For over three decades, the NTSB has expressed concern about the lack of safety management and preventive maintenance. NTSB accident investigations have revealed that, in numerous cases, safety management system (SMS) or system safety programs could have prevented loss of life and injuries. Although an impaired operator or mechanic, a broken vehicle part, or severe weather may be the initiating factor in a transportation accident, there frequently is evidence of a continuous safety problem long before the accident occurred. These programs continually monitor operations and collect appropriate data to identify emerging and developing safety problems before they result in death, injury, or significant property damage. Having identified these risks, these programs then devise interventions and evaluate how well they perform at successfully mitigating risk.
Aviation, railroad, highway and marine organizations should establish SMS or system safety programs. These programs establish processes to collect and analyze data on potential safety problems and then evaluate mitigations to resolve the safety risk before an accident happens. They help to predict and correct problems to prevent accidents, but they are also a natural complement to investigations when accidents do occur. A fundamental principle of such systems is nonpunitive reporting that applies to both operating companies and the personnel involved in transportation organizations.
SMS and system safety programs can be effective in all organizations regardless of size. It is important to have information on how to scale these programs—from the smallest operators with just a few personnel and vehicles, to large organizations with thousands of employees and large numbers of vehicles and facilities. Regardless of the size of the organization, it is possible and necessary to foster a safety conscious environment that will identify hazards early on and mitigate the associated risks.
Title: Marine Accident Report: Fire on Board the Small Passenger Vessel Port Imperial Manhattan, Hudson River, New York City, New York, November 17, 2000
NTSB Report Number: MAR-02-02, adopted on 6/11/2002 [Summary | PDF Document]
Title: Aircraft Accident Brief: Crash of Sundance Helicopters, Inc., Aerospatiale AS350BA, N270SH, Near Grand Canyon West Airport, Arizona, September 20, 2003
NTSB Report Number: AAB-07-03, adopted on 10/30/2007 [Full Text | PDF Document]
Title: Aircraft Accident Report: Crash of Pinnacle Airlines Flight 3701, Bombardier CL-600-2B19, N8396A, Jefferson City, Missouri, October 14, 2004.
NTSB Report Number: AAR-07-01, adopted on 1/10/2007 [Summary | PDF Document]
Title: Highway Accident Report: Motorcoach Fire on Interstate 45 During Hurricane Rita Evacuation, Near Wilmer, Texas, September 23, 2005
NTSB Report Number: HAR-07-01, adopted on 2/21/2007 [Summary | PDF Document]
Title: Aircraft Accident Summary Report: In flight Fire, Emergency Descent and Crash in a Residential Area Cessna 310R, N501N Sanford, Florida July 10, 2007
NTSB Report Number: AAR-09-01, adopted on 1/28/2009 [Summary | PDF Document]
Title: Aircraft Accident Report: Loss of Control on Approach, Colgan Air, Inc., Operating as Continental Connection Flight 3407, Bombardier DHC 8 400, N200WQ, Clarence Center, New York, February 12, 2009
NTSB Report Number: AAR-10-01, adopted on 2/2/2010 [Summary | PDF Document]
Title: Railroad Accident Report: Collision of Metrolink Train 111 with Union Pacific Train LOF65-12 Chatsworth, California, September 12, 2008
NTSB Report Number: RAR-10-01, adopted on 1/21/2010 [Summary | PDF Document]
NTIS Report Number: PB2010-916301
Title: Railroad Accident Report: Collision of Two Washington Metropolitan Area Transit Authority Metrorail Trains Near Fort Totten Station, Washington, D.C., June 22, 2009
NTSB Report Number: RAR-10-02, adopted on 7/27/2010 [Summary | PDF Document]
NTIS Report Number: PB2010-916302
Title: Special Investigation Report: Special Investigation Report on the Safety of Parachute Jump Operations
NTSB Report Number: SIR-08-01, adopted on 9/16/2008 [Summary | PDF Document]
NTIS Report Number: PB2009-917001
For more information on the safety recommendations in these reports that address this Most Wanted List issue area, see: http://www.ntsb.gov/safetyrecs/private/QueryPage.aspx.