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Remarks to the Association for the Advancement of Automotive Medicine (AAAM) 2017 Conference, Las Vegas, Nevada
T. Bella Dinh-Zarr, PhD, MPH
Las Vegas, Nevada

​Thank you, Jim [Fell], for that kind introduction.  Thank you, also, to Carl Schulman and Gary Smith, as well as the organizing committee for inviting me.  I also would like to recognize my NTSB [National Transportation Safety Board] colleague and an AAAM [Association for the Advancement of Automotive Medicine] past president Dr. Mary Pat McKay on becoming an AAAM Fellow last night.  Congratulations, Mary Pat and the other honorees.

I am delighted to be here with all of you today, some colleagues whom I know well and others whom I hope to know.  You are colleagues who are conducting the latest, cutting-edge, lifesaving research in so many different areas of road traffic injury prevention.  Carl and Jim were so prepared that they asked me quite a while back for a title, and although I provided them with the title “Before, During, and After the Crash: Advancing Transportation Safety at the NTSB” at that time, in recent weeks I have made a slight change.  I will still discuss the NTSB’s work before, during, and after a crash – and give you a glimpse into what we do every day – but recently I have become even more convinced of the importance of a story to support good data and how we, as scientists, can and must, use stories to advance our efforts.  This goes beyond the NTSB and encompasses all of you and your important work as well, so my revised title is “Before, During, and After the Crash: Advancing Transportation Safety with Science and Story.”

Let’s face it - no one is more passionate about data than all of you.  Think about it.  You have spent the past 3 days discussing AIS [Abbreviated Injury Scale], finite element modeling and naturalistic driving data…and this is while you are in Las Vegas!  So I certainly do not need to tell you about the importance of science.  Nevertheless, I hope I can convince you of the importance of science’s partner – the story – in hopes that you will use it to help more people understand and use your important work.

Let me first tell you a little about the NTSB – and then we will delve further into “Science and Story”.  The NTSB is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States [U.S.] and significant accidents in other modes—railroad, highway, marine and pipeline.  We conduct investigations to determine the probable cause of these accidents, and we make safety recommendations to prevent their recurrence.

When a transportation disaster does occur, our on-call Go Team leaves immediately to fly to the scene, wherever it may be, to begin the investigation.  In fact, I am the Board Member on duty this week.  Generally, when I am on Go Team, I stay in Washington, DC, where planes are always waiting to leave at a moment’s notice, but I asked one of the other 3 Board Members to cover for me and I flew across the country to be here with you today because what you are doing is so important and it is an honor to be here to talk about how, together, we can prevent tragedies, rather than only investigate them.

When you think of the NTSB, you may think of our dark blue uniforms with the bright yellow letters on the back.  You will see us at the scene of disasters in all modes of transportation – aviation, maritime, highway, rail, as well as incidents involving pipelines and hazardous materials.  NTSB has a “Most Wanted List of Transportation Priorities” which are 10 safety issues we know have the chance of moving forward if given some good hard pushes.  In fact, six of our ten current Most Wanted List issues relate to your research.  These issues are collision avoidance technology, occupant protection, fatigue, event data recorders, distractions, as well as alcohol and other drug impairment.

We also hold meetings and conduct special studies on various topics, including alcohol impairment, rear seat safety, pedestrian safety, and speeding.  This information always is available to the public.

The concepts of Before, During, and After a crash are somewhat arbitrary delineations since we are always in between accidents, before or after, but I thought it might be a useful way to think about what we do at the NTSB.


So let us start with the Before phase.  The NTSB originated in the Air Commerce Act of 1926, in which Congress charged the Commerce Department with investigating the causes of aircraft accidents.  Later, that responsibility was given to the Civil Aeronautics Board's Bureau of Aviation Safety, when it was created in 1940.

In 1967, Congress consolidated all transportation agencies into a new U.S. Department of Transportation (DOT) and established the NTSB as an independent agency placed within the DOT.  So the NTSB is 50 years old this year.

Then, in 1974, Congress reestablished the NTSB as a completely separate and independent entity, outside the DOT, reasoning that "...No federal agency can properly perform such (investigatory) functions unless it is totally separate and independent from any other ... agency of the United States." 
In 1996, Congress assigned the NTSB the additional responsibility of coordinating assistance to families of accident victims.

At the NTSB, we are on call 24 hours a day, 365 days a year, and investigators travel throughout the country and to every corner of the world to investigate significant accidents and develop factual records and safety recommendations with one aim—to ensure that such accidents never happen again.
We are fortunate at the NTSB because Congress mandated our mission to be a noble one – to be an independent agency that investigates transportation accidents, determine their probable causes, and make recommendations to prevent their recurrence.  Our sole purpose is to save lives and prevent injuries by advancing transportation safety.   We do not have regulatory authority and we have no financial incentives to promote our recommendations.  As a result, we are very proud of our independence, transparency, and scientific rigor.

You often will hear us speak of our independence and that is because we are an independent agency headed by 5 independent Board Members, who are appointed by the President and confirmed by the U.S. Senate for a fixed term – we do not change when there is a new Administration.  We do not report to anyone so we can make recommendations to anyone, such as the U.S. Department of Transportation, state governments, associations, or private companies.  Currently there are 4 Members on the Board (one spot is vacant) so each Member is “on call” every 4 weeks – as I am now – in case of a major transportation disaster.  We value scientific and investigative rigor because our credibility lies in our reports and recommendations.  As for transparency, our work, deliberations, and votes are done in public, webcast meetings in compliance with what is known as the Government in the Sunshine Act.
Although Board Members, like myself, are not political in the traditional sense, we really never can forget our party affiliation – by law, NTSB is bipartisan since no more than 3 of the 5 board members can be nominated by the same party – but we never let that get in the way of safety.  This philosophy of collegiality for the sake of a good cause is strong among the current NTSB Board Members.  We still disagree with each other – and we often do, vehemently, which is one of the great privileges and responsibilities of being independent Board Members of an independent agency.  Yet, I feel very lucky to be able to say, after working closely with the other 3 current members that, for these Board Members and certainly for myself, our disagreements are for the sake of keeping our transportation system safe, not for any political gain or gamesmanship.


Now on to the During-the-Accident-Investigation Phase:  Our Response Operations Center (known as the ROC) is constantly monitoring the news around the clock so we are alerted to accidents of all sizes.  When there has been a major accident and we decide to launch a full investigative team, called a Go Team, with a Board Member, the entire agency springs into action.  We often launch within hours of learning about an accident so it is fast paced.  We gather our Go Bags, which contain safety gear like hard hats, safety goggles, reflective vests, gloves, steel toe boots, and everyone gathers at DCA National Airport, where we take one of the airplanes, which hold between 8 to 16 people, directly to the accident scene.  While in the air, I am briefed so we can be ready to give our first “Plant the Flag” press conference soon after landing so law enforcement, first responders, local officials, and the public know we are on scene and beginning the investigation.  At the scene, the person in charge is the (aptly named) Investigator in Charge or IIC.  He or she leads the investigation, organizes the personnel, holds organizational meetings, and briefs me and my Special Assistant so I can speak to families, the press, and politicians as needed.  Although it is hectic, there is an established order which helps various activities run smoothly.

Responding to and investigating transportation accidents, the DURING part, is how our agency often is defined by others and by ourselves.  Accidents are tragic, dramatic and memorable, and during the long hectic and exhausting days at the scene of an accident, the situations test how well we have prepared ourselves, both technically and ethically, to do our jobs.


Finally, although the NTSB is most often seen publicly DURING an accident, it is actually AFTER an accident when most of our work takes place: careful work in matters of crash reconstruction and engineering, interviews and human factors, review and analysis of medical and legal issues, family assistance, retrieving information from event data recorders, and other areas specific to each accident.  AFTER an accident also is when the 5 Board Members of the NTSB meet in a public or sunshine meeting and when we determine the Safety Recommendations that will be made to help prevent future accidents.

We issue and follow up on our safety recommendations.  Although we have no regulatory authority, our good reputation has enabled us to make and pursue adoption of recommendations for the benefit of safety.  We have issued over 14,000 safety recommendations to more than 2,500 recipients and about 80% have been adopted.

The formula for our Implementation Rate is: 

(# of recommendations closed acceptably ÷ # of all closed recommendations) * 100 = implementation rate 


  • # of recommendations closed acceptably = (closed-acceptable + closed acceptable alternate + closed-exceeds recommended action)
  • # of all closed recommendations = (closed-acceptable + closed acceptable alternate + closed-exceeds recommended action + closed unacceptable action + closed unacceptable action/no response received)

We have a good track record of having our recommendations adopted, but we do not give up on recommendations that are not achieved quickly.  Some take years or even decades to pass, especially if they must pass in all 50 states in the U.S.   At times, we are criticized, even vilified, for our efforts by misguided people, which I will tell you more about today.

As Dr. Steve Hargarten of the Medical College of Wisconsin says, the NTSB is like an infectious disease outbreak investigation team, except what we are investigating is an outbreak of kinetic energy instead of a disease.  We get as much information as we can to make recommendations to prevent the next “outbreak.”  Those on-scene investigations are an important part of our work – that is why we are on call 24 hours a day, 365 days a year, ready to go to the scene of an accident.

Before I get more disapproving looks, yes, I used the word “accident”.  Although the term “accident” is not used now in highway safety, we still use the term for our other investigations because, under the federal statute that created the NTSB, we are charged by Congress with investigating every civil aviation accident – as well as significant accidents in other modes.  Accident is a term of art in aviation.  It also underscores the fact that we investigate unintentional occurrences – we leave the criminal investigations to the FBI.

Federal agencies, states and territories, as well as the transportation industry have used our recommendations to make progress in areas such as: airbags, impaired driving, seat belt laws, school bus design, safety barriers in road design, setting standards for signage, to name a few.

Because of NTSB’s detailed investigations, it may seem that our work is largely technical and mechanical, but like you, my 400 colleagues at the NTSB and I never forget that the true purpose of our work is to serve people.  Their stories help us remember that.  Part of our work is to assist people who have been affected by a transportation disaster, including victims and families of victims.  As a Board Member, I talk with family members at the scene as well as after an accident. I consider this a great responsibility and a great privilege.   Survivors and family members share their stories with me and I carry those stories with me whenever I speak about our safety recommendations.

At the NTSB, at AAAM, and likely at other organizations you are a part of, we often talk about data and science and evidence.  But we do not often talk about stories.  We do not talk about the importance of stories to helping people understand and support science.  We do not talk about the synergy of science and story.  So today, I would like to discuss the importance of using stories to support science.
My own story in public health starts with data, and lots of it.  In the 1990’s, I was immersed in the world of systematic reviews, first at the Cochrane Collaboration in the United Kingdom, and then at the CDC [Centers for Disease Control and Prevention] with The U.S. Guide to Community Preventive Services. 
As many of you know, a systematic review is a form of research that includes an extremely comprehensive search of the literature and uses specified criteria to choose and analyze published and unpublished studies to answer a clearly formulated question.  A meta-analysis can be part of a systematic review.

In the 1990’s, systematic reviews were relatively new and mostly confined to the world of medicine. The Cochrane Collaboration was named after Archie Cochrane, an OB-GYN [Obstetrics and Gynecology] in the UK.  This innovative method of research to get the most complete and most objective evidence on a subject was still in its infancy.  I published one of the first systematic reviews on an injury topic in the United States focusing on injuries related to alcohol.

I loved data, so I loved the idea that systematic reviews would find THE ANSWER, quantitatively and without biases.  I could not quite understand why people did not find the results of a systematic review and meta-analysis as fascinating as I did.  Although I had volunteered at a domestic violence shelter and a Level 1 Trauma Center in Houston, where I witnessed many shocking examples of preventable injuries, I still did not quite understand the importance of connecting these stories with the numbers that all those data points represented.

Even after graduate school, when I had jobs that taught me the vital importance of telling the stories behind the science, I was still learning.  In my work at the FIA Foundation, a philanthropy that funds projects to prevent road traffic deaths globally, I heard stories from around the world, and became friends with people like Casey Marenge, who became paralyzed from the neck down after a car crash in Kenya but, with the help of her family, and her own very strong will, started a foundation to assist other people in wheelchairs in Africa, a foundation called Chariots of Destiny.  I heard stories about children in Vietnam saved from certain death and traumatic brain injury by an affordable Pro-Tec helmet built by people with disabilities.  I got to know a mother named Denise Dias in Guyana who created the “Mothers in Black” organization after her daughter died after being hit by a drinking driver.  Denise stood vigil outside her Parliament until effective drink driving laws were passed.  The FIA Foundation also helped fund Global NCAP [New Car Assessment Program] which I know you heard about earlier in the conference.  I also got to meet AAAM leaders such as Gary Smith and Maria Segui-Gomez.

I met so many amazing people, but somehow, it is really only now, at the NTSB, where I see the immediate and terrible aftermath of transportation disasters, that I have become convinced of the absolute necessity of telling the story in order to save lives and prevent injuries.  In addition, although I always think of my work in injury beginning with the Cochrane Collaboration, Sue Baker, injury pioneer and AAAM President in 1975 (shown in this recent photo with Ellen MacKenzie, AAAM President in 1994, and Andrea Gielen, director of the Hopkins Injury Center) reminded me, when I was at Hopkins recently, that it was while I was a student volunteer at Ben Taub – the Level 1 Trauma Center in Houston - where I first came face to face with the violent results of a lack of injury prevention, whether it was from crashes or from guns and knives.

I volunteered in both the injury center and the ED [Emergency Department] as an interpreter in a city where Spanish-speaking and Vietnamese-speaking populations are high.  As I told Sue Baker, I was a pretty good Spanish interpreter but a rather poor Vietnamese interpreter.  The Ben Taub ED was an eye-opening place for a student to learn about and remember the lessons of injury prevention.  Sue Baker tells me that I am the first public health scientist to have been appointed to the NTSB – and if Sue Baker says that, I will not argue with it!

I also am the first Board Member with a background in injury prevention, especially road traffic injury prevention, rather than aviation.  Because of that, in my first Go Team launch to an aviation accident in Ohio, I did what researchers do, I overprepared and learned all the technical details.  I learned everything I could about the aircraft, a Hawker 700A business jet that crashed on descent to an airport, destroying 2 apartment buildings and killing all 9 people aboard.  I learned how an aircraft enters into aerodynamic stall and the standard operating procedures for this type of aircraft.  I wanted to know everything, so I could explain every technical detail accurately to the families and the community, a community that was in shock because an airplane plowed right into their neighborhood and burst into flames.  I will never forget the sight of older people sitting on their porches just a few houses down as we walked through the blackened and flattened area where the Hawker crashed.  I also wanted to make sure I was ready for the rather aggressive press corps that day.

After that accident, I received a handwritten letter addressed simply to “the lady at the NTSB”.  It was one of the first letters I had ever received at the NTSB and it was from a member of that Ohio community.  She was an elderly lady who, seemingly unimpressed with my technical recall about the aircraft, wrote instead to thank me for my compassion!  She said although she had not met me, she watched the news avidly because she lived close by and felt I showed compassion towards the community.  That letter reminded me that while it is vital to learn all the technical details, I should not forget the story of people who are affected by tragedy, like the elderly lady who took the time to write a message to me.

Sometimes the story is about someone who was not affected, someone who just reminds people of a face behind the numbers.  That was the case in Utah.

At the NTSB, we are sometimes criticized for our safety recommendations.  We are not criticized by the public – who seem to understand our mission, but rather, by groups that are misinformed and worry unnecessarily that they might lose profits if a safety recommendation is implemented.  Nowhere has that been more evident than with our recommendations related to impaired driving.  I have been called a lot of names, but I think your former president Jim Fell has been called even more names than I have!

Ten thousand people.  As we all know, that is how many people die every year due to alcohol-impaired driving in our nation.  The NTSB has made many different recommendations in this area.  We have recommended reducing the illegal per se BAC [blood alcohol concentration] limit for all drivers; conducting high-visibility enforcement of impaired driving laws; incorporating passive alcohol-sensing technology into enforcement efforts; expanding the use of in-vehicle devices to prevent operation by an impaired driver; and DUI [driving under the influence] courts and other programs to reduce recidivism by repeat offenders.

We made these recommendations 4 years ago as part of our Reaching Zero study, but we get the most criticism for our recommendation for states to reduce their illegal per se to .05 BAC or lower.  As you heard from Jim Fell on Monday, this is despite the fact that about 100 countries around the world already have a .05 or lower BAC law and there have been dozens of studies demonstrating that such a law would reduce the number of impaired driving crashes.

I always try to be optimistic, but even I was surprised earlier this year when, against high odds and during a short legislative session of 45 days, the State of Utah passed the first .05 BAC law in the United States.  Utah and Oregon passed the first .08 law also.

How did it happen?  In part, because people in Utah requested safety information and the NTSB was able to provide it.  When Utah legislators reached out to me early on, we provided unbiased information, including Jim Fell’s comprehensive work, and I testified twice in their state legislature.  We told them that in countries with a .05 BAC law, people consume more alcohol per capita and yet were less likely to die from impaired driving.  We told them that a .05 BAC law is a broad deterrent that decreases the number of impaired drivers on the road at all BAC levels – high and low – so amazingly, it also reduces the number of high BAC drivers (yes, those well over .05 BAC), who are involved in the most crashes, from getting behind the wheel.  We showed them studies demonstrating that even at a .05 BAC, people have problems with coordination, vision, and steering.  When people called me (or Jim Fell) a prohibitionist, we told them that a .05 BAC law was not about drinking at all – it simply helps people to separate their drinking from their driving.  We told them it meant people should “Choose One: Drink or Drive”! We told them that a law could save 1,790 lives nationwide every year. 

Opponents of the .05 law used scare tactics and spread misinformation through expensive full-page ads in many newspapers.  These ads contradict information from NTSB, NHTSA [National Highway Traffic Safety Administration, the CDC, and many other sources.  Yet these ads told a story, a false story, but a story nonetheless.  Opponents tried to mislead Utah residents with a story about innocent people getting put in jail after having one drink with dinner.  I have to admit, they were clever and had catchy slogans like “Arrive on vacation, leave on probation.”

We provided stacks of information and studies and statistics, all of which legislators and the governor appreciated.  I thought surely the statistic of saving 1,790 lives a year would be all they would need.  But no, in the end, although our statistics helped, it was the power of the story that prevailed.  My first op ed [opinion editorial] was full of numbers but my second op ed, which was very well received, described my brother, a doctor, who often visited Utah with his family to snowboard and said he did not want to get hit by drunk drivers.  I wrote that by passing a .05 BAC law, they would be taking the first step to saving 1,790 lives nationwide, and I thanked them for protecting their families - and mine.  I cannot tell you how many comments I received about “the story about my brother”!  Supporters of .05 BAC also showed up at hearings to tell their story, often citing NTSB information.

The NTSB is not here to engage misguided opponents of safety in a public fight (as much as I love a good fight for a good cause).  We are here – as an objective source -  to provide solid, accurate, independent safety information for people to make informed decisions.  These personal stories help people understand that information and remember it.

Since AAAM has been discussing automation, I also wanted to briefly share with you the NTSB’s recent – and first – investigation into a crash involving a level 2 automated vehicle.  In May of last year, a 2015 Tesla Model S, was traveling eastbound on a divided highway near Williston, Florida.  A truck traveling westbound was making a left turn across the eastbound lanes.  The Tesla’s automation did not detect – nor was it designed to detect – the crossing vehicle.  The Tesla struck the side of the semitrailer, then crossed underneath, shearing off the car’s roof.  Sadly, the car driver died.  The NTSB determined the probable cause was the truck driver’s failure to yield the right of way, combined with the car driver’s inattention due to overreliance on vehicle automation.  A contributing factor was the vehicle’s operational design, which permitted prolonged disengagement from the driving task.

This crash reminds us that, even as we encourage game-changing, cutting-edge technology like automated vehicles, we must remember to remind everyone to keep safety at the forefront, something which I know we all do ourselves.

The work that you do every day, reminds us to remember our roots, even as we move from partially automated vehicles to self-driving cars.  Seatbelts, airbags, other forms of occupant protection, pedestrian protection, collision avoidance – let us not forget the vital safety technology that we have today, technology that we will continue to build on, technology that will continue to save lives.

Your scientific and technical work gives you legitimacy and power behind what you say.  Your stories show your humanity so people will remember why you do your work.  I know it is a fine line between providing information and advocacy, a line that some of you cannot cross, but real-life stories also are information.  Information that people will remember.  Stories give power to the data to overcome incorrect and misleading information.  It is hard for us to believe sometimes, but people need scientists like us to present the data and tell the story.  It is important for us to speak up, even for issues we thought were long accepted like seat belts and seatbelt laws.  In fact, just 2 weeks ago, I was in Massachusetts where they are, once again, debating a primary seat belt law.

Science alone and story alone cannot do it, but together, they are a more powerful force than the sum of their parts. That is the synergy of science and story.

As scientists and as those who believe in science and data, it is our job to tell the story of data, to make the data sing, to make people feel something about the data.

Scientists do not usually talk about feelings but it is worth remembering what the great writer Maya Angelou said: “I've learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel.”  We can make people feel something about data and science, using stories, and perhaps they will be inspired to support worthy, evidence-based efforts.  Stories are what will inspire people to remember the science.  Maya Angelou also said: “I think a hero is any person really intent on making this a better place for all people.”

In these times, when sometimes it seems that a misleading story can overcome science, it is up to us, as people who believe in data, people who analyze the data, to remember the power of the true story to support good science.  The story helps us make sense of the data.  The story helps us feel something about the data.  The story helps us remember the data.  The story helps us bring humanity to the data.  In addition, we should remember, there is ALWAYS a story.  Together, we can advance transportation safety using science and story.  Thank you again for inviting me to speak.  Thank you for the important, heroic work you do to advance science to save lives and prevent injuries.  Also, I very much look forward to hearing your stories.