Testimony of Mark V. Rosenker
Acting Chairman, National Transportation Safety Board
Committee on Appropriations
Subcommittee on Transportation, Treasury, the Judiciary, HUD and Related Agencies
United States Senate
May 31, 2005
Thank you, Chairman Bond and Members of the Subcommittee for allowing me the opportunity to present testimony on behalf of the National Transportation Safety Board (NTSB) regarding the agency's appropriation needs for fiscal year 2006. It is truly an honor and a pleasure to represent an agency dedicated to the care and safety of our Nation and its citizens.
The NTSB is an independent Federal agency charged by Congress with investigating every civil aviation accident in the United States and significant accidents in other modes of transportation-railroad, highway, marine and pipeline-and issuing safety recommendations aimed at preventing future accidents. The Safety Board is responsible for maintaining the government's database of civil aviation accidents; serves as the "court of appeals" for any airman, mechanic or mariner whenever certificate action is taken by the Federal Aviation Administration (FAA) or the U.S. Coast Guard (USCG) Commandant, or when civil penalties are assessed by the FAA; and is tasked with ensuring that transportation disaster survivors and victims' families receive timely, effective, complete, and compassionate assistance from the operator, other government agencies, and community service organizations. In addition, the NTSB Academy, now in its third year of operation, provides quality training for accident investigations. The Academy also provides a platform for accident reconstruction and evaluation and uses its training resources to facilitate family assistance and first responder training programs.
Since its inception in 1967, the NTSB has investigated more than 124,000 aviation accidents and over 10,000 surface transportation accidents. In addition, the Safety Board has issued more than 12,000 safety recommendations in all modes of transportation with an 82 percent adoption rate for recommendations made. In FY 2004, the Safety Board issued 151 new safety recommendations and closed 311 recommendations. For the first time since 1975, the number of open safety recommendations is under 800.
I would like to begin by highlighting just some of the NTSB's accomplishments in 2004-2005.
Advocacy Program: The goal of NTSB's advocacy program is to implement safety recommendations. The expeditious implementation of recommended safety improvements remains a priority at the Board. Paramount in our efforts to achieve this goal is our work with the modal administrations of the Department of Transportation to focus on open recommendations, particularly those from our Most Wanted List. The Board's persistence in this endeavor has yielded significant safety benefits. For example, following a series of SWAT meetings, the FAA took positive actions and 7 aviation recommendations were reclassified from "Open-Unacceptable" to "Closed-Acceptable" or "Closed-Acceptable Alternate." For instance, Safety Recommendation A-00-39, which asked that Air Traffic Control facilities retain recorded voice communications and radar data for 45 days whenever equipment for properly archiving the data is available, was classified "Closed-Acceptable." Similarly, following a SWAT meeting with the Federal Motor Carrier Safety Administration (FMCSA), FMCSA took action on H-04-20, which recommended that the agency utilize motor carrier safety information collected by the Department of Defense when determining whether further review of a motor carrier is warranted. That recommendation was subsequently classified "Closed-Acceptable Action."
Historically, the Safety Board has corresponded with recommendation recipients through traditional, and inefficient, written communications. Frequently, the recipients misunderstood the Board's position, and significant time was lost in trying to gain both understanding and agreement through the written process. To improve this cumbersome approach, the Safety Board initiated the SWAT program. SWAT focuses on more frequent face-to-face meetings with recommendation recipients to ensure that the Board's position is clearly and fully understood. Safety Board staff meet with appropriate Federal and State agencies and with industry representatives to speed the implementation of safety improvements. Although staff may gain a greater appreciation for recipients' concerns through the SWAT program, SWAT is not intended to compromise or dilute the essential intent of the Board's recommendations. The principal benefits of the program are that Safety Board staff are able to clearly articulate the objectives of the Board's recommendations; the recommendation recipients can present additional information and perspectives about their concerns regarding recommendations; and the Board realizes a substantial reduction in the time spent between the issuance of a recommendation and the implementation of the associated safety improvement.
With all 5 Board Members and NTSB staff working as a team, we have seen significant progress in State legislatures advancing the adoption of our recommendations. Each Board Member focuses on advocacy activities in 10 States. Board Members meet with State officials, departments, and public advocacy groups to encourage support for our recommendations. From January 2004 to date, Board Members and staff have testified 48 times in 23 different States. During the same time period, 47 States have enacted 14 booster seat laws, 3 primary seat belt enforcement laws, 11 teen driving laws, 8 laws addressing hard-core drunk driving, 5 laws to require personal flotation devices for children on boats, and 6 laws for mandatory boater education. Since 1993, in response to our safety recommendations, 40 States and the District of Columbia have enacted graduated driver licensing laws, revolutionizing the way States license young drivers.
Most Wanted Safety Improvements: The Office of Safety Recommendations and Communications is responsible for coordinating strategies for implementing safety recommendations, supporting victims of transportation disasters, keeping the media apprised of important safety developments, and ensuring that Congressional, Federal, and State government leaders are provided with timely and accurate information. The office also manages the most critical open safety recommendations on the NTSB's list of Most Wanted Transportation Safety Improvements.
The NTSB's Most Wanted list was established in 1990 to increase the public's awareness of, and support for, recommendations having the greatest potential for preventing accidents and saving lives. The Most Wanted list also focuses attention on recommendations that may have become stalled but, if accomplished, would significantly reduce deaths and injuries.
In 2003, the Safety Board separated Federal and State issues on the Most Wanted list to maximize its utility and to allow the Board to focus on a more manageable number of recommendations. In September 2004, at the Board Meeting on the Most Wanted List of State issues, the Board reviewed 319 actions emanating from 10 safety recommendations and 197 recommendation classifications, including 173 safety improvements that were completed. Further action that is still needed by the States, however, includes improving child occupant protection, enacting primary seat belt laws, eliminating hard-core drinking driving, enhancing recreational boating safety, and, added to the list during the September meeting, improving school bus/grade crossing safety.
The meeting on the Most Wanted List of Federal issues was held in November 2004. Two items were removed from that list: the recommendation for marine voyage data recorders, which was almost complete, and the recommendation to enhance the safety of locomotive cab voice recorders, which the Federal Railroad Administration refuses to adopt. The Board also revised the classifications of two FAA responses on runway incursions and aircraft icing from "Open-Acceptable Response" to "Open-Unacceptable Response" because of lack of progress by the FAA. In addition to reducing dangers to aircraft flying in icy conditions and stopping runway incursions, improvements that Federal agencies still need to make include eliminating flammable fuel/air vapors in aircraft fuel tanks, implementing positive train control, and preventing medically unqualified drivers from operating commercial vehicles.
The Board will again review its Most Wanted State issues list in September 2005 and Federal issues list in November 2005. We will keep the Subcommittee informed of any changes made during those reviews.
Office of Aviation Safety (OAS)
The NTSB is required by law to investigate and determine the probable cause of all of the nearly 2,000 civil aviation accidents and certain public-use aircraft accidents that occur each year. While the NTSB continues to fulfill its obligations to investigate each civil aviation accident, staffing constraints cause us to handle many of the smaller accidents as limited investigations.
Earlier, I mentioned the accident investigations closed by OAS last year. I would like to briefly discuss two of those accidents-American Airlines flight 587 in Belle Harbor, New York, and Air Midwest flight 5481 in Charlotte, North Carolina.
On November 12, 2001, American Airlines flight 587, an Airbus A300-605R (N14053) crashed in Belle Harbor, New York, shortly after taking off from John F. Kennedy International Airport on a flight to Santo Domingo. All 260 people aboard the plane died, as did 5 persons on the ground. It was the second deadliest aviation accident in American history. On October 26, 2004, the Safety Board determined that flight 587 crashed because the plane's vertical stabilizer separated in flight as a result of aerodynamic loads that were created by the first officer's unnecessary and excessive rudder pedal inputs after the aircraft encountered wake turbulence. The Board said that contributing to the crash were characteristics of the airplane's rudder system design and elements of the airline's pilot training program. As a result of the investigation, the Safety Board issued 13 safety recommendations.
On January 3, 2003, Air Midwest (U.S. Airways Express) flight 5481, a Raytheon (Beechcraft) 1900D (N233YV) crashed on takeoff at Charlotte-Douglas International Airport. Two crewmembers and 19 passengers aboard the airplane were killed and one person on the ground received minor injuries. Impact forces and a post-crash fire destroyed the airplane. On February 26, 2004, the Safety Board determined that the probable cause of the accident was the airplane's loss of pitch control during takeoff. The loss of pitch control was the result of incorrect rigging of the elevator control system, compounded by the airplane's center of gravity, which was substantially aft of the certified aft limit. As a result of the investigation, the Safety Board issued 21 safety recommendations.
Currently, the Safety Board has 8 ongoing major investigations, including the Canadair Challenger crash near Montrose, Colorado; a Gulfstream jet crash at Houston, Texas; the Canadair Challenger jet crash at Teterboro Airport, New Jersey; the Jetstream crash in Kirksville, Missouri; and the KingAir crash in Martinsville, Virginia. Furthermore, in July, the Safety Board convened a pubic hearing to examine issues related to feasibility and benefits of cockpit image recorders on commercial aircraft, and in June 2005, the Board will convene a public hearing to examine the Canadair regional jet crash in Jefferson City, Missouri.
The NTSB also assisted in several foreign investigations in the past year. These include the China Northern CRJ, which crashed on takeoff from Baotou, China; the Flash Airlines B737-300, which crashed on take-off near Sharm-el-Sheikh, Egypt; and the Air Transat charter flight 961, an Airbus A-310-308, enroute from Varadero, Cuba, to Quebec City, Canada, which lost a rudder and returned to Cuba.
Office of Highway Safety (OHS)
The OHS investigates highway accidents involving issues with wide-ranging safety significance, such as bridge collapses, multiple fatalities on public transportation vehicles, and accidents at grade crossings. The office also examines the safety programs of the Federal Highway Administration, Federal Motor Carrier Safety Administration, and the National Highway Traffic Safety Administration.
Highway fatalities account for about 95 percent of all transportation deaths in the United States each year, causing about 120 fatalities a day. As I mentioned earlier, OHS completed 6major accident investigations in 2004, including a school bus run-off-bridge accident in Omaha, Nebraska, which resulted in four fatalities; a daycare van run-off-road accident near Memphis, Tennessee with 5 fatalities; a fatigued driver in a motorcoach near Victor, New York, resulting in 5 fatalities; an elderly driver who crashed into a farmers' market near Santa Monica, California, which resulted in 10 fatalities and 63 injuries; a barge/bridge collapse with 14 fatalities near Webbers Falls, Oklahoma; and 6 accidents involving driver seizures and medical issues that resulted in 8 fatalities and 27 injuries.
Each of these accident investigations has the potential to yield significant safety improvements if our recommendations are implemented. The accident near Memphis, Tennessee, involved a 15-passenger van, operated by a child care center, which ran off the road, killing the driver and 4 children. The Board's report made recommendations for improved oversight of child care transportation, improved vehicle crashworthiness standards, improved vehicle inspections, better driver qualifications and medical exams, the use of age-appropriate child restraints, and improved guard rail anchorages.
Two similar accidents near North Hudson, New York, which occurred 7 months apart, involved a motorcoach and a tractor semi-trailer that collided with stopped traffic on a congested interstate. The congestion was created by a U.S. Border Patrol checkpoint. Four persons were killed and 56 people were injured in these two accidents. The Board made urgent recommendations to immediately develop comprehensive traffic control guidelines specifically tailored to U.S. Border Patrol checkpoints located on highways. These urgent recommendations were issued approximately 1 month after the second accident.
The Office of Highway Safety has 17 ongoing investigations, including a motorcoach collision with an SUV near Hewitt, Texas; a truck that rear-ended a bus near Hampshire, Illinois; and 2 school bus accidents, one in Arlington, Virginia, and another in Liberty, Missouri.
Office of Railroad, Pipeline and Hazardous Materials Investigations (ORPH)
Since January 2004, ORPH has completed 18 accident investigations, including 12 railroad, 3 pipeline, and 3 hazardous materials reports.
By law, the Safety Board determines the probable cause of railroad accidents involving passenger trains or any train accident that results in at least one fatality or major property damage. However, due to staffing constraints, the Board was not able to launch go-teams to investigate each of the accidents covered by the Act.
I would like to discuss two railroad accident investigations by the Safety Board: the derailment of a Canadian Pacific Railway freight train near Minot, North Dakota, and the derailment of a Norfolk Southern Railway freight train in Graniteville, South Carolina.
On January 18, 2002, an eastbound Canadian Pacific Railway freight train, traveling about 41 mph derailed 31 cars about ½ mile west of the city limits of Minot, North Dakota. Five tank cars carrying anhydrous ammonia catastrophically ruptured, and a vapor plume covered the derailment site and surrounding area. The plume affected about 11,600 people in the area. One resident was fatally injured, and from 60 to 65 residents of the neighborhood nearest the derailment site were rescued. As a result of the accident, 11 people sustained serious injuries and 322 people sustained minor injuries. The probable cause of the derailment was an ineffective inspection and maintenance program that did not identify and replace cracked joint bars before they completely fractured and led to the breaking of the rail at the joint. Contributing to the severity of the accident was the catastrophic failure of 5 tank cars and the instantaneous release of about 146,700 gallons of anhydrous ammonia. The Safety Board made 8 safety recommendations to improve track inspections and tank car performance.
On January 6, 2005, a northbound Norfolk Southern Railway freight train collided with a locomotive that was parked on an industrial siding in Graniteville, South Carolina. Hours before the accident, another Norfolk Southern Railway train had used the same main track to enter the industrial siding. The local train crew secured their train and departed the area. About 8 hours later, the accident train proceeded toward Graniteville with authority to use the main track without restrictions. The engineer of the accident train initiated an emergency application of the brakes as the train neared the switch. The train was diverted onto the sidetrack and struck the lead locomotive of the parked local train. The 2 locomotives and 16 head cars derailed. Included in the derailment were 3 pressure tank cars filled with chlorine. One chlorine tank car was breached, which prompted an evacuation of about 5,400 people for an extended period. The engineer and 8 other people died from inhalation injuries due to the chlorine gas release. The conductor and 72 other people were hospitalized. The investigation is ongoing.
In addition to launching on 17 investigations and completing 18 major reports, ORPH held a symposium in March 2005 on Positive Train Control at the NTSB Academy and held a public hearing on April 26-27, 2005, regarding a Union Pacific train derailment near Macdona, Texas.
Currently, the Office of Railroad, Pipeline and Hazardous Materials Investigations has 18 railroad, 2 pipeline, and 3 hazardous materials accident investigations in process.
Office of Marine Safety (OMS)
OMS investigates marine accidents on navigable waters and territorial seas of the United States and accidents involving U.S. merchant vessels worldwide. In 2002, the NTSB and the USCG reached an agreement making the Board responsible for the investigation of accidents that risked high loss of life to innocent third parties, such as passenger vessel accidents, and accidents that involve significant safety issues related to USCG safety functions.
Passenger vessel accidents constituted 80 percent of the 21 marine accidents investigated by the Board in the past 4 years. Since March 2003, 4 of the Board's major accident investigation launches have been marine accidents, all of which were of major consequence: the boiler explosion aboard the Bahamian Flag cruise ship Norway in Miami, Florida; the allision of the Staten Island Ferry near St. George, Staten Island, New York; and the Taki-Tooo, which capsized while transiting Tillamook Bar near Garibaldi, Oregon.
At approximately 6:48 a.m. on May 25, 2003, a boiler room explosion aboard the S/S Norway, docked in the port of Miami-Dade, killed 4 and injured at least 20 crewmembers. During the 3 weeks after the accident, an additional 4 crewmembers died from injuries. Nearly 50 fire-rescue units from Miami-Dade County, the City of Miami, and Miami Beach responded to the explosion in the boiler room. The investigation is ongoing.
On October 15, 2003, the Staten Island Ferry Andrew J. Barberi was at the end of its regularly scheduled trip from Manhattan to Staten Island when it allided with a maintenance pier at the Staten Island Ferry terminal. Fifteen crewmembers and an estimated 1,500 passengers were on board. Ten passengers died and 70 were injured in the accident. An 11th passenger died 2 months later as a result of injuries sustained in the accident. Damages totaled over $8 million, with repair costs of $7 million for the Barberi and $1.4 million for the pier. The probable cause of this accident was the assistant captain's unexplained incapacitation and the failure of the New York City Department of Transportation to implement and oversee safe, effective operating procedures for its ferries. As a result of its investigation, the Safety Board made 8 safety recommendations.
On June 14, 2003, at about 7:15 a.m., the small passenger vessel Taki-Tooo capsized while transiting Tillamook Bar near Garibaldi, Oregon. The Taki-Tooo was one of four U.S. Coast Guard-inspected small passenger vessels leaving the bay at the same time for charter fishing excursions. Rough bar warnings were posted and had prohibited recreational and uninspected commercial vessels from transiting the bar that morning. After the accident, one of the rescue units also could not launch because conditions were too rough. The Taki-Tooo's course took her close to the North Jetty as the vessel turned to the north. The Taki-Tooo capsized after being struck on its port side by a large wave. Of the 19 persons on board, 9 died and 2 are missing and presumed drowned. The Board will consider this report in June.
In addition to investigating 21 accidents and completing 5 marine reports, OMS completed a major reconsideration of the collision between the U.S. Coast Guard Cutter Cowslip and the foreign flag vessel Ever Grade and issued two recommendations related to the availability of children's lifejackets aboard small passenger vessels and small passenger vessel stability.
The OMS currently has 10 ongoing accident investigations.
The NTSB Academy is in its second year of operation in Ashburn, Virginia, with a record number of individuals (over 1,500) attending classes, training sessions, symposiums, forums, and other programs. This number far exceeded all expectations. During the year, 15 courses were taught on topics such as the sciences involved in accident investigations and techniques used to assist survivors and victims' families following a transportation disaster. Sixty-five students from 35 foreign countries attended Academy courses in 2004, more than doubling the 16 countries represented in 2003. Additionally, 9 new courses and partnership programs are scheduled for the 2005 calendar year; more will be added as they are identified. Yet the Academy has only 6 staff to develop and deliver these programs.
In addition, the Academy has formed alliances and partnerships with other Federal agencies and private organizations to meet the training needs of other government agencies and the transportation and emergency response communities, including Airports Council International of North America, the Air Transport Association, the Aviation Safety Alliance, the Civil Aviation Administration of China, the Federal Bureau of Investigation, the National Association of State Boating Laws Administrators, the National Aeronautics and Space Administration, the Transportation Safety Institute and the Society of Automotive Engineers.
As a developing center of excellence for accident and transportation safety training, the Academy has been sought out as a venue for other organizations' training and outreach use. Recently, the Society of Automotive Engineers conducted its forum on developing transportation-related technologies and the Armed Forces Institute of Pathology taught its annual course for medical examiners at the Academy. NTSB, as the chair of the International Transportation Safety Alliance, hosted the Chairman's meeting with 10 countries that have independent safety boards at the Academy in March of this year.
TRANSPORTATION DISASTER ASSISTANCE (TDA)
In 1996, Congress passed the Aviation Disaster Family Assistance Act that gave the NTSB responsibility for assisting the victims of aviation disasters and their families. The Board's primary responsibility involves coordination between Federal agencies, commercial airlines, State and local authorities, and the families of victims. Additionally, in 1997, Congress enacted the Foreign Air Carrier Support Act to ensure foreign air carriers operating to the United States meet the same standards for victim assistance as their domestic U.S. counterparts. The TDA team's mandatory responsibilities include assistance at all major aviation accidents, as well as accidents in other modes of transportation. TDA staff launched on 16 major accidents, providing support to all modes, and responded to approximately 1,500 inquiries from family members. In one instance, a TDA staff member launched to three major investigations within a 10-day period.
In addition, the TDA provides comprehensive courses at the NTSB Academy for professionals who support families of major transportation accident victims following a tragedy. These courses bring together leading experts in the field and cover a wide range of topics, including initial accident notification, grief and trauma, forensic procedures, multi-cultural memorial services, and effective family briefings.
The increasing demands of a growing transportation environment and advancements in transportation technologies, coupled with our needs to adjust mission resources to accommodate inflation, salary increases, and the strain of a static budget, create significant challenges for the NTSB to investigate the accidents that Congress requires us to investigate under our mandate.
For example, there is a 24 percent staffing shortage in the Office of Aviation Safety (OAS) alone. With a forecasted activity growth of between 4 and 5 percent in world aircraft by the year 2015, OAS will be overloaded and it will be increasingly difficult to keep on schedule with current investigations and reports. Also, without additional resources, the Safety Board will struggle to maintain its currency with emerging technologies and its focus on incidents that, if investigated, may prevent major accidents.
Similarly, our Office of Highway Safety (OHS), due to shrinking resources, is unable to fully staff all 3 major highway investigation teams. Without sufficient personnel in key technical areas, our highway office can only select a limited number of accidents and incidents to investigate. These investigations can yield significant life-saving lessons learned; consequently, fewer investigations will reduce our prospects for identifying these life-saving lessons. The opportunities to improve highway safety in our Nation, which has more than 42,000 deaths on its roadways each year, are significant. However, resources are necessary to ensure that the NTSB can continue to focus on those highway issues that will make meaningful improvements for our citizens. Likewise, resource limitations impact our Office of Railroad, Pipeline and Hazardous Materials Investigations and our Office of Marine Safety. In both of these modal offices, managers have either had to curtail some investigations or repeatedly launch the same investigators to multiple accidents. In the end, the timeliness of our recommendations suffers.
The Board appreciates the support of the Committee in providing approximately $3 million above the FY 2004 appropriation level. However, the Board had to absorb $3.9 million, which included a government-wide pay increase, an inflationary increase, and an FY 2005 across-the-board rescission. As a result, the increase amounted to essentially no increase in our resources and only allowed us to maintain our FY 2003 staffing level.
The President's budget for FY 2006 requests $76.7 million for the National Transportation Safety Board. This level is the same as the amount appropriated for the Board's Salaries and Expenses account for the current year. This level will fund 401 full-time equivalent (FTE) positions, requiring a reduction of 15 FTEs. Since 2002, the Safety Board has received an approximately $ 3 million increase each year. But, as outlined in the paragraph above, these increases have only allowed us to maintain our current staffing levels. In our 2006 Budget Submission to OMB, the Safety Board requested $97.7 million to ensure that the Board could continue to support our Congressional mandate.
Currently, the Safety Board is below necessary manpower strength by 73 positions, or more than 17 percent. These vacant positions include technical specialties in such critical areas as systems modeling, structural mechanics, and data recorders. An additional reduction of 15 FTEs, based on the President's budget, would result in further 3-percent reduction in our technical resources. The byproduct of this shortage is that additional risk to the traveling public continues to grow if the NTSB positions are not filled.
There were nearly 2,000 aviation accidents and incidents in 2004 that our mission would require the NTSB to investigate. There were approximately 600 aviation-related deaths in 2003. The Office of Aviation Safety currently has 132 employees for both major and regional investigations, and there are less that 3 complete major investigation teams. As a result, the NTSB cannot launch on all general aviation air carrier accidents. In aviation, minor accidents and incidents, which should be investigated to identify safety issues that could prevent major accidents, are not being addressed. Additionally these same investigators must respond to an increasing number of aviation accidents worldwide to fulfill U.S. responsibilities as a signatory to the International Convention on Civil Aviation.
There are approximately 7 million highway accidents each year that result in over 42,000 deaths. There are less than 3 complete teams for the Office of Highway Safety. OHS currently has 34 employees, including 18 investigators. Due to current staffing limitations, the NTSB could investigate only 48 accidents in 2003. The NTSB cannot adequately pursue safety investigations that could yield the greatest life-saving opportunities because of these staffing restraints.
In 2003, there were almost 3,000 railroad accidents and over 860 railroad-related deaths. Staffing shortages allowed the NTSB to launch on only 10 railroad accidents. Likewise, although there were 11 pipeline accidents that involved fatalities, 25 with property damages reported over $1 million, and 5 with potential significant environmental damage in 2003, staffing shortages only allowed the NTSB to launch on 2 of those accidents. There are less than 2 full teams for railroad, 1 team for pipeline, and 1 team for hazardous materials investigations. Finally, there is less than one complete accident investigation team for the Office of Marine Safety. As a result, the NTSB chose not to lead the investigations of 5 passenger vessel accidents that, if fully staffed, the Board would have investigated.
The NTSB is lacking critical expertise, the Board's accident reports continue to take 2 to 3 years to complete because the NTSB does not have the critical resources to conduct concurrent investigations, and the NTSB has undertaken additional duties mandated by Congress without corresponding increases in funding for the appropriate staffing to fulfill those duties. Additional and significant funding is necessary for the NTSB to fill our vital technical vacancies in order to accomplish the mission mandated by Congress.