Testimony of
Jim Hall, Chairman
National Transportation Safety Board
before the
Committee on Appropriations
Subcommittee on Transportation
United States Senate
Regarding
Transportation Safety Issues
February 24, 2000

 


written testimony for the record:

Good morning, Mr. Chairman and Members of the Committee.  It is a pleasure to provide testimony today regarding transportation safety issues.

The National Transportation Safety Board has been the eyes and ears of the American people at accident sites for over three decades.  When Congress established the Board, it believed that an independent investigative agency was needed to investigate accidents, to make recommendations to improve the transportation system, and to provide oversight to the Department of Transportation (DOT) modal administrations.  Over the years, our recommendations have led to numerous safety improvements in all transportation modes.

Although eight out of every ten of our safety recommendations have been implemented over the years, the Board believes more can be accomplished.  In 1990, the Safety Board  developed a "Most Wanted" list of safety issues to focus attention on  recommendations that have the most potential to save lives, and to highlight recommendations with the greatest impact on safety.  Many of the issues we will discuss today are on the "Most Wanted" list, or are issues that we believe need additional attention.
 

AVIATION

Runway Incursions

The prevention of runway incursions has been an issue on the Safety Board's "Most Wanted" list since the list's inception in 1990.  It has remained on that list because of the potential for significant loss of life should a collision occur.

Since the Board issued its original runway incursion safety study in 1986, the number and rate of runway incursions have steadily increased.  According to Federal Aviation Administration (FAA) figures, there were 325 runway incursions in 1998, an 11 percent increase from 1997.  This trend must be reversed, and we remain concerned that FAA efforts to address runway incursions through technological developments fall short of what is needed.

The FAA has studied this issue for years and they have developed several action plans. Unfortunately, implementation of the most recent plan - the Airport Surface Operation Safety Action Plan issued in October 1998 - has not yet been finalized.  This plan identified goals, objectives, and 51 required actions to be implemented encompassing management and procedural changes.  According to the DOT's Inspector General, the FAA's runway safety program continues to be ineffective in reducing runway incursions.  To date, they have not implemented 65 percent of the near-term actions they deem necessary, such as pilot education and training, incursion awareness efforts, airport improvements management and procedural changes, nor have they implemented controls to ensure the accuracy of runway incursion data.

Traffic volume is increasing and congestion is worsening.  It is past time for the FAA to expeditiously move forward regarding this matter.

Explosive Mixtures in Fuel Tanks on Transportation Category Aircraft

As a result of the Board's on-going investigation into the TWA flight 800 crash near East Moriches, New York, on July 17, 1996, four recommendations were issued to 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.  We are disappointed that the FAA has still taken no action to develop operational procedures that will reduce the potential for explosive fuel-air mixtures or to require that fuel should be loaded in center wing tanks.

In November 1999, over three years after the TWA accident, the FAA proposed a major initiative that would affect the design, certification, and maintenance standards applied to transport category aircraft fuel tanks.  This initiative would require:  1) operators to undergo a design review revalidating the fuel tank designs in their aircraft to make certain that failures could not ignite fuel vapors, 2) operators to develop and implement an FAA-approved maintenance and inspection program for fuel tanks, and 3) new certification standards that would apply to future aircraft designs to minimize the development of combustible vapors.  This initiative is currently under review by the Safety Board.
 

HIGHWAY

Child Safety in Highway Transportation

There should be nothing more important to all of us than the safety of our children.  Over 15,000 children under the age of ten died in motor vehicle crashes during the 1990s.  Yet, we continue to tolerate a situation in which six out of ten children in fatal automobile crashes are unrestrained, and eight out of ten children who are restrained are in child safety seats that have been improperly installed.

In an effort to end these needless tragedies, the Board issued safety recommendations to the automobile manufacturers, the states, and others, to establish fitting stations where parents and caregivers can go at their convenience to ensure that they use the correct seat for the size of their child; install the seat and secure the child into the seat properly; and obtain information about the compatibility between safety seats and various vehicles.
 
 I am pleased to say that within five months of the recommendations' issuance, DaimlerChrysler announced its "Fit for a Kid" program.  DaimlerChrysler has made its child safety seat fitting stations available to every family in America, and they should be congratulated for this life-saving effort.  In addition, General Motors and the National SAFE Kids Campaign have also partnered to educate parents about the need to buckle up children by establishing a mobile fitting station program that will be available in all 50 states; they have also conducted hundreds of periodic child safety seat inspections.  In addition, at the local level, safety advocacy groups, police officers, and fire, medical and rescue personnel are conducting periodic safety seat inspections.  We applaud these efforts.  By making child safety set fitting stations available, countless children will be saved from needless death and injury.

Heavy Truck Safety

Highway crashes now account for more than 40,000 deaths and 3 ½ million injuries in the United States annually.  Many of those deaths and injuries were a result of accidents involving large trucks.  In 1998, 412,000 large trucks were involved in crashes, resulting in 5,374 deaths and 127,000 injuries.

To address the important issue of heavy truck safety, the NTSB, over the past year, held four public hearings, the subjects of which were:  federal and state oversight of the truck and bus industry; technological applications for heavy vehicle safety; safety issues related to the implementation of the North American Free Trade Agreement, and the effectiveness of the Commercial Drivers License program.  The Board will issue reports on results of these hearings in the near future.

However, one concern, the need for collision avoidance devices, has been previously addressed in safety recommendations as a result of previous accident investigations.  Collision warning devices, which assist in an operator's decisionmaking, are currently available or under development for use in large trucks and buses. This device can prevent injuries, and save countless lives and millions of dollars each year.  According to one manufacturer of a collision warning system, several heavy truck fleets have made this equipment standard on newly purchased trucks.  U.S. Express Enterprises, a Chattanooga, Tennessee, company, began installing a collision warning system in its vehicles in 1996, and has seen a decrease in its company's accident costs by two-thirds.
 
In January 1995, the Safety Board issued a safety recommendation to the DOT to sponsor fleet testing and incorporate testing results into demonstration and training programs to educate the potential end-users of the systems.  We were disappointed that the DOT has stated that it had no plans to conduct an operational test of rear-end collision avoidance systems for heavy trucks, even though they are a proven lifesaver.
 

MARINE

Cruise Ship Safety

Travel by cruise ship remains one of the most popular leisure pastimes for U.S. citizens, and this popularity continues to increase each year.  According to the Cruise Lines International Association, cruise ships carried 5.4 million vacationers from U.S. ports in 1998.  That figure was expected to increase to 6 million in 1999.

During the past three years, the Safety Board has investigated three cruise ship accidents involving fire, which caused multiple injuries and death.  In two of the accidents - the Vistafjord that occurred in April 1997, and the Universe Explorer that occurred in July 1998 -- the Safety Board discovered the same safety problem.  The fire started early in the morning when most people were asleep in their cabins.  However, neither ship was equipped with automatic smoke alarms that sound locally in the crew and passenger accommodation areas.  As a result of these accidents, the Safety Board asked the two cruise lines and the International Council of Cruise Lines to have smoke alarms that sound locally in crew and passenger accommodation areas installed in all cruise ships so that crews and passengers will receive immediate warning of the presence of smoke and will have maximum time to escape.

Accident history has shown that most fire-related transportation deaths are not the result of burn injuries, but rather,  smoke inhalation.  Smoke alarms that sound locally can permit sufficient time to alert the passengers of possible dangers on the ship, and the Safety Board will continue its efforts to encourage the industry to accept these recommendations.

Recreational Boating Safety

Nationwide, there were 818 recreational boating fatalities reported to the Coast Guard in 1998, and according to the American Red Cross, another 350,000 persons were injured.

The Safety Board has twice conducted major studies of recreational boating accidents, the most recent in 1993.  A review of fatal recreational boating accidents as part of that study showed minimal use of personal flotation devices (PFDs).  Of the 478 fatalities that occurred in the accidents examined in the 1993 study, 351 resulted from drowning.  Of those who drowned and for whom information on PFD use was available, 85 percent did not wear PFDs.

In 1998, the Board also released a study on personal watercraft (PWC) safety.  Personal watercraft are a type of recreational boat that has become increasingly popular in recent years.  Manufacturers estimate that about 200,000 PWC are sold each year and that more than 1 million are in current operation.  PWC now account for more than one-third of the new recreational boat sales in the United States.

PWC are the only type of recreational vessel for which the leading cause of fatalities is not drowning; in PWC fatalities, more persons die from blunt force trauma than from drowning.    In addition, more than half of the accident-involved PWC operators were younger than 30 years of age.

The Safety Board believes it is incumbent on the states to increase the level of recreational boating safety, and we have asked the states to:

We believe these actions will improve recreational boating safety, particularly among our young people.
 

PIPELINE
 
Pipeline Integrity

Currently, there are over 1.7 million miles of natural gas pipelines and over 165,000 miles of liquid pipelines crisscrossing this country.  A mechanism needs to be in place to find problems before defects grow to a critical size and result in catastrophic failures.
 
 In 1987, as the result of investigations into three pipeline accidents, the Safety Board recommended that Research and Special Programs Administration (RSPA) require pipeline operators to periodically inspect their pipelines to identify corrosion, mechanical damage, or other time-dependent defects that may prohibit their safe operation.  Since the issuance of the Board's recommendation, the RSPA has been studying the issue and has yet to reach any conclusions.  Because of RSPA's inaction, the Board has classified its recommendation as "Open-Unacceptable Response."
 
We have continued to see similar accidents in the 13 years since our 1987 recommendation was issued.  For instance:

Until appropriate action is taken by RSPA, we will continue to see hazardous materials releases that could have been prevented.

Training of Pipeline Employees

The Safety Board has long been concerned about the need to adequately train personnel in all transportation modes, including pipeline.  In 1987, after several pipeline accidents in which inadequate training was an issue, the Safety Board recommended that RSPA require operators to develop training programs for pipeline personnel.

In October 1998, RSPA published a Notice of Proposed Rulemaking (NPRM) to require pipeline operators to develop a written qualification program for individuals operating pipelines.  However, it did not establish training requirements for personnel and it allowed companies to evaluate an individual's ability to perform tasks using methods such as oral examinations or observations of job performance.  In January 1999, the Safety Board provided comments to RSPA that urged them to amend the rule to include strong training and testing requirements to ensure that employees can properly perform their jobs.  Unfortunately, we believe the RSPA did not adequately address these important issues, and after 12 years of inaction by RSPA, the Safety Board classified the recommendation as "Closed-Unacceptable Action."
 We believe that having adequately trained personnel is essential to reduce the  potential for disaster in the pipeline industry.  .
 

RAILROAD

Grade Crossing Safety

Data indicates that every 160 minutes, a collision between a train and car or truck occurs at one of the more than 259,000 highway/rail grade crossings in the United Sates each year that result in nearly 400 fatalities.  Since its creation in 1967, the Board has investigated more than 400 accidents that occurred at railroad grade crossings and issued more than 1,200 grade crossing safety recommendations.
 
Ideally, either closing crossings so that they no longer exist, or separating the rail traffic from the highway traffic through bridges and overpasses, is the most effective means to eliminate accidents between highway vehicles and trains.  The Safety Board strongly supports the Federal Railroad Administration's (FRA) goal to reduce the number of grade crossings through separation and closure by 25 percent by the year 2001, and we urge the FRA to meet that goal.

However, if closure or separation is not possible, the next most desirable method to improve grade crossings safety is to equip crossings without a warning of a train's approach with active devices that warn the motorist of an oncoming train.  As we saw in the accident at Bourbonnais, Illinois, however, flashing lights and gates do not guarantee that an accident can be prevented.  Many previous Board investigations of accidents that occurred at active crossings have involved highway vehicle drivers who did not comply with train-activated warning devices installed at the crossings.  This failure often includes deliberate driver decisions, such as driving around a lowered crossing gate arm or ignoring flashing lights.  Because of these deliberate actions, the Safety Board believes strong consideration should be given to installation of devices that will prevent a motorist from driving around lowered gates, such as four-quadrant gates or median barriers.

The Safety Board recognizes that not all passive grade crossings will be upgraded in the near future with active warning devices, which cost about $150,000 per crossing, and a cross bus sign located a few feet on either side of the railroad tracks is not adequate.  The Safety Board has recommended, as an interim measure, the installation of stop and stop ahead signs at all passive crossings, unless an analysis determines that the installation of a stop sign would reduce the level of safety.

In addition, education and enforcement must be a part of any effective grade crossing improvement plan.  Many motorists fail to understand the level of risk at grade crossings, and do not realize that a 150-car train traveling at 50 miles per hour will take about 1½ miles to stop.  The Safety Board fully supports the education efforts of Operation Lifesaver and other efforts to provide information about grade crossing safety to drivers, and has recommended that grade crossing questions be included on all driver's license tests.

Positive Train Separation

The Safety Board has repeatedly investigated railroad collisions that could have been prevented had a system that mandated train separation been in effect.  The Safety Board is a strong advocate of advanced control systems that will provide a safety net for human performance failures in the operation of trains.  In  1987, the Safety Board recommended that Federal standards require the installation and operation of a train control system on mainline tracks that will provide for positive separation of all trains.  These advanced electronic systems can reduce both the number and severity of train accidents caused by the failure of an engineer to take action to prevent a train collision.

Although the Safety Board is disappointed that the railroad industry and the FRA have not moved on positive train separation (PTS) as quickly as we would have liked, there has been some activity that may eventually result in the development and utilization of a viable PTS system for the Nation's railroads.  This has been a topic addressed by the RSAC (spell out), and tests are being conducted across the country.

However, it has been 13 years since the Board's 1987 safety recommendation was issued, and we are disappointed that the FRA and the industry are just now beginning to move on this issue.

Before closing, I would like to discuss two important issues that transcend all transportation modes - human fatigue in transportation operations and the need for automatic information recording devices.

Human Fatigue in Transportation Operations

Human fatigue in transportation operations is one of the most widespread safety issues in the transportation industry. Fatigue problems permeate our entire society, exacting a heavy toll on our safety, productivity, and quality of life.  While it remains one of the more perplexing problems to substantiate in accident investigations, the body of scientific evidence collected over the past decade clearly reflects the critical need for adequate rest for those people operating safety-critical equipment.

 Following the investigation of several accident investigations during the 1980s that involved operator fatigue, the Safety Board, in May 1989, issued three recommendations to the Department of Transportation which stated:

Expedite a coordinated research program on the effects of fatigue, sleepiness, sleep disorders, and circadian factors on transportation system safety.  (I-89-1)

Develop and disseminate education material for transportation industry personnel and management regarding shift work; work and rest schedules; and proper regimens of health, diet, and rest.  (I-89-2)

Review and upgrade regulations governing hours of service for all transportation modes to assure that they are consistent and that they incorporate the results of the latest research on fatigue and sleep issues.  (I-89-3)

In the over ten years that have passed since the 1989 recommendations were issued, the Safety Board has issued an additional 70 fatigue-related safety recommendations, which were the result of major accident investigations, special investigations, or safety studies that identified operator fatigue as a factor.  In addition, operator fatigue has been on the Safety Board's "Most Wanted" list since the list's inception in 1990.  Had the DOT acted more aggressively on the intermodal recommendations issued in 1989, the need for the 70 additional recommendations to the States and industry may have been minimized.

The various Secretaries of Transportation over the years have expressed their concerns about operator fatigue.  In 1995, Secretary Federico Pena stated that "fatigue among transportation operators remains a critical safety problem."  In a 1999 update, Secretary Rodney Slater stated, "We know that alertness is a key to safe vehicle operation.  To reduce crashes and accidents and their personal and financial consequences, we need to ensure that vehicle operators are ready and capable of operating their vehicles or other transportation equipment."

Although the DOT's efforts to coordinate operator fatigue research and develop and disseminate educational have generally been responsive to our recommendations, little has been done to revise the antiquated hours-of-service regulations. Because of this lack of action, the Safety Board on June 1, 1999, issued the following safety recommendation, which supersedes I-89-3:

Require the modal administrations to modify the appropriate Codes of Federal Regulations to establish scientifically based hours-of-service regulations that set limits on hours of service, provide predictable work and rest schedules, and consider circadian rhythms and human sleep and rest requirements.  Seek Congressional authority, if necessary, for the modal administrations to establish these regulations.  (I-99-1)
In a July 13, 1999, letter, we were advised about the National Highway Traffic Safety Administration's approach to driver fatigue.  In the Board's December 9, 1999, response, the Board reiterated its position that little progress had been made to revise the hours-of-service regulations to incorporate the results of the latest research on fatigue and sleep issues.

It is past time for the Department to act on this matter, and we eagerly await a substance response and action on this recommendation.

Automatic Information Recording Devices

Transportation recorders have played major roles in the Safety Board's accident investigations, and are probably the single-most effective investigative tool we have.  They provide us with critical information that can lead to determining the probable causes of accidents and, ultimately, to safety improvements.  The information can also be used to identify safety trends and develop corrective actions.

Cockpit voice recorders and flight data recorders have been in commercial aircraft for many years, and we have found them to be indispensable tools.  The same is true of trains which have required event recorders since 1993.  The Board has also issued safety recommendations with regard to the need for voyage recorders in the marine industry and on-board recorders in heavy vehicles.

 In addition, we believe video technology has progressed to the point where it has become technically feasible to produce and crash-protect cockpit video recordings that meet the needs of accident investigators, and video recorders for all modes of transportation may become a reality in the not-too-distant future.  On February 8, 2000, the Safety Board recommended to the FAA that a crash-protective video recording system be required on all turbine-powered nonexperimental, nonrestricted-category aircraft that are not currently required to be equipped with a crashworthy flight recorder device.  Safety Board staff are reviewing this matter with regard to the use of video recorders on all passenger-carrying aircraft.

We believe there are no compelling arguments why on-board recording devices, and in some cases video recording devices, are not used in all modes of transportation.  There has been some reluctance on the part of the transportation industry and labor to endorse the use of some recording devices because of the uncertainty regarding the ultimate use of the information.  As a result, the Safety Board has asked Congress to provide us with the authority to withhold from public disclosure voice and video recorder information comparable to the protections provided for cockpit voice recorders. We believe it is appropriate and timely to ensure that there are no legislatively-defined differences between the treatment of new video technology and existing voice recorders, and we will continue to work with our authorizing committees to ensure this protection.

Mr. Chairman, that completes our statement.  The Safety Board's testimony discusses just a few of the many transportation safety issues that are of concern to the Board.  We believe that action on these issues will make our  transportation system even safer.

Speeches & Testimony