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NTSB PRESS RELEASE
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National Transportation Safety Board
Washington, DC 20594
FOR IMMEDIATE RELEASE: November 8, 2007
SB-07-56
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NTSB WARNS OF RUNWAY COLLISION RISK; ENCOURAGED BY POTENTIAL
FOR TECHNOLOGY TO IMPROVE ROAD SAFETY
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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:
-- AVIATION --
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.
-- HUMAN FATIGUE (MULTIMODAL) --
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).
-- RAILROAD --
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).
-- HIGHWAY --
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
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