NTSB Press Release

National Transportation Safety Board
Office of Public Affairs


October 28, 2008

Washington, DC --The National Transportation Safety Board today issued its 2009 Federal Most Wanted List of safety improvements.  Newly added to the list of 15 areas of concern were: Improve Emergency Medical Services (EMS) Flight Operations, Restrict the Use of Cell Phones by motorcoach drivers, and require Electronic On-Board Recorders by all motor carriers. 

 Among the issues removed from the list were positive train control, which has been on the list since its inception in 1990, fatigue in the railroad industry and aircraft fuel tank flammability.

 "Our Most Wanted List, which was created in 1990, was designed to raise the public's awareness and support for transportation safety issues," said NTSB Chairman Mark V. Rosenker.  "The safety issues on this list are critical to improving transportation safety.  When acted upon, these recommendations will reduce accidents and save lives."

 2009 Most Wanted List


 The Board added Improve the Safety of Emergency Medical Services (EMS) Flights.  The Board believes that a concerted effort must be made to improve the safety of emergency medical services flights.  In 2006, the Safety Board issued a special investigation report addressing the safety issues involved in these operations.  Although the Board has issued recommendations to improve EMS safety, the Federal Aviation Administration (FAA) has not implemented the changes.  In the last 11 months, there have been 9 EMS accidents resulting, in 35 fatalities. 

 Improve Runway Safety - In the last two decades, the Safety Board has issued numerous safety recommendations addressing this issue and believes that implementing a safety system for ground movement with direct warnings to flight crews will improve runway safety.  Another recommendation in this issue area would require pilots to conduct landing distance assessments before every landing based on existing performance data, actual conditions, and incorporating a minimum safety margin of 15 percent.  Also, a new recommendation was added to this subject area that would provide pilots with information or alerts in the cockpit regarding attempted takeoffs from a taxiway or the wrong runway.   

Reduce Dangers to Aircraft Flying in Icing Conditions -Actions need to be taken to improve flight safety in icing conditions.  The FAA has yet to complete efforts to revise icing certification criteria, testing requirements, and restrictions on operating in icing conditions.  A recommendation added this year on deice boots addresses a widely held, but incorrect, belief that activation of deice boots be delayed rather than started immediately upon entering icing conditions.      

 Require Image Recorders - Conventional cockpit image recorders (CVR) and flight data recorders (FDR) do not show the initial cockpit environment leading up to a crash.  Image recording systems, a supplement to the CVR and FDR that are currently on large aircraft - and that could be retrofitted on smaller planes that do not have voice recorders - would  provide critical information about the actions inside the cockpit and immediately before and during an accident.     

The Board removed the area Eliminate Flammable Fuel/Air Vapors in Fuel Tanks on Transport Category Aircraft from the list.  On July 21, 2008, The Federal Aviation Administration published a final rule titled "Reduction of Fuel Tank Flammability in Transport Category Airplanes."  The rule requires fuel/air mixtures in all fuel tanks to be below a prescribed flammability level for all newly manufactured aircraft that have more than 30 seats, as well as modifications to passenger-carrying aircraft manufactured after January 1, 1992. 

 The Board kept the issue Improve Crew Resource Management Training for on-demand Part 135 carriers on the list with no changes.


Congressional activity allowed the Board to remove one of its original items from the Most Wanted List - established  in 1990 - positive train control, an anti-collision technology.  On October 1, 2008, 19 days after an accident involving a Metrolink passenger train and a Union Pacific freight train in Chatsworth, California, Congress passed the Rail Safety Improvement Act of 2008; the President signed it into law October 16.  The Chatsworth accident claimed 25 lives and resulted in more than 100 injuries. Among its provisions, this law requires Class 1 railroads, and regularly scheduled intercity or commuter rail passenger carriers, to develop and submit to the Secretary of Transportation, within 18 months, its plan for the implementation of a positive train control system by December 31, 2015.  Each plan must describe how it will provide for interoperability of the system with movements of trains of other railroad carriers over its lines. 

 "We are thrilled to see this long-needed technology being mandated and a timeline for its implementation being given," Rosenker said.  "Many lives will be saved as a result of this legislation."


The Board added restrict the Use of Cellular Telephones by Motorcoach Drivers.  Research shows that using a cellular telephone while driving degrades driving performance, resulting in slower reaction times, slower driving speeds, and increased instances of attention lapses.  In 2006, the Board recommended that the Federal Motor Carrier Safety Administration (FMCSA) prohibit cellular telephone use by commercial driver's license holders with a passenger-carrying or school bus endorsement, while driving under the authority of that endorsement, except in emergencies.     

 Require Electronic On-Board Data Recorders to Maintain Accurate Carrier Records on Driver Hours of Service and Accident Conditions - For more than three decades, the Safety Board has advocated the use of on-board recorders, for all motor carriers to increase hours of service compliance by commercial drivers.  The Board added this issue to the Most Wanted List because the FMCSA proposal is not applicable to all operators subject to hours of service regulations, does not establish the proper incentives, and does not create a level playing field for compliance with the rules.  Electronic On-Board Recorders would also result in more accurate data collected on accident conditions.     

Remaining on the list in the highway mode are: Improve the Safety of Motor Carrier Operations; Prevent Medically Unqualified Drivers from Operating Commercial Vehicles; Enhance Protection for Motorcoach Passengers; Enhance Protection for School Bus Passengers; and Prevent Collisions by Using Enhanced Vehicle Safety Technology.  On the last issue, Acting Chairman Rosenker said, "New technologies like anti-collision devices and electronic stability control are already proving their worth in saving lives on our highways."   


Human Fatigue in Aviation, Marine, and Pipeline - The Safety Board has long been concerned about the effects of fatigue on persons performing critical functions in all modes of transportation.  Fatigue in the transportation industry presents unnecessary risk to the traveling public.  This issue has been on the most wanted list since its inception.

Setting work hour limits based on fatigue research, circadian rhythms, and sleep rest requirements will reduce unnecessary risk to the traveling public. 

Fatigue in the railroad industry was removed from the Most Wanted List today due to the Railroad Safety Improvement Act of 2008, which addressed railroad hours of service limits and established fatigue management requirements.

 "All of these safety related issues highlighted in the Most Wanted List should be addressed promptly," Rosenker said. "Though we are encouraged by progress being made, resulting in some items being removed from the list, several of these safety concerns have been on this list since its inception.

That is unacceptable.  I urged the modal agencies to move on these safety recommendations immediately."

NTSB Media Contact:     (202) 314-6100

Keith Holloway:  
Improve Emergency Medical Service Flights
Motor Carrier Operations

Peter Knudson:   
Runway Safety  
Medically Unqualified Drivers
Protection for School Bus Passengers           
Enhance Protection for School Bus


Ted Lopatkiewicz:
Image Recorders
Crew Resource Management for Part 135
Restrict Use of Cellular Telephones

Bridgett Serchak:
On-Board Recorders
Protection for Motorcoach Passengers
Collision Protection Technology

Terry N. Williams:
Icing Conditions
Positive Train Control



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.