# Presentation: 472524

## Federal Most Wanted Transportation Safety Improvements

***“... ******a program to increase the public’s awareness of, and support for, action to adopt safety steps that can help prevent accidents and save lives*****.”**
***November 14, 2006***

## Slide 2

## 866 Open Recommendations

**Aviation: 373**
**Highway: 258**
**Railroad: 106**
**Marine: 77**
**Pipeline: 32**
**Intermodal: 19**

- November 2006

## Issue areas selected for intensive follow-up and heightened awareness because they:

- Will impact and enhance safety of the nation’s transportation system
- Have a high level of public visibility and interest
- Will benefit from special form of encouragement

## 47 Safety Recommendations on Most Wanted List

-     **DOT Secretary    1**
**    ****FAA****	****	****   20**
**    ****FMCSA****	****	****     9**
**    ****NHTSA****	****	****     4**
**	**

**PHMSA     1**
**FRA****	****         1**
**USCG        2**

**State Recommendations:  9**
**November  2006**

**Federal Recommendations:  38**

## Office of Safety Recommendations& Advocacy

**Darrin Broadwater**
**Mike Brown**
**Pat Cariseo**
**Barbara Grider**

**Jeff Marcus**
**Julie Perrot**
**Alan Pollock**
**Pat Sullivan**

##  Today’s Presenters

**Sandy Rowlett**
**Bob Swain**
**Nora Marshall**
**Dan Bower**
**Jim Cash**
**Jana Price**
**Jim Southworth**
**Jack Spencer**
**Bruce Magladry**
**Mitch Garber**

## Action / Timeliness Criteria

**Red****:** Unacceptable response
**Yellow****:** Acceptable response – progressing slowly
**Green****:** Acceptable response – progressing in a timely manner

## Aviation

**Highway**

**Pipeline**

**Rail**

-  Stop Runway Incursions/Ground Collisions of Aircraft
-  Eliminate Flammable Fuel/Air Vapors in Fuel Tanks on Transport
-     Category Aircraft
-  Reduce Dangers to Aircraft Flying in Icing Conditions
-  Require Restraint Systems for Children Under Age 2
-  Improve Audio and Data Recorders/Require Video Recorders
-  Reduce Accidents and Incidents Caused by Human Fatigue

-  Improve the Safety of Motor Carrier Operations
-  Prevent Medically-Unqualified Drivers from Operating Commercial Vehicles
-  Enhance Protection for Bus Passengers

-  Reduce Accidents and Incidents Caused by Human Fatigue

-  Implement Positive Train Control ** **

**Marine**

-  Improve Drug and Alcohol Testing of Crews After Accidents
-  Reduce Accidents and Incidents Caused by Human Fatigue

**U.S. DOT**

-  Reduce Accidents and Incidents Caused by Human Fatigue

## Stop Runway Incursions

**and**
**    ****Ground Collisions of Aircraft**

## Safety Improvements Wanted

- Develop ground movement safety systems that will provide direct warning to flight crews in the cockpit
**	****A-00-66**

## Slide 12

## Slide 13

## RUNWAY 14R

**RUNWAY 14R**

**RUNWAY 27L**

## Slide 15

** **

## Slide 17

## Slide 18

##  Separation:  35 Feet

** ****Separation:  35 Feet**

## Slide 20

## FAA Actions

**FAA Actions**

- Final Approach Runway Occupancy Signal

## Runway Status Lights

## Enhanced Airport Lighting Program

## Enhanced Airport Lighting Program

## Stop Runway Incursions andGround Collisions of AircraftProposed Safety Board Action

| Timeliness Classification | RED |
| --- | --- |

**Stop Runway Incursions and****Ground Collisions of Aircraft****Proposed Safety Board Action**

- Keep issue area on Most Wanted List
- Retain red classification: Unacceptable response

## Eliminate Flammable

**Fuel / Air Vapors in**
**Transport Category Aircraft**

## Safety Improvements Wanted

-     ...preclude the operation of transport-category airplanes with explosive fuel/air mixtures in the fuel tanks:
- Develop airplane design modifications such as nitrogen-inerting systems and insulation between heat-generating equipment and fuel tanks  **A-96-174**
- Modify operations to reduce the potential for fuel-air mixtures in the fuel tanks that will preclude explosive fuel-air mixtures in the fuel tank**   ****A-96-175  (Closed -Unacceptable)**

##  Fuel Tank

-  **Fuel Tank**
**Explosions**

**346 fatalities total**

**Avianca 727, November 1989**

**PAL 737, May 1990**

**TWA 747, July 1996**

## Widespread Problem

- Affects multiple airplane manufacturers
- Recent for Airbus fuel pumps:
- Airworthiness Directive 2006-12-02

## Fuel tank explosions since TWA 800

**Transall C160R, May 2004**

**Transmile, May 2006**

**Thai Airways, March 2001**

## Inside of the left wing fuel tank, a hole burned through the fuel pump conduit,exposing power wires to the fuel vapor

## Chafed fuel pump wires from a domestic airliner were also found during Transmile investigation

## Wing fuel tanks are also at risk

- FAA NPRM only cites heated center wing fuel tanks

**Transmile Airlines, B-727, May 4, 2006**

- Destroyed structural integrity within the wing

## FAA Proposed NPRM:

-  Issued on November 23, 2005
-  Affects over 3,200 retrofit and new large
-        passenger jets
-  Cost estimates vary, typically between
-        $100,000 - $250,000 per airplane

## FAA NPRM Focus

-  FAA and industry focus on center fuselage tanks
-  Wing tanks are also at risk, but not addressed in  NPRM

## Current Use, New Airplanes, R&D

**Current:**
-  Military use of nitrogen in fuel tanks is common
-  Nitrogen systems in a limited number of Boeing airplanes
-  No protective nitrogen systems on Airbus airplanes
**Future:**
-  787 wing and fuselage tanks protected
-  Research on nitrogen-based fire suppression systems

## Eliminate Flammable

- Fuel/Air Vapors in Fuel Tanks

| Timeliness Classification | YELLOW |
| --- | --- |

**Proposed Safety Board Actions**
-  Keep the issue area on Most Wanted List
-  Retain yellow designation:    Acceptable response – progressing slowly

## Require Restraint Systems

**for**
**Children Under Age 2**** **

## Safety Improvement Wanted

- Require all occupants be restrained during takeoff, landing and turbulence, and require infants and small children be restrained appropriately for their size        **A-95-51**

## NTSB Board MeetingAugust 2004

- Child restraint issue discussed in depth
- Board voted to keep issue on Most Wanted List
- Classified recommendation as ‘unacceptable response’

## FAA Response

- FAA withdrew rulemaking on child restraints, August 2005
- FAA told NTSB it will *not* require use of child restraints, October 2005

## Reduce Dangers to Aircraft

**Flying in Icing Conditions**

## Safety Improvements Wanted

- Research into effects of in-flight icing, including freezing rain and critical ice shapes  **A-98-92**
- Upgrade aircraft certification standards and operational procedures  **A-96-54, ****A-96-56, A-98-100**

## Recent Recommendations

- 11 recommendations and 1 safety alert related to icing in past two years
- Approach is a case-by-case basis

## Cessna 208B Caravan

- Single-engine turboprop airplane
- Several icing-related fatal accidents in last 6 years
- 4 recommendations issued in December 2004

## Cessna 208 – Moscow   November 19, 2005

- 8 fatal in accident on approach
- FDR equipped
- Resulted in 3 urgent recommendations
- 120 knots minimum airspeed
- Prohibit flight in icing conditions worse than      light icing
- Disengage autopilot in icing conditions
- All adopted by FAA

## Saab 340B     January 2, 2006

- Loss of Control Incident
- Departed controlled flight in icing conditions
- Lost 5,000 feet altitude
- Nearly inverted

## Saab 340B    January 2, 2006

- Resulted in 4 urgent recommendations
- Minimum airspeed
- Modify stall protection
- Ice detection
- Disengage autopilot in icing conditions
- FAA working with Saab and EASA to determine response
- FAA issued Safety Alert for operators

## Under Investigation: Cessna 560Pueblo, CO     February 16, 2005

- 8 fatalities
- Crashed on approach
- Atmospheric conditions conducive to icing
- Ice accretion was discussed on CVR
- Board meeting early next year

## Bombardier Challenger CL-600Montrose, CO     November 29, 2004

- 3 fatalities, 3 seriously injured
- Crashed during takeoff
- Flight crew failed to ensure the wings were free of ice or snow contamination accumulated while on ground
- Board issued alert to pilots regarding ground icing

## Recent Recommendations

- In the past two years:
- 11 recommendations
- 1 alert related to icing
- Recent recommendations address aircraft on case-by-case basis
- Most Wanted List addresses all airplanes

## FAA Recent Actions

- FAA issued NPRM
*Airplane Performance and Handling Characteristics in Icing Conditions*
- Results of research sponsored by FAA and NASA (as requested in A-98-92) are currently included in Appendix R of Advisory Circular   20-73A

## FAA - Recent Actions AC20-73A

## FAA Recent Actions and Limitations

- Also issued a proposed Advisory Circular (AC25.21-1X ) to provide methods to meet requirements of NPRM
- Both actions partially satisfy the intent of
- 	A-98-92
- Need to ensure full range of Appendix C, including large droplets, are included in determining shapes to be used in testing
- Will only apply to newly certificated airplanes

## Reduce Dangers to Aircraft Flying in Icing Conditions

| Timeliness Classification | RED |
| --- | --- |

**Proposed Safety Board Action**
-  Keep issue area on Most Wanted List
-  Retain red designation: Unacceptable response

## Improve Aviation Audio and Data Recorders andRequire Cockpit Video Recorders

## Retrofit 30 minutes to 2-hour CVRs

- Retrofit 30 minutes to 2-hour CVRs
- 10-minute backup power
- Dual redundant CVR/FDR
- 737 additional parameters
- Cockpit image recorders

## Safety Improvements Wanted

** **

**Accident Recorder Improvements**

**Safety Improvements Wanted**

- 2-hour cockpit voice recorder with battery back-up power  **A-99-16**
- Dual combination recorders  **A-99-17**
- Reliable aircraft electrical power  **A-99-18**

## FAA  Activity

** ****FDR Enhancement NPRM February 2005**
- Retrofit 2-Hour CVR
- Partial recorder independent power supply
- No mandatory dual redundant CVR/FDR requirement
**FAA continues to review comments **
**Final rule expected May 2007**

## Safety Improvements Wanted

**Additional Boeing 737**
**Flight Data Recorder Parameters**

**Safety Improvements Wanted**

-  Upgrades for 737 series aircraft  **A-99-28 and 29**

## Safety Improvements Wanted

**Cockpit Image Recorders**

**Safety Improvements Wanted**

- Adopt technical standard for image recorder   **A-99-59**
- Require image recorder in all Part 121/135 turbine aircraft not previously equipped with recorders ** A-03-64**
- 2-hour cockpit image recorder in larger transport category aircraft  **A-00-30 and 31**

## Video Recorder Update

**Video Recorder Update**

- Technical Standard Order issued July 2006
- FAA-NTSB-Industry follow on flight test
- MD helicopter image recorder

## Improve Audio and Data RecordersRequire Cockpit Image RecordersProposed Safety Board Action

| Timeliness Classification | RED |
| --- | --- |

**Improve Audio and Data Recorders****Require Cockpit Image Recorders****Proposed Safety Board Action**

- Keep issue area on Most Wanted List
- Retain red designation: Unacceptable response

## Reduce Accidents and Incidents Caused by Human Fatigue

## 1989 DOT Fatigue Recommendations

**1989 DOT Fatigue Recommendations**

**I-89-1****:** Research – Closed Acceptable
**I-89-2****:** Education – Closed Acceptable
**I-89-3****:** Hours of Service Regulations – Closed Superseded

## Safety Improvements Wanted

- Establish scientifically-based hours-of-service rules that set limits on work hours, provide predictable work and rest schedules, and consider circadian rhythms and human sleep and rest requirements
- 	**I-99-1**
- Modal recommendations to FRA, FMCSA, FAA, USCG, and PHMSA

## Aviation (Flight Crew)

**A-94-194, A-95-113, A-06-10**
- Flight and duty time limits set in 1938 and 1958
- FAA issued NPRM in 1995 to update flight/duty time regulations –  but no rule issued

## Aviation (Maintenance)

**A-97-71 **
- FAA has conducted research on fatigue in maintenance, but no rulemaking proposed

## Proposed Safety Board ActionAviation

| Timeliness Classification | RED |
| --- | --- |

**Proposed Safety Board Action****Aviation**

- Reclassify A-94-194 and A-95-113
- 	‘Closed – Unacceptable’
- Keep issue area on Most Wanted List
- Assign red timeliness designation: Unacceptable response

## Marine

**Marine**

**M-99-1**
- Work-hour limitations date to early 1900s
- International Maritime Organization amended regulations in 1995
- Coast Guard and Maritime Transportation Act
- Crew Endurance Management demonstration project

## Proposed Safety Board ActionMarine

- Keep issue area on Most Wanted List
- Assign yellow timeliness designation:
- 	Acceptable response - progressing slowly

| Timeliness Classification | YELLOW |
| --- | --- |

## Pipeline

**Pipeline**

**P-98-30, P-99-12**
- No Federal hours-of-service regulations exist for controllers of pipeline systems
- PHMSA Advisory Bulletin
- Public workshop on control room operations

## Proposed Safety Board ActionPipeline

- Keep issue area on Most Wanted List
- Assign yellow timeliness designation:
- 	Acceptable response – progressing slowly

| Timeliness Classification | YELLOW |
| --- | --- |

## Department of Transportation

**Department of Transportation**

**I-99-1**
- Require modal administrations to establish scientifically-based hours-of-service regulations
- DOT Human Factors Coordinating Committee Operator Fatigue Management (OFM) Program
- 2006 Safety Board recommendation to incorporate information similar to OFM in pilot training programs

## Keep issue area on Most Wanted List
Assign yellow timeliness designation:
	Acceptable response – progressing slowly

- Assign yellow timeliness designation:
- 	Acceptable response – progressing slowly

**Proposed Safety Board Action****U.S. DOT**

| Timeliness Classification | YELLOW |
| --- | --- |

## Implement Positive

**Implement Positive**
**Train Control Systems**

## Safety Improvements Wanted

- Facilitate development and implementation of positive train control systems that include collision avoidance, and
- Require implementation of positive train control on main line tracks, giving priority to high-risk corridors where commuter and intercity passenger railroads operate  **R-01-6**

## Human Factors Causes

-  Fatigue
-  Sleep apnea
-  Medication
-  Reduced visibility
-  Distractions

## Train Accidents

**Train Accidents**

**FRA reported accidents for 2005**
**203 head-on, rear-end, and side collisions**
**183 or 90% attributed to human factor causes**

## Accidents Under Investigation 

**Accidents Under Investigation**** **

- Lincoln, AL
- Anding, MS

- Chicago, IL
- Abington, PA

## FRA Action

- Final rule, effective June 2005, establishes standards for the development and use of processor-based signal and train control systems

## Positive Train Control Projects

**Positive Train Control Projects**

**Amtrak **
- 430 miles installed on Northeast Corridor
- 45 miles installed on Michigan Line
**New Jersey Transit**
- 23 miles of 540 miles installed
**North American Joint Positive Train Control  Project**
- 120 miles being installed between Chicago and St. Louis

## Positive Train Control Projects

**Positive Train Control Projects**

**Union Pacific Railroad**
- 333 miles in signaled territory
- 140 miles in dark territory
**Alaska Railroad**
-  611 miles under development

## Positive Train Control Projects

**Positive Train Control Projects**

**BNSF Railway**
- Centralia - Beardstown, IL
- 135 miles
-  Dallas / Fort Worth - Oklahoma City
- 167 miles
**Norfolk Southern Railway**** **
- Charleston - Columbia, SC
- 122 miles

## PTC Projects

**Amtrak ****–** Advanced Civil Speed Enforcement System, Incremental Train Control System
**New Jersey Transit** – Advanced Civil Speed Enforcement
**Union Pacific**** –** Communication Based Train Management
**Alaska Railroad** – Collision Avoidance System
**BNSF Railway** – Electronic Train Management System
**Norfolk Southern Railway**** **– Optimized Train Control

## Implement PositiveTrain Control SystemsProposed Safety Board Action

| Timeliness Classification | YELLOW |
| --- | --- |

**Implement Positive****Train Control Systems****Proposed Safety Board Action**

- Keep issue area on Most Wanted List
- Retain yellow designation:
-    Acceptable response – progressing slowly

## Improve Drug and Alcohol Testing of Crews
After Accidents

**After Accidents**

## Safety Improvements Wanted

- Clear post-accident collecting and testing procedures, responsibilities and time limits, and abstinence from alcohol**M-98-71, M-98-73, M-98-76, M-98-77, M-98-79, M-98-81**
- Task force to evaluate deficiencies in post- accident testing and implement program based on ‘lessons learned’**M-98-72**
- Breath and urine-testing devices on foreign ships in U.S. waters and U.S. oceangoing ships**M-98-75**

## NTSB Special Investigation ReportAlcohol and Drug Testing

- 1998 report cited 28 major marine accidents since *Exxon Valdez*
- Identified shortcomings in post-accident testing process

## Congressional Action

**1998**  Federal law requires the establishment of procedures to ensure post-accident alcohol testing within 2 hours, unless prevented by concerns for safety directly related to accident

**Coast Guard Action**

**2003  **Notice of proposed rulemaking on chemical testing following serious marine incidents
**2005**  Final rule published December 22, 2005

## Current Status

** **

**Current Status**

- 7 out of 8 recommendations closed with acceptable classifications
- M-98-76 remains open with unacceptable classification

## Improve Drug and Alcohol Testing of Crews After AccidentsProposed Safety Board Action

** **

**Improve Drug and Alcohol Testing of Crews After Accidents****Proposed Safety Board Action**

- Remove Safety Recommendation
- 	M-98-76 from Most Wanted list
- Remove issue area from Most Wanted List

## Improve the Safety of Motor Carrier Operations 

## Safety Improvements Wanted

- Change the way safety fitness ratings are determined so adverse vehicle and driver performance alone are sufficient to result in an overall unsatisfactory rating for the carrier  **H-99-6**

## Truck Fitness Safety Ratings

**Safety Fitness Factors**
- General
- Drivers
- Operations
- Vehicles
- Hazardous Materials
- Accidents

## Truck Fitness Safety Ratings

**Accident Factors**
- General
**Drivers**
- Operations
**Vehicles**
- Hazardous Materials
- Accidents

## FMCSA Actions

**FMCSA Actions**

- Under Comprehensive Safety Analysis  2010, developing new performance-based operational model
- Pilot testing of new rating system in fiscal year 2008
- Continue to develop standards to  measure overall safety of motor carrier operations

## Improve the Safety ofMotor Carrier OperationsProposed Safety Board Action

| Timeliness Classification | RED |
| --- | --- |

**Improve the Safety of****Motor Carrier Operations****Proposed Safety Board Action**

- Keep issue area on Most Wanted List
- Assign red designation:
-    Unacceptable response

## Prevent Medically Unqualified Drivers from Operating Commercial Vehicles

## Safety Improvements Wanted

- Develop comprehensive medical oversight program that addresses:
- Examiner qualifications
- Adequacy of regulations
- Non-regulatory guidance
- Review process
- Tracking mechanisms
- Enforcement and Reporting
-    	**H-01-17 thru H-01-24**

## FMCSA Actions

**FMCSA Actions**

- Establishment of Medical Review Board
- Survey for development of National Registry of Certified Medical Examiners
- NPRM to merge CDL/medical certificates – publication expected November 15, 2006

## FMCSA Actions Remaining

**FMCSA Actions Remaining**

- Only progress on H-01-19 (regulatory update)
- No measurable progress on other recommendations
- Current initiatives may be responsive

## Prevent Medically Unqualified Drivers from Operating Commercial VehiclesProposed Safety Board Action

| Timeliness Classification | RED |
| --- | --- |

**Prevent Medically Unqualified Drivers from Operating Commercial Vehicles****Proposed Safety Board Action**

- Reclassify H-01-17 and -20 ‘Open – Unacceptable’
- Keep issue area on Most Wanted List
- Change to red designation:  Unacceptable response

## Enhance Protection

**for Bus Passengers**

## Safety Improvements Wanted

- Roof strength requirements to provide maximum survival space  **H-99-50**
- Easy opening window and roof exits that stay open during evacuations **H-99-9**
- Occupant protection systems during impacts and rollovers  **H-99-47**
- Standard definitions for bus body types ** H-99-43**

## Slide 106

## New Orleans

**New Orleans**
**May 1999**

## NHTSA Actions

**2002**: No NHTSA-Industry consensus on vehicle safety standards
**2004-2006**: NHTSA – Transport Canada window   related research conducted
**2006:** NHTSA review of FMVSS 217
**2005-2008**: NHTSA bus data collection 		 mechanism devised

**1999:** Recommendations issued

## Enhance Protectionfor Bus PassengersProposed Safety Board Action

| Timeliness Classification | YELLOW |
| --- | --- |

**Enhance Protection****for Bus Passengers****Proposed Safety Board Action**

- Reclassify H-99-43 ‘Open – Acceptable Alternate’ and remove from Most Wanted List
- Keep issue area on Most Wanted List
- Retain yellow designation: Acceptable response – progressing slowly

## Most Wanted List

**Federal Issues**

**Vote to adopt full report**