Safety Report

Transportation Safety Databases

National 

Transportation 

Safety Board

Washington, D.C.

A

A

N TION

L TRA SPOR

ATIO

N

B OARD

SAF E T Y

N

T

E PLURIBUS UNUM 

NTSB/SR-02/02

PB2002-917004

Safety Report

Transportation Safety Databases

NTSB/SR-02/02

PB2002-917004 National Transportation Safety Board

Notation 7471 490 L’Enfant Plaza, S.W.

Adopted September 11, 2002 Washington, D.C. 20594
National Transportation Safety Board. 2002. Transportation Safety Databases. Safety Study NTSB/

SR-02/02. Washington, DC.

Abstract: The National Transportation Safety Board relies on many external databases when performing

accident investigations, safety studies, and special investigations. Most of these databases are sponsored

and operated by the modal administrations of the U.S. Department of Transportation (DOT). The Board's

ability to study important safety issues is often affected by poor data quality. The Board studied

transportation safety databases to evaluate data quality issues and to encourage improvements in this area.

The effort had four specific objectives: (a) highlight the value and potential uses of transportation safety

data; (b) describe some accident and incident databases commonly used by the Board; (c) summarize past

Board recommendations involving transportation data; and (d) evaluate Bureau of Transportation Statistics

(BTS) efforts to establish data quality standards, identify information gaps, and ensure compatibility

among the safety data systems maintained by the DOT.

The Safety Board's past recommendations indicate that exposure data are not adequately detailed to

support the analysis of risk factors for transportation accidents, reducing the ability of the Federal

government to understand safety problems and target safety resources. BTS efforts to identify information

gaps and to establish data quality standards are an important first step toward improving data quality. As a

result of this finding, the Board issued a recommendation to the BTS to develop a long-term program to

improve the collection of data describing exposure to transportation risk in the United States.

The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad, highway, marine,

pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through the Independent Safety Board

Act of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, study

transportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The Safety Board

makes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and

statistical reviews.

Recent publications are available in their entirety on the Web at <http://www.ntsb.gov>. Other information about available publications also

may be obtained from the Web site or by contacting:

National Transportation Safety Board

Public Inquiries Section, RE-51

490 L’Enfant Plaza, S.W.

Washington, D.C. 20594

(800) 877-6799 or (202) 314-6551

Safety Board publications may be purchased, by individual copy or by subscription, from the National Technical Information Service. To

purchase this publication, order report number PB2002-917004 from:

National Technical Information Service

5285 Port Royal Road

Springfield, Virginia 22161

(800) 553-6847 or (703) 605-6000

The Independent Safety Board Act, as codified at 49 U.S.C. Section 1154(b), precludes the admission into evidence or use of Board reports

related to an incident or accident in a civil action for damages resulting from a matter mentioned in the report. 
iii Safety Report

Contents

Acronyms and Abbreviations ........................................................................................................... v

Executive Summary ............................................................................................................................ vii

Chapter 1: Uses of Transportation Safety Data ........................................................................ 1

Surveillance ................................................................................................................................................... 2

Identification of Risk Factors ........................................................................................................................ 2

Development and Evaluation of Prevention Strategies ................................................................................. 4

Chapter 2: Overview of Transportation Safety Databases ................................................. 5

Aviation Databases ......................................................................................................................................... 6

Aviation Accident Database .................................................................................................................. 6

FAA Incident Data System .................................................................................................................... 6

Aviation Safety Reporting System ........................................................................................................ 7

Highway Databases ........................................................................................................................................ 8

Fatality Analysis Reporting System ...................................................................................................... 8

National Accident Sampling System/General Estimates System ......................................................... 8

National Accident Sampling System/Crashworthiness Data System ................................................... 9

Motor Carrier Management Information System .................................................................................. 9

Marine Databases ......................................................................................................................................... 10

Boating Accident Report Database ..................................................................................................... 10

Marine Information for Safety and Law Enforcement ........................................................................ 10

Pipeline Databases ....................................................................................................................................... 11

Hazardous Liquid Pipelines ................................................................................................................ 11

Natural Gas Gathering and Transmission Systems Incident Database ............................................... 11

Natural Gas Distribution Systems Incident Database ......................................................................... 12

Railroad Databases ...................................................................................................................................... 12

Rail Equipment Accident/Incident Report Database .......................................................................... 12

Highway–Rail Grade Crossing Incident Report Database .................................................................. 12

Railroad Injury and Illness Summary Database .................................................................................. 13

Intermodal Databases ................................................................................................................................... 13

Safety Management Information Statistics Database .......................................................................... 13

Hazardous Materials Information System Incident Database ............................................................. 14

Chapter 3: Previous Safety Recommendations ...................................................................... 15

Category I: Develop a New Database or Reporting System ........................................................................ 17

Category II: Modify an Existing Database and/or Reporting Form ............................................................ 19

Category III: Improve the Accuracy or Completeness of Information Submitted ...................................... 21

Category IV: Address Problems of Underreporting ..................................................................................... 23

Category V: Analyze or Disseminate Existing Data .................................................................................... 25

Chapter 4: Initiatives Sponsored by the Bureau of Transportation Statistics .......... 27

Initiatives Launched Under ISTEA ............................................................................................................. 27

Increased Momentum Under TEA-21 ......................................................................................................... 28

Crafting a Long-Term Plan .......................................................................................................................... 30

Implementing the Safety Data Action Plan ................................................................................................. 32
Contents iv Safety Report

Chapter 5: Analysis ........................................................................................................................... 34

Conclusions ............................................................................................................................................ 37

Recommendations ............................................................................................................................... 38

Appendixes:

A: Major Federal Safety and Activity Databases ................................................................................. 39

B: Data Recommendations by Mode and Topic .................................................................................. 41
v Safety Report

Acronyms and Abbreviations

AIDS Accident/Incident Data System

ASRS Aviation Safety Reporting System

ATC air traffic control

ATS American Travel Survey

BARD Boating Accident Report Database

BTS Bureau of Transportation Statistics

CAB Civil Aeronautics Board

CAMI Civil Aerospace Medical Institute

CDC U.S. Centers for Disease Control

CFR Code of Federal Regulations

DOT U.S. Department of Transportation

FAA Federal Aviation Administration

FAA-AFS Federal Aviation Administration Flight Standards Service

FAR Federal Aviation Regulations

FARS Fatality Analysis Reporting System

FHWA Federal Highway Administration

FMCSA Federal Motor Carrier Safety Administration

FR Federal Register

FRA-RRS Federal Railroad Administration’s Office of Safety Analysis

FTA Federal Transit Administration

GPRA Government Performance and Results Act of 1993

GSA General Services Administration

GXIR Highway–Rail Grade Crossing Incident Report Database

HMIS Hazardous Materials Information System

ISTEA Intermodal Surface Transportation Efficiency Act

ITDB Intermodal Transportation Database

MCMIS Motor Carrier Management Information System

MINMOD Marine Investigations Module

MISLE Marine Information for Safety and Law Enforcement

MSIS Marine Safety Information System

MTB Materials Transportation Bureau

NASA National Aeronautics and Space Administration
vi Safety Report

NASDAC National Aviation Safety Data Analysis Center

NASS/CDS National Accident Sampling System/Crashworthiness Data System

NASS/GES National Accident Sampling System/General Estimates System

NCIPC National Center for Injury Prevention and Control

NHTS National Household Travel Survey

NHTSA National Highway Traffic Safety Administration

NMAC near-midair collision

NMACS Near Midair Collision System

NPRM notice of proposed rulemaking

NPTS Nationwide Personal Transportation Survey

NRC National Research Council

NTAD National Transportation Atlas Database

NTD National Transit Database

NTL National Transportation Library

NTSB National Transportation Safety Board

OE operational error

PFD personal flotation device

RAIR Rail Equipment Accident/Incident Report Database

RSPA Research and Special Programs Administration

RSPA-OHM Research and Special Programs Administration’s Office of 

Hazardous Materials Safety

RSPA-OPS Office of Pipeline Safety

SAMIS Safety Management Information Statistics Database

SDR service difficulty report

TEA-21 Transportation Equity Act for the 21st Century

TWA Trans World Airlines

USC United States Code

USCG U.S. Coast Guard

USCG-MSEP U.S. Coast Guard’s Office of Marine Safety and Environmental 

Protection

UNISHIP Unified Shippers Enforcement Data System
vii Safety Report

Executive Summary

The National Transportation Safety Board relies on many external databases when

performing accident investigations, safety studies, and special investigations. Most of

these databases are sponsored and operated by the modal administrations of the U.S.

Department of Transportation (DOT). The Board’s ability to study important safety issues

is often affected by poor data quality. The Board studied transportation safety databases to

evaluate data quality issues and to encourage improvements in this area. The effort had

four specific objectives: (a) highlight the value and potential uses of transportation safety

data; (b) describe some accident and incident databases commonly used by the Board; (c)

summarize past Board recommendations involving transportation data; and (d) evaluate

Bureau of Transportation Statistics (BTS) efforts to establish data quality standards,

identify information gaps, and ensure compatibility among the safety data systems

maintained by the DOT.

The Safety Board’s past recommendations indicate that exposure data are not

adequately detailed to support the analysis of risk factors for transportation accidents,

reducing the ability of the Federal government to understand safety problems and target

safety resources. BTS efforts to identify information gaps and to establish data quality

standards are an important first step toward improving data quality. As a result of this

finding, the Board issued a recommendation to the BTS to develop a long-term program to

improve the collection of data describing exposure to transportation risk in the United

States.

1 Safety Report

Chapter 1

Uses of Transportation

Safety Data

Transportation safety databases are used by Federal, State, and local government

organizations to monitor transportation accidents and to develop programs for improving

safety. The National Transportation Safety Board (NTSB) relies on many of these external

databases when performing accident investigations, safety studies, and special

investigations. The most recent directory of the U.S. Department of Transportation (DOT)

data sources, published in 1996 by the Bureau of Transportation Statistics (BTS), lists 173

different databases and data collection forms.1 Among these data sources, the DOT modal

administrations maintain over 40 major databases containing accident, incident, and

related transportation activity data.2 A recent data quality review, requested by Congress

and performed by the BTS, concluded that improvements to existing DOT data systems

were needed.3

The Safety Board initiated this safety study on transportation safety databases to

evaluate data quality issues and to encourage improvements in this area. The study has the

following four specific objectives:

1. highlight the value and potential uses of transportation safety data;

2. describe the primary accident and incident databases used by the Board;

3. summarize past Board recommendations citing deficiencies in existing data;

and

4. evaluate government efforts to establish data quality standards, identify

information gaps, and ensure compatibility among DOT safety data systems.

Transportation safety data are valuable because they inform us about the risk of

harmful outcomes associated with transportation operations. Many different approaches

can be applied to the analysis and management of risk. The U.S. Centers for Disease

Control (CDC) National Center for Injury Prevention and Control (NCIPC) advocates a

data-driven approach that is quite relevant to the field of transportation safety.4

 This

1 Bureau of Transportation Statistics, Directory of Transportation Data Sources (Washington, DC:

U.S. Department of Transportation, BTS, 1996).

2 Bureau of Transportation Statistics, Safety Data Action Plan, (Washington, DC: U.S. Department of

Transportation, BTS, 2000).

3 Bureau of Transportation Statistics, Transportation Statistics Beyond ISTEA: Critical Gaps and

Strategic Responses (Washington, D.C: U.S. Department of Transportation, BTS, 1998).

4 National Center for Injury Prevention and Control, “Research Agenda” (Washington, DC: Centers

for Disease Control, U.S. Department of Health and Human Services, June 2002).
2 Safety Report

approach is grounded in the science of epidemiology5 and consists of three stages:

surveillance, identification of risk factors, and development and evaluation of prevention

strategies.

Surveillance

The principal function of most transportation safety databases maintained by the

Federal government is to collect information that can be used for surveillance.

Surveillance is the recording and cataloguing of harmful events that result from

transportation operations. These harmful events can include property damage, human

injury, or pollution. In a transportation context, surveillance data are used for trend

analysis and for studying the relation of harmful events to basic characteristics of people,

vehicles, and environments. Surveillance data are used to answer questions such as:

• What kinds of harmful events result from transportation activity?

• What proportion of transportation operations result in a harmful outcome?

• What kinds of vehicles are involved?

• What kinds of people are involved?

• How, when, and where do these harmful events occur?

Most Federal transportation safety surveillance databases have evolved

independently within the different Federal agencies responsible for overseeing safety in

different modes of travel. As a result, the databases have different reporting requirements,

data coding conventions, and levels of sophistication.6 Most “accident” or “incident”

databases record events resulting in injury, property damage, or pollution. In some modes,

however, surveillance databases have also been developed to monitor the occurrence of

near-miss events. Near-miss databases are designed to record and catalogue occurrences in

which a harmful event nearly occurred and they are particularly useful for analyzing

safety issues associated with rare events (for example, commercial jet accidents).

Identification of Risk Factors

Monitoring the incidence and severity of transportation accidents and injuries does

not, by itself, lead to the improvement of transportation safety. Safety improvement results

5 “Epidemiology is the field of public health and medicine that studies the incidence, distribution, and

etiology of disease in human populations. The purpose of epidemiology is to better understand disease

causation and to prevent disease in groups of individuals.” (Reference Manual on Scientific Evidence

[Washington, DC: Federal Judicial Center, 2000] 333.)

6 The Safety Board maintains the Federal government’s database of aviation accidents. The DOT

maintains aviation incident and activity databases and transportation safety databases in the nonaviation

modes.

Chapter One
3 Safety Report

from influencing the factors that affect the likelihood of harmful outcomes. Accident

investigations document the circumstances of individual accidents, often pointing out one

or more factors that are seen as causal to the event of interest. For example, an aircraft

structure may have failed, a driver may have fallen asleep, a recreational boater may have

been going too fast, or a passenger may not have worn a life jacket. Sometimes an

accident investigation pursues the notion of cause back to a company’s operating

procedures or to a weakness in existing safety regulations. However, some factors

influencing accident likelihood can be difficult to observe in the context of a single

accident. These relationships emerge only when the characteristics of many accidents are

considered together and compared with the characteristics of similar nonaccident

operations. Understanding these patterns depends on the identification and objective

analysis of risk factors in groups of transportation accidents.

Risk factors are characteristics of people, vehicles, or environments that are related

to the increased incidence of transportation crashes, injuries, or other harmful outcomes.7

Statistical techniques can be used to analyze the strength of the relation between specific

risk factors and harmful outcomes. Because many different risk factors can affect the

likelihood of an accident, a common framework can be quite useful for identifying

potential risk factors and organizing them for analysis. Some injury epidemiologists use a

schematic approach to the identification of risk factors called the Haddon Matrix.8

 The

Haddon Matrix organizes risk factors according to a three-phase conceptualization of the

event sequence (pre-crash, crash, post-crash) as it relates to people, vehicles, and

environments (table 1–1).9 This approach is advantageous because it promotes

consideration of a wide array of factors that can influence the likelihood of a harmful

outcome in a format that is easy to interpret. The Haddon Matrix has been credited with

broadening the focus of highway safety efforts from a preoccupation with accident

prevention to an increased emphasis on the crashworthiness of vehicles and the quality of

emergency medical care.10

7 Pipeline characteristics, rather than vehicle characteristics, are of interest in the pipeline mode.

8 “Injury epidemiology is a young scientific field with a theoretical basis within the wider framework

of epidemiology. This new discipline has focused on the development of epidemiological tools to identify

problems, define their extent, and determine causative factors that are amenable to intervention. An equally

important objective has been to develop evaluation methods to determine the effectiveness of

countermeasures.” (National Research Council, Commission on Life Sciences, Injury in America: A

Continuing Public Health Problem [Washington, DC: National Academy Press, 1985] 25.)

9 William Haddon, a public health physician who served as the first Administrator of the National

Highway Traffic Safety Administration (NHTSA), developed this model.

10 Allan F. Williams, “The Haddon Matrix: Its Contribution to Injury Prevention and Control,”

Proceedings, 3rd National Conference on Injury Prevention and Control (Queensland, Australia: University

of Queensland, 2000) 15-16.

Chapter One
4 Safety Report

Development and Evaluation 

of Prevention Strategies

Prevention strategies vary considerably from mode to mode, because many of the

factors affecting accident likelihood are mode specific. In general, prevention strategies

seek either to minimize the likelihood of a particular kind of harmful event (for example, a

crash), or to minimize its impact (in terms of property damage, injury, or environmental

pollution). For example, the Federal Aviation Regulations (FAR) prohibit pilots from

operating aircraft under visual flight rules when weather conditions cause flight visibility

to decrease below certain levels (Title 14 Code of Federal Regulations (CFR) Part

91.155). Pilots who wish to fly under such conditions are required to receive specialized

training and to fly under instrument flight rules. This strategy aims to reduce the

likelihood of crashes resulting from pilot spatial disorientation. The FARs also prohibit

pilots from operating aircraft without an approved automatic type emergency locator

transmitter, which can be used to locate an aircraft in the event of a crash (14 CFR

91.207). This strategy aims to minimize the consequences of injuries suffered by aircraft

occupants by reducing the time it takes for rescue crews to locate a downed aircraft. Safety

data can be useful for evaluating the effectiveness of existing preventative strategies such

as these. However, data must be relevant, accurate, and detailed if they are to be used for

this purpose.

To summarize, a scientific approach to controlling the harmful outcomes

associated with transportation operations depends on access to relevant, accurate, detailed

data. These data should foster a broad understanding of the losses and consequences

stemming from transportation operations, the risk factors related to these outcomes, and

the effectiveness of preventive measures. When such data are collected and made

available for analysis, safety resources can be more effectively targeted, and the

government’s ability to ensure the safety of the traveling public is enhanced.

Table 1–1. The Haddon matrix, with example risk factors from the highway mode. 

 Risk factor 

Phase Human/Host Agent/Vehicle Physical environment 

Pre-crash Driver intoxication Poor visibility from inside 

the vehicle 

Narrow road, poor lighting, 

and sharp curves 

Crash Lack of restraint use Reaction of vehicle 

structures to impact forces 

Hard structures adjacent to 

the roadway 

Post-crash Hemorrhaging High difficulty and cost to 

repair vehicle 

Remote area 

Source: Adapted from information provided in W. Haddon, Jr., “Approaching the Reduction of Road Losses—

Replacing Guesswork With Logic, Specificity and Scientifically Determined Fact,” Paper presented at the National 

Road Safety Symposium, Canberra, Australia, 1972. 

Chapter One
5 Safety Report

Chapter 2

Overview of Transportation 

Safety Databases

The BTS has identified many transportation safety databases in its various printed

and on-line publications. Some of the major safety databases identified by the BTS are

listed in appendix A. This chapter discusses the primary accident and incident databases

used by the Safety Board (table 2–1).

Table 2–1. Databases reviewed for the study. 

Mode of transportation 

and database name 

Operating 

agency 

Aviation: 

Aviation Accident Database NTSB 

Accident/Incident Data System (AIDS) FAA 

Aviation Safety Reporting System (ASRS) FAA/NASA 

Highway: 

Fatality Analysis Reporting System (FARS) NHTSA 

National Accident Sampling System/General Estimates System (NASS/GES) NHTSA 

National Accident Sampling System/Crashworthiness Data System (NASS/CDS) NHTSA 

Motor Carrier Management Information System (MCMIS) FMCSA 

Marine: 

Boating Accident Report Database (BARD) USCG 

Marine Information for Safety and Law Enforcement (MISLE) USCG 

Pipeline: 

Hazardous Liquid Pipelines Accident Database RSPA 

Natural Gas Gathering and Transmission Systems Incident Database RSPA 

Natural Gas Distribution Systems Incident Database RSPA 

Rail: 

Rail Equipment Accident/Incident Report (RAIR) Database FRA 

Highway–Rail Grade Crossing Incident Report (GXIR) Database FRA 

Railroad Injury and Illness Summary Database FRA 

Intermodal: 

Safety Management Information Statistics (SAMIS) Database FTA 

Hazardous Materials Information System (HMIS) Incident Database RSPA 

FAA = Federal Aviation Administration; FMCSA = Federal Motor Carrier Safety Administration; FRA = Federal Railroad 

Administration; FTA = Federal Transit Administration; NASA = National Aeronautics and Space Administration; NHTSA = 

National Highway Traffic Safety Administration; NTSB = National Transportation Safety Board; RSPA = Research and 

Special Programs Administration; USCG = United States Coast Guard. 
6 Safety Report

Information describing each database was obtained from a variety of printed

sources.11 In addition, the managers of each database were interviewed to obtain

additional information and to learn about scheduled improvements to each system. The

following discussions identify the agency responsible for day-to-day operations, general

nature of information stored in each database, reporting procedures, year established,

annual records added, frequency of update, and means of dissemination for selected

transportation databases.

Aviation Databases

Aviation Accident Database

The National Transportation Safety Board maintains the Aviation Accident

Database, which contains the probable cause and other data describing (a) all civil aviation

accidents occurring in the United States and its territories; (b) government public use

accidents occurring under certain conditions; (c) accidents occurring in foreign states

involving civil aircraft of U.S. registry or manufacture or a U.S.-based operator; and (d)

some nonaccident events (aviation incidents) that could affect the safety of U.S. aircraft

operations (event occurrences).12 Data entered into the database come directly from Safety

Board investigation records. Board investigators enter accident/incident data using an

automated data entry system. Newly entered information is uploaded daily from regional

and field offices via the Board’s wide area computer network. Established in 1962, the

database underwent major revisions in 1981 and 1982. On January 1, 2001, the database

was revised again and updated to a relational database format. Additionally, a new

software program was developed to facilitate data entry. The current version of the

database describes accidents that occurred between 1982 and the present. Approximately

2,000 new accident records are added to the database each year. The Board publishes

annual statistical summaries of the data, for both commercial and general aviation, and

makes these summaries available via the Internet and other sources. Narrative reports can

be found on the Board’s Web site, where an on-line search tool is provided

(http://www.ntsb.gov).

FAA Incident Data System

The Federal Aviation Administration’s (FAA) Flight Standards Service (FAAAFS) maintains the FAA Accident/Incident Data System (AIDS). The FAA AIDS

database contains incidents only, using the Safety Board’s Aviation Accident Database as

the primary source for accident information. Because of its broad reporting criteria, the

AIDS database contains many different kinds of incidents, ranging from airport events

involving collisions between aircraft and catering trucks to the loss of a cabin door in

11 These included (a) Bureau of Transportation Statistics, Directory of Transportation Data Sources,

(Washington, DC: U.S. Department of Transportation, BTS, 1996); and (b) Source and Accuracy Statements

maintained by the Bureau of Transportation Statistics.

12 Title 49 CFR 831.2 contains more detailed criteria for reporting aviation accidents and incidents.

Chapter Two
7 Safety Report

flight. The database does not contain reports of near-midair collisions, which are handled

through separate reporting procedures and are contained in a separate database called the

Near Midair Collision System (NMACS). Operators, airport personnel, and air traffic

controllers inform FAA inspectors of aviation incidents. FAA inspectors investigate the

incidents and submit data on standardized forms (FAA form 8020-5). The incident data

system has been in use since 1974, although commercial aviation incidents were not

included until 1978. Thousands of incidents are entered into the AIDS database each year.

The FAA currently does not publish an annual statistical summary of AIDS data. The

FAA’s Office of System Safety does, however, provide public Internet access to

abbreviated incident reports with an on-line search tool for locating incident records on its

Web site. The FAA’s publicly accessible data clearinghouse at its headquarters office, the

National Aviation Safety Data Analysis Center (NASDAC), offers more advanced search

capability and data access.

Aviation Safety Reporting System

The Aviation Safety Reporting System (ASRS) was established by a memorandum

of agreement between the FAA and the National Aeronautics and Space Administration

(NASA). The FAA funds the database, NASA Ames Research Center manages it, and

Battelle Corporation’s ASRS division handles the processing and analysis of reports. The

ASRS is a confidential reporting system containing operator-submitted narratives

describing events or conditions related to the safety of flight. Individuals who submit

reports are granted limited immunity from enforcement action on the part of the FAA. The

system is designed primarily as an early warning system for the FAA and for participants

in the National Airspace System. Pilots, air traffic controllers, flight attendants,

mechanics, and ground personnel are encouraged to submit reports after witnessing any

event during which they feel aviation safety was compromised. This information is used to

detect and correct unsafe conditions. However, because the reports are mostly narrative,

statistical analysis is difficult. Because of resource limitations, ASRS staff store only a

fraction of the 30,000 reports submitted each year. A representative sample of reports,

approximately 10 percent of the total, is entered in the database. Analysts examine the

remaining reports and retain any they believe describe significant issues. These reports are

coded differently from the randomly selected cases, so the two types of cases can be

distinguished. In total, about one-third of ASRS submissions are retained. Created in

1975, ASRS data are available for 1983 to the present. NASA publishes a monthly

newsletter, ASRS Callback, which highlights recent reports addressing safety issues of

general importance. The FAA’s Office of System Safety provides the capability to search

ASRS database records on line. Neither the FAA nor NASA publish an annual statistical

summary of ASRS reports.

Chapter Two
8 Safety Report

Highway Databases

Fatality Analysis Reporting System

The National Highway Traffic Safety Administration’s (NHTSA) National Center

for Statistical Analysis maintains the Fatality Analysis Reporting System (FARS). The

FARS contains data describing all fatal accidents occurring on public roads in the United

States. Data included in the FARS database are collected by State and local police officers,

coroners, emergency medical services, and State motor vehicle administrations. NHTSA

funds 125 data collectors employed by the motor vehicle authorities of the States. These

collectors obtain data from the sources listed above and encode relevant information using

data entry programs developed by NHTSA. During the first half of each calendar year,

data describing all fatal accidents that occurred during the previous year are transmitted

electronically to NHTSA headquarters. More than a dozen full- and part-time NHTSA

employees run automated checks at NHTSA headquarters, looking for errors in the incoming reports, and working to correct any that are found. The FARS was established in 1975.

Data describing approximately 40,000 fatal accidents are added to the FARS annually.

Official data files are released once each year. NHTSA publishes an annual summary of

FARS data,13 and its Web site provides an on-line search capability.

National Accident Sampling System/

General Estimates System

NHTSA’s National Center for Statistical Analysis maintains the National Accident

Sampling System/General Estimates System (NASS/GES). The NASS/GES contains an

annual sample of police-reported traffic crashes in the United States, which is used to

estimate the number of U.S. traffic accidents and their injury outcomes. Unlike the FARS,

which only contains data describing fatal accidents, the NASS/GES contains data on both

fatal and nonfatal accidents. Data contained in the NASS/GES are gathered using a cluster

sampling approach. Each year, about 400 police jurisdictions are selected for visits by

NHTSA-contracted data collectors. Data processing contractors code information from

police accident reports into an electronic file using NHTSA software. These records are

sent to one of NHTSA’s regional data centers for quality review and processing. Police

jurisdictions are selected using a weighted sampling procedure. Reports within each

jurisdiction are selected using a sampling procedure that ensures that important but

infrequent kinds of accidents are adequately represented in the sample. Mathematical

weights are assigned to each record to reflect the probability of selection so that national

estimates can be made.14 The NASS/GES was created in 1988. More than 50,000 accident

records are recorded in the database each year. Official data files are released once each

year. NHTSA publishes annual summaries of the records contained in the NASS/GES.

13 National Highway Traffic Safety Administration, Traffic Safety Facts (Washington, DC: Department

of Transportation, NHTSA.)

14 NHTSA’s NASS/GES “Analytical User’s Manual,” 1988–1997.

Chapter Two
9 Safety Report

National Accident Sampling System/

Crashworthiness Data System

NHTSA’s National Center for Statistical Analysis also maintains the National

Accident Sampling System/Crashworthiness Data System (NASS/CDS). The NASS/CDS

was designed to provide detailed information about the crashworthiness of specific

models of passenger vehicles and the injuries sustained by their occupants. To qualify for

investigation and inclusion in the NASS/CDS, the crash must result in the towing of at

least one vehicle from the crash scene. Special crash investigators, contracted by the

NHTSA, collect NASS/CDS crash data on a continuous basis from police accident

reports, vehicle and on-scene inspections, medical examiner’s and coroner’s reports,

emergency room and hospital records, driver and vehicle occupant interviews, and witness

interviews. Over 100 NASS/CDS investigators divided into 24 field research teams

conduct in-depth investigations of a sample of police-reported crashes and enter the data

by computer. Completed records are reviewed by analysts at NHTSA headquarters, and

complete annual data sets are delivered to the John A. Volpe National Transportation

Systems Center in Cambridge, Massachusetts. The sampling procedure used to select

police jurisdictions is similar to that used for the NASS/GES. However, the report

sampling process is designed to ensure adequate representation of accidents within

predefined categories. Sampling strata include: (a) type and model year of vehicle, (b)

severity of injury, (c) transport of victims to a medical facility, (d) overnight

hospitalization, and (e) tow status of the accident vehicles. Mathematical weightings are

assigned to each record to reflect the probability of selection so that national estimates can

be made based on the sample of accidents contained in the NASS/CDS. Approximately

5,000 police-reported crashes are investigated and included in the NASS/CDS each year.

Official data files are released once each year. NHTSA publishes reports summarizing

NASS/CDS data every 3 years. An on-line query system is provided through NHTSA’s

Web site.

Motor Carrier Management Information System

The Federal Motor Carrier Safety Administration’s (FMCSA) Analysis Division

maintains the Motor Carrier Management Information System (MCMIS), which contains

census, crash, inspection, enforcement, and compliance review information. Accidents

contained in the MCMIS crash data involve at least one truck or bus. In addition to this

requirement, each accident must result in at least one of the following outcomes: (a) a

fatality, (b) at least one injury requiring transport to a medical facility, or (c) damage

requiring that at least one vehicle be towed from the accident scene. Created in 1989, the

MCMIS contains data gathered from police accident reports by State agencies (the agency

varies from State to State) which are transferred electronically to the FMCSA for inclusion

in the MCMIS. Nearly 100,000 accident records are added to the MCMIS each year. Data

summaries from the MCMIS are presented in combination with other information from

the NASS/GES and the FARS in the annual Large Truck Crash Overview published by the

FMCSA. The FMCSA is developing an on-line query system for users of MCMIS data.

Anticipated completion date for the query system is September 3, 2002.

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10 Safety Report

Marine Databases

Boating Accident Report Database

The U.S. Coast Guard’s (USCG) Office of Boating Safety maintains the Boating

Accident Report Database (BARD), which contains data on recreational boating accidents

occurring in State waters. Title 33 CFR 173.55 requires that boat owners and operators

report accidents involving a death, injury requiring medical care beyond first aid, or more

than $500 in property damage to the State boating law administrator’s office. State boating

law officials determine whether an event meets the criteria for inclusion in the BARD, and

the operator reports are sometimes supplemented by findings from State investigations.

State boating law offices enter and transmit data records electronically to the Coast Guard

using custom-built software. The BARD system was created in 1995, and it superseded a

database that contained data on recreational boating accidents that had occurred between

1969 and 1994. Data for roughly 8,000 new accidents are added to the BARD each year.

The Coast Guard publishes an annual statistical summary of BARD data.

Marine Information for Safety and Law Enforcement

The Coast Guard’s Office of Marine Safety and Environmental Protection (USCGMSEP) maintains the Marine Information for Safety and Law Enforcement (MISLE)

information system. One module of the MISLE, the Marine Casualty and Pollution

Database, contains data describing all safety-related investigations involving commercial

vessels operating in U.S. territorial waters or U.S.-registered commercial vessels

operating elsewhere in the world. Investigations are initiated for events resulting in any of

the following: (a) one or more deaths, (b) one or more injuries resulting in substantial

impairment of any body part or function, (c) a fire causing property damage exceeding

$25,000, (d) an oil spill exceeding 200 barrels, or (e) “any other injuries, casualties,

accidents, complaints of unsafe working conditions, fires, pollutions, and incidents the

Officer in Charge, Marine Inspection deems necessary to promote the safety of life or

property or protect the marine environment.”15 A vessel’s “owner, agent, master, operator,

or person in charge” is responsible for notifying the Coast Guard when a commercial

vessel is involved in a reportable accident or incident. Computerized data, entered by

Coast Guard staff, are reviewed by front-line supervisors and then transmitted to the

USCG-MSEP for inclusion in the MISLE safety module. Casualty and pollution data are

available, in one form or another, from 1975 to the present. The MISLE was implemented

in December 2001. Previously, data describing investigations of accidents or incidents

involving commercial vessels were stored in the Marine Investigations Module

(MINMOD) of the Marine Safety Information System (MSIS). Commercial vessel

casualties, injuries, and deaths prior to 1992 can be found in the CASMAIN database. In

the year 2000, approximately 17,000 casualty and 8,000 pollution events were added to

the MISLE (then MSIS). MISLE data summaries describing oil spills involving

commercial vessels are integrated into a number of Coast Guard publications. The Coast

Guard does not currently publish annual summaries of commercial marine casualties or

vessel losses.

15 Title 46 CFR Subpart 4.05, “Notice of Marine Casualty and Voyage Records.”

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11 Safety Report

Pipeline Databases

Hazardous Liquid Pipelines

The Research and Special Programs Administration’s (RSPA) Office of Pipeline

Safety (OPS) maintains the Hazardous Liquid Pipelines Accident Report database, which

contains data describing accidents involving hazardous liquid pipelines.16 To be

reportable, an event must result in (a) an explosion or fire not intentionally set by the

operator, (b) a loss of 5 or more gallons of hazardous liquid or carbon dioxide, excepting

some spills under 5 barrels that do not cause water pollution or that result from

maintenance activity, (c) death of any person, (d) personal injury necessitating

hospitalization, or (e) estimated property damage, including cleanup, recovery, value of

lost product, and damage to property exceeding $50,000.17 Following an accident, pipeline

operators are required to submit a report to RSPA (DOT form 7000-1) as soon as

practicable, but not more than 30 days after the event. Reports are reviewed for accuracy

and completeness by RSPA staff and entered into a database monthly. The database was

established in 1970 and was revised in 1986 and 2002. Before 2002, between 80 and 250

new accident records were added to the database annually. In January 2002, RSPA

reduced the threshold for reporting hazardous liquid pipeline accidents from 50 barrels to

5 gallons or 5 barrels, depending on the circumstances of the spill.18 As a result of this

change, the total number of hazardous liquid pipeline accidents reported in 2002 will be

much higher than the number reported in prior years. RSPA publishes annual tables

summarizing hazardous liquid pipeline accidents on the Internet.

Natural Gas Gathering and 

Transmission Systems Incident Database

RSPA-OPS also maintains the Natural Gas Gathering and Transmission Systems

Incident Database, which contains data describing incidents involving natural gas

gathering and transmission pipelines.19 A release of gas from a liquefied natural gas

facility is reportable if it results in (a) death or injury requiring in-patient hospitalization,

(b) estimated property damage, including cost of gas lost, of $50,000 or more, (c)

emergency shutdown of a transmission facility, or (d) an event that is “significant” in the

view of the pipeline operator (49 CFR Ch. 1, Section 191.3). Incident data are collected by

pipeline operators and submitted directly on RSPA form 7100.2 to RSPA-OPS for

database entry. Reports are reviewed for accuracy and completeness by RSPA staff. The

database was revised in 1984 and again in 2001. Data describing 50 to 100 pipeline

incidents are added to the Natural Gas Gathering and Transmission Systems Incident

16 Based on RSPA form F 7100.1. Hazardous liquid pipelines carry petroleum, petroleum products, or

anhydrous ammonia.

17 These requirements are paraphrased; precise language is contained in 49 CFR 195.50.

18 Details are given in 49 CFR 195.50.

19 Gas pipelines are classified according to function. Gathering lines transport gas from a production

facility to a transmission line or processing facility, transmission lines transport gas to distribution centers,

and distribution lines transport gas to customers.

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12 Safety Report

Database each year. Summary tables are published annually by RSPA and made available

on the Internet.

Natural Gas Distribution Systems Incident Database

RSPA-OPS also maintains the Natural Gas Distribution Systems Incident

Database, which contains data describing incidents associated with natural gas distribution

pipelines. Reporting requirements for natural gas distribution pipelines are the same as

those for gathering and transmission pipelines. Incident data are collected by pipeline

operators and submitted directly on RSPA form 7100.1 to RSPA-OPS for database entry.

The database, last revised in 1984, is currently being redesigned to effect reporting for

2003. Data describing between 80 and 200 new gas distribution incidents are added to the

Natural Gas Distribution Systems Incident Database each year. Summary tables are

published annually by RSPA-OPS and made available on the Internet.

Railroad Databases

Rail Equipment Accident/Incident Report Database

The Federal Railroad Administration’s (FRA) Office of Safety Analysis (FRARRS) maintains the Rail Equipment Accident/Incident Report (RAIR) Database. This

database contains information describing collisions, derailments, fires, explosions, or

other events involving the operation of railroad on-track equipment, signals, track, or track

equipment (standing or moving) that result in damage greater than the annual dollar value

serving as a reporting threshold ($6,700 for calendar year 2002) (49 CFR Ch. 2, Section

225.19). Rail operators submit rail accident reports monthly to a Federal contractor using

standardized forms (FRA form 6180.54). The contractor reviews the accident reports,

enters them into the RAIR database, and finalizes each annual data file by the spring of the

following calendar year. The RAIR database was established in 1975. Between 2,500 and

3,000 new records are added to the RAIR database each year. The RAIR data are

summarized in an annual FRA-RRS publication, Railroad Safety Statistics Annual Report,

and an on-line search capability is provided on the FRA’s Web site.

Highway–Rail Grade Crossing Incident 

Report Database

The FRA-RRS also maintains the Highway–Rail Grade Crossing Incident Report

(GXIR) Database, which contains data describing impacts between railway equipment and

highway users. Any contact between railway equipment and a highway user, or a highway

user’s vehicle, qualifies for inclusion in the database; there is no minimum injury or

damage threshold (49 CFR Ch. 2, Section 225.19). Operators submit reports monthly on

FRA form 6180.57 to a contractor working for the FRA. Where reported damage exceeds

the RAIR reporting threshold, a record is created in both the GXIR and the RAIR

databases. Like the RAIR database, the GXIR was established in 1975. More than 3,000

incidents are added to the GXIR database each year. The GXIR data are also summarized

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in an annual FRA-RRS publication, Railroad Safety Statistics Annual Report, and an online search capability is provided on the FRA’s Web site.

Railroad Injury and Illness Summary Database

The FRA-RRS also maintains the Railroad Injury and Illness Summary Database,

which contains, among other things, data describing railroad employee injuries and deaths

sustained during events that do not qualify for inclusion in either the RAIR or the GXIR

database. The Railroad Injury and Illness Summary Database is the primary source of data

for railroad employee and railroad trespasser injuries and fatalities. To be reportable,

injury or death must be sustained during the operation of a railroad. Additional criteria

require that injuries or illnesses included in the database: (a) require medical treatment

other than first aid, (b) result in a day away from work, (c) cause temporary restriction of

work or motion, (d) cause the employee to be transferred to another job, (e) result in

termination of the employee, or (f) cause the employee to lose consciousness. Railroad

injury/illness reports are submitted to an FRA contractor monthly. Annual data files are

finalized by the spring of the following calendar year and delivered to the FRA-RRS. The

Railroad Injury and Illness Summary Database was established in 1975. Approximately

13,000 records are added to the database each year. The data are summarized in an annual

FRA-RRS publication, Railroad Safety Statistics Annual Report, and are searchable on

line.

Intermodal Databases

Safety Management Information Statistics Database

The Federal Transit Administration’s (FTA) Office of Safety and Security, located

within the Office of Program Management, maintains the Safety Management Information

Statistics (SAMIS) Database. SAMIS is a component of the National Transit Database

(NTD), which also contains public mass transportation financial and operating data.

Safety statistics are submitted annually by over 500 federally funded transit agencies

operating in communities with populations over 50,000.20 Incidents are included in the

database if they involve a collision, a derailment, an injury, a fatality, a fire, or if transit

property damage exceeds $1,000. The data are submitted in a summary table. Incident

types (for example, collisions, derailments, casualties, nonarson fires) make up the table

rows; injury counts, and fatality and injury counts by type of victim (for example, patrons,

employees, others) are recorded in the table columns. Separate tables are submitted for

each type of service provided by the reporting transit agency. The SAMIS database was

established in 1978. Over 60,000 incidents are added to the database each year. The FTA

publishes the Safety Management Information Statistics (SAMIS) Annual Report and

provides a tool on the FTA’s Safety and Security Web page for finding and viewing reports

20 Transit services include automated guideway transit (rail); light rail (street car); cable car (rail); bus

(nonrail); commuter rail (rail); monorail (rail); demand response (nonrail); publico (nonrail); ferryboat

(nonrail); trolleybus (nonrail); heavy rail; aerial tramway (nonrail); inclined plane (rail); vanpool (nonrail);

and jitney (nonrail).

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from specific transit agencies. In 2000, the FTA began a project examining the timeliness,

quality, and usefulness of the NTD with the ultimate goal of developing redesign

recommendations. This project was initiated at the request of the U.S. House and Senate

Committees on Appropriations as part of the U.S. Department of Transportation (DOT)

FY 2000 Appropriations Act. This request was made because of congressional concern

about the timeliness, accuracy, and relevance of NTD data. Based on feedback from users

of the NTD, the FTA developed and is testing a new NTD prototype using a relational

database structure.

Hazardous Materials Information System Incident Database

RSPA’s Office of Hazardous Materials Safety (RSPA-OHM) maintains the

Hazardous Materials Information System (HMIS), which contains data on reportable

incidents involving the transportation of hazardous materials. A reportable incident is one

that occurs during the transportation (including loading, unloading and temporary storage)

of a hazardous material/waste and results in one of the following outcomes: (a) a fatality

occurring within 365 days of the event, (b) an injury requiring hospitalization, (c) property

damage in excess of $50,000, (d) evacuation of the general public, (e) closure of a major

transportation artery or facility, (f) alteration of the operational flight pattern or routing of

an aircraft, (g) any release involving a radioactive material or infectious substances,

(h) the release of a marine pollutant exceeding 450 liters or 400 kilograms, or (i) any

unintentional release of a hazardous material from a package or any quantity of hazardous

waste discharged during transportation (49 CFR Ch. 1, Section 171.15). Operators must

submit data on DOT form 5800.1 directly to RSPA-OHM within 30 days of a reportable

incident. RSPA-OHM uses operator reports to update the HMIS monthly. The HMIS was

established in 1971. Currently, about 15,000 new records are added to the database each

year. RSPA-OHM publishes annual summary tables on its Web site.

Chapter Two
15 Safety Report

Chapter 3

Previous Safety Recommendations

This chapter examines past safety recommendations concerning data that were

issued by the Safety Board between January 1968 and October 2001.21 A complete list of

these 233 data recommendations is provided in appendix B. Recommendations in this

sample address the collection, processing, storage, analysis, use, or dissemination of

transportation-related safety data (henceforth, “data recommendations”).

Most data recommendations (more than half) addressed issues in the aviation and

highway modes. However, when data recommendations were examined as a proportion of

recommendations issued within each mode, the relative emphasis on data issues appeared

greatest in the intermodal and highway categories (table 3–1).

Because Federal agencies maintain most sources of safety data that are national in

scope, it is not surprising that the Safety Board issued 83 percent of its data

recommendations to agencies of the Federal government. The remaining 17 percent were

issued to State governments, industry/trade associations, city governments, and private

companies. Table 3–2 contains a list of Federal agencies that have received data

recommendations from the Board since 1968.

21 Recommendations were identified using keyword searches of the Safety Board’s electronic records.

These searches were supplemented by manual searches of Board studies and special investigation reports.

Only recommendations involving data useful for the surveillance of accidents or safety-related incidents and

corresponding exposure data were included in the set. Data types included accident, incident, vehicle census,

operator census, and transportation activity. Recommendations involving the collection or analysis of data

from vehicle recorders were not included in the sample, because the Federal government does not use

aggregated vehicle recorder data for safety surveillance purposes.

Table 3–1. Data recommendations versus all recommendations issued in each mode. 

Mode of 

transportationa

Data 

recommendations 

All 

recommendations 

Data recommendations as a 

percentage of recommendations 

issued in each mode 

Aviation 66 4,367 1.5 

Highway 66 1,897 3.5 

Marine 25 2,239 1.1 

Pipeline 25 1,193 2.1 

Railroad 34 1,955 1.7 

Intermodal 17 226 7.5 

All modes 233 11,877 2.0 

a Recommendations dealing with transit data issues are classified in National Transportation Safety Board records as 

highway or rail recommendations, and were counted as such for this table. 
16 Safety Report

A taxonomy, consisting of the following five broad classifications, is used to

categorize these recommendations:

I. Develop a new database or reporting system,

II. Modify an existing database and/or reporting form,

III. Improve the accuracy or completeness of information submitted,

IV. Address problems of underreporting, and

V. Analyze or disseminate existing data.

This taxonomy accommodated all 233 data recommendations, although some

recommendations were coded in more than one category.22 A review of these

categorizations, shown in table 3–3, indicates that the Safety Board’s recommendations

concerning data improvement have been wide-ranging.

22 Twenty-three recommendations were coded in two categories, and two recommendations were coded

in three categories. Multiple codings were necessary because some recommendations proposed more than

one desired action.

Table 3–2. Federal agencies receiving data recommendations from the 

National Transportation Safety Board. 

Federal agency 

Number of data 

recommendations 

Federal Aviation Administration (FAA) 58 

Research and Special Programs Administration (RSPA) 27 

Office of the Secretary of Transportation (DOT) 25 

National Highway Traffic Safety Administration (NHTSA) 23 

United States Coast Guard (USCG) 21 

Federal Railroad Administration (FRA) 20 

Federal Highway Administration (FHWA) 10 

Civil Aeronautics Board (CAB)a 3 

Federal Transit Administration (FTA)b 3 

General Services Administration (GSA) 2 

Centers for Disease Control (CDC) 1 

Federal Motor Carrier Safety Administration (FMCSA) 1 

Total 194 

a The Civil Aeronautics Board was abolished on January 1, 1985. 

b Includes data recommendations issued to the Urban Mass Transportation Administration, which was 

redesignated the Federal Transit Administration by an act of Congress, December 18, 1991. 

Chapter Three
17 Safety Report

The remainder of this chapter discusses some specific data issues the Safety Board

has addressed. Because the Board has issued over 200 data recommendations, it was

necessary to discuss only a sample of issues. In selecting issues to discuss, staff attempted

to highlight dominant issues and themes within each category of desired action. Efforts

were made to ensure broad modal representation in the issues discussed. The discussion

focuses chiefly on recommendations issued to the Office of the Secretary of

Transportation and to the operating administrations of the DOT. These organizations

received the bulk of all data recommendations the Board has issued.

Category I: Develop a New Database 

or Reporting System

The Safety Board has issued numerous recommendations asking for the creation of

new exposure data systems. In 1979, for example, the Board published a safety study that

compared single-engine aircraft makes, models, and configurations in terms of accident

rates, fatal accident rates, and accident types.23 The Board found that three models of

single-engine fixed-wing aircraft had significantly higher in-flight airframe separation

rates than similar aircraft. The Board also found that weather was more of a factor in

accidents involving these aircraft models than for the broader set. However, without

exposure data adequately describing the conditions under which different models of

aircraft were flown, and the characteristics of their pilots, it was not possible for the Board

to analyze the relative importance of aircraft design, weather conditions, or pilot

proficiency as potential causes for in-flight breakups. Following that study, the Board

23 National Transportation Safety Board, Single-Engine, Fixed-Wing General Aviation Accidents 1972–

1976, Safety Study NTSB/AAS-79/01 (Washington, DC: NTSB, 1979).

Table 3–3. Data recommendations by mode and recommendation category. 

 I II III IV V 

Mode 

Develop 

new 

database 

Modify 

existing 

database 

Improve data 

accuracy, 

currency, or 

completeness

Improve 

event 

identification 

and reporting

Improve data 

analysis or 

dissemination 

Number of 

recommendations for 

mode 

Aviation 19 10 11 19 15 66 

Highway 13 25 16 2 13 63 

Marine 5 5 8 0 7 25 

Pipeline 3 4 8 2 12 25 

Railroad 9 7 7 2 6 27 

Transita 4 4 1 1 4 10 

Intermodal 9 3 1 3 3 17 

Total 62 58 52 29 60 b233 

a Transit recommendations were tabulated separately in this table. Transit recommendations were identified by manual 

review of each data recommendation in the sample. 

b A total of 233 recommendations were issued. In analyzing these, National Transportation Safety Board staff coded a 

total of 260 desired actions. 

Chapter Three
18 Safety Report

recommended that the FAA collect more detailed general aviation exposure data that

would support the analysis of pilot and other characteristics as risk factors for specific

kinds of aviation accidents (Safety Recommendation A-79-44). The FAA notified the

Board that it would study the issue, but took no further action.

The Safety Board remains concerned about the quality of general aviation

exposure data. Existing FAA flight activity estimates say nothing about pilot

characteristics or about the environmental conditions in which nonaccident flights are

conducted. Existing estimates provide only very general information about hours flown

within broad categories of aircraft and overlapping purposes of flight.24 Furthermore, the

FAA still does not collect data on commercial operator nonrevenue flights, general

aviation departures, or air tour operator flying activity, even though the Board has

suggested the value of collecting this kind of information for monitoring aviation safety.

The lack of detailed aviation exposure data in general aviation and other sectors limits the

ability of the Board to analyze risk factors for aviation accidents. In the 2001 study, Public

Aircraft Safety, for example, the Board recommended that the FAA identify and

implement exposure data collection methods independent of the General Aviation and Air

Taxi Activity Survey25 that could be used to check the accuracy of nonairline flight hour

estimates (A-01-74). Communications on this matter are ongoing.

In a 1997 study on excavation damage prevention, the Safety Board examined the

leading cause of accidents to pipelines—excavation and construction activity.26 The Board

was limited in its efforts to examine the rate of excavation damage events because

excavation exposure data were not available from any national data collection system. The

Board suggested that one-call communication centers, voluntarily established in local

areas to notify utility companies about digging activities, represented the best opportunity

for collecting excavation activity data. However, existing one-call systems are operated

locally and are not designed to support the development of regional or national excavation

activity estimates. The Board recommended that RSPA, in conjunction with the American

Public Works Association, develop a plan for collecting excavation damage exposure data,

and use this data to assess the effectiveness of State excavation damage prevention

programs (P-97-22 and -24).

24 A discussion of the issues related to current general aviation activity estimates are contained in the

following publication: National Transportation Safety Board, Public Aircraft Safety, Safety Study NTSB/SS01/01 (Washington DC: NTSB, 2001).

25 The FAA’s General Aviation and Air Taxi Activity (GAATA) Survey is used for estimating annual

flight hours for general aviation, air taxi, and public aircraft.

26 National Transportation Safety Board, Protecting Public Safety Through Excavation Damage

Prevention, Safety Study NTSB/SS-97/01 (Washington, DC: NTSB, 1997).

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19 Safety Report

In its Transportation Equity Act for the 21st Century (TEA-21), Congress directed

the DOT to conduct a study to determine “best practices” for preventing damage to

underground facilities. As a result of this requirement, RSPA formed a working group

consisting of 160 damage prevention stakeholders to study the problem. This working

group produced a report, the Common Ground Study of One-Call Systems and Damage

Prevention Best Practices.

27 After the publication of that study, RSPA facilitated the

establishment of a nonprofit private sector organization, known as the Common Ground

Alliance, to promote the use of the “best practices” identified in the study. RSPA recently

indicated to Safety Board personnel that it is working with the Common Ground Alliance

to develop a system for the collection of nationwide excavation damage exposure data as

recommended by the Board.

Category II: Modify an Existing Database 

and/or Reporting Form

Highway recommendations made up 43 percent of the recommendations seeking

modifications in the design of existing databases or report forms. Recipients of category II

recommendations in the highway mode have included NHTSA, the Federal Highway

Administration (FHWA), and the DOT. Highway data recommendations most often

targeted the NASS, FARS, and State highway crash information systems, typically

seeking the addition of new variables to these databases or the addition of new coding

options. For example, the Safety Board recommended that NHTSA modify the FARS so

that the database could store test results for operator drug use (H-90-16), and NHTSA

agreed to do so. NHTSA also agreed to add a variable to FARS identifying cross-median

accidents (H-98-17) and to modify the database so that wheel failures could be

differentiated from tire failures (H-92-103). NHTSA’s responsiveness to

recommendations of this sort has resulted in positive changes to existing highway data

systems, improving the ability of the Safety Board and other organizations to monitor

specific highway safety issues.

The Safety Board has also issued a number of category II recommendations in the

marine mode. In 1986, for example, the Board determined that existing Coast Guard

boating accident data could not be used to determine the in-service effectiveness and

performance of personal flotation devices (PFDs). The required information was not being

reported on boating accident report forms. As a result, the Board recommended that the

Coast Guard, in coordination with the National Association of State Boating Law

Administrators, expedite revision of the Boating Accident Report form to include specific

variables permitting assessment of PFD performance (M-86-100). The Coast Guard

concurred with this recommendation, revising the Boating Accident Report form to enable

assessment of PFD performance and distributing the new form to each State boating law

administrator in March 1988.

27 U.S. Department of Transportation, Research and Special Programs Administration, Office of

Pipeline Safety, Common Ground Study of One-Call Systems and Damage Prevention Best Practices

(Washington, DC: OPS, 1999).

Chapter Three
20 Safety Report

In aviation, the Safety Board has sought modifications to several maintenance and

incident databases maintained by the FAA. The Board recommended changes to the

Service Difficulty Report (SDR) form in 1997, after investigating three incidents

involving failed elevator trim cables on Shorts Brothers SD3-60 airplanes. The Board

searched for information on such failures in the FAA’s SDR database but found little

information that could assist the Board in evaluating the adequacy of current inspection

and maintenance procedures for this type of airplane. For example, existing reports

contained no information on flight hours since last inspection and rarely described the

total time elevator trim cables had been installed in the airplanes. The Board issued Safety

Recommendation A-97-125, asking the FAA to modify the SDR system so that it would

contain more complete and accurate information about component failures (category II),

but also asked the FAA to relate to the operators who submit SDRs the need for complete

and accurate information when they report component failures and to remind FAA

inspectors assigned to Part 121 and Part 135 operators of their need to review the

component failure reports for accuracy and completeness (category III). The FAA

published a notice on September 15, 2000, requesting comments on information collection

requirements for the final rule, prior to issuing a revised SDR form.28 The FAA

subsequently issued a series of postponements in the effective date of the rule, citing the

need for revisions to take industry feedback into account. The currently scheduled date for

issuance of the final rule is January 2003.29 The Board continues to monitor this important

effort.

The Safety Board has a history of recommendations seeking improvements in the

design of RSPA’s pipeline safety reporting forms. In a 1978 study on the safe service life

for liquid petroleum pipelines the Board found that the Liquid Pipeline Accident

Reporting System supported little useful analysis beyond the tabulation of cumulative

accident totals.30 The Board made several recommendations to RSPA, asking the agency

to evaluate its data needs and improve its safety data collection and analysis activities.

One of these recommendations suggested that RSPA redesign the Hazardous Liquid

Pipeline Accident Report system (P-78-59). In a 1996 report that evaluated accident data

and Federal oversight of petroleum product pipelines, the Board concluded that RSPA’s

failure to fully implement the Safety Board’s 1978 recommendations had hampered its

ability to effectively oversee the Nation’s pipelines.31 The Board again recommended that

RSPA evaluate its data needs and redesign its data collection systems (P-96-1). In a 1997

study on protecting public safety through excavation damage prevention, the Board found

that RSPA’s pipeline accident databases did not capture basic information about the causes

of pipeline failures, including excavation activity, which was commonly associated with

28 The Board determined that the proposed changes would significantly improve the SDR process, and

closed Safety Recommendation A-97-125 in January 2000.

29 “Air Carrier Certification and Operations: Service Difficulty Reports; Effective Date Delay,” 66

Federal Register (FR) 58911, November 23, 2001.

30 National Transportation Safety Board, Safe Service Life for Liquid Pipelines, Safety Study

NTSB/PSS-78/01 (Washington, DC: NTSB, 1978).

31 National Transportation Safety Board, Evaluation of Accident Data and Federal Oversight of

Petroleum Product Pipelines, Special Investigation Report NTSB/SIR-96/02 (Washington, DC: NTSB,

1996).

Chapter Three
21 Safety Report

pipeline ruptures.32 The Board recommended that RSPA revise the causal categories on its

gas and hazardous liquid pipeline accident report forms to eliminate overlapping and

confusing categories, to clearly list excavation damage as one of the data elements, and to

consider developing subcategories. In a 1998 report on brittle-like cracking in plastic pipe

for gas service, the Safety Board noted that RSPA’s accident data were insufficient to serve

as a basis for assessing the long-term performance of plastic pipe, which is commonly

used for natural gas distribution, echoing the conclusion that RSPA’s accident/incident

report forms were poorly designed.33

In recent years, RSPA has made serious efforts to redesign its pipeline accident

data collection system. Citing the recommendations of the DOT Inspector General, the

Safety Board, Congress, and the White House, RSPA issued a notice of proposed

rulemaking (NPRM) that redesigned the Hazardous Liquid Pipeline Accident Report

form. The final rule pertaining to this change was issued January 8, 2002. The revised

form includes more detailed information on pipeline characteristics and a better

description of the causes of pipeline failures. The reporting threshold was also reduced

from 50 barrels to 5 gallons of spilled product, with some exceptions for spills that are

greater than 5 gallons, but less than 5 barrels.34 RSPA revised its Incident Report For Gas

Transmission and Gathering Systems and Annual Report For Gas Transmission and

Gathering Systems. Changes to these forms were final on August 8, 2001. The revisions to

the incident form will facilitate the collection of more detailed information. The revisions

to the annual report will allow the collection of more detailed information describing

miles of pipe operated by class and decade of installation for each pipeline operator. RSPA

is also in the process of revising the Incident Report for Gas Distribution Systems and

expects to complete this activity by the end of 2002. These improvements will enhance

RSPA’s ability to perform methodologically sound accident trend analyses. The Board will

continue to monitor RSPA’s important work in this area.

Category III: Improve the Accuracy or 

Completeness of Information Submitted

More than a third of the category III recommendations sought more complete and

accurate reporting of toxicological test results. Although many accident databases contain

data fields for recording the toxicological test results of drivers or operators, this

information is often missing. This occurs because accident investigators often do not

request tests that would detect the presence of toxicological substances in the blood of

transportation operators. Furthermore, if a test is performed too long after an initiating

accident event, toxicological substances can be metabolized by the body, and test results

32 National Transportation Safety Board, Protecting Public Safety Through Excavation Damage

Prevention, Safety Study NTSB/SS-97/01 (Washington, DC: NTSB, 1997).

33 National Transportation Safety Board, Brittle-Like Cracking in Plastic Pipe for Gas Service, Special

Investigation Report NTSB/SIR-98/01 (Washington, DC: NTSB, 1998).

34 Excepted spills are those resulting from maintenance activity, that occur on company property, that

do not result in water pollution, and that are cleaned up promptly, as specified in 49 CFR Part 195.

Chapter Three
22 Safety Report

can be inaccurate. The Safety Board has long been concerned about issues involving the

intoxication of transportation operators because operator intoxication has been identified

as a causal factor for accidents involving all types of vehicles. As a result, the Board has

sought more consistent and accurate reporting of toxicological test results in all modes so

that the extent of this problem can be better monitored.

In 1984, for example, the Safety Board issued a recommendation asking the FAA

to establish implied consent to toxicological testing as a condition of issuance of an

airman certificate (A-84-46). The FAA responded favorably to this recommendation,

adopting a new rule (14 CFR 91.17), effective April 9, 1986, that requires aircraft

crewmembers to submit to chemical tests for detecting alcohol performed by an

authorized law enforcement officer to investigate a suspected violation of FAA rules

against alcohol or drug use. In 1992, after completing a study of alcohol involvement in

general aviation accidents, the Board recommended that the FAA take steps to ensure

consistent, accurate reporting of toxicological test results involving air crewmembers. The

Board recommended that the FAA establish procedures for receiving, processing, and

analyzing toxicological test results reported by the States and distribute procedures for the

States to follow when notifying the FAA of test results and refusals (A-92-107 and -108).

The FAA designated the Civil Aerospace Medical Institute (CAMI) Toxicological and

Accident Research Laboratory as the central reporting office for toxicological test results.

The FAA also established procedures for the reporting of toxicological test results which

were distributed to State and local law enforcement agencies.

In 1988, the Safety Board recommended that the FRA require railroads to collect

all appropriate toxicological samples as soon as practicable and not more than 4 hours

after the triggering event (R-88-31). FRA regulations at that time, 49 CFR Part 219, stated

only that toxicological testing should be performed “as soon as possible” following an

accident. In 1994, the FRA adopted a rule change incorporating the 4-hour time limit.

In 1993, the Safety Board addressed toxicological testing in recreational boating

accidents in a safety study that concluded that alcohol involvement was not being

adequately documented.35 The Board recommended that the 41 U.S. States without such

laws enact legislation requiring a chemical test to determine the alcohol concentration of

recreational boat operators involved in fatal accidents (M-93-2). In addition, the Board

recommended that 11 States without such laws enact legislation requiring toxicological

testing of all recreational boating fatalities (M-93-6). As of September 2002, 28 of the 41

States targeted in Safety Recommendation M-93-2 had taken action requiring the testing

of boat operators in fatal accidents. Recommendation M-93-2 remains open. Six of the 12

States targeted had responded favorably to Safety Recommendation M-93-6 and that

recommendation also remains open. The Safety Board continues to work with the States

on the development of more stringent regulations in these areas.

The Safety Board’s interest in data accuracy and completeness has not been

limited to toxicological test results. For example, in a 1978 study on the safe service life

35 National Transportation Safety Board, Recreational Boating Safety, Safety Study NTSB/SS-93/01

(Washington, DC: NTSB, 1993).

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23 Safety Report

for liquid petroleum pipelines, the Board found inconsistency in the data submitted by

pipeline operators.36 As a result, the Board asked RSPA to provide clear instructions and

definitions to ensure the accuracy and consistency of data submitted on the Hazardous

Liquid Pipeline Accident Report forms (P-78-60). The Board again documented problems

in the accuracy and completeness of pipeline safety data in a 1980 report on pipeline

data.37 As a result, the Board asked RSPA to train its personnel to more effectively

validate incoming leak reports. RSPA responded that, beginning in 1985, a validation

procedure would be used by each regional office, with additional instruction distributed to

each State agent. In 2002, RSPA reported to the Safety Board that new quality control

procedures had been put into place, and that five new staff positions had been created, one

at each of RSPA’s regional offices. The new positions are designated part-time inspection

and part-time file review. RSPA has also implemented a new file review policy. Under this

new policy, operators will be contacted twice annually for further information on reported

incidents until a report is “closed” or final. These new personnel and policies should

improve the quality of pipeline incident/accident data collected by RSPA.

The Safety Board’s 1997 study on excavation damage prevention noted continued

problems with the accuracy of data submitted on pipeline incident/accident reports.38

Specifically, the Board was concerned that RSPA provided facility operators with

inadequate guidance for estimating property damage and other costs resulting from an

accident. The Board recommended that RSPA develop better written guidelines for

estimating such damage (P-97-20). RSPA has made substantial revisions to its accident

and incident reporting forms in recent years. The revised accident/incident forms allow

operators to break down damage estimates into specific categories, which should guide

them in deciding what to include in damage estimates. The revised forms are accompanied

by revised instructions that also detail the costs that are to be included in damage estimates

for pipeline accidents and incidents. RSPA’s recent efforts have improved the

completeness and accuracy of accident/incident information submitted by pipeline

operators.

Category IV: Address Problems of Underreporting

Aviation recommendations made up two-thirds of the recommendations

concerning underreporting. Subsequent to Safety Board recommendations, changes have

been made to improve the reporting of aviation maintenance and incident data. In 1993,

for example, the Board determined that the FAA’s SDR database was of limited value in

36 National Transportation Safety Board, Safe Service Life for Liquid Petroleum Pipelines, Safety Study

NTSB/PSS-78/01 (Washington, DC: NTSB, 1978).

37 National Transportation Safety Board, The Materials Transportation Bureau’s Pipeline Data System,

Safety Effectiveness Evaluation NTSB/SEE-80/04 (Washington, DC: NTSB, 1980). The MTB was a unit of

RSPA and has since been abolished. RSPA’s Office of Pipeline Safety currently performs the incident

reporting and data analytic functions formerly assigned to the MTB.

38 National Transportation Safety Board, Protecting Public Safety Through Excavation Damage

Prevention, Safety Study NTSB/SS-97/01 (Washington, DC: NTSB, 1997).

Chapter Three
24 Safety Report

identifying accurate service defect histories because many reportable service difficulties

were not actually being reported. When investigating a 1992 accident in New York

involving a Trans World Airlines (TWA) L-1011, the Board searched the FAA’s SDR

database for information on stall warning system failures. The database contained only 2

such reports, but 24 additional records were identified by Lockheed and TWA. None of

these incidents was found in the FAA’s SDR database. The Board has issued a number of

recommendations designed to improve the SDR system. To increase ease of submission,

the Board recommended that the FAA develop electronic reporting for SDRs. The Board

also asked the FAA to encourage submission of malfunction and defect reports among

members of the general aviation community (A-93-61 and -62). The FAA subsequently

identified operators who were not submitting SDR data electronically and encouraged

them to do so. The FAA also published an advisory circular39 to promote understanding

and participation of the general aviation community in the SDR program.

In 1998, the Safety Board investigated the near-collision of a US Airways

McDonnell-Douglas DC-9 and an Air Canada Airbus A-319 above the intersection of

runways 22 and 31 at LaGuardia Airport, Flushing, New York. The Board noted that the

air traffic controller advising these aircraft did not file a report of an operational error (OE)

or a near-midair collision (NMAC) because radar separation standards were not in effect.

The controller also made no mention to the pilots of their option to file an NMAC report,

despite communications from the crew of both aircraft that a near-midair collision had

occurred. The Board determined that under FAA Order 8020.11, controllers were actually

required not to ask flight crew members if they intend to file an NMAC report. Although

the crew of the two aircraft involved in the 1998 near-midair collision did, in fact, file

NMAC reports, the Board was concerned that the existing FAA policy might result in

underreporting of near-midair collisions. The Board recommended that the FAA amend its

existing policies to require that controllers ask any member of a flight crew receiving air

traffic control (ATC) services who expresses concern about the proximity of another

aircraft if he or she desires to file a formal NMAC report (A-00-37). The FAA agreed to a

similar change, directing controllers, workload permitting, to notify any member of a

flight crew receiving air traffic control services who expresses concern about the

proximity of another aircraft to contact facility representatives.

Although the bulk of recommendations addressing underreporting have been in the

aviation mode, the Safety Board has addressed underreporting in other modes as well.

During the 1990s, for example, the Board had limited success in analyzing

accident/incident trends using the hazardous materials accident/incident data in the HMIS.

In a 1992 report addressing cargo tank rollover protection, the Board cited problems with

underreporting of accidents to the FHWA and RSPA, differences in reporting requirements

between the two agencies, and inadequacies in the type of data collected about accidents

involving cargo tank trucks.40 The Board concluded that FHWA and RSPA accident

databases were not adequate to identify trends or problems related to the design and

39 U.S. Department of Transportation, Federal Aviation Administration, Service Difficulty Program

(General Aviation), Advisory Circular 20-109A (Washington, DC: FAA, 1993).

40 National Transportation Safety Board, Cargo Tank Rollover Protection, Special Investigation Report

NTSB/SIR-92/01 (Washington, DC: NTSB, 1992).

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25 Safety Report

construction of bulk liquid cargo tanks. As a result, the Board issued Safety

Recommendation H-92-6 to RSPA and H-92-9 to the FHWA suggesting that the two

agencies “jointly implement a program to collect information necessary to identify

patterns of cargo tank equipment failures, including reporting of all accidents involving a

DOT specification cargo tank.”

Recently, the Safety Board has been concerned about underreporting of hazardous

materials incidents involving the loading or unloading of bulk containers, such as railroad

tank cars, highway cargo tanks, and intermodal bulk containers. The Board has

historically and consistently considered such loading and unloading operations to be

transportation-related functions, and has investigated three such accidents since

November 1998.41 One of these accidents, involving the rupture of a railroad tank car

containing hazardous waste near Clymers, Indiana, was not reported to the HMIS. DOT

Hazardous Materials Regulations (49 CFR 171.16) place the responsibility for submitting

Hazardous Materials Incident Reports on the carrier. In this case, the incident was not

reported because the railroad had delivered the tank car to a chemical plant more than

2 months before the accident took place, and the unloading operation was performed by

nonrailroad personnel. The Board was concerned that other loading and unloading

accidents like this one were not being reported to the DOT. The Board recommended that

RSPA develop and implement policies and procedures to ensure that comprehensive

reports concerning all significant failures of U.S. DOT specification tank cars, highway

cargo tanks, and intermodal bulk containers containing hazardous materials are submitted

to RSPA (I-01-1). RSPA published an NPRM in 2001 titled Applicability of the Hazardous

Materials Regulations to Loading, Unloading, and Storage (66 Federal Register (FR)

32420). However, the proposed rule would result in the adoption of a criterion that

effectively removes the loading and unloading of railroad tank cars, highway cargo tanks,

and other bulk containers as regulated operations under the hazardous materials

regulations. Consequently, incidents or accidents involving these operations would no

longer be reportable under the HMIS system. Communications between the Board and

RSPA are ongoing, and the Board will monitor RSPA’s rulemaking activities in this area.

Category V: Analyze or Disseminate Existing Data

The Safety Board has issued numerous recommendations asking the modal

agencies of the DOT to analyze or disseminate existing data. Recommendations calling

for short-term analysis projects and longer term research programs have a long history.

For example, the Board’s 1972 study on stall/spin accidents examined accident records for

37 small, fixed-wing, U.S. general aviation aircraft.42 An evaluation was made of the

relative frequency of occurrence of stall/spin accidents involving each airplane. Other

types of events that preceded or were associated with a stall/spin (such as engine failure)

were also considered in connection with broad and detailed causal factors. Based on the

41 HZM-01-01, HZB-00-02, HZB-00-03.

42 National Transportation Safety Board, General Aviation Stall/Spin Accidents, 1967–1969, Safety

Study NTSB/AAS-72/08 (Washington, DC: NTSB, 1972).

Chapter Three
26 Safety Report

results of these analyses, the Board recommended that the FAA conduct further statistical

review, technical evaluation, and operational testing of aircraft exhibiting a “very high”

frequency of stall/spin accidents (A-72-230). The FAA responded favorably to this

recommendation by performing additional analyses of stall/spin accident data and by

developing an operational test to reassess performance and handling characteristics of

airplanes found to be susceptible to stall/spin accidents. The FAA also pursued research

programs to relate design and handling characteristics to stall/spin likelihood. The FAA

revised regulations governing spin certification requirements for small airplanes.

Another recommendation involving an analysis project was issued in the marine

mode. On April 26, 1984, a tow consisting of 12 barges laden with grain was being pushed

ahead by the U.S. towboat Erin Marie when it collided with a pier of the Poplar Street

Bridge, which crosses the upper Mississippi River between St. Louis, Missouri, and East

St. Louis, Illinois.43 As a result of the collision, 8 of the 12 barges broke free from the Erin

Marie. One barge sank, three were punctured, and two other barges sustained minor

damage. The Board determined that the probable cause of this accident was the tow vessel

operator’s insufficient knowledge of the St. Louis Harbor which resulted in his failure to

identify the main navigation span of the Poplar Street Bridge in time to align his tow for

safe passage. The Board concluded that tow vessel operators on inland waterways should

have a more thorough knowledge of navigation issues in seldom-visited areas covered by

their licenses. As a result, the Board recommended that the Coast Guard analyze the cause

of accidents in areas of Western rivers and develop questions addressing local hazards for

exams used to award licenses to tow vessel operators planning to operate in these areas

(M-85-18). The Coast Guard responded favorably, developing questions involving

hazardous areas of Western rivers, such as around inland locks, dams, bridges, rivers, and

hazardous cargo facilities, and including these questions on license exams.

43 National Transportation Safety Board, Ramming of the Poplar Street Bridge by the Towboat M/V

Erin Marie and its Twelve-Barge Tow, St. Louis, Missouri, April 26, 1984, Marine Accident Report

NTSB/MAR-85/02 (Washington, DC: NTSB, 1985).

Chapter Three
27 Safety Report

Chapter 4

Initiatives Sponsored by the

Bureau of Transportation Statistics

The Bureau of Transportation Statistics (BTS) was formed in 1991, under the

authority of the Intermodal Surface Transportation Efficiency Act (ISTEA). In this act,

Congress recognized the importance of high-quality transportation statistics as a foundation upon which policy decisions should be made. Congress also recognized that existing

data sources were in need of improvement, and determined that the best way to improve

transportation data would be to establish a central intermodal statistical agency. Congress

gave the BTS the following responsibilities (Title 49 United States Code [USC] Chapter I,

Section 111):

1. compiling and analyzing transportation statistics,

2. issuing data collection guidelines,

3. making statistics accessible,

4. identifying information needs,

5. implementing a comprehensive long-term data collection program, and 

6. coordinating the collection of statistical information.

Although the BTS was to serve as the central coordinating agency for

transportation statistics, Congress placed certain limitations on the authority of the new

agency. The BTS was not granted the authority to require collection of data by any other

department or agency or to reduce the authority of any other office of the DOT to collect

and disseminate data independently. These limitations preserved the autonomy of data

processes within the individual operating agencies of the DOT. BTS’s mission, stated in

the agency’s Strategic Plan for Transportation Statistics (2000-2005), is to “lead in

developing transportation data and information of high quality and to advance their

effective use in both public and private decision making.”44

Initiatives Launched Under ISTEA

After the passage of ISTEA, the BTS initiated a number of efforts to make

transportation statistics more accessible. In 1993, the BTS began publishing National

Transportation Statistics. This annual report is a compilation of safety and activity

44 Bureau of Transportation Statistics, A Strategic Plan for Transportation Statistics (2000–2005).

(Washington, DC: U.S. Department of Transportation, BTS, 2000) 1.
28 Safety Report

statistics from all modes of transportation. It contains information on traffic flows, miles

traveled, commodity flows, accidents, and injuries. In 1996, the BTS published a

Directory of Transportation Data Sources. During the late 1990s, the BTS worked to

make transportation statistics more accessible via the Internet, compiling links to the Web

pages of the DOT operating administrations and making them available on the agency’s

Web site.

The BTS also worked to improve the analysis of transportation statistics. Shortly

after the agency’s creation in 1991, the BTS began developing statistical reports on special

topics, including economics and finance, freight, geospatial information, international

travel maritime transportation, and bicycle safety. In 1994, the BTS began publishing

Transportation Statistics Annual Report. Unlike National Transportation Statistics, this

annual report contains detailed analysis of transportation statistics and commentary on

statistical trends. The BTS also developed reports documenting information needs for

better analysis of transportation data. These reports included Information Needs to

Support State and Local Transportation Decision Making, published in 1997, and the

congressionally mandated Transportation Statistics Beyond ISTEA: Critical Gaps and

Strategic Responses, published in 1998. Also in 1998, the BTS launched a quarterly

periodical, the Journal of Transportation and Statistics, containing peer-reviewed works

of scholarly research involving transportation statistics.

The BTS also initiated programs to improve the collection of transportation

activity data. The agency joined forces with the FHWA to help administer the Nationwide

Personal Transportation Survey (NPTS).45 The BTS created the American Travel Survey

(ATS) in 1995, a tool designed to measure patterns of long-distance travel among U.S.

residents. Conducted every 5 years, the NPTS and the ATS assessed amount of travel,

purposes of travel, and characteristics of travelers in all modes of transportation using

large, representative samples of Americans.

When the National Research Council (NRC) reviewed the statistical programs of

the BTS in 1996, the NRC concluded that the BTS had been relatively successful at

compiling data and making statistics readily available to the public. However, the NRC

stated that it was important the BTS do more to “take on the leadership functions assigned

to it by the 1991 ISTEA to improve the relevance and quality of transportation data.”46

Increased Momentum Under TEA-21

The passage, in June 1998, of the Transportation Equity Act for the 21st Century

(TEA-21)47 gave the BTS new responsibilities, including the following:

45 The NPTS measures patterns of local travel for a representative sample of people residing in the

United States.

46 Constance F. Citro and Janet L. Norwood, eds., The Bureau of Transportation Statistics: Priorities for

the Future (Washington, DC: National Academy of Sciences/National Research Council Panel on Statistical

Programs and Practices of the Bureau of Transportation Statistics, 1997).

47 Enacted as Public Law 105-178.

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29 Safety Report

1. support DOT efforts to measure agency performance,

2. establish a new intermodal transportation database,

3. create a National Transportation Library, and

4. develop the National Transportation Atlas Database.

TEA-21 authorized the BTS to coordinate its long-term data collection planning

with DOT efforts to measure performance outcomes under the Government Performance

and Results Act of 1993 (GPRA; 107 Stat. 285 et seq.). Specifically, Congress specified

that the BTS should

...review and report to the Secretary of Transportation on the sources and

reliability of the statistics proposed by the heads of the operating administrations

of the Department to measure outputs and outcomes as required by the

Government Performance and Results Act of 1993, and the amendments made by

such Act, and shall carry out such other reviews of the sources and reliability of

other data collected by the heads of the operating administrations of the

Department as shall be requested by the Secretary [from 49 USC Section 111, Part

c, Subpart 3].

This provision granted the BTS the authority to audit the quality of DOT safety data systems used for DOT performance measures.

The BTS created the Data Initiative Working Group, a mechanism for developing

data quality standards, in 1999. The Data Initiative Working Group was composed of

technical experts and data system managers from throughout the DOT. Members of the

Data Initiative Working Group began their work by compiling information about the

origins, collection procedures, and possible sources of error for each DOT-supported

database related to a GPRA performance measure. This information was compiled in

standardized “source and accuracy statements.” In addition to compiling source and

accuracy statements, the BTS and the Data Initiative Working Group developed a Guide to

Good Statistical Practice discussing appropriate practices in the analysis and presentation

of statistical information, including the definition of errors and documentation of data

quality.

The BTS began to develop a new Intermodal Transportation Database (ITDB) to

provide a single source for transportation safety and activity data from all the modes, eliminating the need to search for such information from individual modal agencies. Based on

congressional guidelines, the BTS stated the following vision for the ITDB:

The ITDB when fully developed will describe the basic mobility provided by the

transportation system, identify the denominator for safety rates and environmental

emissions, illustrate the links between transportation activity and the economy,

and provide a framework for integrating critical data on all aspects of

transportation.48

48 Bureau of Transportation Statistics, Transportation Statistics Annual Report 1999 (Washington, DC:

U.S. Department of Transportation, BTS, 2000) 144.

Chapter Four
30 Safety Report

A trial version of the ITDB went on line in May 2001, providing access to data sets from a

number of accident/incident and exposure databases.

Also under TEA-21, the BTS created the National Transportation Library (NTL).

The NTL, which the BTS administers in cooperation with the Transportation Research

Board, is a large on-line collection of documents and databases provided by public and

private organizations throughout the Nation. The public can search the NTL collection via

the Internet, and then read, download, and print many of the electronically available

documents, free of charge. The BTS also provides a small reference staff to assist the

public in locating documents and answering questions.

The BTS continued development of the National Transportation Atlas Database

(NTAD), a program the agency had started prior to TEA-21. This new electronic

geographic information system contains information on transportation facilities,

transportation services provided on those facilities, transportation flow volumes through

those facilities, and other background information (such as political and environmental

features). It is intended as a primary data system to support transportation mapping and

network analysis nationwide and as a starting point for a future data system, the National

Spatial Data Infrastructure. The NTAD is still evolving. However, data sets on CD-ROM

are available from the BTS Publications Department. A project to develop a combined

geographic representation of transportation infrastructure began in fiscal year 2001.

In response to directives set forth in both ISTEA and TEA-21, the BTS expanded

its role in the collection of transportation activity data. In cooperation with the FHWA, the

BTS combined the NPTS and the ATS to create the National Household Travel Survey

(NHTS), which is currently administered every 5 years. The 2001-2002 NHTS sampled

65,000 households, asking for information describing trips people made by all means

including car, bus, train, plane, as well as biking and walking trips. In addition to the

NHTS, the BTS developed the Omnibus Survey, a monthly survey of travel activity first

administered in 2000. Each Omnibus Survey is administered to 1,000 U.S. households and

1,000 nonresidential U.S. establishments. The survey consists of a core set of items,

asking for information about general travel activity, supplemented by special items serving

the short-term information needs of the operating administrations of the DOT. Omnibus

Survey results are posted on BTS’s Web site. In addition to the NHTS and the Omnibus

Survey, the BTS began to perform short-term targeted activity surveys, providing

“snapshots” of special populations of travelers, including boaters and airline passengers.

Crafting a Long-Term Plan

In the spring of 1999, the BTS organized a National Transportation Safety Conference, sponsored by the Office of the Secretary of Transportation, bringing together

transportation interests from the Federal government, State and local governments, and

other organizations from across the country. The purpose of this conference was to identify priorities for future efforts aimed at improving transportation safety data. Conference

participants indicated that better data collection and reporting were needed to improve

Chapter Four
31 Safety Report

transportation safety. In response to the findings of this conference, the DOT Safety Council, a committee made up of high-ranking DOT staff from the Office of the Secretary of

Transportation and the offices of the modal administrators, established data improvement

as a top priority for the DOT. Under the direction of the DOT Safety Council, the BTS

developed a new initiative titled, “Safety in Numbers: Using Statistics to Make the Transportation System Safer.” The following objectives guided the project:

1. work with constituents to prioritize actions that will improve the timeliness,

relevancy, and quality of safety data;

2. develop a road map to improve safety data that includes recommendations

from across the transportation community; and

3. improve transportation safety-related products and customer service to meet

the needs of DOT’s constituents.

The BTS organized four safety data workshops in September and October 1999,

which were attended by Safety Board staff. These workshops were organized by mode:

one for marine, one for aviation, and two for surface transportation. Each workshop

brought together approximately 200 participants from government, industry, professional

and trade associations, and academia. Participants discussed the characteristics of existing

safety data systems, the relation of these characteristics to safety policy, and information

needs. Common themes were heard across the four workshops, including concerns about

data relevancy, timeliness, and quality; comparability of definitions across the modes; and

deficiencies in existing exposure data. Recommended next steps varied by mode because

of differences in the relative sophistication of the modal data collection systems.

The BTS used feedback from the modal workshops to draft a Safety Data Action

Plan published in September 2000.49 This plan, produced under the direction of the DOT

Safety Council, identified the BTS as the DOT’s lead agency for coordinating data

improvement efforts, and proposed 10 project areas to be managed by the BTS over the

next few years, as follows: 

1. reengineer existing data systems,

2. develop common criteria for reporting deaths and injuries,

3. develop common denominators for safety measures,

4. advance the timeliness of safety data,

5. develop common data on accident circumstances,

6. develop better data on accident precursors,

7. expand the collection of “near-miss” data to all modes,

8. link safety data with other data,

9. explore options for using technology in data collection, and

10. expand, improve, and coordinate safety data analysis.

49 Bureau of Transportation Statistics, Safety Data Action Plan (Washington, DC: U.S. Department of

Transportation, BTS, 2000).

Chapter Four
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BTS data improvement efforts are guided by a Committee on Transportation

Statistics, established by the Deputy Secretary of Transportation, chaired by the director of

the BTS, and composed of senior leaders from the operating administrations of the DOT.

Implementing the Safety Data Action Plan

In 2001, the BTS assigned tasks related to 9 of the 10 research projects described

in the Safety Data Action Plan to four working groups consisting of internal staff; staff

from the operating administrations of the DOT and other Federal agencies; and outside

contractors.50 In January 2002, the BTS sponsored another Intermodal Safety Data

Conference in Washington, D.C. At this conference, the BTS presented draft

implementation plans for projects 2, 3, 5, and 9, and status reports for projects 1, 6, 7, and

10. No progress was reported for project 4 (advance the timeliness of safety data), because

the BTS decided that this project would be addressed as part of project 1.

The draft implementation plans contained a variety of recommendations

addressing safety data improvement needs. The project 2 report found that the different

modal agencies responsible for safety data collection used a variety of definitions for

incidents, accidents, fatalities, and nonfatal injuries. The report recommended that the

DOT develop cross-modal definitions for these outcomes. The report also noted that

accident databases in different modes of transportation classify injuries differently, leading

to incompatible definitions of injury severity. Furthermore, for some databases, uninjured

persons involved in transportation accidents or incidents were not being consistently

documented. The report recommended the creation of a common injury classification and

coding scheme and the collection of data describing both injured and uninjured persons.

The project 3 report catalogued exposure measures used for calculating safety

statistics in each mode of transportation, pointing out differences and similarities in

current exposure data collection practices across modes. The report recommended that

different sets of exposure measures be used for cross-modal comparisons, depending on

the purpose of travel. The report suggested different sets of exposure measures, for

example, when making cross-modal comparisons of risk for passenger travel, occupational

travel, or recreational travel. The report went on to identify specific exposure measures

that would be needed to facilitate comparisons of transportation risk across modes.

The project 5 report noted that some DOT accident databases are so limited in their

capacity to document causal information that they only allow the recording of a single

contributing factor. The report recommended that accident data quality, adequacy, and

completeness should receive significant attention and proposed a minimum list of accident

data elements. The report contained more than 20 additional recommendations, including

greater utilization of electronic reporting by State governments, winnowing of existing

accident databases to remove seldom-used variables, greater use of sampling in safety data

50 Project 8 was excluded because BTS’s Intermodal Transportation Database team had already

assumed responsibilities related to this task (linking safety data with other transportation data).

Chapter Four
33 Safety Report

collection, expanded use of confidential reporting systems, and collection of more detailed

information describing crash-related injuries. A list of possible research projects exploring

methods for improving the quality of accident data collected was also included.

The project 9 report indicated that each of the modes is engaged in independent

technology development efforts related to the safety mission of their respective agencies.

A list of eight technologies, ranked in terms of priority for further development as tools for

improving data collection, was included in the report. The top three technologies were

electronic identification of vehicle operators, automated real-time operator performance

monitoring, and hands-free wearable computers for data collection. The report

recommended development of multiple unspecified projects exploring applications for

these three top-ranked technologies.

BTS staff working on project 1 reported that auditing DOT data systems would be

the first step toward reengineering DOT data systems.51 The first systems selected for

audit included the NTD, the HMIS, the FAA’s safety databases assessable through

NASDAC, the BTS’s Origin and Destination Survey, and RSPA’s Unified Shippers

Enforcement Data System (UNISHIP). Draft audit reports for the HMIS, the Origin and

Destination Survey, and the UNISHIP databases were provided to the Safety Board for

review. These audit reports followed a format specified in another BTS draft document,

Working Plan for Project # 1—Data Quality Assessments. Each audit report contained

information describing the background of the selected system, frame and sampling

information, data collection procedures, data preparation procedures, data dissemination

practices, self-evaluation by the data process owner, and a BTS analysis of the data from

the database to assess missing values. Each audit also contained a summary evaluation and

a list of BTS recommendations for improving data quality and completeness.

The BTS staff are conducting interviews with senior modal staff to determine

existing data analysis capabilities within the DOT in support of project 10, which is just

getting under way.

The BTS had planned to use its implementation plans for projects 2, 3, 5, and 9 to

develop data improvement projects during the 2002 and 2003 fiscal years. However,

Federal budgetary changes during summer 2001 affected funding for the Safety Data

Action Plan projects. Seven BTS statisticians are available for part-time assignment to

database audits, but these staffers are also responsible for developing data quality

standards, and producing GPRA-related reports. The Data Initiative Working Group,

consisting of mid-level managers from the operating administrations of the DOT, meets

bimonthly and is currently reviewing final reports for the 10 research projects performed

in 2001.

51 TEA-21 gave the BTS the authority to audit data systems used to provide DOT performance

measures.

Chapter Four
34 Safety Report

Chapter 5

Analysis

The Safety Board has issued a variety of recommendations seeking the

improvement of transportation safety data. An analysis of past recommendations revealed

that roughly 30 percent of the Board’s data recommendations addressed the collection or

use of exposure data in some way. These measures are needed to calculate broad safety

indicators (for example, fatality rates), risks for operational categories (for example,

vehicle type comparisons), and to evaluate safety interventions (for example, seat belt

use).

Broad indicators of transportation activity, such as vehicle miles, vehicle

departures, hours of operation, or passenger miles, are available in all modes of

transportation. These measures are commonly used to calculate accident and injury rates

by qualifying how often a risk event had the chance to occur. Most activity measures are

derived by estimation methods that vary by mode. For example, a vehicle census or an

operator survey may be used to develop transportation activity estimates. Depending on

the estimation method used, different activity measures will have varying levels of

precision.

Although the Safety Board recognizes that broad indicators of transportation

activity are well documented, activity measures specific to operational segments within a

mode of transportation are less likely to be available. Activity measures for specific

segments of transportation are necessary for safety comparisons between groups, such as

comparing the safety of different models of vehicles or comparing operators with different

levels of training. They are also useful for determining the effectiveness of safety

interventions, particularly those designed to target specific operators, equipment, or

conditions. 

There are many examples of exposure data limitations that restrict the

transportation community’s ability to assess risk. In aviation, for example, the flight hour

activity for air carrier nonrevenue flights are not reported, activity of air tour operators is

based on survey responses from a small fraction of aircraft owners, and no reliable

estimates of general aviation departures are available. Activity data are sparse for

recreational boating, with only one national survey conducted in the last 10 years. Data

describing activity at the Nation’s highway–rail crossings are lacking. The U.S. Census

Bureau conducts the Vehicle Inventory and Use Survey that estimates miles traveled, but

that data cannot support comparisons of certain types of interstate versus intrastate

operations. Estimates of active pipeline mileage are available, through the Federal Energy

Regulatory Commission, for only some varieties of pipelines that carry potentially

hazardous petroleum products. The collection of more detailed exposure data would

support improved safety surveillance, making it possible to normalize accident trends

within each sector and to monitor overall risk.
35 Safety Report

Many existing exposure data collection programs are insufficient to support the

analysis of risk factors for transportation accidents because they lack adequate detail. For

example, general aviation exposure data are expressed in terms of annual flight hours by

aircraft category and region, but the FAA does not collect data describing the

characteristics of active pilots, flight conditions, or specific models of aircraft flown. In

the highway mode, the FHWA collects highway exposure data including annual vehicles

miles traveled, but the data do not describe driver characteristics, driving conditions, or

specific vehicle models. In the marine mode, DOT databases provide no information on

passenger or cargo movement via commercial vessels, and surveys of recreational boat

use are conducted at infrequent, irregular intervals and therefore do not collect standard

information over time. The FRA requires railroads to submit exposure data including train

miles, freight train miles, and passenger train miles, but the FRA does not collect exposure

data describing train or highway vehicle activity at highway–rail crossings despite the fact

that hundreds more people die at grade crossings than die as train passengers. The FTA

collects transit exposure data including passenger miles traveled, vehicle miles traveled,

vehicle hours, and unlinked passenger trips, but FTA exposure data contain little or no

information about the population of transit users. Without detailed information about the

people and vehicles involved in transportation activities, and the conditions under which

such activities take place, it is difficult to assess the degree to which various factors may

influence the likelihood and severity of transportation accidents. This circumstance

lessens the usefulness of the relatively detailed data collected for transportation accidents

as a tool for monitoring and improving transportation safety.

The BTS addressed exposure data issues as part of the Safety Data Initiative

through its project 3, Common Denominators for Safety Measures. The term for that

project’s “common denominators” refers to the relationship between accident measures

and representative exposure data that are used to assess transportation risks. The BTS

report concluded that exposure data collection could be made more consistent across the

modes, and recommended the collection of information such as trip length, trip time,

number of vehicle occupants, and hours of duty for most modes. The BTS has also been

developing its Omnibus and ATS surveys to collect better data on household travel

activity. These surveys may facilitate better analysis of risk factors for the most common

forms of travel, such as personal highway vehicle travel. However, these surveys are not

as useful for qualifying travel for specific types of vehicles or for specific purposes, such

as commercial trucks. The Safety Board concludes that the DOT’s exposure data

collection programs can be improved and expanded to better support the monitoring of

accident risk for specific transportation sectors, to support the detailed analysis of risk

factors, and to evaluate the effectiveness of strategies for preventing transportation

accidents.

Any programmatic effort to improve exposure data collection and make it more

relevant for safety data analysis will require the participation and expertise of the

operating administrations of the DOT. It will also require consideration of the statistical

methods to appropriately use the data. Congress made the BTS responsible for issuing

data collection guidelines and implementing a comprehensive long-term data collection

program. It is therefore logical that the BTS would be the appropriate agency to lead any

Chapter Five
36 Safety Report

DOT-wide effort to improve exposure data. The Safety Board concludes that the BTS

should develop a long-term program to improve the collection of data describing exposure

to transportation risk in the United States. Within each mode, representative exposure data

should be maintained for distinct transportation sectors, industry segments, or travel

purposes because these differences relate to unique operational and/or regulatory

characteristics. These data should be collected in such a fashion that they are useful for:

(a) the normalization of accident data on at least an annual basis; (b) the analysis of risk

factors involving people, vehicles, and environments; and (c) the evaluation of safety

improvement strategies implemented at the State or national level.

In reviewing BTS efforts to establish data quality standards, identify information

gaps, and ensure compatibility between DOT safety data systems, the Safety Board

recognizes a number of important BTS accomplishments. The BTS has drafted standards

for data collection and analysis, and these standards are being refined as BTS staff gain

experience during audits of existing DOT databases. The agency has published several

reports identifying DOT safety data gaps, including Information Needs to Support State

and Local Transportation Decision Making, published in 1997, and Transportation

Statistics Beyond ISTEA: Critical Gaps and Strategic Responses, published in 1998. The

BTS has identified additional gaps through its Safety Data Initiative and Data Gaps

projects, which began in 1999 and 2001, respectively. The BTS has also begun to explore

areas of incompatibility among different DOT safety data systems through the Safety Data

Initiative. In short, the BTS has led safety data improvement efforts in recent years, and

the Safety Board commends the DOT’s efforts in this area.

Although the BTS does not have the authority to require changes in data collection

programs, the BTS is authorized to audit safety databases that are used to calculate DOT

performance measures. These audits will help to highlight areas of inconsistency between

the modal databases and should point out specific problems in each database involving the

completeness of records. These audits should lay the groundwork for future cooperative

efforts aimed at improving DOT safety data. The BTS will complete five such audits

during the 2002 fiscal year and plans to continue at a rate of five audits per year given

current resources. At that pace, it will take at least 8 years for the BTS to audit the 40-plus

safety databases mentioned in the Safety Data Action Plan. After these audits are

completed, additional time will be required for the modal agencies to make voluntary

changes that may remedy deficiencies identified in BTS audits. BTS audits of DOTsponsored safety databases need to be accelerated to support timely, coordinated

reengineering efforts by the modal agencies. The Safety Board urges the BTS to complete

audits of the 40-plus safety data systems referenced in the Safety Data Action Plan and

make the results of these audits available to modal administrations prior to modal

reengineering of those data systems.

Chapter Five
37 Safety Report

Conclusions

1. The Department of Transportation’s exposure data collection programs can be

improved and expanded to better support the monitoring of accident risk for specific

transportation sectors, to support the detailed analysis of risk factors, and to evaluate

the effectiveness of strategies for preventing transportation accidents.

2. Bureau of Transportation Statistics audits of Department of Transportation-sponsored

safety databases need to be accelerated to support timely, coordinated reengineering

efforts by the modal agencies.
38 Safety Report

Recommendations

As a result of this safety study, the Safety Board made the following

recommendation to the Bureau of Transportation Statistics:

Develop a long-term program to improve the collection of data describing

exposure to transportation risk in the United States. Within each mode,

representative exposure data should be maintained for distinct

transportation sectors, industry segments, and travel purposes. (I-02-05)

By the National Transportation Safety Board

Marion C. Blakey John A. Hammerschmidt

Chairman Member

Carol J. Carmody John Goglia

Vice Chairman Member

George W. Black, Jr.

Member

September 11, 2002
39 Safety Report

Appendix A

Major Federal Safety and Activity Databases

NTSB Aviation Accident Database

FAA Accident/Incident Data System (AIDS)

FAA/NASA Aviation Safety Reporting System (ASRS)

FAA National Airspace Incident Monitoring System (NAIMS)

FAA General Aviation and Air Taxi Activity Survey (GAATA Survey)

Near Mid-Air Collisions System (NMACS)

Pilot Deviations (PD)

Operational Errors (OE)

BTS Omnibus Survey

BTS Form 41, Schedules T100 and T100(f) Air Carrier Data

BTS Form 41 T-3 passengers enplaned and other traffic data

NHTSA Fatality Analysis Reporting System (FARS)

NHTSA National Accident Sampling System/General Estimates System (NASS/GES)

NHTSA National Accident Sampling System/Crashworthiness Data System (NASS/CDS)

NHTSA Crash Outcome Data Evaluation System (CODES)

NHTSA Motor Vehicle Defects Investigation Database

NHTSA Motor Vehicle Defects Non-compliance Database

NHTSA National Occupant Protection Use Survey (NOPUS)

FHWA Highway Performance Monitoring System (HPMS)

FHWA Licensed Drivers Data

FHWA/BTS National Household Travel Survey (NHTS)

FMCSA Motor Carrier Management Information System (MCMIS)

FRA Rail Equipment Accident/Incident Report (RAIR) Database

FRA Highway-Rail Grade Crossing Incident Report (GXIR) Database

FRA Railroad Injury and Illness Summary Database

FRA Railroad Operations Database

FTA National Transit Database (NTD)

FTA Safety Management Information Statistics (SAMIS) Database

RSPA Hazardous Liquid Pipelines Accident Database

RSPA Natural Gas Gathering and Transmission Systems Incident Database

RSPA Natural Gas Distribution Systems Incident Database

RSPA Hazardous Materials Information System (HMIS) Incident Database

U.S. Army Corps of Engineers Lock Performance Monitoring System

U.S. Census Bureau/BTS Commodity Flow Survey (CFS)

University of Michigan Transportation Research Institute 

Trucks Involved in Fatal Accidents (TIFA)

USCG Boating Accident Report Database (BARD)
40 Safety Report

USCG Search And Rescue Management Information System (SARMIS)

USCG Marine Safety Information System (MSIS) Vessel Casualty Data

USCG Marine Safety Information System (MSIS) Pollution Data

USCG Merchant Mariner Licensing and Documentation (MMLD) System

USCG Marine Information for Safety and Law Enforcement (MISLE)

More information on these and other sources of transportation safety data is

available on the Bureau of Transportation Statistic’s Web site <http://www.bts.gov>.

Appendix A
41 Safety Report

Appendix B

Data Recommendations by Mode and Topic

Aviation ..................................................................................................................................................... 44

Aircraft Accident/Incident Data............................................................................................................ 44

Air Traffic/Operational Incident Data................................................................................................... 46

Maintenance Incidents and Related Information .................................................................................. 47

Exposure Data ....................................................................................................................................... 48

Toxicological Testing ............................................................................................................................ 50

Other Topics .......................................................................................................................................... 51

Highway .................................................................................................................................................... 52

NASS Development .............................................................................................................................. 52

Work Zones ........................................................................................................................................... 53

School Buses ......................................................................................................................................... 53

Commuter Buses ................................................................................................................................... 54

Air Bag and Restraint Use..................................................................................................................... 54

Motor Carriers and Commercial Vehicles............................................................................................. 55

Toxicological Testing ............................................................................................................................ 56

Accident Environment/Event Data........................................................................................................ 57

Accident Vehicle Data........................................................................................................................... 57

Other Topics .......................................................................................................................................... 57

Marine........................................................................................................................................................ 58

BARD Development ............................................................................................................................. 58

Tow Vessels and Inland Waterways ...................................................................................................... 59

Survival Equipment............................................................................................................................... 59

Toxicological Testing ............................................................................................................................ 60

Marine Exposure Data........................................................................................................................... 60

Pipeline ...................................................................................................................................................... 61

Develop Analysis Plan .......................................................................................................................... 61

Excavation Exposure Data .................................................................................................................... 61

Improve Report Completeness/Accuracy.............................................................................................. 62

Improve Event Identification ................................................................................................................ 62

Redesign Pipeline Reporting System .................................................................................................... 62

Other Topics .......................................................................................................................................... 62

Railroad ..................................................................................................................................................... 63

Highway–Rail Grade Crossings............................................................................................................ 63

Hazardous Materials.............................................................................................................................. 64

Rail Accident/Incident Data.................................................................................................................. 64

Toxicological Testing ............................................................................................................................ 65

Rail Exposure Data................................................................................................................................ 66

Rail Maintenance Data .......................................................................................................................... 66
42 Safety Report

Transit........................................................................................................................................................ 67

Rail Rapid Transit ................................................................................................................................. 67

Transit Buses ......................................................................................................................................... 68

Intermodal.................................................................................................................................................. 69

Cross Modal Accident Data .................................................................................................................. 69

HMIS Development .............................................................................................................................. 69

Toxicological Testing ............................................................................................................................ 71

Appendix B
43 Safety Report

The National Transportation Safety Board maintains a status record of safety

recommendations. Responses to a given safety recommendation are classified to track the

action taken by the recommendation recipient. This appendix uses the following

recommendation status classifications:

Recommendation status and 

abbreviation used in this appendix Description of status 

 

Open—Await Response 

(OAWR) 

Automatically assigned to newly issued safety 

recommendations. 

Open—Response Received 

(ORR) 

Recipient response under evaluation but has not been 

approved by the Board Members. 

Open—Acceptable Response 

(OAR) 

Recipient response indicates a planned action that would 

comply with the safety recommendation when completed. 

Open—Acceptable Alternate Response 

(OAAR) 

Response by recipient indicates an alternate plan that would 

satisfy the objective of the safety recommendation when 

implemented. 

Open—Unacceptable Response 

(OUR) 

Response by recipient expresses disagreement with the 

need outlined in the recommendation or action is not being 

taken in a timely manner. 

Closed—Exceeds Recommended Action 

(CERA) 

Response to safety recommendation has been completed 

and surpassed what the Safety Board envisioned. 

Closed—Acceptable Action 

(CAA) 

Response by recipient indicates action on the safety 

recommendation has been completed and meets the 

objective of the recommendation. 

Closed—Acceptable Alternate Action 

(CAAA) 

Response by recipient indicates an alternate course of 

action has been completed that meets the objective of the 

recommendation. 

Closed—Unacceptable Action 

(CUA) 

Response by recipient expresses disagreement with the 

need outlined in the recommendation. 

Closed—Unacceptable Action/ 

No Response Received 

(CUAN) 

No response to the recommendation was ever received. 

Closed—No Longer Applicable 

(CNLA) 

The recommended action has been overtaken by events. 

Closed—Reconsidered 

(CR) 

Recipient rejects the safety recommendation and supports 

this rejection with a rationale with which the Board concurs. 

Closed—Superseded 

(CS) 

Applied to a previous recommendation held in an open 

status when a new, more appropriate safety 

recommendation is issued. 

Appendix B
44 Safety Report

Aviation

Databases related to aviation data recommendations issued by the National

Transportation Safety Board are listed below. Most of these databases are maintained by

the FAA, two are maintained by the BTS, and one—the Aviation Accident/Incident

Database—is maintained by the Safety Board.

Aircraft Accident/Incident Data

Database name or description Sponsoring organization 

Automated Runway Incursion Information System Federal Aviation Administration 

Aviation Accident/Incident Database National Transportation Safety Board 

Aviation Safety Reporting System (ASRS) Federal Aviation Administration 

BTS Form 298–C, Report of Financial and Operating 

 Statistics for Small Aircraft Operators 

Bureau of Transportation Statistics 

BTS Form 41, Schedules T100 and T100(f), 

 U.S. Air Carrier Traffic and Capacity Data 

Bureau of Transportation Statistics 

Civil Aircraft Registry Federal Aviation Administration 

Comprehensive Airmen Information System (CAIS) Federal Aviation Administration 

FAA Incident Data System (FIDS) Federal Aviation Administration 

Federal Aviation Interactive Reporting System (FAIRS) General Services Administration 

General Aviation and Air Taxi Activity (GAATA) Survey Federal Aviation Administration 

List of air taxi certificate holders Federal Aviation Administration 

Mechanical Reliability Reports (MRR) Federal Aviation Administration 

National Wildlife Strike Database Federal Aviation Administration 

Near Midair Collision System (NMACS) Federal Aviation Administration 

Operational Errors (OE) Federal Aviation Administration 

Pilot Deviations (PD) Federal Aviation Administration 

Service Difficulty Reporting (SDR) Database Federal Aviation Administration 

Recommendation Recipient and recommended action Status 

A-68-033 FAA: Monitor the Lebanon VOR area for signal interference. Install dual 

navigation facilities at locations where potential problems are found. 

Review pertinent standards for compatibility of ground and airborne 

navigation components. Provide leadership in developing and 

implementing an industrywide operational incident reporting system for 

the interim period. Ensure a wider dissemination of existing operational 

incident data among elements of your organization. 

CAA 

A-72-148 FAA: Require incident reporting of events involving damage/injury from 

jet blast during ground operation not incident to flight. 

CUA 

A-72-165 FAA: Develop a system to evaluate the effectiveness of improvements 

and developments in midair collision avoidance systems, to assess, 

measure, and analyze hazard trends. 

CUA 

Appendix B
45 Safety Report

Recommendation Recipient and recommended action Status 

A-90-014 FAA: Establish reporting requirements, a reporting system, and a 

database on successful and unsuccessful high energy rejected takeoffs 

of transport category airplanes. 

CR 

A-91-041 FAA: Establish a national database for the purpose of identifying and 

tracking pilots who have been involved in accidents and/or have 

violated FARs, and correlate activity of such pilots with the designated 

pilot examiner who administered their flight test(s). 

CAA 

A-93-166 FAA: Direct the Office of Aviation System Standards to implement an 

appropriate management/supervisor structure to ensure that a method 

of resolving conflicts, grievances, and incident reporting exists at the 

appropriate management level in each flight inspection area office. 

CS 

A-940-87a FAA: Improve criteria to specify the operational and maintenance 

related incidents that are required to be reported to a central aviation 

authority, and implement procedures to verify that all incidents meeting 

such criteria are being reported. 

CAA 

A-94-088 FAA: Develop and implement a program guaranteeing that personnel 

who bring safety-related concerns to the attention of management can 

do so without fear of retribution, and with assurance that such concerns 

will be addressed thoroughly and impartially. 

CAA 

A-94-057 FAA: Require reporting of wake vortex encounters and establish a 

system to collect and analyze pertinent information, such as recorded 

radar data, atmospheric data, and operational information, including 

selected flight data recorder data. 

CUA 

A-96-042 FAA: Issue appropriate bulletins to urge pilots and maintenance 

personnel to report all bird strike incidents using FAA form 5200-7. 

CAA 

A-96-062 FAA: Develop an organizational structure and a communications 

system that will enable the aircraft evaluation group (AEG) to obtain 

and record all domestic and foreign aircraft and parts/systems 

manufacturers’ reports and analyses concerning incidents and 

accidents involving aircraft types operated in the United States, and 

ensure that the information is collected in a timely manner for effective 

AEG monitoring of the continued airworthiness of aircraft. 

CUA 

A-00-018 FAA: Consider the accident and incident history of foreign air carriers as 

a factor when evaluating the adequacy of a foreign civil aviation 

authority’s oversight and whether a reassessment may be warranted. 

CAA 

a Safety Recommendation A-94-087 is also listed in the table of safety recommendations that addressed data 

concerning maintenance incidents and related information. 

Appendix B
46 Safety Report

Air Traffic/Operational Incident Data

Recommendation Recipient and recommended action Status 

A-69-030a FAA: (1) Amend the FARs to require reporting of additional flight safety 

incidents and delete from the regulations the operators’ option to file 

such reports. (2) Establish requirements for reporting operational 

incidents, particularly those involving the air traffic control system. (3) 

Provide for input of mechanical interruption summary data into the MAC 

computer system. (4) Improvement of risk factor assignment criteria 

and evaluation, and inclusion of these data into the computer program 

with readily available retrieval capability. 

CAA 

A-81-154 FAA: Establish a program to periodically reemphasize use of the NASA 

ASRS by controllers to report hazardous conditions. 

CAA 

A-83-037 FAA: Expedite the development and implementation of computer 

programming procedures at all appropriately equipped en route and 

terminal radar facilities by which less-than-standard aircraft separation 

occurrences are automatically detected and flagged for investigation 

and analysis of possible controller errors or pilot deviations. 

CAAA 

A-83-038 FAA: Institute air traffic control directives and procedures to require, 

when the assigned first-line supervisor is occupied working a control 

position, that there is adequate supervision to ensure detection and 

reporting of all controller errors or deviations, detection and monitoring 

of fatigue and/or stress, and control of each controller’s workload. 

CUA 

A-83-039 FAA: Revise immediately air traffic control directives to reduce or 

eliminate, possibly by means of an immunity program, the punitive 

nature of controller operational error/deviation investigation. 

CAA 

A-83-040 FAA: Improve compliance with existing directives to air traffic controllers 

and staff on the use of the FAA-sponsored NASA ASRS program to 

supplement existing incident reporting programs, with the view toward 

instituting quality control measures and improvements in the traffic 

control system. 

CAA 

A-86-039 FAA: Revise the near-midair collision reporting and investigating 

program to make clear that near collisions on or near the airport 

surface constitute an occurrence which must be investigated as a nearmidair collision. 

CUA 

A-86-040 FAA: Revise and enforce the requirements to report and investigate 

operational errors, pilot deviations, and near-midair collisions that 

involve aircraft on the ground and in the air, and develop a combined 

database for causal analyses of runway incursion incidents. 

CAA 

A-00-027 FAA: Establish a formal method for air traffic control personnel to report 

instances in which sectors become overloaded so that the 

circumstances causing or permitting overloading can be identified and 

addressed. 

CUA 

Appendix B
47 Safety Report

Maintenance Incidents and Related Information

Recommendation Recipient and recommended action Status 

A-00-037 FAA: Amend FAA Order 7110.65, “Air Traffic Control,” to require that 

controllers ask any member of a flight crew receiving ATC services who 

expresses concern about the proximity of another aircraft if he or she 

desires to file a formal near-midair collision report. 

CAAA 

A-00-038 FAA: Modify FAA form 8020-21, “Preliminary Near Midair Collision 

Report,” to include a section describing air traffic control actions 

relevant to the incident. 

CAA 

ASRS = Aviation Safety Reporting System, NASA = National Aeronautics and Space Administration. 

a Safety Recommendation A-69-030 was a multi-part recommendation; it is also listed in the table of safety 

recommendations that addressed data concerning maintenance incidents and related information.

Recommendation Recipient and recommended action Status 

A-69-030a FAA: (1) Amend the FARs to require reporting of additional flight safety 

incidents and delete from the regulations the operators’ option to file 

such reports. (2) Establish requirements for reporting operational 

incidents, particularly those involving the air traffic control system. (3) 

Provide for input of mechanical interruption summary data into the MAC 

computer system. (4) Improvement of risk factor assignment criteria 

and evaluation, and inclusion of these data into the computer program 

with readily available retrieval capability. 

CAA 

A-79-104 FAA: (a) Revise 14 CFR 121 to require that operators investigate and 

report the circumstances of any incident wherein damage is inflicted on 

a component identified as “structurally significant” regardless of the 

phase of flight, ground operation, or maintenance in which the incident 

occurred; and (b) require that damage reports be evaluated by 

appropriate FAA personnel to determine whether the damage cause is 

indicative of an unsafe practice and assure that proper actions are 

taken to disseminate relevant safety information to other operators and 

maintenance facilities. 

CUA 

A-80-050 FAA: Issue an advisory circular, or by other means, advise operators of 

specific illustrations of failures and malfunctions which should be 

reported to the SDR program under 14 CFR 121.703(c) and 14 CFR 

135.415(c). 

CAA 

A-84-008 FAA: Provide air carrier inspectors, for use in their surveillance 

activities, failure trend information based on airline maintenance data 

which have been reported by airlines, and analyzed and ranked by the 

FAA for their significance on flight safety. 

CAA 

A-90-172 FAA: Create the mechanism to support a historical database of 

worldwide engine rotary part failures to facilitate design assessments 

and comparative safety analysis during certification reviews and other 

FAA research. 

CAA 

A-93-061 FAA: Establish standardized reporting formats for malfunction defect 

reports and SDRs that include the capability for electronic submission. 

Encourage electronic submission for all operations under 14 CFR Parts 

21, 43, 91, 121, 125, 127, 135, and 145. 

CAA 

Appendix B
48 Safety Report

Exposure Data

Recommendation Recipient and recommended action Status 

A-93-062 FAA: Encourage persons or organizations operating under 14 CFR 

Parts 43 and 91 to submit malfunction or defect reports and provide 

guidance to improve the quality and content of the general aviation 

service difficulty database. 

CAA 

A-93-063 FAA: Ensure prompt analysis and dissemination of SDR data and 

dissemination of alerting information is being accomplished in 

accordance with FAA policies and procedures. 

CAA 

A-93-064 FAA: Encourage foreign regulatory agencies to provide service difficulty 

data from resident operators and manufacturers to the FAA for 

incorporation into the FAA service difficulty database. 

CAA 

A-94-087b FAA: Improve criteria to specify the operational and maintenance 

related incidents that are required to be reported to a central aviation 

authority, and implement procedures to verify that all incidents meeting 

such criteria are being reported. 

CAA 

A-97-125 FAA: Modify the SDR system so that it contains more complete and 

accurate information about component failures; for example, (a) revise 

the SDR form and database to include cycles and times since last 

inspection for failed components; (b) relate to the operators the need for 

complete and accurate information when they report component 

failures; and (c) remind FAA inspectors assigned to Part 121 and Part 

135 operators of their need to review the component failure reports for 

accuracy and completeness. 

CAA 

SDR = Service Difficulty Report. 

a Safety Recommendation A-69-030 was a multI-part recommendation; it is also listed in the table of safety 

recommendations that addressed air traffic/operational incident data. 

b Safety Recommendation A-94-087 is also listed in the table of safety recommendations that addressed aircraft 

accident/incident data. 

Recommendation Recipient and recommended action Status 

A-72-172 FAA: Establish and maintain a separate listing of all current holders of 

air taxi operator certificates to permit identification of each operator by 

type of service performed. 

CAA 

A-72-191 CAB: Require all air taxi operators registered with the CAB, and 

designated as commuter air carriers, to report hours flown, miles flown, 

and number of departures in scheduled revenue operations. 

CNLA 

A-72-192 CAB: Require all air taxi operators to report passengers carried, hours 

flown, and miles flown, and number of departures in revenue operation. 

CNLA 

A-74-042 FAA: Collect from commercial operators and make available, on a 

calendar year basis: (a) for nonrevenue operations, hours flown, miles 

flown, and departures; (b) for passenger and cargo operations, 

separate tabulations of hours flown, miles flown, departures, freight tonmiles flown, and freight ton-miles available; and (c) for passenger 

operations, seat-miles available and passenger-miles flown. 

CUA 

Appendix B
49 Safety Report

Recommendation Recipient and recommended action Status 

A-74-043 FAA: Conduct a comprehensive sampling survey to estimate general 

aviation departures by make and model and by the kinds of flying 

depicted on the aircraft registration, identification, and activity report 

(AC form 8050-73). 

CUA 

A-74-044 CAB: Require the periodic reporting of certain additional statistical 

activity data for certificated route and supplemental air carrier 

operations. 

CNLA 

A-79-044 FAA: Generate, through a stratified sampling of general aviation pilots, 

representative data about general aviation flight activity. 

CUA 

A-85-013 FAA: Require the registration of ultralight vehicles and develop a mail 

notification system for effective dissemination of significant safety 

information to owners of new and used ultralight vehicles. 

CAAA 

A-93-12 DOT: Devise a method for collecting data from air tour operators that 

can be included in civil aviation exposure information for industry 

comparisons. 

CS 

A-95-057 DOT: Establish and maintain a database of all air tour operators that 

would provide data for use in determining the scope of air tour 

operations and accident rates that can be used to assess the safety of 

the air tour industry. 

CUA 

A-97-053 FAA: Revise procedures for registering experimental aircraft built from 

kits so that the Aircraft Registry database reflects the aircraft kit 

manufacturer, model name and serial number, and make and model of 

installed powerplant. 

CAA 

A-01-073 FAA: Revise the GAATA Survey to more clearly distinguish between 

government aircraft operations that qualify for legal public aircraft status 

and those that do not. 

OAR 

A-01-074 FAA: Identify and implement methods independent of the GAATA 

Survey to check the accuracy of nonairline flight hour estimates. 

OAR 

A-01-075 FAA: Implement a program to (a) measure and track currency of aircraft 

owner contact information in the Civil Aircraft Registry, and (b) 

systematically improve the currency of this information. 

OAR 

A-01-076 FAA: Revise the sampling strategy of the GAATA Survey to achieve a 

precision of public use flight hour estimates equivalent to the precision 

of estimates for personal, business, or corporate general aviation. 

OAR 

A-01-077 FAA: Develop a new reporting matrix on the GAATA Survey form that 

separates administrative purpose-of-flight from the actual flying activity 

performed. Incorporate these changes in published flight hour 

estimates. 

OAR 

A-01-078 FAA: Revise the GAATA Survey form so that aircraft owners can report 

public aircraft flight hours according to the level of government served 

(Federal, State, or local) within each purpose-of-flight. 

OAR 

A-01-079 FAA: Remove Civil Air Patrol flight hours from future estimates of public 

aircraft activity so that the figures are consistent with the current legal 

definition of public aircraft. 

OAR 

A-01-080 FAA: With GSA, define purpose-of-flight categories in the FAIRS that 

correspond to purpose-of-flight categories in the GAATA Survey. 

OAR 

Appendix B
50 Safety Report

Toxicological Testing

Recommendation Recipient and recommended action Status 

A-01-081 GSA: Collect data in such a way that it is possible to distinguish Federal 

public from other Federal aircraft operations. 

OAR 

A-01-082 GSA: With FAA, define purpose-of-flight categories in the FAIRS that 

correspond to purpose-of-flight categories in the GAATA Survey 

OAR 

GAATA Survey = General Aviation and Air Taxi Activity Survey, FAIRS = Federal Aviation Interactive Reporting System. 

Recommendation Recipient and recommended action Status 

A-84-046 FAA: Issue a rule which establishes implied consent to toxicological 

testing as a condition of issuance of an airman certificate. 

CAA 

A-88-036 FAA: Require commercial operators to collect or to cause the collection 

of toxicological speciments from surviving crewmembers involved in 

reportable aircraft incidents or accidents. 

CUA 

A-92-107 FAA: Establish procedures for receiving, processing, and analyzing 

toxicological test results reported by the States. 

CAA 

A-92-108 FAA: Distribute, in conjunction with the NASAO, to State aviation 

authorities and law enforcement agencies the procedures for States to 

follow when notifying the FAA of toxicological test results and refusals to 

submit to testing. 

CAA 

A-92-109 FAA: Amend 14 CFR 91.17 to require crewmembers to submit to a 

toxicological test for drugs when, under authorization of State or local 

laws, a test is requested by a law enforcement officer. 

CUA 

A-92-110 FAA: In cooperation with industry organizations, develop and 

disseminate new informational materials on (a) effects of alcohol and 

other drugs on flying and in general aviation accidents, and (b) 

procedures or actions that will encourage pilots, fixed-base operator 

personnel and others to intervene when a general aviation pilot 

attempts to fly after consuming alcohol or using other drugs. 

CAA 

A-92-113 States: Enact comprehensive laws pertaining to alcohol and drug use in 

aviation, or amend existing laws as appropriate. 

Various 

NASAO = National Association of State Aviation Officials. 

Appendix B
51 Safety Report

Other Topics

Recommendation Recipient and recommended action Status 

A-72-193 CAB: In proceedings involving suspension of service by a certificated 

carrier and substitution of service by an air taxi commuter operator, 

request of the FAA a written safety evaluation of such an operator; 

make a specific finding as to the operator’s safety fitness; and place the 

FAA evaluation in the public docket of such a proceeding. The 

evaluation should include all accident data concerning the operator 

available in NTSB files. 

CAA 

A-72-230 FAA: Conduct further statistical review, technical evaluation, and 

operational testing of those aircraft which exhibited a “very high” 

stall/spin frequency of occurrence. 

CAA 

A-76-128 FAA: Include in air carrier training programs flightcrew discussions of 

formal reports involving approach and landing accidents or incidents. 

CAA 

A-92-069 FAA: Ensure that flight attendant training programs provide detailed 

guidance on the relative probability of hazards associated with 

emergency situations, such as fire, toxic smoke, and explosion. 

CAA 

A-00-079 FAA: Review the 6-foot height requirement for exit assist means to 

determine if 6 feet continues to be the approprate height below which 

an assist means is not needed. The review should include, at a 

minimum, an examination of injuries sustained during evacuations. 

OUA 

A-00-091 FAA: Document the extent of false indications for cargo smoke 

detectors on all airplanes and improve the reliability of the detectors. 

OAR 

Appendix B
52 Safety Report

Highway

Databases related to highway data recommendations issued by the National

Transportation Safety Board are listed below.

NASS Development

Database name or description Sponsoring organization 

Highway Management Information System (HMIS) Federal Highway Administration 

CDL Driver Database Federal Motor Carrier Safety Administration 

Fatality Analysis Reporting System (FARS) National Highway Traffic Safety Administration 

Florida Vehicle Database Florida Department of Motor Vehicles 

Insurance Industry Data Systems Insurance Companies 

National Accident Sampling System (NASS) National Highway Traffic Safety Administration 

National Commercial Truck Database System National Governors Association 

National Electronic Injury Surveillance System (NEISS) U.S. Department of Health and Human 

 Services 

Safety Net Federal Highway Administration 

State Police Accident Reports & Data Systems States 

CDL = commercial driver’s license 

Recommendation Recipient and recommended action Status 

H-78-020 FHWA: Conduct a comprehensive study to identify highway safety 

accident problem factors for which data must be collected to identify 

the problem magnitude, and support research and countermeasure 

formulation. 

CAA 

H-78-021 NHTSA: Establish a NASS advisory committee to provide NHTSA with 

a broader perspective on types of data that should be collected and 

methods of data storage and retrieval. 

CAA 

H-78-022 NHTSA: Study the practical problems associated with collecting key 

data, such as injury data, to determine the magnitude of any problems 

and to assess the impact on the effectiveness of the NASS program 

before selecting the number and location of future NASS investigation 

sites. 

CAA 

H-78-023 NHTSA: Study effects on cost and quality of data collection that could 

result from the need for NASS investigators to testify in liability cases 

resulting from motor vehicle accidents. 

CAA 

H-78-024 NHTSA: Do not increase the number of NASS accident investigation 

sites until after experience with field data collection and processing is 

evaluated, exposure data system design, sample design, accident 

causation methodology, and other NASS studies are completed and a 

comprehensive plan is made public. 

CAA 

Appendix B
53 Safety Report

Work Zones

School Buses

Recommendation Recipient and recommended action Status 

H-78-025 NHTSA: Retain sanitized accident reports and case files completed by 

each NASS investigation team and file at a central location for use by 

persons interested in further research. 

CAA 

H-78-026 NHTSA: Revise currently proposed NASS data collection forms to 

include substantially increased emphasis on the highway environment. 

CAA 

Recommendation Recipient and recommended action Status 

H-92-032 NHTSA: Revise reporting of work zone fatalities to distinguish persons 

driving highway maintenance vehicles within work zones from other 

drivers who crash while traversing the work zone site. 

CAAA 

H-92-033 NHTSA: Review, with FHWA, all State accident report forms, select 

elements that comprehensively document work zone accidents, and 

encourage the States to incorporate these elements in their accident 

report forms. 

CAA 

H-92-034 FHWA: Review, with NHTSA, all State accident report forms, select 

elements that comprehensively document work zone accidents, and 

encourage the States to incorporate these elements in their accident 

report forms. 

CAA 

H-92-035 FHWA: Develop a program to collect exposure data for construction 

work zones on the Interstate system. 

OAR 

Recommendation Recipient and recommended action Status 

H-70-015 NHTSA: Examine, in accident research investigations and studies, the 

nature of school bus disintegration and its significance in injury 

causation. 

CAA 

H-85-009 Florida Department of Highway Safety and Motor Vehicles: Adopt 

regulations to require the owner of a private bus to declare annually if 

the bus is to be used for pupil transportation; use the data to identify 

privately owned and operated schoolbuses subject to vehicle 

inspection and driver certification requirements 

OAR 

H-89-049 NHTSA: Collect and evaluate accident data on the crash performance 

of the roof and emergency exits on small school buses in rollovers. 

CAA 

Appendix B
54 Safety Report

Commuter Buses

Air Bag and Restraint Use

Recommendation Recipient and recommended action Status 

H-89-050 NHTSA: Collect and evaluate accident data involving small school 

buses to ascertain whether school buses rated 10,000 pounds or less 

should be required to meet Federal Motor Vehicle Safety Standard

221, regarding body joint strength 

CAA 

H-99-052 NHTSA: Modify methods of collecting accurate, timely, and sufficient 

data on passenger injuries resulting from school bus accidents so that 

thorough assessments can be made relating to school bus safety. 

CAA 

Recommendation Recipient and recommended action Status 

H-81-055 DOT: Establish a separate vehicle classification for commuter buses 

for the collection of accident data and development of safety statistics. 

CUA 

H-81-056 DOT: Institute a program for gathering and analyzing exposure data for 

the commuter bus industry. 

CUA 

Recommendation Recipient and recommended action Status 

H-83-063 States: Use State accident data systems to collect and analyze data 

on the use/misuse of child safety seats. 

CAA 

H-85-023 NHTSA: Add child safety seat use/misuse variables to FARS. CUA 

H-85-024 NHTSA: Revise NASS report forms to include additional information 

on restraint and child seat misuse. 

CR 

H-85-026 NHTSA: Train NASS investigation teams to investigate child seat 

use/misuse. 

CR 

H-96-017 NHTSA: Evaluate passenger-side air bag safety using all available 

data; modify performance and testing requirements 

CAA 

H-97-004 States: Replace current restraint use data collection systems with 

uniform procedures, tools, and sampling procedures to be provided by 

NHTSA. 

Various 

H-97-013 NHTSA: Establish, with CDC, database of airbag-induced injuries 

identified by the medical community. 

OAAR 

H-97-022 CDC: Establish, with NHTSA, database of airbag-induced injuries 

identified by the medical community. 

OAR 

Appendix B
55 Safety Report

Motor Carriers and Commercial Vehicles

Recommendation Recipient and recommended action Status 

H-81-002 FHWA: Establish database to study relation between Federal motor 

carrier/hazmat regulations and motor carrier accident/incidents. 

CAA 

H-81-003 FHWA: Perform periodic inspections providing statistically valid data 

on carrier compliance with Federal motor carrier safety regulations and 

motor vehicle-related Federal hazardous materials regulations. 

CAA 

H-81-004 FHWA: Develop a plan for using the management information system 

of the Bureau of Motor Carrier Safety for improving enforcement, 

evaluating the effectiveness of enforcement, and for assisting State 

enforcement programs. 

CAAA 

H-81-005 FHWA: Allocate more resources to the development of the Bureau of 

Motor Carrier Safety’s management information system. 

CAA 

H-81-006 FHWA: Develop explicit criteria to ensure that the resources of the 

Bureau of Motor Carrier Safety are focused on companies in most 

need of attention; include such factors as accident experience and 

related exposure data. 

CAA 

H-83-038 AAMVA: Coordinate program among States to collect accident, traffic 

conviction, and other data for truckdrivers transporting hazardous 

materials. 

CAA 

H-88-027 RSPA: Revise the criteria for reporting hazardous materials incidents 

to include vacuum failures of cargo tanks. 

CUA 

H-88-029 State of California: Develop information system to serve as a 

clearinghouse for employment history and training data on commercial 

bus operators. 

CAAA 

H-90-012 DOT: Develop a program to merge elements concerning commercial 

vehicle operations from the separate DOT-operated and supported 

highway accident databases. 

OAR 

H-92-006 RSPA: Implement, in cooperation with FHWA, a program to collect 

information necessary to identify patterns of cargo tank equipment 

failures. 

OAR 

H-92-009 FHWA: Implement, in cooperation with RSPA, a program to collect 

information necessary to identify patterns of cargo tank equipment 

failures. 

OUR 

H-92-059 FHWA: Review the National Highway Data System to ensure that 

sufficient data can be obtained to readily evaluate the role of braking 

deficiencies in commercial vehicle accidents. 

CAA 

H-92-060 States: Encourage State commercial vehicle accident investigation 

agencies to develop policies requiring collection of data from injury or 

fatal accident-involved vehicles, especially brake system data. 

Various 

H-92-061 States: Review the National Highway Data System for your jurisdiction 

to ensure that sufficient data can be obtained to readily evaluate the 

role of braking deficiencies in commercial vehicle accidents. 

Various 

Appendix B
56 Safety Report

Toxicological Testing

Recommendation Recipient and recommended action Status 

H-92-062 States: Require towing companies, in order to preserve evidence for 

accident investigations, to employ methods of releasing locked 

airbrakes that do not alter brake adjustment when removing wreckage. 

Various 

H-92-063 TRAA and ITA: Encourage members to discontinue practice “backing 

off” airbrakes on commercial vehicles during wreckage removal. 

OAWR 

AAMVA = American Association of Motor Vehicle Administrators, TRAA = Towing and Recovery Association of 

America, ITA = Interstate Towing Association, “States” refers to the U.S. States, territories, and District of Columbia. 

Recommendation Recipient and recommended action Status 

H-90-011 DOT: Assess and revise the reporting and accuracy of existing 

database elements regarding toxicological tests in DOT-operated and 

supported highway accident databases and trucking operations 

databases. 

OAR 

H-90-013 DOT and Others: Standardize procedures for postaccident 

toxicological specimen collection, chain of custody, testing, and 

reporting among the States for accidents involving medium and heavy 

trucks. 

OAR 

H-90-014 DOT and Others: Establish a postaccident alcohol and other drug 

analytic test plan with results reported at state-of-the-art sensitivity 

levels. 

OAR 

H-90-015 DOT: Provide funding incentives, guidance, and assistance to the 

States to obtain complete toxicological tests and report results to DOT 

on all vehicle operators in fatal commercial vehicle accidents. 

OAWR 

H-90-016 NHTSA: Revise the FARS to include standardized drug toxicological 

tests; use results to estimate national drug involvement in fatal 

accidents. 

CAA 

H-90-040 NGA: Coordinate development of national programs for state 

implementation of standardized testing for alcohol and other drugs. 

CUAN 

H-90-041 NGA: Develop a program for the reporting of all accident toxicological 

results to the national commercial truck database system. 

CUAN 

H-90-042 States: Enact legislation or issue regulations to require the collection of 

blood samples for alcohol and other drug toxicological testing from all 

vehicle operators in fatal commercial truck accidents. 

CUA 

H-90-043 States: Report alcohol and other drug toxicological tests requested 

and results obtained in fatal accidents to the FARS operated by 

NHTSA. 

CUA 

NGA = National Governors Association. 

Appendix B
57 Safety Report

Accident Environment/Event Data

Accident Vehicle Data

Other Topics

Recommendation Recipient and recommended action Status 

H-81-021 NHTSA: Revise FARS form to record distance from edge of road to 

objects struck. 

CR 

H-81-025 States: Record distance from edge of road to objects struck, road 

curvature. 

CR 

H-81-052 Virginia: Revise accident data system to permit accident data storage 

and retrieval for each roadway on divided highway facilities. 

CAAA 

H-98-017 NHTSA: Include data element identifying cross median accidents in 

the Minimum Uniform Crash Criteria. 

CAA 

Recommendation Recipient and recommended action Status 

H-72-022 NHTSA: Expand data collection and analysis for recreational vehicles. CAA 

H-87-006 15 States and D.C.: Include vehicle identification number on police 

accident reports and computerized databases. 

OAR 

H-87-007 NHTSA: Include vehicle identification number in FARS accident 

records. 

CAA 

H-92-103 DOT: Encourage States to separate wheel from tire defects in accident 

vehicle records. 

CAA 

Recommendation Recipient and recommended action Status 

H-72-039 DOT: Negotiate with U.S. Department of Health, Education, and 

Welfare to use the NEISS for collecting data on nonoperating motor 

vehicle accidents and injuries. 

CAA 

H-79-052 New York City Police Commissioner: Provide accident data to highway 

transportation officials until a central accident records system is 

implemented. 

CAA 

H-81-046 DOT: Direct NHTSA and FHWA to meet with All Insurance Research 

Advisory Council to establish consultative arrangement to use 

insurance industry data for agency research. 

CAA 

H-97-006 States: Incorporate standardized data elements developed by NHTSA, 

FRA, and Association of Governor's Highway Safety Representatives 

on State police accident report forms. 

Various 

Appendix B
58 Safety Report

Marine

Databases related to marine data recommendations issued by the National

Transportation Safety Board are listed below.

BARD Development

Database name or description Sponsoring organization 

Boating Accident Report Database (BARD) United States Coast Guard 

State Boating Accident Report Databases U.S. States and territories 

Recommendation Recipient and recommended action Status 

M-69-047 USCG and States: Use the same boating accident report form and 

collect more detailed information describing weather, engine and 

material failures, operator intoxication, and physical impairment. 

Conduct thorough, uniform investigations. 

CNLA 

M-71-020 USCG and States: Develop information useful for formulating 

preventative measures for boating accidents. 

CAA 

M-71-021 USCG: Consider the use of specially trained investigators who would 

be familiar with small boat design and operations, and who could 

conduct on-scene investigations in depth. 

CAA 

M-71-022 USCG and NASBLA: Consider establishment of a training program for 

boating accident investigators. 

CAA 

M-71-023 USCG: Evaluate the effectiveness of the present narrative boating 

accident investigation report as source of data documenting the need 

for minimum safety standards for recreational boats and equipment: 

CAA 

M-71-024 USCG: Consider limiting narrative reports to accidents investigated on 

scene and in sufficient detail to develop preventative measures. 

CAA 

M-71-025 USCG: Review boating accident reports, analyzing those involving 

similar or identical boats to determine design changes necessary to 

prevent recurrence. 

CAA 

M-71-026 States: Utilize Federal and State funds to increase the number of State 

boating officials and necessary equipment to expand and improve the 

effectiveness of boating accident investigations 

CAA 

M-71-027 USCG: Consider alternative investigative techniques in recreational 

boating accident investigations, such as those used in highway 

accidents, and select accidents for in-depth investigation which have 

the best potential for preventative countermeasures. 

CAA 

M-93-010 USCG: Implement a fatal accident reporting system, comparable to 

the NHTSA FARS, and develop a three-level report form and 

corresponding data files. Develop guidelines for the submission of 

data and standardization of cause codes. Develop uniform data entry 

at the State level 

CAA 

NASBLA = National Association of State Boating Law Administrators. 

Appendix B
59 Safety Report

Tow Vessels and Inland Waterways

Survival Equipment

Recommendation Recipient and recommended action Status 

M-71-008 USCG: Analyze the casualties involving towing vessels operating in 

inland waters to determine whether there is a need for legislation 

requiring inspection of all towing vessels. 

CAAA 

M-85-018 USCG: Analyze the cause of accidents in critical areas of western 

rivers which are difficult to navigate and in areas with above average 

accident rates or recurrent major accidents to determine which 

accidents resulted from personnel error or operator unfamiliarity with 

the area. Use this data to develop exam or exercise questions on local 

knowledge of these areas. 

CAA 

M-88-006 State of Louisiana: Require the Board of New Orleans-Baton Rouge 

Steamship Pilot Commissioners to compile data on accidents and 

submit an annual report to the Louisiana DOT. 

CAA 

M-00-010 USCG: Seek authority to require domestic towing companies to 

develop and implement an effective safety management system to 

ensure adequate management oversight of the maintenance and 

operation of all towing vessels. 

OAAR 

Recommendation Recipient and recommended action Status 

M-71-031 USCG: Analyze casualty reports of towing vessels to evaluate the 

need for regulations requiring inflatable liferafts of sufficient capacity to 

accommodate all persons on board. 

CAA 

M-72-027 USCG: Analyze data on loss of U.S. vessels more than 20 miles off 

shore which were not subject to provisions of the 1960 SOLAS 

Convention and determine to what degree the carriage of emergency 

position-indicating radio beacons might have reduced loss of life; 

determine whether carriage of these beacons should be mandatory for 

these types of vessels. 

CNLA 

M-86-100 USCG: Revise the Boating Accident Report Form, in coordination with 

the NASBLA, to include data that would enable assessment of 

personal flotation device performance. 

CAA 

NASBLA = National Association of State Boating Law Administrators. 

Appendix B
60 Safety Report

Toxicological Testing

Marine Exposure Data

Recommendation Recipient and recommended action Status 

M-83-070 USCG: In coordination with the NASBLA, revise the Boating Accident 

Report Form to include a specific accident causal entry for alcohol 

involvement in recreational boating accidents. 

CAA 

M-83-074 NASBLA: In coordination with the USCG, revise the Boating Accident 

Report Form to include a specific accident causal entry for alcohol 

involvement in recreational boating accidents. 

CAA 

M-83-078 10 States: Require procedures for toxicological tests in the event of a 

recreational boating fatality to document the role of alcohol in 

recreational boating accidents and fatalities. 

CS 

M-93-002 States: Enact legislation requiring a chemical test to determine the 

blood alcohol concentration of all recreational boat operators involved 

in a fatal boating accident. 

OAR 

M-93-006 States: Enact legislation requiring toxicological testing of all 

recreational boating fatalities. 

OAR 

M-93-007 NASBLA: Urge members to seek legislative action requiring a 

chemical test to determine the blood alcohol concentration of all 

recreational boat operators involved in a fatal boating accident. 

CAA 

NASBLA = National Association of State Boating Law Administrators. 

Recommendation Recipient and recommended action Status 

M-72-003 USCG: (a) Evaluate conditions of marine traffic in major ports and 

waterways to determine needed traffic controls; (b) establish a priority 

list for establishment of traffic control; (c) compile casualty data on a 

more localized basis; (d) obtain data pertaining to traffic density, traffic 

patterns, types of cargo moved, and other pertinent data for 

determining the need for traffic control. 

CAA 

M-98-091 USCG: Collect recreational boating exposure data, such as 

“operational use time” or “vessel running time” and update this 

information on an annual basis or conduct periodic surveys 

CAA 

Appendix B
61 Safety Report

Pipeline

Databases related to pipeline data recommendations issued by the National

Transportation Safety Board are listed below. All of these databases are maintained by

RSPA.

Develop Analysis Plan

Excavation Exposure Data

Database name or description Sponsoring organization 

Incident Report: Gas Transmissions and 

Gathering Systems 

Research and Special Programs Administration 

Accident Report: Hazardous Liquid Pipeline Research and Special Programs Administration 

Incident Report: Gas Distribution System Research and Special Programs Administration 

Recommendation Recipient and recommended action Status 

P-78-058 RSPA: Publish a plan for using pipe safety data. CS 

P-78-061 RSPA: Computerize liquid pipeline accident data; analyze. CUA 

P-80-061 RSPA: Develop pipeline data analysis plan. CUA 

P-80-062 RSPA: Create office responsible for pipeline data analysis. CAA 

P-80-063 RSPA: Postpone promulgation of new forms until analysis plan in 

place. 

CUA 

P-90-009 Kansas Power & Light: Develop collection and analysis program. CAA 

P-96-001 RSPA: Develop plan for collection and analysis of gas and liquid data. OAR 

Recommendation Recipient and recommended action Status 

P-97-022 RSPA: Develop plan for collecting excavation damage exposure. OAR 

P-97-023 RSPA: Ensure that excavation exposure data are consistently 

collected. 

OAR 

P-97-024 RSPA: Use excavation exposure data to evaluate State safety 

programs. 

OAR 

P-97-026 APWA: Develop plan for collecting excavation damage exposure data. CUAN 

P-97-027 APWA: Ensure that excavation exposure data are consistently 

collected. 

CUAN 

P-97-028 APWA: Use excavation exposure data to evaluate State safety 

programs. 

CUAN 

APWA = American Public Works Association. 

Appendix B
62 Safety Report

Improve Report Completeness/Accuracy

Improve Event Identification

Redesign Pipeline Reporting System

Other Topics

Recommendation Recipient and recommended action Status 

P-78-060 RSPA: Improve instructions/definitions on liquid form. CUA 

P-78-062 RSPA: Check liquid reports for completeness. CAA 

P-80-064 RSPA: Improve directions on report forms, define uncommon terms. CR 

P-80-065 RSPA: Train personnel to validate incoming leak reports. CAAA 

P-97-020 RSPA: Distribute guidelines to operators to improve report accuracy. OAR 

Recommendation Recipient and recommended action Status 

P-68-002 RSPA: Improve communication with State agencies. CAA 

P-72-042 RSPA: Require operators to maintain leak/emergency report log. CAAA 

P-88-002 RSPA: Require reporting of incidents involving excess concentrations 

of hydrogen sulfide in gas pipes. 

CUA 

Recommendation Recipient and recommended action Status 

P-78-059 RSPA: Redesign liquid system to be more like gas. CUA 

P-97-021 RSPA: Revise incident categories on gas and liquid report forms. OAR 

Recommendation Recipient and recommended action Status 

P-80-069 RSPA: Examine safety of fillet-welded reinforced sleeves using 

incident reports. 

CUA 

P-85-021 AGA: Companies examine records for failures like Phoenix, Arizona, 

accident. 

CAA 

AGA = American Gas Association. 

Appendix B
63 Safety Report

Railroad

Databases related to railroad data recommendations issued by the National

Transportation Safety Board are listed below.

Highway–Rail Grade Crossings

Database name or description Sponsoring organization 

AAR–RPI Accident Data Association of American Railroads 

FRA test center data Federal Railroad Administration 

Grade Crossing Incident Report Database Federal Railroad Administration 

Grade Crossing Inventory Database Federal Railroad Administration 

Hours-of-Duty Records Railroad Operators 

Operator near-miss databases for highway–rail crossings Railroad Operators 

Railroad Accident/Incident Report Database Federal Railroad Administration 

TOFC/COFC Reporting System Association of American Railroads 

Recommendation Recipient and recommended action Status 

H-83-002 State of Arkansas: Encourage railroad companies operating within the 

State to develop a near-miss data system that will permit them to 

promptly report violators of grade crossing safety laws to State 

authorities. 

CAA 

H-96-001 DOT: Amend the DOT/Association of American Railroads Grade 

Crossing Inventory Database to include vertical profile information on 

all highway–rail grade crossings in the United States. 

OAR 

H-98-033 DOT: Develop a standardized hazard index or a safety prediction 

formula that will include all variables proven by research or experience 

to be useful in evaluating highway–rail grade crossings, and require 

the States to use it. 

OAR 

Appendix B
64 Safety Report

Hazardous Materials

Rail Accident/Incident Data

Recommendation Recipient and recommended action Status 

R-69-027 AAR: Review the function of the Bureau of Explosives (BE) regarding 

its performance in protecting the public from danger resulting from 

railroad accidents involving hazardous materials and develop a 

cooperative program with the carriers to help fulfill the BE’s 

responsibility. The Safety Board endorses the FRA’s proposed 

amendment to the regulations which will provide that reports of 

incidents and accidents involving hazardous materials presently made 

to the BE by rail carriers will also be filed with the FRA. 

CNLA 

R-79-016 FRA: Develop a database that will allow the definition and rating of 

railroad safety problems, particularly those related to derailment of 

hazardous materials. 

CAA 

R-80-014 DOT: Collect data on tank car derailment behavior to identify breach 

mechanisms, analyze these mechanisms, identify control methods, 

and incorporate findings in new car construction. 

CAA 

AAR = Association of American Railroads. 

Recommendation Recipient and recommended action Status 

R-74-001 FRA: Revise criteria for reporting train accidents so that the causal 

categories involving rail failures are consistent with other FRA 

regulations and accurately identify areas requiring further corrective 

measures. 

CAA 

R-74-008 AAR and AREA: Gather and evaluate data necessary to identify the 

types and magnitude of rail failures experienced by American 

railroads. Computerize the information for rapid retrieval. 

CAAA 

R-78-005 FRA: Analyze the data relating to the role of radio in train accidents 

and report the findings. 

CUA 

R-83-106 FRA: Require that landslides on railroad rights-of-way be reported 

separately from other weather-related accident data. 

CR 

R-91-040 FRA: Require the recording of data pertaining to postcrash fires 

involving locomotive fuel tank rupture and spillage, and types of 

locomotives involved, to enhance current accident data collection and 

analysis. 

CS 

R-94-009 AAR: Collect data from your members on vessel collisions with 

railroad bridges and, if appropriate, take steps to increase protection 

for bridges identified as vulnerable. 

CAA 

R-96-013 FRA: Conduct appropriate research and develop a database that can 

be used to assess the risk posed by flattened rail heads. 

CAAA 

Appendix B
65 Safety Report

Toxicological Testing

Recommendation Recipient and recommended action Status 

R-97-011 FRA: Develop and maintain separate identifiable data records for 

commuter and intercity rail passenger operations. 

OAR 

R-95-023 AAR: Advise the NTSB within 90 days of progress toward developing 

and maintaining a database of incidents involving unsafe conditions for 

TOFC/COFC shipments. 

CAA 

AAR = Association of American Railroads, AREA = American Railway Engineering Association. 

Recommendation Recipient and recommended action Status 

R-83-032 FRA: With the assistance of the AAR and the RLEA, develop and 

promulgate a requirement that alcohol/drug abuse involvement 

accidents/incidents be fully reported to the FRA. 

CAA 

R-88-023 FRA: Amend 49 CFR 219 to require postaccident toxicological testing 

of all employees in safety-sensitive positions. 

CR 

R-88-026 FRA: Amend 49 CFR 219 to require toxicological testing in all train 

accidents in which estimated railroad damage, based on replacement 

costs and other estimated losses, including nonrailroad property 

losses, are $150,000 or more. 

CR 

R-88-027 FRA: Amend 49 CFR 219 to require toxicological testing of all 

employees involved in any impact accident resulting in an injury as 

defined in 49 CFR 225.5(3)(III). 

CR 

R-88-031 FRA: Amend 49 CFR 219 to require railroads to collect all appropriate 

toxicological samples as soon as practicable and not more than 

4 hours after the triggering event. 

CAA 

R-89-033 Burlington Northern Railroad Company: Reemphasize to on-line 

officers involved in the sample collection process the need to collect 

toxicological samples promptly. 

CAA 

R-01-017 FRA: Modify 49 Code of Federal Regulations 219.201(b) as necessary 

to ensure that the exemption from mandatory postaccident drug and 

alcohol testing does not apply to any railroad signal, maintenance, and 

other employees whose actions may have contributed to the 

occurrence or severity of the accident. 

OAR 

RLEA = Railway Labor Executives Association. 

Appendix B
66 Safety Report

Rail Exposure Data

Rail Maintenance Data

Recommendation Recipient and recommended action Status 

R-91-039 FRA: Develop a uniform simplified format for work-record data 

collected by the rail carriers. 

CAA 

R-98-041 FRA: Modify the grade crossing inventory system to include 

information on (1) the sign distances available to a motorist, and (2) 

the presence of curves on the roadway and on the tracks. Direct 

States to include these data as a part of the regularly scheduled 

updates of the database. 

CAA 

R-98-042 FRA: Encourage the railroads to ensure that the U.S. Department of 

Transportation identification number is properly posted at all grade 

crossings. 

OUR 

Recommendation Recipient and recommended action Status 

R-72-001 FRA: (a) to the extent that data are available, promulgate regulations 

to insure the retirement of critical car components before normal 

service failure; (b) where data are not available, initiate programs to 

determine the data required to promulgate regulations in those areas; 

(c) promulgate regulations to prevent misapplication of critical 

components. 

CNLA 

R-00-009 FRA: Audit the AAR and individual railroad equipment repair 

databases to determine whether adequate quality control procedures 

have been incorporated to ensure that database information is 

complete, accurate, and secure. Direct the AAR and individual 

railroads to correct all identified deficiencies. 

OAR 

Appendix B
67 Safety Report

Transit

Databases related to transit data recommendations issued by the National

Transportation Safety Board are listed below.

Rail Rapid Transit

Database name or description Sponsoring organization 

Safety Management Information System Federal Transit Administration 

New York City Transit Authority Automated Management 

 Information System 

City of New York 

Recommendation Recipient and recommended action Status 

R-71-019 FRA: Establish, by regulation, a uniform system of data gathering and 

accident reporting encompassing all the rail rapid transit operations in 

the United States from which safety statistics can be compiled. 

CAA 

R-73-034 State agencies authorizing rapid transit systems: Develop budget, 

planning, and technical safety capability competent to: (a) define 

safety criteria that the system must meet for operating authorizations 

to be issued; (b) describe the data that is to be presented, and the 

methods to be used by the transit authority in demonstrating to the 

agency that the system meets the safety criteria established; (c) 

schedule agency safety activities to be in consonance with the transit 

program development schedules. 

CNLA 

R-81-115 NYCTA: Revise the NYCTA Automated Management Information 

System to provide sufficient detailed information to permit analysis of 

the incidence and causes of equipment failures or malfunctions 

affecting the safety of passengers. 

CAA 

R-85-113 NYSPTSB: Require the NYCTA to establish integrated reporting 

systems on track and structures fires and car equipment fires. 

CAA 

R-85-114 NYSPTSB: Require the NYCTA to ensure that all track and structures 

fires and all repairs and maintenance of car equipment are being 

reported in its data collection systems. 

CAA 

R-88-034 UMTA: Require that all employees involved in a rail rapid transit 

accident with a fatality, injury, or property damage be tested in a timely 

manner for alcohol and drugs. 

CS 

R-91-036 UMTA: Develop an accident/incident reporting form for rail rapid transit 

systems that distinguishes between passenger and employee injuries 

and fatalities and require transit systems to file these reporting forms 

periodically. Publish this information and exposure rate data for each 

system annually. Regularly analyze the data to determine trends in 

accidents and injuries. 

CAA 

NYCTA = New York City Transit Authority, NYSPTSB = New York State Public Transportation Safety Board, UMTA was 

the Urban Mass Transportation Administration. 

Appendix B
68 Safety Report

Transit Buses

Recommendation Recipient and recommended action Status 

H-97-026 DOT: Collect accident data involving school children riding transit 

buses, including pedestrian accidents to assist development of 

appropriate means to ensure that school children riding on transit 

buses are afforded an equivalent level of operational safety as school 

children riding on school buses. 

OAR 

H-98-044 DOT: Collect accurate, timely, and sufficient data so thorough 

assessments can be made regarding transit bus safety. 

OAR 

H-98-045 DOT: Evaluate the collected data, as part of the oversight program, to 

identify the underlying causes of transit bus accidents that could lead 

to the identification of safety deficiencies at transit agencies. 

OAWR 

Appendix B
69 Safety Report

Intermodal

Databases related to intermodal data recommendations issued by the National

Transportation Safety Board are listed below.

Cross Modal Accident Data

HMIS Development

Database name or description Sponsoring organization 

Hazardous Materials Information System (HMIS) Research and Special Programs Administration 

Recommendation Recipient and recommended action Status 

I-71-004 DOT: Develop and publish, on a regular basis, comparable data on 

losses and loss rates associated with all modes of freight 

transportation. 

CNLA 

I-81-010 DOT: Develop method to cross-reference accidents compiled by DOT 

administrations to periodically assess the validity of the data and the 

completeness of the data files. 

CAA 

I-01-001 

RSPA: Ensure that comprehensive reports are submitted for all 

significant failures of US DOT specification containers of hazardous 

materials. 

OAR 

Recommendation Recipient and recommended action Status 

H-69-002 DOT: Develop a uniform, cross-modal reporting form for hazardous 

materials incidents and accidents. 

CAA 

H-69-003 DOT: Develop a centralized reporting system, coordinating the 

handling of reports of all hazardous materials incidents and accidents 

by carriers to the administrations and the Coast Guard, and operating 

through a central “clearinghouse” where such data would be collected 

and evaluated. 

CAA 

H-69-004 DOT: Develop uniform regulations for all modes of transport relating to 

the shipment and carriage of hazardous materials to assure 

substantial uniformity as to reporting requirements and processing of 

hazardous materials incident and accident reports. 

CAA 

I-76-009 DOT: Redesign the hazardous materials incident data reporting 

system so it will generate information about what emergency actions 

were taken, why they were taken, and what influence they had on the 

outcome of the emergency, for use in training firefighters and law 

enforcement personnel. 

CAA 

Appendix B
70 Safety Report

Toxicological Testing

Recommendation Recipient and recommended action Status 

I-79-014 RSPA: Incoporate hazardous materials incident survival action data in 

the new centralized HMIS. 

CAA 

I-79-015 RSPA: Establish procedures to promptly utilize survival action data 

and evaluate the influence of regulatory safeguards on the outcome of 

serious hazardous materials incidents. 

CAA 

I-79-016 RSPA: Use survival action data to revise emergency guidelines, 

incorporating recommended actions, their purpose, and the effect they 

should have in reducing losses following the release of hazardous 

materials. 

CAA 

I-81-008 DOT: Include NHTSA as a member of the task force for the HMIS 

which will determine hazardous materials data needs for accident 

reports. 

CAA 

I-81-009 DOT: Consider the development of uniform short supplemental 

accident data forms to supplement existing FHWA, FRA, and NHTSA 

accident report forms. 

CAA 

Recommendation Recipient and recommended action Status 

H-00-015 FMCSA: Establish, in coordination with the DOT, FRA, FTA, and 

USCG, comprehensive toxicological testing requirements for an 

appropriate sample of fatal highway, railroad, transit, and marine 

accidents to identify the role played by common prescription and overthe-counter medications. Review and analyze the results of such 

testing at intervals not to exceed every 5 years. 

OAWR 

I-00-001 DOT: Establish, in coordination with the DOT, FMCSA, FRA, FTA, and 

USCG, comprehensive toxicological testing requirements for an 

appropriate sample of fatal highway, railroad, transit, and marine 

accidents to identify the role played by common prescription and overthe-counter medications. Review and analyze the results of such 

testing at intervals not to exceed every 5 years. 

OAWR 

M-00-004 USCG: Establish, in coordination with the DOT, FMCSA, FRA, FTA, 

and USCG, comprehensive toxicological testing requirements for an 

appropriate sample of fatal highway, railroad, transit, and marine 

accidents to identify the role played by common prescription and overthe-counter medications. Review and analyze the results of such 

testing at intervals not to exceed every 5 years. 

OAWR 

Appendix B
71 Safety Report

Recommendation Recipient and recommended action Status 

R-00-004 FRA: Establish, in coordination with the DOT, FMCSA, FTA, and 

USCG, comprehensive toxicological testing requirements for an 

appropriate sample of fatal highway, railroad, transit, and marine 

accidents to identify the role played by common prescription and overthe-counter medications. Review and analyze the results of such 

testing at intervals not to exceed every 5 years. 

OAR 

R-00-008 FTA: Establish, in coordination with the DOT, FMCSA, FRA, and 

USCG, comprehensive toxicological testing requirements for an 

appropriate sample of fatal highway, railroad, transit, and marine 

accidents to identify the role played by common prescription and overthe-counter medications. Review and analyze the results of such 

testing at intervals not to exceed every 5 years. 

ORR 

Appendix B