating compartment throughout the accident sequence. Timeliness Classification: Acceptable (progressing slowly).
Further details, including the texts of the specific safety recommendations in each issue area, summaries of federal agency actions, and the status of each recommendation can be found on the NTSB website at www.ntsb.gov.
NTSB Office of Public Affairs: (202) 314-6100
The National Transportation Safety Board (NTSB) is an independent federal agency charged with determining the probable cause
of transportation accidents, promoting transportation safety, and assisting victims of transportation accidents and their families.