National Transportation Safety Board

Washington, DC 20594

OFFICIAL BUSINESS

Penalty for Private Use $300

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We Are All Safer
xii N a t i o n a l T r a n s p o r t a t i o n S a f e t y B o a r d

Lessons Learned and Lives Saved 1975 - 2005
N a t i o n a l T r a n s p o r t a t i o n S a f e t y B o a r d i

Lessons Learned and Lives Saved 1975 - 2005

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

1975 - 2005

Lessons Learned and

Lives Saved

NTSB/SR-05/01

PB2005-917001

We Are All Safer
ii N a t i o n a l T r a n s p o r t a t i o n S a f e t y B o a r d

Lessons Learned and Lives Saved 1975 - 2005

National Transportation Safety Board. 2005. We Are All Safer: Lessons Learned and 

Lives Saved 1975-2005. 3rd ed. Safety Report NTSB/SR-05/01. Washington, DC.

Abstract: On April 1, 1975, the National Transportation Safety Board became a totally independent 

Federal agency. This report commemorates the 30th anniversary of the agency’s independence and 

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 NTSB-inspired safety advances in all modes of transportation: aviation, 

highway, marine, railroad and pipeline. The report 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. Another section highlights the “Most Wanted List” and 

focuses on additional safety advances that the Safety Board strongly believes are needed to increase 

transportation safety. A list of the most prominent conferences and information-sharing meetings that 

have been sponsored by the Safety Board are included, as is a list of all 35 Board Members who have 

served on the Safety Board to date. 

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

highway, marine, pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress 

through the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the probable causes 

of the accidents, issue safety recommendations, study transportation safety issues, and evaluate the safety effectiveness 

of government agencies involved in transportation. The Safety Board makes public its actions and decisions through 

accident reports, safety studies, special investigation reports, safety recommendations, and statistical reviews.

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

available publications also may be obtained from the Web site or by contacting:

National Transportation Safety Board

 Public Inquiries Section, RE-51

 490 L’Enfant Plaza, S.W.

 Washington, D.C. 20594

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

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

Information Service. To purchase this publication, order report number PB2005-917001 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. 
N a t i o n a l T r a n s p o r t a t i o n S a f e t y B o a r d iii

Lessons Learned and Lives Saved 1975 - 2005

Contents

“Out of Tragedy, Good Must Come” .....iv

Federal Law Gives Safety Board 

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

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

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

Public Trust ...............................................................ix

Independent Watchdog .............................................ix

Recommendations: Implementation is Key ...................ix

Leveraging Resources ................................................x

Statutory Authority .....................................................x

The Safety Board and the Law ....................................xi

NTSB-Inspired Safety 

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

Aircraft Icing Prevention ...........................................1

Airplane Maintenance and Inspection .......................2

Alcohol and Drugs in Transportation .........................4

Bridge 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

Commercial Fishing Vessel and Towing Safety ...........17

Grade Crossing Safety ............................................18

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

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

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

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

Railroad Tank Car Safety .........................................23

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

Runway Safety ........................................................24

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

School Bus Safety ...................................................25

Teen Drivers ...........................................................26

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 ............................................................33

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

Marine ..............................................................36

Intermodal .........................................................36

Action needed by the States .....................................37

Highway ............................................................37

Marine ..............................................................39

Communicating Our Safety Message 

 to the Public and Industry ................40

Board Members ...................................43
iv N a t i o n a l T r a n s p o r t a t i o n S a f e t y B o a r d

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Out of Tragedy, Good 

Must Come 

Lessons Learned and Lives Saved 

Dear Fellow Citizens:

The National Transportation Safety Board is marking 

another milestone in its nearly four-decade history of independent, 

objective accident investigations, and advocacy efforts that 

have yielded thousands of safety improvements throughout the 

transportation industry, not only in the United States but also 

across the globe.

Thirty years ago in the fall of 1974, Congress passed a law 

making the Safety Board a totally independent agency. The law took 

effect on April 1, 1975, ending all administrative ties with the U.S. 

Department of Transportation that had been in place since 1967. 

More than 80 percent of all the recommendations issued 

in our history have been implemented. The exact number of 

lives that have been saved because of these improvements is 

incalculable. The Safety Board has made a major contribution to 

the welfare of those using all modes of transportation—highway, 

rail, marine, aviation and pipeline. 

Promoting safety in all transportation modes to 

government, industry, and the public is not an easy task. There 

are still many improvements to make. The Safety Board Members 

and staff are committed to promoting safety and continuing to 

advocate our recommendations to regulators and private industry 

until positive changes are made. 

Many of our significant safety accomplishments during the 

past 30 years are highlighted in this document and highlight the 

Safety Board’s mission to push for safety improvements. These 

accomplishments are the results of positive action taken on safety

recommendations issued by the Safety Board—a direct result of 

aviation, highway, rail, marine, pipeline, and hazardous materials 

accident and incident investigation findings and causes.
N a t i o n a l T r a n s p o r t a t i o n S a f e t y B o a r d v

Lessons Learned and Lives Saved 1975 - 2005

We are proud of these accomplishments, but realize that 

our work is unfinished, and our mission continues. The Safety 

Board will continue to build on its safety history and is committed 

to ensuring that we, and the transportation industry, do not forget 

the lessons learned from past accidents, or worse, repeat them.

During this anniversary year, the Safety Board has 

aggressively worked to close open recommendations. For the 

first time since 1975, the Board has fewer than 1,000 open 

recommendations, and at the time of this printing, the number was 

below 825. It is important to understand the work that is required 

to close recommendations.

For instance, when we issue a recommendation to the 

States and Territories, there are 56 recipients, including 5 U.S. 

Territories and District of Columbia. This year we completed an 

agencywide focus on highway recommendations to the States, 

evaluating 59 recommendations that involved reviewing actions 

by 2,300 recipients. As a result, the Safety Board closed 50 of 

the 59 recommendations, or the equivalent of recommendations 

to more than 1,700 recipients. And more than 1,200 involved 

positive action, signifying that a safety improvement had been 

implemented.

Why is this important? The safety loop is not closed until 

our recommendations are accepted. The tragedy of accidents can 

only be translated to good when future accidents can be prevented 

and lives saved. Out of tragedy, good must come.

We will continue to aggressively pursue safety in all modes. 

The staff of the Safety Board do not have jobs—they have a 

mission.

Ellen Engleman Conners

Chairman

March 2005

1975-2005

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Federal Law Gives Safety 

Board a Unique Mandate

Since 1967, a series of Federal laws created and shaped the 

National Transportation Safety Board into an organization that uses 

an aggressive approach to prevent and reduce 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 to as wide 

an audience 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. 

Lean Independent Agency

The Safety Board has investigated more than 120,000 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 only about 425 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.

Aggressive 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, 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.

In 2003, the NTSB Academy opened its doors in 

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

comprehensive training and learning facility.

The NTSB Academy’s motto is “Independence, 

integrity, and innovation in transportation 

accident investigation.” The facility is “dedicated 

to the victims of transportation accidents and their 

families. From tragedy we draw knowledge to 

improve the safety of all.”
N a t i o n a l T r a n s p o r t a t i o n S a f e t y B o a r d vii

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In 2003, the NTSB Academy opened its door as the agency’s 

first comprehensive training and learning facility. The Academy trains 

and teaches its own employees and transportation industry personnel 

from throughout the United States and the world. It designs its courses to 

further the Academy’s motto: “Independence, integrity, and innovation in 

transportation accident investigation.”

“Independence is the linchpin of the National 

Transportation Safety Board’s efforts to find probable 

cause during its comprehensive investigative process. 

The Board’s professional, thorough analysis, 

unfettered by potential interference, results in 

accident reports that are recognized worldwide for 

their objectivity and credibility. Those reports are the 

basis for NTSB’s thoughtful safety recommendations, 

made on behalf of the traveling public, to government 

and industry, which over the years, have prevented 

numerous accidents and saved countless lives.”

“The Safety Board has made significant contributions 

to safety not only in the United States but also around 

the world. Our participation in international accident 

investigations, our studies, our seminars, and our 

recommendations give us the opportunity to share 

what we have learned with others in our mutual 

efforts to improve safety. We are recognized as one 

of the premier safety agencies and have encouraged 

other countries to adopt our model for accident 

investigation.” 

Mark V. Rosenker, Vice Chairman

Carol J. Carmody, Member
viii N a t i o n a l T r a n s p o r t a t i o n S a f e t y B o a r d

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“Federal Government’s role evolves to respond 

to today’s complex issues. Trusting partnerships 

with the States and industry enable higher levels of 

achievement through shared responsibilities and 

commitments. Better decisions are the product of 

proactive and creative sharing of the best information. 

Voluntary initiatives in safety at the State and industry 

level will benefit us all.”

“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.”

Richard F. Healing, Member

Deborah A. P. Hersman, Member
N a t i o n a l T r a n s p o r t a t i o n S a f e t y B o a r d ix

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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. 

Independent 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. 

Recommendations: Implementation is Key

Since the Safety Board began its work, more than 12,250 

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 an 80-percent-plus acceptance rate on 

recommendations. Contributing to this high 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. 

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.

Safety recommendations have three 

straightforward goals: to prevent 

accidents, to save lives, and to 

reduce injuries.
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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 publicuse 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. 

Through a series of laws since the 1960s, Congress 

has mandated the Safety Board’s independence 

and expanded its safety and disaster assistance 

responsibilities. 
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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

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.
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N a t i o n a l T r a n s p o r t a t i o n S a f e t y B o a r d 1

Lessons Learned and Lives Saved 1975 - 2005

NTSB-Inspired Safety Advances

Since the National Transportation Safety Board gained its total 

independence from the U.S. Department of Transportation in 1975, 

thousands of safety improvements have been inspired by Safety Board 

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.

Aircraft Icing Prevention

Education and training. A major information and training 

campaign by NASA and the Federal Aviation Administration educates 

aircraft manufacturers, operators, and pilots of air carriers and general 

aviation propeller-driven 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 Federal Aviation Administration 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 

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.
2 N a t i o n a l T r a n s p o r t a t i o n S a f e t y B o a r d

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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.

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. 

Airplane Maintenance and Inspection

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.

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. 

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, 

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.

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

a 747 brought down the plane in 1996, killing all 

230 on board.
N a t i o n a l T r a n s p o r t a t i o n S a f e t y B o a r d 3

Lessons Learned and Lives Saved 1975 - 2005

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 Federal Aviation Administration 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.

These changes stem from the crash of an Alaska Airlines MD-83 

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 Federal Aviation 

Administration inspectors and mechanics who work on and repair highenergy 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. 

Structural fatigue and corrosion. Older aircraft are 

subjected to periodic reviews, inspections, and modifications to eliminate 

corrosion and metal fatigue and the Federal Aviation Administration 

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 

The jackscrew assembly of a MD-83 is recovered from 

the Pacific Ocean in 2000.

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.
4 N a t i o n a l T r a n s p o r t a t i o n S a f e t y B o a r d

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during the titanium melting process and the crack had been missed 

during several inspections.

Wiring and insulation. The inspection, repair, and 

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

and cabin of MD-11 aircraft was ordered by the Federal Aviation 

Administration 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.

Alcohol and Drugs in Transportation

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 

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.

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. 

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 the rails. The first mandatory drug and alcohol-testing 

rule for any mode of transportation was adopted by the Federal Railroad 

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. 

Twenty-seven students and parents died in this fiery 

crash in 1988, caused by a drunk driver.
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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 Federal Aviation Administration also has regulations to identify 

pilots involved in alcohol- or drug-related 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.

Bridge Safety

Bridge allisions, 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 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 

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.
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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 Motor Vehicles

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.

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. 

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 

Safety Board recommendations have reduced 

accidents and improved trucking safety through 

commercial driver’s licensing, better braking systems, 

and more driver training.

Aircraft accidents in the 1960s and 1970s alerted 

investigators to the need for teamwork, sharing of 

information, and safety duties among crew members.
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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 

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. Federal Aviation 

Administration 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 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. 

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 

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 off-duty 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.
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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 

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 Contrail 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.

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. 

NTSB investigators probed the 1998 fire aboard a 

cruise ship that heavily damaged the ship shortly after 

it left the Port of Miami.
N a t i o n a l T r a n s p o r t a t i o n S a f e t y B o a r d 9

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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.

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 

Safety Board recommendations in the 1990s led to 

more airbag research, changes in airbag design, and a 

public education program.

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.

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.
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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 

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 Federal Aviation Administration 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 Federal 

Aviation Administration mandated installation of a sophisticated anticollision 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 

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 

recommednations.
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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 Federal Aviation 

Administration 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 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.

Today’s passenger aircraft are equipped with devices 

that help prevent accidents and save lives, including 

ground proximity and anti-airborne collision 

warnings.
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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. 

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.

Mode C 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.

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.

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. 

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.
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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.

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 an 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 currentrelated 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 

Aircraft evacuation slides have been upgraded to 

better resist heat from post-crash fires.

Fire aboard a DC-9 in 1983 led to smoke detectors in 

lavatories and floor-level escape lighting.
14 N a t i o n a l T r a n s p o r t a t i o n S a f e t y B o a r d

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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.

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. There were no injuries to the 

123 passengers and crew onboard, but a miscommunication resulted in 

some passengers exiting the same side of the aircraft where the fire was 

being extinguished.

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. 

A flight attendant depended on a “thumbs up” hand signal from one 

of the rescuers to stop the evacuation because verbal communications 

failed.

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 New Orleans Riverwalk suffered extensive 

damage when it was struck by a bulk carrier vessel 

in 1996.

Fire and rescue response following aircraft incidents 

and accidents has improved because of NTSB 

investigations.
N a t i o n a l T r a n s p o r t a t i o n S a f e t y B o a r d 15

Lessons Learned and Lives Saved 1975 - 2005

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.

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 that pilothouses of passenger vessels be continuously staffed, and 

that pilots monitor river activities and maintain emergency and working 

radio frequencies to find out about emergencies in that part of the 

river. The regulations 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.

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 N a t i o n a l T r a n s p o r t a t i o n S a f e t y B o a r d

Lessons Learned and Lives Saved 1975 - 2005

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.

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. 

On the tracks. 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 

NTSB accident investigations pointed to the need to 

reduce overcrowding at truck parking areas along the 

nation’s highways.
N a t i o n a l T r a n s p o r t a t i o n S a f e t y B o a r d 17

Lessons Learned and Lives Saved 1975 - 2005

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.

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.

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 

Lifesaving devices and emergency position radio 

beacons are a few of the improvements made to 

commercial fishing vessels following numerous NTSB 

safety recommendations.

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.
18 N a t i o n a l T r a n s p o r t a t i o n S a f e t y B o a r d

Lessons Learned and Lives Saved 1975 - 2005

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.

Grade Crossing Safety

Emergencies on the tracks. 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 intersection safety. 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.

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 

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.
N a t i o n a l T r a n s p o r t a t i o n S a f e t y B o a r d 19

Lessons Learned and Lives Saved 1975 - 2005

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 Federal Aviation Administration. 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 Federal Aviation Administration 

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.

Helicopter Safety

Research by both the Federal Aviation Administration 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.

Reconstruction of the forward cargo hold of a DC9 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.
20 N a t i o n a l T r a n s p o r t a t i o n S a f e t y B o a r d

Lessons Learned and Lives Saved 1975 - 2005

Passenger and Occupant Protection

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.

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.

Aircraft seats. The Federal Aviation Administration 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. 

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.

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 

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.

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.

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.

!
N a t i o n a l T r a n s p o r t a t i o n S a f e t y B o a r d 21

Lessons Learned and Lives Saved 1975 - 2005

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.

Passenger rail car 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.

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 

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.

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.

3%

2%

1%

0%

43% reduction

Front Seat Reart Seat

Injury Risk Injury to Children 0 to 12 Years Old

A child’s risk of injury is reduced by 43% when moved 

from the front seat to the rear seat.

Source: Partners for Child Passenger Safety
22 N a t i o n a l T r a n s p o r t a t i o n S a f e t y B o a r d

Lessons Learned and Lives Saved 1975 - 2005

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 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 

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 

This device, an excess flow valve, increases pipeline 

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

emergency situations.

NTSB safety recommendations have resulted in 

periodic pipeline inspections, higher toughness and 

corrosion standards, and better liquid pipeline failure 

detection.
N a t i o n a l T r a n s p o r t a t i o n S a f e t y B o a r d 23

Lessons Learned and Lives Saved 1975 - 2005

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.

Railroad Tank Car Safety

Tank car testing. The Federal Railroad Administration and 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.

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 N a t i o n a l T r a n s p o r t a t i o n S a f e t y B o a r d

Lessons Learned and Lives Saved 1975 - 2005

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. 

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 Federal Aviation 

Administration 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.

Tank car couplers were upgraded to prevent tank 

punctures. Couplers also help hold cars together 

during derailments.

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.
N a t i o n a l T r a n s p o r t a t i o n S a f e t y B o a r d 25

Lessons Learned and Lives Saved 1975 - 2005

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 Federal Aviation Administration 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.

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. 

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 N a t i o n a l T r a n s p o r t a t i o n S a f e t y B o a r d

Lessons Learned and Lives Saved 1975 - 2005

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 prestandard 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 

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 14 percent of the drivers involved in deadly 

crashes; more than 22 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.

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.
N a t i o n a l T r a n s p o r t a t i o n S a f e t y B o a r d 27

Lessons Learned and Lives Saved 1975 - 2005

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 

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.

 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 N a t i o n a l T r a n s p o r t a t i o n S a f e t y B o a r d

Lessons Learned and Lives Saved 1975 - 2005

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. 

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.

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.
N a t i o n a l T r a n s p o r t a t i o n S a f e t y B o a r d 29

Lessons Learned and Lives Saved 1975 - 2005

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.

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.

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 N a t i o n a l T r a n s p o r t a t i o n S a f e t y B o a r d

Lessons Learned and Lives Saved 1975 - 2005

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.
N a t i o n a l T r a n s p o r t a t i o n S a f e t y B o a r d 31

Lessons Learned and Lives Saved 1975 - 2005

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 260 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 58 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 will continue to 

aggressively push for these safety advances.

Accident investigations that inspired these recommendations 

include 10 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. Deicing aircraft is a critical step in reducing the 

dangers of flying in icing conditions. 
32 N a t i o n a l T r a n s p o r t a t i o n S a f e t y B o a r d

Lessons Learned and Lives Saved 1975 - 2005

The 1994 in-flight icing encounter, subsequent loss of control, 

and crash of a commuter airliner in Roselawn, Indiana, which took 

68 lives, prompted the Safety Board to examine the issue of airframe 

structural icing and conclude that the icing certification process has been 

inadequate. The certification process has not required manufacturers to 

demonstrate the airplane’s flight handling and stall characteristics under 

a realistic range of adverse ice accretion/flight-handling conditions. 

The Federal Aviation Administration has not adopted a systematic and 

proactive approach to the certification and operational issues of turbineengine driven transport category airplane icing.

The consequences of operating an airplane in icing conditions 

without first having thoroughly demonstrated adequate handling/

controllability characteristics in those conditions are sufficiently severe that 

they warrant a thorough certification test program, including application 

of revised standards to airplanes currently certificated for flight in icing 

conditions.

Eliminate Flammable Fuel/Air Vapors in Fuel Tanks on 

Transport Category Aircraft

• Modify procedures to reduce the potential for flammable 

fuel/air vapors in fuel tanks until permanent changes can be 

implemented.

• Implement design changes to eliminate the vulnerabilities of 

flammable fuel/air vapors in all transport category aircraft.

Center wing fuel tank explosions have resulted in 346 fatalities. 

Operating transport-category airplanes with flammable fuel/air vapors 

in fuel tanks presents an avoidable risk of explosion. A fuel tank design 

and certification philosophy that relies solely on the elimination of all 

ignition sources, while accepting the existence of fuel tank flammability, 

is fundamentally flawed because experience has demonstrated that all 

possible ignition sources cannot be predicted and reliably eliminated. As 

a result of the TWA 800 accident that occurred in July 1996, the Safety 

Board asked the Federal Aviation Administration to address both longterm and short-term solutions to the fuel tank issue.

Stop Runway Incursions/Ground Collisions of Aircraft

• Give immediate warnings of probable collisions/incursions 

directly to flight crews in the cockpit.

In the late 1980s, an inordinate number of runway incursions and 

ground collision accidents resulted in substantial loss of life, and the Safety 

Board issued numerous safety recommendations addressing the issue. The 

Federal Aviation Administration completed action on a number of important 

objectives to make the ground operation of aircraft safer. However, these 

incidents continue to occur with alarming frequency.

The system the FAA currently deploys to prevent runway collisions 

requires a controller to do the following: Determine the nature of the 

problem, determine the location of the aircraft, identify the aircraft 

involved, determine what action to take, and issue appropriate warnings 

or instruction The flight crew must then respond to the situation and take 

action.

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 Academy and is used as a 

training tool for investigators.
N a t i o n a l T r a n s p o r t a t i o n S a f e t y B o a r d 33

Lessons Learned and Lives Saved 1975 - 2005

Simulations of the FAA’s airport movement area safety system 

performance using data from actual incursions show that alerts may occur as 

little as 8 to 11 seconds before a potential collision. Until there is a system in 

place to positively control ground movements of all aircraft, with direct warning 

to pilots, the potential for this type of disaster will continue to be high.

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 identify the causes of complex accidents.

In order to rapidly, effectively, and efficiently determine the factors 

related to an aircraft accident, the Safety Board’s investigators must 

have as much information as possible. Automatic information recording 

devices, such as cockpit voice recorders and flight data recorders have 

proven to be very useful in gathering pure factual information. The fact 

that this information is recorded immediately prior to and during the 

accident sequence often gives investigators the ability to quickly determine 

and correct a problem. This knowledge results in the development of 

timely, more precise safety recommendations that are likely to reduce future 

similar accidents.

Require Restraint Systems for Children Under Age 2

• Require restraints for infants and small children during takeoff, 

landing, and in turbulent conditions to provide them the same 

level of safety as other passengers.

Infants and young children deserve the same protection that 

is provided to other aircraft passengers. During take-off, landing, and 

turbulence, adults are required to be buckled up, baggage and coffee pots 

are stowed, and computers are turned off and put away, yet infants and 

toddlers need not be restrained.

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.

Over the last three decades, the Safety Board has investigated a 

long list of accidents in which crewmembers failed to operate their trains 

effectively and in accordance with operating rules for a variety of reasons, 

including fatigue, sleeping disorders, use of medications, or distractions 

within the operating cab. Because of these human performance 

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 2003, the government reported 145 railroad 

head-on, rear-end, and side collisions with 91percent 

attributed to human factor causes. Implementing 

positive train control systems would have a major 

impact on reducing these types of accidents.
34 N a t i o n a l T r a n s p o r t a t i o n S a f e t y B o a r d

Lessons Learned and Lives Saved 1975 - 2005

deficiencies, the Safety Board has advocated the implementation of a 

system that compensates for human error and that incorporates collision 

avoidance to prevent train collisions. The Safety Board believes that 

this system, known in the industry as positive train control, is particularly 

important where passenger trains and freight trains operate. 

Improve Survivability of Recorders

• Improve event recorder design survivability on new and rebuilt 

locomotives to protect data from fire and impact forces during 

train accidents.

Since 1993 when the Federal Railroad Administration required 

the use of locomotive event recorders, the Board has advocated the 

development of standards for the crashworthiness of these devices. When 

these devices were required to be used, there was no requirement that 

event recorders on locomotives be designed to meet crash forces or fire 

exposure standards. As a result, the Safety Board has investigated many 

accidents in which critical event recorder data were lost because the event 

recorders were compromised by impact forces, fire exposure, and in 

some cases, water. The Safety Board called on the FRA to develop and 

implement event recorder crashworthiness standards

Highway

The Federal Motor Carrier Safety Administration should act to:

Improve the Safety of Motor Carrier Operations 

• Prevent motor carriers from operating if that puts vehicles with 

mechanical problems on the road or unqualified drivers behind 

the wheel. 

 The two most important factors in safe motor carrier operations 

are the operational status of the trucks and the performance of the 

individuals who drive them. If significant problems exist with trucks and/or 

the qualifications or fitness for duty of the drivers, the carrier should be rated 

by the Federal Motor Carrier Safety Administration as unsatisfactory, forcing 

corrections of the problems identified within a specified time period, along 

with greater FMCSA oversight because problems in either of these areas 

could result in severe consequences for safety. If the problems persist, the 

motor carrier should have its license to operate revoked. The Safety Board 

has called on the FMCSA to implement such a system.

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.

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.
N a t i o n a l T r a n s p o r t a t i o n S a f e t y B o a r d 35

Lessons Learned and Lives Saved 1975 - 2005

Based on its investigations of accidents involving drivers with 

serious medical conditions, the Safety Board has determined that serious 

flaws exist in the medical certification process for commercial vehicle 

drivers. Such flaws can lead to increased highway fatalities and injuries 

for commercial vehicle drivers, their passengers, and the motoring public. 

Many drivers whose occupations and serious medical conditions 

are known to their employers, health care providers, and others are never 

reported to the appropriate motor vehicle licensing authorities, thereby 

potentially endangering the drivers themselves and others.

Enforcement authorities cannot, in most instances, determine the 

validity of a medical certificate during safety inspections and routine stops 

because of the absence of procedures or information sources to validate 

the medical certificate. The inability to authenticate the information on 

a medical certificate hampers enforcement authorities in their ability to 

identify unfit drivers and place them out of service. 

In the absence of a mechanism to track all medical certification 

examinations, a commercial driver with a serious medical condition who 

is denied a medical certificate by one examiner may be able to obtain a 

certificate from another examiner, thus subverting the purpose of the medical 

certification process.

The National Highway Traffic Safety Administration and the U.S. 

Department of Transportation should act to:

Enhance Protection for Bus Passengers

• Redesign motor coach window emergency exits so passengers 

can easily open them.

• Issue standards for stronger bus roofs and require them in new 

motor coaches.

• Devise new standards to protect motor coach passengers from 

being thrown out of their seats or ejected when a bus sustains a 

front, side, or rear impact or rolls over.

One of the primary causes of passenger injury in motorcoach 

buses occurs when passengers are thrown from their seating area 

during an accident. In its 1999 special investigation report on bus 

crashworthiness, the Safety Board concluded that the overall injury risk 

to occupants in motorcoach accidents involving rollover and ejection 

may be reduced significantly by retaining the occupant in the seating 

compartment throughout the collision.

The Safety Board asked the National Highway Traffic Safety 

Administration to require new motorcoach bus occupant protection systems 

that retain passengers in their seating area. In addition, stronger bus roofs 

and easy-to-open bus window emergency exits are needed to enhance 

safety. Furthermore, to ensure consistent application of safety standards, 

the various Federal agencies responsible for bus safety should use a 

consistent definition for “bus.”

This bus accident in New Orleans in 1999 

claimed 22 lives and prompted the NTSB to issue 

recommendations aimed at preventing medically 

unqualified drivers from operating motor vehicles.
36 N a t i o n a l T r a n s p o r t a t i o n S a f e t y B o a r d

Lessons Learned and Lives Saved 1975 - 2005

Marine 

The U.S. Coast Guard should act to:

Improve Drug and Alcohol Testing of Crews After 

Accidents

• Strengthen and clarify regulations to require that drug and 

alcohol testing be conducted quickly after serious marine 

accidents.

In accidents involving human error, the Safety Board must 

first determine whether toxicological issues can be excluded as causal 

to the accident. If drugs and alcohol cannot be excluded, the Board 

may jeopardize its assessment of other critical issues, such as fatigue. 

Therefore, post-accident toxicological testing is extremely important to 

accident investigations. The potential effects of alcohol or drug use as 

a causal factor in major marine accidents frequently cannot be ruled out 

because testing is not done at all, or is often not done correctly and in 

a timely manner. This is usually attributable to lack of knowledge of the 

testing requirements for alcohol because U.S. Coast Guard regulations 

for post-accident alcohol and drug testing are unclear. The Safety Board’s 

recommendations, issued to the Coast Guard in 1998, call for a series of 

improvements related to alcohol and drug testing.

Intermodal 

The U.S. Department of Transportation, Federal Aviation 

Administration, U.S. Coast Guard, and Pipeline and Hazardous Materials 

Safety Administration should act to:

Update Hours-of-Service Regulations in Aviation, 

Marine, and Pipeline Industries

• Set working hour limits for flight crews, aviation mechanics, 

pipeline controllers, mariners, and other transportation 

operators, and provide predictable work and rest schedules 

based on current fatigue research, circadian rhythms, and sleep 

and rest requirements.

The Safety Board first addressed the issue of operator fatigue in 

transportation in 1989 in three recommendations that were issued to the 

Secretary of Transportation calling for research, education, and revisions 

to existing regulations. The Safety Board’s 1999 safety study of U.S. DOT 

efforts to address operator fatigue continued to show that this problem 

was widespread. Operating a vehicle without the operator’s having 

adequate rest, in any mode of transportation, presents an unnecessary 

risk to the traveling public. The laws, rules, and regulations governing 

this aspect of transportation safety are archaic in many cases and are not 

adequate to address the problem.

Despite the acknowledgment by the U.S. DOT that fatigue is 

a significant factor in transportation accidents, little progress, with the 

exception of a final rule by the Federal Motor Carrier Safety Administration, 

has been made to revise the hours-of-service regulations to incorporate the 

results of the latest research on fatigue and sleep issues.
N a t i o n a l T r a n s p o r t a t i o n S a f e t y B o a r d 37

Lessons Learned and Lives Saved 1975 - 2005

Action needed by the States

Highway 

Improve Child Occupant Protection

• Enact State laws requiring booster seats for young children.

In the decade of the 1990s, almost 17,000 children under age 

10 died in motor vehicle crashes—6 out of 10 were not buckled up. The 

vast majority of children under age 8 who are buckled up are improperly 

restrained in a seatbelt that was designed for adults, rather than in a 

booster seat. The booster seat aids in the proper positioning of the 

vehicle’s existing lap/shoulder belt. Ten times more children ride in the 

front seat of the car than need to, even though an available back seat is 

safer than the front seat. Furthermore, vehicles should be equipped with 

lap/shoulder belts at all seating positions, including the center rear seat.

Enact Primary Seatbelt Enforcement Laws

• Increase the number of people who wear seatbelts through 

stronger enforcement laws.

Lap/shoulder belts, when used, reduce the risk of fatal injury 

to front seat passenger car occupants by 45 percent and the risk of 

moderate-to-critical injury by 50 percent. When adults are buckled up, 

87 percent of children are buckled up, but when adults are not buckled 

up, only 24 percent of children are buckled up. States with primary 

enforcement have about 10-15 percent higher seatbelt use compared 

to States with secondary enforcement. It is estimated that more than 

21,000 lives could have been saved in 2001 if all passenger vehicle 

occupants over age 4 used seatbelts. 

Promote Teen Highway Safety

• Strengthen underage drinking and driving laws.

• Enact graduated driver licensing legislation.

• Prohibit nighttime driving by young novice drivers.

• Restrict the number of teen passengers traveling with young 

novice drivers.

Motor vehicle crashes remain the leading cause of death for 15 

to 20 year olds. In the decade of the 1990s, 63,000 youth aged 15 to 20 

died in traffic crashes, more than 120 each week. In 2001, 3,608 drivers 

15 to 20 years old were killed, and an additional 337,000 were injured in 

motor vehicle crashes. In 2000, teen drivers constituted about 7 percent 

of licensed drivers, but were involved in 14 percent of all highway fatalities. 

About 20 percent of teen driving occurs at night, but about 50 percent of 

teen fatalities (those occurring with a teenager at the wheel) occur during 

the hours of darkness. The risk of a crash involving a teenage driver 

increases with each additional teen passenger in the vehicle, and crash 

severity increases with alcohol involvement among 15- to 20-year-old 

drivers. 

Boosting the proper use and installation of car booster 

seats is a goal of a broad coalition of highway safety 

advocates, including the NTSB.

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. 
38 N a t i o n a l T r a n s p o r t a t i o n S a f e t y B o a r d

Lessons Learned and Lives Saved 1975 - 2005

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:

• Frequent, statewide sobriety checkpoints. 

• Legislation to create stricter sanctions for those arrested for the 

first time with a high blood alcohol concentration.

• Zero blood alcohol requirement for convicted DWI offenders 

when they get their licenses back.

• Administrative rather than court-based license revocation for 

refusing to take or failing the sobriety test.

• Vehicle sanctions for DWI offenders.

• Eliminate plea-bargaining DWI offenses and programs that 

divert offenders and purge the offense record.

• Retain DWI offense records (to identify and prosecute repeat 

offenders) for at least 10 years.

• Develop and operate special sanction (court-based) programs 

for hardcore DWI offenders.

Hard core drinking drivers (repeat offender-drinking drivers with 

a prior driving-while-intoxicated arrest or conviction within the past 10 

years or offenders with a blood alcohol concentration of 0.15 percent or 

greater) pose an increased risk of crashes, injuries, and fatalities. 

Hard core drinking drivers are overrepresented in fatal crashes. 

Although hard core drinking drivers constituted only 0.8 percent of all 

drivers on the road in the National Roadside Survey, they constituted 27 

percent of drivers in fatal crashes during the same time period in 1996. 

In 1998 alone, hardcore drinking drivers were involved in a minimum of 

6,370 highway fatalities. 

Improve School Bus/Grade Crossing Safety

• Install stop signs at passive crossings.

• Prioritize for upgrade to lights and gates, crossings that school 

buses traverse that now only have warning signs.

• Install noise-reducing switches on new buses.

• Enhance bus driver training and evaluation.

• Include grade crossing questions on commercial driver license 

exams.

While school bus grade crossing accidents are infrequent 

occurrences, the results can be catastrophic when they do occur. School 

buses often carry large numbers of children, and exposing them to the 

risk of collision at a grade crossing poses grave danger. Passive grade 

crossings are particularly dangerous because there are no active warning 

devices to signal that a train is approaching. Ensuring that drivers “stop, 

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.

Most Wanted Goal

A Most Wanted List goal is to reduce the 

number of highway crashes involving 

hard core drinking drivers—those who 

repeatedly drink large amounts of alcohol 

and drive. The problem is a serious 

one. Although hard core drinking drivers 

represented less than 1 percent of all 

drivers on the road, they constituted 27 

percent of drivers in fatal crashes during a 

recent survey period.
N a t i o n a l T r a n s p o r t a t i o n S a f e t y B o a r d 39

Lessons Learned and Lives Saved 1975 - 2005

look, and listen” at all grade crossings will help ensure the safety of the 

nation’s school children.

In 2004, the States and railroads reported 245,729 grade 

crossings; 44 percent were passive crossings. Over 86,000 of the 

passive crossings are public crossings (as opposed to those on private 

property). About 42 percent of the fatalities from all grade crossing 

accidents in 2003 were at passive crossings.

Marine

Enhance Recreational Boating Safety

• Require mandatory education of boat operators.

• Require use of lifejackets for children.

• Require safety instruction prior to personal watercraft rental.

Unlike general aviation and motor vehicle operations, an 

operator of a recreational boat is not required to demonstrate an 

understanding of the rules of the road or an ability to operate the vessel. 

A Safety Board study found that as few as 7 percent and no more than 

22 percent of first-time boat operators take some type of voluntary 

boating safety course, and many of those courses do not require persons 

to demonstrate an ability to operate the vessel. The study also indicated 

that 85 percent of those who drowned in a boating accident were 

not wearing personal flotation devices. Operators of rented personal 

watercraft had less experience than did operators of privately owned 

personal watercraft. Only one out of three renters included in the Safety 

Board’s accident analysis indicated that the rental agent had required 

them to demonstrate personal watercraft riding ability.

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.

The NTSB strongly believes that recreational boating 

safety can be enhanced and accidents reduced by 

requiring boat operators to take safety training courses.

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.
40 N a t i o n a l T r a n s p o r t a t i o n S a f e t y B o a r d

Lessons Learned and Lives Saved 1975 - 2005

Communicating Our Safety 

Message to the Public and 

Industry

In the past three 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 25 major conferences that have attracted more 

than 7,500 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: 

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 Academy, 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, DC

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 Academy, Ashburn, Virginia 

June 2004

Air Cargo Safety Forum

Topics: Current state of the cargo industry, operations, human factors, and 

regulatory issues. NTSB Academy, 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, DC 

October 2003

Vehicle Recorders Symposium

Topics: State-of-the-art accident recorder technology, accident recorder 

survivability/crashworthiness requirements, video/imaging recorder 
N a t i o n a l T r a n s p o r t a t i o n S a f e t y B o a r d 41

Lessons Learned and Lives Saved 1975 - 2005

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, DC 

November 2001

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, DC 

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, DC 

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, DC 

June 1999
42 N a t i o n a l T r a n s p o r t a t i o n S a f e t y B o a r d

Lessons Learned and Lives Saved 1975 - 2005

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

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

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

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

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

Child Passenger Safety Symposium

Ways to increase use of child restraints and to reduce their misuse.

Washington, DC

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, DC

April 1983
N a t i o n a l T r a n s p o r t a t i o n S a f e t y B o a r d 43

Lessons Learned and Lives Saved 1975  2005

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, 35 individuals have served as Board 

Members. Ten 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. 

George W. Black, Jr.

1996-2003

Marion C. Blakey

Chairman

2001-2002

Isabel A. Burgess

1969-1976

James E. Burnett, Jr.

Chairman

1981-1991

G. H. Patrick Bursley

1979-1985

Carol J. Carmody

Vice Chairman

2000-Present

Susan M. Coughlin

Vice Chairman

1990-1994

Ellen Engleman Conners

Chairman

2003-Present

Lee V. Dickinson, Jr.

1988-1990

Elwood T. Driver

Vice Chairman

1978-1981

Donald D. Engen

Vice Chairman

1982-1984

Robert T. Francis II

Vice Chairman

1995-1999

John K. Lauber

1985-1995

Oscar M. Laurel

1967-1972

Francis H. McAdams

1967-1983

Joseph T. Nall

1986-1989

Joseph J. O’Connell, Jr.

Chairman

1967-1969

John H. Reed

Chairman

1967-1976

Mark V. Rosenker

Vice Chairman

2003-Present

Louis M. Thayer

1967-1976

Webster B. Todd, Jr.

Chairman

1976-1977

Carl W. Vogt

Chairman

1992-1994

John J. Goglia

1995-2004

Patricia A. Goldman

Vice Chairman

1979-1988

Vernon Grose

1983-1984

William R. Haley

1972-1977

James E. Hall

Chairman

1993-2001

John A. Hammerschmidt

Vice Chairman

1991-2003

Christopher A. Hart

1990-1993

Richard F. Healing

2003-Present

Deborah A. P. Hersman

2004-Present

Philip A. Hogue

1976-1979

Kay Bailey Hutchinson

Vice Chairman

1976-1978

James B. King

Chairman

1977-1982

James L. Kolstad

Chairman

1987-1992

The NTSB has five board members. (l to r) Ellen 

Engleman Conners, Chairman; Deborah A. P. 

Hersman; Mark V. Rosenker, Vice Chairman; Carol J. 

Carmody; and Richard F. Healing.

George W. Black, Jr.

1996-2003

Marion C. Blakey

Chairman

2001-2002

Isabel A. Burgess

1969-1976

James E. Burnett, Jr.

Chairman

1981-1991

G. H. Patrick Bursley

1979-1985

Carol J. Carmody

Vice Chairman

2000-Present

Susan M. Coughlin

Vice Chairman

1990-1994

Ellen Engleman Conners

Chairman

2003-Present

Lee V. Dickinson, Jr.

1988-1990

Elwood T. Driver

Vice Chairman

1978-1981

Donald D. Engen

Vice Chairman

1982-1984

Robert T. Francis II

Vice Chairman

1995-1999
xii N a t i o n a l T r a n s p o r t a t i o n S a f e t y B o a r d

Lessons Learned and Lives Saved 1975 - 2005