Good morning Mr. Chairman and Members of the Committee. It is a pleasure to be here today to review the National Transportation Safety Board's (NTSB) activities and fiscal year 1997 budget request.
Before I begin, I would like to thank you and this Committee for your support for the Safety Board and its programs during this difficult time of budget reductions. As a result of your actions, the Safety Board is able to continue its work at current levels on behalf of the traveling public.
Mr. Chairman, the year since our last appearance has been a busy one for the Safety Board. Along with our accident investigation responsibilities, we completed studies on air tour operations, aviation safety in Alaska, and the air traffic control system; hosted, with the National Aeronautics and Space Administration (NASA), a multimodal fatigue symposium attended by close to 600 people, including participants from 16 countries; published the proceedings of the pipeline excavation damage prevention workshop; and issued 343 safety recommendations in all modes of transportation.
In 1995 the NTSB launched "Go Teams" to 3 aviation, 3 highway, 4 marine, 1 pipeline, and 4 railroad accidents, and adopted 24 major accident reports, studies, or special investigations (9 aviation, 4 highway, 4 marine, 3 hazardous materials/pipeline, and 4 railroad). Over 2,300 accidents in all modes of transportation were investigated by the NTSB in 1995.
Mr. Chairman, the end product of Board investigations are the safety recommendations, culminating in satisfactory action by the recommendation recipients. Over the years, these recommendations have ranged from fire resistant materials and floor-level escape lighting in aircraft cabins, to child safety seats in automobiles and improved school bus construction standards, to the requirement for the installation of head shields on railroad tank cars and improved cabin safety in railroad passenger cars, to new recreational boating safety and commercial fishing vessel regulations, to the development of one-call notification systems in all 50 States and improved regulations for buried pipelines.
The safety improvements mentioned would not have occurred as soon without the Safety Board providing the impetus. The men and women of the National Transportation Safety Board look with pride upon safety enhancements that statistics show contribute to the United States having one of the safest transportation systems in the world.
Although it would not be feasible to discuss every investigation, adopted report or safety recommendation issued, I would like to share with you some of the NTSB's activities since my last appearance before this Committee.
As you are aware, to identify those recommendations with the greatest impact on transportation safety, the Safety Board in September 1990 adopted the "Most Wanted" list of transportation issues. To date, seven "Most Wanted" issues have been satisfied and consequently removed from the list. Because of action taken by the Federal Aviation Administration (FAA), two items from the original 1990 "Most Wanted" list were removed in 1995 -- brake wear limits and performance in transport category aircraft, and structural fatigue testing.
In May 1995, three new areas were added to the "Most Wanted" list and they were:
Commuter Airline Safety;
Aircraft Wake Turbulence Protection; and
Flight Data Recorder Expanded Parameter Recording.
The Board believes these safety issues have the greatest potential to save lives, and they will continue to receive intensive follow-up activity, as noted in many of the accident investigations mentioned in this testimony. We expect to review the list once again this Spring.
According to the FAA, U.S. commercial air carrier passenger enplanements were up 8.2 percent in 1994, after averaging increases of only 1.5 percent during the preceding 4 years. The commuter airline industry continues to be the fastest growing sector of the aviation community, with passenger traffic increasing by 67 percent during the 1990s. In 1994, the regional/commuter airlines enplaned 53.6 million passengers. One example of why we advocated "one level of safety" for all air carriers, and why we are so pleased with the FAA's recent promulgation of a final rule to implement this, is that by the year 2006, commuter air carriers are expected to carry 115.1 million passengers, a 154.1 percent increase.
Aviation accident data for the past year show something of a mixed, but improving picture. Overall, the preliminary data showed that 1,040 persons lost their lives last year in 2,211 civil aviation accidents, either in the United States or involving U.S. registered aircraft.
Commuter airline fatalities declined from 25 in 1994 to 9 persons in 1995 -- the lowest level since 1989. It was also the fourth consecutive decline in fatal accident rates. For major scheduled airlines, the number of fatalities declined in 1995 to 166 persons from 264 in 1994. Most of the fatalities occurred in an accident that happened in December involving American Airlines near Cali, Colombia. After hitting a historic low in 1994 of 1,990 general aviation accidents, there was a rise to 2,066 in 1995, with fatal accidents rising from 402 to 408.
Completed Aviation Investigations
USAir/Charlotte, North Carolina
In April 1995, the Safety Board adopted its report on the July 2, 1994, USAir accident near the Charlotte/Douglas International Airport. The aircraft collided with trees and a private residence, killing 37 passengers and injuring the remaining 20 passengers and crew. Our investigation found that this was a windshear-involved accident -- the first such accident in the United States in almost a decade. The Board determined that the flightcrew continued an approach into severe convective activity that was conducive to a microburst, and that the flight crew failed to recognize a windshear condition in a timely manner. Safety recommendations were adopted on the following issues: standard operating procedures for both air traffic controllers and flightcrews; the dissemination of weather information to flightcrews; and USAir flightcrew training.
Runway Collision/St. Louis, Missouri
In August 1995, the Safety Board adopted the report of the November 22, 1994, runway collision at the St. Louis/Lambert International Airport involving Trans World Airlines flight 427 and a Cessna 441. This accident is the most recent example of why the runway incursion issue is still a "Most Wanted" item. The two individuals on board the Cessna were fatally injured. The Board determined that the installation and utilization of Airport Surface Detection Equipment (ASDE-3), and particularly ASDE-3 enhanced with the Airport Movement Area Safety System (AMASS), could have prevented this accident. Once again, the Board issued safety recommendations regarding the runway incursion issue, including airport markings, signs, and lighting.
American Eagle/Morrisville, North Carolina
In October 1995, the Safety Board adopted the report of the December 13, 1994, American Eagle accident. Flight 3379 crashed on approach to the Raleigh-Durham International Airport, killing 15 of the 20 individuals on board. The Safety Board found that the captain made a series of errors which led to the tragedy. The Board further found that the pilot's performance problems might have been detected by the carrier had better hiring, training, and proficiency check procedures been in place.
"The Board ... recommended that the FAA order airlines to conduct more thorough background checks on pilot applicants, including training records." Mr. Chairman, that is a quote from testimony presented by a former Board Chairman before this Committee on April 6, 1989. The recommendation mentioned in that statement was a result of a Continental Airlines accident at Denver's Stapleton International Airport. What has happened in the intervening seven years? On November 15, 1995, the NTSB once again forwarded safety recommendations to the FAA regarding, among other things, the sharing of pilot information. The Safety Board still believes the sharing of pilot information is of utmost importance, and we urge prompt action.
Air Transport International/Kansas City, Missouri
In August 1995, the Safety Board adopted the report of the accident that occurred February 16, 1995, involving a DC-8 operated by Air Transport International (ATI). The aircraft crashed while attempting a three-engine takeoff at Kansas City, Missouri, to ferry the aircraft to its maintenance base. All three crewmembers on board were killed and the airplane was destroyed. Training and crew fatigue were identified as issues. As you are aware, fatigue in all modes of transportation is a "Most Wanted" issue.
Phoenix Air/Fresno, California
Mr. Chairman, as you will recall, revisions to the Board's authorization expanded our authority to investigate some public use aircraft accidents. The report adopted by the Board in August 1995 regarding the December 14, 1994, Learjet accident in Fresno, California involved a public use aircraft accident.
At the time of the accident, a Learjet, under contract to the U.S. Air Force for target practice involving the California Air National Guard, overflew the runway, touched down in a street, and crashed into a two-story apartment building, killing two people. The flightcrew had declared an emergency inbound to Fresno Air Terminal due to engine fire indications. The airplane had been modified with electronic equipment to satisfy the mission requirements, and evidence found in the wreckage showed that the electrical power cables for the special mission equipment had not been installed in accordance with specifications. Issues examined in this investigation were: maintenance, inspection and quality assurance; related safety recommendations were issued.
Air Tour Sightseeing Operations
Based on a series of accidents involving air tour aircraft, the Safety Board conducted a special study of air tour operations. Two regional public hearings were held, and federal regulations and FAA certification and oversight were among the issues discussed. In June 1995, the Safety Board issued its report and safety recommendations -- the most important of which is the development of national "air tour" definitions and national air tour standards with local variations, and that all air tour operations be conducted within Part 135 of the Federal Aviation Regulations. This would allow the FAA to establish a data base of air tour operators, making it possible to calculate exposure levels and FAA surveillance requirements.
Aviation Safety in Alaska
Flight operations in Alaska are diverse, and they are responsive to the State's challenging aviation environment and its unique air transportation requirements. Due to the large geographic area and lack of other forms of transportation, aviation is often the only way to traverse much of the State. In 1995, the Safety Board conducted a safety study on aviation safety in Alaska to examine Alaska's current aviation environment and air transportation activities, to identify the associated risk factors and safety deficiencies, and to recommend practical measures for managing the risks to safe flight operations given the reality of Alaska's aviation environment and the potential application of new technologies.
The Safety Board's study focused on the following safety issues:
- The operational pressures on pilots and commercial operators to provide reliable air service in an operating environment and aviation infrastructure that are often inconsistent with these demands;
- The adequacy of weather observing and reporting;
- The adequacy of airport inspections and airport condition reporting;
- The potential effects on safety of current regulations for pilot flight, duty, and rest time applicable to commuter airlines and air taxis in Alaska;
- The adequacy of the current instrument flight rules system and the enhancements needed to reduce the reliance of Alaska's commuter airline and air taxi operations on visual flight rules; and
- The needs of special aviation operations in Alaska.
- Safety recommendations were issued to the Federal Aviation Administration, the United States Postal Service, the National Weather Service, and the State of Alaska regarding these issues.
Air Traffic Control (ATC) Equipment Failures
As a result of several ATC equipment outages at en route centers, the Safety Board initiated a special investigation into the FAA's capability to cope with the continued use of current aging ATC equipment until the next generation of equipment becomes available beginning in late 1997. The special investigation focused on the problems that had become visible at the five air route traffic control centers (ARTCCs) with the oldest controller display computer systems.
The Board issued its report in January 1996, concluding that while the en route ATC system is safe and the public should not be unduly alarmed, the equipment failures examined have had a detrimental effect on the efficiency of air traffic movement. Safety recommendations were issued to the FAA regarding: personnel issues, simulator-based training, identification of safety deficiencies, and the need for a program to evaluate suggestions and repair techniques proposed by technicians in the field and to share this information with technicians at other facilities.
On-Going Aviation Investigations
The Safety Board is continuing the most complex and expensive aircraft accident investigation in our history, the September 8, 1994, accident involving USAir flight 427 at Pittsburgh, Pennsylvania. As you know, the Boeing 737 aircraft crashed while on approach, killing all 132 people on board. The investigative team, consisting of nearly 100 investigators from the Safety Board and other domestic and foreign organizations, have expended more than 40,000 investigative staff hours in direct support of the investigation. Wake vortex flight tests were conducted involving a Boeing 737 and a 727 in late September, and in December the Board reconvened the public hearing.
The main reason this investigation is so complex and costly is the inadequate number of parameters on the flight data recorder (FDR) aboard flight 427. The absence of data prevented us from knowing the role of some of the airplane's critical flight controls in the accident sequence. In contrast, in other recent major accidents -- a SAAB 340 over Louisiana and the ATR-72 accident near Roselawn, Indiana -- information received from newer flight data recorders immediately provided the Board with important information that led us to immediate corrective actions.
American Eagle/Roselawn, Indiana
On October 31, 1994, American Eagle flight 4184, an ATR-72, crashed into a soybean field 3 miles south of Roselawn, Indiana, killing all 68 people on board. In contrast to the Pittsburgh FDR, the FDR on the American Eagle aircraft recorded almost 100 key parameters. Because of the information received from the FDR, within a week of the accident the Safety Board issued recommendations to the FAA to restrict the operation of ATR aircraft in icing conditions until a fix could be developed to counteract the phenomenon the accident aircraft encountered. Last November the Board issued recommendations regarding retention of flow control-related documents.
The investigation of this accident is completed, and French Bureau Enquetes-Accidents will soon be reviewing the Board's draft report, in accordance with ICAO regulations. We expect to complete action on this accident, following the mandated ICAO French review, this Spring.
Flight Data Recorders
Mr. Chairman, this is my second appearance before your Committee, and the second time I have discussed the importance of enhanced flight data recorders. Aviation accident investigations conducted by the Board will continue to be hampered until the entire airline fleet has been retrofitted with upgraded FDRs. We believe the American people are entitled to every reasonable safety protection, and flight recorders are the best possible witnesses for any accident or incident. That is why we have recommended enhancements in flight recorder technology, and why we have placed this issue on our "Most Wanted" list.
We have passed the time when we can allow airliners carrying hundreds of passengers to be equipped with FDRs recording scarcely more information than we got from foil recorders at the dawn of the jet age. The Board should never again be in the position -- as it was following the United Airlines accident in Colorado Springs -- of not being able to determine the probable cause of an accident because of the absence of data.
Atlantic Southeast Airlines/Carrollton, Georgia
On August 21, 1995, Atlantic Southeast Airlines flight 7529 made an off-airport forced landing near Carrollton, Georgia. The pilot and seven passengers were killed; the remaining 21 occupants survived, most with serious burn injuries. The initial on-scene examination indicated that one of the left engine's propellers separated in flight. On August 25, 1995, the Safety Board issued an urgent safety recommendation calling for immediate inspections of Hamilton Standard propellers on numerous commuter airplanes. The Board also issued two priority recommendations directed at longer term actions by the FAA to improve the safety of those propellers.
American Airlines/Windsor Locks, Connecticut
On November 12, 1995, an American Airlines McDonnell Douglas MD-80 from Chicago, Illinois, struck trees on a ridge line 2.65 miles from the end of runway 15 at Bradley International Airport, Windsor Locks, Connecticut. The airplane then landed safely at the airport. The airplane structure contained debris from trees of up to about 1 1/2 inches in diameter in the landing gear and in both engines. There was leading edge damage on both the wings and the horizontal stabilizers, as well as evidence of a tail strike. The Board's investigation is examining, among other things, pilot instrument procedure approach plate design, and ATC safety equipment.
Foreign Aviation Investigations
A less known but highly significant part of the Safety Board's activities involves its participation in investigations of incidents and accidents in other countries as the U.S. accredited representative under Annex 13 of the International Civil Aviation Convention of 1944. NTSB participation in international accidents provides a direct benefit to ensuring the safety of U.S. aviation, as well as the safety of airline travelers worldwide, and at times provides an early warning of problems that can be identified and corrected. Below are two examples of the importance of Safety Board participation in international accident investigations.
April 10, 1995, during a takeoff roll at Cairo, Egypt, an Egypt Air Airbus Industrie A300B4 airplane equipped with General Electric CF6-50C2 engines sustained an uncontained separation of the stage 3 through 9 high pressure compressor (HPC) rotor spool in the No. 1 engine. The crew rejected the takeoff, stopped the airplane on the runway, and ordered an emergency evacuation of the passengers. One passenger sustained a minor injury in the course of exiting the aircraft via the emergency slide.
A small fire along the underside of the HPC in the left engine was reported to the crew by the crew of another aircraft. Post-accident investigation revealed substantial engine damage in the area of the HPC. Numerous pieces of the compressor were scattered along the runway.
On August 25, 1995, the Safety Board issued two urgent safety recommendations to the Federal Aviation Administration regarding the need for revised maintenance programs for inspection procedures of all General Electric Aircraft Engine CF6 operators, and that General Electric CF6-50, -80A, and -80C2 model engines be required to have repeated inspections of all high pressure compressor rotor stage 3 to 9 spools, and that the maximum interval between inspections should be less than 4,000 cycles.
On September 16, 1995, the right main landing gear of a Delta Air Lines Boeing 767-332ER, collapsed while the airplane was making a right turn during its taxi for takeoff at Hamburg Airport, Hamburg, Germany. The airplane was 5 years and 3 months old and had 3,807 cycles and 25,196 hours. Post-accident examination revealed multiple fractures on the outer cylinder aft trunnion, which had broken into three large sections. Examination by the Safety Board's materials laboratory of two fragments of the outer cylinder aft trunnion revealed that the aft trunnion had multiple fractures and contained six areas of stress corrosion cracking.
On October 27, 1995, the Safety Board issued two urgent safety recommendations to the FAA regarding the inspection of the main landing gear outer cylinder aft trunnion.
The NTSB is also participating in the December 20, 1995, American Airlines accident near Cali, Colombia. Of the 164 people aboard, 160 people died, including at least 62 U.S. citizens. This investigation is being conducted by the Colombian Government under ICAO rules. NTSB staff have been chosen by Columbian investigative officials to lead the investigative activities in human performance, operations, aircraft performance, and air traffic control. The flight data recorder, which recorded approximately 300 parameters, has provided a wealth of information that has been of enormous assistance to the investigative team.
Mr. Chairman, dedicated NTSB investigators endured difficult climatic and geographic conditions over the Christmas holidays to be on-scene at this tragedy. They deserve to be recognized for their selfless dedication to aviation safety.
The most recent foreign accident in which the NTSB is participating is the February 6, 1996, accident involving a Boeing 757 in the Atlantic Ocean near Puerto Plata, Dominican Republic. The flight was a tour group returning to Germany. There were 176 passengers and 9 crew on board the flight; all were fatal. The accident airplane was owned and operated by a Turkish air charter company, Birgenair, on behalf of a Dominican airline, Alas Nationales. Although the Dominican Civil Air Authority is in charge, they have requested extensive assistance from the NTSB.
This accident scenario is complicated by a lack of sufficient radar data to track the flight path of the airplane and the deep water location of the wreckage. Such an event, once again points out the importance of multiple parameter flight recorders in the investigation of such accidents.
The Board coordinated with the governments of the Dominican Republic, Germany, and Turkey, as well as the airframe and engine manufacturers on a plan to recover the flight recorders and other wreckage as necessary. It is estimated that the recovery effort will cost a minimum of $1.4 million. Although we have received contributions from the interested parties and governments, the Board will have to use a portion of it's emergency fund to help defray the costs of this investigation.
About four billion tons of regulated hazardous materials are shipped each year, with more than 250,000 shipments of hazardous materials entering the U.S. transportation system daily. The issue of railroad hazardous materials tank cars has been of interest to the NTSB for several years and is an item on our "Most Wanted" list. More than 1.52 million carloads of poisons, chemicals, pesticides, and other hazardous materials are transported yearly by railroad, and the potential for disaster is significant.
Tank Car Failure and Release of Arsenic Acid/Chattanooga, Tennessee
In February 1995, the Safety Board adopted the report of the June 6, 1994, release of 3,079 gallons of arsenic acid from a Norfolk Southern tank car at a rail yard in Chattanooga, Tennessee. The arsenic acid entered the storm drain system. Contaminated water from that system was then discharged into Citico Creek, and then into the Tennessee River near intake pipes for the City's municipal water supply. The Tennessee River is the sole source of water for the Chattanooga water system. Repair costs to the tank car were $29,900 and the value of the spilled arsenic acid was $24,630. However, the environmental cleanup and disposal costs were estimated to be $8.77 million. Issues examined were:
- The configuration and construction of eduction pipe systems in tank cars;
- The adequacy of quality control inspections to ensure that tank cars are constructed in accordance with designs and that modifications are performed correctly;
- The evaluation, selection, and inspection of coatings or linings to protect tank cars from corrosive damage by the cargo transported; and
- The adequacy of actions taken in response to the leaking tank car.
Railroad Tank Car Failure/Bogalusa, Louisiana
The Safety Board is investigating an October 1995 tank car failure and release of nitrogen tetroxide in Bogalusa, Louisiana, resulting in the evacuation of over 3,000 people. Nitrogen tetroxide is an oxidizer and a poisonous gas. Our investigation has revealed severe internal corrosion to the tank. Additionally, the investigation has revealed that before the tank car was last filled with cargo, four valves had been replaced. Issues being examined include: containers authorized for transporting nitrogen tetroxide; tank car repairs; cargo handling procedures; and emergency response.
In the United States, there are more than 194 million registered vehicles, and 175 million licensed drivers. More than 94 percent of all transportation fatalities (about 40,000) and 99 percent of transportation injuries (5 million) are the result of motor vehicle crashes. Since 1965, the number of drivers has increased 77 percent, and the number of vehicles has increased by 106 percent. By the year 2000, drivers and vehicles are expected to increase another 7 percent, and miles traveled by 15 percent. Over the years, some of issues the Safety Board has examined include drunk driving, schoolbus safety, child safety seats, truck driver fatigue and grade crossing safety.
Completed Highway Investigations
Grade Crossing Accident/Intercession City, Florida
In May 1995, the Safety Board adopted the report of a grade crossing accident near Intercession City, Florida involving Amtrak's Silver Meteor that occurred on November 30, 1993. The failure to coordinate the roadway routing of an 82-ton turbine generator transport to a utility plant was causal. Fifty-nine persons were injured when the Amtrak train derailed after impact with the 82-ton turbine generator that was on a special vehicle, which had bottomed out on the grade crossing. The locomotive and other wreckage came to rest on or near high-pressure petroleum product pipelines buried parallel to the tracks. Safety recommendations were issued to nearly two dozen organizations regarding oversight of oversize moves, oversize move coordination, pipeline notification and hazard identification and avoidance, permitting procedures, and lounge car seat support design.
Propane Truck Collision with Bridge Column/White Plains, New York
In November 1995, the Safety Board adopted the report of the July 27, 1994, accident involving a cargo-tank semitrailer loaded with 9,200 gallons of propane, that crashed into a bridge column, propelling the propane tank into a house across the road and releasing propane that ignited. The accident killed the driver, injured 23 people, and damaged nearby homes.
Mr. Chairman, this accident was caused by the fatigue of the truck driver. As I mentioned earlier, fatigue in all modes of transportation is a "Most Wanted" issue, and the Board urged the Federal Highway Administration and the trucking industry to evaluate and revise its hours of service regulations.
Multiple Vehicle Collision During Fog/Menifee, Arkansas
In November 1995, the Safety Board adopted the report of the January 9, 1995, multiple-vehicle, rear-end collision that occurred during localized fog near Menifee, Arkansas. The accident involved eight loaded truck tractor semitrailer combinations and one light-duty delivery van. Five people were killed. Issues examined by the Board were collision warning technology use during low-visibility driving conditions, the emergency channel nine override feature for citizens band radios, and the nonuniformity in state laws governing four-way emergency hazard flasher operation.
On-Going Highway Investigations
Grade Crossing Accident/Sycamore, South Carolina
Amtrak's Silver Star crashed into a tractor lowboy-trailer at a passive grade crossing near Sycamore, South Carolina, on May 2, 1995. The trailer was not loaded at the time of the collision, and the driver indicated that he bottomed out and became stuck on the hump crossing. There were no fatalities, but over 50 Amtrak passengers were taken to area hospitals. Issues being looked into are the crossing profile, passive crossings, emergency response, motor carrier practices, and emergency notifications.
Schoolbus-Train Collision/Fox River Grove, Illinois
Mr. Chairman, any accident is tragic, but never more so than when it involves children. On October 25, 1995, seven children were killed when a Metra passenger train crashed into a schoolbus at an active grade crossing in Fox River Grove, Illinois. The schoolbus was stopped at a traffic signal. At the accident location, the nearest rail is 30 feet, 4 inches from the intersection stop line. The 38 foot, 4-inch long school bus exceeded the space available, causing the rear of the bus to extend over the railroad tracks. The train engineer saw the schoolbus stopped on the crossing about 200 yards before the impact.
We issued urgent safety recommendations regarding train speed reductions and highway traffic signals on October 31, 1995, and held a public hearing in January of this year. Issues being examined include: communications and coordination between railroads and city, county and state governments; preemptive and interconnecting railroad grade crossing signals and highway traffic lights; schoolbus route planning and schoolbus driver training; railroad-highway intersection design; and train whistle bans and train whistle audibility within schoolbuses.
As part of our outreach on this most important issue, the Safety Board has held three community briefings regarding schoolbus safety, the most recent being the one held February 26, 1996, at Middletown Community College, Virginia.
Safety at Passive Grade Crossings
I have thus far discussed three accidents that occurred at highway/railroad grade crossings. 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. Passive crossings, those that have no train-activated warning devices, account for more than 60 percent of crossing deaths each year.
The Safety Board has begun a safety study to determine if a reduction in the number of grade crossing accidents could be achieved through engineering improvements, improved enforcement of existing traffic laws, development of safety regulations and standards, and public education programs. Data collection by the
Board's highway and railroad investigative staff began for this study in February 1996. We expect to complete the study in late Spring 1997.
Child Passenger Protection
In 1994, the Safety Board initiated a safety study to evaluate the performance of occupant restraint systems for children under the age of 11. The goal of this study is to examine the overall performance of child occupant restraint systems (safety seats and seat belts), the adequacy of relevant Federal regulations, and the comprehensiveness of state child safety seat and seat belt use laws. This study is in the data collection and analysis stage, and we expect completion in FY 1996.
As you are aware, the Safety Board does not wait for completion of an investigation or study if we become aware of safety problems that require immediate attention. During the data collection phase of the study, we investigated four accidents in which an infant was killed or severely injured as a result of an air bag deployment. Those accidents were:
- November 14, 1994 -- Banning, California. A 3-month-old child was seated in the right front passenger seat in a rear-facing, improperly installed infant safety seat; the harness straps were not properly threaded to securely hold the child in the seat, and the two-part seat was not properly secured in its base. The child sustained skull fractures.
- July 18, 1995 -- Gilbertsville, Pennsylvania. A 20-day-old child seated in the front passenger seat in a convertible child safety seat that was facing rearward was killed.
- September 20, 1995 -- Long Beach, California. A 5-month-old child seated in the right front passenger seat in an infant safety seat facing rearward was killed.
- October 3, 1995 -- Irvine, California. A 6-month-old child seated in the right front passenger seat in a convertible child safety seat that was facing rearward was severely injured.
- All of the above injuries or fatalities were caused by the impact of the air bag compartment cover flap to the back of the infant safety seat at the location of the child's head. On November 2, 1995, the Safety Board issued urgent safety recommendations to government officials, automobile manufacturers, child safety seat manufacturers, and several organizations regarding the dangers of placing a rear-facing child safety seat in the front seat of a vehicle equipped with a passenger side air bag.
50-State Outreach Program
The Safety Board has initiated a 50-state outreach program to follow-up on safety recommendations issued to the individual states. Examples of these recommendations include: administrative license revocation laws, zero blood alcohol content laws for youth, primary enforcement of seat belt laws, boating while intoxicated laws, and required use of personal flotation devices by children age 12 and under.
The Safety Board is pleased that eight additional youth zero tolerance laws were enacted by the States in 1995 -- there are now 28 States plus the District of Columbia that have a zero tolerance standard for drivers under age 21. Also in 1995, Arkansas became the 39th State to enact administrative license revocation. We will continue to work with State legislatures and safety organizations on these vital safety concerns.
Much of this Nation's commerce (98 percent) travels between U.S. ports and points overseas, or on the tens of thousands of miles of inland waterways. Marine transportation is as diverse as cruise ships carrying thousands of passengers at a time to recreational boats, and from supertankers to tow boats. Water transport produces about 790 billion ton-miles a year, employing almost 200,000 persons. In 1995, there was a 6.5 percent increase in cruise ship passengers over 1994. These figures are expected to continue to rise in the coming years.
Completed Marine Investigations
ALL ALASKAN/Bering Sea
In July 1995, the Safety Board adopted the report of the accident that occurred on July 24, 1994, involving the U.S. fish processing vessel ALL ALASKAN, which caught fire near the western end of Unimak Island, Alaska. The fire burned out of control for several days before burning itself out. One person died, and vessel and cargo damage was estimated to be close to $31 million. The NTSB issued recommendations on July 17, 1995, regarding fire protection and construction standards, firefighting training, fire watch procedures, and U.S. Coast Guard and company post-accident toxicological testing procedures.
Engineroom Fire on Board the SEAL ISLAND/St. Croix, U.S. Virgin Islands
On December 12, 1995, the Safety Board completed action on the accident involving the Liberian tankship SEAL ISLAND in St. Croix, U.S. Virgin Islands on October 8, 1994. The accident occurred when lubricating oil sprayed onto the hot turbine casing and a fire erupted, burning for about 6 hours and killing three people. Issues examined were: the adequacy of management oversight of maintenance and report practices; the decision to make and the risk introduced by the temporary repair modification to the lubricating oil duplex strainer; the adequacy of emergency equipment and drills on board ocean-going ships; the adequacy of the emergency response by refinery personnel; and the adequacy of the U.S. Coast Guard's fire contingency planning for St. Croix.
ARGO COMMODORE/San Francisco Bay
In November 1995, the Safety Board adopted its report on the December 3, 1994, engineroom fire aboard the ARGO COMMODORE, a small passenger vessel on a dinner cruise in San Francisco Bay. The fire was caused by a short circuit in the starboard main engine electrical starting system. This accident involved on-going concerns related to small passenger vessels, including the issues of crew emergency training and passenger briefings -- issues on our "Most Wanted" list.
On-Going Marine Investigations
The Safety Board has six marine accidents under investigation. Those accidents are:
- April 20, 1995 -- MAERSK SHETLAND -- The United Kingdom tank ship MAERSK SHETLAND was outbound and overtaking the towboat BIG BAY in the Corpus Christi Channel when the vessels collided. The collision ruptured the barge's No. 2 port tank, releasing 4,514 barrels of cumene, a flammable aromatic hydrocarbon liquid. Five thousand persons in the surrounding communities were evacuated because of strong cumene vapors.
- May 27, 1995 -- ALASKA SPIRIT -- A fire erupted in the living quarters on board the U.S. fish processing vessel ALASKA SPIRIT while the vessel was moored in Seward, Alaska. The master received fatal injuries due to smoke inhalation, the entire second deck and pilothouse were completely incinerated, with damages estimated at about $3 million.
- June 10, 1995 -- ROYAL MAJESTY -- The Panamanian passenger ship ROYAL MAJESTY grounded on a sand bar located about 10 nautical miles east of Nantucket Island, Massachusetts. It has been determined that mechanical failure of the vessel's navigation system and human error contributed to the ship's grounding.
- June 18, 1995 -- CELEBRATION -- The Liberian registered passenger vessel CELEBRATION experienced a fire in the machinery control room while cruising near San Salvador Island in the Bahamas chain. As in several previous passenger vessel accidents, the NTSB is again looking at the adequacy of fire fighting procedures.
- June 23, 1995 -- STAR PRINCESS -- The Liberian vessel STAR PRINCESS was southbound in Lynn Canal near Juneau, Alaska when it grounded on Poundstone Rock, which was marked by a lighted buoy to identify it as a hazard to navigation.
- January 19, 1996 -- U.S. Tug SCANDIA and Tankbarge NORTH CAPE -- The U.S. Tug 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, a fire broke out in the SCANDIA's engineroom. The crew abandoned ship and the SCANDIA and NORTH CAPE ran aground near Point Judith, Rhode Island. The barge was holed on its ports and starboard sides and spilled about 828,000 gallons of heating oil.
Integrated Bridge Systems Public Forum
In marine transportation, integrated bridge systems and electronic charts, oriented to the earth's surface by precise radio navigation systems such as the Global Positioning System (GPS) and Loran, offer the potential for great improvements in navigation safety. However, the investigation of the grounding of the passenger vessel ROYAL MAJESTY near Boston on June 10, 1995, and the Board's subsequent urgent safety recommendations, indicate that there is a need to gather information on the state of the development of advanced electronic navigation and integrated bridge systems, the adequacy of industry and Government oversight, and the need for proper crew training in the use of this new equipment. The NTSB is sponsoring a two-day public forum to address these issues in March.
Fishing Vessel Safety
Each year approximately 250 fishing vessels are lost and about 100 fishermen die in the commercial fishing industry. Despite actions taken since the release of the Safety Board's 1987 safety study on uninspected commercial fishing vessel safety, statistics continue to show a disproportionate number of fishing vessel casualties in relation to the number of vessels in service. The Safety Board is currently collecting data for a study that will focus on the need for commercial fishing vessel inspection, licensing of fishing vessel masters, and crew training requirements. We expect completion of the study in late FY 1996.
Pipelines carry more hazardous materials in this country than any other form of transportation. Annually, almost 600 billion ton-miles are carried in oil pipelines in 203,000 miles of pipe, and more than 17 billion cubic feet of natural gas are delivered through 1.1 million miles of gas pipeline. From 1984 to 1994, the number of miles of gas pipeline distribution mains increased by 23 percent.
Special Investigation Into Liquid Pipelines
Fifty-seven percent of crude petroleum and petroleum products are transported by pipeline. The potential threat to public safety from the release of such products has become more severe in recent years as the rate of residential and commercial development adjacent to all types of pipelines has increased. In a special investigation of U.S. liquid pipelines released in January 1996, the NTSB found that the Research and Special Programs Administration still lacks an adequate system to address corrosion control, to inspect and test pipelines, to limit the release of product from failed pipelines, and to analyze operator performance. Safety recommendations were adopted regarding these issues.
Explosion and Fire/Allentown, Pennsylvania
On June 9, 1994, following excavation work, there was a pipeline explosion and fire in buildings housing the elderly in Allentown, Pennsylvania, resulting in one fatality. Issues examined in this accident were pipeline excavation damage prevention and rapid shut-down of failed gas service lines; related safety recommendations regarding were issued.
Most excavation accidents are preventable, but data show them to be the leading cause of reported pipeline accidents. The Allentown accident was the fifth excavation-involved pipeline accident in a 15-month period, and led to the Board's September 1994 workshop on this issue hosted with the Office of Pipeline Safety. The proceedings of that workshop were published by the NTSB in October 1995.
Amtrak carries about 21 million intercity passengers a year, and rapid rail systems carry almost 2 billion passengers a year. The railroads haul at least $28 billion of freight business each year, and amass more than 1.1 trillion ton miles. Light rail passenger trips between 1980 and 1993 increased by 41.4 percent. Over the years, the NTSB has issued railroad safety recommendations in all railroad areas, from passenger car interiors, to rail rapid transit safety, to continuous welded rail, to hours of service for railroad personnel.
Completed Railroad Investigations
Amtrak Derailment/Selma, North Carolina
In March 1995, the Safety Board adopted the report of the accident involving Amtrak's Silver Meteor when it derailed following a collision with an intermodal trailer that had either fallen or was falling from a flat car on a passing CSX freight train at Selma, North Carolina on May 16, 1994. The accident killed the Amtrak assistant engineer. It was determined that the trailer was not properly secured to the flat car, and the Safety Board issued recommendations regarding the loading, securing and inspection of shipments.
Collision and Derailment of Burlington Northern Freight Trains/Thedford, Nebraska
In September 1995, the Safety Board adopted the report of the railroad collision that occurred June 8, 1994, near Thedford, Nebraska. An eastbound Burlington Northern (BN) train that had stopped for a train ahead was struck in the rear by a following eastbound BN train. The lead unit of the striking train derailed and came to rest on an adjacent track where it was struck by a westbound BN train. The engineer and conductor of the striking eastbound train were killed. Issues examined were: train crew inattentiveness as a result of fatigue, and positive train separation, both "Most Wanted" items. The Safety Board reiterated two recommendations regarding positive train separation.
Railroad Rear-End Collision/Cajon, California
In November 1995, the Safety Board adopted the report of the December 14, 1994, railroad collision that occurred at Cajon, California. A westbound Atchison, Topeka and Santa Fe Railway Company intermodal train collided with the rear end of a standing westbound Union Pacific Railroad Company unit coal train. Issues examined by the NTSB were air brake testing in mountain-grade territory; management oversight of train handling practices; feed-valve braking; and two-way end-of-train devices. Of the safety recommendations issued, two urgent recommendations dealt with end-of-train devices.
On-Going Railroad Investigations
New York City Transit Commuter Train Collision
A rear-end collision involving two New York City Transit commuter trains occurred June 5, 1995, on the Williamsburg Bridge. A southbound train had been standing at a red stop signal for about 15 to 20 seconds, when it was struck in the rear by another southbound train. The train operator of the striking train was fatally injured. The Safety Board held a two-day public hearing regarding this accident in New York City in November 1995. Issues being looked into are: oversight of rapid transit operations; standards for rapid transit equipment; and subway signal standards and installations.
Metro Collision-Shady Grove Station/Rockville, Maryland
The Safety Board is investigating the January 6, 1996, accident involving a Washington Metropolitan Area Transit Authority train. Train T-111 operating on Metro's Red Line collided head on with a standing, unattended equipment train at the Shady Grove Metro Station at Rockville, Maryland. The T-111 train operator received fatal injuries. At the time of the accident, it was snowing heavily in the Washington Metropolitan Area. Train T-111 reported station overruns at the two previous stations. Issues being examined include: train car crashworthiness, human performance, automatic train control/signals, weather, and management oversight of train operations, including rules, policies, and procedures.
Derailment of Burlington Northern Santa Fe Freight Train/Cajon Pass, California
On February 1, 1996, a Burlington Northern Santa Fe freight train derailed at Cajon Pass, California, killing the conductor and trainman and injuring the engineer. Forty of the 49 cars derailed, four of which contained hazardous materials. Approximately 60 people were evacuated in a radius of 1 1/2 miles, and Interstate 15 was closed until the evening of February 2, 1996. On February 5, 1996, Interstate 15 was once again closed, and an evacuation was implemented because of the fear of unstable hazardous materials. This accident occurred within sight distance of the location of a collision and derailment that occurred December 1994. Issues being examined in this accident are: management oversight, training, trains operating with unarmed 2-way telemetry devices, and mechanical inspection and repair of freight cars.
Collision and Derailment of New Jersey Transit Commuter Trains
Jersey City, New Jersey
On February 9, 1996, at about 8:40 a.m., New Jersey Transit commuter Train 1254, operating eastbound from Waldwick to Hoboken, New Jersey, collided head-on with the lead locomotive of New Jersey Transit Commuter Train 1107, a westbound train operating between Hoboken, New Jersey and Suffern, New York. There were over 400 passengers on the two trains; three fatalities and 162 injuries resulted from the collision. Issues being looked into include: operator fatigue, fitness for duty, crashworthiness of cab cars; and positive train separation.
Collision and Derailment of MARC Commuter Train and Amtrak
Silver Spring, Maryland
On February 16, 1996, a MARC commuter train from West Virginia to Washington D.C. collided with an Amtrak train en route from Washington, D. C. to Chicago, Illinois, killing 11 people. The impact ruptured a 1,500 gallon diesel tank on the first of two Amtrak locomotives, igniting a fire that swept through the front MARC passenger car. Issues being looked into include: the signals; human performance, and fuel tank integrity
Managing Fatigue in Transportation
The National Transportation Safety Board has investigated accidents in every mode of transportation in which the effects of fatigue, circadian factors and sleep loss have been found to be causal or contributory. Nearly 80 fatigue-related safety recommendations have been issued since 1972 to the modal administrations in the Department of Transportation, transportation operators, associations and unions. Still, a fatigue factor continues to be found by many Safety Board accident investigations.
In November 1995, the Safety Board, in partnership with the NASA Ames Research Center, conducted the first ever, multi-modal symposium focusing on fatigue in transportation. The symposium was attended by nearly 600 people, including participants from 16 different countries, representing every mode of transportation, and provided tangible approaches for the transportation community to address the problem of fatigue. We expect to issue a report of the proceedings of the symposium in late Spring.
Fiscal Year 1997 Request
For fiscal year 1997, the Board is requesting $40,300,000, which is $1,526,000 more than our FY 1996 appropriation. This figure is just sufficient to allow the Board to maintain its staff at its current 350 FTE level.
That concludes my prepared statement. I will be happy to respond to any questions you may have.
Jim Hall's Speeches