NTSB Press Release

National Transportation Safety Board
Office of Public Affairs


November 8, 2007

WASHINGTON, D.C. - Six near runway collisions at San Francisco, New York, Ft. Lauderdale and other airports were narrowly averted in just the last six months leading the NTSB to highlight the issue of runway safety as among its most important issue areas to be addressed by the Federal Aviation Administration (FAA).

At the public meeting today, the NTSB reviewed its "Most Wanted List" of safety improvements, a list established in 1990 that focuses attention on critical changes needed by federal agencies to reduce accidents and save lives.

Half of the 44 safety recommendations in the 15 federal issue areas on the Most Wanted List were issued to the Federal Aviation Administration (FAA), with the rest going to the Federal Motor Carrier Safety Administration (FMCSA), the National Highway Traffic Safety Administration (NHTSA), the Federal Railroad Administration (FRA), the Pipeline and Hazardous Materials Safety Administration (PHMSA), the National Air Traffic Controllers Association (NATCA), and the United States Coast Guard.

One of the two new issue areas added to the Most Wanted List today was collision prevention through enhanced vehicle safety technology, which NTSB Chairman Mark V. Rosenker called "one of the most encouraging developments in transportation safety in a very long time." Rosenker said that innovations like collision warning systems (CWS) have "opened the door to the possibility of major advances in motor vehicle safety." He continued, "I can't think of any other set of technologies that holds as much potential for improving motor vehicle safety as these do." The NTSB has asked the National Highway Traffic Safety Administration to act more quickly in setting performance standards for CWS and adaptive cruise control systems in new commercial and passenger vehicles.

The Board also voted to add human fatigue in railroad operations as a new issue area on the List, asking that adjustments to crewmember work schedules be revised to reduce the likelihood of train crews operating equipment in a fatigued condition. "Human fatigue has played a role in many rail accidents in the past few years, some of them fatal," Rosenker said. "The manner in which crewmembers are scheduled should be reformed to reduce the likelihood in which loaded trains, often weighing thousands of tons, are being controlled by fatigued operators."

The NTSB also added three safety recommendations on air traffic controller fatigue to the existing aviation issue area that addresses human fatigue. The Board is asking the FAA to develop a program to educate controllers and those who schedule them about the causes, effects and safety implications of fatigue. And the Board asked the FAA to work in conjunction with National Air Traffic Controllers Union (NATCA) in revising work-scheduling policies to reduce the incidence of fatigue on the job. "Since air traffic controllers play such a crucial role in the safety of our air transportation system, we must ensure that the performance of these professionals is not compromised by something as preventable as human fatigue," said Rosenker.

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.

Issues on the Most Wanted List:


RUNWAY SAFETY -- The Board expanded the issue area of runway incursions to include runway excursions, incidents when aircraft on the ground depart the runway environment. Three additional recommendations were added to this area, which was renamed "Improve Runway Safety." Two of the recommendations ask the FAA to require that aircraft not be allowed to cross any runway without specific authorization from air traffic controllers. The third recommendation, addressing the danger of runway excursions, requests that airline pilots be required to incorporate a 15% safety margin into landing distances calculations.

While the FAA is in the process of developing and testing new technologies to make ground operation of aircraft safer, runway safety incidents continue to occur with alarming frequency and consistency. The FAA indicates that during fiscal year (FY) 2006 there were 330 incursions and during FY2007 there were 371. A system being installed at airports by the FAA provides warning to air traffic controllers, but not to the flight crews, a situation that greatly reduces the amount of time that pilots have to react to an impending incursion. The Board's recommendations ask for a direct warning to the cockpit. Since its inception, the Most Wanted List has included one or more recommendations related to runway safety.

Recommendations: 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. Implement ATC procedures requiring an explicit clearance for each runway crossing. Require operators to conduct arrival landing distance calculations before every landing based on existing performance data, actual conditions, and incorporating a minimum safety margin of 15%.

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 in May 2006, 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 developed a proposed rule for the long-term recommendation to reduce fuel tank flammability and submitted the rulemaking package to the Department of Transportation. The Department of Transportation has missed two proposed release dates and the earliest estimate for a final rule is February 2008.

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 efforts to revise icing certification criteria, testing requirements, and restrictions on operations in 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. The addition of video recording devices would provide critical information to investigators about the actions in the cockpit of small aircraft not equipped with CVRs or FDRs, and would supplement the recorded data already provided on large aircraft. These additional information components will aid in the development of timely, more precise safety recommendations that are likely to reduce future similar accidents.

Recommendation: In addition to adopting the 2-hour CVR requirement in the NPRM, require the retrofit of existing aircraft CVR systems with Recorder Independent Power Supplies (RIPS), and require that for existing aircraft, the FDR and CVR be on separate generator buses 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 or actively directing transportation operations (air traffic control), without adequate rest 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. The Safety Board added an issue area related to railroad fatigue to its Most Wanted List. The Federal Railroad Administration (FRA) currently does not have the statutory authority to establish those regulations but Congress is acting to provide that authority.

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. Additionally, a fatigue awareness and countermeasures training program should be developed for air traffic controllers.

Timeliness Classification: Aviation (flight crews, aviation mechanics and air traffic controllers): Unacceptable.
Marine: Unacceptable.
Pipeline controllers: Acceptable (progressing slowly).
Train crewmembers: Acceptable (progressing in a timely manner).


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: Complete efforts to implement a PTC 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: Acceptable (progressing slowly).

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: Acceptable (progressing slowly).

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 slowly).

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: Continue efforts to improve the occupant seating compartment on school buses.

Timeliness Classification: Acceptable (progressing slowly).

PREVENT COLLISIONS BY USING ENHANCED VEHICLE SAFETY TECHNOLOGY -- After investigating 9 rear-end collisions in which 20 people died and 181 were injured, the Safety Board concluded that developing and installing new technologies - such as collision warning systems (CWS) and adaptive cruise control (ACC) - in commercial trucks, buses, and passenger vehicles will substantially reduce accidents.

In May 2005, NHTSA released the results of a report showing potential to reduce rear-end crashes by 10 percent and reporting positive user reaction to the systems. Another report conducted for the U.S. Department of Transportation, released in January 2007, yielded preliminary findings indicating that a combined CWS and ACC bundled safety system account for a statistically significant reduction in rear- end crashes through reduced exposure to safety-critical driving scenarios. The Board has requested but has not yet received any information on NHTSA's interpretation of the commercial vehicle testing or timeline for future actions to mandate use of this technology. The Board voted today to add this issue to the Most Wanted list.

Recommendations: Continue efforts to develop performance standards for enhanced vehicle safety technology in new passenger and commercial vehicles.

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 Media Contacts: (202) 314-6100

Runway Safety - Peter Knudson
Fuel Tank Vapors - Bridget Serchak
Aircraft Icing - Terry Williams
Recorders - Ted Lopatkiewicz
Air Taxi Crew Resource Management - Ted Lopatkiewicz
Human Fatigue / Hours-of-Service - Terry Williams
Positive Train Control - Terry Williams
Motor Carrier Operations - Keith Holloway
Medically-Unqualified Drivers - Peter Knudson
Motorcoach Passenger Protection - Bridget Serchak
School Bus Occupant Safety - Peter Knudson
Collision Prevention Through Vehicle Technology - Bridget Serchak



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.