Aviation Safety, Most Wanted List
Public Helicopter Operations: Act Before an Accident
March 30, 2015 ntsbgov Leave a comment
A helicopter pilot died disoriented and confused in Alaska on March 30, 2013.
He was no novice; in fact, he was flying a search-and-rescue mission for the Alaska Department of Public Safety (DPS). But when he set out – highly motivated to save the life of a stranded snowmobiler – he set in motion a chain of events that ended in three deaths: His own, the snowmobiler's, and that of an Alaska State Trooper serving as an observer.
The pilot was qualified to fly search and rescue missions in visual meteorological conditions but not instrument meteorological conditions in the accident helicopter. Ultimately he found himself in instrument meteorological conditions, in a helicopter that was neither equipped nor certified for instrument flight rules. Minutes after picking up the stranded snowmobiler, he became spatially disoriented, lost control of the helicopter and crashed.
The pilot and the trooper who died in this crash died in the service of others. They routinely shouldered risk in the line of duty to enhance the safety of their fellow Alaskans. But risks that should have been weighed systematically and objectively were assessed subjectively and individually. The pilot's training was not in line with the conditions of his mission. His flight observer was not a trained tactical flight officer who could have better assisted with aeronautical tasks. The Alaska DPS was not using formal flight-dispatch and flight-following procedures that included up-to-date weather information and assistance with risk-assessment decisions.
During the NTSB's accident investigation, even before we issued our final report, the Alaska DPS responded to the lessons that were coming to light and implemented a number of safety improvements. All Alaska DPS pilots who fly the type of helicopter involved in this accident were required to receive training in how to safely escape from an inadvertent encounter with instrument meteorological conditions; formal risk assessments were required before any helicopter missions are initiated; and a formal tactical flight officer training program was developed. At the time the NTSB report was issued, flight-tracking equipment was installed in 34 of the 42 aircraft in the Alaska DPS fleet, with plans to soon have this equipment installed in the entire Alaska DPS aircraft fleet. Finally, organizations within the Alaska DPS were assigned responsibility for using this equipment to perform flight following for all Alaska DPS aircraft flying missions.
Many of the recommendations that the NTSB made in the accident report related to sharing the lessons of the Talkeetna accident beyond the state of Alaska. Why? The Alaska DPS moved admirably and with great purpose after it experienced the accident. Yet the Talkeetna accident had many commonalities with crashes of Maryland State Police and New Mexico State Police helicopters in 2008 and 2009 respectively. And public helicopter operations accidents are by no means limited to law enforcement. We also investigated the 2010 collision of a California Department of Fish and Game helicopter with power lines.
As in the case of the Alaska DPS, in many cases, the states in which these accidents occurred have learned from their mistakes, and have raised the bar for safety in their public helicopter operations.
But states with public helicopter operations are not learning from each other. In the Talkeetna accident, we recommended that 44 additional states, the Commonwealth of Puerto Rico, and the District of Columbia familiarize their public helicopter operators with the lessons of all three accidents.
Substitute the name of your state for "Alaska" in the first line of this article. Then ask yourself what your state is doing to guarantee the safety of its public helicopter operations, with the most recent NTSB recommendations in mind.
If you work in public helicopter operations, the odds are that there are NTSB recommendations pending in your state. Have you heard about, or been involved in, favorable actions on those recommendations? If not, reach out to colleagues.
States feeling the budget pinch nevertheless find ways to make changes after lives are lost. But actions now may save lives instead.
Many of those who are involved in public helicopter operations put their lives on the line in the service of others. These NTSB recommendations are intended to prevent extra, unnecessary risk to the brave men and women who do so, and their passengers.
Earlier NTSB reports on public helicopter operations are also available at NTSB.gov.
Enhance Public Helicopter Safetyhelicopter safetyMWL2015
Highway Safety, Most Wanted List
AAA Teen Distracted Driving Study Shows Need for Cultural Shift
By Kelly Nantel
When teens crash cars, they are usually driving distracted.
That's the conclusion of a new naturalistic study by the AAA Foundation for Traffic Safety. The study examined real-time video focusing on teen drivers involved in crashes. More than half – 58% – were distracted by tasks other than driving. Nearly nine of out of 10 crashes when the car ran off the road involved distraction, as did more than three of four rear-end crashes.
Dr. Jurek Grabowski, Director of Research at the AAA Foundation, will be just one of many participants in NTSB's "Disconnect from Deadly Distractions" roundtable on March 31 in Washington. The day-long series of discussions will focus on distractions in all modes of transportation.
The roundtable is structured to encourage a true dialog among attendees, where researchers, law enforcement, industry, safety advocacy groups, and regulators will be free to build on – and/or debate –findings from across modes and across disciplines.
In just a few years, the use of portable electronic devices, or PEDs, has grown explosively. Teen drivers – and all drivers – have suddenly had to contend with new distractions in transportation.
But the distractions that AAA noted in its most recent study were not limited to PEDs. Such activities as grooming and dancing also preceded several crashes.
And, as both the AAA Foundation and the NTSB have long noted, using a hands-free phone does not eliminate distraction. Even hands-free phones pose the risk of cognitive distraction. In "Roadhouse Blues" Jim Morrison sang "Keep your eyes on the road, your hands upon the wheel." That's good advice. But your mind must be on the driving task as well.
The same goes for operators of every kind of vehicle in transportation, from commercial motor vehicles to aircraft to ships and trains. The beauty of a multimodal discussion is that lessons learned in the cockpit or the pilothouse can be applied to the driver's seat – or vice versa.
The NTSB-hosted roundtable discussion will cover 5 topical tracks:
The Science of Distraction;
Education, Legislation and Enforcement;
Technology and Engineering;
Policy and Regulation; and
Future Endeavors/Challenges.
In a culture that fosters a myth of multitasking, we will need a cultural shift to eliminate distraction in transportation. We hope that the conversation on March 31 will bring us a step closer to that shift. The roundtable is open to the public to attend and observe. Details on the event can be found at http://www.ntsb.gov/news/events/Pages/2015_Distraction_forum.aspx.
Distracted DrivingDistractionMWL2015Teen Driving
Trains and Trespassing: Ending Tragic Encounters
By Robert Sumwalt
Last week, a personal trainer lost his life next to railroad tracks near Atlanta. He was the second fitness guru to die this year on railroad property in the process of making videos.
This week – yesterday and today – I have been privileged to preside over an NTSB forum on the subject of trains and trespassing, in which experts throughout the railroad, research, regulatory, and safety advocacy worlds examined the problem of trains striking pedestrians.
Pedestrian trespassing still causes the majority of all deaths in railroad transportation. According to Operation Lifesaver, Inc., more than 900 railroad trespassers were struck by trains last year and more than half of those struck were killed. So statistically speaking, it is likely that four people were struck by trains and two died during the time we spent discussing the problem.
Trespassing on railroad property is both against the law, and potentially tragic.
Walking along railroad tracks is trespassing. Taking a short-cut across the tracks is trespassing. Sitting on railroad property nearby the tracks is trespassing. It is against the law.
Even so, railroad trespassing is glamorized in movies, television, and songs. Those who have not done it themselves likely know somebody who has. While it is a crime, it is an all-too-common one. And trespassers pay the highest penalty not when they are caught and penalized by other human beings, but when their "sentence" is a collision with a train weighing thousands of tons with no time to brake.
Why do people trespass on railroad property? The answers are diverse.
Many really don't even think that they are committing a crime. Others do not realize the danger, thinking they will surely hear an approaching train. Others glamorize the risk, and seek it on purpose. Some are purposely taking their own lives.
Still others take short-cuts across the tracks so often that they forget the danger. Dotted across the country are footpaths leading up to tracks – they are so well-worn that they can be seen from the air.
The tragic consequences of these events go far beyond what happens to those who are struck. They ripple through families, communities, and train crews.
During the forum, experts discussed the diversity of trespassing accidents and incidents; current trespassing prevention strategies; challenges to trespassing prevention; and moving prevention forward.
But we began the forum with some first-hand accounts. Mark Kalina shared the memory of the night that he lost his legs to a train taking a risk as a college student.
Often engineers pay a high price, even when there is nothing that they can do to avoid striking someone on the tracks. Norma Kirby, an Amtrak engineer, recounted the effect of trespassing incidents and accidents on her own life. Chian Gavin, who works in Amtrak's employee assistance program, gave an overview of the effect of such experiences within a railroad's workforce.
High-school principal Danny Knot painted a vivid picture of the effect on his school of the trespassing loss of two students; and Art Miller explained the emotional and career effects of a trespassing strike on a movie set – effects he felt although he was not even present.
Five personal struggles. Five out of the hundreds involved in these tragic encounters every year, and the thousands who are touched by them.
While the remainder of the forum helped us to better understand possible advances against the tide of rail trespassing deaths and injuries, there is no single stereotype of a trespasser, and no single magic bullet to stop trespassing deaths and injuries. Yet the stakes for individuals, and for their communities, can be enormous.
During the two days of the forum we looked into many promising ideas, including a community approach that has been used to help tackle bigger and more diverse problems than railroad trespassing; it is possible that it will result in safety gains here too. I am excited to see whether this approach takes hold.
But whatever new approaches may drive down the statistics, there is something that you can do, as a reader of this blog, that I promise will be 100% effective in protecting you against such a tragic encounter: Stay off railroad property.
Don't take a short-cut across the tracks. Don't walk on the tracks. Don't lie next to the tracks. Don't run across the tracks. Don't pose for a "selfie" next to the tracks. Don't let your family members do it either, and don't let others in your neighborhood. It simply is not worth the risk.
At the NTSB, we are interested in ending trespassing because trespassing ends lives. We hope that the conversation that has begun in this forum will result in new approaches to countering trespassing in the future.
Railroad Trespassing
First-Hand Insights Into Working with the NTSB On-scene
Not everybody can endear themselves to an audience that includes highway patrol and local police officers by telling them how soon they will show up at a crash scene and how long they will stay.
Jennifer Morrison (left) on-scene at Davis, OK accident
But Jennifer Morrison, an investigator-in-charge with the NTSB's Office of Highway Safety, recently did just that.
"You can expect we will be to the scene of the crash investigating all these areas within 12–24 hours and stay for 7–10 days," she said.
Jennifer and I were speaking to the Lifesaver's National Conference on Highway Safety Priorities in Chicago – or simply "Lifesavers."
The conference attendees included law enforcement officers, state transportation officials, and safety advocates. Lifesavers is the largest gathering of national highway professionals in the United States. Each year, the conference provides a forum for the presentation of proven countermeasures and initiatives that address today's critical highway safety issues.
Jennifer and I were thrilled to speak at one of the conference's first sessions, "Who is the NTSB and Why are They at the Scene of My Crash?" The session focused on when and why the NTSB shows up at an accident scene and the challenges of coordinating an NTSB safety investigation alongside a parallel police-led criminal investigation.
As Jennifer explained, the severity of an accident does not by itself dictate whether the NTSB will pursue such an investigation. If the accident can shed light on a pressing highway safety issue, the NTSB might investigate even if there are no fatalities.
While the NTSB often covers high-profile events and receives considerable media attention for its activities, what goes on behind the scenes is often misunderstood—or not known. We aimed to demystify the NTSB investigative process and to share some real-world experiences from safety investigations that we have conducted in parallel with police investigations.
Jennifer described how the NTSB uses a multi-disciplinary team approach that covers five key areas: human performance, survival factors, motor carrier operations, highway factors, and vehicle factors.
Kelly Nantel talks with local law enforcement on-scene at an NTSB investigation
As Jennifer explained, sometimes the NTSB arrives on scene even quicker than within12-24 hours. In the case of a median crossover crash that killed four members of the North Central Texas College softball team last September, the NTSB contacted Captain Ronnie Hampton of the Oklahoma Highway Patrol within 2 hours of the crash, and federal investigators were on scene within 10 hours.
Captain Hampton joined us to share his experience working with NTSB. He told his counterparts, "We learned a lot by working with NTSB, how they break work down by disciplines. They are not gun-toting law enforcement officers. They are there to ID safety issues, whereas we aim to enforce the law and bring any necessary charges against the drivers."
Master Sergeant Robert Story of the Illinois State Police echoed a similar beneficial experience from working with NTSB on a crash that killed eight on an Illinois Interstate in 2003. "They are a great connection for law enforcement. Our relationship with NTSB gave us additional contacts and resources," he said.
Both Hampton and Story echoed the belief that NTSB was sensitive to their ongoing criminal investigations. "They are looking for causation, looking at it as an accident," Story told conference attendees, "we look at it as a crash where someone possibly violated the law."
Throughout the session, I emphasized the importance of collaboration and information sharing among the NTSB and law enforcement during an investigation.
This was echoed by McHenry County, Illinois, Assistant State's Attorney Donna Kelly, who explained that NTSB investigators are not meant to be "regulars" in the court room, so requesting their testimony is tricky. The NTSB is specifically charged with uncovering the causes of accidents and making recommendations, not with placing fault or blame.
We also stressed the importance of our "party system" to our investigations. The NTSB designates other organizations as parties to the investigation, including agencies of local, state, or federal government; private companies; or others. For highway investigations, the NTSB has complete discretion over which organizations it designates as parties. Only those organizations that can provide expertise to the investigation are granted party status, and only those persons who can provide needed technical or specialized expertise are permitted to serve on the investigation.
Most important to the success of an investigation, perhaps, is the NTSB's independence. The NTSB is an independent Federal investigation agency. In other words, we are not affiliated with other government agencies, because we often make recommendations to them. These recommendations aim to make highways safer and ultimately save lives.
And that's one of the many things all attendees at the Lifesavers Conference have in common: we are all in this life-saving business together.
Inside NTSBNTSB Investigation Process
Enhance Public Helicopter Safety
Every day, hundreds of federal, state, and local governments use helicopters to accomplish missions that are critical for public safety and welfare. Such operations include law enforcement, firefighting, search and rescue operations, aerial surveying of natural resources and wildlife, and a host of other public functions.
I had the opportunity to ride along with the Los Angeles Police Department on one of their helicopter missions. During that three-hour flight, they provided air support in apprehending wanted criminals (on two occasions) and in locating suspected stolen goods from the backyard of a house. I was impressed with their professionalism and commitment to their personal safety, as well as maintaining a safe and secure environment for their community. I know those commitments are shared by other public helicopter operators, as well.
Because of the important work performed by public helicopter operations, the NTSB is particularly concerned with their accident record. Between 2004 and 2014, there were over 130 accidents involving public helicopters, resulting in 52 fatalities and nearly as many serious injuries. Tragically, we've investigated crashes where the very people who were to be rescued or transported died in the helicopter sent to take care of them. For example, the Board recently deliberated and adopted an accident report involving a helicopter operated by the Alaska Department of Public Services that was sent to rescue a stranded snowmobiler. After locating and picking up the snowmobiler, the helicopter crashed, killing all aboard. While we realize how important this work is, we also recognize that the ultimate goal is to safely bring back everyone who boards that helicopter. Risks need to be properly anticipated and managed.
Unlike privately owned and operated helicopters, public helicopters are not required to adhere to certain Federal Aviation Administration (FAA) regulations; their decisions and programs are solely the responsibility of the public operators. To be clear – many, perhaps most – public helicopters are operated to high standards, despite the lack of an FAA requirement to do so. However, NTSB accident investigations have uncovered deadly gaps in operational and maintenance requirements of some public helicopter operators.
These accident investigations have resulted in several safety recommendations intended to seal these gaps. To highlight the critical need to implement these recommendations, the NTSB has added Enhance Public Helicopter Safety to our 2015 Most Wanted List of Transportation Safety Improvements.
We look forward to continuing our work with industry organizations, such as the Airborne Law Enforcement Association and Helicopter Association International, and government agencies alike to further the goal of enhancing public helicopter operations.
MWL2015