Transportation safety improvements from the

National Transportation Safety Board, an

independent agency whose mission saves

lives via accident investigations,

safety recommendations, and advocacy.

1967-2007

NTSB

40th Anniversary

Dedicated to Excellence

Lessons Learned and

Lives Saved

1967 - 2007

National Transportation Safety Board

E PLURIBUS UNUM

Safety Report

NTSB/SR-07/01

PB2007-917001 

Nat  ional Transportation Safety Board

Lessons Learned and Lives Saved

National Transportation Safety Board

Transportation safety improvements from 

the National Transportation Safety Board, an 

independent agency, whose mission saves 

lives via accident investigations, 

safety recommendations and advocacy.

Lessons Learned and

Lives Saved

Lessons Learned and

Lives Saved

NTSB/SR-07/01

PB2007-917001

We Are All Safer
ii National Transportation Safety Board

Lessons Learned and Lives Saved

National Transportation Safety Board. 2007. We Are All Safer: Lessons Learned and 

Lives Saved, 5th Edition. Safety Report/SR-07/01. Washington D.C.

Abstract: To help mark the NTSB’s 40th anniversary, this report highlights some of the thousands 

of transportation safety improvements that have resulted from NTSB accident investigations and 

recommendations. Accidents have been prevented, lives saved and injuries reduced because of NTSBinspired safety advances in all modes of transportation: aviation, highway, marine, railroad and pipeline. 

This reports also gives a brief history of the Safety Board, its responsibilities, and the legislation that 

created it, that strengthened its independence, and that has expanded its safety role over the years. This 

report includes information on the “Most Wanted List.” The list focuses on additional safety advances 

the Safety Board strongly believes are needed to further increase transportation safety. The report also 

lists noteworthy Safety Board public forums and meetings, and a list of Board Members, 1967 through 

the present.

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

Records Management Division, CIO-40

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 PB2007-917001 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. 
Nat iii ional Transportation Safety Board

Lessons Learned and Lives Saved

40 Years of Lessons Learned and Lives 

Saved....................................................iv

The Safety Board’s 

Unique Mandate ..................................vi

Independent Agency .................................................vi

Safety Mission ...........................................................vi

Public Trust ...............................................................vii

Objective and Unbiased ...........................................vii

Safety Recommendations ..........................................vii

Leveraging Resources ..............................................viii

Statutory Authority ...................................................viii

The Safety Board and the Law ....................................ix

NTSB-Inspired Safety 

 Advances ............................................1

Airplane Maintenance and Inspection .......................1

Alcohol and Drugs in Transportation .........................3

Bridge Safety ..........................................................4

Commercial Fishing Vessel and Towing Safety ...........5

Commercial Motor Vehicles .....................................6

Commuter Airline Safety ..........................................7

Crew Communications ............................................7

Cruise Ship Safety ...................................................8

Data Reporting and Recorders .................................9

Design and Technology Advances ............................10

Emergency Evacuations ...........................................12

Emergency Response to Accidents ............................14

Excavation Damage Prevention ................................15

Fatigue in Transportation .........................................16

Grade Crossing Safety ............................................17

Hazardous Materials ...............................................18

Helicopter Safety ....................................................19

Icing Prevention on Aircraft.......................................19

Passenger and Occupant Protection .........................20

Pipeline Safety ........................................................22

Railroad Tank Car Safety .........................................24

Recreational Boating ...............................................24

Runway Safety ........................................................25

Safety in Alaska’s Skies ............................................25

School Bus Safety ...................................................26

Teen Drivers ...........................................................27

Train and Mass Transit Safety ...................................27

Training .................................................................28

Weather and Visibility Hazards .................................29

Work Zone Safety ...................................................30

NTSB Most Wanted List .......................31

“Most Wanted List” Highlights Needs for 

More Safety Advances ....................................31

Actions needed by Federal Agencies .........................31

Aviation .............................................................31

Railroad ............................................................32

Highway ............................................................33

Marine ..............................................................33

Intermodal .........................................................34

Action needed by the States .....................................34

Highway ............................................................34

Marine ..............................................................35

Commmunicating Our Safety 

Message...............................................36

Board Members....................................41
iv National Transportation Safety Board

Lessons Learned and Lives Saved

Dear Fellow Citizens:

Forty years ago the National Transportation Safety Board 

was created with a straightforward and noble mission—to investigate 

transportation accidents, find out what happened, and issue safety 

recommendations to make sure that similar accidents don’t happen in the 

future.

Since the NTSB was launched on April 1, 1967, we have 

investigated more than 138,000 accidents in all modes of transportation: 

aviation, highway, marine, pipeline and rail. We have issued more than 

12,600 safety recommendations, each with the goal of improving safety 

for the traveling public, saving lives and, reducing injuries.

Our recommendations have an 82 percent acceptance rate, a 

record that shows trust in our investigative accuracy by the transportation 

industry, and Federal, State and local transportation safety regulators in 

the United States and around the world.

To mark four decades of lessons learned and lives saved, this 

publication attempts to provide a brief look at examples of some of 

our recommendations that have been implemented and how they have 

impacted safety. These positive actions have been the result of the NTSB’s 

independence, professionalism, and thorough accident analyses, which 

are recognized for their objectivity and credibility.

As the NTSB marks this major milestone, I am honored to serve 

as Chairman, and I look forward to the safety challenges of future. I 

hope you will see from reading this publication how a small, independent 

federal agency has made a big difference in transportation safety.

Mark V. Rosenker

Chairman

National Transportation Safety Board

April 2007

Mark V. Rosenker

40 Years of Lessons Learned 

and Lives Saved 1967-2007
National Transportation Safety Board

Lessons Learned and Lives Saved

“Our transportation system is vital to the nation’s 

economy and well-being. And although this system 

generally performs well, when transportation 

accidents do occur, it is imperative that we be able to 

reassure the American public that the Government is 

conducting thorough, timely, honest, competent, and 

unbiased investigations. Since 1967, the NTSB has 

fulfilled that role.”

“The NTSB enjoys broad bipartisan support because 

of our independence, the quality and dedication of 

our staff and the significant contributions we have 

made to transportation safety in the United States 

and around the world.”

“Over the years, important responsibilities have 

been added to the NTSB’s mission of accident 

investigation. In October 2006, we observed 

the 10th anniversary of the passage of important 

legislation that gave us the lead in coordinating 

assistance for families of the victims of major aviation 

accidents. Since then, our efforts have led us to 

provide assistance in all modes of transportation 

when called upon. Our Transportation Disaster 

Assistance program is now the model used by other 

federal agencies, the transportation community, the 

non-profit sector and other accident and disaster 

assistance agencies worldwide.”

“As the newest Member of the NTSB, I am honored 

to serve as the agency marks its 40th anniversary. 

During my many years in the aviation industry I 

have admired the Safety Board’s work of producing 

objective and thorough accident investigations. 

The NTSB has earned world-renowned credibility 

and in so doing continues to fulfill our primary 

goal of advancing the traveling public’s safety and 

therefore their trust. The Safety Board has steadfastly 

and successfully improved safety by issuing 

recommendations that have wide acceptance in all 

modes of transportation. I am happy to have the 

opportunity to be part of the Safety Board’s legacy.”

Deborah A. P. Hersman 

Member

Kathryn O’Leary Higgins 

Member

Robert L. Sumwalt III

Vice Chairman

1967-2007

NTSB

40th Anniversary

Steven R. Chealander 

Member
vi National Transportation Safety Board

Lessons Learned and Lives Saved

The Safety Board’s Unique 

Mandate

Since 1967, a series of Federal laws created and shaped 

the National Transportation Safety Board into a highly-respected 

organization with the goal of preventing and reducing the severity of 

future transportation accidents. It independently addresses real-world 

safety problems, allows full government and industry participation in its 

investigations, issues safety recommendations and works hard to get 

them implemented, and disseminates its reports and findings as widely as 

possible.

The Safety Board also provides oversight of transportation 

regulatory agencies, and is the eyes and ears of millions of Americans 

traveling through our nation’s skies; traveling on our roads, rails, and 

waterways each day; and living and working near pipelines. The Safety 

Board does not regulate transportation equipment, personnel, or 

operations, and it does not initiate enforcement action. 

Independent Agency

The Safety Board has investigated more than 128,000 aviation 

accidents and over 10,000 surface transportation accidents—becoming 

the world’s premier transportation accident investigation agency. On 

call 24 hours a day, 365 days a year, investigators travel throughout 

the country and to every corner of the world to investigate significant 

accidents and develop factual records and safety recommendations. As 

a small and lean organization with less than 400 employees, the Safety 

Board reacts quickly to changes in the transportation environment. The 

Safety Board strives to restore and maintain the public’s confidence 

in the safety of the nation’s transportation systems following accidents 

and serious incidents in aviation, rail, highway, marine, pipeline, and 

hazardous materials.

Safety Mission

The Safety Board gets involved when there is a breakdown 

in a transportation system such as an accident or serious incident. It 

investigates these events, determining the probable cause, and makes 

recommendations to prevent them from happening again. It takes the 

“lessons learned” from real-world accidents and uses them as catalysts 

to prevent future transportation deaths, injuries, and property damage. 

In addition to individual accident investigations, the Safety Board 

often consolidates a series of accident and incident investigations on 

specific safety issues and publishes safety studies or sponsors industry 

conferences and workshops on recurring safety issues such as human 

fatigue, corporate safety culture, motorcycle safety, transportation disaster 

assistance, and transportation recording devices. These studies often 

spur action by industry and government agencies to improve safety. 

This proactive focus, along with the agency’s authority, independence, 

objectivity, technical competence, and worldwide reputation, has been 

the cornerstone of the Safety Board’s success.

Little Time to Celebrate 

On April 1, 1967, most Safety Board employees 

had the same duties as they had in their previous 

government jobs – only under a new agency name. 

The new Safety Board’s initial staff of 185 was 

taken from the Civil Aeronautics Board’s (CAB) 

Bureau of Safety, which had existed since 1940, 

and its Bureau of Hearing Examiners.

Investigators had little time to celebrate the new 

agency because there were three major domestic 

airplane crashes with a total of 83 fatalities in 

the United States in the previous month. Some 

investigators left Washington as CAB employees 

on March 30 when a DC-8 crashed in New 

Orleans. When they returned home, they were 

NTSB employees. Others were assisting with the 

foreign investigation of a DC-8 crash in Liberia 

less than a month earlier. And on April 3, an 

air taxi flight crashed in Lexington, Kentucky, 

killing 9 people.

The first five members of the Board were not 

sworn in until May 2, 1967. Paramount to 

the ongoing need to investigate accidents was 

the need to create organizational units and 

procedures for accomplishing the agency’s mission. 

Only offices of administration and government 

affairs were lacking that first year.

CAB one day, NTSB the next: Investigators were 

CAB employees on March 30, 1967, when they 

went to New Orleans to probe a DC-8 crash. They 

returned as NTSB employees. This photo shows 

Board Member Oscar Laurel briefing reporters at the 

accident site.
Nat vii ional Transportation Safety Board

Lessons Learned and Lives Saved

In 2003, the NTSB Training Center opened its door as the 

agency’s first comprehensive training and learning facility. The center 

trains and teaches Safety Board employees and transportation industry 

personnel from throughout the United States and the world. It designs its 

courses to further its motto: “Independence, integrity, and innovation in 

transportation accident investigation.”

Public Trust

The public relies on and trusts the information provided by 

the Safety Board, whose work results in widely disseminated public 

documents so that the lessons learned from one accident or incident 

can be used to prevent future tragedies. During investigations, the Safety 

Board regularly provides factual briefings to the media and families of 

victims to ensure that accurate information is provided to the public 

in a timely and informative manner. This tradition of openness and 

independence has gained the trust of the American people. 

Objective and Unbiased

The Safety Board provides independent oversight of the nation’s 

transportation system by monitoring the effectiveness of regulatory 

bodies at the Federal, State, and local levels. These investigations help 

regulatory organizations recognize and acknowledge when their safety 

regulations or programs are ineffective and improve them, sometimes 

after repeated accidents. The public has consistently shown strong 

support for the Safety Board’s independent, unbiased assessment of the 

cause of accidents and needed safety improvements. 

Safety Recommendations 

Since the Safety Board began its work, more than 12,600 

safety recommendations have been issued with three straightforward 

goals: to prevent accidents, to save lives, and to reduce injuries. Safety 

Recommendations are the primary tool used by the Safety Board to 

pursue safety improvements and prevent future accidents. Its reputation 

for careful and deliberate examination of the facts and circumstances, 

impartiality, technical competence, and thoroughness has enabled the 

Safety Board to achieve a high acceptance rate on recommendations. 

Contributing to this success rate is the practice of including industry and 

regulatory agencies as participants in the investigation. This practice 

quickly alerts these entities to accident findings, and they are more 

amenable to recommended changes because of their participation on 

the technical investigative team. The Safety Board believes that every one 

of its recommendations is important, and when implemented, all of them 

will improve safety.

The Safety Board also has a “Most Wanted List”—a series of 

safety recommendations selected for intensive follow-up and heightened 

awareness because they will impact or enhance the safety of the national 

transportation system, have a high level of public visibility or interest, 

and are recommendations that would benefit from more attention. A 

major change was instituted in 2003 to the list: a new classification 

and timeliness system using red, yellow, and green color-coding. 

The first chairman, Joseph J. O’Connell, Jr. 

undertook the search for additional staff to carry 

out the Safety Board’s surface transportation 

safety duties. Only 19 days later, two freight 

trains collided head on in New York City, killing 

the six crewmembers.

By the end of 1967, the Safety Board’s aviation 

staff had investigated eight major accidents, 

conducted seven public hearings, issued 10 

major accident reports, assisted in seven 

foreign investigations, and read out 42 cockpit 

voice recorders and 87 flight data recorders. 

Investigators in 11 field offices that had been 

part of the CAB investigated more than 860 

general aviation accidents and issued 3,111 

summary reports during the year. Thirty-five 

safety recommendations were issued to the FAA 

and 47 FAA notices of proposed rulemaking 

Eight major aviation accidents were investigated in 1967, 

including a 707 that crashed after aborting takeoff from 

Cincinnati, killing one.

First NTSB Seal, 1968-1973
viii National Transportation Safety Board

Lessons Learned and Lives Saved

were reviewed. The surface staff had investigated 

or assisted other transportation agencies in six 

major accidents including a bridge collapse in 

West Virginia that killed 46 people. Six major 

surface accident reports were issued and studies 

on recreational boating accidents and increased 

train accident rates were adopted. The Board 

of Hearing Examiners processed 214 airman 

appeals in 1967.

As the year drew to a close, the NTSB began 

investigating its first celebrity aviation accident, 

the death of singer Otis Redding and 6 others in 

Madison, Wisconsin on December 10.

Red indicates that action in the issue area is unacceptable. Yellow is 

assigned to those issues with an acceptable overall status, but where 

implementation is progressing slowly. Green indicates acceptable status 

and timely progression.

Leveraging Resources

The Safety Board has a long history of partnering with industry and 

other agencies to accomplish its mission. It multiplies its resources several 

times over by allowing technical experts from industry and other government 

entities to assist us in our accident investigations. This “party system” 

enables operators, manufacturers, labor organizations, and regulators full 

participation in the fact-finding phase of accident investigations. Parties do 

not participate in the Safety Board’s analysis. In addition, the Safety Board 

further leverages its resources by inviting corporate executives, safety officers, 

and experts from industry and academia to symposia and workshops on 

safety topics that often affect the whole industry.

Statutory Authority

Congress has charged the Safety Board with investigating every 

civil aviation accident in the United States and significant accidents in the 

other modes of transportation—railroad, highway, marine, and pipeline—

and issuing safety recommendations aimed at preventing future accidents. 

The rules are spelled out in Chapter VIII, Title 49 of the Code of Federal 

Regulations.

Under these mandates, the Safety Board determines the probable 

cause of all U.S. civil aviation accidents and certain public-use aircraft 

accidents; selected railroad, highway, marine, and pipeline accidents; 

and releases of hazardous materials in all forms of transportation. The 

Safety Board is responsible for maintaining the government’s database 

of U.S. civil aviation accidents and provides investigators to serve as U.S. 

Accredited Representatives as specified in international treaties for aviation 

accidents overseas involving U.S.-registered aircraft, or involving aircraft 

or major components of U.S. manufacture. 

The Safety Board opened its doors on April 1, 1967. Although 

independent, it relied on the U.S. Department of Transportation (DOT) 

for funding and administrative support. On April 1, 1975, under the 

Independent Safety Board Act, all organizational ties to DOT were 

severed. The Safety Board is not part of DOT, or affiliated with any of its 

modal agencies. 

In 1996, the President and the Congress gave the Safety 

Board the additional responsibility of coordinating the Federal effort 

for the families of the victims of major aviation accidents. The Board 

has a Transportation Disaster Assistance staff that has implemented a 

family assistance plan and reviews air carriers’ family assistance plans. 

In 1997, legislation was enacted to extend the Family Assistance Act 

to foreign carriers flying into and out of the United States. Following 

the Safety Board’s lead, many other countries are establishing similar 

policies and procedures for improving how families will be treated 

following a transportation accident. 

On call 24 hours a day, 365 days a year, the NTSB 

investigates hundreds of accidents a year including 

these: a fire aboard a small passenger vessel in Port 

Richey, Florida in 2004 (top), and a school bus 

accident in Huntsville, Alabama, that claimed four 

lives in 2006.
National Transportation Safety Board ix

Lessons Learned and Lives Saved

The Safety Board and the Law

Laws enacted by Congress give the Safety Board the mandate to 

determine the probable cause of the following:

All U.S. civil aviation accidents and certain public-use aircraft 

accidents

Selected highway accidents

Railroad accidents involving passenger trains or any train 

accident that results in at least one fatality or in major property 

damage

Major marine accidents and marine accidents involving a public 

and a nonpublic vessel

Pipeline accidents involving a fatality, substantial property 

damage, or significant injury to the environment 

Releases of hazardous materials in all forms of transportation

Selected transportation accidents that involve problems of a 

recurring nature

These laws also give the Safety Board the authority to do the 

following:

Conduct special studies on safety problems

Maintain official U.S. census of aviation accidents

Evaluate the effectiveness of government agencies involved in 

transportation safety

Evaluate the safeguards used in the transportation of hazardous 

materials

Review appeals from airmen and merchant seamen whose 

certificates have been revoked or suspended

Review appeals from airmen, mechanics, and repairmen who 

have been assessed penalties by the FAA

Lead U.S. teams on foreign airline accident investigations to 

assist foreign authorities under provisions of the International 

Civil Aviation Organization agreements

Evaluate the effectiveness of emergency responses to hazardous 

materials accidents

Coordinate Federal support services for functions of victims of 

major transportation accidents

•

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•

•

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NTSB investigators are on call 24 hours a day, 365 

days a year and travel to accident sites in the United 

States and throughout the world.

National Transportation Safety Board 

Lessons Learned and Lives Saved

Safety Advances Inspired by 

NTSB Investigations

Since 1967, thousands of safety improvements have been 

inspired by Safety Board investigations and recommendations.

Many of the advances have had a major impact on 

transportation safety, and all of them—big and small—have saved lives. 

They range from improving communications among aircraft, rail, and 

ship crews, to complete redesigns of structural and electronic systems, to 

envisioning new technologies and seeing them through until they become 

standard equipment on transportation vehicles.

Presented here are some examples of those improvements— 

some from a single recommendation and others the result of numerous 

recommendations. Many examples include information and lessons 

learned from specific accidents and incidents that inspired Safety Board 

investigators to push for changes.

Airplane Maintenance and Inspection

Corrosion and structural fatigue. Older aircraft are 

subjected to periodic reviews, inspections, and modifications to eliminate 

corrosion and metal fatigue and the FAA requires increased fatigue 

testing on newly certified airplanes—all part of a comprehensive program 

to prevent structural failure.

In 1988, an Aloha Airlines 737 experienced a structural failure 

and explosive decompression en route from Hilo to Honolulu, Hawaii. 

A section of fuselage skin and structure separated from the airplane in 

flight. One flight attendant was killed. The Safety Board’s investigation 

revealed that the fuselage failure was caused by disbonding of the 

fuselage lap joints and multi-site fatigue cracking.

Titanium engine components. Tighter controls and scrutiny 

of the titanium melt, and manufacturing process for aircraft engines 

and improvements in the airline industry’s inspection process have been 

mandated. 

In 1989, a United Airlines DC-10 equipped with General 

Electric engines crashed during an emergency landing in Sioux City, 

Iowa, following an uncontained failure of an engine front compressor fan 

disk. Of the 286 persons on board, 111 were killed in the crash landing. 

The investigation revealed that the failure stemmed from a crack that 

originated from a tiny “hard nugget” or inclusion. It had been formed 

during the titanium melting process and the crack had been missed 

during several inspections.

Gas turbine disks. More frequent eddy current inspections 

of disks in gas-turbine engines were mandated along with new service 

bulletins to inspectors and airline engine repair technicians outlining 

inspection procedures and specific repair tools and techniques to be used 

on high-rotating components.

NTSB’s investigation of a 737 that lost a large section 

of its fuselage while on a flight in the Hawaiian 

islands in 1988 led to major changes in inspections, 

maintenance, and repair of older aircraft.
 National Transportation Safety Board

Lessons Learned and Lives Saved

A series of non-fatal incidents alerted the Safety Board. In 

one incident, an engine failure and fire occurred while mechanics were 

repairing and testing an engine on a US Airways 767 in Philadelphia. 

Similar incidents that were investigated involved engines on Thai Airways 

and Gulf Air aircraft, and an uncontained engine failure on a Varig Brasil 

Airlines 767 in Sao Paulo, Brazil, in June 2000. 

Fire protection. Airlines operating MD-80, MD-90, and 

DC-9 series airplanes are required to inspect primary and alternate static 

port heaters for evidence of electrical arcing or thermal damage and to 

replace damaged heaters. 

In 1999, a Delta Air Lines MD-88 experienced a fire in the 

forward cargo compartment, traced to a static port heater, shortly after 

takeoff from Northern Kentucky International Airport. 

Fuel tank hazards. Major advances have been made by 

the industry and the Federal Aviation Administration in evaluating and 

researching the hazards posed by fuel vapor when it reaches elevated 

temperatures in fuel tanks, flammability and ignition energies of Jet A 

fuels, shortcomings in fuel tank electrostatic and lightning protection, 

and electrical surge protection for fuel quantity indication systems. 

Improvements have also been made to fuel pumps and fuel tank wiring.

In 1996, a TWA 747 experienced an in-flight explosion of its 

center wing fuel tank near East Moriches, New York, shortly after takeoff 

from JFK International Airport, New York. All 230 on board died. 

Insulation and wiring. The inspection, repair, and 

replacement of wiring, insulation, and circuit breakers in the cockpit 

and cabin of MD-11 aircraft was ordered by the FAA after the crash 

of a Swissair MD-11 in the North Atlantic near Nova Scotia, Canada, 

following an inflight fire.

All 229 on board died in the 1998 crash. The Canadian report 

concluded that the fire most likely started from a wire arcing event; 

flammable insulation materials propagated a fire above the ceiling in 

the cockpit; and the type of circuit breakers used in the aircraft were not 

capable of protecting against all types of wire arcing events. The Safety 

Board assisted the Canadian Safety Board in the investigation.

Landing gear upgrades. Improvements have been made 

to large aircraft landing gear design, inspection techniques, and 

maintenance procedures.

Several changes resulted from investigations in the U.S. and 

abroad. One was in 1993, when a USAir Fokker F-28 experienced a 

collapsed main landing gear during landing at the Pittsburgh, Pennsylvania, 

airport. The Safety Board’s investigation discovered improper assembly of 

the main landing gear torque link, and shimmy damper assembly, as well 

as shortcomings in the maintenance procedures and manual.

Parts lubrication. Lubricant applications procedures, used 

for critical aircraft systems, have been tightened. Airlines are required 

to give the FAA performance results and test data to make sure that any 

changes in lubricants or their use does not pose a potential hazard. 

Principal inspectors and aircraft certification offices must grant approval.

A fuel-air vapor explosion in the center wing tank of a 

747 brought down the plane in 1996, killing all 230 

on board.

The jackscrew assembly of a MD-83 is recovered from 

the Pacific Ocean in 2000.
National Transportation Safety Board 

Lessons Learned and Lives Saved

These changes stem from the crash of an Alaska Airlines MD83 into the Pacific Ocean off the coast of California in 2000, killing 

all 88 on board. The Safety Board said the accident was the result of 

an in-flight failure of the nut threads on the jackscrew assembly for the 

horizontal stabilizer trim system. The failure was caused by excessive wear 

because of the airline’s insufficient lubrication of the jackscrew assembly, 

its extended lubrication interval, and the government’s approval of the 

extension.

Rotating engine parts. Major improvements have been 

made in inspection techniques, practices, and requirements and more 

stringent regulations have been established for both FAA inspectors and 

mechanics who work on and repair high-energy rotating parts of gas 

turbine engines that power large aircraft. This includes revised training 

courses for FAA inspectors to better analyze an airline’s performance in 

correctly inspecting and repairing engines.

In Pensacola, Florida, two passengers were killed in 1996 when 

a Delta Air Lines MD-88’s left engine failed during takeoff, sending 

debris into the aircraft cabin. The Safety Board’s final report said the 

engine’s front compressor fan hub had failed because the airline’s 

inspection process did not detect the metal fatigue crack. 

Alcohol and Drugs in Transportation

On seas. Major upgrades in marine post-accident alcohol 

and drug testing requirements and standards went into effect in 2006 

by the U.S. Coast Guard to assure that marine operators are not under 

the influence of alcohol and/or drugs. This represents a significant 

benefit to investigating and determining causes of accidents and their 

prevention. 

The Safety Board’s investigation into the September 27, 1996 

ramming of a Portland, Maine, bridge by the Liberian Tankship Julie 

N showed major inadequacies in post-accident testing of mariners 

for alcohol and drugs. The vessel struck the bridge and spilled about 

170,000 gallons of oil into the waterway. There were no injuries, but the 

ship and bridge suffered substantial damage.

On waterways. States have enacted laws dealing with boating 

while intoxicated, and most have specific blood alcohol concentration 

limits. The National Association of State Boating Law Administrators 

issued State guidelines that include specific prohibitions against operating 

a boat while intoxicated.

In a boating accident study conducted during the 1980s, the Safety 

Board urged the adoption of clearly defined blood alcohol concentration 

limits for intoxication similar to that applied to highway vehicle operators.

On highways. States undertook comprehensive reviews 

of their driving-under-the-influence legislation and how the laws are 

implemented following the Safety Board’s accident report on the worst 

drunk driving accident in the nation’s history.

A pickup truck, driven by a drunk driver on the wrong side of an 

interstate highway, struck a school activity bus, killing 27 children and 

Debris from an engine that failed during takeoff 

punctured the cabin of a MD-88 in 1996, killing two 

passengers. Improvements in engine inspection and 

training resulted from the accident.

Investigators found a flaw into a titanium fan 

compressor disk that failed in flight, causing major 

damage to the flight controls of a DC-10 that crashed 

in 1989.
 National Transportation Safety Board

Lessons Learned and Lives Saved

parents in Carrollton, Kentucky, in 1988. The driver of the pickup had 

a blood alcohol concentration of more than two times the legal limit in 

most States in 1988.

On rails. The first mandatory drug and alcohol-testing rule 

for any mode of transportation was adopted by the Federal Railroad 

Administration following a series of deadly train accidents investigated by 

the Safety Board in the 1980s.

One of the most serious was the 1987 collision between an 

Amtrak passenger train and a Conrail freight train in Chase, Maryland, 

in which 16 people were killed and more than 170 others were injured. 

The Safety Board’s report said a marijuana-impaired freight train engineer 

failed to heed a signal and stop the train. Another notable accident was 

the collision of two freight trains in Possum Grape, Arkansas, in 1982. An 

alcohol-impaired engineer relinquished control of one of the trains to a 

brakeman who was unqualified to run the train, causing the accident.

In the skies. Airlines are required to perform pre-employment, 

random, and post-accident drug and alcohol testing for the presence of 

certain illicit drugs in persons employed in safety-sensitive positions. The 

FAA also has regulations to identify pilots involved in alcohol- or drugrelated motor vehicle offenses by requiring them to report an alcohol- or 

drug-related driving conviction or administrative action.

Alcohol-related aviation accidents prompted the Safety Board 

to issue safety recommendations that underscore benefits of a National 

Driver Registry search. In one accident, a Beech G-18S airplane on 

an unscheduled air cargo flight from Milwaukee to Atlanta crashed 

near Copperhill, Tennessee. The airplane was destroyed, and the pilot 

was killed. The Safety Board determined that the pilot’s blood alcohol 

concentration was well above the limit allowed by most States at the time 

and that the pilot had been convicted of seven drunk-driving offenses 

during the previous 41⁄2 years.

Young drivers. States have set 21 as the minimum drinking 

age and have tougher and more vigorous enforcement of minimum 

drinking age laws that include stricter penalties. These include license 

actions taken against underage purchasers and the vendors who sell to 

persons under the minimum age — major steps in combating one of the 

single most deadly threats: the alcohol-impaired driver.

Numerous investigations of alcohol-related crashes and a Safety 

Board study found that teenagers were over-represented in the population 

of drunk driver accidents.

Truck drivers. States adopted tougher driving under the influence 

of alcohol laws for commercial motor vehicle drivers, in part because of a 

1990 Safety Board study on fatigue, alcohol, and drug use that analyzed 

182 accident investigations involving 186 heavy trucks in 8 States. 

Bridge Safety

Bridge protection and response. An intermodal— marine, 

highway, and railroad—task force on bridge information systems 

compiled ownership and contact information on more than 5,000 

Investigators reconstructed part of the cockpit to a 

MD-11 to help find the cause of a 1998 accident.

The worst drunk driving accident in U.S. history 

prompted stricter drinking and driving laws. Twentyseven students and parents died in this fiery crash in 

1988, caused by a drunk driver.
National Transportation Safety Board 

Lessons Learned and Lives Saved

bridges vulnerable to impact from marine traffic. If a bridge is struck by a 

marine vessel, the bridge owner and local emergency response agencies 

are notified to stop highway and railroad traffic until inspectors determine 

that the bridge is safe for transportation.

One of the Safety Board’s accident investigations that prompted 

these improvements occurred in 1993 when a towboat operator became 

lost and disoriented in dense fog because of his inability to interpret his 

radar presentation. The barges struck an unprotected railroad bridge, 

displacing the railroad track. An Amtrak passenger train derailed on the 

bridge and plunged into the Big Bayou Canot, near Mobile, Alabama, 

resulting in the loss of 47 lives and causing 111 injuries.

Inspections. States are required to conduct recurring 

underwater inspections of bridges and their footings for scouring and 

damage from the movement of debris and changes in the streambed 

material composition.

The Safety Board’s investigation into bridge collapses caused 

by erosion included the 1987 collapse of a New York State Thruway 

bridge near Amsterdam, New York, which sent four automobiles and 

a tractor semitrailer 80 feet to the creek below and killed 10 people; 

the 1989 collapse near Covington, Tennessee; and the 1967 collapse 

of a highway bridge spanning the Ohio River between Ohio and West 

Virginia, which killed 46 motorists. 

Commercial Fishing Vessel and Towing Safety

Fishing vessel safety devices. Congress passed the 

Commercial Fishing Industry Vessel Safety Act of 1988 and several years 

later the U.S. Coast Guard published final rules to improve the safety of 

commercial fishing vessels. These regulations for the first time required 

commercial fishing vessels to carry specific lifesaving devices, including 

life rafts, survival suits, and emergency-position-indicating radio beacons.

In 1987, the Safety Board issued a safety study on uninspected 

commercial fishing vessels that, along with a number of individual Safety 

Board accident reports, identified critical safety problems throughout the 

commercial fishing vessel industry.

Towing vessel safety. Regulations were issued to improve 

navigation safety by requiring towline and towing equipment inspections 

and maintenance; the addition of towing vessel equipment such as 

charts, marine publications, compass, or swing meters, radar, and vessel 

position finding devices; and training of towboat operators in radar use.

These changes followed investigations of several towing vessel 

accidents involving U.S. towboats, including the Fremont. The 1992 collision 

with a containership occurred in the Houston ship channel. The barge being 

towed by the Fremont was struck in fog and sank, spilling all of its cargo of 

molten sulfur. The lack of a compass on the towing vessel resulted in the 

operator’s inability to evaluate the vessel’s movement into the navigation 

channel and into the path of a containership.

Forty-seven lives were lost when an passenger train 

derailed on a bridge and plunged into a bayou in 

1993. Barges had previously hit the railroad bridge 

displacing the track.

Ten people died when a New York State Thruway 

bridge collapsed in 1987. This was one of several 

NTSB-investigated accidents that resulted in 

improved underwater inspections of bridges and their 

footings.
 National Transportation Safety Board

Lessons Learned and Lives Saved

Commercial Motor Vehicles

Antilock brake systems. Federal regulations require new 

commercial motor vehicles over 10,000 pounds gross weight—large 

trucks and buses—to be equipped with antilock brake systems. 

Recommended practices to assess tire performance were developed 

and include tests on free-rolling cornering, straight line braking, and 

combined cornering and braking.

The changes stem from numerous accident investigations and 

a safety study on the performance of heavy vehicle brakes. In 1,500 

roadside inspections of big trucks conducted with the cooperation of 

the States, the Safety Board reported that 46 percent of the trucks were 

placed out of service because of improperly adjusted brakes. Another 10 

percent were placed out of service for other brake problems.

Better truck brakes. Automatic slack adjusters are required 

by the National Highway Traffic Safety Administration on all new trucks 

equipped with air-mechanical brake systems. 

Numerous accident investigations involving heavy truck brakes 

and a 1989 safety study uncovered systemic deficiencies with heavy truck 

and bus braking systems.

Commercial driver’s licenses. Congress enacted a law 

mandating a national commercial driver’s license, which requires most 

truck and bus drivers to obtain this license and prohibits such drivers 

from having more than one driver’s license. An alcohol/drug testing 

program is also included under the program, and the Federal Highway 

Administration revised motor carrier regulations to require that motor 

carriers check a driver’s record, initially and at least annually, with State 

licensing agencies; and to require motor carriers to update their records 

when they move or change their names. 

In 1980 and 1986, the Safety Board evaluated truck driver 

performance and identified ways to alleviate shortcomings in detecting 

and controlling unsafe drivers. The Safety Board’s 1986 study endorsed 

a national license for commercial truck drivers to help bar unqualified 

drivers from operating trucks. 

Driver training. An information program was developed by 

the National Safety Council for those considering a career in commercial 

truck driving to explain the duties and responsibilities of the vocation, the 

value of formal training, and factors to consider in selecting a truck driver 

training school, including which schools meet Federal minimum standards. 

Heavy trucking associations and unions encouraged the development and 

use of simulator-based training for heavy truck operators.

The importance of proper technical and safety training were cited 

in numerous Safety Board investigations, including a 1984 crash in which a 

tractor semitrailer hit a police car traveling in the opposite direction, killing 

all four officers in the car, and a 1982 crash in which a tractor semitrailer 

hit a church van head on, killing 10 of the van’s 11 occupants. 

Truck maintenance. The American Trucking Associations 

developed and distributed brake maintenance materials that established 

inspection techniques and encouraged their dissemination to all truck 

Safety Board recommendations have reduced accidents 

and improved trucking safety through commercial 

driver’s licensing, better braking systems, and more 

driver training.

An accident in Davie, Florida, in 2005 killed four, 

and sparked a massive fire when a tanker truck 

carrying 9,000 gallons of fuel overturned onto a 

passenger vehicle while negotiating an interstate 

entrance ramp.
National Transportation Safety Board 

Lessons Learned and Lives Saved

mechanics. The National Highway Traffic Safety Administration and the 

Federal Highway Administration developed such hardware as the roller 

dynamometer, which is capable of measuring the braking capability of a 

heavy vehicle at roadside inspection stations.

A 1989 Safety Board study examined the effectiveness of air brake 

systems on heavy trucks and buses and concluded that there was a serious 

problem with out-of-adjustment brakes, a major contributor to crashes.

Commuter Airline Safety

Stricter safety standards. Commuter airline flights in aircraft 

with 10 or more passenger seats were brought under the more stringent 

safety standards that apply to large air carriers in 1997. This included the 

installation of safety devices like altitude encoding transponders, ground 

proximity warning systems, and cockpit voice recorders. FAA surveillance 

and commuter regulations concerning pilot training, scheduling, dispatch 

services, airport certification, and airline management oversight were aligned 

with requirements for the larger airlines.

Safety Board studies of commuter airlines in 1980 and 1994 

called for “sweeping” action to improve safety, advocating “one level 

of safety” to bring commuter airline regulations in line with stricter 

regulations governing the operation of larger aircraft. 

Crew Communications

On ships. Ship bridge resource management training and 

certification for masters and mates operating on vessels in ocean and nearocean service is required by the U.S. Coast Guard. The Coast Guard also 

requires documentation that those trained can effectively apply teamwork 

to maintain a safe navigational watch. Bridge resource management 

focuses on such bridge officer skills as teamwork, teambuilding, 

communication, leadership, and decision-making, and addresses stress, 

attitudes, and risk. It begins before the voyage with the passage plan and 

continues through the end of the voyage with the passage debrief.

The Safety Board promoted this teamwork approach after it 

investigated the 1989 grounding of the World Prodigy on a reef in Rhode 

Island Sound. The damaged ship spilled 7,000 barrels of diesel oil. 

The Safety Board concluded that the master’s impaired judgment from 

acute fatigue and poor decision-making, coupled with a lack of bridge 

management techniques, left the vessel without a qualified watch officer 

several minutes before the grounding.

Another accident was the 1992 grounding of the QE2 in 

Vineyard Sound, Massachusetts, which was the result of the failure by the 

pilot, master, and watch officers to discuss and agree on a navigational 

plan for departing Vineyard Sound and to maintain situational awareness 

after an unplanned course change. 

On trains. A comprehensive crew resource management 

training program has been implemented in the rail industry through 

the cooperation of the Federal Railroad Administration, the Association 

of American Railroads, rail unions, and major railroads. The training 

Lesson Learned

The value of crew resource management 

was demonstrated in 1989, when a DC-10 

experienced a catastrophic engine failure 

over Iowa that destroyed the aircraft’s 

hydraulic systems, rendering it virtually 

uncontrollable. The cockpit crew and a offduty captain who was flying as a passenger 

worked as a team to bring the aircraft down 

to a crash landing at Sioux City. Although 

more than 100 people perished, almost 200 

others survived.

An uncontained failure in the engine on the tail of a 

DC-10 resulted in the loss of hydraulics and aircraft 

control.
 National Transportation Safety Board

Lessons Learned and Lives Saved

consists of video presentations and workbooks that cover four areas: 

crewmember proficiency, situational awareness, effective communications 

and teamwork, and strategies for appropriately challenging and 

questioning authority and resolving conflicts.

The need for train crew resource management was highlighted 

in numerous Safety Board investigations including the 1998 collision 

of Norfolk Southern and Conrail freight trains in Butler, Indiana, which 

resulted in one death and two injuries. The report pointed to a lack of crew 

resource management including the failure of the engineer and conductor 

to observe and confirm signal aspects and their failure to continuously and 

directly supervise a student engineer.

On airplanes. Crew resource management, formerly called 

cockpit resource management, encourages teamwork on large airlines 

and on regional and commuter airlines. Crew resource management 

requires the captain to serve as a crew leader who relies on other 

crewmembers for vital safety-of-flight tasks, and requires the captain 

to share duties with, and solicit information and help from, other 

crewmembers.

In several airline accidents investigated by the Safety Board 

in the 1960s and 1970s, the Safety Board detected a culture and 

work environment in the cockpit that, rather than facilitating safe 

transportation, may have contributed to accidents. 

In 1978, as a result of a landing gear problem, a United Airlines 

DC-8 was in a holding pattern while waiting to land in Portland, Oregon. 

Although the first officer knew the aircraft was low on fuel, he failed to 

express his concerns convincingly to the captain. The plane ran out of fuel 

and crashed, killing 10.

Cruise Ship Safety

Fire safety inspections. As part of their compliance with the 

International Safety Management Code, major cruise lines are required 

to routinely inspect laundry ventilation systems for combustible material 

and clean the ducts to prevent fires. Several cruise lines improved their 

ventilation and dust systems in laundry rooms to prevent the spread of fire 

to other parts of the ships.

These changes are the result of the Safety Board’s investigation 

into the 1998 fire aboard the Ecstasy cruise ship shortly after it left Miami 

and lost propulsion with more than 3,400 on board. There were no 

fatalities; however, 22 crewmembers and passengers were injured. The 

Safety Board said unauthorized welding by crewmembers in the main 

laundry ignited a large accumulation of lint in the ventilation system, and 

the ship’s crew failed to maintain the laundry exhaust ducts in a fire-safe 

condition. 

Locating ship passengers. International maritime 

regulations require passenger ships to have procedures for locating 

and rescuing trapped passengers and crewmembers, and specific crew 

assigned and trained for this task. These regulations also require that 

mock search and rescues of passengers be conducted during required 

abandon-ship drills.

Lesson Learned

The 1995 grounding in an Alaskan canal 

of the Star Princess, which was fitted 

with a voyage data recorder, showed the 

usefulness of these devices in accident 

reconstruction and in improving management 

oversight. In this case, the recorder helped 

Safety Board investigators determine that 

the pilot and the watchstanders failed to use 

equipment available to properly monitor the 

progress of the cruise ship’s course. Had 

this been done, the pilot’s navigation error 

might have been detected in time to avoid 

the accident. 

Aircraft accidents in the 1960s and 1970s alerted 

investigators to the need for teamwork, sharing of 

information, and safety duties among crew members.

NTSB investigators probed a fire aboard a cruise ship 

that heavily damaged the vessel in 1998 after it left 

the Port of Miami.
National Transportation Safety Board 

Lessons Learned and Lives Saved

The changes stem from Safety Board investigations of cruise ship 

fires. In one of the investigations, in 1996, fire broke out on the Universe 

Explorer near Juneau, Alaska, killing 5 crew and injuring more than 50 

others. The Safety Board pointed to numerous inadequacies in crew 

communications and passenger preparedness to deal with the onboard fire.

Sprinklers and alarm systems. The U.S. Coast Guard 

obtained international agreement to require tougher fire safety 

improvements on all passenger ships, and the new requirements were 

applied to existing ships as well as to new ships. Recommendations 

resulted in improved standards for structural fire protection, sprinkler 

installations, low-level emergency lighting, smoke/fire detection systems, 

crew qualifications, emergency drills, and crew language requirements 

to ensure the safety of passengers on foreign-registered vessels operating 

from U.S. ports.

In a 1989 safety study, a 1993 special investigation report on 

passenger vessels, and investigations of fires aboard several cruise ships, 

including the 1984 fire on the Scandinavian Star that killed two people, 

the Safety Board identified serious shortcomings in cruise ship safety. 

Data Reporting and Recorders

Air bag research. Passenger side air bags have been 

evaluated and the National Highway Traffic Safety Administration 

established performance requirements for them based on actual 

accidents. It also evaluated the design of child restraint systems to 

simplify the placement of a child in a restraint system, and revised safety 

standards to provide for secure and uniform installation of child restraint 

systems. Federal highway safety regulators developed crash standards 

using biologically representative child dummies and a crash investigation 

to evaluate the long- and short-term variations in air bag designs and 

advanced air bag technologies.

These additional changes resulted from the Safety Board’s 1996 

safety study on the performance and use of child restraints, seatbelts, and 

airbags.

Highway vehicle event recorders. Federal highway safety 

regulators now routinely gather information from previously untapped 

sources of data-collecting sensors and event recorders already installed 

in vehicles. This information plays a major role in understanding 

the dynamics of a crash and its injury-causing impacts and enables 

researchers and engineers to design safer vehicles.

Use of these information sources was partly prompted by a 

1996 Safety Board study that examined the performance and use of 

child restraints, seatbelts, and airbags in highway accidents. The data 

showed that 38 children and 23 adults were killed when air bags 

deployed during crash impacts investigated during a 3-year period. 

These accidents pointed to the need for more information available for 

crash investigators to pinpoint causes and seek safety remedies.

Voyage recorders. All passenger lines and new cargo 

vessels are required to have voyage data recorders similar to flight data 

recorders on aircraft, and many cargo lines operating older vessels have 

Safety Board recommendations in the 1990s led to 

more airbag research, changes in airbag design, and a 

public education program.

Improved procedures to locate and rescue cruise ship 

passengers, along with the installation of sprinkler 

systems and other fire and smoke detection upgrades, 

stem from numerous NTSB investigations and 

recommendations.
10 National Transportation Safety Board

Lessons Learned and Lives Saved

voluntarily installed them. Automatic data recording devices are useful 

for management oversight and provide crucial, factual information for 

accident investigation; they have played a key role in identifying and 

addressing accident causes.

Since the 1970s, the Safety Board has promoted the use of 

recorders on various types of vessels and other modes of transportation.

Design and Technology Advances

Aircraft rudders. Upgraded rudder control systems were 

mandated by the FAA on all new Boeing 737 aircraft and rudder system 

retrofits on older 737 aircraft, the world’s most popular aircraft. The 

system includes redesigned actuators and control rods and a system 

that alerts the cockpit crew to rudder system failures. Flight simulators 

for 737s have been updated to more accurately reflect aerodynamics 

associated with the aircraft’s roll and yaw characteristics. Specific training 

was developed for cockpit crews to better prepare them to react more 

effectively to unusual situations.

These improvements stem from one of the Safety Board’s most 

complicated and lengthy investigations and a reexamination of an 

earlier crash of a United Airlines 737 in 1991 in Colorado Springs that 

killed all 25 on board. The lengthiest investigation involved a USAir 

737 that crashed on approach to Pittsburgh in 1994, killing all 132 on 

board. The Safety Board report said the aircraft’s loss of control was 

attributed to a deflection of the rudder surface in a direction opposite 

to that commanded by the pilots because of a jam of a rudder control 

component. 

Anti-collision devices on cargo planes. The FAA 

mandated installation of a sophisticated anti-collision system on all 

large cargo planes flying in the U.S.—the same requirement that was 

previously applied to passenger-carrying aircraft. Called TCAS (traffic 

collision avoidance system), the system alerts flight crews when they are 

too close to another aircraft during flight and gives the crew evasive 

options.

The improvements stem from the near mid-air collisions of an 

Air Canada passenger Airbus A-320 and a FedEx cargo MD-10 over 

Lincoln, Nebraska, in 1999. The cargo plane was not required to have a 

TCAS on board.

This improvement is the latest step in a long history of 

implemented Safety Board recommendations since the late 1960s that 

called for and supported the development of an airborne collision 

avoidance system that would be independent of the ground-based 

air traffic control system to provide pilots with an additional source of 

information on potential conflicts in flight. Since 1993, the use of TCAS 

has been expanded to include installation in more aircraft, and air traffic 

controllers now receive annual training in the operation of TCAS and the 

roles and responsibilities of flightcrews in responding to TCAS alerts.

Automatic flight controls. The FAA required modifications 

to the automatic flight control systems of Airbus A-310 and A-300-600 

models, and testing of the modifications. The autopilot was redesigned 

Voyage data recorders are now required on ships like 

this one in San Francisco Bay. 

One of the longest and most complex accident 

investigations in the Safety Board’s history involved the 

crash of a 737 in 1994 on approach to Pittsburgh. A 

redesigned rudder system and pilot training to handle 

unusual aircraft upsets were the result of the Safety 

Board’s investigation and recommendations.
National Transportation Safety Board 11

Lessons Learned and Lives Saved

to disengage when an aircraft is in go-around mode at low altitudes or 

when pilots exert manual force on the control column, giving pilots better 

control in certain conditions.

The changes were the result of a 1994 China Airlines A-300 

that crashed on approach to Nagoya, Japan, killing 264 of the 271 

on board; and the 1991 in-flight upset of a Interflugen A-310 on 

approach to Moscow, Russia. That aircraft landed safely. Investigations 

showed that the pilot’s ability to gain manual control of the airplane 

was hindered by the electronic system. The Safety Board assisted in the 

investigations.

Center high-mounted stop lights. Center high-mounted 

stop lights have been required on all new passenger cars since the 1986 

model year and on all new light trucks since the 1994 model year.

As early as 1975, Safety Board investigations resulted in 

a recommendation that automobile brake lights be mounted high 

enough to separate the function of brake lights from tail lights so that 

a following driver could see the lights of at least two vehicles directly 

ahead. A 1998 study concluded that center brake lights prevent 

92,000 to 137,000 police-reported crashes and 58,000 to 70,000 

nonfatal injuries.

Fail-safe thrust reversers. Design changes were mandated 

for large aircraft engine reverser systems. An additional lock was added 

to prevent thrust reversers from deploying in flight.

In 1991, a Lauda Air 767 experienced an uncommanded inflight deployment of an engine thrust reverser after takeoff from Bangkok, 

Thailand. The pilots lost control and the airplane crashed, killing 

all 223 people aboard. The investigation by the Thai airworthiness 

authorities and the Safety Board revealed the possibility of an in-flight 

thrust reverser deployment, shortcomings in the fail-safe thrust reverser 

design requirement on 767 airplanes, and lack of flightcrew operational 

procedures to address such an anomaly. 

Ground proximity warnings. U.S.-registered turbinepowered airplanes with six or more seats are required to be installed with 

an improved version of ground proximity warning equipment. Called the 

terrain awareness and warning system, the device gives flightcrews earlier 

alerts to possible collisions with mountains or the ground.

The recommendation for the technological upgrade in ground 

proximity warning devices came after an American Airlines 757 crashed 

in Cali, Colombia, in 1995. It hit a mountaintop on its approach to the 

airport, killing 160 of the 164 on board. Investigators believed that a 

more sophisticated warning device would have given the flightcrew an 

earlier warning, adding a few seconds of time to take actions to avoid the 

crash.

Developing, upgrading and requiring terrain collision warning 

systems on passenger aircraft had been promoted by the Safety Board 

since the early 1970s when it first called for the development of an 

onboard warning system after a nonfatal accident in 1971 involving a 

DC-9 that struck antennas as it was landing in Gulfport, Mississippi. 

Today’s passenger aircraft are equipped with devices 

that help prevent accidents and save lives, including 

ground proximity and anti-airborne collision 

warnings.

NTSB seal, 1974-1978
12 National Transportation Safety Board

Lessons Learned and Lives Saved

Improved emergency braking capabilities. Federal 

regulations require heavy trains operating over mountainous terrain to be 

properly equipped with a two-way end-of-train device. A two-way end-oftrain device allows a train crew to initiate an emergency brake application 

from the rear of a train, as well as from the front.

As the result of an investigation involving the derailment of a 

runaway freight train in Cajon Pass, California, in 1994, the Safety Board 

determined that an important safety device, a two-way end-of-train 

device that could be activated in an emergency to assist in stopping the 

train, was not properly armed and ready for service.

Safer air bags. The National Highway Traffic Safety 

Administration permits automobile manufacturers to depower air bags to 

reduce the risk of air bag-induced injuries to children and to short-statured 

and senior-citizen occupants. Standards were issued for establishing 

procedures to permit air bag on/off switches for adults and children at 

risk and for next-generation air bags that can tailor the deployment of the 

air bag according to the crash severity, size, and posture of the occupant; 

seatbelt use or non-use; and the occupant’s proximity to the air bag.

These additional changes resulted from the Safety Board’s 1996 

study on the performance and use of child restraints, seatbelts, and airbags.

Transponders. General aviation aircraft operating in 

controlled airspace near major airports are required to be equipped 

with Mode C transponders, which give air traffic controllers altitude 

information. Mode C transponders permit radar to automatically display 

the altitudes of aircraft equipped with them, and they provide air traffic 

control computers with route and altitude information that sound alarms 

when imminent collision hazards are detected.

Waterway navigation upgrades. The U.S. Coast Guard 

requires mandatory participation in the Vessel Traffic Services system that 

tracks ships in waterways systems in the United States as spelled out in the 

Oil Pollution Act of 1990.

Many of the Safety Board’s recommendations from its Exxon 

Valdez report were contained in the 1990 act. The 1989 Exxon Valdez

oil tanker accident in Alaska focused national attention on the need for 

a viable vessel traffic service system to prevent marine accidents. Eight 

tanks ruptured and about 258,000 barrels of crude oil spilled, causing 

catastrophic damage to the environment. 

Emergency Evacuations

Aircraft evacuation slides. Evacuation slides on aircraft 

are coated with a material to resist heat from postcrash fires because of 

Safety Board recommendations issued after a runway overrun accident 

involving a Continental Airlines DC-10 in Los Angeles in 1978. 

In the accident, which killed two people, 40 occupants were 

forced to jump to the ground while another 15 persons used the escape 

rope in the cockpit. There were 31 serious injuries. Heat from the intense 

fire caused several evacuation slides to deflate and melt.

New air bag standards and reducing the risk of air 

bags to children and short-statured persons stem from 

Safety Board accident investigations.

The 1989 oil spill in Alaska resulted in better use of 

vessel traffic services to curb marine accidents.
National Transportation Safety Board 13

Lessons Learned and Lives Saved

Aircraft exits. Redesigned emergency tailcone release handles 

are required on all commercial and military DC-9s and MD-80s to 

assure the avail­ability of this exit in the event of an emergency, following 

the Safety Board’s investigation of a 1990 runway accident in Detroit, 

Michigan.

Two Northwest Airlines jets, a DC-9 and 727, collided, killing 

a flight attendant and seven passengers. The DC-9’s tailcone release 

mechanism failed. 

Fire blocking materials and escape lighting. Fireblocking cabin and seat materials have been required on all airliners 

built since 1990. Floor-level escape lighting along aisles that guide 

passengers toward an exit during reduced visibility because of smoke is 

the result of Safety Board investigations and recommendations.

Safety Board investigators credited fire-blocking seat materials 

with saving lives following a takeoff accident and fire aboard a Delta 

Air Lines 727 at Dallas/Fort Worth in 1988. A study showed that fireblocking materials gave passengers additional time to exit the aircraft. 

Moored vessels. Permanently moored vessels are required 

to be protected from waterborne and current-related risks. Owners must 

complete risk assessments including risks associated with the location of 

the vessel on a waterway, vessel traffic, and environmental factors before 

permits will be issued. Periodic reviews are required by the U.S. Army 

Corps of Engineers.

These changes were prompted by a 1998 accident on the 

Mississippi River at St. Louis, when 14 towed barges struck the center 

pier of a bridge. Eight barges broke away and three drifting barges 

struck a moored casino vessel, President Casino on the Admiral. The 

accident caused no deaths, but did cause several million dollars in 

damage. The Safety Board’s analysis showed that authorities had not 

adequately protected the permanently moored vessel from waterborne 

and current-related risks, and the failure to conduct emergency drills 

and a chaotic evacuation jeopardized the lives of the 2,000 on 

board. 

Rail car exits. Rail passenger cars are required to have easily 

accessible, interior, quick-release mechanisms adjacent to doors to allow 

passengers to open exterior doors and exit the train in an emergency. 

Rules require doors to be wider and emergency instructions to be clearly 

marked.

Eight Job Corps students and three train crewmembers were killed 

in the collision of an Amtrak and commuter passenger train in 1996 in 

Silver Spring, Maryland. A fire ensued, and some passengers were unable 

to escape because of a cumbersome emergency device that thwarted easy 

opening. More than 25 passengers on both trains were injured.

Smoke detectors. Smoke detectors and automatic-discharge 

fire extin­guishers are required in airliner lavatories. Stiff fines are also 

imposed when anyone attempts to disable a smoke detector, and the 

Federal Aviation Administration requires airlines to prohibit smoking in 

lavatories. The agency also urges routine flight attendant inspections of 

lavatories before takeoff and periodic inspections during flight.

Aircraft evacuation slides have been upgraded to better 

resist heat from post-crash fires.

Major upgrades in rail passenger safety resulted from a 

1996 accident in the Washington, D.C. suburbs Two 

passengers trains collided, killing 11.
14 National Transportation Safety Board

Lessons Learned and Lives Saved

In 1983, an Air Canada DC-9 flying between Dallas and 

Toronto developed smoke in the cabin while the airplane was cruising at 

33,000 feet. The fire is thought to have started in a lavatory, probably 

when a motor overheated. The crew declared an emergency, but it took 

about 20 minutes before they could land at the closest large airport, near 

Cincinnati, Ohio. When the plane finally stopped, only half of the 46 

persons aboard were able to escape the burning aircraft before being 

overcome by smoke and fumes. 

Emergency Response to Accidents

Airport emergencies. A designated radio frequency has 

been set up to allow for direct communications between airport fire and 

rescue and flight crews in the event of an emergency, and standardized 

hand signals have been established for use in emergency situations when 

radio communications fail.

Airport fire and rescue response have been factors in numerous 

Safety Board investigations, including the 1997 incident when an 

American Airlines MD-82 sustained a contained engine failure and tail 

pipe fire during the takeoff initial climb from Tucson, Arizona. The aircraft 

returned to Tucson for a successful landing. 

The Safety Board report said that the crew experienced 

difficulty in establishing radio contact with the airport vehicles, and 

there was a problem hearing the captain’s evacuation on the public 

address system. 

Emergency position indicating radio beacons. Manned, 

uninspected vessels operating on the high seas or more than 3 nautical 

miles from the coastline of the Great Lakes are required to be equipped 

with alerting equipment, including emergency-position-indicating radio 

beacons.

In the 1980s, the Safety Board pushed for requiring automatic 

radio beacons on uninspected vessels after investigating several 

accidents, including the disappearance of the fishing vessel Amazing 

Grace off Cape Henlopen, Delaware, in 1984. A 16-day U.S. Coast 

Guard search found an empty life raft and none of the estimated seven 

crewmembers on board. If the vessel had been equipped with a radio 

beacon, the Safety Board report said, the search area could have been 

narrowed substantially, saving the time, cost, and possibly, lives. 

Marine distress calls. The U.S. Coast Guard upgraded and 

installed new recording devices in its group communications centers, 

enabling them to easily record and replay radio transmissions.

The upgrades were the result of the Safety Board investigation 

of an accident involving a recreational sailboat, the Morning Dew,

which stuck a jetty and sank in the Charleston, South Carolina, 

harbor. All four on board, members of the same family, drowned in 

the 1997 accident. The accident report showed a major failure in 

communications that delayed search and rescue efforts by more than 

9 hours after the first radio transmission to the Coast Guard from the 

sailing vessel.

Fire and rescue response following aircraft incidents 

and accidents has improved because of NTSB 

investigations.

Lifesaving devices and emergency position radio 

beacons are a few of the improvements made to 

commercial fishing vessels following numerous NTSB 

safety recommendations.
National Transportation Safety Board 15

Lessons Learned and Lives Saved

Lower Mississippi River alerts. The Port of New Orleans 

improved its communications system and upgraded its river alert network 

to inform moored vessels and nearby shore side businesses of potential 

hazards from large vessels on the Mississippi River. Revised regulations 

require pilothouses of passenger vessels be continuously staffed, pilots 

to monitor river activities and maintain emergency and working radio 

frequencies, and also require that harbor police use public address 

systems to alert people of an emergency and that evacuation procedures 

for vessels moored or docked in the area be revised.

In 1996, the bulk carrier Bright Field lost propulsion power in 

the lower Mississippi River and struck a wharf adjacent to a shopping 

mall and hotel. Although the accident caused no fatalities, more than 

60 people were injured during evacuations of a gaming vessel and an 

excursion vessel located near the impact area. The Safety Board report 

said emergency preparedness and evacuation plans of vessels moored 

in the wharf area were inadequate.

Excavation Damage Prevention

Call 911. Pipeline best-practices guidelines urge excavators to 

immediately notify 911 and pipeline owners and operators when gas or 

fuel escapes and endangers lives and property. This was one of several 

issues that received extra emphasis on the Safety Board’s Most Wanted 

List of Safety Improvements but were later removed because of the 

progress made to prevent these accidents.

In 1998, in St. Cloud, Minnesota, a communications network 

installation crew struck and ruptured an underground gas service 

pipeline. More than a half hour later, an explosion occurred, killing four 

people, injuring another, and destroying six buildings. The Safety Board 

investigation report said the accident was more severe because of the 

cable contractor’s delay in notifying proper authorities. 

One-call systems. Safety Board investigations, safety 

studies, and safety promotion activities have been instrumental in 

convincing Federal and State agencies, pipeline industry organizations, 

and pipeline operators to develop one-call notification systems, State 

laws, and public education programs aimed at reversing the increasing 

trend of excavation-caused damage to gas lines and other buried 

facilities. There are one-call notification centers in all States and the 

District of Columbia, and excavation damage prevention laws in most 

States and the District of Columbia. 

In the 1970s, excavation damage to pipelines was estimated to 

cause 50 to 60 percent of all pipeline accidents.

Preventing ruptures. A “Common Ground Study,” which 

listed best practices in preventing ruptures due to excavation, including 

pipeline design and planning, location, and safe excavation practices, 

was distributed by the Research and Special Programs Administration. In 

addition, a public education campaign, “Dig Safely,” includes a manual 

on how to effectively use these materials: print ads for newsletters, public 

service announcements, brochures, and bill inserts.

The New Orleans Riverwalk suffered extensive 

damage when it was struck by a bulk carrier vessel 

in 1996.

Lesson Learned

Immediately notifying authorities of gas leaks 

and pipeline ruptures is critical to saving 

lives and reducing property damages—one 

of the many lessons learned through NTSB 

pipeline accident investigations. Federal 

and State agencies, and the pipeline 

industry were convinced to set up “one-call” 

notification systems in all States and the 

District of Columbia.
16 National Transportation Safety Board

Lessons Learned and Lives Saved

These actions stem from the Safety Board’s investigation into 

a natural gas transmission line rupture and fire in a residential area of 

Indianapolis, Indiana, that killed one resident, destroyed 6 homes, and 

damaged 65 others. The pipe was damaged by a drilling operation to 

install an adjacent pipeline.

Fatigue in Transportation

Highway rest areas. The Federal Highway Administration 

and the Federal Motor Carrier Safety Administration compiled and 

published guides for long-haul truck drivers to alert them to public 

and private rest areas and parking spaces along their route and their 

availability. The guide is electronically available on the FMCSA Website.

This was a major safety issue in numerous accident investigations 

and a series of Safety Board public hearings in 1999 on truck and bus 

safety issues. The recommendation’s aim is to reduce the incidents of 

overcrowding at parking areas—a safety hazard. 

Mariner awareness. Marine pilot associations instruct their 

members to be aware of the hazards of human fatigue and sleep apnea 

when operating a vessel. Merchant marine physical exam reports have 

been revised to fully explain the duties of a mariner to the examining 

physician. Reports must indicate any and all medications taken, the 

dosage, possible side effects, and the medical condition for which the 

medication is being taken.

The Safety Board investigated the 1995 grounding of the 

passenger vessel Star Princess on Poundstone Rock in Lynn Canal, 

northwest of Juneau, Alaska. The Safety Board report pointed to the pilot’s 

poor performance, which may have been exacerbated by chronic fatigue 

caused by sleep apnea. In addition, the third mate failed to properly 

maneuver the vessel because of fatigue and excessive workload, the master 

failed to provide proper navigation watch because of alcohol impairment, 

and the shipping company failed to provide a fit and rested crew. 

Rail guidelines. Major railroad unions and major freight 

railroads developed work/rest guidelines to combat human fatigue, 

a factor in transportation accidents in all modes, and numerous rail 

accidents.

In 1990, two Atchison, Topeka and Santa Fe Railway freight 

trains collided head-on in Corona, California, killing four crewmembers 

and injuring another. The Safety Board’s investigation showed that an 

engineer who was asleep had failed to heed a stop signal. A 1988 headon collision of two Conrail freight trains in Thompsontown, Pennsylvania, 

killed the engineers and brakemen on both trains. The Safety Board said 

the sleep-deprived condition of the engineer and several crew of one 

of the trains contributed to their failure to stay alert and comply with a 

signal. None of the crewmembers had more than 2 hours of sleep during 

the previous 24 hours.

Transit fatigue course. The Federal Transit Administration 

has incorporated a human fatigue awareness course offered at the 

Transportation Safety Institute and has aimed the course at employees 

and supervisors involved in safety-sensitive jobs.

NTSB accident investigations pointed to the need to 

reduce overcrowding at truck parking areas along the 

nation’s highways.

Lesson Learned

After 60 years, revised truck driver hoursof-service rules have been issued by the 

Federal government. The rules aim to 

provide truck drivers with a work schedule 

more in line with sleep and human fatigue 

research. The goal is to reduce driver 

fatigue and accidents.
National Transportation Safety Board 17

Lessons Learned and Lives Saved

Human fatigue has been uncovered as a factor in numerous 

Safety Board investigations, including a 1995 accident in which a New 

York City Transit subway car struck another train on a bridge, killing 

the operator and injuring scores of passengers. The train operator was 

asleep and failed to stop at a signal. 

Trucking hours-of-service. Revised truck driver hours-ofservice regulations were issued by the U.S. Department of Transportation, 

the first major rewrite in 60 years. The regulations provide commercial 

truck drivers a work and rest schedule that is more in line with a person’s 

circadian rhythm—a change aimed at reducing driver fatigue and 

accidents.

A 1990 Safety Board study of fatal-to-the-truck-driver accidents 

found that the most frequently cited probable cause was fatigue. The 

Board said the 31 percent incidence of fatigue in fatal-to-the-truck-driver 

accidents represented a valid estimate of the portion of fatal-to-the-driver 

heavy truck accidents that were fatigue-related. A 1995 Safety Board study 

of truck driver fatigue found that the top factors affecting fatigue were the 

number of hours slept in the past 24 hours in the most recent sleep period, 

and whether the sleep was obtained at one time or in split sleep periods.

Grade Crossing Safety

Track emergencies. Major railroads have instituted a 24-

hour toll free emergency notification telephone system that can be used 

by the public to report emergencies to the railroads’ communications 

centers, such as struck or broken-down vehicles at rail/highway grade 

crossings. This system includes signs at grade crossings that post the 

number to call to reach the railroad.

This change was the result of dozens of Safety Board 

investigations involving accidents at grade crossings when trains were 

unable to stop in time after seeing vehicles blocking the tracks. One 

was the 1995 accident in Sycamore, South Carolina, where a tractor 

semitrailer was stuck on the tracks for more than a half hour before it 

was hit by an Amtrak passenger train. Two locomotives and 14 passenger 

cars derailed, and the truck was heavily damaged.

Highway intersections. A nationwide database was set up 

to track, monitor, and inspect about 3,500 highway-railroad crossings 

with interconnected road signals and rail warning lights. All States quickly 

inspected and made safety adjustments to these intersections. This 

database helps State and local school safety officials plan and monitor 

school bus routes, and is available to train drivers to use in avoiding 

potential grade crossing hazards.

This improvement was the result of a 1995 accident in which a 

school bus and commuter train collided at a grade crossing in Fox River 

Grove, Illinois, killing 7 high school students and seriously injuring 24 

others. One of the major factors cited by the Safety Board was a timing 

problem with an interconnected signal system.

Stop, look and listen. States have programs, encouraged by 

Safety Board investigations and recommendations, to educate the public 

about the dangers of highway-railroad grade crossings.

NTSB recommendations have consistently pushed for 

better grade-crossing safety through driver education, 

engineering solutions at crossings, and enforcement 

of laws.

Grade crossing accidents involving school buses are 

rare, but can be deadly, prompting the Safety Board 

to add school bus and grade crossing safety to its Most 

Wanted List of safety recommendations in 2004. 

Accident investigations have pointed to the need for 

several improvements, including enhanced bus driver 

education and evaluation, and installing stop signs at 

passive crossings.
18 National Transportation Safety Board

Lessons Learned and Lives Saved

The Safety Board pushed for a strong “Operation Lifesaver” 

education program in the late 1970s. The program became an 

independent operation and widened its coverage during the 1980s. 

Working with individual States, Operation Lifesaver provided a threepronged attack on the problem of grade-crossing safety: education 

of drivers, engineering solutions to high-accident crossings, and 

enforcement of grade-crossing laws.

Hazardous Materials

Community coordination. Major railroads improved 

coordination with communities adjacent to railroad yards and along 

hazardous materials routes, and established hazardous materials training 

programs and evaluation systems for their employees. New Federal 

regulations established training and testing requirements for employees 

involved with the transportation of hazardous materials. Rail carriers 

are required to train and test train crews about hazardous materials 

emergency response procedures before they operate a train.

Chemicals on the rails. The American Chemistry Council 

requires its members to have an ongoing chemical distribution risk 

management program to evaluate risks of transporting chemicals by rail 

and to implement risk reduction methods.

In almost half of cases investigated for a safety study, the Safety 

Board found that local emergency response incident commanders did not 

have a hazardous materials emergency response plan to follow. In many 

cases, incident commanders and railroad personnel had not been in 

contact with each other to develop a plan of action in the event of a train 

accident involving hazardous materials.

Safer cargo compartments. Fire safety standards and 

requirements for baggage and cargo compartments in large passenger 

aircraft were upgraded by the FAA. The Pipeline and Hazardous 

Materials Safety Administration (formerly the Research and Special 

Programs Administration) prohibits airlines from carrying chemical 

oxygen generators in cargo and baggage compartments of passenger 

aircraft and instituted tougher packaging standards for those shipped 

in cargo planes. The FAA also strengthened its oversight, became more 

proactive in enforcing rules and penalizing violators, and revised training 

requirements for airline employees and shippers who handle cargo to 

recognize undeclared or unauthorized hazardous materials.

The changes were the result of several Safety Board investigations, 

including the crash of a ValuJet DC-9 in the Florida Everglades in 1996. 

All 110 on board died after an undetected fire in the cargo hold, ignited by 

oxidizers the aircraft was carrying, spread to the passenger cabin, burned 

through aircraft controls, and disabled the flight crew. 

Shipping and handling. The FAA developed a hazardous 

materials education and enforcement program that focuses on freight 

forwarders. The FAA also issued new regulations that require all shippers 

and freight forwarders to certify that packages being shipped do not 

contain unauthorized explosives, destructive devices, or hazardous 

materials.

Reconstruction of the forward cargo hold of a DC-9 

that crashed in 1996, killing all 110 on board, helped 

investigators determine the probable cause of the crash 

and make numerous recommendations that have been 

implemented to upgrade fire safety standards and 

hazardous materials rules and enforcement.

National 

Transportation

Safety Board

Washington, D.C.

NTSB seal since 1979
National Transportation Safety Board 19

Lessons Learned and Lives Saved

Helicopter Safety

Engine upgrades. Research by both the FAA and the 

manufacturer led to product improvements including the mandatory 

introduction of an engine governor and a larger optional engine 

in Robinson helicopters. Special awareness training was instituted 

that addressed loss of rotor control events and pilot proficiency, and 

restrictions on operating in certain wind conditions. 

In 1996, the Safety Board concluded a special investigation of 

Robinson Helicopter Company R22 helicopters following 34 accidents 

in which an in-flight loss of main rotor control resulted in the main rotor 

contacting the tail boom or fuselage in flight. In all of these accidents, 

the occupants of the helicopters were killed.

Icing Prevention on Aircraft

Education and training. A major information and training 

campaign by NASA and the FAA educates aircraft manufacturers, 

operators, and pilots of air carriers and general aviation propellerdriven aircraft to the hazards of thin and often imperceptible rough ice 

accumulations; the importance of activating deicing devices; and the need to 

maintain minimum speeds in icing conditions.

The Safety Board’s investigation report of a Comair Embraer120 that crashed in Monroe, Michigan, in 1997 pointed to a lack 

of requirements to maintain adequate minimum airspeeds in icing 

conditions. Control of the aircraft was lost, the Safety Board said, when 

the airplane accumulated a thin, rough accretion of ice.

Modifications to aircraft. Modifications were made to 

Jetstream 31 airplanes to prevent early aerodynamic stall due to ice 

accretion, and expanded deicing boots were installed on the wings of the 

ATR-42 and -72 regional aircraft.

The improvements were made following a fatal accident involving 

a United Express Jetstream 31 at Pasco, Washington, in 1989, a nonfatal 

USAir Express Jetstream 31 accident at Beckley, West Virginia, in 1991, 

and the 1994 crash of an American Eagle ATR-72 in Roselawn, Indiana. 

Safety Board investigations revealed that ice buildup during certain phases 

of flight caused subsequent loss of roll control of the airplane.

On-board detection. Deicing and anti-icing requirements for 

major air carriers and commuters have been significantly upgraded, and 

the FAA and the aviation industry have developed on-board ice detection 

systems capable of alerting crews when an aircraft encounters freezing 

drizzle and freezing rain—types of previously under-researched and 

dangerous precipitation.

A series of icing-related accidents, investigated by the Safety 

Board, resulted in a wide range of icing-prevention improvements. Icing 

was a major factor in the 1994 American Eagle ATR-72 crash in Indiana 

that claimed the lives of all 68 onboard, a USAir Fokker F-28 crash at 

LaGuardia Airport in 1992 that killed 27 people, and the 1997 Comair 

EMB-120 crash that killed 29 people.

Aircraft wreckage is strewn across a field in Roselawn, 

Indiana, after the 1994 crash of an ATR-72. NTSB’s 

investigation led to upgrades in the aircraft’s deicing 

design.

The 1982 crash of a 737 in the Potomac River 

claimed 78 lives. It was one of several major accidents 

that focused attention on the need for icing technology 

and deicing equipment improvements.
20 National Transportation Safety Board

Lessons Learned and Lives Saved

An earlier accident was the 1982 crash of an Air Florida 737 

in Washington, D.C., killing 69 of the 74 passengers and crew and 

4 motorists on the bridge. The Safety Board said ice buildup on the 

wings and engine pressure probes, a long period between deicing, 

and limited crew experience in winter weather conditions led to the 

accident. 

Passenger and Occupant Protection

Child restraint “fitting stations.” “Fitting stations” exist in 

all States. Fitting stations are locations operated by auto manufacturers 

and dealers, law enforcement and first responders, private safety 

advocacy organizations, and government agencies that help parents 

and guardians check for correct child safety seat anchoring and harness 

configurations. Staff at these stations also point out errors in the use of 

child restraints and demonstrate the proper use of such seats.

A 1996 Safety Board study on the performance and use of child 

restraint systems examined 120 accidents and found that in 62 percent 

of the cases, the child safety seat was improperly secured in the vehicle, 

the child was improperly secured in the safety seat, or both. Some of the 

problems uncovered were seatbelts misrouted or worn too loosely, child 

restraints facing the wrong direction, locking clips not used when needed, 

and harnesses too loose or inappropriately threaded through the wrong 

slots.

Rail car passenger safety. Dozens of safety improvements 

have been made in rail passenger cars. These include securely attached 

seats, seat cushions, and appliances; impact-resistant windows that can 

be used as emergency exits; and retention devices on overhead luggage 

racks. Flammability standards have been upgraded and smoke detectors 

installed. Additions include passenger emergency briefing cards and 

placards; conspicuous markers and levers to facilitate operation of doors 

and emergency windows; emergency light sticks that can be used by 

passengers to find their way out of cars and their way along tracks in the 

dark; more reliable interior emergency lights; and additional emergency 

exit windows.

Realistic weight calculations. Decades-old and out-ofdate standards to estimate the average weight of aircraft and vessel 

passengers were overhauled by the FAA and U.S. Coast Guard to 

fit reality. The new guidelines require changes in calculating aircraft 

weight and the number of people who can be safety carried on small 

recreational vessels.

Three fatal accidents investigated by the Safety Board put the 

spotlight on the problem. On January 8, 2003, an Air Midwest Raytheon 

1900D crashed shortly after takeoff from Charlotte-Douglas International 

Airport, Charlotte, North Carolina, killing all 21 onboard. On October 

2, 2005, the public vessel Ethan Allen sank on Lake George, New York, 

during a sightseeing cruise, killing 20 passengers. And on March 6, 

2004, the small passenger vessel Lady D capsized in Baltimore Harbor, 

killing 5 passengers.

Parents and guardians get help at child restraint 

“fitting stations”—locations in all States where trained 

technicians make sure appropriate seats are used and 

installed correctly.

Passenger capacity and vessel stability were factors in 

a sightseeing boat accident on Lake George, N.Y., in 

2005, killing 20.
National Transportation Safety Board 21

Lessons Learned and Lives Saved

Air bag warning labels. The automobile industry sent letters 

and warning labels to owners of 60 million cars on the road that are 

equipped with air bags, advising the owners about the dangers that air 

bags pose to children. The National Highway Traffic Safety Administration 

requires these highly visible and permanent warning labels on all new 

vehicles.

These additional changes resulted from the Safety Board’s 1996 

study on the performance and use of child restraints, seatbelts, and 

airbags.

Getting the word out about air bags. The automobile 

and insurance industries and the National Highway Traffic Safety 

Administration initiated an air bag safety campaign in 1996. The multimillion-dollar effort aimed to educate the public about the importance 

of putting children in the back seats of vehicles with air bags, buckling 

seatbelts, strengthening State seatbelt use laws, and increasing 

enforcement. This effort included a mail campaign to all parents who 

recently had children based on hospital records.

These additional changes resulted from the Safety Board’s 1996 

study on the performance and use of child restraints, seatbelts, and 

airbags.

Adjustable upper anchorages. Major car manufacturers 

provide adjustable upper anchorages for the shoulder portion of seatbelts 

in front seats, and many manufacturers also provide them in the rear seat.

In its 1988 safety study on seatbelt performance, the Safety 

Board found that properly worn and routed seatbelts reduced injuries 

in 80 percent of the crashes examined. One of the methods of 

encouraging proper seatbelt use is to improve the shoulder fit of the belts 

by providing occupants with a way to adjust the shoulder strap upperattachment point, the Safety Board said.

Aircraft seats. The FAA required upgraded G force 

crashworthiness of seats on newly certificated transport-category aircraft 

and that seats be tested dynamically for their strength in addition to the 

requirement for static testing.

The Safety Board’s concern about seat integrity was underscored 

during its investigation of the 1987 crash of a Ryan Air Beech 1900 

in Homer, Alaska, that killed 18 of the 21 persons aboard. The crash 

induced high vertical G forces, and the seats failed. 

Rear seatbelts. Rear-seat lap/shoulder belts are required 

in newly manufactured cars, light trucks, multipurpose vehicles, and 

convertibles; and manufacturers developed a program to install lap/

shoulder belt retrofit kits in existing models.

A 1986 Board study concluded that lap belts provide a 

significantly lower level of protection than lap/shoulder belts and, in the 

crashes investigated, sometimes induced serious or fatal injuries that 

probably would not have occurred had lap/shoulder belts been used.

Water safety for youngsters. Many States have passed 

laws requiring personal flotation device use by children and require 

Safety of the millions of recreational boaters has been 

an NTSB goal, with numerous States requiring that 

children use personal flotation devices.

Child safety seats, properly used, substantially reduce 

deaths and injuries from highway crashes.
22 National Transportation Safety Board

Lessons Learned and Lives Saved

recreational boating education. The National Recreational Boating 

Safety Coalition, formed with the Safety Board’s assistance, seeks to 

reduce deaths, injuries, and property damage associated with the use 

of recreational boats. The coalition, composed of numerous insurance 

trade associations and other safety organizations, serves as a forum for 

the exchange of information about State and Federal legislative activities 

and education programs.

In 1993, the Safety Board issued recommendations to the States 

to require education, operator licenses, and use of personal flotation 

devices by children.

Young children in cars. States passed and strengthened 

child passenger protection laws. Between 1980 and 1984, more 

than 3,000 children under 5 years of age were killed in motor vehicle 

accidents and more than 250,000 were injured. Studies indicate that 

between 45 and 70 percent of the fatalities and up to half of the injuries 

could have been prevented by the proper use of a child safety seat. 

In 1982, the Safety Board launched a special investigation that 

demonstrated that children secured in safety seats remained unharmed 

in motor vehicle crashes that killed or severely injured their parents. The 

Safety Board investigated 53 accidents and found dramatic differences in 

injuries to infants and small children who did and did not have safety seat 

protection. 

Pipeline Safety

Periodic inspections. All hazardous liquid and gas 

transmission lines must be periodically tested to assess their integrity. 

Operators must follow a pipeline management program for areas in 

which a pipeline accident would result in high monetary costs, damage 

to the environment, and deaths and injuries. Operators are required to 

test, identify, and remedy corrosion damage; to validate maximum safe 

operating pressures; to set up frequency assessments; and to address other 

risks to pipeline safety.

Several pipeline accidents prompted the Safety Board to push for 

mandatory inspection requirements including a natural gas explosion and 

fire in Beaumont, Kentucky, in 1985 that killed five, and a 1986 pipeline 

rupture and fire at Mounds View, Minnesota, that killed two.

Assessing pipeline safety. The Pipeline and Hazardous 

Materials Safety Administration (formerly the Research and Special 

Programs Administration) improved its safety assessment of State pipeline 

regulators and operators by revising the guidance and evaluation criteria 

used by Federal inspectors. The changes are designed to accurately 

assess pipeline operational safety, identify problems, and take action 

to correct them, and provide more timely communications to pipeline 

operators about violations.

This improvement stems from a 1996 propane gas leak that caused 

an explosion in a commercial building in San Juan, Puerto Rico. In the worst 

pipeline disaster investigated by the Safety Board, 33 people were killed 

and 69 were injured; the building was destroyed and several others were 

heavily damaged. The accident report cited numerous oversight and safety 

NTSB safety recommendations have resulted in 

periodic pipeline inspections, higher toughness and 

corrosion standards, and better liquid pipeline failure 

detection.

Air bag warning labels are required on all vehicles in 

the United States, thanks in part to numerous NTSB 

accident investigations and a series of public forums 

and meetings on air bag safety in the 1990s.

WARNING

DO NOT place rear-facing child seat

on front seat with air bag.

DEATH OR SERIOUS INJURY can occur.

The back seat is the safest place

for children 12 and under.

!
National Transportation Safety Board 23

Lessons Learned and Lives Saved

evaluation failures by State and Federal regulators that allowed lax safety 

and training at the local gas company.

Corrosion standards. External corrosion standards for 

hazardous liquid and carbon dioxide pipeline operators were upgraded, 

requiring them to inspect the condition of protective pipe coating 

whenever a pipeline is exposed and to take corrective action when 

degradation is found. Also upgraded were compliance standards for 

cathodic protection for underground and submerged metallic pipelines.

In 1996, a steel pipeline transporting liquid butane ruptured near 

Lively, Texas, sending a butane vapor cloud into a surrounding residential 

area. The butane vapor ignited as two residents in a pickup truck drove into 

the vapor cloud and died of thermal injuries. A Safety Board investigation 

concluded that the accident resulted from the failure to adequately protect 

the pipeline from corrosion. For a pipeline, the coating is the primary 

protection against corrosion, but all coatings have damaged or defective 

areas at which corrosion can occur. Cathodic protection is a technique for 

preventing corrosion of an underground or submerged pipeline by applying 

DC electrical current to the pipe surface from an external source.

Liquid pipeline failure detection. Many pipeline operators 

are using internal inspection devices to identify and remove deteriorated 

segments from their pipeline systems, and new pipelines are designed 

to accommodate internal inspection devices to detect system weakness 

before an accident occurs. Pipeline operators have installed more 

effective systems for monitoring pipeline operations, as well as remote 

and automatic valves, so that operators will be promptly alerted to 

failures and can rapidly isolate those areas. 

Safety Board investigations have continually identified the need 

for improved monitoring systems, improved means to rapidly shut off 

failed pipe segments, and improved methods for periodically analyzing 

the condition of the pipe system. 

Rapid shutoff of damaged service lines. Regulations 

require gas distribution operators to install an excess flow valve on new 

and renewed high-pressure gas service lines when a customer requests 

one and agrees to pay the cost. An excess flow valve is a device capable 

of shutting off the flow of gas in service lines that experience an abnormal 

flow increase. The Safety Board investigated numerous pipeline 

accidents caused by excavation damage that could have been minimized 

by excess flow valves.

Toughness standards. Federal regulations require minimum 

toughness standards, improved quality assurance, more stringent 

chemical composition, and higher yield and tensile strength for various 

types of gas and hazardous liquid pipelines.

A natural gas pipeline rupture in Edison, New Jersey, in 1994 

resulted in an explosion and fire that ignited several buildings in an 

apartment complex. About 1,500 residents were evacuated. There were 

several minor injuries but no deaths. The Safety Board’s investigation found 

that excavation damage to the pipe had been compounded by the pipe’s 

brittleness—two major factors in its rupture.

This device, an excess flow valve, increases pipeline 

safety by shutting off the flow of gas in service lines in 

emergency situations.

The nation’s railroad tank cars are stronger and 

safer because of Safety Board investigations and 

recommendations that resulted in tank car head shields, 

and thermal and puncture protection.
24 National Transportation Safety Board

Lessons Learned and Lives Saved

Railroad Tank Car Safety

Tank car testing. The Federal Railroad Administration and 

the Pipeline and Hazardous Materials Safety Administration (formerly 

the Research and Special Programs Administration) published new 

regulations that require nondestructive testing of tank cars. The FRA also 

issued an emergency order requiring dual-diameter tank car owners to 

implement a sampling inspection program.

These improved standards were prompted, in part, by the Safety 

Board’s on-scene investigation of the catastrophic failure of a pressure tank 

car filled with 32,000 gallons of liquid propane in Dragon, Mississippi, 

in 1992. A white vapor cloud filled the area and ignited into a fireball. 

Examination revealed a preexisting crack of about 21 inches. Five 

additional tank cars of similar design were examined, and three of them 

had cracks ranging from two to 30 inches.

Tank car protection. The U.S. Department of Transportation 

issued regulations that require top and bottom shelf couplers and 

headshields, thermal and puncture protection to be included in the 

design of several types of new tank cars used to transport flammable 

gases, ammonia, and a wide variety of hazardous material. Existing cars 

of that specification had to be retrofitted. Headshields protect tank cars 

from being punctured at the ends of the tank car, the most vulnerable 

area for punctures.

Tank car protection upgrades stems from several accident 

investigations. In 1974, in a railroad yard in Decatur, Illinois, a tank car 

was punctured by a box car coupler, allowing a flammable gas to escape 

and vaporize. About 10 minutes later, the tank car exploded, killing 7 

yard employees and injuring 349 other persons. In a 1991 safety study, 

the Safety Board investigated 45 railroad accidents and concluded that 

hazardous materials that are highly flammable or toxic, or that pose a 

threat to the environment, were frequently transported in tank cars that 

provided inadequate protection.

Recreational Boating

Personal watercraft. States, the U.S. Coast Guard, and 

safe boating associations have implemented a series of safety guidelines 

for those who rent and use personal watercraft, such as jet skis and 

other small, propelled water vehicles. Safeguards include a checklist 

for boat rental businesses to help evaluate a person’s ability to operate 

a personal watercraft. Boating courses offered by the Coast Guard 

Auxiliary, U.S. Power Squadrons, Boat/US, and nationwide associations 

representing boating administrators and boating law administrators 

include information on the safe operation of personal watercraft. Offthrottle steering improvements are being added to personal watercraft, 

and States are encouraged to conduct alcohol testing of boat operators 

involved in fatal accidents.

In a 1998 Safety Board study, investigators analyzed hundreds of 

reported personal watercraft accidents in 1996 and 1997. The analysis 

showed major deficiencies in protection for personal watercraft riders from 

injury, operator experience and training, and boating safety standards. 

Tank car couplers were upgraded to prevent tank 

punctures. Couplers also help hold cars together 

during derailments.

The NTSB strongly believes that recreational boating 

safety can be enhanced and accidents reduced by 

requiring boat operators to take safety training courses.
National Transportation Safety Board 25

Lessons Learned and Lives Saved

Runway Safety

Aircraft overruns. The Port Authority of New York and New 

Jersey installed “arrestor beds” at the end of runways at JFK International 

and LaGuardia airports. Arrestor beds are cellular concrete systems that 

deform readily and reliably when an aircraft traverses it. As tires crush 

the material, the drag forces decelerate the aircraft. 

The Safety Board investigated two major runway overrun 

accidents in 1989 and 1994 at New York’s LaGuardia Airport. Two 

people died in one of the accidents when the aircraft ran off the runway 

and crashed into the bay. 

In 2003, a landing Gemini Air Cargo MD-11 overshot the 

runway and came to a stop in the arrestor bed. Four years earlier, 

arrestor bed technology also safely stopped an American Eagle 

commuter plane that overran a runway at the airport.

Airport ground collisions. The FAA issued air traffic bulletins 

to controllers in airport towers, emphasizing the higher risk of collision to 

aircraft and ground vehicles on airports when aircraft are maneuvering 

near runway intersections. Controllers are advised to use more caution 

and to state the runway intersection when authorizing an aircraft to taxi 

into position to hold or when clearing an aircraft for takeoff from an 

intersection.

These bulletins were prompted by the collision of two Cessna 

aircraft on the Sarasota, Florida, airport runway in 2000, killing both 

general aviation pilots.

Safety in Alaska’s Skies

Harsh flying environment. Major upgrades to air taxi 

aircraft safety have been made by the FAA in Alaska, a particularly harsh 

flying environment with a history of aircraft accidents above the rate 

in the lower 48 States. These improvements were targeted at the most 

common type of fatal accident in Alaska: continued visual flight into 

adverse weather.

Improvements include wider use of the Global Positioning 

System, upgraded equipment and policies for communicating and 

gathering weather information, advanced avionics in aircraft, improved 

navigational aids, more published approaches, and a new system 

for disseminating information about runway conditions to pilots. The 

State of Alaska has stepped up its inspections of airport conditions and 

obtained funding for equipment and training for its airport employees to 

communicate with pilots about safe conditions for landing.

These changes resulted from the Safety Board’s numerous 

aircraft accident investigations and recommendations and from a safety 

study of Alaska’s unique flying hazards.

This cargo jet was stopped from running off the 

runway at New York’s LaGuardia airport in 2003. 

It was stopped by an “arrestor bed”—a cellular 

concrete structure at the end of the runway that slows 

the aircraft.

Debris from a small aircraft litters a runway after a 

fatal runway collision in 2000. NTSB’s investigation 

and recommendations improved the flow of runway 

status information between pilots and controllers.

Lesson Learned

Alaska’s harsh flying environment is a 

challenge to NTSB investigators and aviation 

safety proponents. NTSB investigations 

have resulted in a series of safety

improvements in Alaska involving upgraded 

pilot education, and airport, aircraft and 

navigation aid improvements.
26 National Transportation Safety Board

Lessons Learned and Lives Saved

School Bus Safety

Easier exits. The National Highway Traffic Safety 

Administration issued school bus standards for improving total surface 

area for egress, including standards for the size of school bus side 

windows and roof hatches, and requiring that exit doors remain open 

during emergencies.

Safety Board investigations of numerous school bus accidents 

in the 1970s and 1980s pointed to the need for more ways to exit buses 

and better designs for emergency doors, windows, and roof hatches.

One of the most horrific accidents was the collision of a pickup 

truck and church bus in 1988 in Carrollton, Kentucky. The church bus fuel 

tank was punctured and fire engulfed the entire bus. The bus driver and 26 

bus passengers were killed. Contributing to the severity of the accident was 

the partial blockage by the rear bench seats of the area leading to the rear 

emergency exit, which impeded rapid passenger egress.

Another accident occurred in 1989 when a truck and school 

bus collided in Alton, Texas. The bus fell into an excavation pit partially 

filled with water. The bus front boarding door was jammed shut, but the 

rear emergency exit door was operable. The bus had no other emergency 

exits. Nineteen students died at the accident scene, and two died later in 

the hospital. The fatalities were the result of drowning or complications 

related to the submersion. Contributing to the severity of the accident, the 

Safety Board said, was the lack of a sufficient number of emergency exits 

on the school bus to accommodate the rapid egress of all students. 

School bus design. The U.S. Department of Transportation 

enacted tougher construction standards for school buses that required 

greater body joint strength, roof rollover protection, redesigned 

energy-absorbing seats, and emergency exit and fuel system protection 

improvements.

In a 1987 study on the performance of buses built to the new 

standards, the Safety Board found that the standards had significantly 

improved the safety of school bus transportation and recommended rapid 

retirement of all pre-standard buses in the fleet. In a 1999 study of bus 

crashworthiness, the Safety Board determined that occupant protection 

could be improved for side impact collisions and rollovers.

School bus drivers. The U.S. Labor Department no longer 

allows States to employ 16- and 17-year-old school bus drivers. The 

Safety Board sought this action because its investigations showed that 

these drivers were statistically over-represented in school bus accidents 

when compared to older bus drivers. 

Upgraded school bus inspections. States upgraded the 

quality of school bus inspection and repair by revising the qualifications 

and training for inspectors and mechanics. Quality control procedures 

have been instituted to determine whether needed repairs have been 

performed adequately and whether major repairs are required.

One of the dozens of school bus accidents investigated by the 

Safety Board occurred in 1983. A school bus accident near Newport, 

Arkansas, killed the driver, 4 teachers, and 4 students, and injured 2 

Today’s school buses are designed and built with 

dozens of safety improvements including tougher 

construction standards, greater joint strength, roof 

rollover protection, energy absorbing seats, better 

emergency exits, and upgraded fuel protection.

One of the Safety Board’s goals is to improve safety for 

young novice drivers. Many States have instituted 

NTSB-backed graduated driver licensing, or 

provisional license systems. They include restrictions on 

the number of allowed passengers, mandatory seat belt 

use, limited driving times, and violation-free driving 

records before drivers are ready for a full license.
National Transportation Safety Board 27

Lessons Learned and Lives Saved

teachers and 27 students. The investigation determined that the school 

bus was in poor mechanical condition and a post-accident inspection 

indicated major repairs were needed.

Teen Drivers

Protecting young drivers. States have enacted laws 

providing for a provisional license system, called graduated driver 

licensing, for young novice drivers—a significant change in the way 

teen drivers are licensed. These laws include a three-stage system for 

these drivers (learners permit, intermediate phase, and full unrestricted 

license). They require young novice drivers to wear seatbelts and 

remain violation free during the intermediate phase in order to obtain 

the unrestricted license. Some States also restrict nighttime driving and 

the number of passengers teen drivers can carry under an intermediate 

phase license.

Safety Board investigations consistently confirmed these grim 

facts: teen drivers represent less than 7 percent of the driving population 

but account for more than 13 percent of the drivers involved in deadly 

crashes; more than 21 percent of all highway fatalities occur in crashes 

that involve teenage drivers; the risk of a crash increases greatly with 

each additional teen passenger riding with a younger teen driver; and 

two-thirds of passengers who were killed in teen crashes were teenagers 

themselves, between the ages of 15 and 19.

Train and Mass Transit Safety

Locomotive fuel tank integrity. Manufacturers have 

designed the fuel tanks of locomotives to better withstand derailments 

and grade crossing accidents. Upgrades include reinforced tank skin, 

bulkheads with heavier steel, and tanks that are integrated into the 

locomotive frame.

The Safety Board’s investigations documented many instances 

when locomotive fuel tanks ruptured during collisions. In the 29 

locomotive derailments investigated by the Board in 1991 alone, diesel 

fuel spills occurred in more than half of the accidents. 

 In 1997, the Safety Board investigated two Amtrak passenger 

train derailments involving locomotives equipped with “integrally 

situated” fuel tanks. This type of fuel tank is located within the 

locomotive frame structure and was found to clearly outperform framesuspended fuel tanks. Integrally situated fuel tanks provide a higher 

ground clearance than conventional designs. As a result, less fuel tank 

damage and no significant spillage or subsequent fire occurred in either 

of the accidents, despite serious track damage.

Stronger train bodies. Light rail and transit car safety 

standards have been toughened to require stronger car body corner post 

structures in self-propelled passenger cars and control cab locomotives.

The actions by the Federal Railroad Administration and Federal 

Transit Administration followed the Safety Board’s investigation into a 

1993 commuter train crash in Gary, Indiana. One train failed to heed a 

Steam Locomotives: Learning 

Safety Lessons from History

Steam locomotives were built long before the Safety 

Board was on the job, but that didn’t stop investigators 

from figuring out ways to make them safer. 

In fact, the Safety Board has investigated several 

tourist railroad accidents and issued recommendations 

to improve their safety. Riding steam locomotives is 

a popular tourist attraction with more than 360 in 

operation.

A significant tourist railroad accident occurred in 

1995 near Gettysburg, Pennsylvania, when a steam 

locomotive, built in 1948, failed and released steam 

through the firebox door and into the locomotive cab, 

seriously burning the engineer and the two firemen. 

Investigators found that the train crew had allowed 

the water in the locomotive boiler to drop to an 

insufficient level and the boiler and its associated 

equipment had not been properly maintained.

The Federal Railroad Administration revised and 

updated regulations regarding steam locomotive safety. 

Actions that resulted from the accident include the 

addition of a redundant water-monitoring system for 

steam engines; certification of steam locomotive operators 

and repairers; updated and expanded Federal regulations 

for steam locomotives; and increased compliance for 

employees and volunteers with the Hours-of-Service Act to 

minimize fatigue hazards.
28 National Transportation Safety Board

Lessons Learned and Lives Saved

stop signal and collided with another train, with the major damage to the 

left corners of the lead cars of both trains. Seven passengers died and 

95 were injured.

Train brakes. Freight train braking rules were strengthened 

to require the ability for emergency application of air brakes when train 

equipment is left unattended.

In 1997, the Safety Board investigated an accident involving an 

Apache Railway freight train in Holbrook, Arizona. The crew was removing 

one car from the train when the remainder of the train rolled down a 

descending grade and derailed several cars, including a tank car that 

spilled its entire contents of hydrogen oxide. A fire ignited and a nearby 

residential area was evacuated.

Train safety supervision. Supervision of passenger train 

crews and the management of train movements have improved because 

of Safety Board investigations and recommendations. Improvements 

include expanded supervision and management of train operations on the 

Northeast Corridor, including mandatory speed and signal compliance 

checks; regular crew fitness-for-duty checks at reporting points; written 

notification of speed restrictions; special permission procedures for trains 

entering out-of-service track sections; and a reporting system for Amtrak 

crew efficiency, rule compliance, and toxicology tests while Amtrak trains 

are using non-Amtrak or “host” railroad tracks.

Training

Hazardous materials training. Major railroads, carriers, 

shippers, and emergency response agencies have improved their 

communication and coordination during hazardous materials accidents and 

incidents. Training programs for operating crews and supervisors have been 

implemented that spell out steps to take immediately following a hazardous 

materials incident or accident, including procedures for working more closely 

with emergency response agencies during wreckage-clearing operations 

and requirements for train crews to maintain up-to-date listings showing the 

position of hazardous materials cars in their trains. Shippers also include an 

emergency 24-hour telephone number on their shipping papers that allows 

access to detailed information on the characteristics of the material.

Dozens of hazardous materials accidents investigated by the 

Safety Board led to improvements. They include a freight train derailment 

in Freeland, Michigan, in 1989, when a tank car containing a chlorosilane 

mixture was punctured, causing the cargo to ignite. The manufacturer’s 

material safety data sheet contained conflicting information and did not 

provide effective firefighting procedures; emergency responders attempted 

various techniques over a 5-day period before they were able to extinguish 

the blaze. 

Recurrent training. Amtrak improved its initial and recurrent 

emergency training for all crews including on-board service personnel for 

passenger safety and instituted a database to monitor compliance with 

training requirements.

Lack of consistent emergency training was an issue uncovered 

in an Amtrak passenger train accident in Kingman, Arizona, in 1997. 

Lesson Learned

Dozens of hazardous materials accidents 

investigated by the NTSB have resulted in 

improved communications, coordination 

and training among local emergency 

responders and jurisdictions, railroads and 

shippers; better 24-hour emergency contact 

information; and more accurate hazardous 

materials manifests on trains and planes.

In 2003, the NTSB Training Center opened its doors 

in Ashburn, Virginia, and is the Safety Board’s first 

comprehensive training and learning facility.
National Transportation Safety Board 29

Lessons Learned and Lives Saved

The train derailed in the dark after it crossed a small bridge that was 

damaged by a flash flood. Ten Amtrak employees and more than 170 

passengers were injured.

Train crew qualifications. Two Safety Board investigations 

of passenger train accidents in 1996 at Secaucus, New Jersey, and Silver 

Spring, Maryland, have led to improvements in the physical testing and 

physical qualifications of train crews and signal system design. In the 

Secaucus accident, two New Jersey Transit commuter trains collided head 

on, killing the engineers on both trains and one passenger. The Safety 

Board determined that the probable cause of the accident was that one 

of the train engineers failed in correctly perceiving a red signal because 

of an eye disease and color vision deficiency, which he failed to report 

to New Jersey transit during annual medical exams. In the Maryland 

accident, three crew members and eight passengers on a Maryland 

commuter train were killed when the engineer failed to respond to a signal 

and the train collided with an Amtrak passenger train. The Safety Board 

said the engineer and crew failed to obey signals because of multiple 

distractions, and Federal and State regulators failed to conduct analyses on 

the human factors impact of signal modifications on that rail line. 

Training guidelines. The U.S. Coast Guard revised its 

enforcement guidelines so that its inspectors can better assess crew 

training on sophisticated integrated bridge systems on ships and the 

crew’s ability to recognize system failures, especially in high-tech 

navigation equipment.

In 1995, the Royal Majesty passenger ship with more than 

1,500 on board ran aground near Nantucket Island, Massachusetts. 

The Safety Board investigation said the cruise line company failed to 

adequately train watch officers in the automated features of the ship’s 

integrated bridge system and global positioning system. The ship’s 

navigation system failed, the ship veered off course, and the crew failed 

to take corrective action. 

Weather and Visibility Hazards

Airport windshear alerts. Numerous improvements have 

been made to low-level wind shear alert systems and Doppler weather 

radars at large airports nationwide to increase their effectiveness, 

including the addition of new technology, better placement near airports, 

increased area coverage, and improved compatibility with other systems 

at airports. These alert systems provide pilots with faster and more 

accurate weather information, and a complete windshear training 

program is available to pilots.

These upgrades were prompted by numerous Safety Board 

investigations, including that of a USAir DC-9 that collided with trees 

and crashed in Charlotte, North Carolina, in 1994, killing 37. During 

severe weather, the aircraft missed its approach. Two other windshear 

accidents that prompted improvements were the 1975 crash of an 

Eastern Air Lines 727 in New York, and the 1985 crash of a Delta Air 

Lines L-1011 while landing at Dallas/Fort Worth during a thunderstorm, 

killing 135 persons.

Aviation accidents involving windshear and severe 

weather conditions have led to major improvements 

in windshear detection education, advances in 

technology, and improved weather monitoring. They 

include the 1985 crash of an L-1011 that claimed 

135 lives (top photo), and a DC-9 accident in 1999 

that killed 11.

Driving with headlights on during the day improves 

vehicle visibility and safety.
30 National Transportation Safety Board

Lessons Learned and Lives Saved

Eyes on the skies. The National Weather Service has 

improved the monitoring of its meteorologists located at government air 

traffic control center weather service units to ensure adequate staffing 

when significant adverse weather is forecast.

The improvements stem from the American Airlines DC-9 crash in 

Little Rock, Arkansas, in 1999. The aircraft ran off the runway in adverse 

weather, killing 11 and injuring 110 of the 145 on board. Weather 

information dissemination was a major issue in the investigation report.

Lights on for safety. The National Safety Council and other 

safety organizations encouraged motorists, through public information, 

to drive with their low-beam headlights on during the day. Daytime 

headlight use increases vehicle visibility and more quickly alerts 

pedestrians and other drivers to impending hazards and crashes.

Reduced visibility. Several States have implemented 

comprehensive detection systems and response plans that include the 

detection of traffic flow disruptions and procedures for uniform driver 

response through reduced visibility areas, especially fog-prone areas and 

areas affected by smoke and dust. The Transportation Research Board 

compiled and published preferred practices, and a Safety Board public 

hearing on the issue resulted in information that was distributed to all 

States.

The changes stem from the Safety Board investigation of six 

limited visibility crashes since 1990 that killed 40 people and involved 

more than 450 vehicles.

Work Zone Safety

Highway construction. The nationwide Manual of Uniform 

Traffic Control Devices was strengthened by the Federal Highway 

Administration to require that work zone flaggers be stationed far enough 

ahead of work zone workers and that they use audible warning devices, 

such as horns, to alert highway workers to the approach of erratic 

vehicles.

These changes stem from several work zone accident 

investigations, including a 1990 tragedy when 10 people died and two 

were injured in a chain reaction crash that occurred in a highway work 

zone in Sutton, West Virginia. A vehicle transporter carrying eight cars 

entered a highway repair work area reduced to one lane and struck 

the rear of a vehicle. A chain reaction resulted and five vehicles were 

burned and destroyed, including three West Virginia highway department 

vehicles.

Preventing multi-car pileups is the goal of the NTSB 

after it investigated six limited visibility crashes in the 

1990s.

The potential for work zone accidents on the 

nation’s highway has been reduced thanks to safety 

improvements following several work zone accident 

investigations.
National Transportation Safety Board 31

Lessons Learned and Lives Saved

NTSB Most Wanted List

‘Most Wanted List’ Highlights Needs for More 

Safety Advances

This publication highlights many of the safety recommendations 

that have been implemented; however the Safety Board’s work is far 

from finished. In virtually every accident investigation, the Safety Board 

identifies areas for improvement. Many are given higher priority by 

placing them on NTSB’s “Most Wanted List of Safety Improvements.” 

Fully implementing these recommendations, the Board believes, will save 

many more lives in the future.

The Most Wanted List was introduced in 1990. It has proven 

successful in giving extra emphasis to more than 265 recommendations 

—most of them very tough to implement. Half of them have been 

implemented to the Safety Board’s satisfaction, and many more are 

nearing implementation.

The current Most Wanted List focuses government, industry, and 

public attention on 46 recommendations that the Safety Board strongly 

believes should be acted on quickly. These recommendations advocate a 

wide range of safety upgrades in all modes of transportation—all uncovered 

during dozens of accident investigations. Significant progress has been made 

on many of these issues, but progress on some lags behind and is long 

overdue. The Safety Board continues to push for these safety advances.

Accident investigations that inspired these recommendations 

include 11 major aviation crashes, dozens of passenger train and freight 

train derailments and collisions, multiple highway crashes, catastrophic 

pipeline ruptures and oil spills, and numerous ship collisions in the past 

decade. They also stem from NTSB safety studies, special reports, and 

forums focusing on personal watercraft, recreational boating, commuter 

airlines, hardcore drinking drivers, air bags, seatbelts and child passenger 

safety, bus crashworthiness, and human fatigue in transportation.

The list is divided into two sections: Actions needed by Federal 

agencies and actions needed by the States.

Actions needed by Federal Agencies

AVIATION

The Federal Aviation Administration should act to:

Reduce Dangers to Aircraft Flying in Icing Conditions

Use current research on freezing rain and large water droplets 

to revise the way aircraft are designed and approved for flight in 

icing conditions. 

Conduct additional research with NASA to identify realistic ice 

accumulation and incorporate new information into aircraft 

certification and pilot training requirements.

•

•

Deicing aircraft is a critical step in reducing the 

dangers of flying in icing conditions. 
32 National Transportation Safety Board

Lessons Learned and Lives Saved

Eliminate Flammable Fuel/Air Vapors in Fuel Tanks on 

Transport Category Aircraft

Implement design changes to eliminate the generation of 

flammable fuel/air vapors in all transport category aircraft. 

Stop Runway Incursions/Ground Collisions of Aircraft

Give immediate warnings of probable collisions/incursions 

directly to flight crews in the cockpit.

Improve Audio and Data Recorders/Require Video 

Recorders

Require cockpit voice recorders to retain at least 2 hours of audio.

Require back-up power sources so cockpit voice recorders collect 

an extra 10 minutes of data when an aircraft’s main power fails.

Install video recorders in cockpits to give investigators more 

information to solve complex accidents.

Install dual combination recorders.

Expand parameters recorded on Boeing 737 airplanes.

Reduce Accidents and Incidents Caused by Human 

Fatigue

Set working hour limits for flight crews and aviation mechanics 

based on fatigue research, circadian rhythms, and sleep and rest 

requirements.

Improve Crew Resource Management

Require commuter and on-demand air taxi flight crews to receive 

crew resource management training. 

RAILROAD

The Federal Railroad Administration should act to:

Implement Positive Train Control Systems

Prevent train collisions and overspeed accidents by requiring 

automatic control systems to override mistakes by human 

operators.

PIPELINE

The Pipeline and Hazardous Materials Safety Administration 

should act to:

Reduce Accidents and Incidents Caused by Human 

Fatigue

Set working hour limits for pipeline controllers based on fatigue 

research, circadian rhythms, and sleep and rest requirements. 

•

•

•

•

•

•

•

•

•

•

•

NTSB’s goal to eliminate airliner fuel tank explosions 

is on the agency’s Most Wanted List. Smoke rises from 

a fuel tank explosion in an aircraft parked at a gate 

in Bangkok, in 2001 (top photo). A tragic accident, 

attributed to an explosion of a fuel air mixture in 

center wing tank occurred on 1996 when a 747 

crashed into the Atlantic Ocean, and claimed 230 

lives. Reconstructing a portion of the downed plane 

aided NTSB investigators in finding the accident’s 

probable cause. The reconstruction is housed at the 

NTSB Training Center and is used as a training tool 

for investigators.
National Transportation Safety Board 33

Lessons Learned and Lives Saved

HIGHWAY

The Federal Motor Carrier Safety Administration should act to:

Improve the Safety of Motor Carrier Operations

Prevent motor carriers from operating if they put vehicles with 

mechanical problems on the road or unqualified drivers behind 

the wheel. 

Prevent Medically Unqualified Drivers from Operating 

Commercial Vehicles

Establish a comprehensive medical oversight program for 

interstate commercial drivers.

Ensure that examiners are qualified and know what to look for.

Track all medical certificate applications.

Enhance oversight and enforcement of invalid certificates.

Provide mechanisms for reporting medical conditions.

The National Highway Traffic Safety Administration should act to:

Enhance Protection of Motorcoach Passengers

Redesign motorcoach window emergency exits so passengers 

can easily open them.

Issue standards for stronger bus roofs and require them in new 

motorcoaches.

Devise new standards to protect motorcoach passengers from 

being thrown out of their seats or ejected when a bus sustains a 

front, side, or rear impact or rolls over.

Enhance Protection for School Bus Passengers

Devise new standards to protect school bus passengers from 

being thrown out of their seats or ejected when a bus sustains a 

front, side, or rear impact or rolls over.

MARINE

The U.S. Coast Guard should act to:

Reduce Accidents and Incidents Caused by Human 

Fatigue

Set working hour limits for mariners based on fatigue research, 

circadian rhythms, and sleep and rest requirements. 

•

•

•

•

•

•

•

•

•

•

•

The deadliest runway accident in the United States 

was a collision between a 737 and a commuter at 

Los Angeles in 1991, killing 34. The Safety Board 

wants immediate warnings of probable collisions and 

incursions to be sent directly to flight crews.

In 2005, the government reported that 90 percent 

of 203 railroad head-on, rear-end and side 

collisions were attributed to human factors causes. 

Implementing positive train control systems would 

have a major impact on reducing these types of 

accidents.
34 National Transportation Safety Board

Lessons Learned and Lives Saved

INTERMODAL

The U.S. DOT should act to:

 Reduce Accidents and Incidents Caused by Human 

Fatigue

Set working hour limits for transportation operators based 

on fatigue research, circadian rhythms, and sleep and rest 

requirements. 

Action needed by the States

HIGHWAY

Improve Child Occupant Protection 

Enact State laws requiring booster seats for young children.

Enact Primary Seat Belt Enforcement Laws

Increase the number of people who wear seat belts through 

stronger enforcement laws.

Promote Teen Highway Safety 

Enact graduated driver licensing legislation.

Restrict the number of teen passengers traveling with young 

novice drivers.

Prohibit use of wireless communications devices by young novice 

drivers.

Reduce Hard Core Drinking Driving

Enact State legislation and take other actions that are proven 

to reduce crashes involving those who repeatedly drink large 

amounts of alcohol and drive including:

o Frequent, statewide sobriety checkpoints. 

o Legislation to create stricter sanctions for those arrested 

for the first time with a high blood alcohol concentration 

of 0.15 or higher.

o Zero blood alcohol requirement for convicted DWI 

offenders when they get their license back.

o Administrative rather than court-based license revocation 

for refusing to take or failing the sobriety test.

o Vehicle sanctions for DWI offenders.

o Eliminate plea-bargaining DWI offenses and programs 

that divert offenders and purge the offense record.

o Retain DWI offense records for at least 10 years to 

identify and prosecute repeat offenders.

o Develop and operate special sanction court-based 

programs for hard-core DWI offenders.

•

•

•

•

•

•

•

Improving motor carrier safety is an important issue 

on the Most Wanted List. The NTSB’s goal is to 

prevent unqualified drivers from getting behind the 

wheel, and getting vehicles with mechanical problems 

off the road.

Because the NTSB believes that enacting graduated 

driver licensing laws in every State is critical to the 

safety of young novice drivers, the issue is on the Most 

Wanted List. Strictly adhering to driving laws, speed 

limits, and limiting driving times and the number 

of passengers are elements of an effective graduated 

licensing program. 
National Transportation Safety Board 35

Lessons Learned and Lives Saved

Improve School Bus/Grade Crossing Safety

Install stop signs at passive crossings.

Upgrade school bus railroad crossings that only have warning 

signs to crossings with lights and gates.

Install switches on new buses that allow drivers to turn off radios 

and other devices that mask the sound of train warning horns.

Enhance bus driver training and evaluation.

Include grade crossing questions on Commercial Drivers License 

exams.

MARINE

Enhance Recreational Boating Safety 

Require mandatory education of boat operators.

Require use of life jackets for children.

Require safety instruction prior to personal watercraft rental.

For updates on the Most Wanted List, visit the NTSB Web site at 

<http://www.ntsb.gov> and click on the Most Wanted List box on the 

front page.

•

•

•

•

•

•

•

•

School bus grade crossing accidents are infrequent, 

but the results can be deadly when they occur. In 

this school bus accident in Tennessee in 2000, three 

students were killed and several others were injured.

Requiring personal flotation devices for children 

on recreational boats is one of the NTSB’s goals to 

enhance safety. NTSB safety studies show that far too 

many people who drown in boating accidents were not 

wearing personal flotation devices.
36 National Transportation Safety Board

Lessons Learned and Lives Saved

Communicating Our Safety 

Message

In the past four decades, NTSB has planned and 

sponsored numerous conferences, forums, and symposia to focus 

government, industry, and public attention on lessons learned from 

accident investigations and the importance of implementing its safety 

recommendations.

In addition to dozens of public hearings and public meetings that were 

integral to NTSB investigations of major accidents, the agency has held 

more than 30 major conferences that have attracted more than 10,000 

attendees. These include representatives of all modes of transportation 

from private industry, Federal, State, and local government in the United 

States, and more than 30 foreign countries.

Here are some of the events and their topics:

Runway Incursion Forum

Topics: Review of the worst runway accident and worst aviation accident in

history: the collision of two 747 in the Canary Islands in 1977; assessment

of the current runway incursion problem and potential technological

solutions with presentations by the NTSB, FAA and industry groups.

Washington, D.C., March 2007

Passenger Vessel Safety on Sole State Waters

Topics: Review of several NTSB boating accidents; certification and

inspection of small passenger vessels under Coast Guard jurisdiction;

and challenges of certification and inspection programs addressing

vessels under State jurisdiction.

NTSB Training Center, Ashburn, Virginia, October 2006

Meeting the Challenges in a New Era of Disaster Response

Topics: New developments in family assistance, evolving communications

technology affecting the family assistance process, academic findings

relating to family assistance operations, examples of how family assistance

model has been successfully used and modified in recent disasters of all

types of transportation, criminal and natural disasters.

NTSB Training Center, Ashburn, Virginia, October 2006

Motorcycle Safety Forum

Topics: Safety research and initiatives, and safety countermeasures

that may reduce the likelihood of motorcycle accidents and fatalities,

including trends and safety statistics, vehicle design, rider protective

equipment, public education, and rider impairment.

Washington, D.C., September 2006
National Transportation Safety Board 37

Lessons Learned and Lives Saved

Positive Train Control Systems Symposium

Topics: Issues discussed at the forum included: review of PTC systems,

train control and traffic control, railroad industry perspectives, application

of Global Positioning Systems, standardization and interoperability, and

regulatory initiatives.

NTSB Training Center, Ashburn, Virginia, March 2005

Personal Flotation Devices Forum

Topics: Impact of laws mandating the wearing of personal flotation

devices on various types of recreational boats, new personal flotation

devices technology, and alternatives.

NTSB Training Center, Ashburn, Virginia, August 2004

Aviation Image Recording Forum

Topics: Current state of recorder and video technology, investigative uses,

and legal, privacy, and regulatory issues.

Washington, D.C., July 2004

Highway Vehicle Electronic Data Recorders Symposium

Topics: State-of-the-art recorder technology for passenger and

commercial vehicles, developments and trends in data recording

technology, legal issues, privacy, and hands-on demonstration of

electronic data recorder extraction.

NTSB Training Center, Ashburn, Virginia, June 2004

Air Cargo Safety Forum

Topics: Current state of the cargo industry, operations, human factors,

and regulatory issues.

NTSB Training Center, Ashburn, Virginia, March 2004

Driver Education and Training Forum

Topics: Quality and effectiveness of novice driver education and

training programs, and their strengths, weaknesses and possibilities for

improvement.

Washington, D.C., October 2003

Vehicle Recorders Symposium

Topics: State-of-the-art accident recorder technology, accident recorder

survivability/crashworthiness requirements, video/imaging recorder

technology, data privacy, acquiring data during regular commercial

operations, and proactive use of data in commercial operations to

prevent accidents and improve efficiency.

Alexandria, Virginia, June 2003

Transportation Safety and Potentially Sedating or 

Impairing Medications

Topics: Examination of the impact of prescription and over-the-counter

medications on the performance and abilities of vehicle operators.

Washington, D.C., November 2001
38 National Transportation Safety Board

Lessons Learned and Lives Saved

Child Safety Seat Roundtable

Topic: Identify what actions need to be taken by the Federal government, 

child restraint manufacturers, retailers, safety advocates, and others to 

increase the availability of affordable booster seats for use with lap-only 

belts.

Washington, D.C., December 2000

General Aviation Accident Prevention Symposium

Topic: Review of general aviation accident investigations conducted by

NTSB including analysis of causes and preventive measures outlined by

panels of government experts and safety officials.

Washington, D.C., April 2000

International Symposium on Transportation Safety and 

the Law

Topics: Concerns about the growing need for data to improve

transportation safety and the use of that data in regulatory actions,

lawsuits, and criminal prosecutions.

Arlington, Virginia, April 2000

International Conference on Child Safety in Aviation

Topics: Developments for protecting young children, and problems and

challenges to make protection affordable to all young children flying on

aircraft.

Arlington, Virginia, December 1999

Aircraft Maintenance Forum

Topics: Practices used by airlines that outsource maintenance to ensure

quality work and inspections done by contract maintenance firms.

Chicago, Illinois, August 1999

Roundtable on Simplifying Child Safety Seat Designs

Topics: Effective and easy ways of installing, designing, and securing child

safety seats.

Arlington, Virginia, June 1999

Conference on Preventing Damage to Underground 

Facilities

Topics: Dangers of working around pipelines and the consequences of

excavation damage to pipelines.

Washington, D.C., June 1999

International Symposium on Transportation Recorders

Topics: Methods for expanding the use of event recorders in all modes of

transportation to improve safety, including the commercial and economic

advantages of installing recorders by an international panel of recorder

experts.

Arlington, Virginia, May 1999

Boosting the proper use and installation of car booster 

seats is a goal of a broad coalition of highway safety 

advocates, including the NTSB.

This bulk tanker split in two in rough seas in 

the Bering Sea off Alaska in 2004. During crew 

evacuation, a helicopter crashed, killing six on board. 
National Transportation Safety Board 39

Lessons Learned and Lives Saved

Public Transit Bus Operations Hearing

Topics: Lack of significant Federal safety oversight of transit operations

including driver qualification and training, driver hours of service, bus

maintenance, and maintenance.

St. Louis, Missouri, March 1998

Forum on Passive Grade Crossing Safety

Topics: Lessons learned for the public, industry, and government from

passive grade crossing accidents.

Jacksonville, Florida, May 1997

International Symposium on Family Assistance for 

Transportation Disasters

Topics: Government and private industry roles and responsibilities to

victims of major transportation disasters and their families.

Arlington, Virginia, September 1998

Symposium on Corporate Culture and Transportation 

Safety

Topics: Effects of organizational management philosophy and practices

on the day-to-day safety operations of transportation systems.

Arlington, Virginia, April 1997

Forum on Air Bags and Child Passenger Safety

Topics: Review of air bag-related fatalities, particularly involving children,

and public confusion and concern; and government, industry, and 

consumer information sharing on the role of air bags, benefits and safety

concerns, and improvements in child passenger transportation.

Washington, D.C., March 1997

Integrated Bridge Systems Public Forum

Topics: Design standards for ship integrated bridge systems; industry

and government oversight of manufacturers, installers, and operators

of integrated bridge systems; training and certification; and impact of

technology on safety, crew workload, and watch-keeping.

Vienna, Virginia, March 1996

Multimodal Symposium: Managing Fatigue in 

Transportation

Topics: Human fatigue knowledge, countermeasures and resources,

fatigue in accident investigations, sleep and medical disorders,

performance effects of fatigue, and education and training

approaches.

Tysons Corner, Virginia, November 1995

Aviation Accident Investigation Symposium

Topics: Discussion and critique by aviation industry of Safety

Board’s practices, programs, and procedures used during accident

investigations.

Tysons Corner, Virginia, March 1994

NTSB has investigated tens of thousands of general 

aviation accidents since 1967. These photos shows a 

vintage Lockheed aircraft that crashed and burned at 

an air show in Midland, Texas, in 2004.
40 National Transportation Safety Board

Lessons Learned and Lives Saved

Airline Commuter Safety Forum

Topics: Upgraded regulations, onboard equipment and training for

commuter airlines to make requirements similar to those of large aircraft

operators.

Atlanta, Georgia, June 1994

Child Passenger Safety Symposium

Topics: Ways to increase use of child restraints and to reduce their

misuse.

Washington, D.C., September 1985

Aviation Accident Investigation Symposium

Topics: Discussion and critique by aviation industry of Safety

Board practices, programs, and procedures used during accident

investigations.

Washington, D.C., April 1983

Motorcoach safety is a top NTSB priority. These 

photos show the damage to a motorcoach that collided 

with the underside of an arched stone overpass in 

Alexandria, Virginia, in 2004 (top); and the burned 

shell of a motorcoach in Wilmer, Texas, in 2005, that 

took 23 lives.
National Transportation Safety Board 41

Lessons Learned and Lives Saved

2007 Safety Board Members (l to r) Member Kitty 

Higgins, Vice Chairman Robert Sumwalt, Chairman 

Mark V. Rosenker, Member Debbie Hersman and 

Member Steven Chealander.

Board Members

Advocating and implementing transportation safety advances is a 

team effort that involves the entire Safety Board staff and its leaders. Since 

the Safety Board came into existence, 38 individuals have served as Board 

Members. Eleven of them have also been confirmed as chairmen. Each 

Board Member is nominated by the President and confirmed by the Senate 

to serve 5-year terms. 

Joseph J. O’Connell, Jr.* 

1967 - 1969

Oscar M. Laurel

1967 - 1972

Louis M. Thayer

1967 - 1976

John H. Reed*

1967 - 1976

Francis H. McAdams

1967 - 1983

Isabel A. Burgess

1969 - 1976

William R. Haley

1972 - 1977

Webster B. Todd, Jr.*

1976 - 1979

Philip A. Hogue

1976 - 1979

Kay Bailey Hutchinson

1976 - 1978

James B. King*

1977 - 1982

Elwood T. Driver

1978 - 1981

Patricia A. Goldman

1979 - 1988

G. H. Patrick Bursley

1979 - 1985

James E. Burnett, Jr.*

1981 - 1991

Donald D. Engen

1982 - 1984

Vernon Grose

1983 - 1984

John K. Lauber

1985 - 1995

Joseph T. Nall

1986 - 1989

James L. Kolstad*

1987 - 1992 

Lee V. Dickinson, Jr.

1988 - 1990

Susan M. Coughlin

1990 - 1994

Christopher A. Hart

1990 - 1993

John A. Hammerschmidt

1991 - 2003

Carl W. Vogt*

1992 - 1994

James E. Hall*

1993 - 2001

Robert T. Francis II

1995 - 1999

John J. Goglia

1995 - 2004

George W. Black, Jr.

1996 - 2003

Carol J. Carmody

2000 - 2005

Marion C. Blakey*

2001 - 2002

Richard F. Healing

2003 - 2005

Ellen Engleman Conners*

2003 - 2006

Mark V. Rosenker*

2003 - Present

Deborah A. P. Hersman 

2004 - Present

Kathryn O. Higgins

2006 - Present

Robert L. Sumwalt III

2006 - Present

Stephen R. Chealander

2007 - Present

1967 Safety Board Members 

Joseph O’Connell, Jr. 

Chairman

Francis McAdams

Member

Louis Thayer

Member

Oscar Laurel

Member

John Reed

Member

* Designated as Chairman by the President during either entire or part of Board membership