NTSB calls for Safety Management Systems on all U.S. vessels

The following is the text of a press release issued by the National Transportation Safety Board:


(WASHINGTON) — 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 industry.

“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

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 remains Red.

“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 Yellow.


“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 this issue.

“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 remains Yellow.

“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 remains Yellow.


“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

By Professional Mariner Staff