NTSB's Most Wanted

Only an airline pilot's quick thinking stood between 300 travelers and catastrophe on a Los Angeles runway one afternoon last August. Two passenger jets came within 12 seconds of colliding-one plane almost landing on top of the other-before an automated radar system alerted air traffic controllers in the airport tower.

Asiana Airlines Flight 204 from South Korea was less than two miles from touchdown on Los Angeles International Airport's Runway 24L when a controller inadvertently cleared Southwest Airlines Flight 440 for takeoff to Albuquerque, N.M., from the same strip of pavement. The Asiana pilot saw a Boeing 737 rolling into the path of his own Boeing 747 and pulled up just in time. As the descending plane swooped within 185 feet of the one on the ground and zoomed skyward again, an unidentified voice on the tower radio frequency declared, "That was close!"

If the Asiana flight crew hadn't been vigilant, if the weather hadn't been perfect, if it hadn't been daytime, the National Transportation Safety Board says, the outcome might have been different. It was just one of at least 325 near misses at airports across the country in 2004 that could have been prevented, NTSB says, if the Federal Aviation Administration would try harder.

In a new report, FAA and four other federal agencies take knocks for not doing more to prevent accidents and enhance safety for the traveling public. "We were very lucky on Aug. 19," says NTSB Chairwoman Ellen Engleman Conners. "Safety should never be dependent on luck."

The critique accompanied the safety board's Nov. 9 release of its annual list of most wanted federal improvements in aviation, railroad, highway, marine, pipeline and intermodal transportation. Now in its 15th year, the Most Wanted List for 2005 focuses attention on 12 high-profile safety issues that could use an extra public nudge. This year's list consolidates 50 federal and 10 state recommendations, directing almost half at FAA.

Stopping runway incursions tops the list. Fifteen years ago, after a horrific accident in Atlanta, the safety board asked FAA to equip the country's 433 commercial airports with systems that can ensure the safe movement of airplanes, sense impending collisions, and send warnings directly to airplane cockpits-skipping control tower middlemen.

To reduce runway mixups, FAA has improved collision-avoidance technology at the 59 busiest airports and is testing several runway lighting enhancements. It credits the im-provements with a 50 percent reduction in runway incursions since 2000, although they have increased over the past 12 years.

NTSB is still waiting, less patiently these days, for what it calls "immediate, clear, unambiguous notification" to flight crews. "I don't know how many times we have to reiterate this," member Carol Carmody groused at a board meeting in November. Because Southwest Airlines tipped off investigators after the Los Angeles incident, NTSB also is questioning FAA's reporting procedures. Member Deborah Hersman wonders whether "the fact this highly visible close call wasn't reported may suggest that there are deeper reporting problems."

FAA says no two airports share the same set of safety problems, yet NTSB is looking for a "silver bullet" solution. "Certainly there are challenges in terms of safety advances in our country," says Administrator Marion Blakey, "but reporting of runway incursions, we do not believe is one of them."

The close call at LAX unnerved NTSB members so much that they changed FAA's stop-light-style grade for runway incursions from yellow to red. Two more aviation safety items on the Most Wanted List also went from yellow to red, for a total of four out of five. The fifth, recommending mandatory restraints for infants and toddlers on airplanes, stayed at yellow.

The Federal Motor Carrier Safety Administration, the National Highway Traffic Safety Administration, the U.S. Coast Guard and the Federal Railroad Administration also have been too slow to implement recommended safety measures, according to investigators.

They downgraded the motor carrier safety agency from a green score to yellow on regulating the fitness of commercial vehicles and drivers. They deleted a recommendation to equip large ocean-going vessels with voyage data recorders because the Coast Guard has complied, but left another Coast Guard recommendation-about drug and alcohol testing after serious marine accidents-at yellow. They gave up begging the railroad agency to require voice recorders in the cabs of trains, deleting the recommendation out of frustration over lack of compliance.

New this year, NTSB wants the highway safety agency to collect data on the medical condition of motorists involved in accidents. The investigators are calling for greater oversight of drivers with high-risk conditions after a study of six accidents in which drivers had seizures or blackouts.

Since its inception in 1967, NTSB has issued more than 12,000 safety recommendations. The overall compliance rate is 82 percent-and slightly higher for items on the Most Wanted List. Except for the recommendation to the Coast Guard on data recorders, none of the 2004 grades improved on this year's list.

"Our recommendations are derived from the hard lessons we have learned over the years investigating many tragic accidents," says Engleman Conners. "Quite simply, implementing these measures will save lives."