Honorable Jim Hall
Chairman, National Transportation Safety Board
Subcommittee on Transportation and Related Agencies
Committee on Appropriations
House of Representatives
Fiscal Year 1999 Budget Request
February 11, 1998
Good afternoon Chairman Wolf and Members of the Committee. It is certainly a pleasure to again appear before you to discuss the National Transportation Safety Board’s fiscal year 1999 budget request. We at the Safety Board are once again in your debt, and we thank you for your continued support. As you know, the investigation involving TWA flight 800 is on going, and the additional resources you provided to continue this investigation are appreciated.
Mr. Chairman, the Safety Board has investigated over 100,000 accidents in its 31 year existence, but the investigation alone will accomplish nothing if recommendations aren’t issued and adopted to prevent recurrence. Eight out of every 10 of our safety recommendations have been implemented over the years – a record of which I think we can be very proud. I would like to begin today by discussing new initiatives in our Office of Safety Recommendations and Accomplishments and our "Most Wanted" list of safety issues.
Safety Recommendations and Accomplishments
Safety recommendations are the primary tool used by the Board to motivate implementation of safety improvements and prevent future accidents. The implementation of the safety recommendations achieves our ultimate goal of saving lives, reducing injuries, and preventing future accidents.
I have recently taken steps to put more emphasis on the development and follow-up of our recommendations and restructured some of our resources to aggressively pursue and tackle all of our recommendations. To do this, I have centralized the agency’s recommendation function by moving five specialists to the Office of Safety Recommendations and Accomplishments. They will no longer have collateral duties, but will focus full-time on recommendation development and implementation. We have also added emphasis to an internal review process that assesses safety proposals submitted by our nine regional offices, and we have strengthened a program where we recognize our investigators for getting safety improvements on the books without going through the formal recommendation process.
"Most Wanted" List of Safety Issues
The Board uses its "Most Wanted" list of safety issues to focus attention on Board recommendations that have the most potential to save lives and highlight recommendations with the greatest impact on transportation safety. In May 1997, the Safety Board removed railroad hazardous materials tank car recommendations from the list because regulations are being modified to achieve an acceptable level of safety. The Board also added four issues to the list in 1997. Those issues are:
-- Airframe Structural Icing – The hazards of aircraft structural icing were first addressed by the Safety Board in a 1981 safety study. New safety recommendations were issued following the Board’s investigation of an in-flight icing encounter and loss of control by American Eagle Flight 4184 at Roselawn, Indiana on October 31, 1994, most of which are in an acceptable status. Airframe structural icing is also an issue being looked into as a result of the accident that occurred January 9, 1997, involving Comair flight 3272 near Monroe, Michigan. At the Safety Board’s request, research on icing is being conducted at the National Center for Atmospheric Research and the NASA Lewis Research Center.
-- Explosive Mixtures in Fuel Tanks on Transport Category Aircraft – As a result of the Board’s on-going investigation of the TWA flight 800 crash near East Moriches, New York, on July 17, 1996, four recommendations were issued to the Federal Aviation Administration (FAA) to require the development and implementation of design or operational changes that will preclude the operation of transport category airplanes with explosive fuel-air mixtures in the fuel tank. The Safety Board asked that consideration be given to the development of airplane design modification -- such as the addition of insulation between heat-generating equipment and fuel tanks -- for both newly certificated airplanes and, where feasible, existing airplanes.
-- Airplane Cargo Compartment Fires – The hazard of fire in airplane cargo compartments was first highlighted in safety recommendations issued following the Board’s investigation of an accident in February 1988, involving American Airlines flight 132 in Nashville, Tennessee. The airplane was carrying a 104-pound fiber drum of textile treatment chemicals that was undeclared and improperly packaged. An in-flight fire broke out in the cargo compartment. Later that year the Board asked the FAA to require fire and smoke detection systems for all Class D cargo compartments. The FAA initiated regulatory action in response to this recommendation, but never issued a final rule. The need for fire detection and suppression systems in cargo compartments was again highlighted during the investigation of the ValuJet accident in May 1996 near Miami, Florida, when poorly packaged oxygen generators were improperly carried as cargo, resulting in a fire in the cargo compartment, with the subsequent loss of the aircraft with all 110 persons on board. Last summer, almost ten years after the American Airlines accident in Nashville, the Safety Board again called on the FAA to require smoke detection and fire suppression systems for all Class D cargo compartments. The FAA responded that it would move as quickly as possible to issue a final rule, and that it expected the rule to be issued by December 1997. Unfortunately, that rule has still not been issued.
-- Automatic Information Recording Devices – The Safety Board has consistently sought the use of event data recorders in all modes of transportation to assist in accident investigations and the determination of probable cause. The need for and benefits of information about the events leading up to an accident/incident cannot be overstated. In order to fully define transportation safety problems and to propose effective solutions to these problems, accident investigators need the information that is provided by automatic data recorders.
The Safety Board does review and update its Most Wanted list at least once each year. This year, however, we plan to complete a major review and possible reorganization of the list.
According to research from the FAA, the International Civil Aviation Organization (ICAO), and Boeing, civil aviation is expected to grow about four to six percent per year in the United States, with even higher growth overseas. That growth will not occur without accidents, and the cost of those accidents is ultimately felt by the traveling public. According to the FAA, the direct cost of the 1989 DC-10 accident in Sioux City, Iowa totaled more than $300 million. The economic benefits derived from a small investment in the Safety Board, whose mission is to prevent accidents, can only lead to a reduction in costs to the transportation industry and the American taxpayer.
Completed Major Aviation Investigations
Since my appearance before you last March, the Safety Board has completed action on five major aviation investigations. Below is a list of those accidents, followed by a summary of the Board’s findings.
• May 11, 1996 -- ValuJet Airlines flight 592 -- Miami Florida
• July 6, 1996 -- Delta Air Lines flight 1288 -- Pensacola, Florida
• October 19, 1996 -- Delta Air Lines flight 554 -- LaGuardia Airport, New York
• November 19, 1996 -- United Express flight 5925 and Beech King Air -- Quincy, Illinois
• December 22, 1996 -- Airborne Express -- Narrows, Virginia
ValuJet Airlines Flight 592/Miami, Florida
On May 11, 1996, ValuJet flight 592, a DC-9-32, crashed into the Everglades about 10 minutes after takeoff from Miami International Airport. Both pilots, three flight attendants, and all 105 passengers were killed.
Issues examined by the Safety Board included: minimization of the hazards posed by fires in class D cargo compartments; equipment, training, and procedures for addressing in-flight smoke and fire aboard air carrier airplanes; guidance for handling of chemical oxygen generators and other hazardous aircraft components; procedures for handling company materials and hazardous materials; ValuJet’s oversight of its contract maintenance facilities; FAA’s oversight of ValuJet and ValuJet’s contract maintenance facilities; FAA’s and the Research and Special Programs Administration’s (RSPA) hazardous materials program and undeclared hazardous materials in the U.S. mail; and ValuJet’s procedures for boarding and accounting of lap children.
On August 19, 1997, the Safety Board determined that the accident, resulting from a fire in the Class D cargo compartment from the actuation of one or more oxygen generators improperly carried as cargo, was probably caused by the failure of SabreTech to properly prepare, package, identify, and track unexpended chemical oxygen generators before presenting them to ValuJet for carriage; the failure of ValuJet to properly oversee its contract maintenance program to ensure compliance with maintenance, maintenance training, and hazardous materials requirements and practices; and the failure of the FAA to require smoke detection and fire suppression systems in Class D cargo compartments.
It was also determined that the FAA failed to adequately monitor ValuJet’s heavy maintenance program and responsibilities, including ValuJet’s oversight of its contractors and SabreTech’s repair station certificate, and that the FAA failed to adequately respond to prior chemical oxygen generator fires with programs to address the potential hazards. ValuJet also failed to ensure that both ValuJet and its contract maintenance employees were aware of the carrier’s no-carry hazardous materials policy, and to provide appropriate hazardous materials training.
Delta Air Lines Flight 1288/Pensacola, Florida
On July 6, 1996, an MD-88 operated as Delta Air Lines flight 1288 en route from Pensacola, Florida to Atlanta, Georgia, experienced an engine failure during takeoff at Pensacola Regional Airport. Uncontained engine debris from the front compressor fan hub of the No. 1 engine penetrated the left aft fuselage, killing two passengers and injuring two others. The takeoff was rejected, and the airplane was stopped on the runway.
Issues examined by the Safety Board included: the limitations of the blue etch anodize inspection process; manufacturing defects; standards for the fluorescent penetrant inspection process; the performance of non-destructive testing; the use of alarm systems for emergency situations; and instructions regarding emergency exits.
On January 13, 1998, the Safety Board determined the probable cause to be the failure of Delta Air Lines to detect a detectable fatigue crack spawned by a manufacturing process that went undetected by Volvo and Pratt & Whitney. The lack of sufficient redundancy in the in-service inspection program contributed to the accident.
Delta Air Lines/LaGuardia Airport, New York
On October 19, 1996, Delta Air Lines flight 554, a MD-88, struck the approach light structure at the end of the runway deck during the approach to land on runway 13 at LaGuardia Airport, New York. The flight was a regularly scheduled domestic passenger flight from Atlanta Georgia with two flightcrew members, three flight attendants, and 58 passengers on board. There were no fatalities or serious injuries as a result of the accident. The airplane sustained substantial damage to the lower fuselage, wings, main landing gear, and both engines.
Safety issues examined by the Safety Board included: possible hazards of monovision contact lenses; visual illusions encountered during the approach; non-instantaneous vertical speed information; weather conditions encountered during the approach; the guidance in air carriers’ manuals regarding flightcrew member duties; the stabilized approach criteria in air carriers’ manuals; emergency evacuation procedures; special airport criteria and designation; and runway light spacing.
On August 25, 1997, the Safety Board determined that the probable cause of the accident was the inability of the captain, because of his use of monovision contact lenses, to overcome his misperception of the airplane’s position relative to the runway during the visual portion of the approach. This misperception occurred because of visual illusions produced by the approach over water in limited light conditions, the absence of visual ground features, the rain and fog, and the irregular spacing of the runway lights.
United Express and Beech King Air/Quincy, Illinois
On November 19, 1996, United Express flight 5925, a Beech 1900C, collided with a Beech King Air A90 at Quincy Municipal Airport near Quincy, Illinois. Flight 5925 was completing its landing roll on runway 13, and the King Air was in its takeoff roll on runway 4. The collision occurred at the intersection of the two runways that resulted in a fire that engulfed both airplanes. All 10 passengers and two crewmembers aboard flight 5925, and the two occupants aboard the King Air were killed.
Safety issues examined by the Board included: the importance of emphasizing careful visual scanning techniques during flight training; Beech 1900C certification standards and the crashworthiness and placarding of emergency exit doors; the certification of small airports used by scheduled commuter airlines; and aircraft rescue and fire fighting protection on scheduled commuter aircraft having 10 seats or more.
On July 1, 1997, the Safety Board determined that the failure of the pilots in the King Air A90 to effectively monitor the common traffic advisory radio frequency or to properly scan for traffic was the probable cause of the accident. A Cherokee pilot’s interrupted radio transmission which led to a misunderstanding of the transmission contributed to the accident.
Airborne Express/Narrows, Virginia
On December 22, 1996, a DC-8-63, operated by Airborne Express, Inc., impacted mountainous terrain in the vicinity of Narrows, Virginia, while on a post-modification functional evaluation flight. The airplane was destroyed by the impact and a post-crash fire. The three flightcrew members and three maintenance-avionics technicians on board were fatally injured.
Issues examined by the Safety Board included: airplane stall recovery procedures for functional evaluation flights; stall warning systems; fidelity of the Airborne Express DC-8 flight training simulator; guidelines and limitations for conducting functional evaluation flights; and FAA oversight of air carrier functional evaluation flight programs.
On July 15, 1997, the Safety Board determined that the inappropriate control inputs applied by the flying pilot during a stall recovery attempt; the failure of the non-flying pilot-in-command to recognize, address, and correct the inappropriate control inputs; and the failure of Airborne Express to establish a formal, functional evaluation flight program were the probable causes of the accident. The inoperative stick shaker stall warning system and Airborne Express’ DC-8 flight training simulator’s inadequate fidelity in reproducing the airplane’s stall characteristics contributed to the accident.
On-Going Major Aviation Investigations
The Safety Board has nine on-going, major aviation investigations, and one aviation safety study underway. Below is a list of those accidents, followed by a summary of each.
• September 8, 1994 – USAir flight 427 -- Aliquippa, Pennsylvania
• July 17, 1996 – TWA flight 800 -- near East Moriches, New York
• September 5, 1996 – Federal Express flight 1406 -- Newburgh, New York
• January 9, 1997 – Comair flight 3272 -- Monroe, Michigan
• May 12, 1997 – American Airlines flight 903 -- over West Palm Beach, Florida
• July 31, 1997 – Federal Express flight 14 -- Newark, New Jersey
• August 5, 1997 – Korean Airlines flight 801 -- Guam
• August 7, 1997 – Fine Air flight 101 -- Miami, Florida
• October 8, 1997 – Scenic Airlines -- Montrose, Colorado
• January 13, 1998 – Gates Lear Jet 25B -- Houston, Texas
As you are aware, on September 8, 1994, USAir flight 427 crashed near Pittsburgh, Pennsylvania, killing all 132 people on board. The investigation of this accident has been hampered by the few parameters recorded by the airplane’s flight data recorder (FDR). Many newer airplanes, including Boeing 737s, record over 100 parameters. The airplane that was USAir flight 427 only recorded 11 parameters, the minimum number required by the FAA. The examination of radar data and the FDR data indicates that USAir flight 427 passed through the wake vortices of a preceding Delta Boeing 727. As USAir flight 427 began to exit the wake vortices, the airplane suddenly yawed to the left with no change in pitch or roll. The cause of the sudden yawing motion has been the focus of the Safety Board’s investigation.
The Safety Board has issued safety recommendations addressing pilot training for the recognition of and recovery from unusual events that could lead to a loss of control and modifications to components of the Boeing 737 series rudder system to improve further the safety of the design. The investigation of the USAir flight 427 accident has found that pilots may not be adequately trained and periodically tested to respond to sudden events that can cause an airplane to assume an unusual attitude. Additionally, the investigation has documented several safety concerns in the Boeing 737 rudder system components. The components addressed in the safety recommendation included the yaw damper system, the standby rudder actuator and its input rod bearings, and possible latent failures in the main rudder power control unit (PCU) servo valves. One of the failure mechanisms identified by the investigation includes failure which could result in the rudder moving opposite to the pilot’s command.
In response to an airworthiness directive issued August 4, 1997, the entire Boeing 737 fleet, over 2,800 airplanes, is in the process of being modified with an improved rudder PCU servo valve. In addition, on August 1, 1997, the FAA published a final rule that requires installation of a newly designed rudder-limiting device and yaw damper system by August 1, 2000. Although we are pleased with this action, we continue to be concerned that the FAA is not requiring the installation until 2000.
The Board’s staff is drafting the report of this accident, and we expect to complete action this summer.
Trans World Airlines/near East Moriches, New York
On July 17, 1996, TWA flight 800, a Boeing 747-131, 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.
The investigation of this accident is the most extensive in the Safety Board’s 30-year history, involving an underwater search and recovery operation. To recover the remains of the victims and wreckage required 677 surface-supplied dives, 3,667 scuba dives, and 209 remotely-operated vehicle dives. All 230 victims have been identified and their remains returned to their loved ones, and between 95 and 98 percent of the wreckage of the 400,000 pound aircraft has been recovered.
Although this investigation is on-going, the examination of the wreckage has determined that there was an explosion of the airplane’s center fuel tank that resulted in the structural breakup of the airplane. The center fuel tank was nearly empty when the airplane departed John F. Kennedy International Airport. Safety recommendations addressing the development and implementation of design or operational changes that would preclude the operation of transport-category airplanes with explosive fuel/air mixtures have been issued to the FAA.
In December 1997, a five-day public hearing, televised gavel to gavel nationwide, was held in Baltimore, Maryland. Issues discussed at our hearing included: recovery operations; recorded data and wreckage examination; medical factors and cabin interior; fuel flammability; aircraft design and certification; ignition sources; aging aircraft; and flammability reduction.
Mr. Chairman, as I mentioned earlier, we will be forever grateful for the additional resources provided by this Committee to continue this investigation. Because of your generosity, we were able to:
• complete an underwater search and salvage operation of unprecedented scope -- diving and trawling operations that covered 40 square miles of ocean floor;
• create a 94-foot long reconstruction of the center section of the airplane to better demonstrate the relationship of the various pieces of structure and systems and the sequence of the breakup of the airplane;
• conduct test flights with a leased Boeing 747-100, outfitted with over 150 sensors, that measured temperature, vibrations, and pressure in the center wing tank;
• conduct a series of explosives tests on a retired Boeing 747-100 located in Bruntingthorpe, England;
• contract with the California Institute of Technology to study the explosive characteristics of Jet A fuel, and with the University of Nevada at Reno to study the chemical characteristics of Jet A fuel;
• conduct several quarter scale explosive tests in a custom-built, reusable center wing tank model;
• contract with two independent computational engineering firms to create a mathematical model of the explosion dynamics being studied in the quarter scale testing;
• conduct at Wright Patterson Air Force Base extensive testing of static charging related to spraying and dripping fuel; and
• conduct numerous examinations of fuel system wiring – both from TWA flight 800 and from other retired Boeing 747s.
In addition, more quarter scale testing is planned and the results of these tests will be used to further refine our mathematical models. This week a team of investigators is in Calverton identifying and examining more of the TWA airplane’s electrical system.
Mr. Chairman, the American people can be proud of the selfless determination of hundreds of investigators from dozens of organizations, who have worked so diligently to find the cause of this tragedy. You have my assurance that our efforts toward that end will not diminish.
Federal Express/Newburgh, New York
On September 5, 1996, a Federal Express DC-10-10, on a 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 airplane. Within about one hour, flames were sighted venting from the airplane, which was subsequently destroyed by fire. The fire restarted because of imbedded hot spots, making access to the wreckage difficult. Although it made up only a small part of the cargo, the cargo manifest included radioactive materials, flammable liquids, corrosives, and biohazards.
The aircraft was equipped with smoke detectors, and the first indication of a problem was the illumination of lights for the main cabin detectors 7, 8, and 9. This accident illustrates the value of early smoke and fire detection. Crew performance, emergency response, and the carriage of undeclared hazardous materials are issues being examined as a result of this accident.
On January 9, 1997, Comair flight 3272, an Embraer 120, crashed near Monroe, Michigan, destroying the airplane and killing all 29 people on board. There were reports of moderate icing in the area at the time of the accident.
In May 1997, the Safety Board issued four urgent safety recommendations to the FAA regarding icing. Almost concurrently, the FAA issued a notice of proposed rulemaking to modify operating procedures in icing conditions. Comair has modified its operating procedures based on the FAA’s proposed rule, and the FAA issued a final rule late last year. The Safety Board is working with the National Center for Atmospheric Research and the NASA Lewis Research Center regarding weather issues, and in January 1998 Safety Board personnel traveled to Brazil, where the airplane is manufactured, to review all pertinent test data on icing and to perform studies in the engineering simulator.
Issues being examined regarding this accident include: flightcrew training; operations in icing conditions; and aircraft performance.
American Airlines/over West Palm Beach, Florida
On May 12, 1997, American Airlines flight 903, an Airbus A300, departed controlled flight over West Palm Beach, Florida. While flying level at 16,000 feet in instrument conditions, the airplane pitched, rolled, and descended rapidly. The flightcrew regained control at 12,500 feet. Flight attendants informed the Captain of injuries in the passenger cabin, and he declared an emergency and landed at Miami International Airport without further incident.
Issues being examined include the design and use of flight automation systems and passenger safety during flight upsets.
Federal Express/Newark, New Jersey
On July 31, 1997, Federal Express flight 14, an MD-11, experienced a hard landing, bounced, and then rolled, causing the right wing tip to strike the ground. A fire broke out shortly after the hard landing and the airplane came to rest inverted. The airplane and cargo were destroyed by impact and post-crash fire. The two pilots and three company personnel on the aircraft were able to exit the wreckage through the pilot’s windows.
Issues being examined by the Safety Board include main landing gear design and pilot recovery technique from a bounced landing.
On August 5, 1997, Korean Air flight 801, a Boeing 747-300, crashed into a hillside while attempting to land at Won Pat International Airport at Agana, Guam. The airplane was on a regularly scheduled passenger flight from Seoul, Korea to Guam. There were 254 passengers and crew aboard the aircraft; 228 lost their lives. At the time of the accident there was heavy rain. The glide slope for the runway had been reported as out of service since July 7, 1997, and remained so until September 1997.
The Safety Board has scheduled an investigative hearing to be held in March. Issues to be examined at our hearing include:
• controlled-flight-into-terrain accidents, airline procedures and training, and regulatory actions designed to avoid such accidents;
• air traffic control and policies and procedures for installation and maintenance of navigational aids;
• FAA development, installation, and quality assurance oversight of the Minimum Safe Altitude Warning (MSAW) system, and MSAW operational practices at Guam and nationwide;
• post-accident search and rescue activities; and
• FAA oversight of foreign air carriers to ensure an acceptable level of safety during operations to and from the United States.
Fine Air/Miami, Florida
On August 7, 1997, Fine Air flight 101, a DC-8-61 cargo plane, crashed shortly after takeoff from Miami International Airport, Miami, Florida. The airplane initially crashed in the grass at the end of the runway then slid through the airport fence, across a four-lane road and into an industrial office/warehouse complex. The airplane had a crew of four; all on board and a driver on the ground were killed.
Issues being examined include: cargo lock-down procedures; cargo balance when loading; flight data recorder malfunctions; and FAA oversight of cargo airlines.
American Corporate Aviation/Houston, Texas
On January 13, 1998, a Gates Learjet 25B being operated by American Corporate Aviation crashed while on an instrument approach to runway 26 at George Bush Intercontinental Airport in Houston, Texas. The wreckage, which was subjected to an intense post-crash fire, was found about two miles from the runway threshold. The two pilots on board were killed. The airplane was being flown from Houston’s William P. Hobby Airport to Intercontinental Airport to pick up five passengers for a charter flight to Fargo, North Dakota.
Issues being examined include: pilot training; FAA oversight of the operator; air traffic control procedures and systems; and post-crash search and rescue activities.
Emergency Evacuation of Commercial Aircraft
The Safety Board has begun a safety study on the emergency evacuation of commercial aircraft. Safety recommendations issued following a runway collision involving two Northwest Airlines aircraft in 1990 at Detroit, Michigan, and an accident involving a ValuJet Airline’s uncontained engine failure in 1995 at Atlanta, Georgia, highlighted the Board’s concerns regarding this issue. However, each year many evacuations occur under less severe circumstances. Because these events receive less scrutiny, much less is known about them. The Board’s study will enhance the Board’s understanding of the incidence of evacuations and evacuation-related injuries. This is a multi-year study and will not be completed until the end of fiscal year 1999 or in fiscal year 2000.
Foreign Aviation Investigations
Aerospace products are one of the largest U.S. exports. Because of the ever-increasing number of U.S. manufactured and U.S-registered aircraft operating overseas, and the Safety Board’s status as the sole U.S. accredited representative at foreign accident investigations under the provisions of the ICAO, U.S. manufacturers and operators rely heavily upon the Board to facilitate their involvement in the investigation of foreign incidents and accidents. 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 a critical contribution both to U.S. foreign relations and to strengthening the nation’s balance of trade posture through aviation exports. In addition, aviation safety issues that arise in foreign accident investigations increasingly have had wide-reaching implications for both U.S. aviation interests and the industry worldwide. Other U.S. aviation industry representatives, including the FAA, airlines, and manufacturers, work under the jurisdiction of the Safety Board during these investigations, many of which have led to significant safety improvements.
For example, Safety Board personnel are participating in the investigation of the crash of a Silk Air Boeing 737-300 which occurred December 19, 1997, 33 miles northeast of Palembang, Indonesia. The airplane was flying a regularly scheduled passenger flight from Jakarta, Indonesia, to Singapore. All 94 passengers and seven crewmembers on board died in the accident. Most of the wreckage came to rest at the bottom of a river that is about 30 feet deep, and extensive search and salvage operations have led to the recovery of a large portion of the aircraft, including the flight data recorder and cockpit voice recorder. The Boeing 737 is the world’s most widely used airliner, with over 2,800 world wide.
In 1997, Safety Board investigators participated in numerous accidents in foreign countries, and we offered the services of our laboratory for numerous others. The participation in foreign investigations accounts for a significant and important portion of our annual investigative workload.
In 1996, there were 44,525 transportation fatalities; 43,436 of those fatalities occurred in the surface transportation modes. Although unable to investigate every surface transportation accident, the Safety Board provides independent oversight of the nation’s transportation system by investigating accidents and conducting studies that involve issues that have the most potential to save lives.
In an effort to better conduct the Board’s important work in surface transportation, in August 1997, I reorganized the management structure of the Office of Surface Transportation Safety, and each of the four modal divisions became separate offices. I believe the modifications will improve communications and the timeliness of investigations and reports by having a more independent and visible status, as well as increase the impact the Board can have on improving transportation safety in the surface modes.
Each year highway traffic accidents cost the nation about 40,000 lives, more than five million injuries, and $137 billion in medical costs, lost productivity, and property damage. That equals $375 million each day. The Board’s limited highway resources prevent us from investigating most highway accidents. We devote our resources to accidents that have a significant impact on the public’s confidence in highway safety, generate high public interest, or concern technical safety issues that cause or contribute to accidents or injuries on a national scale.
Completed Major Highway Investigations or Reports
Since my last appearance, the Safety Board completed action on three major highway investigations or reports. Below is a list of those accidents or reports, followed by a summary of each.
• April 25, 1996 -- Plymouth Meeting, Pennsylvania
• November 26, 1996 -- Cosmopolis, Washington
• March 17 - 20, 1997 --Public Forum, Air Bags and Automobile Occupant Restraint Use
Plymouth Meeting, Pennsylvania
On April 25, 1996, a 1988 Mack truck with a concrete mixer body was unable to stop as it approached a "T" intersection at the bottom of an exit ramp in Plymouth Meeting, Pennsylvania. As the truck proceeded through the intersection, it collided with and overrode a 1985 Subaru passenger car. The Subaru driver was killed and the truckdriver sustained minor injuries. The truckdriver was unrestrained; the Subaru driver was found restrained in her vehicle.
Issues examined by the Safety Board included the maintenance and truck inspection practices of JFM Materials Company, Inc. and the adequacy of Federal and State guidelines for conducting truck air brake system inspections.
On September 30, 1997, the Safety Board determined that the improper maintenance of the accident truck by JDM Materials Company, Inc., the fracture of the drain valve, and the inoperative low-air-warning switch which resulted in the driver’s loss of braking control were the probable causes of the accident. The lack of Federal and State inspection procedures for commercial vehicles with dual air brake systems to detect reversed air brake lines or inoperative low-air-warning switches contributed to the accident.
On November 26, 1996, near Cosmopolis, Washington, a utility truck fatally injured a 10-year-old child who ran from behind a transit bus that transported him from school to his residence. The transit bus stopped in the northbound lane (opposite the residence) and activated it headlights and four-way flashers. Meanwhile, a southbound utility truck proceeded around a curve in the road and approached the bus. When its driver saw the bus with its lights activated, he slowed the truck to a speed of about 20 miles per hour. As the truckdriver came to a near stop, the lights on the transit bus were deactivated and the busdriver began to drive away from the stop. At the same time the truckdriver began to accelerate, the child ran out from behind the transit bus and the utility truck struck him.
On September 30, 1997, the Safety Board determined that the accident was probably caused by the lack of adequate safety procedures and equipment (similar to those in place for school bus operations) to ensure the safety of children being discharged from transit buses used to transport students. The Safety Board also found no mechanism in place that documents the extent to which transit buses are being used to transport children to and from school.
Air Bags and Automobile Occupant Restraint Use
In March 1997, the Safety Board convened a public forum in Washington D. C. regarding air bag and automobile occupant restraint use with the participation of representatives from the National Highway Traffic Safety Administration (NHTSA), the automobile industry, air bag manufacturers, insurance, safety and consumer groups, family members involved in crashes in which air bags deployed, and automobile safety specialists from Australia, Canada and Europe.
The following actions by the automobile industry and the NHTSA were taken as a result of several safety recommendations issued by the Board following the forum.
The automobile industry has:
• begun producing vehicles with less aggressive airbags;
• participated in improved public education through warning labels and the distribution of education materials; and
• initiated efforts to increase adult seatbelt use and have children ride in back seats of automobiles.
The NHTSA has:
• established procedures to permit cut-off switch hardware that will allow activating or disabling airbag protection; and
• initiated efforts to develop a time schedule for the installation of advanced-technology airbags
On-Going Major Highway Investigations
The Safety Board is investigating six major highway accidents and conducting two highway safety studies. Below is a list, followed by a summary of each.
• February 12, 1997 – Multiple vehicle head-on collision -- Slinger, Wisconsin
• June 11, 1997 – Transit bus collision with pedestrians -- Normandy, Missouri
• July 29, 1997 – Collision between two vehicles -- Jackson, Michigan
• July 29, 1997 –Passenger motor coach collision -- Stoney Creek, Virginia
• October 16, 1997 – Tractor semi-trailer and full size school bus -- Franklin, North Carolina
• October 31, 1997 – Tractor semi-trailer and full size school bus -- Easton, Maryland
• Safety Study -- Safety at Passive Grade Crossings
• Safety Study – Intrastate Trucking
On February 12, 1997, a 1993 Freightliner tractor/double trailer (both trailers empty) was traveling northbound on U.S. 41 at Slinger, Wisconsin, when it lost control and crossed over the 50-foot snow-covered median into the southbound lanes. A 1994 Mack tractor pulling a flatbed trailer loaded with lumber and traveling southbound struck the right front of the Freightliner, lost control, and crossed over the median into the northbound lanes. A 1997 Dodge van carrying nine adult occupants struck and under-rode the right front side of the flatbed trailer. A 1992 Ford straight truck operated by Glandt Dahlke, Inc., loaded with produce, also traveling northbound, struck the right rear side of the flatbed trailer. Eight of the nine van occupants suffered fatal injuries, and the remaining occupant suffered serious injuries.
Although the weather was clear at the time of the accident, it had been snowing for approximately 10 hours. Motorists and the emergency responders stated that the roadway was icy in places.
Issues being examined include adverse weather countermeasures (pavement treatment); stability of double trailers and operating requirements for double trailers in snow and ice conditions; double trailer driver training/experience; company procedures for driver selection, training, qualifications, and certification; and restraint availability and use.
On June 11, 1997, a 40-foot 1981 GMC transit bus operated by Bi-State Development Agency was involved in a single vehicle accident involving multiple pedestrians in Normandy, Missouri. The bus, operated by a trainee driver who was being monitored by a line trainer, began to pull forward and reportedly continued forward in an uncontrolled manner for approximately 130 feet. The bus surmounted a five-inch high curb and continued on to a station platform, where it collided with two passenger shelters, four public phone booths, one mail box, one portable toilet facility, and several other fixed objects. The accident resulted in four pedestrian fatalities and a number of injuries.
Issues being examined include: pedal shape and placement; Bi-State’s driver training program; and positive separation between pedestrians and bus traffic. The Board will be conducting a public hearing in March in St. Louis on transit bus safety issues that arose as a result of this accident.
On July 29, 1997, near Jackson, Michigan, a 1985 GMC pickup truck with an extended cab and enclosed camper shell traveling westbound collided with a dump truck pulling a low-boy trailer hauling a front end loader.
The GMC pickup truck contained two adults and three children riding in the extended cab and eight children riding in the rear of the pickup truck. The two adults riding in the pickup truck and nine children received fatal injuries. The remaining two children received serious injuries. The driver of the dump truck was uninjured. According to the Sheriff’s office, the dump truck had the right of way and the driver of the pickup truck either ran the stop sign or drove out in front of the dump truck. The road had recently been paved and had no posted speed limit signs, although the speed limit was 55 mph in the area.
Issues being examined include human performance and State laws restricting riding in the open bed of a pickup truck.
Stony Creek, Virginia
Also on July 29, a motorcoach carrying 35 people ran off the road on northbound I-95. The bus went down a sloping 150-foot embankment, through trees, and ended on its side, three-quarters under water in the 30-yard-wide Nottoway River. Individuals were trapped in the bus and had to be removed by the fire department.
Those on board included the driver, 29 students (ages 10 - 12 years) and five chaperones. There was one adult fatality and about 10 injuries. The charter bus was taking the students on a Pathway to Freedom tour (tracing the route of the Underground Railroad) sponsored by the U.S. Department of Transportation and Shoney’s restaurants. The trip included children from all over the country and began on July 10, 1997, in Charleston, South Carolina, and was to end in Washington, D. C. on August 13, 1997.
Issues being examined include: driver fatigue; physical condition of the driver/medical qualifications; use of rumble strips on interstate highways; and bus egress information.
Franklin, North Carolina
On October 16, 1997, a tractor-semitrailer was descending a steep, rural, two-lane road when it went out of control and collided with a school activity bus transporting the Hayesville girl’s volleyball team on its way home from a tournament in Rosman, North Carolina. The 48-year-old school bus driver (also the team’s coach) and a 16-year-old student were killed. The truckdriver was not injured.
The tractor-semitrailer was hauling (interstate) three large concrete septic tanks, each described as being the size of a car. The 33-year-old truck driver, who refused to take a blood-alcohol test, was charged with two counts of second-degree murder and one count of driving while impaired.
Issues being examined include: adequacy of CDL revocation process; medical qualifications for commercial vehicle operators; adequacy of load securement regulations; and shipper selection of authorized carriers.
On October 31, 1997, in dense fog, an empty tractor semi-trailer traveling west approaching Easton, Maryland, allegedly ran a red traffic light at the intersection of Route 50 and Dutchman Lane. The semi-trailer struck the driver’s area of a southbound school bus, killing the bus driver. Twenty-two students were injured. The bus was fully loaded transporting elementary, middle, and high school students.
Issues being examined include: school bus crashworthiness; medical qualifications of commercial drivers and adequacy of regulations; and conspicuity of school buses.
Safety at Passive Grade Crossings
Every year about 4,600 motor vehicles are involved in accidents at railroad grade crossings that kill about 500 and injure more than 1,800 persons. Two-thirds of all crossings have no train-activated warning devices, and these passive crossings are rarely targeted by Federal safety programs and research projects.
As part of a safety study on passive grade crossings in May 1997, in Jacksonville, Florida, the Safety Board held a public forum on this issue to facilitate the sharing of information on passive grade crossing safety. Several hundred individuals from government, industry, safety organizations, and private citizens attended this forum.
Information from the forum will be incorporated into the Board’s final report, which will examine how the number of grade crossing accidents could be reduced through engineering improvements in the physical characteristics of the crossings, in warning devices such as signs and train horns, and public education programs. The study will also address the role of intelligent transportation systems at passive grade crossings. Completion of this special study is expected in late spring 1997.
Commercial motor vehicles are driven billions of miles each year in commercial cargo operations, yet the extent of information regarding the scope of intrastate trucking operations varies widely. For example, the State of Texas registers intrastate trucking operations, while the State of California maintains information only on the number of licensed drivers. The Board’s study will document how some of the operations may differ between interstate and intrastate trucking, examine how exemptions to the regulations influence safety, and the explore the impact of intrastate truck operations on highway safety. We estimate completion of this study in FY 1999.
Symposium on Corporate Culture and Transportation Safety
The effect that corporate management philosophies and practices have on transportation safety was the subject of a two-day public forum held in April 1997 by the Safety Board and attended by more than 550 people from around the world. Corporate culture is a topic of increasing interest to the Board over the past few years, and we have begun to address the role that corporate culture plays in the cause of the accidents we investigate. Presentations were made by researchers and industry leaders, and workshops, led by Safety Board staff, were held to explore how to apply the information presented.
This nation has a substantial interest in maintaining a safe marine transportation system. Each year there are over 4,000 commercial vessel accidents, over 7,000 pollution incidents, and over 1,700 accidental personal injuries reported to the U.S. Coast Guard. In addition, there are about 6,500 recreational boating accidents with over 700 deaths each year. There are approximately 50 marine accidents annually that are reported to the Safety Board as major marine accidents. However, the Safety Board does not have the resources to investigate more than a handful of these accidents each year.
Completed Major Marine Investigations
Since my last appearance, the Safety Board has completed action on four major marine accidents. Below is a list of those accidents, followed by a summary for each.
• June 10, 1995 – ROYAL MAJESTY -- near Nantucket Island, Massachusetts
• June 23, 1995 – STAR PRINCESS -- Lynn Canal, Alaska
• October 15, 1995 -- PATRIOT -- off Mexico’s Yucatan Peninsula
• December 14, 1996 – BRIGHT FIELD -- at New Orleans, Louisiana
Grounding of ROYAL MAJESTY near Nantucket Island, Massachusetts
On June 10, 1995, the Panamanian passenger ship ROYAL MAJESTY, with 1,509 persons on board, grounded on a sand bar about 10 miles east of Nantucket Island, Massachusetts. The ROYAL MAJESTY was being navigated by a global positioning system (GPS). Although the navigation watch personnel were plotting positions on the navigation chart, they were not verifying positions by any alternate method of navigation. The GPS-determined positions were in error by about 20 miles.
Issues examined include: the performance of the ROYAL MAJESTY’S integrated bridge system and the global positioning system; the performance of the ROYAL MAJESTY’S watch officers; the effects of automation on watch officers’ performance; the training standards for watch officers aboard vessels equipped with electronic navigation systems and integrated bridge systems; and the design, installation, and testing standards for integrated bridge systems.
On March 12, 1997, the Safety Board determined that the cause of the accident was the watch officers’ over-reliance on the automated features of the integrated bridge system; the company’s failure to ensure that its officers were adequately trained in the automated features of the integrated bridge; the deficiencies in the design and implementation of the integrated bridge system, the procedures for its operation, and the implications of this automation on bridge resource management; and the second officer’s failure to take corrective action after several clues indicating that the vessel was off course. Thirty safety recommendations addressing these matters were adopted.
Grounding of the STAR PRINCESS/Lynn Canal, Alaska
On June 22, 1995, the Liberian-registered passenger vessel STAR PRINCESS, carrying 1,568 passengers and 639 crewmembers, grounded on the submerged Poundstone Rock in Lynn Canal, about 21 miles northwest of Juneau. The vessel’s bottom sustained significant damage. The total cost resulting from required repairs and the delay before the vessel could return to service was estimated at $27.16 million.
Issues examined include: the adequacy of the pilot’s physical fitness for duty; the importance of bridge resource management; the pilotage practices in the Alaskan cruise industry; and the need for search and rescue planning.
On June 20, 1997, the Safety Board determined that the grounding of the STAR PRINCESS was probably caused by the pilot’s poor performance, which may have been exacerbated by chronic fatigue caused by sleep apnea. Seventeen safety recommendations were issued to the Coast Guard, Princess Cruise Lines, and several marine associations as a result of this accident.
Near Grounding of PATRIOT/Yucatan Peninsula
On October 15, 1995, the Liberian-registered PATRIOT tank ship came within 10 miles of grounding on the north side of the Yucatan Peninsula near Campeche, Mexico. Although the Safety Board did not have jurisdiction over the incident because it occurred in international waters and did not involve a public or privately owned vessel of the United States, the owner of the vessel, Conoco Shipping Company, asked the Safety Board to undertake an investigation because of the potential damage to the ship, injuries to the crew, damage to the environment, and in an attempt to prevent similar incidents in the future.
Issues examined include: the master’s decision making; Conoco Shipping Company’s monitoring of weather; its management of the movement of its vessels, and its shoreside support for shipboard decision making.
On April 8, 1997, the Safety Board determined that the probable cause of the near grounding was the master’s decision to sail his vessel into the predicted path of a hurricane, a decision that resulted from the company’s ineffective management of the movement of its vessels and inadequate shoreside support for critical shipboard decisions affecting vessel safety. Six safety recommendations were issued as a result of this investigation.
Allision of the BRIGHT FIELD with a Wharf/New Orleans, Louisiana
On December 14, 1996, the fully loaded Liberian bulk carrier BRIGHT FIELD temporarily lost propulsion power as the vessel was navigating outbound in the lower Mississippi River at New Orleans, Louisiana. The vessel struck a wharf adjacent to a populated commercial area that included a shopping mall, a condominium parking garage, and a hotel. Total property damages to the BRIGHT FIELD and to shoreside facilities were estimated at about $20 million.
Issues examined by the Safety Board included: the adequacy of the ship’s main engine and automation systems; the adequacy of emergency preparedness and evacuation plans of vessels moored in the wharf area; and the adequacy of port risk assessment for activities within the Port of New Orleans.
On January 13, 1998, the Safety Board determined that the probable cause of the accident was the failure of the company to adequately manage and oversee the maintenance of the engineering plant aboard the BRIGHT FIELD. Contributing to the amount of property damage and the number and types of injuries sustained during the accident was the failure of the Coast Guard, the Board of Commissioners of the Port of New Orleans, and International RiverCenter, Inc. to adequately assess, manage, or mitigate the risks associated with locating unprotected commercial enterprises in areas vulnerable to vessel strikes. Twenty-one safety recommendations were issued as a result of this investigation.
On-Going Marine Investigations
The Safety Board is currently investigating five major marine accidents and is conducting two special studies. Below is a list of these accidents and reports, followed by a summary.
• January 19, 1996 -- SCANDIA AND NORTH CAPE --near Pt. Judith, Rhode Island
• July 27, 1996 -- UNIVERSE EXPLORER -- near Juneau, Alaska
• September 27, 1996 – JULIE N -- near Portland, Maine
• April 6, 1997 -- VISTAFJORD – 20 nm south of Freeport, Bahamas
• January 14, 1998 -- MALLARD/GEERD TIDE – Freshwater Bayou, Louisiana
• Special Study – Fishing Vessel Safety
• Special Study – Personal Watercraft Safety
Fire on the SCANDIA and Grounding of NORTH CAPE/near Pt. Judith, Rhode Island
On January 19, 1996, the 11-foot long, uninspected U.S. tug SCANDIA suffered an engine room fire while towing the unmanned U.S. tankbarge NORTH CAPE, five miles off Pt. Judith, Rhode Island. The fire forced the six-member tug crew to abandon the vessel amid 15-foot waves and 45-knot winds. The fully-laden oil barge then drifted aground and spilled 828,000 gallons of home heating oil, causing the largest pollution incident in Rhode Island’s history.
Issues being looked into include: the adequacy of oil spill preventative measures for tank vessels; the adequacy of fire safety aboard uninspected tugs; and the adequacy of the emergency response.
Fire on Board the UNIVERSE EXPLORER/near Juneau, Alaska
On July 27, 1996, the Panamanian passenger ship UNIVERSE EXPLORER was underway in the Lynn Canal en route from Juneau, Alaska to Glacier Bay with 732 passengers and 274 crew on board. This ship is used most of the year as a floating university campus. About 3:00 a.m., a fire was discovered in the main laundry room, which was not outfitted with a sprinkler system. Dense smoke and heat from the fire spread from the laundry upward two decks via an open stairwell. The fire resulted in the deaths of five crewmembers and caused smoke inhalation injuries to 27 other crewmen.
Issues being examined include: the adequacy of fire prevention, detection, and suppression procedures; the adequacy of escape, rescue, medical care, and evacuation procedures on board; 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.
Allision of the JULIE N with Bridge/Portland, Maine
On September 27, 1996, the JULIE N, a Liberian tankship, allided with the Million Dollar Bridge at Portland, Maine. The ship was under the direction of a state-licensed docking master when it struck the bridge and spilled about 170,000 gallons of oil into the waterway.
A public hearing was held regarding this accident that focused on Federal drug and alcohol programs for testing marine personnel after accidents; and Federal, State and local pollution risk assessment involving vessels carrying oil and navigating into the Portland Harbor.
Fire on board the VISTAFJORD/near Freeport, Bahamas
On April 6, 1997, the Bahamian passenger ship VISTAFJORD was underway on a voyage from Fort Lauderdale, Florida to the Azores with 569 passengers and 422 crew on board. At 1:12 a.m., a fire was discovered in a storage room adjacent to the laundry when a heat detector activated an alarm on the fire control panel in the wheelhouse. The fire was isolated to its compartment of origin but it developed heavy, black smoke that spread through the ship via the ventilation system. There were no smoke alarms that automatically sounded in the crew accommodation area when the smoke was initially detected, nor were such alarms required. One crewman lost his life, and six additional crew members and four passengers were injured.
As a result of this accident, the Safety Board is examining the adequacy of smoke alarms in passenger and crew accommodation areas on board passenger ships.
Collision of the MALLARD and the GEERD TIDE/MALLARD
Freshwater Bayou, Louisiana
On January 14, 1998, the MALLARD, a 26-foot-long aluminum boat, was enroute from a hunting camp in Freshwater Bayou, Louisiana with seven persons on board to a duck hunting blind located about 4 - 5 miles away. At the same time, the U.S. small passenger vessel GEERD TIDE was underway in the opposite direction with 25 passengers and four crew on board. The GEERD TIDE, a 100-foot-long offshore crewboat, had departed from Intracoastal City, Louisiana, and was bound for an offshore site in the Gulf of Mexico. At 5:55 a.m. the two vessels collided. The initial impact heavily damaged the MALLARD’s bow causing it to take on water and to capsize, trapping everyone on board inside the vessel’s cabin. Six of the seven occupants of the MALLARD received fatal injuries. There were no reported injuries to persons on board the GEERD TIDE.
Issues being examined include: the adequacy of operator qualifications for both vessels; the adequacy of management oversight for both vessels; the adequacy of bridge-to-bridge radio requirements; and the adequacy of post-accident drug and alcohol testing.
Fishing Vessel Safety
For the second time in a decade, the Safety Board has undertaken a study of the commercial fishing industry. In a study adopted by the Safety Board in 1987 on fishing vessel safety, the Board concluded that the commercial fishing vessel industry is one of the highest risk industries in the world and has the poorest safety record of any industry in the United States. Although improvements have been made since our earlier study, little progress has been made in the areas of professional competency of crewmembers and the safe conditions of vessels.
According to the Coast Guard, in 1996, 85 fishermen were killed in accidents on U.S. commercial fishing vessels, and 147 vessels were lost. The goal of our current study is to focus greater attention on the need for oversight regarding the seaworthiness of commercial fishing vessels and the professional competency of fishing vessel masters and crew. Completion is expected on this study in February 1998.
Personal Watercraft Safety
According to the U.S. Coast Guard, about 2.4 million personal watercraft are in operation. Often rented or owned by operators who have little vessel safety training, personal watercraft are the only vessel type for which the leading cause of death is not drowning. The Safety Board’s study will review state accident reports for all fatal accidents and for a sample of nonfatal personal watercraft accidents.
Issues being looked into include: enforcement of existing laws regarding operator age, training, and licensing; personal flotation devices; and the quality of accident data. Completion of this study is expected in late spring 1998.
More than 1.6 million miles of pipelines carry natural gas to about 60 million customers in the United States. These gas pipelines are operated by 500 gas gathering, 1,065 transmission, 1,389 distribution, and 52,000 master meter companies. Additionally, there are about 155,400 miles of hazardous liquid pipelines subject to Federal safety jurisdiction.
The Safety Board is responsible for investigating all pipeline accidents in which there is a fatality, substantial property damage, or a significant impact on the environment. Since my last appearance before this Committee, the Safety Board completed action on one pipeline accident and a safety study. Below is a summary of each.
Propane Gas Explosion/San Juan, Puerto Rico
On November 21, 1996, a commercial building located in a shopping district in San Juan, Puerto Rico exploded, killing 33 people and injuring 69. A gas crew had responded to a report of a gas leak, and leak detection work was underway when an explosion occurred. This accident is the deadliest pipeline accident in the Safety Board’s 30-year history.
A four-day public hearing was held in June 1997. On December 16, 1997, the Safety Board determined that the probable cause of the accident was the failure of San Juan Gas Company, Inc., to oversee its employees’ actions to ensure timely identification and correction of unsafe conditions; to require employees to strictly adhere to operating practices; and to provide adequate training to employees. As a result of this accident, 13 safety recommendations regarding leak detection, employee training, public education, and information collection were issued.
Protecting Public Safety Through Excavation Damage Prevention
The U.S. underground infrastructure comprises about 20 million miles of pipe, cable, and wire. Excavation and construction activities are the largest single cause of pipeline accidents. Reports from the 20th World Gas Congress confirm that excavator damage is also the leading cause of accidents in other countries. In an effort to bring attention to these types of accidents and to foster improvements in excavation damage prevention programs, the Safety Board and the Research and Special Programs Administration sponsored a symposium that brought together about 400 representatives from pipeline operators, excavators, trade associations, and local, state and Federal government agencies.
The Board’s safety study analyzed the findings of the workshop, and twenty seven safety recommendations were issued that focused on excavation damage prevention programs; employee training; the accuracy of information regarding buried facilities; and system measures, reporting requirements and data.
On-Going Pipeline Investigations
The Safety Board has five on-going pipeline investigations. Below is a list of those accidents, followed by a summary of each.
• May 24, 1996 – Marathon Pipe Line Company – Gramercy, Louisiana
• June 26, 1996 – Colonial Pipeline Company – Fork Shoals, South Carolina
• August 24, 1996 – Koch Pipeline Company – Lively, Texas
• October 23, 1996 – Tennessee Gas Pipeline Company – Tiger Pass, Louisiana
• July 21, 1997 – Citizens Gas and Coke Utility – Indianapolis, Indiana
Marathon Pipe Line Company Rupture/Gramercy, Louisiana
On May 23, 1996, a 20-inch diameter steel-products pipeline ruptured and released 11,870 barrels (498,540 gallons) of gasoline. The escaping gasoline quickly filled a utility right-of-way and then entered the Blind River, causing environmental damage. Excavation work had been performed in the area near the rupture several months before the accident.
Issues being examined include the operator’s ability to identify that a pipeline rupture had occurred and excavation damage prevention programs in place at the time of the accident.
Koch Pipeline Company Rupture/Lively, Texas
On August 24, 1996, an 8-inch diameter liquid butane pipeline ruptured at Lively, Texas, sending a butane vapor cloud into the surrounding residential area. The butane vapor ignited when two teenage residents in a pickup truck drove into the vapor cloud. The ensuing explosion and fire resulted in their deaths. Post-accident examination revealed the presence of significant corrosion at the center of the pipe rupture.
Issues being examined include the adequacy of pipeline inspection techniques and the adequacy of education regarding pipeline safety.
Tennessee Gas Pipeline Company/Tiger Pass, Louisiana
On October 23, 1996, the dredge DAVE BLACKBURN dropped its port stern spud while dredging in Tiger Pass, Louisiana, striking and rupturing Tennessee Gas Pipeline Company’s 12-inch submerged natural gas transmission pipeline. Within seconds of dropping the spud, natural gas escaping from the damaged pipeline was ignited and set ablaze the tug G. C. LINSMIER and the stern of the dredge.
Issues being examined include: public education to inform people on the potential dangers of propane gas and on actions to take during emergencies; excavation damage prevention programs; pipeline company employee qualifications and training; operator response to gas leak complaints; and operator oversight.
Colonial Pipeline Company Rupture/Fork Shoals, South Carolina
On June 26, 1996, a 36-inch diameter pipeline ruptured and released2 fuel oil into the Reedy River near Fork Shoals, South Carolina. The quantity of oil spilled totaled 957,600 gallons, and the spill migrated up to 25 miles downstream from the rupture site. The failure occurred only six weeks after the pipeline operator had identified and reported a defect in the pipeline to the Office of Pipeline Safety a defect in the pipeline.
Issues being examined include: leak detection; rapid shutdown of the leaking pipe; and the ability of the controller to safely operate the pipeline under restricted conditions.
Citizens Gas and Coke Utility Rupture/Indianapolis, Indiana
On July 21, 1997, a 20-inch diameter natural gas transmission pipeline ruptured. The escaping gas ignited causing the death of one person, destruction of seven nearby houses, and damage to 20 or more other houses. The area of the ruptured pipe segment was located in a highway project to widen a road.
Issues being looked into include excavation activity and the use of directional drilling to install underground utilities.
Railroads are one of this nation’s safest forms of transportation, but the potential for tragedy exists in railroad transportation as it does in every other mode of transportation. Millions of passengers are carried each year on Amtrak and rapid rail systems, and over 1.52 million carloads of hazardous materials move by rail each year. Projected growth rates show that there will be 600 million train miles in the year 2002, an increase of 108 million train miles from 1997.
Completed Major Railroad Investigations
Since my last appearance, the Safety Board completed four major railroad investigations. Below is a list of those accidents, followed by a summary of each.
• February 9, 1996 -- Collision and derailment of New Jersey Transit Commuter Train – near Secaucus, New Jersey
• February 16, 1996 – Derailment and collision of a Maryland Rail Commuter Train and an Amtrak train – Silver Spring, Maryland
• November 23, 1996 – Derailment of Amtrak train – Secaucus, New Jersey
• January 12, 1997 – Derailment of Union Pacific freight train – near Kelso, California
Collision and Derailment of New Jersey Transit Commuter Train/Secaucus, New Jersey
On February 9, 1996, an eastbound New Jersey Transit (NJT) commuter train collided nearly head-on with a westbound NJT commuter train near Secaucus, New Jersey resulting in three fatalities and 158 injuries. About 400 passengers were on the two trains.
Issues examined by the Board included: the medical condition of the engineer; the adequacy of medical standards and examinations for locomotive engineers; and the adequacy of the NJT train crewmembers’ response to the accident.
On March 25, 1997, the Safety Board determined that a train engineer failed to perceive correctly a red signal aspect because of his diabetic eye disease and resulting color vision deficiency, which he failed to report to New Jersey Transit during annual medical examinations.
Derailment and Collision of Maryland Rail Commuter Train with Amtrak Train
Silver Spring, Maryland
On February 16, 1996, a Maryland Rail Commuter (MARC) train collided with an Amtrak passenger train near Silver Spring, Maryland. The three MARC crewmembers and eight passengers in the first MARC car received fatal injuries. 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.
Issues examined by the Safety Board included: the performance of the MARC train crewmembers; the oversight of CSX Transportation, Inc. (CSXT) signal system modifications; the Federal oversight of commuter rail operations; the lack of positive train separation control systems; and the adequacy of passenger car safety standards and emergency preparedness.
On June 17, 1997, the Safety Board determined that the probable cause of the accident was the failure of the engineer and the traincrew, because of multiple distractions, to operate the MARC train 286 according to the signal indications; and the failure of the Federal Railroad Administration (FRA), the Federal Transit Administration, the Maryland Mass Transit Administration, and CSXT to ensure that a comprehensive human factors analysis for the Brunswick Line signal modifications was conducted to identify potential sources of human error and to provide a redundant safety system that could compensate for human error.
Thirty-six safety recommendations were issued as a result of this investigation.
Derailment of Amtrak Train/Secaucus, New Jersey
On November 23, 1996, Amtrak passenger train 12 derailed on the Portal Bridge, an open deck through truss swing bridge spanning the Hackensack River in Secaucus, New Jersey. The derailment also resulted in train 12 sideswiping Amtrak passenger train 79. Both locomotives and all 12 following cars of train 12 derailed, coming to rest with both locomotives and the four head cars down the embankment at the east end of the bridge. Train 79 sustained sideswipe damage and stopped with the entire train intact and on the rails west of Portal Bridge. There were 49 minor and four serious injuries, and estimated damages were in excess of $3.6 million.
Issues examined as a result of this accident include: design of Portal Bridge; quality control of bridge components; inspections of the track structure and miter rails on Portal Bridge; and the lack of standards or regulations for special track work.
On October 7, 1997, the Safety Board determined that the probable cause of the accident was the failure of Amtrak management to foster an environment that promoted adequate inspection, maintenance, and repair of the miter rail assemblies on Portal Bridge and to permanently correct defects in the miter rail side bars that were discovered 10 months before the accident. Contributing to the accident were the failure of the FRA to develop track inspection standards for special track work and to periodically inspect such track as part of its oversight responsibilities, and Amtrak’s removal of the miter rail position detection circuitry without installing replacement circuitry or implementing procedures to compensate for the loss of this safety critical system.
Derailment of Union Pacific Railroad Freight Train/near Kelso, California
On January 12, 1997, a Union Pacific Railroad Company (UP) freight train derailed near Kelso, California, resulting in a total damage cost of $4,376,400. While descending a hill the engineer inadvertently activated the multiple-unit engine shutdown switch, which shut down all the locomotive unit diesel engines and eliminated the train’s dynamic braking capability. The train eventually reached a speed of 72 miles per hour and derailed 68 of its 75 cars.
Issues examined by the Safety Board included: the placement of safety-critical locomotive cab controls; adequate train-speed safety margins for steep-grade railroads; and the criticality of dynamic braking systems.
On October 28, 1997, the Safety Board determined that the probable cause of the accident was a prolonged pattern of inattention and lack of action by UP management to protect effectively or relocate the multiple-unit engine shutdown switch in SD60M locomotives after the switch had repeatedly been recognized as subject to inadvertent activation; and failure of UP management to adequately address critical safety issues such as dynamic braking system operational reliance and protection, and authorized maximum train speeds in the event of dynamic braking failure.
On-Going Major Railroad Investigations
The Safety Board is investigating four major railroad accidents and conducting one special investigation. Below is a list of those accidents and the study, followed by a summary of each.
• June 23, 1997 – Collision and derailment of two UP freight trains – Devine, Texas
• July 2, 1997 – Collision of two UP freight trains – Delia, Kansas
• August 9, 1997 – Amtrak passenger train derailment – Kingman, Arizona
• October 9, 1997 – Collision and derailment of Amtrak train – Garden City, Georgia
• Special Investigation -- Safety issues regarding UP
Collision and Derailment of UP Freight Trains/Devine, Texas
On June 23, 1997, a northbound and a southbound UP freight train collided and derailed near Devine, Texas, located about 40 miles southwest of San Antonio. The collision occurred on a single main track between Laredo and San Antonio. There are no wayside signals on this segment of track and authorization orders for train movements are issued by radio to each train by a dispatcher. The accident resulted in four fatalities and one injury.
Issues being looked into include: the effectiveness of train dispatching in non-signalized territory; management oversight in train dispatching in non-signalized territory; positive train control; and crashworthiness of locomotive event recorders.
Collision of UP Freight Trains/Delia, Kansas
On July 2, 1997, near Delia, Kansas, a westbound UP freight train struck the side of an eastbound UP freight train. The collision occurred where the main line and the siding merge. The engineer on the westbound train was killed and the conductor sustained minor injuries. The westbound train failed to stop at the stop signal and entered the route of the eastbound train. Fifteen cars from the eastbound train and two locomotives and three cars from the westbound train were derailed. Following the collision a fire caused by the punctured locomotive fuel tanks on the eastbound train engulfed the derailed cars and locomotives. Five of the derailed cars contained hazardous materials and 1,500 people were evacuated. Damages caused by this accident exceeded $5 million.
Issues being examined include: the effect of fatigue on the engineer on the westbound train; UP’s fatigue countermeasures program; the need for alerters on locomotives; the crashworthiness of locomotives; and positive train separation.
Amtrak Passenger Train Derailment/Kingman, Arizona
On August 9, 1997, an Amtrak train derailed about five miles east of Kingman, Arizona. Amtrak train 4 was en route from Los Angeles, California, to Chicago, Illinois, operating at about 89 miles per hour on the eastbound track when both the engineer and assistant engineer saw a dip in the track as they approach the bridge. They applied the train’s emergency braking and derailed as the train traversed the bridge. The bridge’s foundation support was undermined from severe erosion during a flash flood.
Issues being examined include: safety of track and structures subject to damage in severe storms; passenger safety and emergency procedures; and operating rules and circumstances for weather notifications, including special instructions issued following an accident.
Collision and Derailment of Amtrak Train/Garden City, Georgia
On October 9, 1997, an Amtrak train en route from New York City to Miami, Florida, struck a tractor trailer at a passive grade crossing near Garden City, Georgia. The trailer, a low profile semitrailer combination, was lodged on a high-vertical profile crossing. The crossing was on a CSXT track. Subsequent to the collision, the two locomotive units and all 11 passenger cars derailed. One crewmember sustained serious injuries and the other crewmember and 10 passengers sustained minor injuries.
Issues being examined include CSXT’s emergency notification procedures and identifying high/railroad grade crossings.
Special Investigation -- Safety Issues Regarding the UP Railroad
The Safety Board has launched investigators to seven UP collisions in the past year, and the railroad has experienced 14 recent accidents. We remain concerned over the problems the UP seems to be experiencing, and the Safety Board will host a three-day public hearing in Washington, D. C. in March 1998, to address safety problems at UP since its merger with Southern Pacific Railroad. The effectiveness of safety oversight of the UP will be the focus of the hearing.
The Safety Board has been investigating the nation’s aviation accidents for thirty years and we have investigated well over 110,000 aviation accidents. In October 1996, Public Law 104-264 gave the Safety Board the additional responsibility of coordinating the Federal effort for the families of the victims of major aviation accidents. Since that time, we have hired a family affairs staff of seven; developed, in concert with family advocacy groups and the aviation industry, a Safety Board family assistance plan; and provided family assistance at the following four accidents:
• United Express flight 5925 runway collision in Quincy, Illinois – 14 fatalities
• Comair flight 3272 accident in Monroe, Michigan – 29 fatalities
• Korean Air flight 801 in Guam – 228 fatalities
• Scenic Airlines in Montrose, Colorado – 9 fatalities
The Board’s plan, which will continue to be updated, has been shared with dozens of groups, ranging from the Air Transport Association, to the American Bar Association, to family members of accident victims, to mental health professionals -- particularly the American Red Cross.
In July 1997, the Safety Board’s staff assisted TWA flight 800 family members in arranging activities, including a tour of the Calverton, New York wreckage hangars, to commemorate the first anniversary of that tragedy. Arrangements were also made to see to family needs at the Board’s TWA investigative hearing held in December, and similar arrangements are being made for KAL flight 801 family members at our hearing regarding that accident to be held in March.
The family assistance for Korean Air flight 801 accident in Guam, exceeded any other we have launched on. Three Safety Board employees and a D-mort team comprised of forensic pathologists, odontologists, anthropologists, funeral directors, and FBI finger print experts, along with D-mort equipment, were sent to Guam to assist in victim identification and other family affairs issues. Safety Board and D-mort personnel were on Guam for about one month to assist the more than 700 family members who traveled to Guam in that one month period. Family members were provided twice daily briefings on the accident, and extensive briefings and private meetings were held regarding victim identification. Because of language differences and the lengthy victim recovery, family assistance in this accident was extremely difficult.
As you are aware, Congress recently passed legislation amending the Aviation Disaster Family Assistance Act of 1996 to require foreign air carriers flying in or out of the United States to file family assistance plans and fulfill the same family support requirements as their domestic counterparts. This disparity in the previous legislation was brought to light and corrected as a result of the Board’s experiences at the crash of Korean Air flight 801. At the time of that accident, Korean Air did not have a plan of its own to support the family members who traveled to the accident site, nor were they aware of the Safety Board’s new family responsibilities.
In October 1997, eight employees of the Bureau of Reclamation received fatal injuries in an accident that occurred near Montrose, Colorado. Federal agencies are currently not required to have a plan to assist their employees’ family members should a tragic accident occur. As recommended by the White House Commission on Aviation Safety and Security, Safety Board staff is meeting regularly with Executive Branch officials to assist in their development of a plan to assist their employees’ families following an aviation disaster.
In an effort to promote an understanding of the Federal government’s role in family affairs, in September 1998, the Safety Board will to host an international symposium in Washington, D. C. This symposium will be an opportunity to educate individuals and organizations responding to these tragedies by asking them to share experiences and new techniques in disaster resource management.
Mr. Chairman, since my first meeting with family members of accident victims in Pittsburgh, Pennsylvania, I have believed they deserve a prompt, compassionate, and truthful response following a transportation disaster, and I am proud of the work the Board’s staff has done on family issues. I would like to share with you brief comments from three TWA flight 800 family members.
"My family is grateful to you and your staff for the kindness and sensitivity you have shown to us from the very beginning of your investigation. We admire the work you are doing and are comforted to know that individuals such as [name] are on the job."
"I am aware that it is your job to investigate disasters such as this and that communication with families is part of the procedure that is followed.… No job description could mandate the level of sensitivity and honesty that I have received at every call…. Every contact has left us feeling satisfied that everything possible is being done [to] find the cause of the crash."
"Your commitment to the supervision of the investigation, as well as the wonderful support and comfort you have given the families, has touched us greatly…. Please convey our deep gratitude to all those who have been involved …."
Mr. Chairman, without the support of this Committee we would not have had the resources to provide the needed and much appreciated support to these family members, and we thank you.
Before I summarize the Board’s needs for Fiscal Year 1999, I would like to discuss some of the newer initiatives at our agency.
SAFETY BOARD WEB SITE
At last year’s hearing, I emphasized that the results of the Board’s work were useless if not easily obtainable. As you are aware, the Safety Board has in the past been criticized for not making its information more readily available. I am proud that the Safety Board now offers much of its information on its Web site – www.ntsb.gov. Included on our site are general information about the Board and its Members, press releases, speeches and testimony, the "Most Wanted" list of safety issues and recommendation acceptance rates, a synopsis of over 38,000 aviation accident investigations, aviation accident statistics, a list of accident reports available in all modes of transportation, a list of current position vacancies, our Strategic Plan, and a copy of the Board’s Family Disaster Assistance Plan. We expect to have the full text of all major accident reports and safety studies adopted by the Board in the past two years available on our Web site by April of this year.
At the time of the TWA flight 800 investigative hearing in Baltimore, Maryland, over 3,500 pages of accident information were placed on the Board’s Web site, including the entire hearing docket, a summary of each day’s hearing discussion by day, and the transcript of the hearing by day. On a normal weekday, about 1,100 visitors come to the Board’s site. The week of our hearing we had 78,074 visitors – with over 26,000 on the first day of the hearing alone. In addition, other Web sites that duplicated the Safety Board’s had over 100,000 visitors obtain TWA hearing information.
Although we currently offer only a list of available reports in the surface modes, we will have the Board’s railroad accident database on the Web by the end of April, and the highway, marine and pipeline accident information, as well as Opinions and Orders from our aviation enforcement dockets available at the end of the fiscal year.
Mr. Chairman, following the ValuJet and TWA flight 800 accidents, it became obvious that the Board needed to improve coordination and communications throughout the on-scene phase of an accident investigation. I am pleased to report that in just one year our new headquarters Communications Center has changed the Safety Board’s accident and family operations in a positive and supportive way.
As you will recall, in February 1997, I implemented a 24-hour Communications Center in response to the need to centrally coordinate our accident communications and launch operations. Before this operation began, Board officials made numerous telephone calls to notify the Go-Team members and to gather correct information during launches.
The Communications Center have relieved the investigators of launch logistics nightmares by coordinating travel, lodging, the on-scene command center, and telephone and equipment needs. The operation runs interference for the en route go-team, gathering accident information and alerting local police and fire/rescue personnel of the who, when, and where of the team’s arrival. Now, arriving on-scene, the Investigator-in-charge need only check in with the Communications Center to receive the latest information needed to efficiently initiate the investigation or to arrange a telephone conference. In addition, the Communications Center has provided invaluable assistance during international investigations that literally involve 24-hour communications.
Mr. Chairman, the Board and its employees have found the Communications Center to be an invaluable resource – a resource whose responsibilities change as the needs of our employees change.
FY 1999 BUDGET REQUEST
Mr. Chairman, the Safety Board’s effectiveness depends on a sufficient level of resources to enable us to make timely and accurate determinations of the 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. Without the additional positions you provided the Board in fiscal years 1997 and 1998, we would have been hard pressed to accomplish all that has been done these past two years. I believe the American public have benefited greatly from your investment in the Safety Board. Your continued support of our laboratories also has allowed us to make significant advances in the technical support of our accident investigations and public hearings.
Mr. Chairman, as you will recall, you raised concerns last year regarding the Board’s slow pace in filling much needed positions provided by our Committee. I am pleased to report that we now have either filled or made commitments to fill 29 of our new positions. The Safety Board did not receive qualified applicants following initial recruitment for the remaining three, and we are in the process of reannouncing for those positions. Although the Safety Board has attempted to fill this position, qualified applicants have not been forthcoming.
For fiscal year 1999, the President’s budget contains a request for $53.2 million and 402 full-time equivalent positions for fiscal year 1999. In addition, it is requested that the Board’s Emergency Fund be increased to $2 million from its current $1 million level. We also ask that the language for the fund be modified to permit use of the fund to provide assistance to families of accident victims.
Mr. Chairman, that concludes my testimony. Again, the Safety Board thanks you for your unwavering support, and we look forward to working with you in the coming year.