National Transportation Safety Board Recommendations Research Articles

Fatigue in transportation: NTSB investigations and safety recommendations

ObjectiveWe aim to place into the scientific literature information on the prevalence of operator fatigue as a factor in causing transportation mishaps, and the categories of improvements identified to address...

Prevalence and Treatment of Sleep Apnea in Safety-Critical Railroad Employees

On December 1, 2013 four passengers on a Metro North passenger train in New York City died and 70 were injured as the result of an over speed derailment [1]. Subsequently, it was announced by the National Transportation Safety Board (NTSB) that the locomotive engineer operating the train had sleep apnea [2]. Five NTSB recommendations following rail accidents since 2009 [3-7] have called for medical screening of safety-critical employees for sleep apnea. This short communication provides data on the prevalence and treatment of sleep apnea in three groups of safety-critical railroad employees in order to provide an estimate of the magnitude of this problem for the railroad industry. Table 1 is a summary of data on sleep apnea in railroad employees from three surveys conducted between 2006 and 2009 [8-10] by the Federal Railroad Administration (FRA). The surveys collected information on railroad worker patterns of sleep and work in daily diaries as well as information about demographics and health. The surveys included the following yes/no questions: “Do you have sleep apnea?” and “Are you receiving medical treatment for your condition?” The surveys were conducted by mail with the assistance of railroad labor unions and were random samples of each labor union population. All surveys were approved by the Office of Management and Budget as required by U.S. law.

Keeping It Simple

There have been rumors of regulations, rumors of congressional action, fury in the press, and lots of chatter. The latest rumored timetable of the alleged Federal Aviation Administration (FAA) Notice of Proposed Rule Making is now July 2010. This proposed set of regulations will purportedly address and make regulations of many of the past Advisory Circulars and National Transportation Safety Board recommendations that Congress and others have been pushing.

Civilian Aviation Fatalities Involving Pilot Ethanol and a Previous Record of Substance Abuse

Pilots are subject to the same temptations as the general population, but due to the demands of flying, the use of ethanol or other impairing substances are more likely to have severe consequences. The Federal Aviation Administration (FAA) requires pilots to report all adverse legal actions involving their use of ethanol and/or other drugs. The purpose of this study was to evaluate fatal civil aviation accidents between the years 2000 and 2007 in which ethanol was present in the pilot and the pilot had a record of previous drug and/or alcohol offenses. Case histories and accident information for the period under study were obtained from the National Transportation Safety Board (NTSB). Toxicological information was obtained from the Civil Aerospace Medical Institute's Forensic Toxicology Research Laboratory. During the examined period 215 of the 2391 pilot specimens received for toxicological analysis had documented alcohol or drug related offenses. Of the 215 pilot specimens received, 23 showed evidence of ethanol consumption prior to the fatal incident and 16 of those had ethanol concentrations above the FAA's legal limit of 40 mg x dl(-1). These results confirm earlier reports that pilots with previous alcohol and/or drug offenses are more likely than others to engage in repeated substance abuse in association with flying with resultant fatal accidents. These findings support the NTSB's recommendation that the FAA implement more thorough verification of alcohol and drug offenses as a means of identifying pilots at increased risk of causing accidents.

The National Transportation Safety Board recommendations

The National Transportation Safety Board recommendations

Certification and Design Issues for Rudder Control Systems in Transport Aircraft

A recent transport aircraft accident involving inappropriate rudder inputs by the pilot flying has led to a series of National Transportation Safety Board recommendations regarding certification. In particular, certification standards are sought that will ensure safe handling qualities in the yaw axis throughout the flight envelope, including limits for rudder pedal sensitivity. This study is offered as a first step in establishing such standards. A review of current Code of Federal Regulations part 25 as regards rudder control is briefly summarized, as are pertinent sections of Federal Aviation Administration Advisory Circular 25-7A-Flight Test Guide for Certification of Transport Category Airplanes. An analytical investigation of possible piloting tasks for assessing rudder pedal force/ feel systems is presented. The tasks reflect the philosophy of advisory circular 25-7A. A comparison of the pedal force/ feel systems for three transport aircraft and four rotorcraft is presented. Three parameters for assessing the quality of pedal and rudder systems are discussed, a linearity index, maximum required pedal forces, and lateral acceleration at the pilot's station per unit of pedal force input above breakout.

Safety Recommendations — The engine that drives change

The National Transportation Safety Board (NTSB) considers the recommendations it makes to prevent accidents and improve the safety of the United States transportation system to be its most important product. In its 25-year history the NTSB has made almost 9,000 safety recommendations covering needed improvements in all the modes of transportation to more than 1,250 recipients. These recommendations are made to anyone the NTSB believes can make the change that is necessary to improve safety. Recommendations have been directed to federal, State and local government agencies, private transportation companies, labor unions, trade associations and others. Overall, more than 80 percent of the NTSB's safety recommendations have been accepted by the recipients and the changes called for have been implemented. This has had a very significant positive impact on the safety of the US transportation system. The NTSB is very proud of this record. The changes that have taken place as a result of the NTSB's recommendations have saved thousands of lives and prevented many accidents. How has the NTSB achieved such a good record? The basic foundation and most important reason for this achievement is the NTSB's independence. This independence lends the NTSB credibility. Recipients of the NTSB's recommendations are more willing to carefully and seriously consider taking the action recommended. The second essential reason for the NTSB's credibility is the highly competent, technical qualifications of its investigators and the thoroughness of its investigations and studies. The NTSB also is very careful and prudent in making its recommendations. Each proposed recommendation is carefully evaluated to make sure it is practical, feasible and capable of being implemented. The credibility of the NTSB has grown over the years, and along with that has come an increase in the acceptance rate of the recommendations. This paper will describe the NTSB's safety recommendation program, how it achieves improved safety, and its important elements, such as the Most Wanted Safety Recommendation Program and the Safety Recommendation Information System.

An Investigation into the Loss of the Mobile Offshore Drilling Unit Ocean Ranger

The loss of all 84 persons aboard the mobile offshore drilling unit (MODU) Ocean Ranger on February 15, 1982 and 123 of the 212 persons aboard the MODU Alexander L. Kielland on March 27, 1980 are dramatic examples of MODU accidents. One of the purposes of this paper is to describe the investigative process undertaken by the National Transportation Safety Board (NTSB), the U.S. Coast Guard and the Canadian Royal Commission to determine the cause of the capsizing and sinking of the Ocean Ranger. In that regard, the NTSB analysis and findings are presented. A number of other MODU casualties are summarized in order to put this casualty into perspective. The responsibility for the safe operations of these complex and expensive platforms must be shared among regulators, vessel owners, drilling contractors, operators and labor organizations. The paper examines the national and international rules and regulations that are in place relating to design, construction and operation of MODU's. The NTSB recommendations are put into this shared-responsibility framework.