Testimony before the
Committee on Appropriations
Subcommittee on Transportation and Related Agencies
House of Representatives
Regarding Fiscal Year 1997 Budget Request
March 7, 1996
Good morning Mr. Chairman and Members of the Committee. It is
a pleasure to be here today to review the National Transportation
Safety Board's (NTSB) activities and fiscal year 1997 budget request.
Before I begin, I would like to thank you and this Committee for your support for the Safety Board and its programs during this difficult time of budget reductions. As a result of your actions, the Safety Board is able to continue its work at current levels on behalf of the traveling public.
Mr. Chairman, the year since our last appearance has been a busy one for the Safety Board. Along with our accident investigation responsibilities, we completed studies on air tour operations, aviation safety in Alaska, and the air traffic control system; hosted, with the National Aeronautics and Space Administration (NASA), a multimodal fatigue symposium attended by close to 600 people, including participants from 16 countries; published the proceedings of the pipeline excavation damage prevention workshop; and issued 343 safety recommendations in all modes of transportation.
In 1995 the NTSB launched "Go Teams" to 3 aviation, 3 highway, 4 marine, 1 pipeline, and 4 railroad accidents, and adopted 24 major accident reports, studies, or special investigations (9 aviation, 4 highway, 4 marine, 3 hazardous materials/pipeline, and 4 railroad). Over 2,300 accidents in all modes of transportation were investigated by the NTSB in 1995.
Mr. Chairman, the end product of Board investigations are the safety recommendations, culminating in satisfactory action by the recommendation recipients. Over the years, these recommendations have ranged from fire resistant materials and floor-level escape lighting in aircraft cabins, to child safety seats in automobiles and improved school bus construction standards, to the requirement for the installation of head shields on railroad tank cars and improved cabin safety in railroad passenger cars, to new recreational boating safety and commercial fishing vessel regulations, to the development of one-call notification systems in all 50 States and improved regulations for buried pipelines.
The safety improvements mentioned would not have occurred as soon without the Safety Board providing the impetus. The men and women of the National Transportation Safety Board look with pride upon safety enhancements that statistics show contribute to the United States having one of the safest transportation systems in the world.
Although it would not be feasible to discuss every investigation, adopted report or safety recommendation issued, I would like to share with you some of the NTSB's activities since my last appearance before this Committee.
As you are aware, to identify those recommendations with the greatest
impact on transportation safety, the Safety Board in September
1990 adopted the "Most Wanted" list of transportation
issues. To date, seven "Most Wanted" issues have been
satisfied and consequently removed from the list. Because of action
taken by the Federal Aviation Administration (FAA), two items
from the original 1990 "Most Wanted" list were removed
in 1995 -- brake wear limits and performance in transport category
aircraft, and structural fatigue testing.
In May 1995, three new areas were added to the "Most Wanted" list and they were:
Commuter Airline Safety;
Aircraft Wake Turbulence Protection; and
Flight Data Recorder Expanded Parameter Recording.
The Board believes these safety issues have the greatest potential to save lives, and they will continue to receive intensive follow-up activity, as noted in many of the accident investigations mentioned in this testimony. We expect to review the list once again this Spring.
According to the FAA, U.S. commercial air carrier passenger enplanements
were up 8.2 percent in 1994, after averaging increases of only
1.5 percent during the preceding 4 years. The commuter airline
industry continues to be the fastest growing sector of the aviation
community, with passenger traffic increasing by 67 percent during
the 1990s. In 1994, the regional/commuter airlines enplaned 53.6
million passengers. One example of why we advocated "one
level of safety" for all air carriers, and why we are so
pleased with the FAA's recent promulgation of a final rule to
implement this, is that by the year 2006, commuter air carriers
are expected to carry 115.1 million passengers, a 154.1 percent
Aviation accident data for the past year show something of a mixed, but improving picture. Overall, the preliminary data showed that 1,040 persons lost their lives last year in 2,211 civil aviation accidents, either in the United States or involving U.S. registered aircraft.
Commuter airline fatalities declined from 25 in 1994 to 9 persons in 1995 -- the lowest level since 1989. It was also the fourth consecutive decline in fatal accident rates. For major scheduled airlines, the number of fatalities declined in 1995 to 166 persons from 264 in 1994. Most of the fatalities occurred in an accident that happened in December involving American Airlines near Cali, Colombia. After hitting a historic low in 1994 of 1,990 general aviation accidents, there was a rise to 2,066 in 1995, with fatal accidents rising from 402 to 408.
Completed Aviation Investigations
In April 1995, the Safety Board adopted its report on the July
2, 1994, USAir accident near the Charlotte/Douglas International
Airport. The aircraft collided with trees and a private residence,
killing 37 passengers and injuring the remaining 20 passengers
and crew. Our investigation found that this was a windshear-involved
accident -- the first such accident in the United States in almost
a decade. The Board determined that the flightcrew continued an
approach into severe convective activity that was conducive to
a microburst, and that the flight crew failed to recognize a windshear
condition in a timely manner. Safety recommendations were adopted
on the following issues: standard operating procedures for both
air traffic controllers and flightcrews; the dissemination of
weather information to flightcrews; and USAir flightcrew training.
In August 1995, the Safety Board adopted the report of the November
22, 1994, runway collision at the St. Louis/Lambert International
Airport involving Trans World Airlines flight 427 and a Cessna
441. This accident is the most recent example of why the runway
incursion issue is still a "Most Wanted" item. The two
individuals on board the Cessna were fatally injured. The Board
determined that the installation and utilization of Airport Surface
Detection Equipment (ASDE-3), and particularly ASDE-3 enhanced
with the Airport Movement Area Safety System (AMASS), could have
prevented this accident. Once again, the Board issued safety recommendations
regarding the runway incursion issue, including airport markings,
signs, and lighting.
In October 1995, the Safety Board adopted the report of the December
13, 1994, American Eagle accident. Flight 3379 crashed on approach
to the Raleigh-Durham International Airport, killing 15 of the
20 individuals on board. The Safety Board found that the captain
made a series of errors which led to the tragedy. The Board further
found that the pilot's performance problems might have been detected
by the carrier had better hiring, training, and proficiency check
procedures been in place.
"The Board ... recommended that the FAA order airlines to conduct more thorough background checks on pilot applicants, including training records." Mr. Chairman, that is a quote from testimony presented by a former Board Chairman before this Committee on April 6, 1989. The recommendation mentioned in that statement was a result of a Continental Airlines accident at Denver's Stapleton International Airport. What has happened in the intervening seven years? On November 15, 1995, the NTSB once again forwarded safety recommendations to the FAA regarding, among other things, the sharing of pilot information. The Safety Board still believes the sharing of pilot information is of utmost importance, and we urge prompt action.
In August 1995, the Safety Board adopted the report of the accident
that occurred February 16, 1995, involving a DC-8 operated by
Air Transport International (ATI). The aircraft crashed while
attempting a three-engine takeoff at Kansas City, Missouri, to
ferry the aircraft to its maintenance base. All three crewmembers
on board were killed and the airplane was destroyed. Training
and crew fatigue were identified as issues. As you are aware,
fatigue in all modes of transportation is a "Most Wanted"
Mr. Chairman, as you will recall, revisions to the Board's authorization
expanded our authority to investigate some public use aircraft
accidents. The report adopted by the Board in August 1995 regarding
the December 14, 1994, Learjet accident in Fresno, California
involved a public use aircraft accident.
At the time of the accident, a Learjet, under contract to the U.S. Air Force for target practice involving the California Air National Guard, overflew the runway, touched down in a street, and crashed into a two-story apartment building, killing two people. The flightcrew had declared an emergency inbound to Fresno Air Terminal due to engine fire indications. The airplane had been modified with electronic equipment to satisfy the mission requirements, and evidence found in the wreckage showed that the electrical power cables for the special mission equipment had not been installed in accordance with specifications. Issues examined in this investigation were: maintenance, inspection and quality assurance; related safety recommendations were issued.
Based on a series of accidents involving air tour aircraft, the
Safety Board conducted a special study of air tour operations.
Two regional public hearings were held, and federal regulations
and FAA certification and oversight were among the issues discussed.
In June 1995, the Safety Board issued its report and safety recommendations
-- the most important of which is the development of national
"air tour" definitions and national air tour standards
with local variations, and that all air tour operations be conducted
within Part 135 of the Federal Aviation Regulations. This would
allow the FAA to establish a data base of air tour operators,
making it possible to calculate exposure levels and FAA surveillance
Flight operations in Alaska are diverse, and they are responsive
to the State's challenging aviation environment and its unique
air transportation requirements. Due to the large geographic area
and lack of other forms of transportation, aviation is often the
only way to traverse much of the State. In 1995, the Safety Board
conducted a safety study on aviation safety in Alaska to examine
Alaska's current aviation environment and air transportation activities,
to identify the associated risk factors and safety deficiencies,
and to recommend practical measures for managing the risks to
safe flight operations given the reality of Alaska's aviation
environment and the potential application of new technologies.
The Safety Board's study focused on the following safety issues:
As a result of several ATC equipment outages at en route centers,
the Safety Board initiated a special investigation into the FAA's
capability to cope with the continued use of current aging ATC
equipment until the next generation of equipment becomes available
beginning in late 1997. The special investigation focused on the
problems that had become visible at the five air route traffic
control centers (ARTCCs) with the oldest controller display computer
The Board issued its report in January 1996, concluding that while the en route ATC system is safe and the public should not be unduly alarmed, the equipment failures examined have had a detrimental effect on the efficiency of air traffic movement. Safety recommendations were issued to the FAA regarding: personnel issues, simulator-based training, identification of safety deficiencies, and the need for a program to evaluate suggestions and repair techniques proposed by technicians in the field and to share this information with technicians at other facilities.
On-Going Aviation Investigations
The Safety Board is continuing the most complex and expensive
aircraft accident investigation in our history, the September
8, 1994, accident involving USAir flight 427 at Pittsburgh, Pennsylvania.
As you know, the Boeing 737 aircraft crashed while on approach,
killing all 132 people on board. The investigative team, consisting
of nearly 100 investigators from the Safety Board and other domestic
and foreign organizations, have expended more than 40,000 investigative
staff hours in direct support of the investigation. Wake vortex
flight tests were conducted involving a Boeing 737 and a 727 in
late September, and in December the Board reconvened the public
The main reason this investigation is so complex and costly is the inadequate number of parameters on the flight data recorder (FDR) aboard flight 427. The absence of data prevented us from knowing the role of some of the airplane's critical flight controls in the accident sequence. In contrast, in other recent major accidents -- a SAAB 340 over Louisiana and the ATR-72 accident near Roselawn, Indiana -- information received from newer flight data recorders immediately provided the Board with important information that led us to immediate corrective actions.
On October 31, 1994, American Eagle flight 4184, an ATR-72, crashed
into a soybean field 3 miles south of Roselawn, Indiana, killing
all 68 people on board. In contrast to the Pittsburgh FDR, the
FDR on the American Eagle aircraft recorded almost 100 key parameters.
Because of the information received from the FDR, within a week
of the accident the Safety Board issued recommendations to the
FAA to restrict the operation of ATR aircraft in icing conditions
until a fix could be developed to counteract the phenomenon the
accident aircraft encountered. Last November the Board issued
recommendations regarding retention of flow control-related documents.
The investigation of this accident is completed, and French Bureau Enquetes-Accidents will soon be reviewing the Board's draft report, in accordance with ICAO regulations. We expect to complete action on this accident, following the mandated ICAO French review, this Spring.
Mr. Chairman, this is my second appearance before your Committee,
and the second time I have discussed the importance of enhanced
flight data recorders. Aviation accident investigations conducted
by the Board will continue to be hampered until the entire airline
fleet has been retrofitted with upgraded FDRs. We believe the
American people are entitled to every reasonable safety protection,
and flight recorders are the best possible witnesses for any accident
or incident. That is why we have recommended enhancements in flight
recorder technology, and why we have placed this issue on our
"Most Wanted" list.
We have passed the time when we can allow airliners carrying hundreds of passengers to be equipped with FDRs recording scarcely more information than we got from foil recorders at the dawn of the jet age. The Board should never again be in the position -- as it was following the United Airlines accident in Colorado Springs -- of not being able to determine the probable cause of an accident because of the absence of data.
On August 21, 1995, Atlantic Southeast Airlines flight 7529 made
an off-airport forced landing near Carrollton, Georgia. The pilot
and seven passengers were killed; the remaining 21 occupants survived,
most with serious burn injuries. The initial on-scene examination
indicated that one of the left engine's propellers separated in
flight. On August 25, 1995, the Safety Board issued an urgent
safety recommendation calling for immediate inspections of Hamilton
Standard propellers on numerous commuter airplanes. The Board
also issued two priority recommendations directed at longer term
actions by the FAA to improve the safety of those propellers.
On November 12, 1995, an American Airlines McDonnell Douglas MD-80
from Chicago, Illinois, struck trees on a ridge line 2.65 miles
from the end of runway 15 at Bradley International Airport, Windsor
Locks, Connecticut. The airplane then landed safely at the airport.
The airplane structure contained debris from trees of up to about
1 1/2 inches in diameter in the landing gear and in both engines.
There was leading edge damage on both the wings and the horizontal
stabilizers, as well as evidence of a tail strike. The Board's
investigation is examining, among other things, pilot instrument
procedure approach plate design, and ATC safety equipment.
A less known but highly significant part of the Safety Board's
activities involves its participation in investigations of incidents
and accidents in other countries as the U.S. accredited representative
under Annex 13 of the International Civil Aviation Convention
of 1944. NTSB participation in international accidents provides
a direct benefit to ensuring the safety of U.S. aviation, as well
as the safety of airline travelers worldwide, and at times provides
an early warning of problems that can be identified and corrected.
Below are two examples of the importance of Safety Board participation
in international accident investigations.
April 10, 1995, during a takeoff roll at Cairo, Egypt, an Egypt Air Airbus Industrie A300B4 airplane equipped with General Electric CF6-50C2 engines sustained an uncontained separation of the stage 3 through 9 high pressure compressor (HPC) rotor spool in the No. 1 engine. The crew rejected the takeoff, stopped the airplane on the runway, and ordered an emergency evacuation of the passengers. One passenger sustained a minor injury in the course of exiting the aircraft via the emergency slide.
A small fire along the underside of the HPC in the left engine was reported to the crew by the crew of another aircraft. Post-accident investigation revealed substantial engine damage in the area of the HPC. Numerous pieces of the compressor were scattered along the runway.
On August 25, 1995, the Safety Board issued two urgent safety recommendations to the Federal Aviation Administration regarding the need for revised maintenance programs for inspection procedures of all General Electric Aircraft Engine CF6 operators, and that General Electric CF6-50, -80A, and -80C2 model engines be required to have repeated inspections of all high pressure compressor rotor stage 3 to 9 spools, and that the maximum interval between inspections should be less than 4,000 cycles.
On September 16, 1995, the right main landing gear of a Delta Air Lines Boeing 767-332ER, collapsed while the airplane was making a right turn during its taxi for takeoff at Hamburg Airport, Hamburg, Germany. The airplane was 5 years and 3 months old and had 3,807 cycles and 25,196 hours. Post-accident examination revealed multiple fractures on the outer cylinder aft trunnion, which had broken into three large sections. Examination by the Safety Board's materials laboratory of two fragments of the outer cylinder aft trunnion revealed that the aft trunnion had multiple fractures and contained six areas of stress corrosion cracking.
On October 27, 1995, the Safety Board issued two urgent safety recommendations to the FAA regarding the inspection of the main landing gear outer cylinder aft trunnion.
The NTSB is also participating in the December 20, 1995, American Airlines accident near Cali, Colombia. Of the 164 people aboard, 160 people died, including at least 62 U.S. citizens. This investigation is being conducted by the Colombian Government under ICAO rules. NTSB staff have been chosen by Columbian investigative officials to lead the investigative activities in human performance, operations, aircraft performance, and air traffic control. The flight data recorder, which recorded approximately 300 parameters, has provided a wealth of information that has been of enormous assistance to the investigative team.
Mr. Chairman, dedicated NTSB investigators endured difficult climatic and geographic conditions over the Christmas holidays to be on-scene at this tragedy. They deserve to be recognized for their selfless dedication to aviation safety.
The most recent foreign accident in which the NTSB is participating is the February 6, 1996, accident involving a Boeing 757 in the Atlantic Ocean near Puerto Plata, Dominican Republic. The flight was a tour group returning to Germany. There were 176 passengers and 9 crew on board the flight; all were fatal. The accident airplane was owned and operated by a Turkish air charter company, Birgenair, on behalf of a Dominican airline, Alas Nationales. Although the Dominican Civil Air Authority is in charge, they have requested extensive assistance from the NTSB.
This accident scenario is complicated by a lack of sufficient radar data to track the flight path of the airplane and the deep water location of the wreckage. Such an event, once again points out the importance of multiple parameter flight recorders in the investigation of such accidents.
The Board coordinated with the governments of the Dominican Republic, Germany, and Turkey, as well as the airframe and engine manufacturers on a plan to recover the flight recorders and other wreckage as necessary. It is estimated that the recovery effort will cost a minimum of $1.4 million. Although we have received contributions from the interested parties and governments, the Board will have to use a portion of it's emergency fund to help defray the costs of this investigation.
About four billion tons of regulated hazardous materials are shipped each year, with more than 250,000 shipments of hazardous materials entering the U.S. transportation system daily. The issue of railroad hazardous materials tank cars has been of interest to the NTSB for several years and is an item on our "Most Wanted" list. More than 1.52 million carloads of poisons, chemicals, pesticides, and other hazardous materials are transported yearly by railroad, and the potential for disaster is significant.
In February 1995, the Safety Board adopted the report of the June
6, 1994, release of 3,079 gallons of arsenic acid from a Norfolk
Southern tank car at a rail yard in Chattanooga, Tennessee. The
arsenic acid entered the storm drain system. Contaminated water
from that system was then discharged into Citico Creek, and then
into the Tennessee River near intake pipes for the City's municipal
water supply. The Tennessee River is the sole source of water
for the Chattanooga water system. Repair costs to the tank car
were $29,900 and the value of the spilled arsenic acid was $24,630.
However, the environmental cleanup and disposal costs were estimated
to be $8.77 million. Issues examined were:
The Safety Board is investigating an October 1995 tank car failure
and release of nitrogen tetroxide in Bogalusa, Louisiana, resulting
in the evacuation of over 3,000 people. Nitrogen tetroxide is
an oxidizer and a poisonous gas. Our investigation has revealed
severe internal corrosion to the tank. Additionally, the investigation
has revealed that before the tank car was last filled with cargo,
four valves had been replaced. Issues being examined include:
containers authorized for transporting nitrogen tetroxide; tank
car repairs; cargo handling procedures; and emergency response.
In the United States, there are more than 194 million registered vehicles, and 175 million licensed drivers. More than 94 percent of all transportation fatalities (about 40,000) and 99 percent of transportation injuries (5 million) are the result of motor vehicle crashes. Since 1965, the number of drivers has increased 77 percent, and the number of vehicles has increased by 106 percent. By the year 2000, drivers and vehicles are expected to increase another 7 percent, and miles traveled by 15 percent. Over the years, some of issues the Safety Board has examined include drunk driving, schoolbus safety, child safety seats, truck driver fatigue and grade crossing safety.
Completed Highway Investigations
In May 1995, the Safety Board adopted the report of a grade crossing
accident near Intercession City, Florida involving Amtrak's Silver
Meteor that occurred on November 30, 1993. The failure to coordinate
the roadway routing of an 82-ton turbine generator transport to
a utility plant was causal. Fifty-nine persons were injured when
the Amtrak train derailed after impact with the 82-ton turbine
generator that was on a special vehicle, which had bottomed out
on the grade crossing. The locomotive and other wreckage came
to rest on or near high-pressure petroleum product pipelines buried
parallel to the tracks. Safety recommendations were issued to
nearly two dozen organizations regarding oversight of oversize
moves, oversize move coordination, pipeline notification and hazard
identification and avoidance, permitting procedures, and lounge
car seat support design.
In November 1995, the Safety Board adopted the report of the July
27, 1994, accident involving a cargo-tank semitrailer loaded with
9,200 gallons of propane, that crashed into a bridge column, propelling
the propane tank into a house across the road and releasing propane
that ignited. The accident killed the driver, injured 23 people,
and damaged nearby homes.
Mr. Chairman, this accident was caused by the fatigue of the truck driver. As I mentioned earlier, fatigue in all modes of transportation is a "Most Wanted" issue, and the Board urged the Federal Highway Administration and the trucking industry to evaluate and revise its hours of service regulations.
In November 1995, the Safety Board adopted the report of the January
9, 1995, multiple-vehicle, rear-end collision that occurred during
localized fog near Menifee, Arkansas. The accident involved eight
loaded truck tractor semitrailer combinations and one light-duty
delivery van. Five people were killed. Issues examined by the
Board were collision warning technology use during low-visibility
driving conditions, the emergency channel nine override feature
for citizens band radios, and the nonuniformity in state laws
governing four-way emergency hazard flasher operation.
On-Going Highway Investigations
Amtrak's Silver Star crashed into a tractor lowboy-trailer at
a passive grade crossing near Sycamore, South Carolina, on May
2, 1995. The trailer was not loaded at the time of the collision,
and the driver indicated that he bottomed out and became stuck
on the hump crossing. There were no fatalities, but over 50 Amtrak
passengers were taken to area hospitals. Issues being looked into
are the crossing profile, passive crossings, emergency response,
motor carrier practices, and emergency notifications.
Mr. Chairman, any accident is tragic, but never more so than when
it involves children. On October 25, 1995, seven children were
killed when a Metra passenger train crashed into a schoolbus at
an active grade crossing in Fox River Grove, Illinois. The schoolbus
was stopped at a traffic signal. At the accident location, the
nearest rail is 30 feet, 4 inches from the intersection stop line.
The 38 foot, 4-inch long school bus exceeded the space available,
causing the rear of the bus to extend over the railroad tracks.
The train engineer saw the schoolbus stopped on the crossing about
200 yards before the impact.
We issued urgent safety recommendations regarding train speed reductions and highway traffic signals on October 31, 1995, and held a public hearing in January of this year. Issues being examined include: communications and coordination between railroads and city, county and state governments; preemptive and interconnecting railroad grade crossing signals and highway traffic lights; schoolbus route planning and schoolbus driver training; railroad-highway intersection design; and train whistle bans and train whistle audibility within schoolbuses.
As part of our outreach on this most important issue, the Safety Board has held three community briefings regarding schoolbus safety, the most recent being the one held February 26, 1996, at Middletown Community College, Virginia.
I have thus far discussed three accidents that occurred at highway/railroad
grade crossings. Every year about 4,600 motor vehicles are involved
in accidents at grade crossings. These accidents kill about 500
people, and they injure more than 1,800 people annually. Passive
crossings, those that have no train-activated warning devices,
account for more than 60 percent of crossing deaths each year.
The Safety Board has begun a safety study to determine if a reduction in the number of grade crossing accidents could be achieved through engineering improvements, improved enforcement of existing traffic laws, development of safety regulations and standards, and public education programs. Data collection by the
Board's highway and railroad investigative staff began for this study in February 1996. We expect to complete the study in late Spring 1997.
In 1994, the Safety Board initiated a safety study to evaluate
the performance of occupant restraint systems for children under
the age of 11. The goal of this study is to examine the overall
performance of child occupant restraint systems (safety seats
and seat belts), the adequacy of relevant Federal regulations,
and the comprehensiveness of state child safety seat and seat
belt use laws. This study is in the data collection and analysis
stage, and we expect completion in FY 1996.
As you are aware, the Safety Board does not wait for completion of an investigation or study if we become aware of safety problems that require immediate attention. During the data collection phase of the study, we investigated four accidents in which an infant was killed or severely injured as a result of an air bag deployment. Those accidents were:
The Safety Board has initiated a 50-state outreach program to
follow-up on safety recommendations issued to the individual states.
Examples of these recommendations include: administrative license
revocation laws, zero blood alcohol content laws for youth, primary
enforcement of seat belt laws, boating while intoxicated laws,
and required use of personal flotation devices by children age
12 and under.
The Safety Board is pleased that eight additional youth zero tolerance laws were enacted by the States in 1995 -- there are now 28 States plus the District of Columbia that have a zero tolerance standard for drivers under age 21. Also in 1995, Arkansas became the 39th State to enact administrative license revocation. We will continue to work with State legislatures and safety organizations on these vital safety concerns.
Much of this Nation's commerce (98 percent) travels between U.S. ports and points overseas, or on the tens of thousands of miles of inland waterways. Marine transportation is as diverse as cruise ships carrying thousands of passengers at a time to recreational boats, and from supertankers to tow boats. Water transport produces about 790 billion ton-miles a year, employing almost 200,000 persons. In 1995, there was a 6.5 percent increase in cruise ship passengers over 1994. These figures are expected to continue to rise in the coming years.
Completed Marine Investigations
In July 1995, the Safety Board adopted the report of the accident
that occurred on July 24, 1994, involving the U.S. fish processing
vessel ALL ALASKAN, which caught fire near the western end of
Unimak Island, Alaska. The fire burned out of control for several
days before burning itself out. One person died, and vessel and
cargo damage was estimated to be close to $31 million. The NTSB
issued recommendations on July 17, 1995, regarding fire protection
and construction standards, firefighting training, fire watch
procedures, and U.S. Coast Guard and company post-accident toxicological
On December 12, 1995, the Safety Board completed action on the
accident involving the Liberian tankship SEAL ISLAND in St. Croix,
U.S. Virgin Islands on October 8, 1994. The accident occurred
when lubricating oil sprayed onto the hot turbine casing and a
fire erupted, burning for about 6 hours and killing three people.
Issues examined were: the adequacy of management oversight of
maintenance and report practices; the decision to make and the
risk introduced by the temporary repair modification to the lubricating
oil duplex strainer; the adequacy of emergency equipment and drills
on board ocean-going ships; the adequacy of the emergency response
by refinery personnel; and the adequacy of the U.S. Coast Guard's
fire contingency planning for St. Croix.
In November 1995, the Safety Board adopted its report on the December
3, 1994, engineroom fire aboard the ARGO COMMODORE, a small passenger
vessel on a dinner cruise in San Francisco Bay. The fire was caused
by a short circuit in the starboard main engine electrical starting
system. This accident involved on-going concerns related to small
passenger vessels, including the issues of crew emergency training
and passenger briefings -- issues on our "Most Wanted"
On-Going Marine Investigations
The Safety Board has six marine accidents under investigation. Those accidents are:
In marine transportation, integrated bridge systems and electronic
charts, oriented to the earth's surface by precise radio navigation
systems such as the Global Positioning System (GPS) and Loran,
offer the potential for great improvements in navigation safety.
However, the investigation of the grounding of the passenger vessel
ROYAL MAJESTY near Boston on June 10, 1995, and the Board's subsequent
urgent safety recommendations, indicate that there is a need to
gather information on the state of the development of advanced
electronic navigation and integrated bridge systems, the adequacy
of industry and Government oversight, and the need for proper
crew training in the use of this new equipment. The NTSB is sponsoring
a two-day public forum to address these issues in March.
Each year approximately 250 fishing vessels are lost and about
100 fishermen die in the commercial fishing industry. Despite
actions taken since the release of the Safety Board's 1987 safety
study on uninspected commercial fishing vessel safety, statistics
continue to show a disproportionate number of fishing vessel casualties
in relation to the number of vessels in service. The Safety Board
is currently collecting data for a study that will focus on the
need for commercial fishing vessel inspection, licensing of fishing
vessel masters, and crew training requirements. We expect completion
of the study in late FY 1996.
Pipelines carry more hazardous materials in this country than any other form of transportation. Annually, almost 600 billion ton-miles are carried in oil pipelines in 203,000 miles of pipe, and more than 17 billion cubic feet of natural gas are delivered through 1.1 million miles of gas pipeline. From 1984 to 1994, the number of miles of gas pipeline distribution mains increased by 23 percent.
Fifty-seven percent of crude petroleum and petroleum products
are transported by pipeline. The potential threat to public safety
from the release of such products has become more severe in recent
years as the rate of residential and commercial development adjacent
to all types of pipelines has increased. In a special investigation
of U.S. liquid pipelines released in January 1996, the NTSB found
that the Research and Special Programs Administration still lacks
an adequate system to address corrosion control, to inspect and
test pipelines, to limit the release of product from failed pipelines,
and to analyze operator performance. Safety recommendations were
adopted regarding these issues.
On June 9, 1994, following excavation work, there was a pipeline
explosion and fire in buildings housing the elderly in Allentown,
Pennsylvania, resulting in one fatality. Issues examined in this
accident were pipeline excavation damage prevention and rapid
shut-down of failed gas service lines; related safety recommendations
regarding were issued.
Most excavation accidents are preventable, but data show them to be the leading cause of reported pipeline accidents. The Allentown accident was the fifth excavation-involved pipeline accident in a 15-month period, and led to the Board's September 1994 workshop on this issue hosted with the Office of Pipeline Safety. The proceedings of that workshop were published by the NTSB in October 1995.
Amtrak carries about 21 million intercity passengers a year, and rapid rail systems carry almost 2 billion passengers a year. The railroads haul at least $28 billion of freight business each year, and amass more than 1.1 trillion ton miles. Light rail passenger trips between 1980 and 1993 increased by 41.4 percent. Over the years, the NTSB has issued railroad safety recommendations in all railroad areas, from passenger car interiors, to rail rapid transit safety, to continuous welded rail, to hours of service for railroad personnel.
Completed Railroad Investigations
In March 1995, the Safety Board adopted the report of the accident
involving Amtrak's Silver Meteor when it derailed following a
collision with an intermodal trailer that had either fallen or
was falling from a flat car on a passing CSX freight train at
Selma, North Carolina on May 16, 1994. The accident killed the
Amtrak assistant engineer. It was determined that the trailer
was not properly secured to the flat car, and the Safety Board
issued recommendations regarding the loading, securing and inspection
In September 1995, the Safety Board adopted the report of the
railroad collision that occurred June 8, 1994, near Thedford,
Nebraska. An eastbound Burlington Northern (BN) train that had
stopped for a train ahead was struck in the rear by a following
eastbound BN train. The lead unit of the striking train derailed
and came to rest on an adjacent track where it was struck by a
westbound BN train. The engineer and conductor of the striking
eastbound train were killed. Issues examined were: train crew
inattentiveness as a result of fatigue, and positive train separation,
both "Most Wanted" items. The Safety Board reiterated
two recommendations regarding positive train separation.
In November 1995, the Safety Board adopted the report of the December
14, 1994, railroad collision that occurred at Cajon, California.
A westbound Atchison, Topeka and Santa Fe Railway Company intermodal
train collided with the rear end of a standing westbound Union
Pacific Railroad Company unit coal train. Issues examined by the
NTSB were air brake testing in mountain-grade territory; management
oversight of train handling practices; feed-valve braking; and
two-way end-of-train devices. Of the safety recommendations issued,
two urgent recommendations dealt with end-of-train devices.
On-Going Railroad Investigations
A rear-end collision involving two New York City Transit commuter
trains occurred June 5, 1995, on the Williamsburg Bridge. A southbound
train had been standing at a red stop signal for about 15 to 20
seconds, when it was struck in the rear by another southbound
train. The train operator of the striking train was fatally injured.
The Safety Board held a two-day public hearing regarding this
accident in New York City in November 1995. Issues being looked
into are: oversight of rapid transit operations; standards for
rapid transit equipment; and subway signal standards and installations.
The Safety Board is investigating the January 6, 1996, accident
involving a Washington Metropolitan Area Transit Authority train.
Train T-111 operating on Metro's Red Line collided head on with
a standing, unattended equipment train at the Shady Grove Metro
Station at Rockville, Maryland. The T-111 train operator received
fatal injuries. At the time of the accident, it was snowing heavily
in the Washington Metropolitan Area. Train T-111 reported station
overruns at the two previous stations. Issues being examined include:
train car crashworthiness, human performance, automatic train
control/signals, weather, and management oversight of train operations,
including rules, policies, and procedures.
On February 1, 1996, a Burlington Northern Santa Fe freight train
derailed at Cajon Pass, California, killing the conductor and
trainman and injuring the engineer. Forty of the 49 cars derailed,
four of which contained hazardous materials. Approximately 60
people were evacuated in a radius of 1 1/2 miles, and Interstate
15 was closed until the evening of February 2, 1996. On February
5, 1996, Interstate 15 was once again closed, and an evacuation
was implemented because of the fear of unstable hazardous materials.
This accident occurred within sight distance of the location of
a collision and derailment that occurred December 1994. Issues
being examined in this accident are: management oversight, training,
trains operating with unarmed 2-way telemetry devices, and mechanical
inspection and repair of freight cars.
On February 9, 1996, at about 8:40 a.m., New Jersey Transit commuter
Train 1254, operating eastbound from Waldwick to Hoboken, New
Jersey, collided head-on with the lead locomotive of New Jersey
Transit Commuter Train 1107, a westbound train operating between
Hoboken, New Jersey and Suffern, New York. There were over 400
passengers on the two trains; three fatalities and 162 injuries
resulted from the collision. Issues being looked into include:
operator fatigue, fitness for duty, crashworthiness of cab cars;
and positive train separation.
On February 16, 1996, a MARC commuter train from West Virginia
to Washington D.C. collided with an Amtrak train en route from
Washington, D. C. to Chicago, Illinois, killing 11 people. The
impact ruptured a 1,500 gallon diesel tank on the first of two
Amtrak locomotives, igniting a fire that swept through the front
MARC passenger car. Issues being looked into include: the signals;
human performance, and fuel tank integrity
The National Transportation Safety Board has investigated accidents in every mode of transportation in which the effects of fatigue, circadian factors and sleep loss have been found to be causal or contributory. Nearly 80 fatigue-related safety recommendations have been issued since 1972 to the modal administrations in the Department of Transportation, transportation operators, associations and unions. Still, a fatigue factor continues to be found by many Safety Board accident investigations.
In November 1995, the Safety Board, in partnership with the NASA
Ames Research Center, conducted the first ever, multi-modal symposium
focusing on fatigue in transportation. The symposium was attended
by nearly 600 people, including participants from 16 different
countries, representing every mode of transportation, and provided
tangible approaches for the transportation community to address
the problem of fatigue. We expect to issue a report of the proceedings
of the symposium in late Spring.
For fiscal year 1997, the Board is requesting $40,300,000, which
is $1,526,000 more than our FY 1996 appropriation. This figure
is just sufficient to allow the Board to maintain its staff at
its current 350 FTE level.
That concludes my prepared statement. I will be happy to respond to any questions you may have.