Testimony of Jim
National Transportation Safety Board
Committee on Appropriations
Subcommittee on Transportation and Related Agencies
House of Representatives
Fiscal Year 1998 Budget Request
March 11, 1997
Good morning Mr. Chairman and Members of the
Committee. It is a pleasure to be here today to represent the
National Transportation Safety Board. Before I begin, I would
like to thank you and the other Members of the Committee for your
continued support of our activities, and for your interest in
the Safety Board's programs.
Your support was all the more important when
you consider 1996 was dominated by accidents that demanded monumental
efforts by the Safety Board's staff -- and strained this agency's
resources. Not only is the TWA flight 800 investigation the most
costly in the Board's history, but where we usually are able to
complete on-scene accident investigation activities in ten days
to two weeks, we have now been on-scene on Long Island for nearly
In a few weeks, the Safety Board will celebrate
its 30th anniversary. During these three decades, the Board has
investigated more than 100,000 aviation accidents and 10,000 surface
accidents, and conducted scores of safety studies. Our object
has been not just to find probable cause, but more importantly,
to issue safety recommendations aimed at ensuring that similar
accidents do not happen again.
But, Mr. Chairman, the results of accident
investigations or safety studies are useless unless the information
is readily available to those who need it. The Board has tried
many different ways to disseminate safety information -- from
the "Most Wanted" list of safety issues, to public forums
and symposia, to participating with other safety organizations
in meetings and conferences, and testifying before Congress and
state legislatures. More and more, transportation is becoming
a global system, and it is essential that lessons learned by safety
professionals are shared with all on that global system.
As part of this effort, the Safety Board has
been an active member of the International Transportation Safety
Association, which is made up of independent accident investigation
boards from around the world. We at the Safety Board are hopeful
that this organization will go a long way toward improving the
safety of transportation worldwide by learning from the experiences
of others. Our aviation specialists also maintain a constant dialaogue
with their counterparts through the International Civil Aviation
Organization and the European Civil Aviation Conference.
The Board has also placed much of its information
on the World Wide Web. If you pull up the Board's home page at
www.ntsb.gov, you will be able to view press releases, speeches
and Congressional testimony, the "Most Wanted" list,
and aviation accident information and statistics. During the initial
weeks of the TWA 800 investigation, the Board's home page was
an important source of information for many family members.
The "Most Wanted" list is composed
of those safety issues with the greatest potential for positive
impact on transportation safety. Safety recommendations placed
on the "Most Wanted" list receive more intensive follow-up
activity to persuade government agencies and industry to act on
them as quickly as possible. In April 1996, the Safety Board added
three issues to the list. Those issues were:
-- Pilot Background Checks -- The Board
has addressed pilot screening four times in the last eight years.
Most recent safety recommendations on this subject were issued
to the Federal Aviation Administration following the December
13, 1994, accident involving an American Eagle Jetstream 3201
on approach to Raleigh-Durham, that killed 15 persons. We were
pleased that this matter was addressed in Public Law 104-264,
the Federal Aviation Reauthorization Act of 1996.
-- Safety of Passengers in Railroad Cars
-- Dating back to a train derailment on June 28, 1969, at Glendale,
Maryland that injured 144 persons, the National Transportation
Safety Board has made passenger rail car safety recommendations
as a result of at least 13 accidents, which claimed 27 lives and
injured 898 persons. Today, there is only one federal passenger
car requirement: four window exits per car with bullet-proof glass.
The Safety Board has raised safety issues about rail car construction,
signs and emergency preparedness more than a dozen times in the
past 25 years. The most recent of these was the February 16, 1996,
accident near Silver Spring, Maryland involving a Maryland Rail
Commuter and an Amtrak train, resulting in 11 fatalities. Four
safety recommendations regarding passenger car safety were issued
in March 1996 as a result of the Silver Spring accident -- 1 to
the Federal Railroad Administration and 3 to the Maryland Mass
Transit Administration. Although the Federal Railroad Administration
has not completed action on the urgent safety recommendation issued
to it, they have taken action on several initiatives to ensure
ready passenger egress and rescue access consistent with the intent
of the Board's recommendation. They have required inspection of
emergency window exits for proper operation, and have issued a
proposed rule on passenger train emergency preparedness and passenger
equipment safety standards. The State of Maryland has complied
with all three of the Board's recommendations, resulting in two
of the recommendations closed with acceptable action or exceeding
recommended action, and one in an open acceptable status.
-- Highway Vehicle Occupant Protection
-- The protection to vehicle occupants through consistent use
of restraints has long been advocated by the Safety Board, but
it has found that there is a need for stricter and more consistent
enforcement of seat belt laws by the states. The Board has also
recommended measures to address the dangers posed by airbags to
children and small statured adults, as well as measures to ensure
the use of proper child passenger restraints.
-- Flight Data Recorders -- Although not a new issue on the "Most Wanted" list, I would like to discuss the importance of enhanced flight data recorders (FDR). Almost two years have passed since the Safety Board issued its recommendations for enhanced FDRs, and the Department has failed to enact any rulemaking on this important safety issue. We applaud this Committee for bringing attention to this subject in last year's Committee report, which stated: "The Committee does not believe the FAA has worked as diligently as possible to encourage the retrofit of expanded parameter flight data recorders (FDRs) into existing aircraft .... Therefore, the Committee directs FAA to work closely with NTSB over the coming year to develop a plan for the retrofit of expanded parameter FDRs into commercial aircraft."
On July 16, 1997, the FAA issued the NPRM on
enhanced FDRs, with a 30-day comment period. NTSB comments on
the rule were generally favorable. However, the NPRM would not
require FDR retrofits to begin for at least another two years.
Further, no action was taken on the Board's urgent recommendation
to expedite the retrofit of Boeing 737 airplanes.
We agree with you that the FAA has not worked as diligently as possible on this issue. We are aware that a rulemaking package was forwarded to the Office of the Secretary of Transportation on February 7, 1997. However, the DOT and Office of Management and Budget review process has been lengthy. How much longer must we wait before action is taken?
Mr. Chairman, we are convinced that the Board's
"Most Wanted" list remains one of our most effective
methods for the identification of those issues we believe have
the greatest potential for saving lives. Since its inception,
nine "Most Wanted" safety issues have been removed from
the list because of positive action taken by the recommendation
recipients. The Board's staff is currently developing proposals
for consideration by the Board of additional items to be added
to the list, as well as removal of any items that may be successfully
resolved. Attached to this testimony is a copy of the current
"Most Wanted" list of safety issues.
Last year was a year of change at the Safety
Board. As a direct result of three Congressional hearings, the
ValuJet accident in Miami, and the TWA flight 800 accident, Congress
passed legislation that requires the Safety Board to coordinate
assistance to family members of the victims of airline accidents
resulting in major loss of life. This followed a request from
President Clinton that the Safety Board take the lead in coordinating
family assistance following transportation accidents. As a response
to these directives, I have established a Family Affairs Division,
and we are currently preparing a federal response plan for major
aviation disasters. Since this legislation became law, we have
provided on-scene assistance at two major aviation accidents.
That assistance included twice-daily Safety
Board briefings to those family members on scene, and conference
calls to those family members who did not travel to the scene.
We also coordinated with the Red Cross, which provides volunteers
to assist families of victims, and arranged for mobile morgues
from the Department of Health and Human Services (HHS). The mobile
morgues are fully equipped, supplied, and staffed by forensic
doctors, dentists, anthropologists, and other technical personnel.
All participants are members of the disaster mortuary teams who
also support FEMA in case of natural disasters. Each team member
is a volunteer, private citizen who is deputized by HHS to work
for us at an accident scene. We have completed a memorandum of
understanding with HHS, and consider them an important partner
in our accident investigation response.
The Safety Board has been in regular contact
with the families of the victims of recent aviation disasters,
including the families of TWA flight 800 victims since that accident
occurred in July. We have provided those family members with a
toll-free 800 number to use should they have questions, and we
send periodic written updates on the accident. Also, at the families'
request, on February 8, 1997, we organized and coordinated a tour
of the Calverton, New York, wreckage hangars for 150 family members.
Although a difficult day, all family members, I believe, were
appreciative of our efforts.
The Safety Board has been providing family assistance with existing staff. As you will note -- both in the fiscal year 1997 supplemental request and in our fiscal year 1998 budget request -- we have requested additional resources for this new function.
About 575 million passengers boarded U.S. scheduled
airlines in this country last year, about twice our population.
And in ten years, it is estimated that domestic aviation operations
will increase another 60 percent.
Preliminary aviation statistics for 1996 show
an increase in the number of airline passenger deaths and major
accidents, from 168 people in 1995, to 380 people in 1996. Three
hundred forty of those fatalities were aboard the ValuJet and
TWA aircraft. The major accident rate per million hours flown
was 0.439 -- the fifth highest in the last 15 years. I would like
to stress, however, that an air carrier accident is a rare occurrence,
and aviation remains one of the safest modes of transportation.
The 1996 commuter rate was the lowest in the
last 15 years, 0.032 per 100 departures. A total of 14 people
were killed in a single fatal commuter airline accident in 1996,
and there were almost 3.2 million commuter departures nationwide
last year. This success is a tribute to the past efforts by the
Board and subsequent FAA and industry efforts to raise the level
of safety of commuter airlines to that of major air carriers.
General aviation fatalities were also the lowest
in the past 15 years. General aviation has seen a steady decline
in deaths. In 1996, 631 people lost their lives in general aviation
accidents, a decrease from 733 people in 1995.
Completed Major Aviation Investigations
Since our last appearance before your Committee,
the Safety Board adopted the reports of seven major aviation accidents
and one special investigation. Below are summaries of those reports.
American Eagle/Roselawn Indiana
In July 1996, the Safety Board completed action
on the aviation accident that occurred October 31, 1994, at Roselawn,
Indiana. The airplane, an ATR 72, was in a holding pattern and
was descending to a newly assigned altitude when an initial uncommanded
roll excursion began, followed by a loss of control. The airplane
was destroyed by impact forces, and the four crew and 64 passengers
were killed. The Board determined that the probable cause was
a sudden and unexpected aileron hinge moment reversal that was
related to ice accretion beyond the airplane's deice boots, and
that this occurred because ATR failed to disseminate adequate
information concerning previously known effects of freezing precipitation
on the airplane's stability, control, and operating characteristics,
and because of the French DGAC's inadequate oversight of the airplane
and its failure to provide the FAA with timely information about
previous ATR incidents and accidents in icing conditions.
The Board focused on the forecasting and communication
of hazardous weather information to flightcrews, federal regulations
regarding aircraft icing and icing certification requirements,
monitoring of aircraft airworthiness, and flightcrew training
for unusual events. Safety recommendations addressing these issues
and the flight characteristics and performance of ATR airplanes
ValuJet Airlines/Atlanta, Georgia
On June 8, 1995, ValuJet Airlines flight 597,
began its takeoff roll at Atlanta, Georgia, when a loud bang was
heard by the airplane occupants and air traffic control personnel.
The flightcrew of a following airplane reported to the ValuJet
crew that the right engine was on fire, and the takeoff roll was
rejected. There were no fatalities, although the aircraft was
destroyed by fire. On July 30, 1996, the Board determined that
the cause of the accident was the failure of Turk Hava Yollari
maintenance and inspection personnel to perform a proper inspection,
allowing a detectable crack to grow to a length at which the disk
ruptured, propelling engine fragments into the fuselage.
Atlantic Southeast Airlines/Carrollton,
On August 21, 1995, Atlantic Southeast Airlines
flight 529, while climbing through 18,100 feet, experienced the
loss of a propeller blade from the left engine propeller. The
airplane then crashed while attempting an emergency landing near
Carrollton, Georgia, about 31 minutes after departing the Atlanta
Hartsfield International Airport. The captain and seven passengers
received fatal injuries. On November 26, 1996, the Safety Board
determined that the accident was caused by an in-flight fatigue
fracture and separation of a propeller blade. The fracture was
caused by a fatigue crack from multiple corrosion pits that were
not discovered because of inadequate and ineffective inspection
and repair techniques, training, documentation and communication.
Issues examined by the Safety Board were the
manufacturer's engineering practices, propeller blade maintenance
repair, propeller testing and inspection procedures, the relaying
of emergency information by air traffic controllers, crew resource
management training, and the design of crash axes carried in aircraft.
Safety recommendations concerning these issues were made to the
Federal Aviation Administration.
Tower Air/Jamaica, New York
On December 20, 1995, Tower Air flight 41,
a Boeing 747, veered off the runway during an attempted takeoff
at JFK International Airport in New York. The runway was slippery
at the time of the accident, and the captain failed to reject
the takeoff in a timely manner. Inadequate Boeing 747 slippery
runway operating procedures developed by Tower Air and the Boeing
Commercial Airplane Group and the inadequate fidelity of Boeing
747 flight training simulators for slippery runway oeprations
contributed to the accident.
Fifteen safety recommendations were issued
as a result of this accident on various subjects, including: slippery
runways; adequacy of flight simulators; galley latches; crew resource
management; air carrier surveillance standards; and runway friction
American Airlines/East Granby, Connecticut
On November 13, 1996, the Safety Board adopted
its report on the aviation accident that occurred November 12,
1995, at Bradley International Airport at East Granby, Connecticut.
An American Airlines MD-83, operated as flight 1571, was substantially
damaged when it struck trees while on approach. The airplane also
struck an instrument landing system antenna as it landed short
of the runway on grassy, even terrain.
The Safety Board determined that the flightcrew
failed to maintain the required minimum descent altitude. The
failure of the approach controller to furnish the flightcrew with
a current altimeter setting, and the flightcrew's failure to ask
for a more current setting contributed to the accident. Safety
recommendations regarding the following areas were issued: tower
shutdown procedures; non-precision approach flight procedures;
precipitous terrain and obstruction identification during approach
design; the issuance of altimeter settings by air traffic control;
low level windshear system maintenance and recertification; and
ValuJet Airlines/Nashville, Tennessee
On January 7, 1996, ValuJet fight 558, a DC-9,
struck the runway approach light area tail first at Nashville
International Airport, followed by main landing gear and nosegear.
The nosewheel tires and rims separated after ground impact, and
then the airplane became airborne again. The pilots performed
a go-around and touched down on the second attempt on its main
landing gear. The airplane sustained substantial damage to the
tail section, nosegear, aft fuselage, flaps, slats, and both engines.
There were five minor injuries.
The Safety Board determined that the flightcrew's
improper procedures and actions in response to an in-flight abnormality
resulted in the inadvertent in-flight activation of the ground
spoilers during the final approach. Safety recommendations in
the following areas were issued: the adequacy of ValuJet's operations
and maintenance manuals, specifically winter operations nosegear
shock strut servicing procedures; the adequacy of ValuJet's pilot
training/crew resource management training programs; flightcrew
actions/decisionmaking; the role of communications; ValuJet's
flightcrew pay schedule; Federal Aviation Administration oversight
of ValuJet; and the adequacy of cockpit voice recorder duration
Continental Airlines/Houston, Texas
On February 19, 1996, Continental Airlines
flight 1943, a DC-9-32, landed wheels up at the Houston Intercontinental
Airport. The airplane slid 6,850 feet before coming to rest in
the grass about 140 feet left of the runway centerline, and sustained
substantial damage to its lower fuselage. The Safety Board determined
that the accident was caused by the captain's decision to continue
the approach contrary to Continental Airlines standard operating
procedures that mandated a go-around.
Issues examined by the Board were: checklist
design, flightcrew training, adherence to standard operating procedures,
adequacy of FAA surveillance, and flight attendant tailcone training.
Safety recommendations were issued to the Federal Aviation Administration
regarding the above areas.
Special Investigation of Accidents Involving
the Robinson Helicopter Company R22
The National Transportation Safety Board's
special investigation of accidents involving loss of main rotor
control by the Robinson Helicopter Company R22, adopted on April
2, 1996, was prompted, in part, by an accident that occurred during
an instructional flight near Richmond, California in June 1992.
The Safety Board reviewed fatal accidents involving certificated
helicopters; reexamined the available wreckage of R22 accidents;
reviewed the original certification process, certification requirements,
and subsequent review of the R22 certification; and reviewed the
Safety Board's recommendation history for the R22. The following
issues were addressed:
! The implementation of appropriate measures
to reduce the probability of loss of main rotor control accidents.
! The need for continued research to study
flight control systems and main rotor blade dynamics in lightweight,
low rotor inertia helicopters.
! The establishment of operational requirements
to be addressed during future certification of lightweight, low
rotor inertia helicopters.
! The need for the FAA to review and revise,
as necessary, its procedures to ensure that internal recommendations,
particularly those addressed in special certification reviews,
are appropriately resolved and brought to closure.
Safety recommendations addressing these issues
Cessna 177B/Cheyenne, Wyoming
On March 7, 1997, the Safety Board adopted
the report of the April 11, 1996, accident involving a Cessna
177B carrying a commercial pilot/flight instructor, a seven-year-old
passenger and her father. The aircraft was destroyed in an accident
following takeoff. At the time of the aircraft's takeoff, there
were strong winds and rain, with visibility at 2.5 miles. The
flight originated from Half Moon Bay, California, on the previous
day with intermediate stops at Reno and Elko, Nevada, before terminating
for the night in Cheyenne. The aircraft was ultimately destined
for Falmouth, Massachusetts.
The Board concluded that the probable cause
of the accident was the pilot-in-command's improper decision to
take off into deteriorating weather conditions when the airplane
was overweight and when the density/altitude was higher than he
was accustomed to, resulting in a stall caused by failure to maintain
As a result of this accident, Congress in 1996
passed the "Child Pilot Safety Act." This law prohibits
an individual who does not hold a valid private pilot certificate
to manipulate the controls of an aircraft if the pilot knows that
the individual is attempting to set a record or engage in an aeronautical
competition or aeronautical feat.
On-Going Major Aviation Accidents
The Safety Board has eight on-going, major
aviation investigations, and I would like to summarize each one.
The September 8, 1994, accident involving USAir
flight 427 at Pittsburgh, Pennsylvania, which killed all 132 people
on board, continues to be one of our most complex investigations.
It has been one of the most far-reaching investigations in the
history of the Safety Board, with Safety Board investigators and
party participants working continually over 2 1/2 years to try
to understand the very complex circumstances of this tragic event.
The investigation has involved tens of thousands of staff hours
and numerous flight tests, resulting in 20 safety recommendations.
The Safety Board is aware that Boeing is actively
engaged in a redesign of the main rudder power control unit for
the existing Boeing 737 series at a cost to Boeing of $120 million
to $140 million. In January 1997, Boeing and the Federal Aviation
Administration announced that the primary and secondary slides
of the PCU servo control valve would be redesigned to preclude
the potential for reverse rudder operation. The FAA plans to issue
an airworthiness directive (AD) that would require the Boeing
737 fleet to be retrofitted with the new valve within two years.
We are encouraged by Boeing's commitment to
move forward. We are concerned, however, that there may be a delay
by the Federal Aviation Administration in issuing a final rule
on the proposed AD, or that the AD might allow more than 2 years
for operators to complete the installation of the new servo control
valve. On February 20, 1997, the Safety Board issued three additional
safety recommendations to the Federal Aviation Administration
regarding the Boeing 737 aircraft. Those recommendations state:
! Require the expeditious installation of a
redesigned main rudder power control unit on Boeing 737 airplanes
to preclude reverse operation of the rudder and to ensure that
the airplanes comply with the intent of the certification requirements.
! Advise Boeing 737 pilots of the potential
hazard for a jammed secondary servo control valve slide in the
main rudder power control unit to cause a reverse rudder response
when a full or high-rate input is applied to the rudder pedals.
! Require the Boeing Commercial Airplane Group
to develop operational procedures for Boeing 737 flightcrews that
effectively deal with a sudden uncommanded movement of the rudder
to the limit of its travel for any given flight condition in the
airplane's operational envelope, including specific initial and
periodic training in the recognition of and recovery from unusual
attitudes and upsets caused by reverse rudder response. Once the
procedures are developed, require Boeing 737 operators to provide
this training to their pilots. (A-97-18)
This investigation continues, and I am proud
of the dedication of the investigative team. I believe these recommendations
reflect, in part, the progress we are making. Safety Board staff
hopes to have a final report regarding this accident before the
Board for consideration this year. We will, of course, keep the
Committee advised of developments.
ValuJet Airlines/Miami, Florida
ValuJet flight 592 crashed into the Everglades
shortly after takeoff from Miami International Airport on May
11, 1996, killing all 110 people on board. Before the accident,
the flightcrew reported to air traffic control that it was experiencing
smoke in the cabin and cockpit. It was learned during the on-scene
phase of the investigation, which lasted over one month, that
cardboard boxes containing as many as 144 chemical oxygen generators,
the property of ValuJet, had been loaded in the forward cargo
compartment shortly before departure.
As a result of this accident, in May 1996, the Safety Board issued safety recommendations to the Federal Aviation Administration and the Research and Special Programs Administration, and held a public hearing in November 1996.
On December 12, 1996, the member airlines of
the Air Transport Association announced that they will voluntarily
install smoke detectors in the cargo holds of their jets. On December
30, 1996, the Department of Transportation announced a permanent
ban on the transportation of chemical oxygen generators as cargo
on passenger airplanes. The ban extends a temporary prohibition
issued on May 23, 1996, and limits the air transportation of chemical
oxygen generators to compartments in cargo-only aircraft. As you
will recall, the Safety Board has been concerned about the shipment
of hazardous materials by air since an American Airlines in-flight
fire that occurred in Nashville, Tennessee on February 3, 1988.
We expect to issue a final report on this accident later this
Delta Airlines/Pensacola, Florida
Delta Airlines flight 1288, an MD-88 operating
from Pensacola, Florida, to Atlanta, Georgia, experienced an uncontained
failure of the left engine during the beginning of the takeoff
roll. Two passengers were fatally injured by debris.
In July 1996, the Safety Board issued four
safety recommendations to the Federal Aviation Administration
regarding Pratt and Whitney JT8D-200 series engines. A public
hearing will be held in Atlanta, Georgia, regarding this accident
late this month.
Trans World Airlines/near East Moriches,
On July 17, 1996, TWA flight 800 tragically
crashed into the Atlantic Ocean near East Moriches, New York,
killing all 230 people on board. The aircraft wreckage in this
accident was ten miles off the coast at a depth of 120 feet, making
this investigation anything but typical.
To ensure the safety of the divers and to identify
the location of the wreckage, the area had to be thoroughly mapped
before the full scale underwater recovery effort could begin.
Heavy wreckage was not lifted from the ocean floor until early
August. By the end of October, the divers had cleared the debris
fields of all large pieces of wreckage. On November 3, scallop
trawlers were brought in to drag the ocean floor. To date, an
area of over 28 square miles has been trawled, with some areas
having been gone over in excess of 20 times. A second pass is
being made over the entire area; trawling will continue until
wreckage is no longer being recovered.
Based on the condition of the wreckage from
the center forward section of the plane and that surrounding the
center wing tank, the investigators are particularly interested
in this area and have created mock-ups of this section. Three
sets of scaffolding were erected on which this section of plane
is being reassembled in order to give the investigators a better
picture of what occurred. The fuselage surrounding the center
wing tank was on one, the top and sides of the center wing tank
on another, and the floor of the center wing tank was on the third.
It is apparent that an explosion occurred in
the center wing tank, but the origin of the explosion and whether
it was the initial event or a secondary event is not yet known.
To date, with over 90 percent of the plane recovered, there is
no physical evidence of a bomb or missile strike.
The Safety Board and the Federal Bureau of
Investigation have called on numerous experts from across the
international aviation community, the Department of Defense, and
academia to assist in this investigation. Work that is either
now underway or will be in the near future include:
! Complete the mock-up of the structure in
the vicinity of the center wing tank. Safety Board contractors
are completing a mock-up measuring approximately 92 feet, the
largest reconstruction in the world.
! Fuel testing -- The Safety Board is engaged
in laboratory and field testing at Cal Tech to study the ignition
and explosive properties of jet A fuel, and the conduct of large
scale tests of fuel-air explosions.
! Acoustic analysis of the cockpit voice recorder
-- Safety Board investigators are working with experts from NASA
and the United Kingdom on additional sound spectrum analysis to
develop data against which the events registered on the TWA 800
CVR may be compared.
! Extensive mapping of interior damage patterns
-- Safety Board investigators will extensively map interior damage
patterns, including damage to occupants, seats, carpet, and floorboards.
! Extensive mapping of center wing tank parts
and surrounding structure -- Safety Board investigators will extensively
map the center wing tank and surrounding area, including integrating
the cabin interior map.
! Evaluation of potential ignition mechanisms
that may have triggered the center wing tank explosion -- This
will include testing of the fuel line fittings, measuring the
static electricity generated by fuel spray, assessment of potential
sources of an electrical discharge, and evaluation of the potential
for penetrates of the tank by high speed particles or fragments.
Mr. Chairman, the investigation into the crash
of TWA flight 800 has been unprecedented, and all parties remain
committed to finding the cause of this tragic event.
Federal Express/Newburg, New York
On September 6, 1996, a Federal Express flight
from Memphis to Boston reported smoke in the cockpit to air traffic
control and diverted to land at Stewart International Airport,
New York. Thick smoke was reported as the five occupants evacuated
the cockpit via the window escape ropes. Within 15 minutes, flames
were sighted in the cockpit; the airplane was destroyed by fire.
It has been determined that the source of the
in-flight smoke and fire was probably from a cargo container that
included a DNA synthesizer. A shipping document stated that the
synthesizer has been decontaminated prior to shipment; however,
several containers in the machine still contained liquids after
the fire was extinguished. Some of the chemicals used by the machine
are extremely flammable. A lithium battery and electronic circuitry
in the unit are also being examined as possible sources of ignition.
Delta Airlines/Laguardia Airport, Flushing,
On October 19, 1996, during an instrument landing
system approach, the wings and landing gear of Delta flight 554,
an MD-88, struck approach lights located on a pier extending into
Flushing Bay, resulting in the separation of the main landing
gears. The airplane subsequently impacted the runway and slid
to a stop.
Issues being examined in the investigation
include: flightcrew performance and training; Delta's procedures
for monitoring flight instruments during approaches; and dissemination
of weather information.
United Express/Quincy, Illinois
On November 19, 1996, United Express flight
5925, a Beechcraft 1900C, collided with a Beechcraft King Air
on a runway at the Quincy Municipal Airport, Illinois, resulting
in 14 fatalities -- everyone who was aboard the two aircraft.
Evidence has revealed that some occupants of
the United Express aircraft moved to the forward air stair door;
however, attempts to open the forward door by individuals at the
airport were unsuccessful. All 14 fatalities were the result of
smoke inhalation. In January 1997, the Safety Board issued a safety
recommendation to the Federal Aviation Administration regarding
the Beech 1900 external air stair exit door.
The Safety Board also had difficulty obtaining
information from the cockpit voice recorder on the Beechcraft
1900C, and on November 28, 1996, Beech and the Federal Aviation
Administration were verbally advised of the problem. A safety
recommendation is with the Board Members for consideration asking
Beech to review and correct the recording capability of the cockpit
voice recorder radio channels for all Beech 1900 aircraft.
Airborne Express/Pearisburg, Virginia
On December 22, 1996, an Airborne Express DC-8
crashed into mountainous terrain near Pearisburg, Virginia in
the Jefferson National Forest. The airplane was destroyed and
all 6 persons on board were fatally injured.
The airplane was engaged in a functional check
flight following major modifications. Evidence indicates that
the initial descent of the aircraft was likely related to a flight
test profile rather than a structures or systems anomaly. Safety
issues being examined include: pilot performance, company management,
and FAA oversight.
Comair flight 3272 crashed on January 9, 1997,
near Monroe, Michigan, destroying the airplane and killing all
29 people on board. The scheduled commuter flight was under instrument
conditions on approach to the Detroit airport at the time of the
accident. Visibility was about 1/2 mile in light snow, with reports
of light to moderate icing in the area.
Issues being examined include: pilot performance
and Comair procedures, weather dissemination, air traffic control
procedures, and airframe icing.
Foreign Aviation Investigations
A major airline accident involving fatalities
anywhere in the world causes significant concerns on the part
of the traveling public, both in the United States and overseas.
The Board's involvement in the investigation of major international
accidents assists in reducing these concerns, and provides us
access to accident prevention measures that have a direct benefit
to the safety of U.S. travelers. It also provides a critical contribution
both to U.S.-foreign relations.
In fiscal year 1996, the Safety Board sent
a U.S. accredited representative to ten foreign accidents, and
participated without travel in 51 other foreign accident investigations.
A synopsis of two of these investigations follows:
! On February 24, 1996, two U.S.-registered
aircraft operated by Brothers to the Rescue, a group that has
been supporting Cuban refugees fleeing via water, were shot down
by Cuban military fighters in international waters near Cuba.
Four persons were killed. The United States protested to the United
Nations and a Resolution was passed that requested the International
Civil Aviation Organization (ICAO) to investigate the circumstances.
The Safety Board was selected to lead the U.S. interagency support
to the investigation.
The Safety Board coordinated meetings with
various U.S. government agencies in Washington, D. C. and Miami,
Florida. Interviews were conducted and considerable material,
including radar tapes and plots, voice tapes and transcripts,
and other items were given to the ICAO team. The final report,
which concludes that the Cubans shot down the aircraft in international
airspace and did not comply with international standards for interception
of aircraft, was forwarded to the United Nations Security Council
and was adopted without change.
! October 2, 1996, an AeroPeru Boeing 757 crashed
into the Pacific Ocean after takeoff from Lima, Peru. All 71 persons
on the airplane were fatally injured. The flightcrew reported
a loss of instrumentation just after takeoff. Based upon the data
from the recorders and evidence from the wreckage, it was confirmed
that tape was inadvertently left on the airplane static ports
after the airplane had been waxed. The Safety Board coordinated
the successful recovery of the recorders and key wreckage from
the Ocean floor. An urgent safety recommendation letter was issued
by the Board to the Federal Aviation Administration to ensure
that such an event does not occur on other airliners.
Pipelines transport about 57 percent of the
crude petroleum and petroleum products moved within the United
States. The potential threat to public safety from such releases
has become more severe in recent years, as the rate of residential
and commercial development adjacent to all types of pipelines
Pipeline Spills During Flooding Near Houston,
Between October 14 and October 21, 1994, eight
pipelines ruptured and 29 others were undermined due to flooding
near Houston, Texas. More than 1.47 million gallons of petroleum
and petroleum products were released into the river. Ignition
of the released products within flooded residential areas resulted
in 547 people receiving minor burn and inhalation injuries.
The Board's special investigation into the
ruptures looked into: (1) the adequacy of Federal and industry
standards on designing pipelines in flood plains; (2) the preparedness
of pipeline operators to respond to threats to their pipelines
from flooding and to minimize the potential for product releases;
and (3) the preparedness of the Nation to minimize the consequences
of petroleum releases. Nine safety recommendations were made regarding
the above issues.
Special Investigation into Liquid Pipelines
Within a 15-month period, the Colonial Pipeline
Company experienced the rupture of two of its petroleum product
pipelines, which resulted in large releases of diesel fuel that
affected major water supplies. In both accidents, the ruptured
section of pipeline had been mechanically damaged during previous
excavation work. There has been a growing concern about the environmental
consequences of releases from pipeline systems that potentially
pose the greatest risk to the environment.
The Board's special investigation into liquid
pipelines reviewed the Research and Special Programs Administration's
(RSPA) responsiveness to implement previous safety recommendations
addressing the prevention of excavation damage, the control of
corrosion damage, the inspection and testing of pipelines, and
methods to more rapidly detect, locate, and shut down failed sections
of a pipeline. Also included in the investigation was a review
of the safety performance of Colonial Pipeline Company. The Board
-- On the basis of the number of accidents
per 1,000 miles of pipeline and the number of barrels of product
released per 1 million barrels of product transported, Colonial's
operating performance is below the level of performance for many
of the 14 pipeline companies with the greatest number of reported
-- Although RSPA's data on hazardous liquid
pipeline accidents can be analyzed to determine some general trends
and conclusions, the data on hazardous liquid pipelines, as they
are currently collected and reported, are not sufficient for RSPA
to perform an effective accident trend analysis or to properly
evaluate operator performance.
-- Although RSPA has taken regulatory action
and undertaken other initiatives to minimize excavation damage,
RSPA has failed to take effective and timely action to address
corrosion control, inspection and testing of pipelines, and methods
to limit the release of product from failed pipelines.
-- RSPA's failure to fully implement the Safety
Board's original 1978 safety recommendations to evaluate and analyze
its accident data reporting needs has hampered RSPA's oversight
of pipeline safety.
-- With the deficiencies of the current accident
data base for hazardous liquid pipelines, RSPA will find it exceedingly
difficult to fully implement an effective risk management program.
The Safety Board issued one new safety recommendation
and reiterated three previous recommendations -- including a 1995
recommendation to expedite requirements for installing automatic
or remote-operated mainline valves on high pressure pipelines
in urban and environmentally sensitive areas to provide for rapid
shutdown of failed pipeline segments.
Sweetwater, Tennessee Hazardous Materials
On February 7, 1996, 500 to 600 people were
evacuated twice from the Sweetwater, Tennessee, area when a hazardous
material -- carbon bisulfide -- spilled from a ruptured railroad
tank car. Approximately 10,418 gallons of the hazardous material
escaped. The tank car was part of an eastbound Norfolk Southern
Corp. train that was idling and waiting for another train to pass.
The ruptured car was manufactured in June of 1969.
Post incident examination of the tank car revealed that the fracture originated where a pad for a bottom center reinforcement bar was welded to the tank. Reinforcement bars were added to the tank in 1990, but were not installed as specified by the Association of American Railroads tank car modification approval.
Issues being looked into regarding this accident
include: characteristics of the steel used to construct the tank
car; modifications to the tank car; and emergency response and
Selkirk, New York, Hazardous Materials Accident
On March 6, 1996, about 3 minutes after a tank
car filled with propane was switched onto a track to be coupled
with other railroad cars, the tank car failed, and 32,000 gallons
of propane were released. A fire ball followed. The tank car separated
into approximately two equal parts. Indications are that the failure
began near the top of the tank, in an area where repair work or
modification work had been previously done.
The tank car was inspected and given a hydrostatic pressure test in December 1995. This was only the 2nd load of cargo transported since the test was completed.
Marathon Pipeline Rupture/Gramercy, Louisiana
On May 24, 1996, a Marathon 20-inch diameter
pipeline ruptured and released 498,540 gallons of gasoline. The
escaping gasoline filled a utility right-of-way between highway
US 61 and the Kansas City Southern Railroad near Gramercy, Louisiana,
causing environmental damage.
Excavation work had been performed in the area
near the rupture several months before the accident, and there
was evidence of mechanical damage to the pipe, including gouges,
scrapes, and dents.
Colonial Pipeline Rupture, Fork Shoals,
On June 26, 1996, 957,600 gallons of fuel oil
spilled into the Reedy River near Fork Shoals, South Carolina,
following the rupture of a 36-inch diameter pipeline owned by
the Colonial Pipeline Company. The spill migrated 25 miles downstream
from the rupture site.
The pipeline wall was very thin due to corrosion
at the Reedy River, and had been scheduled for replacement. In
many places near the rupture, the pipeline wall was less than
half its normal thickness. During the evening of the accident,
the pipeline pressure became too great for the exposed and corroded
section to withstand. Issues being looked into include leak detection,
rapid shutdown of the ruptured pipe, and the ability of the controller
to safely operate the pipeline under restricted conditions.
San Juan Gas Company Pipeline Explosion
San Juan Gas Company received a report of a
gas leak in a shopping and residential district on November 20,
1996. A gas crew responded that afternoon, and a crew returned
the following morning. Leak detection work was underway when an
explosion occurred, destroying the first, second, and third floors
of a six story building and damaging other buildings and parked
cars in the vicinity. There were 33 fatalities, and 80 injuries
as a result of this accident. This is the deadliest pipeline accident
in the Safety Board's 30-year history.
On December 16, 1996, the Safety Board issued
five urgent safety recommendations to the Governor of Puerto Rico
regarding the dissemination of education information; excavation
activities near buried facilities; updating of buried facility
information; the notification to operators of damage by excavators;
and the necessity of an excavation damage prevention program.
On February 25, 1997, the Safety Board issued
four safety recommendations -- two of them urgent -- to the Enron
Corporation regarding leak detection, employee training, public
education, and information collection.
The Board has approved a public hearing regarding
this accident, which will be held in late Spring or early Summer.
Although most people know of the Board's high-profile
aviation investigations, highway transportation is the center
of our transportation infrastructure. Highway fatalities also
account for more than 90 percent of all transportation-related
fatalities in our country.
Completed Highway Investigations
Grade Crossing Accident/Sycamore, South
On March 5, 1996, the Safety Board completed
action on a grade crossing accident that occurred May 2, 1995,
that involved an Amtrak train and a tractor-lowbed semitrailer
combination. The semitrailer had lodged on a passive crossing
near Sycamore, South Carolina, when it was struck by the southbound
Amtrak train. Thirty three persons sustained minor injuries, and
there was a combined property damage to the train and truck that
exceeded $1 million.
The Safety Board determined that the probable
cause of the accident was the motor carrier's failure to provide
the driver with appropriate guidance to respond to emergency situations.
In its final report, the Board addressed identification and warnings
of hump crossings, emergency notifications at grade crossings,
and adequacy of training for commercial drivers. Safety recommendations
were issued to the Secretary of Transportation, the Federal Highway
Administration and several organizations regarding these issues.
Schoolbus-Train Collision/Fox River Grove,
Schoolbuses carry about 9 percent of the U.S.
population during a typical school day, and one of the most tragic
accidents investigated by the Board occurred on October 25, 1995,
in Fox River Grove, Illinois. When a schoolbus crossed railroad
tracks at an active grade crossing and stopped for a red traffic
signal, its rear extended about 3 feet into the path of a Metra
passenger train. The train crashed into the schoolbus, killing
7 of the 35 schoolbus occupants.
The Safety Board determined that the probable
causes of the accident were the failure of the (1) Illinois Department
of Transportation to recognize the short queuing area on northbound
Algonquin Road and to take corrective action, (2) Illinois Department
of Transportation to recognize the insufficient time of the green
signal indication for vehicles on northbound Algonquin Road before
the arrival of a train at the crossing, and (3) Transportation
Joint Agreement School District to identify route hazards and
to provide its drivers with alternative instructions for such
situations. The Board also determined that the Illinois Department
of Transportation, the Illinois Commerce Commission, and the railroads
failed to have a communications system that ensures understanding
of the integration and working relationship of the railroad and
highway signal systems. The Safety Board issued 29 safety recommendations
to 14 recipients as a result of this tragedy.
Following this accident, the Safety Board,
along with Operation Lifesaver, conducted briefings on grade crossing
safety in Congressional Districts. I believe these briefings were
informative to those in attendance, and we would be happy to cooperate
with any Member who would like to hold similar briefings.
Child restraints have been shown to be 69 percent
effective in reducing the risk of death to infants, and 47 percent
effective for children between the ages of 1 and 4. Lap/shoulder
belts reduce the risk of fatal injury by 45 percent and moderate
to critical injury by 50 percent for passenger car occupants who
are older than 5 years.
Mr. Chairman, 15 years ago the Safety Board
told this Committee that "Automobile crashes are the number
one killer and crippler of children." Despite the effectiveness
of child restraints and lap/shoulder belts to reduce the likelihood
of severe and fatal injuries, accidents continue to occur in which
restrained children are being injured and killed.
The Board's Safety Study examined the performance
and use of occupant protection systems for children: child restraint
systems, vehicle seatbelts, and air bags. The Board determined
that children properly restrained in the back seats of vehicles
are less likely to sustain injury than those seated in the front
seats. The important words in the previous sentence are "properly
restrained." Over half of the children in the study sample
who used child restraint systems were improperly restrained; and
about one-quarter of the children who used seatbelts were improperly
restrained. In addition, more than two-thirds of the children
were not in the appropriate restraint for their age, height, and
In 1996, 22 children were killed by air bags.
The Safety Board's study concluded that air bags are a proven
safety device for most properly restrained adults in severe frontal
crashes. However, passenger side air bags can inflict serious
or even fatal injuries to small children, even when those children
are properly restrained. As they are currently designed, air bags
are not acceptable as a protective device for children, and, whenever
possible, parents should keep their children in the back seat,
On March 17 - 20, 1997, I will be chairing
an air bag and child passenger safety public forum in Washington,
D. C. The Safety Board is hosting this forum to facilitate the
sharing of information on air bags and child passenger safety
across the lines of government, industry, safety organizations,
and private citizens. This information exchange will address the
role of air bags in today's vehicles, their benefits and safety
concerns, and proper child passenger transportation in the 1990s.
The Safety Board will use the information obtained during the
public forum to determine if additional safety recommendations
are needed to enhance air bags and child passenger safety.
On-Going Highway Investigations
On February 12, 1997, near Slinger, Wisconsin,
a double tractor-semitrailer lost control on a slippery roadway,
crossed the median into the southbound lane, and struck a single
tractor-semitrailer. The double tractor-semitrailer then swerved
back across the median and struck a northbound van. The van was
then struck by another vehicle from behind. The accident resulted
in eight fatalities -- all in the van, and four injuries. Areas
being looked into include winter highway maintenance, driver experience,
and seat belt usage in the van.
Passive Grade Crossing Safety Public Forum
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. Although
two-thirds of all crossings are passive (have no train-activated
devices), these crossings have rarely been targeted by Federal
safety programs and research projects.
A safety study is currently underway by the
Safety Board to examine how a reduction in the number of accidents
could be achieved through low-cost physical improvements at grade
crossings. As part of this study, the Board will hold a passive
grade crossing public forum in Jacksonville, Florida on May 8
and 9, 1997. The forum will focus on:
-- passive grade crossing concerns;
-- grade crossing safety through education;
-- physical characteristics of passive grade crossings;
-- communications between railroad and highway officials;
-- crossing closures and private/public crossings; and
-- responsibility for grade crossing safety.
Corporate Culture and Transportation Safety
Over the past few years, the Board has begun
to address the role corporate culture plays in the cause of the
accidents it investigates. This is a topic of increasing interest
to the Board, and in April we will sponsor a two-day symposium
addressing the effect that corporate management philosophies and
practices have on transportation safety. We have asked the transportation
community to join us in examining how organizations' culture influences
safety so it can begin to focus on prevention.
We believe this symposium will benefit managers
and employees alike, since safety must be a cooperative effort
involving everyone in the organization.
Marine is one of the most diverse modes of
transportation. In the United States, there are 25,000 miles of
waterways, about 46 million recreational boaters, 200,000 commercial
fishing vessels, and more than 4 million passengers a year board
cruise ships from U.S. ports. Three of the 18 "Most Wanted"
are marine issues: fishing vessel safety, small passenger vessel
safety, and recreational boating safety.
Completed Marine Investigations
Fire on Board U.S Fish Processing Vessel ALASKA SPIRIT
The U.S. fish processing vessel ALASKA SPIRIT,
owned by The Fishing Company of Alaska, Incorporated, caught fire
and burned while moored alongside a dock at the Seward Marine
Industrial Center at Seward, Alaska, on May 27, 1995. The master
of the vessel died, and damage to the vessel was estimated at
$3 million -- half of the $6 million value of the ship. The Safety
Board determined that the Fishing Company of Alaska failed to
address the inadequate fire safety conditions and practices on
the vessel, and that the lack of fire safety standards for commercial
fishing industry vessels contributed to the severity of the damage
and loss of life.
Issues looked into included: adequacy of noncombustible
construction standards for commercial fishing industry vessels;
adequacy of fire detection and fire suppression equipment; drills
and readiness of on-board firefighting hoses; and existing vessel
fire safety standards. Ten safety recommendations were issued
on the above issues.
On-Going Major Marine Investigations
The Safety Board has six major marine accidents
under investigation. Those accidents are:
ROYAL MAJESTY/Nantucket Island, Massachusetts
On June 10, 1995, the Panamanian passenger
ship ROYAL MAJESTY grounded on a sand bar located about 10 nautical
miles east of Nantucket Island, Massachusetts. The ROYAL MAJESTY
was being navigated by a global positioning system which determined
courses to steer and incremental way points automatically. The
navigation watch personnel were plotting these positions on the
navigation chart, but were not verifying positions by any alternate
method of navigation. It was determined that the GPS-determined
positions were in error by about 20 miles. A Board meeting to
consider the final report of this accident is scheduled for March
Issues being looked into: the performance of
the bridge watchstanders; the adequacy of company oversight; training
of bridge watchstanders in the use of the ROYAL MAJESTY'S integrated
bridge system; adequacy of aids to navigation in the approaches
to Boston Harbor; performance of the Raytheon 920 GPS satellite
receiver; adequacy of the system engineering of the Atlas-Krupp
Navigation Command System; effects of automation on operator performance;
and industry oversight of integrated bridge systems.
SCANDIA/Point Judith Rhode Island
On January 19, 1996, the U.S. SCANDIA was underway
en route from New York, New York, to Providence, Rhode Island
with the U.S. Tankbarge NORTH CAPE in tow. As the tow was executing
a turn to enter Narragansett Bay, a fire broke out in the SCANDIA's
engineroom. The U.S. Coast Guard Station Point Judith, Rhode Island,
immediately launched a motor lifeboat to the scene. By the time
boat arrived, the SCANDIA was fully engulfed in flames. About
728,000 gallons of heating oil spilled from the NORTH CAPE.
Issues being looked into include: cause of
the fire which led to the grounding and spill; the Coast Guard's
re-evaluation of risk assessment and standards in the transportation
of oil and hazardous materials by tug/barge systems; and assessment
of Coast Guard search and rescue procedures, and operations.
UNIVERSE EXPLORER/En Route Glacier Bay,
On July 27, 1996, the Panamanian passenger
ship UNIVERSE EXPLORER was underway en route from Juneau, Alaska
to Glacier Bay when a fire was discovered in the main laundry.
Dense smoke and heat from the fire spread from the laundry, upward
to A-deck via an open stairwell. The fire was later brought under
control by the crew. However, the fire resulted in the deaths
of 5 crewmembers and caused smoke inhalation injuries to 27 other
crewmen. The fire also caused extensive damage to the main laundry
and to the crew berthing spaces. Damages are estimated to exceed
Issues being looked into include: adequacy
of fire prevention, detection and suppression procedures of the
UNIVERSE EXPLORER; the adequacy of escape, rescue, medical care
and evacuation procedures on board the UNIVERSE EXPLORER; and
the assessment of the current status of Coast Guard and local
authority contingency planning for response to a major passenger
ship accident in Alaskan waters.
JULIE N/Portland Maine
On September 27, 1996, the Liberian tank vessel
JULIE N struck the Million Dollar Bridge in Portland, Maine, spilling
about 170,000 gallons of oil into the waterway. The ship and bridge
received substantial damage. There was a pilot on board the vessel
at the time of the accident. The Safety Board plans to hold a
public hearing regarding this accident on March 13 and 14, 1997,
in Portland, Maine.
Issues to be looked into at our hearing include:
Toxicological (drug and alcohol testing); and port risk assessment.
SUNDOWNER/Marina del Rey, California
On December 7, 1996, a fire erupted on board
the U.S. pleasure craft SUNDOWNER as the vessel was returning
to its dock in Marina del Rey, California. The fire originated
in the diesel exhaust stack and spread to the vessel structure.
The SUNDOWNER, which was not an inspected passenger vessel, had
been chartered to host a company Christmas party. At the time
of the fire, there were 62 passengers, 7 crew and a disc jockey
on board. Most of the passengers were forced to jump overboard
to escape the fire.
All passengers interviewed stated they did
not receive a safety briefing, they did not know where the life
jackets were stowed, and no one recalled seeing a locker or cabinet
marked "life jackets." Also, the crew of the SUNDOWNER
did not provide guidance or assistance to them in their escape
from the vessel, and there was no organized effort to evacuate
the passengers. Thankfully, the vessel was only about 20 feet
from the pier at the time of the accident, and people swam to
it and climbed out of the water, assisting by those on the pier
and recreational boaters in the area.
Issues being looked into are: bare boat chartering
of passenger vessels; fire safety on small passenger vessels;
crew training for emergencies on small passenger vessels; and
the cause of the fire.
BRIGHT FIELD/New Orleans, Louisiana
On the afternoon of December 14, 1996, the
Liberian bulk carrier BRIGHT FIELD, under the navigation control
of a pilot of the New Orleans Baton Rouge Steamship Pilots Association,
was proceeding at full ahead sea speed when the lube oil pump
on the main engine lost pressure, resulting in the sudden loss
of engine rpms and subsequent loss of steering control. The pilot
used his radio and the ship's whistle to warn persons ashore in
time for them to avoid injury.
No one in the River Walk Shopping Mall was
injured; however, some persons on board a casino boat moored to
the complex were seriously injured when they jumped overboard,
thinking that the BRIGHT FIELD was going to strike the casino
Issues being looked into include: port risk
assessment; bridge resource management, engineering systems, crew
communication and language.
More than 200,000 people are employed by the
railroad industry, an industry where there are 123,000 miles of
railroads. Two of the 18 items on the "Most Wanted"
list are railroad issues -- positive train separation and the
safety of passengers in railroad passenger cars.
Completed Major Railroad Investigations
New York City Transit Subway Collision on
the Williamsburg Bridge
On June 5, 1995, a New York City Transit southbound
J subway train collided with the rear car of a stopped M subway
train on the Williamsburg Bridge. The operator of the J train
was fatally injured, and 69 people were treated at area hospitals
for injuries. The Safety Board determined that the J train operator
failed to comply with a stop indication because he was asleep.
His last sleep period (a Sunday evening nap) was probably less
than 3 hours, and he had received only about 6 hours of sleep
or less in the 24 hours before the accident.
The Safety Board has been concerned about fatigue
in transportation for many years, and it is an issue on our "Most
Wanted" list. During the investigation of this accident the
Safety Board contacted six major transit agencies and found that
none of them provides fatigue-related training in its employee
training program. In a transit system that is not fail safe and
is vulnerable to human error, the issue of fatigue is of great
Special Investigation: Steam Locomotive Firebox Explosion on the Gettysburg
Railroad near Gardners, Pennsylvania
On November 15, 1996, the Safety Board adopted
a special investigation report of a steam locomotive firebox explosion
that occurred June 16, 1995, at Gardners, Pennsylvania. The steam
locomotive failed while the locomotive was pulling a six-car excursion
train, resulting in an explosion of steam through the firebox
door and into the locomotive cab, seriously burning the engineer
and two firemen. There were 310 passengers on the train at the
time of the explosion. The Safety Board determined that the boiler
was not properly maintained and the crew was not properly trained.
Approximately 150 steam locomotives are still
operated in the United States, virtually all used by tourist railroads,
museums, historical groups, and steam-excursion groups. We believe
this accident illustrates the hazards that are always present
in the operation of steam locomotives. The Safety Board pointed
out in its report that Federal regulatory controls and expertise
in operating and maintaining steam locomotives are outdated.
Collision of Washington Metropolitan Area Transit Authority Train
On January 6, 1996, a Washington Metropolitan
Area Transit Authority Metrorail subway train failed to stop as
it entered an above-ground passenger station, at Gaithersburg,
Maryland. The train continued about 470 feet into a Metrorail
yard north of the station, where it struck a standing, unoccupied
subway train. There was a snow storm in the Washington, D. C.
area at the time of the accident. The accident resulted in the
death of the train operator and property damages between $2.1
and $2.6 million.
Issues looked into as a result of this accident
! Adequacy and appropriateness of WMATA methods of management, decisionmaking, and communications;
! Safety implications of the decision to eliminate
routine manual train operation on the Metrorail system;
! Effectiveness of using performance levels
to control train speed;
! Compatibility between railcar braking performance
and design of the automatic train control system; and
! Adequacy of WMATA and Montgomery County emergency
Safety recommendations were issued on the above
Burlington Northern Santa Fe Derailment/Cajon
On February 1, 1996, a Burlington Northern
Santa Fe freight train, comprised of four locomotives and 49 cars,
was traveling westward between Barstow and San Bernardino. The
train derailed after reportedly going out of control at a speed
of about 50 to 55 miles per hour on a 3 percent downgrade. Two
of the three crewmembers received fatal injuries. After the derailment
a fire ignited that engulfed the train and the surrounding area,
and Interstate 15 was twice closed because of the fear of unstable
hazardous materials. The conductor and the brakeman sustained
fatal injuries. Issues looked into as a result of this accident
! Lack of Federal and management oversight
in the use of two-way end-of-train devices;
! The adequacy of operating personnel training
in the use of two-way end-of-train devices;
! The carrier compliance with Federal regulations
for event recorders; and
! Adequacy of wreckage removal operations for
tank cars containing hazardous materials.
Safety recommendations were issued regarding
On-Going Major Railroad Accidents
Collision and Derailment of New Jersey Transit Commuter Train
Secaucus, New Jersey
On February 9, 1996, an eastbound New Jersey
Transit commuter train collided nearly head-on with a westbound
New Jersey Transit commuter train, killing the engineers on both
trains and one passenger, and injuring 162. There were over 400
passengers on the two trains.
Issues being looked into as a result of this
accident include: the medical condition of the engineer of the
eastbound train; the adequacy of medical standards and examinations
for locomotive engineers; the adequacy of the train crewmembers'
response to the accident; and crashworthiness of the trains and
the response effort of emergency personnel.
Collision and resulting Fire Involving MARC/Amtrak Trains
On February 16, 1996, at 5:38 p.m., an eastbound
MARC commuter train collided with a westbound Amtrak train. The
three MARC crewmembers and eight passengers in the first MARC
car received fatal injuries.
The collision resulted in the structural separation
of the front quadrant of the MARC cab control car. The fuel tank
of Amtrak's lead locomotive ruptured on impact and the diesel
fuel ignited. Fire engulfed the rear superstructure of the Amtrak
locomotive, spilled on the MARC cab control car, ignited, and
destroyed the car.
In March 1996, the Safety Board issued four
urgent safety recommendations to upgrade rail passenger safety
to the Federal Railroad Administration and the Maryland Mass Transit
Administration. As you are aware, in April 1996, the Safety Board
elevated its passenger rail safety recommendations to the "Most
Wanted" list of safety issues, urging the Federal Railroad
Administration to inspect all commuter rail equipment across the
country, and to determine if it has effective, easily-used and
identifiable emergency evacuation exits and apparatus. Although
the State of Maryland has complied with our safety recommendations,
we are disappointed that the Federal Railroad Administration has
not taken action.
A 2 1/2 day public hearing was held regarding
this accident in June 1996.
Amtrak Derailment on Portal Bridge/Secaucus,
On November 23, 1996, an eastbound Amtrak train
derailed on the Portal Bridge in Secaucus, New Jersey while proceeding
at about 70 miles per hour. As the train was derailing, a westbound
Amtrak train applied emergency braking, but portions of the train
struck the derailed train. There were no fatalities.
The Portal Bridge is an open deck, swivel bridge.
Safety Board investigators discovered 1 broken and 1 cracked rail
side bar on the miter rail at the point of derailment. Issues
being looked into include: design of Portal Bridge special trackwork;
oversight of special trackwork on moveable bridges; and Portal
Bridge inspection and maintenance.
On January 12, 1997, a Union Pacific freight
train derailed 68 cars near Kelso, California. The derailment
occurred on a descending 2.2% grade at 72 miles per hour while
the train was in a runaway condition. The train's authorized speed
was 15 miles per hour. The train consisted of three locomotive
units and 75 loaded covered hopper cars. Total damage was estimated
Issues being looked into as a result of this
accident include: the location of safety sensitive devices within
a locomotive control compartment; car/train weight; dynamic brake
requirements; retainer valve procedures; and operational speeds.
REGIONAL OFFICE ACTIVITIES
Before I discuss our budget needs, I would
like to take a moment to discuss our nine regional and field offices
-- the backbone of our agency. Most of the Board's visibility
revolves around major accident investigations. But it is the regional
staff that investigates the majority of accidents, it is the regional
staff that supports the Board's safety studies and major investigations,
and it is the regional staff that identifies most emerging safety
problems as a result of their investigations.
Between 30 and 35 percent of all aviation safety
recommendations over the past five years originated from regional
investigations. However, in most cases, safety issues identified
do not need safety recommendations, because the problem is taken
care of locally. Over the past three years, approximately 95 safety
issues were identified and corrected at the local level. Early
identification of safety problems often originates from the regions,
and this means lives saved. We at the Board are proud of their
significant contributions to transportation safety.
FY 1998 BUDGET REQUEST
Mr. Chairman, the Safety Board's request for
resources this year comes in two parts; the first is for supplemental
fiscal year 1997 funding, and the second is for fiscal year 1998
We are requesting $23.2 million in supplemental
funding for fiscal year 1997. Most of these resources ($20.1 million)
will cover anticipated costs of the TWA flight 800 investigation
for the current fiscal year. The remaining $2.2 million would
cover additional high priority requirements, especially in the
area of assistance to families of victims of transportation disasters.
Approximately $12 million of the supplemental request will repay
the U.S. Navy for wreckage and victim recovery they provided last
year, and for the Calverton, New York facility we now occupy.
The balance will fund other investigative activity in fiscal year
1997 such as the fuselage mock-up, wreckage trawling and explosive
testing. Because we want to determine the probable cause of this
accident as expeditiously as possible, we requested a deficiency
apportionment from the Office of Management and Budget to allow
us to spend some of our 4th quarter funding on this effort now,
in anticipation of the supplemental.
For fiscal year 1998, the President's budget
contains $46.0 million and 381 full-time equivalent (FTE) positions
for the Safety Board. This represents an increase of $3.6 million
and 11 FTEs over the FY 1997 enacted level, excluding the $6 million
earmarked for the TWA flight 800 investigation. Approximately
$1.3 million of the requested increase will fund the additional
positions, $2.1 million will cover inflationary increases, and
$.2 million will fund modest enhancements to our laboratories.
In addition, we request that the Board's Emergency
Fund be increased to $2 million from its current $1 million, and
that the language be modified to allow the use of this fund to
provide assistance to families of victims of transportation disasters.
This additional emergency funding would cover family assistance
services provided by other Federal and state agencies and private
organizations on a cost reimbursable basis.
The President's budget also anticipates $6
million of the $46 million required for normal salaries and expenses
would be provided through a tax on U.S. air transportation operators
based on revenue passenger miles flown. In addition, we have discussed
with OMB the possibility of requiring all air carriers operating
to, from or within the United States to carry insurance or surety
bonding to pay for extraordinary accident recovery and investigation
costs incurred by the Safety Board. We fully support the latter
proposal, as we see no other practical alternative that provides
the needed funding to expeditiously pursue catastrophic accident
investigations, and provide the support to the families of victims
that recent legislation has mandated.
As you know, the quantity and complexity of
the Board's accident investigations continues at historically
high levels in all modes of transportation, placing unprecedented
and undue pressures on our limited staff and dollar resources.
Mr. Chairman, our goal is to ensure that the
Safety Board's vital transportation safety programs are provided
adequate staff and funding, and are being managed in the most
effective and efficient manner possible. Our ability to make timely
and accurate determinations of the probable causes of accidents,
to issue realistic and feasible safety recommendations, and to
respond to the families of victims of transportation disasters
in a timely, compassionate, and professional manner following
these tragedies depends on these resources, and the continued
support of your Committee.
Mr. Chairman, that completes my statement.
I will be happy to respond to any questions you or the Committee
members may have.