Good morning Mr. Chairman and Members of the Committee. It is a pleasure to be here today to represent the National Transportation Safety Board. Before I begin, I would like to thank you and the other Members of the Committee for your continued support of our activities, and for your interest in the Safety Board's programs.
Your support was all the more important when you consider 1996 was dominated by accidents that demanded monumental efforts by the Safety Board's staff -- and strained this agency's resources. Not only is the TWA flight 800 investigation the most costly in the Board's history, but where we usually are able to complete on-scene accident investigation activities in ten days to two weeks, we have now been on-scene on Long Island for nearly eight months.
In a few weeks, the Safety Board will celebrate its 30th anniversary. During these three decades, the Board has investigated more than 100,000 aviation accidents and 10,000 surface accidents, and conducted scores of safety studies. Our object has been not just to find probable cause, but more importantly, to issue safety recommendations aimed at ensuring that similar accidents do not happen again.
But, Mr. Chairman, the results of accident investigations or safety studies are useless unless the information is readily available to those who need it. The Board has tried many different ways to disseminate safety information -- from the "Most Wanted" list of safety issues, to public forums and symposia, to participating with other safety organizations in meetings and conferences, and testifying before Congress and state legislatures. More and more, transportation is becoming a global system, and it is essential that lessons learned by safety professionals are shared with all on that global system.
As part of this effort, the Safety Board has been an active member of the International Transportation Safety Association, which is made up of independent accident investigation boards from around the world. We at the Safety Board are hopeful that this organization will go a long way toward improving the safety of transportation worldwide by learning from the experiences of others. Our aviation specialists also maintain a constant dialaogue with their counterparts through the International Civil Aviation Organization and the European Civil Aviation Conference.
The Board has also placed much of its information on the World Wide Web. If you pull up the Board's home page at www.ntsb.gov, you will be able to view press releases, speeches and Congressional testimony, the "Most Wanted" list, and aviation accident information and statistics. During the initial weeks of the TWA 800 investigation, the Board's home page was an important source of information for many family members.
The "Most Wanted" list is composed of those safety issues with the greatest potential for positive impact on transportation safety. Safety recommendations placed on the "Most Wanted" list receive more intensive follow-up activity to persuade government agencies and industry to act on them as quickly as possible. In April 1996, the Safety Board added three issues to the list. Those issues were:
-- Pilot Background Checks -- The Board has addressed pilot screening four times in the last eight years. Most recent safety recommendations on this subject were issued to the Federal Aviation Administration following the December 13, 1994, accident involving an American Eagle Jetstream 3201 on approach to Raleigh-Durham, that killed 15 persons. We were pleased that this matter was addressed in Public Law 104-264, the Federal Aviation Reauthorization Act of 1996.
-- Safety of Passengers in Railroad Cars -- Dating back to a train derailment on June 28, 1969, at Glendale, Maryland that injured 144 persons, the National Transportation Safety Board has made passenger rail car safety recommendations as a result of at least 13 accidents, which claimed 27 lives and injured 898 persons. Today, there is only one federal passenger car requirement: four window exits per car with bullet-proof glass. The Safety Board has raised safety issues about rail car construction, signs and emergency preparedness more than a dozen times in the past 25 years. The most recent of these was the February 16, 1996, accident near Silver Spring, Maryland involving a Maryland Rail Commuter and an Amtrak train, resulting in 11 fatalities. Four safety recommendations regarding passenger car safety were issued in March 1996 as a result of the Silver Spring accident -- 1 to the Federal Railroad Administration and 3 to the Maryland Mass Transit Administration. Although the Federal Railroad Administration has not completed action on the urgent safety recommendation issued to it, they have taken action on several initiatives to ensure ready passenger egress and rescue access consistent with the intent of the Board's recommendation. They have required inspection of emergency window exits for proper operation, and have issued a proposed rule on passenger train emergency preparedness and passenger equipment safety standards. The State of Maryland has complied with all three of the Board's recommendations, resulting in two of the recommendations closed with acceptable action or exceeding recommended action, and one in an open acceptable status.
-- Highway Vehicle Occupant Protection -- The protection to vehicle occupants through consistent use of restraints has long been advocated by the Safety Board, but it has found that there is a need for stricter and more consistent enforcement of seat belt laws by the states. The Board has also recommended measures to address the dangers posed by airbags to children and small statured adults, as well as measures to ensure the use of proper child passenger restraints.
-- Flight Data Recorders -- Although not a new issue on the "Most Wanted" list, I would like to discuss the importance of enhanced flight data recorders (FDR). Almost two years have passed since the Safety Board issued its recommendations for enhanced FDRs, and the Department has failed to enact any rulemaking on this important safety issue. We applaud this Committee for bringing attention to this subject in last year's Committee report, which stated: "The Committee does not believe the FAA has worked as diligently as possible to encourage the retrofit of expanded parameter flight data recorders (FDRs) into existing aircraft .... Therefore, the Committee directs FAA to work closely with NTSB over the coming year to develop a plan for the retrofit of expanded parameter FDRs into commercial aircraft."
On July 16, 1997, the FAA issued the NPRM on enhanced FDRs, with a 30-day comment period. NTSB comments on the rule were generally favorable. However, the NPRM would not require FDR retrofits to begin for at least another two years. Further, no action was taken on the Board's urgent recommendation to expedite the retrofit of Boeing 737 airplanes.
We agree with you that the FAA has not worked as diligently as possible on this issue. We are aware that a rulemaking package was forwarded to the Office of the Secretary of Transportation on February 7, 1997. However, the DOT and Office of Management and Budget review process has been lengthy. How much longer must we wait before action is taken?
Mr. Chairman, we are convinced that the Board's "Most Wanted" list remains one of our most effective methods for the identification of those issues we believe have the greatest potential for saving lives. Since its inception, nine "Most Wanted" safety issues have been removed from the list because of positive action taken by the recommendation recipients. The Board's staff is currently developing proposals for consideration by the Board of additional items to be added to the list, as well as removal of any items that may be successfully resolved. Attached to this testimony is a copy of the current "Most Wanted" list of safety issues.
Last year was a year of change at the Safety Board. As a direct result of three Congressional hearings, the ValuJet accident in Miami, and the TWA flight 800 accident, Congress passed legislation that requires the Safety Board to coordinate assistance to family members of the victims of airline accidents resulting in major loss of life. This followed a request from President Clinton that the Safety Board take the lead in coordinating family assistance following transportation accidents. As a response to these directives, I have established a Family Affairs Division, and we are currently preparing a federal response plan for major aviation disasters. Since this legislation became law, we have provided on-scene assistance at two major aviation accidents.
That assistance included twice-daily Safety Board briefings to those family members on scene, and conference calls to those family members who did not travel to the scene. We also coordinated with the Red Cross, which provides volunteers to assist families of victims, and arranged for mobile morgues from the Department of Health and Human Services (HHS). The mobile morgues are fully equipped, supplied, and staffed by forensic doctors, dentists, anthropologists, and other technical personnel. All participants are members of the disaster mortuary teams who also support FEMA in case of natural disasters. Each team member is a volunteer, private citizen who is deputized by HHS to work for us at an accident scene. We have completed a memorandum of understanding with HHS, and consider them an important partner in our accident investigation response.
The Safety Board has been in regular contact with the families of the victims of recent aviation disasters, including the families of TWA flight 800 victims since that accident occurred in July. We have provided those family members with a toll-free 800 number to use should they have questions, and we send periodic written updates on the accident. Also, at the families' request, on February 8, 1997, we organized and coordinated a tour of the Calverton, New York, wreckage hangars for 150 family members. Although a difficult day, all family members, I believe, were appreciative of our efforts.
The Safety Board has been providing family assistance with existing staff. As you will note -- both in the fiscal year 1997 supplemental request and in our fiscal year 1998 budget request -- we have requested additional resources for this new function.
About 575 million passengers boarded U.S. scheduled airlines in this country last year, about twice our population. And in ten years, it is estimated that domestic aviation operations will increase another 60 percent.
Preliminary aviation statistics for 1996 show an increase in the number of airline passenger deaths and major accidents, from 168 people in 1995, to 380 people in 1996. Three hundred forty of those fatalities were aboard the ValuJet and TWA aircraft. The major accident rate per million hours flown was 0.439 -- the fifth highest in the last 15 years. I would like to stress, however, that an air carrier accident is a rare occurrence, and aviation remains one of the safest modes of transportation.
The 1996 commuter rate was the lowest in the last 15 years, 0.032 per 100 departures. A total of 14 people were killed in a single fatal commuter airline accident in 1996, and there were almost 3.2 million commuter departures nationwide last year. This success is a tribute to the past efforts by the Board and subsequent FAA and industry efforts to raise the level of safety of commuter airlines to that of major air carriers.
General aviation fatalities were also the lowest in the past 15 years. General aviation has seen a steady decline in deaths. In 1996, 631 people lost their lives in general aviation accidents, a decrease from 733 people in 1995.
Completed Major Aviation Investigations
Since our last appearance before your Committee, the Safety Board adopted the reports of seven major aviation accidents and one special investigation. Below are summaries of those reports.
American Eagle/Roselawn Indiana
In July 1996, the Safety Board completed action on the aviation accident that occurred October 31, 1994, at Roselawn, Indiana. The airplane, an ATR 72, was in a holding pattern and was descending to a newly assigned altitude when an initial uncommanded roll excursion began, followed by a loss of control. The airplane was destroyed by impact forces, and the four crew and 64 passengers were killed. The Board determined that the probable cause was a sudden and unexpected aileron hinge moment reversal that was related to ice accretion beyond the airplane's deice boots, and that this occurred because ATR failed to disseminate adequate information concerning previously known effects of freezing precipitation on the airplane's stability, control, and operating characteristics, and because of the French DGAC's inadequate oversight of the airplane and its failure to provide the FAA with timely information about previous ATR incidents and accidents in icing conditions.
The Board focused on the forecasting and communication of hazardous weather information to flightcrews, federal regulations regarding aircraft icing and icing certification requirements, monitoring of aircraft airworthiness, and flightcrew training for unusual events. Safety recommendations addressing these issues and the flight characteristics and performance of ATR airplanes were issued.
ValuJet Airlines/Atlanta, Georgia
On June 8, 1995, ValuJet Airlines flight 597, began its takeoff roll at Atlanta, Georgia, when a loud bang was heard by the airplane occupants and air traffic control personnel. The flightcrew of a following airplane reported to the ValuJet crew that the right engine was on fire, and the takeoff roll was rejected. There were no fatalities, although the aircraft was destroyed by fire. On July 30, 1996, the Board determined that the cause of the accident was the failure of Turk Hava Yollari maintenance and inspection personnel to perform a proper inspection, allowing a detectable crack to grow to a length at which the disk ruptured, propelling engine fragments into the fuselage.
Atlantic Southeast Airlines/Carrollton, Georgia
On August 21, 1995, Atlantic Southeast Airlines flight 529, while climbing through 18,100 feet, experienced the loss of a propeller blade from the left engine propeller. The airplane then crashed while attempting an emergency landing near Carrollton, Georgia, about 31 minutes after departing the Atlanta Hartsfield International Airport. The captain and seven passengers received fatal injuries. On November 26, 1996, the Safety Board determined that the accident was caused by an in-flight fatigue fracture and separation of a propeller blade. The fracture was caused by a fatigue crack from multiple corrosion pits that were not discovered because of inadequate and ineffective inspection and repair techniques, training, documentation and communication.
Issues examined by the Safety Board were the manufacturer's engineering practices, propeller blade maintenance repair, propeller testing and inspection procedures, the relaying of emergency information by air traffic controllers, crew resource management training, and the design of crash axes carried in aircraft. Safety recommendations concerning these issues were made to the Federal Aviation Administration.
Tower Air/Jamaica, New York
On December 20, 1995, Tower Air flight 41, a Boeing 747, veered off the runway during an attempted takeoff at JFK International Airport in New York. The runway was slippery at the time of the accident, and the captain failed to reject the takeoff in a timely manner. Inadequate Boeing 747 slippery runway operating procedures developed by Tower Air and the Boeing Commercial Airplane Group and the inadequate fidelity of Boeing 747 flight training simulators for slippery runway oeprations contributed to the accident.
Fifteen safety recommendations were issued as a result of this accident on various subjects, including: slippery runways; adequacy of flight simulators; galley latches; crew resource management; air carrier surveillance standards; and runway friction measurments.
American Airlines/East Granby, Connecticut
On November 13, 1996, the Safety Board adopted its report on the aviation accident that occurred November 12, 1995, at Bradley International Airport at East Granby, Connecticut. An American Airlines MD-83, operated as flight 1571, was substantially damaged when it struck trees while on approach. The airplane also struck an instrument landing system antenna as it landed short of the runway on grassy, even terrain.
The Safety Board determined that the flightcrew failed to maintain the required minimum descent altitude. The failure of the approach controller to furnish the flightcrew with a current altimeter setting, and the flightcrew's failure to ask for a more current setting contributed to the accident. Safety recommendations regarding the following areas were issued: tower shutdown procedures; non-precision approach flight procedures; precipitous terrain and obstruction identification during approach design; the issuance of altimeter settings by air traffic control; low level windshear system maintenance and recertification; and emergency evacuation.
ValuJet Airlines/Nashville, Tennessee
On January 7, 1996, ValuJet fight 558, a DC-9, struck the runway approach light area tail first at Nashville International Airport, followed by main landing gear and nosegear. The nosewheel tires and rims separated after ground impact, and then the airplane became airborne again. The pilots performed a go-around and touched down on the second attempt on its main landing gear. The airplane sustained substantial damage to the tail section, nosegear, aft fuselage, flaps, slats, and both engines. There were five minor injuries.
The Safety Board determined that the flightcrew's improper procedures and actions in response to an in-flight abnormality resulted in the inadvertent in-flight activation of the ground spoilers during the final approach. Safety recommendations in the following areas were issued: the adequacy of ValuJet's operations and maintenance manuals, specifically winter operations nosegear shock strut servicing procedures; the adequacy of ValuJet's pilot training/crew resource management training programs; flightcrew actions/decisionmaking; the role of communications; ValuJet's flightcrew pay schedule; Federal Aviation Administration oversight of ValuJet; and the adequacy of cockpit voice recorder duration and procedures.
Continental Airlines/Houston, Texas
On February 19, 1996, Continental Airlines flight 1943, a DC-9-32, landed wheels up at the Houston Intercontinental Airport. The airplane slid 6,850 feet before coming to rest in the grass about 140 feet left of the runway centerline, and sustained substantial damage to its lower fuselage. The Safety Board determined that the accident was caused by the captain's decision to continue the approach contrary to Continental Airlines standard operating procedures that mandated a go-around.
Issues examined by the Board were: checklist design, flightcrew training, adherence to standard operating procedures, adequacy of FAA surveillance, and flight attendant tailcone training. Safety recommendations were issued to the Federal Aviation Administration regarding the above areas.
Special Investigation of Accidents Involving the Robinson Helicopter Company R22
The National Transportation Safety Board's special investigation of accidents involving loss of main rotor control by the Robinson Helicopter Company R22, adopted on April 2, 1996, was prompted, in part, by an accident that occurred during an instructional flight near Richmond, California in June 1992. The Safety Board reviewed fatal accidents involving certificated helicopters; reexamined the available wreckage of R22 accidents; reviewed the original certification process, certification requirements, and subsequent review of the R22 certification; and reviewed the Safety Board's recommendation history for the R22. The following issues were addressed:
! The implementation of appropriate measures to reduce the probability of loss of main rotor control accidents.
! The need for continued research to study flight control systems and main rotor blade dynamics in lightweight, low rotor inertia helicopters.
! The establishment of operational requirements to be addressed during future certification of lightweight, low rotor inertia helicopters.
! The need for the FAA to review and revise, as necessary, its procedures to ensure that internal recommendations, particularly those addressed in special certification reviews, are appropriately resolved and brought to closure.
Safety recommendations addressing these issues were adopted.
Cessna 177B/Cheyenne, Wyoming
On March 7, 1997, the Safety Board adopted the report of the April 11, 1996, accident involving a Cessna 177B carrying a commercial pilot/flight instructor, a seven-year-old passenger and her father. The aircraft was destroyed in an accident following takeoff. At the time of the aircraft's takeoff, there were strong winds and rain, with visibility at 2.5 miles. The flight originated from Half Moon Bay, California, on the previous day with intermediate stops at Reno and Elko, Nevada, before terminating for the night in Cheyenne. The aircraft was ultimately destined for Falmouth, Massachusetts.
The Board concluded that the probable cause of the accident was the pilot-in-command's improper decision to take off into deteriorating weather conditions when the airplane was overweight and when the density/altitude was higher than he was accustomed to, resulting in a stall caused by failure to maintain airspeed.
As a result of this accident, Congress in 1996 passed the "Child Pilot Safety Act." This law prohibits an individual who does not hold a valid private pilot certificate to manipulate the controls of an aircraft if the pilot knows that the individual is attempting to set a record or engage in an aeronautical competition or aeronautical feat.
On-Going Major Aviation Accidents
The Safety Board has eight on-going, major aviation investigations, and I would like to summarize each one.
The September 8, 1994, accident involving USAir flight 427 at Pittsburgh, Pennsylvania, which killed all 132 people on board, continues to be one of our most complex investigations. It has been one of the most far-reaching investigations in the history of the Safety Board, with Safety Board investigators and party participants working continually over 2 1/2 years to try to understand the very complex circumstances of this tragic event. The investigation has involved tens of thousands of staff hours and numerous flight tests, resulting in 20 safety recommendations.
The Safety Board is aware that Boeing is actively engaged in a redesign of the main rudder power control unit for the existing Boeing 737 series at a cost to Boeing of $120 million to $140 million. In January 1997, Boeing and the Federal Aviation Administration announced that the primary and secondary slides of the PCU servo control valve would be redesigned to preclude the potential for reverse rudder operation. The FAA plans to issue an airworthiness directive (AD) that would require the Boeing 737 fleet to be retrofitted with the new valve within two years.
We are encouraged by Boeing's commitment to move forward. We are concerned, however, that there may be a delay by the Federal Aviation Administration in issuing a final rule on the proposed AD, or that the AD might allow more than 2 years for operators to complete the installation of the new servo control valve. On February 20, 1997, the Safety Board issued three additional safety recommendations to the Federal Aviation Administration regarding the Boeing 737 aircraft. Those recommendations state:
! Require the expeditious installation of a redesigned main rudder power control unit on Boeing 737 airplanes to preclude reverse operation of the rudder and to ensure that the airplanes comply with the intent of the certification requirements. (A-97-16)
! Advise Boeing 737 pilots of the potential hazard for a jammed secondary servo control valve slide in the main rudder power control unit to cause a reverse rudder response when a full or high-rate input is applied to the rudder pedals. (A-97-17)
! Require the Boeing Commercial Airplane Group to develop operational procedures for Boeing 737 flightcrews that effectively deal with a sudden uncommanded movement of the rudder to the limit of its travel for any given flight condition in the airplane's operational envelope, including specific initial and periodic training in the recognition of and recovery from unusual attitudes and upsets caused by reverse rudder response. Once the procedures are developed, require Boeing 737 operators to provide this training to their pilots. (A-97-18)
This investigation continues, and I am proud of the dedication of the investigative team. I believe these recommendations reflect, in part, the progress we are making. Safety Board staff hopes to have a final report regarding this accident before the Board for consideration this year. We will, of course, keep the Committee advised of developments.
ValuJet Airlines/Miami, Florida
ValuJet flight 592 crashed into the Everglades shortly after takeoff from Miami International Airport on May 11, 1996, killing all 110 people on board. Before the accident, the flightcrew reported to air traffic control that it was experiencing smoke in the cabin and cockpit. It was learned during the on-scene phase of the investigation, which lasted over one month, that cardboard boxes containing as many as 144 chemical oxygen generators, the property of ValuJet, had been loaded in the forward cargo compartment shortly before departure.
As a result of this accident, in May 1996, the Safety Board issued safety recommendations to the Federal Aviation Administration and the Research and Special Programs Administration, and held a public hearing in November 1996.
On December 12, 1996, the member airlines of the Air Transport Association announced that they will voluntarily install smoke detectors in the cargo holds of their jets. On December 30, 1996, the Department of Transportation announced a permanent ban on the transportation of chemical oxygen generators as cargo on passenger airplanes. The ban extends a temporary prohibition issued on May 23, 1996, and limits the air transportation of chemical oxygen generators to compartments in cargo-only aircraft. As you will recall, the Safety Board has been concerned about the shipment of hazardous materials by air since an American Airlines in-flight fire that occurred in Nashville, Tennessee on February 3, 1988. We expect to issue a final report on this accident later this year.
Delta Airlines/Pensacola, Florida
Delta Airlines flight 1288, an MD-88 operating from Pensacola, Florida, to Atlanta, Georgia, experienced an uncontained failure of the left engine during the beginning of the takeoff roll. Two passengers were fatally injured by debris.
In July 1996, the Safety Board issued four safety recommendations to the Federal Aviation Administration regarding Pratt and Whitney JT8D-200 series engines. A public hearing will be held in Atlanta, Georgia, regarding this accident late this month.
Trans World Airlines/near East Moriches, New York
On July 17, 1996, TWA flight 800 tragically crashed into the Atlantic Ocean near East Moriches, New York, killing all 230 people on board. The aircraft wreckage in this accident was ten miles off the coast at a depth of 120 feet, making this investigation anything but typical.
To ensure the safety of the divers and to identify the location of the wreckage, the area had to be thoroughly mapped before the full scale underwater recovery effort could begin. Heavy wreckage was not lifted from the ocean floor until early August. By the end of October, the divers had cleared the debris fields of all large pieces of wreckage. On November 3, scallop trawlers were brought in to drag the ocean floor. To date, an area of over 28 square miles has been trawled, with some areas having been gone over in excess of 20 times. A second pass is being made over the entire area; trawling will continue until wreckage is no longer being recovered.
Based on the condition of the wreckage from the center forward section of the plane and that surrounding the center wing tank, the investigators are particularly interested in this area and have created mock-ups of this section. Three sets of scaffolding were erected on which this section of plane is being reassembled in order to give the investigators a better picture of what occurred. The fuselage surrounding the center wing tank was on one, the top and sides of the center wing tank on another, and the floor of the center wing tank was on the third.
It is apparent that an explosion occurred in the center wing tank, but the origin of the explosion and whether it was the initial event or a secondary event is not yet known. To date, with over 90 percent of the plane recovered, there is no physical evidence of a bomb or missile strike.
The Safety Board and the Federal Bureau of Investigation have called on numerous experts from across the international aviation community, the Department of Defense, and academia to assist in this investigation. Work that is either now underway or will be in the near future include:
! Complete the mock-up of the structure in the vicinity of the center wing tank. Safety Board contractors are completing a mock-up measuring approximately 92 feet, the largest reconstruction in the world.
! Fuel testing -- The Safety Board is engaged in laboratory and field testing at Cal Tech to study the ignition and explosive properties of jet A fuel, and the conduct of large scale tests of fuel-air explosions.
! Acoustic analysis of the cockpit voice recorder -- Safety Board investigators are working with experts from NASA and the United Kingdom on additional sound spectrum analysis to develop data against which the events registered on the TWA 800 CVR may be compared.
! Extensive mapping of interior damage patterns -- Safety Board investigators will extensively map interior damage patterns, including damage to occupants, seats, carpet, and floorboards.
! Extensive mapping of center wing tank parts and surrounding structure -- Safety Board investigators will extensively map the center wing tank and surrounding area, including integrating the cabin interior map.
! Evaluation of potential ignition mechanisms that may have triggered the center wing tank explosion -- This will include testing of the fuel line fittings, measuring the static electricity generated by fuel spray, assessment of potential sources of an electrical discharge, and evaluation of the potential for penetrates of the tank by high speed particles or fragments.
Mr. Chairman, the investigation into the crash of TWA flight 800 has been unprecedented, and all parties remain committed to finding the cause of this tragic event.
Federal Express/Newburg, New York
On September 6, 1996, a Federal Express flight from Memphis to Boston reported smoke in the cockpit to air traffic control and diverted to land at Stewart International Airport, New York. Thick smoke was reported as the five occupants evacuated the cockpit via the window escape ropes. Within 15 minutes, flames were sighted in the cockpit; the airplane was destroyed by fire.
It has been determined that the source of the in-flight smoke and fire was probably from a cargo container that included a DNA synthesizer. A shipping document stated that the synthesizer has been decontaminated prior to shipment; however, several containers in the machine still contained liquids after the fire was extinguished. Some of the chemicals used by the machine are extremely flammable. A lithium battery and electronic circuitry in the unit are also being examined as possible sources of ignition.
Delta Airlines/Laguardia Airport, Flushing, New York
On October 19, 1996, during an instrument landing system approach, the wings and landing gear of Delta flight 554, an MD-88, struck approach lights located on a pier extending into Flushing Bay, resulting in the separation of the main landing gears. The airplane subsequently impacted the runway and slid to a stop.
Issues being examined in the investigation include: flightcrew performance and training; Delta's procedures for monitoring flight instruments during approaches; and dissemination of weather information.
United Express/Quincy, Illinois
On November 19, 1996, United Express flight 5925, a Beechcraft 1900C, collided with a Beechcraft King Air on a runway at the Quincy Municipal Airport, Illinois, resulting in 14 fatalities -- everyone who was aboard the two aircraft.
Evidence has revealed that some occupants of the United Express aircraft moved to the forward air stair door; however, attempts to open the forward door by individuals at the airport were unsuccessful. All 14 fatalities were the result of smoke inhalation. In January 1997, the Safety Board issued a safety recommendation to the Federal Aviation Administration regarding the Beech 1900 external air stair exit door.
The Safety Board also had difficulty obtaining information from the cockpit voice recorder on the Beechcraft 1900C, and on November 28, 1996, Beech and the Federal Aviation Administration were verbally advised of the problem. A safety recommendation is with the Board Members for consideration asking Beech to review and correct the recording capability of the cockpit voice recorder radio channels for all Beech 1900 aircraft.
Airborne Express/Pearisburg, Virginia
On December 22, 1996, an Airborne Express DC-8 crashed into mountainous terrain near Pearisburg, Virginia in the Jefferson National Forest. The airplane was destroyed and all 6 persons on board were fatally injured.
The airplane was engaged in a functional check flight following major modifications. Evidence indicates that the initial descent of the aircraft was likely related to a flight test profile rather than a structures or systems anomaly. Safety issues being examined include: pilot performance, company management, and FAA oversight.
Comair flight 3272 crashed on January 9, 1997, near Monroe, Michigan, destroying the airplane and killing all 29 people on board. The scheduled commuter flight was under instrument conditions on approach to the Detroit airport at the time of the accident. Visibility was about 1/2 mile in light snow, with reports of light to moderate icing in the area.
Issues being examined include: pilot performance and Comair procedures, weather dissemination, air traffic control procedures, and airframe icing.
Foreign Aviation Investigations
A major airline accident involving fatalities anywhere in the world causes significant concerns on the part of the traveling public, both in the United States and overseas. The Board's involvement in the investigation of major international accidents assists in reducing these concerns, and provides us access to accident prevention measures that have a direct benefit to the safety of U.S. travelers. It also provides a critical contribution both to U.S.-foreign relations.
In fiscal year 1996, the Safety Board sent a U.S. accredited representative to ten foreign accidents, and participated without travel in 51 other foreign accident investigations. A synopsis of two of these investigations follows:
! On February 24, 1996, two U.S.-registered aircraft operated by Brothers to the Rescue, a group that has been supporting Cuban refugees fleeing via water, were shot down by Cuban military fighters in international waters near Cuba. Four persons were killed. The United States protested to the United Nations and a Resolution was passed that requested the International Civil Aviation Organization (ICAO) to investigate the circumstances. The Safety Board was selected to lead the U.S. interagency support to the investigation.
The Safety Board coordinated meetings with various U.S. government agencies in Washington, D. C. and Miami, Florida. Interviews were conducted and considerable material, including radar tapes and plots, voice tapes and transcripts, and other items were given to the ICAO team. The final report, which concludes that the Cubans shot down the aircraft in international airspace and did not comply with international standards for interception of aircraft, was forwarded to the United Nations Security Council and was adopted without change.
! October 2, 1996, an AeroPeru Boeing 757 crashed into the Pacific Ocean after takeoff from Lima, Peru. All 71 persons on the airplane were fatally injured. The flightcrew reported a loss of instrumentation just after takeoff. Based upon the data from the recorders and evidence from the wreckage, it was confirmed that tape was inadvertently left on the airplane static ports after the airplane had been waxed. The Safety Board coordinated the successful recovery of the recorders and key wreckage from the Ocean floor. An urgent safety recommendation letter was issued by the Board to the Federal Aviation Administration to ensure that such an event does not occur on other airliners.
Pipelines transport about 57 percent of the crude petroleum and petroleum products moved within the United States. The potential threat to public safety from such releases has become more severe in recent years, as the rate of residential and commercial development adjacent to all types of pipelines has accelerated.
Pipeline Spills During Flooding Near Houston, Texas
Between October 14 and October 21, 1994, eight pipelines ruptured and 29 others were undermined due to flooding near Houston, Texas. More than 1.47 million gallons of petroleum and petroleum products were released into the river. Ignition of the released products within flooded residential areas resulted in 547 people receiving minor burn and inhalation injuries.
The Board's special investigation into the ruptures looked into: (1) the adequacy of Federal and industry standards on designing pipelines in flood plains; (2) the preparedness of pipeline operators to respond to threats to their pipelines from flooding and to minimize the potential for product releases; and (3) the preparedness of the Nation to minimize the consequences of petroleum releases. Nine safety recommendations were made regarding the above issues.
Special Investigation into Liquid Pipelines
Within a 15-month period, the Colonial Pipeline Company experienced the rupture of two of its petroleum product pipelines, which resulted in large releases of diesel fuel that affected major water supplies. In both accidents, the ruptured section of pipeline had been mechanically damaged during previous excavation work. There has been a growing concern about the environmental consequences of releases from pipeline systems that potentially pose the greatest risk to the environment.
The Board's special investigation into liquid pipelines reviewed the Research and Special Programs Administration's (RSPA) responsiveness to implement previous safety recommendations addressing the prevention of excavation damage, the control of corrosion damage, the inspection and testing of pipelines, and methods to more rapidly detect, locate, and shut down failed sections of a pipeline. Also included in the investigation was a review of the safety performance of Colonial Pipeline Company. The Board determined:
-- On the basis of the number of accidents per 1,000 miles of pipeline and the number of barrels of product released per 1 million barrels of product transported, Colonial's operating performance is below the level of performance for many of the 14 pipeline companies with the greatest number of reported accidents.
-- Although RSPA's data on hazardous liquid pipeline accidents can be analyzed to determine some general trends and conclusions, the data on hazardous liquid pipelines, as they are currently collected and reported, are not sufficient for RSPA to perform an effective accident trend analysis or to properly evaluate operator performance.
-- Although RSPA has taken regulatory action and undertaken other initiatives to minimize excavation damage, RSPA has failed to take effective and timely action to address corrosion control, inspection and testing of pipelines, and methods to limit the release of product from failed pipelines.
-- RSPA's failure to fully implement the Safety Board's original 1978 safety recommendations to evaluate and analyze its accident data reporting needs has hampered RSPA's oversight of pipeline safety.
-- With the deficiencies of the current accident data base for hazardous liquid pipelines, RSPA will find it exceedingly difficult to fully implement an effective risk management program.
The Safety Board issued one new safety recommendation and reiterated three previous recommendations -- including a 1995 recommendation to expedite requirements for installing automatic or remote-operated mainline valves on high pressure pipelines in urban and environmentally sensitive areas to provide for rapid shutdown of failed pipeline segments.
Sweetwater, Tennessee Hazardous Materials Accident
On February 7, 1996, 500 to 600 people were evacuated twice from the Sweetwater, Tennessee, area when a hazardous material -- carbon bisulfide -- spilled from a ruptured railroad tank car. Approximately 10,418 gallons of the hazardous material escaped. The tank car was part of an eastbound Norfolk Southern Corp. train that was idling and waiting for another train to pass. The ruptured car was manufactured in June of 1969.
Post incident examination of the tank car revealed that the fracture originated where a pad for a bottom center reinforcement bar was welded to the tank. Reinforcement bars were added to the tank in 1990, but were not installed as specified by the Association of American Railroads tank car modification approval.
Issues being looked into regarding this accident include: characteristics of the steel used to construct the tank car; modifications to the tank car; and emergency response and cleanup events.
Selkirk, New York, Hazardous Materials Accident
On March 6, 1996, about 3 minutes after a tank car filled with propane was switched onto a track to be coupled with other railroad cars, the tank car failed, and 32,000 gallons of propane were released. A fire ball followed. The tank car separated into approximately two equal parts. Indications are that the failure began near the top of the tank, in an area where repair work or modification work had been previously done.
The tank car was inspected and given a hydrostatic pressure test in December 1995. This was only the 2nd load of cargo transported since the test was completed.
Marathon Pipeline Rupture/Gramercy, Louisiana
On May 24, 1996, a Marathon 20-inch diameter pipeline ruptured and released 498,540 gallons of gasoline. The escaping gasoline filled a utility right-of-way between highway US 61 and the Kansas City Southern Railroad near Gramercy, Louisiana, causing environmental damage.
Excavation work had been performed in the area near the rupture several months before the accident, and there was evidence of mechanical damage to the pipe, including gouges, scrapes, and dents.
Colonial Pipeline Rupture, Fork Shoals, South Carolina
On June 26, 1996, 957,600 gallons of fuel oil spilled into the Reedy River near Fork Shoals, South Carolina, following the rupture of a 36-inch diameter pipeline owned by the Colonial Pipeline Company. The spill migrated 25 miles downstream from the rupture site.
The pipeline wall was very thin due to corrosion at the Reedy River, and had been scheduled for replacement. In many places near the rupture, the pipeline wall was less than half its normal thickness. During the evening of the accident, the pipeline pressure became too great for the exposed and corroded section to withstand. Issues being looked into include leak detection, rapid shutdown of the ruptured pipe, and the ability of the controller to safely operate the pipeline under restricted conditions.
San Juan Gas Company Pipeline Explosion
San Juan Gas Company received a report of a gas leak in a shopping and residential district on November 20, 1996. A gas crew responded that afternoon, and a crew returned the following morning. Leak detection work was underway when an explosion occurred, destroying the first, second, and third floors of a six story building and damaging other buildings and parked cars in the vicinity. There were 33 fatalities, and 80 injuries as a result of this accident. This is the deadliest pipeline accident in the Safety Board's 30-year history.
On December 16, 1996, the Safety Board issued five urgent safety recommendations to the Governor of Puerto Rico regarding the dissemination of education information; excavation activities near buried facilities; updating of buried facility information; the notification to operators of damage by excavators; and the necessity of an excavation damage prevention program.
On February 25, 1997, the Safety Board issued four safety recommendations -- two of them urgent -- to the Enron Corporation regarding leak detection, employee training, public education, and information collection.
The Board has approved a public hearing regarding this accident, which will be held in late Spring or early Summer.
Although most people know of the Board's high-profile aviation investigations, highway transportation is the center of our transportation infrastructure. Highway fatalities also account for more than 90 percent of all transportation-related fatalities in our country.
Completed Highway Investigations
Grade Crossing Accident/Sycamore, South Carolina
On March 5, 1996, the Safety Board completed action on a grade crossing accident that occurred May 2, 1995, that involved an Amtrak train and a tractor-lowbed semitrailer combination. The semitrailer had lodged on a passive crossing near Sycamore, South Carolina, when it was struck by the southbound Amtrak train. Thirty three persons sustained minor injuries, and there was a combined property damage to the train and truck that exceeded $1 million.
The Safety Board determined that the probable cause of the accident was the motor carrier's failure to provide the driver with appropriate guidance to respond to emergency situations. In its final report, the Board addressed identification and warnings of hump crossings, emergency notifications at grade crossings, and adequacy of training for commercial drivers. Safety recommendations were issued to the Secretary of Transportation, the Federal Highway Administration and several organizations regarding these issues.
Schoolbus-Train Collision/Fox River Grove, Illinois
Schoolbuses carry about 9 percent of the U.S. population during a typical school day, and one of the most tragic accidents investigated by the Board occurred on October 25, 1995, in Fox River Grove, Illinois. When a schoolbus crossed railroad tracks at an active grade crossing and stopped for a red traffic signal, its rear extended about 3 feet into the path of a Metra passenger train. The train crashed into the schoolbus, killing 7 of the 35 schoolbus occupants.
The Safety Board determined that the probable causes of the accident were the failure of the (1) Illinois Department of Transportation to recognize the short queuing area on northbound Algonquin Road and to take corrective action, (2) Illinois Department of Transportation to recognize the insufficient time of the green signal indication for vehicles on northbound Algonquin Road before the arrival of a train at the crossing, and (3) Transportation Joint Agreement School District to identify route hazards and to provide its drivers with alternative instructions for such situations. The Board also determined that the Illinois Department of Transportation, the Illinois Commerce Commission, and the railroads failed to have a communications system that ensures understanding of the integration and working relationship of the railroad and highway signal systems. The Safety Board issued 29 safety recommendations to 14 recipients as a result of this tragedy.
Following this accident, the Safety Board, along with Operation Lifesaver, conducted briefings on grade crossing safety in Congressional Districts. I believe these briefings were informative to those in attendance, and we would be happy to cooperate with any Member who would like to hold similar briefings.
The Performance and Use of Child Restraint Systems, Seatbelts, and Air Bags for Children in Passenger Vehicles
Child restraints have been shown to be 69 percent effective in reducing the risk of death to infants, and 47 percent effective for children between the ages of 1 and 4. Lap/shoulder belts reduce the risk of fatal injury by 45 percent and moderate to critical injury by 50 percent for passenger car occupants who are older than 5 years.
Mr. Chairman, 15 years ago the Safety Board told this Committee that "Automobile crashes are the number one killer and crippler of children." Despite the effectiveness of child restraints and lap/shoulder belts to reduce the likelihood of severe and fatal injuries, accidents continue to occur in which restrained children are being injured and killed.
The Board's Safety Study examined the performance and use of occupant protection systems for children: child restraint systems, vehicle seatbelts, and air bags. The Board determined that children properly restrained in the back seats of vehicles are less likely to sustain injury than those seated in the front seats. The important words in the previous sentence are "properly restrained." Over half of the children in the study sample who used child restraint systems were improperly restrained; and about one-quarter of the children who used seatbelts were improperly restrained. In addition, more than two-thirds of the children were not in the appropriate restraint for their age, height, and weight.
In 1996, 22 children were killed by air bags. The Safety Board's study concluded that air bags are a proven safety device for most properly restrained adults in severe frontal crashes. However, passenger side air bags can inflict serious or even fatal injuries to small children, even when those children are properly restrained. As they are currently designed, air bags are not acceptable as a protective device for children, and, whenever possible, parents should keep their children in the back seat, properly restrained.
On March 17 - 20, 1997, I will be chairing an air bag and child passenger safety public forum in Washington, D. C. The Safety Board is hosting this forum to facilitate the sharing of information on air bags and child passenger safety across the lines of government, industry, safety organizations, and private citizens. This information exchange will address the role of air bags in today's vehicles, their benefits and safety concerns, and proper child passenger transportation in the 1990s. The Safety Board will use the information obtained during the public forum to determine if additional safety recommendations are needed to enhance air bags and child passenger safety.
On-Going Highway Investigations
On February 12, 1997, near Slinger, Wisconsin, a double tractor-semitrailer lost control on a slippery roadway, crossed the median into the southbound lane, and struck a single tractor-semitrailer. The double tractor-semitrailer then swerved back across the median and struck a northbound van. The van was then struck by another vehicle from behind. The accident resulted in eight fatalities -- all in the van, and four injuries. Areas being looked into include winter highway maintenance, driver experience, and seat belt usage in the van.
Passive Grade Crossing Safety Public Forum
Every year about 4,600 motor vehicles are involved in accidents at grade crossings. These accidents kill about 500 people, and they injure more than 1,800 people annually. Although two-thirds of all crossings are passive (have no train-activated devices), these crossings have rarely been targeted by Federal safety programs and research projects.
A safety study is currently underway by the Safety Board to examine how a reduction in the number of accidents could be achieved through low-cost physical improvements at grade crossings. As part of this study, the Board will hold a passive grade crossing public forum in Jacksonville, Florida on May 8 and 9, 1997. The forum will focus on:
-- passive grade crossing concerns;
-- grade crossing safety through education;
-- physical characteristics of passive grade crossings;
-- communications between railroad and highway officials;
-- crossing closures and private/public crossings; and
-- responsibility for grade crossing safety.
Corporate Culture and Transportation Safety Symposium
Over the past few years, the Board has begun to address the role corporate culture plays in the cause of the accidents it investigates. This is a topic of increasing interest to the Board, and in April we will sponsor a two-day symposium addressing the effect that corporate management philosophies and practices have on transportation safety. We have asked the transportation community to join us in examining how organizations' culture influences safety so it can begin to focus on prevention.
We believe this symposium will benefit managers and employees alike, since safety must be a cooperative effort involving everyone in the organization.
Marine is one of the most diverse modes of transportation. In the United States, there are 25,000 miles of waterways, about 46 million recreational boaters, 200,000 commercial fishing vessels, and more than 4 million passengers a year board cruise ships from U.S. ports. Three of the 18 "Most Wanted" are marine issues: fishing vessel safety, small passenger vessel safety, and recreational boating safety.
Completed Marine Investigations
Fire on Board U.S Fish Processing Vessel ALASKA SPIRIT
The U.S. fish processing vessel ALASKA SPIRIT, owned by The Fishing Company of Alaska, Incorporated, caught fire and burned while moored alongside a dock at the Seward Marine Industrial Center at Seward, Alaska, on May 27, 1995. The master of the vessel died, and damage to the vessel was estimated at $3 million -- half of the $6 million value of the ship. The Safety Board determined that the Fishing Company of Alaska failed to address the inadequate fire safety conditions and practices on the vessel, and that the lack of fire safety standards for commercial fishing industry vessels contributed to the severity of the damage and loss of life.
Issues looked into included: adequacy of noncombustible construction standards for commercial fishing industry vessels; adequacy of fire detection and fire suppression equipment; drills and readiness of on-board firefighting hoses; and existing vessel fire safety standards. Ten safety recommendations were issued on the above issues.
On-Going Major Marine Investigations
The Safety Board has six major marine accidents under investigation. Those accidents are:
ROYAL MAJESTY/Nantucket Island, Massachusetts
On June 10, 1995, the Panamanian passenger ship ROYAL MAJESTY grounded on a sand bar located about 10 nautical miles east of Nantucket Island, Massachusetts. The ROYAL MAJESTY was being navigated by a global positioning system which determined courses to steer and incremental way points automatically. The navigation watch personnel were plotting these positions on the navigation chart, but were not verifying positions by any alternate method of navigation. It was determined that the GPS-determined positions were in error by about 20 miles. A Board meeting to consider the final report of this accident is scheduled for March 12, 1997.
Issues being looked into: the performance of the bridge watchstanders; the adequacy of company oversight; training of bridge watchstanders in the use of the ROYAL MAJESTY'S integrated bridge system; adequacy of aids to navigation in the approaches to Boston Harbor; performance of the Raytheon 920 GPS satellite receiver; adequacy of the system engineering of the Atlas-Krupp Navigation Command System; effects of automation on operator performance; and industry oversight of integrated bridge systems.
SCANDIA/Point Judith Rhode Island
On January 19, 1996, the U.S. SCANDIA was underway en route from New York, New York, to Providence, Rhode Island with the U.S. Tankbarge NORTH CAPE in tow. As the tow was executing a turn to enter Narragansett Bay, a fire broke out in the SCANDIA's engineroom. The U.S. Coast Guard Station Point Judith, Rhode Island, immediately launched a motor lifeboat to the scene. By the time boat arrived, the SCANDIA was fully engulfed in flames. About 728,000 gallons of heating oil spilled from the NORTH CAPE.
Issues being looked into include: cause of the fire which led to the grounding and spill; the Coast Guard's re-evaluation of risk assessment and standards in the transportation of oil and hazardous materials by tug/barge systems; and assessment of Coast Guard search and rescue procedures, and operations.
UNIVERSE EXPLORER/En Route Glacier Bay, Alaska
On July 27, 1996, the Panamanian passenger ship UNIVERSE EXPLORER was underway en route from Juneau, Alaska to Glacier Bay when a fire was discovered in the main laundry. Dense smoke and heat from the fire spread from the laundry, upward to A-deck via an open stairwell. The fire was later brought under control by the crew. However, the fire resulted in the deaths of 5 crewmembers and caused smoke inhalation injuries to 27 other crewmen. The fire also caused extensive damage to the main laundry and to the crew berthing spaces. Damages are estimated to exceed $1 million.
Issues being looked into include: adequacy of fire prevention, detection and suppression procedures of the UNIVERSE EXPLORER; the adequacy of escape, rescue, medical care and evacuation procedures on board the UNIVERSE EXPLORER; and the assessment of the current status of Coast Guard and local authority contingency planning for response to a major passenger ship accident in Alaskan waters.
JULIE N/Portland Maine
On September 27, 1996, the Liberian tank vessel JULIE N struck the Million Dollar Bridge in Portland, Maine, spilling about 170,000 gallons of oil into the waterway. The ship and bridge received substantial damage. There was a pilot on board the vessel at the time of the accident. The Safety Board plans to hold a public hearing regarding this accident on March 13 and 14, 1997, in Portland, Maine.
Issues to be looked into at our hearing include: Toxicological (drug and alcohol testing); and port risk assessment.
SUNDOWNER/Marina del Rey, California
On December 7, 1996, a fire erupted on board the U.S. pleasure craft SUNDOWNER as the vessel was returning to its dock in Marina del Rey, California. The fire originated in the diesel exhaust stack and spread to the vessel structure. The SUNDOWNER, which was not an inspected passenger vessel, had been chartered to host a company Christmas party. At the time of the fire, there were 62 passengers, 7 crew and a disc jockey on board. Most of the passengers were forced to jump overboard to escape the fire.
All passengers interviewed stated they did not receive a safety briefing, they did not know where the life jackets were stowed, and no one recalled seeing a locker or cabinet marked "life jackets." Also, the crew of the SUNDOWNER did not provide guidance or assistance to them in their escape from the vessel, and there was no organized effort to evacuate the passengers. Thankfully, the vessel was only about 20 feet from the pier at the time of the accident, and people swam to it and climbed out of the water, assisting by those on the pier and recreational boaters in the area.
Issues being looked into are: bare boat chartering of passenger vessels; fire safety on small passenger vessels; crew training for emergencies on small passenger vessels; and the cause of the fire.
BRIGHT FIELD/New Orleans, Louisiana
On the afternoon of December 14, 1996, the Liberian bulk carrier BRIGHT FIELD, under the navigation control of a pilot of the New Orleans Baton Rouge Steamship Pilots Association, was proceeding at full ahead sea speed when the lube oil pump on the main engine lost pressure, resulting in the sudden loss of engine rpms and subsequent loss of steering control. The pilot used his radio and the ship's whistle to warn persons ashore in time for them to avoid injury.
No one in the River Walk Shopping Mall was injured; however, some persons on board a casino boat moored to the complex were seriously injured when they jumped overboard, thinking that the BRIGHT FIELD was going to strike the casino boat.
Issues being looked into include: port risk assessment; bridge resource management, engineering systems, crew communication and language.
More than 200,000 people are employed by the railroad industry, an industry where there are 123,000 miles of railroads. Two of the 18 items on the "Most Wanted" list are railroad issues -- positive train separation and the safety of passengers in railroad passenger cars.
Completed Major Railroad Investigations
New York City Transit Subway Collision on the Williamsburg Bridge
On June 5, 1995, a New York City Transit southbound J subway train collided with the rear car of a stopped M subway train on the Williamsburg Bridge. The operator of the J train was fatally injured, and 69 people were treated at area hospitals for injuries. The Safety Board determined that the J train operator failed to comply with a stop indication because he was asleep. His last sleep period (a Sunday evening nap) was probably less than 3 hours, and he had received only about 6 hours of sleep or less in the 24 hours before the accident.
The Safety Board has been concerned about fatigue in transportation for many years, and it is an issue on our "Most Wanted" list. During the investigation of this accident the Safety Board contacted six major transit agencies and found that none of them provides fatigue-related training in its employee training program. In a transit system that is not fail safe and is vulnerable to human error, the issue of fatigue is of great concern.
Special Investigation: Steam Locomotive Firebox Explosion on the Gettysburg
Railroad near Gardners, Pennsylvania
On November 15, 1996, the Safety Board adopted a special investigation report of a steam locomotive firebox explosion that occurred June 16, 1995, at Gardners, Pennsylvania. The steam locomotive failed while the locomotive was pulling a six-car excursion train, resulting in an explosion of steam through the firebox door and into the locomotive cab, seriously burning the engineer and two firemen. There were 310 passengers on the train at the time of the explosion. The Safety Board determined that the boiler was not properly maintained and the crew was not properly trained.
Approximately 150 steam locomotives are still operated in the United States, virtually all used by tourist railroads, museums, historical groups, and steam-excursion groups. We believe this accident illustrates the hazards that are always present in the operation of steam locomotives. The Safety Board pointed out in its report that Federal regulatory controls and expertise in operating and maintaining steam locomotives are outdated.
Collision of Washington Metropolitan Area Transit Authority Train
On January 6, 1996, a Washington Metropolitan Area Transit Authority Metrorail subway train failed to stop as it entered an above-ground passenger station, at Gaithersburg, Maryland. The train continued about 470 feet into a Metrorail yard north of the station, where it struck a standing, unoccupied subway train. There was a snow storm in the Washington, D. C. area at the time of the accident. The accident resulted in the death of the train operator and property damages between $2.1 and $2.6 million.
Issues looked into as a result of this accident included:
! Adequacy and appropriateness of WMATA methods of management, decisionmaking, and communications;
! Safety implications of the decision to eliminate routine manual train operation on the Metrorail system;
! Effectiveness of using performance levels to control train speed;
! Compatibility between railcar braking performance and design of the automatic train control system; and
! Adequacy of WMATA and Montgomery County emergency response procedures.
Safety recommendations were issued on the above subjects.
Burlington Northern Santa Fe Derailment/Cajon Junction, California
On February 1, 1996, a Burlington Northern Santa Fe freight train, comprised of four locomotives and 49 cars, was traveling westward between Barstow and San Bernardino. The train derailed after reportedly going out of control at a speed of about 50 to 55 miles per hour on a 3 percent downgrade. Two of the three crewmembers received fatal injuries. After the derailment a fire ignited that engulfed the train and the surrounding area, and Interstate 15 was twice closed because of the fear of unstable hazardous materials. The conductor and the brakeman sustained fatal injuries. Issues looked into as a result of this accident included:
! Lack of Federal and management oversight in the use of two-way end-of-train devices;
! The adequacy of operating personnel training in the use of two-way end-of-train devices;
! The carrier compliance with Federal regulations for event recorders; and
! Adequacy of wreckage removal operations for tank cars containing hazardous materials.
Safety recommendations were issued regarding these issues.
On-Going Major Railroad Accidents
Collision and Derailment of New Jersey Transit Commuter Train
Secaucus, New Jersey
On February 9, 1996, an eastbound New Jersey Transit commuter train collided nearly head-on with a westbound New Jersey Transit commuter train, killing the engineers on both trains and one passenger, and injuring 162. There were over 400 passengers on the two trains.
Issues being looked into as a result of this accident include: the medical condition of the engineer of the eastbound train; the adequacy of medical standards and examinations for locomotive engineers; the adequacy of the train crewmembers' response to the accident; and crashworthiness of the trains and the response effort of emergency personnel.
Collision and resulting Fire Involving MARC/Amtrak Trains
Silver Spring, Maryland
On February 16, 1996, at 5:38 p.m., an eastbound MARC commuter train collided with a westbound Amtrak train. The three MARC crewmembers and eight passengers in the first MARC car received fatal injuries.
The collision resulted in the structural separation of the front quadrant of the MARC cab control car. The fuel tank of Amtrak's lead locomotive ruptured on impact and the diesel fuel ignited. Fire engulfed the rear superstructure of the Amtrak locomotive, spilled on the MARC cab control car, ignited, and destroyed the car.
In March 1996, the Safety Board issued four urgent safety recommendations to upgrade rail passenger safety to the Federal Railroad Administration and the Maryland Mass Transit Administration. As you are aware, in April 1996, the Safety Board elevated its passenger rail safety recommendations to the "Most Wanted" list of safety issues, urging the Federal Railroad Administration to inspect all commuter rail equipment across the country, and to determine if it has effective, easily-used and identifiable emergency evacuation exits and apparatus. Although the State of Maryland has complied with our safety recommendations, we are disappointed that the Federal Railroad Administration has not taken action.
A 2 1/2 day public hearing was held regarding this accident in June 1996.
Amtrak Derailment on Portal Bridge/Secaucus, New Jersey
On November 23, 1996, an eastbound Amtrak train derailed on the Portal Bridge in Secaucus, New Jersey while proceeding at about 70 miles per hour. As the train was derailing, a westbound Amtrak train applied emergency braking, but portions of the train struck the derailed train. There were no fatalities.
The Portal Bridge is an open deck, swivel bridge. Safety Board investigators discovered 1 broken and 1 cracked rail side bar on the miter rail at the point of derailment. Issues being looked into include: design of Portal Bridge special trackwork; oversight of special trackwork on moveable bridges; and Portal Bridge inspection and maintenance.
Union Pacific Freight Train Derailment/Kelso, California
On January 12, 1997, a Union Pacific freight train derailed 68 cars near Kelso, California. The derailment occurred on a descending 2.2% grade at 72 miles per hour while the train was in a runaway condition. The train's authorized speed was 15 miles per hour. The train consisted of three locomotive units and 75 loaded covered hopper cars. Total damage was estimated at $4,377,250.
Issues being looked into as a result of this accident include: the location of safety sensitive devices within a locomotive control compartment; car/train weight; dynamic brake requirements; retainer valve procedures; and operational speeds.
REGIONAL OFFICE ACTIVITIES
Before I discuss our budget needs, I would like to take a moment to discuss our nine regional and field offices -- the backbone of our agency. Most of the Board's visibility revolves around major accident investigations. But it is the regional staff that investigates the majority of accidents, it is the regional staff that supports the Board's safety studies and major investigations, and it is the regional staff that identifies most emerging safety problems as a result of their investigations.
Between 30 and 35 percent of all aviation safety recommendations over the past five years originated from regional investigations. However, in most cases, safety issues identified do not need safety recommendations, because the problem is taken care of locally. Over the past three years, approximately 95 safety issues were identified and corrected at the local level. Early identification of safety problems often originates from the regions, and this means lives saved. We at the Board are proud of their significant contributions to transportation safety.
FY 1998 BUDGET REQUEST
Mr. Chairman, the Safety Board's request for resources this year comes in two parts; the first is for supplemental fiscal year 1997 funding, and the second is for fiscal year 1998 funding.
We are requesting $23.2 million in supplemental funding for fiscal year 1997. Most of these resources ($20.1 million) will cover anticipated costs of the TWA flight 800 investigation for the current fiscal year. The remaining $2.2 million would cover additional high priority requirements, especially in the area of assistance to families of victims of transportation disasters. Approximately $12 million of the supplemental request will repay the U.S. Navy for wreckage and victim recovery they provided last year, and for the Calverton, New York facility we now occupy. The balance will fund other investigative activity in fiscal year 1997 such as the fuselage mock-up, wreckage trawling and explosive testing. Because we want to determine the probable cause of this accident as expeditiously as possible, we requested a deficiency apportionment from the Office of Management and Budget to allow us to spend some of our 4th quarter funding on this effort now, in anticipation of the supplemental.
For fiscal year 1998, the President's budget contains $46.0 million and 381 full-time equivalent (FTE) positions for the Safety Board. This represents an increase of $3.6 million and 11 FTEs over the FY 1997 enacted level, excluding the $6 million earmarked for the TWA flight 800 investigation. Approximately $1.3 million of the requested increase will fund the additional positions, $2.1 million will cover inflationary increases, and $.2 million will fund modest enhancements to our laboratories.
In addition, we request that the Board's Emergency Fund be increased to $2 million from its current $1 million, and that the language be modified to allow the use of this fund to provide assistance to families of victims of transportation disasters. This additional emergency funding would cover family assistance services provided by other Federal and state agencies and private organizations on a cost reimbursable basis.
The President's budget also anticipates $6 million of the $46 million required for normal salaries and expenses would be provided through a tax on U.S. air transportation operators based on revenue passenger miles flown. In addition, we have discussed with OMB the possibility of requiring all air carriers operating to, from or within the United States to carry insurance or surety bonding to pay for extraordinary accident recovery and investigation costs incurred by the Safety Board. We fully support the latter proposal, as we see no other practical alternative that provides the needed funding to expeditiously pursue catastrophic accident investigations, and provide the support to the families of victims that recent legislation has mandated.
As you know, the quantity and complexity of the Board's accident investigations continues at historically high levels in all modes of transportation, placing unprecedented and undue pressures on our limited staff and dollar resources.
Mr. Chairman, our goal is to ensure that the Safety Board's vital transportation safety programs are provided adequate staff and funding, and are being managed in the most effective and efficient manner possible. Our ability to make timely and accurate determinations of the probable causes of accidents, to issue realistic and feasible safety recommendations, and to respond to the families of victims of transportation disasters in a timely, compassionate, and professional manner following these tragedies depends on these resources, and the continued support of your Committee.
Mr. Chairman, that completes my statement. I will be happy to respond to any questions you or the Committee members may have.
Jim Hall's Speeches