Good morning! Thank you, Mark, for that very kind introduction and I appreciate the invitation to speak today at the closing session of your meeting. Thank you to Doug who has invited me in the past, before my time at the NTSB, and has always been such a gracious host. It is a pleasure and an honor to be back at the ASC with all of you - automotive leaders from around the world who are working together towards the common goal of safety.
Today I would like to give you a glimpse into the work that my colleagues and I do every day at the National Transportation Safety Board.
First, I will give you an overview of the Board’s work: Before, During, and After Transportation Accidents at the NTSB. The concepts of Before, During, and After an accident are somewhat arbitrary categories since we are always in between accidents, before or after, but I thought it might be a useful way to organize explaining the work we do at the NTSB. Then, I’d like to discuss some motor vehicle specific areas that are on our 2016 NTSB Most Wanted List.
In the BEFORE component, I will give you some history of the NTSB, what we do, our values, our mission, and, if you’ll indulge me, I would like to explain how I, a public health scientist, whom a few of you may remember as working on global road safety issues the last time I was here, ended up at the NTSB.
Responding to and investigating transportation accidents, the DURING part, is how our agency often is defined by others and also by ourselves. Accidents are tragic, dramatic and memorable, and it is during the long hectic and exhausting days at the scene of an accident that test how well we have prepared ourselves to do our jobs.
And finally, although the NTSB is most often seen publicly DURING an accident, with our dark blue jackets with the large yellow NTSB letters emblazoned on the backs, because that is when the news media is there, it’s actually AFTER an accident when most of our work takes place -- careful work in matters of engineering, human factors, medical issues, legal issues, family assistance, weather conditions, data recorders, and other areas specific to each accident. AFTER an accident is also 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.
So let’s start with the Before phase. The NTSB originated in the Air Commerce Act of 1926, in which Congress charged the U.S. Department of Commerce 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. Since 1967, the NTSB has investigated accidents in the aviation, highway, marine, pipeline, and railroad modes, as well as accidents related to the transportation of hazardous materials.
Then, in 1974, Congress reestablished the NTSB as a completely separate and independent entity, outside the DOT. It is this separation from other branches of government and indeed any other entity that enables us to conduct investigations and make safety recommendations from a truly independent and objective viewpoint.
At the NTSB, we are on call 24 hours a day, 365 days a year, and investigators travel throughout the country and around the world to investigate significant accidents and develop factual records and safety recommendations with one aim—to ensure that such accidents never happen again. The NTSB's Most Wanted List of Transportation Safety Improvements highlights safety-critical actions every year that should be taken to prevent accidents and save lives.
We are fortunate at the NTSB because Congress mandated our mission to be a noble one – to be an independent agency charged with investigating transportation accidents, determine their probable causes, and make recommendations to prevent their recurrence. Our purpose, somewhat similar to the goals of the ASC, is to save lives and prevent injuries by advancing transportation safety. And like the ASC, which strives to maintain your values of integrity, veracity, and expertise, we at the NTSB fiercely protect our values of independence, credibility, and transparency. These are the values which define our agency and they are also what keep our agency functioning and relevant.
You will often hear us speak of our independence and that is because we are an independent agency that is also headed by 5 independent Board Members who are appointed by the President and confirmed by the U.S. Senate. We do not report to anyone so we can make recommendations to anyone, such as the US Department of Transportation, state governments, associations, or companies. Currently there are 4 Members on the Board (one spot is vacant) so we are “on call” every 4 weeks in case of a major transportation disaster. We value scientific and investigative rigor because our credibility lies in our reports and recommendations. And as for transparency, our work and deliberations and votes are all done in public, televised meetings in compliance with the Government in the Sunshine Act.
We are charged with investigating every civil aviation accident in the United States – historically, the public is most familiar with our investigations of airplane crashes - but we also investigate major transportation accidents in rail, marine, and highways, as well as pipeline disasters. And as we all know only too well, of all the modes of transportation, it is the accidents on our roads that exact the highest number of deaths and injuries.
To date, we have issued over 14,000 safety recommendations to nearly 2,300 recipients.
Although Board Members like myself are not political in the traditional sense, we never can really 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 politics 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, but that is one of the great privileges and responsibilities of being independent Board Members of an independent agency. 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 the transportation system safe, not for any political gain or gamesmanship.
When I was nominated to the NTSB, it was a surprise. I was happily working in international road safety for a philanthropy and I was literally about to go into a meeting at the United Nations when I got the first call from the White House – a call which turned out to be a possibility for a dream job in transportation safety. That first call was just the start of a very long process for White House nomination and then Senate confirmation, a process that included interviews and a very thorough FBI investigation which included everything from visits to my employer in London to my elderly neighbors next door – who insisted the FBI agents come in for coffee so that they could tell them what a good neighbor I was! Even though I had been tapped as a potential nominee, I was well aware that no public health professional had ever been chosen to serve on the NTSB. But I always felt that public health’s focus on prevention was a natural fit for transportation. And I should say that you have been well ahead of the curve at the ASC because this public health and transportation connection is something that the ASC has long recognized and continues to recognize through your work and the public health experts I have seen you invite to your meetings over the years. So, despite a change in the leadership of the Senate, I was confirmed by the Senate and then soon after, appointed Vice Chairman by the President. That occurred almost exactly one year ago today.
Now on to the During-the-Accident-Investigation Phase…our Response Operations Center (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 Hangar 6 at DCA National Airport where we take one of the FAA 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 “Plant the Flag” soon after landing so that law enforcement, first responders, local officials, and the public know that we are on scene and beginning our investigation. At the scene of an accident, 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 us so that I can speak to families, the press, and elected officials as needed. And by “us”, I usually mean myself and my Special Assistant, Shannon Bennett, without whom I could not do my job. I hope you will take a moment to meet Shannon – she is an engineer, a Lieutenant Colonel in the Air Force, and a lawyer, and a great example of the capable men and women we have working hard every day at the NTSB.
Although the on-scene phase of an accident investigation is hectic, there is an established order which helps things run smoothly.
The NTSB has rules about being a “party” to an NTSB investigation—this party process helps to ensure we have all the technical information about specific elements of an accident and is something that some of your companies have participated in. During an NTSB investigation, our investigator-in-charge will appoint parties to the investigation to assist us in the fact gathering process. We have strict rules by which those parties must abide in order to remain party members. Parties cannot speak to the press, or conduct their own investigation, and are named for the express purpose of providing technical expertise to the NTSB, not for purpose of preparing for litigation. We always like to say – no lawyers, except our lawyers!
To those of you whose companies have participated in the party process before, we truly appreciate your help in providing us with the technical information we need to determine a probable cause and make safety recommendations, so that we can prevent these accidents from happening again.
After an accident is where the bulk of our work takes place. We hold public board meetings usually once or twice a month to hear investigative reports and vote on them. Although we have no regulatory authority, our good reputation has enabled us to make and pursue adoption of recommendations for the benefit of safety and the majority of our safety recommendations are eventually adopted.
And although we have a good track record of having our recommendations adopted, we also 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 United States. And we are often criticized, even vilified, for our efforts.
For example, for the past couple months, I have had frequent media interviews with TV, radio, and newspapers, from around the country – in Minnesota, Tennessee, Kentucky, Pennsylvania, many others - about our recommendation to all 50 U.S. States and Territories to change the BAC or Blood Alcohol Content law from .08 to .05 or lower. We made this recommendation 3 years ago and about 100 countries around the world already have a .05 BAC which also means that there have been many peer-reviewed studies demonstrating that such a law would indeed prevent impaired driving crashes. Despite decades of evidence and despite AAA Foundation surveys showing that 63% of Americans would support .05, not a single U.S. state has passed this lifesaving law. Why? Because the myths have endured about .05. Although people in countries with .05 consume more alcohol per capita and yet are still less likely to die from impaired driving, many opponents still think they will lose business and lobby against .05 despite little evidence. Other advocates are not opposed to .05 but believe that we should focus only on solutions to prevent high BAC drivers, which we already do in our interlock and enforcement recommendations, but they forget is that a .05 law is a broad deterrent that decreases the number of impaired drivers on the road at ALL BAC levels – high and low – so it would help do what we want and that is to simply separate drinking from driving.
So persistence is something we value at the NTSB, resulting from past experience. Like the ASC, we recommended seat belts and air bags in cars long before they were an accepted safety feature and now young people look at me in disbelief when I tell them that cars did not always have seat belts – so we know US states will eventually adopt .05 and people will eventually assume it was always the law of the land. Of course, many more lives would be saved if a .05 law were passed sooner, but we are in it for the long run. It isn’t very hard to argue, even against vocal opponents, when we know we are on the right side of these arguments, such as .05. And it is somewhat comforting to know that it is not a question of IF but WHEN recommendations like this will be adopted. We just need to be persistent.
MOST WANTED LIST
Every January, the NTSB releases our “Most Wanted List” of transportation priorities for the year. For over 25 years, the NTSB has chosen ten issues – covering all modes of transportation - that represent safety challenges; challenges which have a strong chance of being advanced if given some good hard pushes by the NTSB. Each Board Member is assigned 2 to 3 issue areas. This year, 6 of the 10 issue areas we selected are related to motor vehicle safety.
While there is so much to cover, there are 3 general areas that present challenges – these also happen to be areas on the Most Wanted List that most intersect with your work and where I would appreciate your help.
- Substance Impairment
- Occupant Protection and
Substance impairment has been on the Most Wanted List before and you may ask why this is a “new” challenge. NTSB has been a longtime supporter of the fight against alcohol-impaired driving with our safety recommendations. Alcohol-impaired driving remains one of the deadliest killers on America’s highways and we cannot forget that. And I’ve told you about some of our recent efforts relating to .05. But in recent years, because of our crash investigations, the NTSB has expanded this issue to include other types of impairing substances. Increasingly in our investigations, across all modes of transportation; we are finding impairment from both prescription and illicit drugs on the rise. As doctors are prescribing more and more opiate-based pain-killers, we have found those substances contributing to crashes. In fact, in testing the blood of both airplane pilots and drivers who have died in crashes, studies have found that the percentage of people with an impairing drug in their system has been steadily and rapidly rising every year. And perhaps, most alarmingly, we are faced with the new challenge of synthetic drugs – specifically, synthetic cannabinoids, many of which because of their constantly changing chemical composition, are not even listed on the drug schedule. Because they are not “known” substances on the drug schedules and the manufacturers of these synthetic drugs design them with incredibly short half-lives, they are very difficult to detect in drug testing and they also have unpredictable effects and side effects.
In November 2015, the Board met and voted on a report on a terrible crash involving a truck-tractor semitrailer that crossed over the median and collided with a medium-size bus carrying 15 members of a women’s community college softball team near Davis, Oklahoma. Four passengers were fatally injured and each of the 13 remaining people received serious or minor injuries. In that report, the Board concluded the probable cause of the crash was the truck-tractor driver’s incapacitation from synthetic cannabinoids.
This crash also brought to light several very concerning issues in the area of strengthening occupant protection. Occupant Protection is another old subject that has become new again - occupant protection in terms of both restraint use and crash worthiness. This bus was what is considered a medium-sized bus – defined as a vehicle between 10,001 lbs and 26,000 lbs. The bus weighed 26,000 pounds – right at the maximum. There currently are no crashworthiness standards to provide protection for the passengers in this size bus. To make matters worse, this type of vehicle is gaining popularity in use throughout this country – you’ll commonly see these buses in use transporting children, retirement home residents, government workers, and company employees.
The crash in Davis provided the Board with insight into another aspect of the occupant protection issue that is near and dear to the NTSB – an issue that ASC has long championed - restraint use. This medium-sized bus was equipped with seatbelts, but none of the students were wearing them. Three of the four passengers who died were fully ejected from the bus. As you see in your work, these types of needless deaths and injuries still happen every day simply as a result of not wearing a seatbelt. Occupant protection is a new challenge because it is thought of as an old issue that we have taken care of – but it is an issue that is still killing people every day. At the NTSB, we are always advocating for interventions that will increase seat belt use, such as primary seat belt laws, and we are also gathering information in order to determine the best ways we can help advance occupant protection in general. In fact, at the end of next month, we will be asking for input from occupant protection experts, including from many of your companies and organizations, on rear seat occupant protection. I know that protecting occupants is at the core of your work, so I look forward to working together on that.
Perhaps the most obvious challenge is technology. Technology is getting more complex every day and devices that help us also can be a dangerous distraction when we drive. Distraction remains on NTSB’s Most Wanted List, but technology also is increasingly able to protect us through advanced occupant protection, crash avoidance systems and, as you have discussed in the past 2 days, vehicles that are more and more automated and culminating, ultimately, in a self-driving car. So technology is part of the challenge and part of the solution – as with everything, it is whether we have the wisdom to use the technology to advance safety rather than abusing it. Because our congressional mandate focuses on making recommendations once an accident has happened, and fortunately there have been no fatal crashes with a self-driving car, we have not issued any recommendations related to automated vehicles but we are keeping in touch with the industry, so we will be prepared should a serious crash occur. And I would consider it a great favor if you would keep me informed about advances in this quickly evolving area. In the meantime, the NTSB speaks out on the benefits of crash avoidance systems including how vehicles can help keep pedestrians safe. I should mention that we have just announced our first Pedestrian Safety Forum, which includes a panel on vehicle improvements, and I hope you can attend in person or via webcast when it takes place on May 10. I would be happy to send you more information.
Another aspect of technology, not often discussed in the motor vehicle world, is the data recorder. The public is used to hearing about flight data recorders for airplanes and even voyage data recorders with the recent sinking of the El Faro cargo ship during Hurricane Joaquin, but collecting information from motor vehicles, especially commercial trucks and buses, is very primitive or often non-existent. With better data collection equipment, such as recorders, in vehicles, we can better determine the probable causes of crashes and prevent them from happening again.
Substance impairment, occupant protection, technology – all challenges but with potential solutions. The ASC has been working for more than 50 years on safety, and I have been privileged to have come to this meeting as part of my past work in global road safety and to have worked with some of you on international efforts. I come to you now in my new role with the government, at the NTSB, and I ask you to help me do my job better. I ask you to keep me informed about how changes in technology will affect safety and I ask you to let me know if there are ways that the NTSB can help advance safety in your work. And I invite you to come visit our state-of-the-art accident investigation labs (and perhaps I can visit yours) so that we learn from each other. But most of all, I ask you to stay in touch with me and the NTSB and to continue speaking out on safety – as you have been doing – especially in the many cases where your support would be vital in getting our safety recommendations adopted.
A former Chairman from the 1990’s used to describe NTSB’s mission and goals by paraphrasing Thomas Jefferson’s quote: "The care of human life and happiness…is the first and only legitimate object of good government." I agree.
And I would add that good government is at its best when it is able to work with companies and organizations like members of the ASC to effect positive change. We are lucky at the NTSB because, with our simple and noble mission of preventing accidents, we are seen as wearing the “white hat” by the public. But I know that we could do more and be more effective and save more lives with your help. I look forward to working with you to save more lives and prevent more injuries. Thank you.