FOR IMMEDIATE RELEASE: February 18, 2010
NTSB ADDS TRANSIT RAILCAR SAFETY, MARINE SMS, AIRLINE PILOT
PROFICIENCY OVERSIGHT TO FEDERAL MOST WANTED LIST
Washington, DC - The National Transportation Safety Board today issued its 2010 Federal Most
Wanted List of Transportation Safety Improvements, adding rail, aviation and marine issues, and
updating the status of other issues on the list. At the same time, the Board removed the issue
areas dealing with improved protection for school bus passengers and fatigue in the pipeline
"Every one of the hundreds of currently open safety recommendations address concerns that the
Safety Board has uncovered in its accident investigations," NTSB Chairman Deborah A.P.
Hersman said. "But the recommendations on the Most Wanted list represent those
improvements that can have the widest benefit."
Besides removing two issue areas on the list, the Board reviewed the remaining 13 issue areas on
the list and added two new ones. Each issue area is color coded by the NTSB to designate its
action/timeliness: Red for Unacceptable Response; Yellow for Acceptable Response,
Progressing Slowly; and Green for Acceptable Response, Progressing in a Timely Manner.
The 2010 Most Wanted list follows.
Coming on the heels of several serious transit rail accidents around the country - notably the June
22, 2009, collision on Washington, D.C.'s system that killed 9 persons - the Board added
"Improve Transit Railcar Design" to the list.
A railcar's ability to withstand the dynamic forces of an accident is essential to protecting the
vehicle's occupants. In accident investigations in recent years, the Board has noted telescoping
of transit cars that have destroyed or greatly compromised survivable space. Two
recommendations are added to the list aimed at improving transit railcar design, and the issue
area was given a Yellow designation.
The NTSB has long been concerned about the issue of Safety Management Systems (SMS) on
board ships, including subsystems such as preventive maintenance. Although the United States
Coast Guard has announced that it intends to require SMS for vessels carrying more than 399
passengers, the Board feels this is unacceptable because it does not cover all U.S.-flagged
vessels. The NTSB believes that the Coast Guard should require an SMS for all domestic
vessels so that the same level of safety is applied to the domestic fleet of vessels as is applied to
the international fleet. This new issue area on the list, "Require Safety Management Systems for
Domestic Vessels" was given a Red designation.
"Improve Oversight of Pilot Proficiency" - This new issue area added by the Board contains two
2005 recommendations calling on the FAA to require airlines to obtain histories of flight check
failures by pilot applicants and to require special training programs for pilots who have
demonstrated performance deficiencies. The designation is Red.
"Require Image Recorders" - Although cockpit voice recorders and flight data recorders record
sounds and relatively comprehensive airplane data during an emergency, they do not show the
critical cockpit environment leading up to the emergency. The Board has requested image
recorders for large transport category aircraft and for smaller aircraft that do not otherwise have
recording devices. This issue was designated Red.
"Improve the Safety of Emergency Medical Services Flights" - The Board has issued a series of
recommendations aimed at improving the safety of this vital service to the public. The FAA has
announced it will issue a proposed rule that will address some of these concerns, and the Board
has upgraded the designation for this issue from Red to Yellow.
"Improve Runway Safety" - The deadliest accident in aviation history was a runway collision in
1977. Runway accidents and incidents continue to occur, including a fatal regional jet accident
in Kentucky in 2006 and an incident last year where an airliner landed on a taxiway in Atlanta.
The NTSB has a series of recommendations aimed at preventing such occurrences, including
requiring moving map displays in the cockpit, giving immediate warnings to the cockpit of
impending incursions, and requiring landing distance assessments with an adequate safety
margin for every landing. The designation was upgraded from Red to Yellow.
"Reduce Dangers to Aircraft Flying in Icing Conditions" - An airliner crash in 1994 prompted
the NTSB to examine the issue of airframe structural icing and conclude that certification
standards have been inadequate. The NTSB continues to believe that the FAA has failed to
make adequate progress in this area and has kept the designation at Red.
"Crew Resource Management for Part 135 Carriers" - Federal regulations require Part 121 and
Scheduled Part 135 operators to provide pilots with crew resource management training. The
NTSB has investigated a number of Part 135 on-demand operators where such training was not
provided, and errors by the crew led to accidents. The FAA has proposed to require a form of
CRM training for these carriers, and the Board has upgraded the designation from Red to
"Enhance Protection for School Bus Passengers" - The Board has recommended that the
National Highway Traffic Safety Administration devise new standards to protect school bus
passengers from being ejected from their seats or the bus during frontal, side or rear-impact
accidents. NHTSA has issued a final rule that increases seatback height, and established
performance specifications for voluntarily installed seat belts. As a result, the Safety Board has
closed the two recommendations in this issue area and removed it from the Most Wanted list.
"Enhance Protection for Motorcoach Passengers" - The Board recommends that motorcoach
window emergency exits be redesigned for easy egress, that standards for bus roofs be
strengthened, and that new standards be devised to protect motorcoach passengers from being
ejected. The designation was downgraded from Yellow to Red, due to the lack of progress on
"Require Electronic Onboard Data Recorders" - This renamed issue area seeks to improve hours
of service monitoring for commercial drivers. The Federal Motor Carrier Safety Administration
has proposed limited use of EOBRs, and the Board has therefore kept the designation at Red.
"Improve the Safety of Motor Carrier Operations" - The Board's recommendation is aimed at
preventing motor carriers from operating if they put vehicles with mechanical problems on the
road or unqualified drivers behind the wheel. Due to FMCSA's continuing slow progress on this
issue, the designation was downgraded from Yellow to Red.
"Prevent Medically Unqualified Drivers from Operating Commercial Vehicles" - Based on its
investigations of accidents involving drivers with serious medical conditions, the NTSB has
determined that serious flaws exist in the medical certification process for commercial vehicle
drivers. Two of the 8 recommendations in this area - dealing with FMCSA developing a
comprehensive medical oversight program that contains several elements - were closed by the
Board, and the designation was upgraded from Red to Yellow.
"Prevent Collisions by Using Enhanced Vehicle Safety Technology" - The Safety Board has
recommended the use of adaptive cruise control and collision warning technologies to improve
highway safety. A Department of Transportation analysis has shown that 48 percent of accidents
could be prevented by the use of certain collision warning systems. The designation on this issue
"Prohibit Cell Phone Use by Motorcoach Drivers" - The Board believes commercial drivers at
the wheels of motorcoaches and school buses should be prevented from using cell phones. With
some progress being made by the Department of Transportation and FMSCA, the designation
"Reduce Accidents and Incidents Caused by Human Fatigue in the Marine, Aviation and
Pipeline Industries" - The Safety Board has long been concerned about the effects of fatigue on
persons performing critical functions in all modes of transportation. The Board believes that
working hour limits should be based on the latest fatigue research. For both the aviation and
marine modes, the Board believes the actions of the FAA and the U.S. Coast Guard are
unacceptable, and maintained designations for both at Red.
However, the Board was pleased to report that the Pipeline and Hazardous Materials Safety
Administration has published a final rule establishing new bases for managing fatigue in the
pipeline industry. The Board called the rule "a significant step forward for an industry that did
not previously have any rules governing hours of service" The Board therefore closed the
recommendation Acceptable Alternate Action and has removed fatigue in the pipeline industry
from the Most Wanted list.
An updated brochure describing each Most Wanted issue area can be accessed at
NTSB media contacts on each issue area may be reached as follows:
Phone number (202) 314-6100
Keith Holloway (email@example.com)
Improve Emergency Medical Helicopter Flights
Motor Carrier Operations
Peter Knudson (Peter.Knudson@ntsb.gov)
Medically Unqualified Drivers
Oversight of Pilot Proficiency
Ted Lopatkiewicz (firstname.lastname@example.org)
Cockpit Image Recorders
Part 135 Crew Resource Management
Cell Phone Use by Bus Drivers
Bridget Serchak (Bridget.Serchak@ntsb.gov)
Onboard Electronic Recorders
Motorcoach Passenger Safety
Enhanced Vehicle Safety Technology
Transit Rail Car Safety
Terry Williams (email@example.com)
Fatigue in Aviation, Marine and Highway