1

Dear Readers:

M o re than 90 years ago, philosopher George Santayana said,

“Those who cannot remember the past are condemned to repeat it.”

I like to say it this way: We can’t aff o rd to let future generations

f o rget the safety lessons we have learned from more than 30 years

of transportation accident investigations.

It is in that spirit that the National Tr a n s p o rtation Safety Board

investigates accidents and offers recommendations aimed at

p reventing similar accidents. It is the Safety Board ’s responsibility to

make transportation safer for each new generation — to take all

that we have learned from past mistakes and apply those

experiences to shaping transportation in the future. Only then does

each tragic accident become an investment in safety.

This publication re c o rds some of the major lessons learned and

the changes that have been made to prevent future accidents. It

documents how we have taken charge of our destiny and pro v i d e d

new generations with a safer transportation system. The Safety

B o a rd will continue to build on this history and is committed to

ensuring that we do not forget our past, or worse, repeat it.

Jim Hall, Chairm a n

National Tr a n s p o rtation Safety Board

National Tr a n s p o rtation Safety Board

Washington, D.C. 20594
I n t ro d u c t i o n . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Av i a t i o n . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

G round proximity warning 

s y s t e m s. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

F i re safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Wi n d s h e a r. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 0

I c i n g. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1

Midair collisions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 2

Rejected takeoff s. . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 3

Runway overru n s. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 4

Alcohol and aviation . . . . . . . . . . . . . . . . . . . . . . . . 1 5

Parachuting safety . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 6

A i rcraft seats. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 7

Seatbelt integrity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 8

Regional and commuter airlines. . . . . . . 1 8

C rew re s o u rce management . . . . . . . . . . . . 1 9

A i rcraft design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 1

S t ructural fatigue and corro s i o n. . . . . . . 2 4

Uncontained failures of 

titanium engine components . . . . . . . 2 5

O ff-wing escape slides. . . . . . . . . . . . . . . . . . . . . 2 6

Pitot-static system blockages. . . . . . . . . . . 2 7

Helicopter safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 7

Fuel tank explosions. . . . . . . . . . . . . . . . . . . . . . . . 2 8

Tu r b o p ropeller airplane safety . . . . . . . . . . 2 9

Flight safety in Alaska. . . . . . . . . . . . . . . . . . . . . . 2 9

S p a c e. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 0

R a i l ro a d . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 3

Passenger rail safety . . . . . . . . . . . . . . . . . . . . . . . 3 3

Rail rapid transit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 6

Alcohol and drug use. . . . . . . . . . . . . . . . . . . . . . . 3 7

Locomotive fuel tank integrity. . . . . . . . . . . 3 7

Tourist and historic railro a d s. . . . . . . . . . . . 3 8

I m p roved emergency braking 

c a p a b i l i t i e s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 9

M a r i n e . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 1

Passenger vessel safety . . . . . . . . . . . . . . . . . . 4 1

R e c reational boating safety. . . . . . . . . . . . . . 4 3

Vessel traffic serv i c e s . . . . . . . . . . . . . . . . . . . . . 4 4

C o m m e rcial fishing vessels . . . . . . . . . . . . . 4 4

E m e rgency position indicating 

radio beacons. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 5

Towing vessel safety. . . . . . . . . . . . . . . . . . . . . . . . 4 7

H i g h w a y . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 9

D runk driving . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 9

R e p o rting drunk drivers . . . . . . . . . . . . . . . . . . . 5 0

School bus safety. . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 1

S e a t b e l t s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 3

Air bags and child passenger 

s a f e t y. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 4

Child safety seats. . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 6

C o m m e rcial driver’s licenses . . . . . . . . . . . 5 6

Heavy truck brakes. . . . . . . . . . . . . . . . . . . . . . . . . . 5 7

Reduced visibility. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 8

Grade crossing safety. . . . . . . . . . . . . . . . . . . . . . 5 8

Center high-mounted stop lights. . . . . . . 5 9

Highway bridge safety . . . . . . . . . . . . . . . . . . . . . . 6 0

E a rthquake pre p a re d n e s s. . . . . . . . . . . . . . . . 6 0

P i p e l i n e . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 3

Pipe replacement pro g r a m s . . . . . . . . . . . . . 6 3

Operating standard s. . . . . . . . . . . . . . . . . . . . . . . . 6 3

Risk management . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 4

Excavation damage pre v e n t i o n. . . . . . . . . 6 4

Liquid pipeline failure detection. . . . . . . . 6 5

Rapid shutoff of damaged 

s e rvice lines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 5

H a z a rdous Materials T r a n s p o rt a t i o n . . . . . 6 7

R a i l road tank car safety. . . . . . . . . . . . . . . . . . . 6 7

E m e rgency re s p o n s e. . . . . . . . . . . . . . . . . . . . . . . 7 0

Shipping and handling . . . . . . . . . . . . . . . . . . . . . 7 1

C o n c l u s i o n . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 3

2

We Are All Safer

Table of Contents Second Edition, July 1998
T

he National Tr a n s p o rtation Safety Board (NTSB) was

established by Congress in 1967 to investigate and

d e t e rmine the causes of accidents in all modes of transp o rtation. Since then, the Safety Board has investigated more than

110,000 aviation accidents and thousands of railroad, marine,

h i g h w a y, and pipeline accidents. The Board is recognized as one of

the world’s premier independent accident investigation agencies

because of the expertise it has accumulated in more than thre e

decades of experience. It is a lean agency of about 400 employees

nationwide that costs each citizen only about 18 cents a year to fund.

On call 24 hours a day, 365 days a year, Safety Board

investigators travel to every corner of the world to investigate

accidents. The Board ’s 24-hour communications center coord i n a t e s

the logistics of accident launches and enables investigators to 

get to accident sites quickly. The center provides simultaneous

communications among investigators on the way to accidents or

a l ready on scene and technical experts at headquarters and

regional off i c e s .

The Safety Board also provides assistance to families aff e c t e d

by aviation and other transportation disasters. After an accident, the

duty of notifying next of kin, making arrangements for transport i n g

family members to a location near the accident site, and re t u rn i n g

victims’ remains are the responsibilities of the carr i e r. The local

community responds with emergency services, and volunteers

p rovide grief counseling and food services. The Safety Board is

responsible for improving and coordinating services to victims’

families, particularly re g a rding the initial notification of the accident,

re c o v e ry and identification of victims, disposition of unidentifiable

remains, re t u rn of personal effects, and access to inform a t i o n .

At the accident site investigators gather a wide range of

i n f o rmation concerning the circumstances of the accident.

Investigators and technical experts analyze this information, 

along with many other facts pertaining to the event, to determ i n e

the probable cause of the accident and to develop safety

recommendations aimed at preventing similar accidents.

3

I n t ro d u c t i o n

“It gives me great pride to 

reflect on the advances we’ve

made in transportation safety

over the past few decades

because of the Safety Board ’s

work. The public’s trust in 

our transportation system

depends on continuing ef f o rts 

to improve safety. ”

Vice Chairman 

R o b e rt T. Francis II

“ E v e ry time you get on an

airplane, a school bus, a

train, a marine vessel or even

in your automobile, you are

p rotected by safety feature s

recommended by the Safety

B o a rd. And we’re not

finished because the Board is

committed to an ever safer

t r a n s p o rtation system.”

B o a rd Member

John Hammerschmidt
4

The Safety Board has issued 11,000 safety recommendations 

in all transportation modes to more than 1,300 recipients in

g o v e rnment, industry, and associations. Since 1990, the Board 

has highlighted many significant issues on its list of “Most Wa n t e d

Tr a n s p o rtation Safety Improvements.” Although the Board has no

re g u l a t o ry or enforcement powers, its reputation for impart i a l i t y,

insightfulness, and thoroughness has helped it reach a

recommendation implementation rate of more than 82 perc e n t .

Tr a n s p o rtation safety is a team eff o rt, achieved when all

elements of the transportation system cooperate and fulfill their

responsibilities. The U.S. Department of Tr a n s p o rtation (DOT) and

state authorities issue safety regulations and enforce them.

Tr a n s p o rtation companies and manufacturers ensure the safety 

of their operations and products. And travelers take responsibility 

for their own safety by becoming familiar with the operational and

safety features of the vehicle being used. In this mix has been

placed an independent watch dog—the National Tr a n s p o rt a t i o n

Safety Board—to determine what led to an accident and what can

be done to prevent a re c u rre n c e .

E v e ry time you travel in an airplane, a school bus, a train, a

boat, and even your own automobile, you are protected by safety

m e a s u res resulting from Safety Board recommendations. This

publication summarizes many of these Safety Board - i n s p i re d

i m p ro v e m e n t s .

“It is not enough to find the

cause of accidents. The

Safety Board’s most

important products are

recommendations that

actually result in correcting

the problem that led to the

accident in the first place.

Innumerable lives have 

been saved because of

accidents that were

prevented by Safety Board

recommendations.” 

Board Member

John Goglia

“The work of the Board

goes far beyond domestic

safety. Its products and

expertise are instrumental in

improving transportation

safety around the globe.

We will continue to work

with our counterparts

worldwide to advance safety. ”

Board Member

George Black
T

he National Tr a n s p o rtation Safety Board is in charge of

investigating all civil aviation accidents in the United States,

including public-use aircraft, except for those operated by

m i l i t a ry and intelligence agencies. Under international tre a t y, the

Safety Board provides U.S.-accredited re p resentatives and

investigators to foreign investigations involving U.S.-re g i s t e re d ,

- c e rtified, or -operated aircraft and aircraft whose airframe, engines,

or other major components are manufactured or designed in the

United States. Because of our nation’s large aviation manufacturing

i n d u s t ry, our investigative authority covers a significant portion of

t r a n s p o rt - c a t e g o ry aircraft worldwide. Civil aviation is a rapidly

g rowing global system.

The importance of aviation to the nation’s economy is

e n o rmous, and forecasters predict steady growth in the industry

t h rough the year 2009. For example, the total number of passengers

b o a rding scheduled commercial airlines in the United States ro s e

f rom 580 million in 1995 to 630 million in 1997. That number is

expected to top 985 million by the year 2009. Air traffic continues

to climb with an estimated 63 million takeoffs and landings at the

n a t i o n ’s airports with control towers in 1997. That number is

expected to exceed 75 million by the year 2009.

Major transportation accidents exact a significant emotional and

m o n e t a ry toll on society. The human cost to victims, survivors, and

their families is immeasurable. The direct cost of just one fatal

c o m m e rcial aviation accident can total hundreds of millions of

d o l l a r s .

Safety Board recommendations to improve aviation safety have

a d d ressed problems in operations, cabin safety, weather, and

a i rcraft design.

5

Av i a t i o n
6

G round Proximity Warning Systems

On December 29, 1972, an Eastern Air Lines Lockheed L-1011

crashed into the Florida Everglades while on approach to Miami

I n t e rnational Airport. Almost two years later, on December 1, 1974,

a TWA Boeing 727 crashed into

a mountain while on approach to

Washington Dulles Intern a t i o n a l

A i r p o rt in Vi rginia. One hundre d

ninety-one persons died in the

two tragedies. There was one

common factor: no mechanical

malfunctions contributed to

either accident.

The Safety Board concluded

that these accidents – term e d

“ c o n t rolled flight into terrain,” 

or “CFIT” for short – could have

been prevented by a terr a i n

w a rning system in the cockpit.

The Board ’s first recommendation calling for the development of 

an onboard warning system was issued after a nonfatal accident in

1971 involving a DC-9 that struck antennas as it was landing in

G u l f p o rt, Mississippi. In 1975, after further Board re c o m m e n d a t i o n s

following accidents in the Florida Everglades and Vi rginia, the

Federal Aviation Administration (FAA) began to re q u i re larg e

passenger aircraft to be equipped with a ground proximity warn i n g

system (GPWS). This device warns flightcrews if their aircraft is

a p p roaching terrain, descending too quickly, or improperly configure d

for landing, usually with an aural warning like “Pull Up, Pull Up,” or

“ Te rrain.” This re q u i rement has dramatically lowered the fre q u e n c y

of CFIT accidents involving transport - c a t e g o ry aircraft in U.S.

airspace. By contrast, CFIT accidents continue to occur overseas in

countries where such devices are not re q u i red, and a special

I n t e rnational Civil Aviation Organization task force is working on

p reventing such accidents.

In 1986, based on a series of accidents involving commuter

a i rcraft, the Safety Board recommended that the re q u i rement for

GPWS be extended to smaller passenger airliners. Following subsequent commuter CFIT accidents, the Board added the issue to its
“Most Wanted” list. Since April 1, 1994, commuter aircraft having 

10 or more seats must be equipped with GPWS. This re q u i re m e n t

should greatly increase the safety of commuter flights, especially

during approach to landing in instrument meteorological conditions.

Another CFIT accident prompted the Safety Board to re c o m m e n d

that the FAA re q u i re aircraft to be equipped with the next generation

of “enhanced” GPWS, which gives flightcrews significantly more

advance warning. The recommendation grew out of the December

20, 1995, crash of an American Airlines Boeing 757 on approach to

Cali, Colombia, killing all but four of the 163 persons on board .

During the descent, with the speedbrakes extended, the pilots failed

to clear the mountain following a ground proximity warning. Based

upon the Board ’s investigation and recommendations, action by the

FAA includes an automatic speedbrake retraction design re v i e w,

amendments to the crew re s o u rce management training advisory

c i rc u l a r, and standardization of navigational aid identifiers on printed

c h a rts and electronic charts displayed on aircraft computers.

The FAA is working on an advanced terrain avoidance warn i n g

system regulation with a proposed rule expected in late 1998,

followed by a final rule in 1999. A major aviation association and

n u m e rous air carriers announced in early 1998 that they had begun

to voluntarily install the new advanced devices.

F i re Safety

Cabin fires, although extremely rare in passenger airliners, can

be devastating. In July 1973, the Safety Board assisted Fre n c h

authorities in their investigation of the crash landing of a Va r i g

Boeing 707 near Paris after a fire in a rear lavatory. Two months

l a t e r, the Board asked the FAA to re q u i re smoke detectors or

f requent in-flight checks of lavatories by flight attendants for early

detection of fires. Another in-flight fire, this time involving a Pan

American Boeing 707 cargo flight, occurred in November 1973. 

And in the summer of 1974, two more airliner lavatory fires, both

nonfatal, prompted the Board to recommend specifically that the

FAA re q u i re installation of automatic-discharge fire extinguishers in

l a v a t o ry waste paper containers in all airliners. The FAA re q u i re d

airlines to prohibit smoking in lavatories. The agency also urg e d

routine flight attendant inspections of lavatories before takeoff and

periodic inspections during flight.

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8

On June 2, 1983, an Air Canada DC-9 flying between Dallas 

and To ronto developed smoke in the cabin while the airplane was

c ruising at 33,000 feet. The fire is thought to have started in a

l a v a t o ry, probably when a motor overheated. The crew declared an

e m e rg e n c y, but it took about 20 minutes before they could land at

the closest large airport, near Cincinnati. When the plane finally

stopped, only half of the 46 persons aboard were able to escape

the burning aircraft before becoming overcome by smoke and

fumes. As a result, the Safety Board made a number of safety

recommendations to both reduce the likelihood of an in-flight fire

and to slow the pro g ress of a developing fire. Most of the Board ’s

recommendations were implemented, and have resulted in the

following fire safety improvements on U.S. airliners:

■ Smoke detectors and automatic-discharge fire extinguishers in

lavatories. Stiff fines are also imposed when anyone attempts

to disable a smoke detector;

■ F l o o r-level escape lighting along aisles that guide passengers

t o w a rd an exit should visibility be reduced by smoke; and

■ F i re-blocking cabin and seat materials, which are re q u i red on

all airliners built after August 19, 1990. Older aircraft re c e i v e

the new materials when they undergo a complete

refurbishment. Safety Board investigators credited fire - b l o c k i n g

seat materials with saving lives following a takeoff accident

and fire aboard a Delta Air Lines Boeing 727 at Dallas/Fort

Wo rth in August 31, 1988. A study showed that fire - b l o c k i n g

materials gave passengers additional time to exit the airc r a f t .

Another concern related to fire safety is the heat-re s i s t a n t

capability of material on evacuation slides. Based on Safety Board

recommendations issued after a runway overrun accident involving 

a Continental Airlines DC-10 in Los Angeles in 1978, evacuation

slides on aircraft are now coated with a material to resist heat fro m

postcrash fires. In the accident, which killed two people, 40 of the

200 occupants were forced to jump to the ground while another 15

persons used the escape rope in the cockpit. Heat from the intense

f i re caused several evacuation slides to deflate and melt. There

w e re 31 serious injuries.

C a rgo compartment fires are another fire safety concern. In

1981, a Saudi Arabian Airlines Lockheed L-1011 experienced an inflight fire after depart u re from Riyadh for Jeddah. Although the
airplane re t u rned and landed at Riyadh, all 301 persons aboard

perished in the ensuing cabin fire, which was later determined to

have started in the aft Class C cargo compartment. The investigation revealed that the design of Class C compartments did not

meet the intent of regulations that re q u i red Class C compart m e n t s

to smother a fire. Safety recommendations issued by the Board

after this accident led to major modifications to all widebody 

airplane Class C cargo compartments aimed at preventing a fire

f rom spreading. 

On November 28, 1987, a South African Airways Boeing 747

“combi” (combined cargo and passenger service) experienced 

an in-flight fire over the Indian Ocean en route from Taiwan to

J o h a n n e s b u rg. The airplane crashed into the Indian Ocean, with 

the loss of all 160 on board. The investigation of that accident was

expensive and complex because portions of the wreckage had to 

be re c o v e red from 15,000 feet under water. The investigation

d e t e rmined that a fire started in the main deck cargo compart m e n t ,

located just behind the passenger cabin. As the result of Safety

B o a rd recommendations, major modifications were re q u i red 

for all “combi” airplanes, and regulations were revised to ensure

m o re rigorous standards of fire suppression and detection on

passenger airc r a f t .

On Febru a ry 2, 1988, an American Airlines DC-9 safely landed in

Nashville with a fire burning in the cargo compartment. The fire was

traced to an improperly packaged and prohibited chemical shipment.

As a result of its investigation of this incident, the Safety Board

recommended that fire detection and suppression equipment be

re q u i red in cargo areas that were previously thought to be so airt i g h t

that a fire could not be sustained. No regulations were issued, and

on May 11, 1996, a ValuJet DC-9 crashed in Miami after a fire

e rupted in a cargo compartment. The Safety Board investigation

concluded that activation of one or more chemical oxygen generators

in the forw a rd Class D cargo compartment initiated the fire. In early

1998, the FAA issued a rule requiring fire detection and suppre s s i o n

systems in all the cargo holds of 3,700 aircraft by 2001.

9
10

Wi n d s h e a r

Since 1968, the Safety Board has issued more than 60 safety

recommendations addressing windshear and related weather

issues. Major recommendations were issued following the 1975

crash of an Eastern Air Lines Boeing 727 in New York, and several

others that followed. 

On August 2, 1985, a Delta Air Lines Lockheed L-1011 crashed

while landing at Dallas/Fort Wo rth International Airport during a

t h u n d e r s t o rm, killing 135 persons. The Safety Board ’s investigation

revealed it to be the seventh fatal transport - c a t e g o ry airc r a f t

accident since 1970 and the 18th overall attributable to the weather

phenomenon now known as windshear.

As a result of the Safety Board ’s recommendations, re s e a rc h

e ff o rts were launched that greatly increased our knowledge and

understanding of the windshear phenomenon. Among the safety

i m p rovements developed as a result of these re c o m m e n d a t i o n s

w e re enhanced windshear training for pilots and

low-level windshear alert systems installed at all

major airports. The Board also recommended the

installation of Te rminal Doppler Weather Radar

(TDWR), an integral part of these alert systems,

to provide pilots with more timely and more

accurate weather information. 

Because of these improvements, there has

been only one windshear- related accident

involving a transport - c a t e g o ry aircraft in the

United States in the last 13 years—the July 1994

DC-9 accident in Charlotte, North Carolina. 

A TDWR had not yet been installed at Charlotte.

The Safety Board believes that the enhanced

radar would have given controllers the opport u n i t y

to issue timely information to the flightcrew about

the severity of the weather and may have

p revented the accident. As of mid-1998, 37

TDWR facilities had been commissioned in

a i r p o rts throughout the country and the FAA is

developing an advanced onboard weather

detection system. Windshear detector radar.
I c i n g

Since the beginning of powered flight, aviators have contended

with the effects of ice on their aircraft. In fact, aviation safety

pioneer Jerome Lederer noted in 1939, “Strange as it may seem, 

a very light coating of snow or ice, light enough to be hardly visible,

will have a tremendous effect on re d u c i n g

the perf o rmance of a modern airplane.”

Almost 60 years later, the commerc i a l

aviation industry is still not able to avoid the

tragic consequences of this phenomenon.

Nine icing-related commercial aviation

crashes have occurred since 1982 in the

United States alone, involving transport -

c a t e g o ry aircraft and commercial passenger

a i rc r a f t .

Beginning in 1975, the Safety Board

issued numerous safety re c o m m e n d a t i o n s

a d d ressing the measurement, fore c a s t i n g ,

avoidance, and protection of aircraft against

such icing conditions. In response to

recommendations issued by the Board 

after its investigation of a USAir Fokker F-28

crash at LaGuardia Airport on March 22,

1992, that killed 27 people, the FAA significantly upgraded the

deicing/anti-icing re q u i rements for major air carriers and commuters.

Following a fatal accident involving a United Express Jetstre a m

31 at Pasco, Washington, on December 26, 1989, and a

subsequent, nonfatal USAir Express Jetstream 31 accident at

B e c k l e y, West Vi rginia, on January 30, 1991, the Safety Board

issued recommendations that led to the modification of all

J e t s t ream 31 airplanes to prevent aerodynamic stall because of ice

a c c retion. The investigation revealed that ice built up during cert a i n

phases of flight and caused subsequent stall and loss of control of

the airplane.

In late 1994, the Safety Board recommended that ATR-42 and

ATR-72 passenger aircraft not be allowed to fly into known or

f o recasted icing conditions while it continued to investigate the

crash of an American Eagle ATR-72 in Roselawn, Indiana, that killed

11
12

all 68 persons aboard. After imposing flight restrictions on ATRs, the

FAA approved a design modification to the ATR deicing system that

was in place on all ATRs in the United States by the 1995-1996

icing season. As a result of these actions, flight operations in icing

conditions have become considerably safer.

Midair Collisions

As air traffic continues its rapid growth, the airspace used by

a i rcraft does not expand. With more aircraft flying more often in this

finite airspace, advances in collision avoidance technology are

critical to maintaining adequate separation of airc r a f t .

Since 1967, the Safety Board has recommended and support e d

the development of an airborne collision avoidance system that

would be independent of the ground-based air traffic control system

to provide pilots with an additional source of information on

potential conflicts in flight. Since 1993, transport - c a t e g o ry airc r a f t

have been equipped with traffic alert and collision avoidance

systems (TCAS). General aviation aircraft operating in contro l l e d

airspace near major airports are now re q u i red to be equipped with

Mode C transponders, which give air traffic controllers altitude

i n f o rmation. Mode C transponders provide several major benefits:

they permit radar to automatically display the altitudes of airc r a f t

equipped with them; they provide air traffic control computers with

route and altitude information that sound alarms when imminent

collision hazards are detected. This technology has greatly enhanced

the prevention of midair collisions and near- c o l l i s i o n s .

All air traffic controllers now receive annual TCAS training as a

result of Safety Board recommendations. This training explains the

operation of TCAS and the roles and responsibilities of flightcrews in

responding to TCAS alert s .

Thanks, at least in part, to the installation of anticollision

equipment and the improved air traffic controller training, several

midair collisions involving transport - c a t e g o ry aircraft have been

avoided in the United States.
Rejected Ta k e o f f s

On May 21, 1988, an American Airlines DC-10, operating near

maximum gross weight, was damaged beyond economical re p a i r

during a rejected takeoff at Dallas/Fort Wo rth International Airport .

During the rejected takeoff, the airplane decelerated normally for five

to six seconds, and then did not continue to adequately decelerate,

resulting in the airplane running off the end of the runway at a

g round speed of about 97 knots. Only two of the 255 occupants

w e re injure d .

Evidence showed that the airplane’s brakes failed during the

rejected takeoff. If the brakes had not failed, the airplane could have

stopped on the ru n w a y. Examination of the airplane’s wheel brake

system revealed that eight of the 10 brakes totally failed when the

brake friction material depleted. Before the rejected takeoff, the

brakes were near the established replacement limit of 0.7 inch.

C e rtification flight test data showed that new brakes, which have

about 2.7 inches of material available, wear, on average, about 1.5

inches during a rejected takeoff. With brake material allowed to wear

down to 0.7 inch before replacement, the replacement limit was

clearly unacceptable. The limits had been established to ensure that

the brakes would not be damaged during normal friction material

w e a r, not necessarily to survive a rejected takeoff .

The Safety Board determined that this oversight evolved from the

FA A’s acceptance of inadequate certification testing pro c e d u re s ,

including using new brakes instead of worn brakes; testing during a

landing rather than a rejected takeoff; and inadequate dynamometer

testing. At the Board ’s urging, the FAA issued airw o rt h i n e s s

d i rectives improving allowable brake wear limits on transport -

c a t e g o ry airplanes.

The Safety Board also conducted a special investigation on the

safety of rejected takeoffs and found serious shortcomings in pilot

training concerning possible rejected takeoff hazards. In re s p o n s e ,

Boeing, working together with segments of the aviation industry,

developed a rejected takeoff training aid to improve pilot training in

this important area. This training aid has since become an FA A

a d v i s o ry circular and is widely used throughout the industry.

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Runway Overruns

A i rcraft occasionally overrun the end of a runway on landing or

during rejected takeoffs. There were major accidents in 1989 and

1994 at New Yo r k ’s LaGuardia Airport. Two people died in one of

the accidents. Although the FAA re q u i res a 1,000-foot safety area at

the end of newly constru c t e d

runways, some runways built

b e f o re that standard was

enacted are adjacent to

wetlands, waterways, or sharp

t e rrain dro p - o ffs that do not allow

the minimum safety are a .

C o n s e q u e n t l y, another method is

needed to protect aircraft on

these ru n w a y s .

In 1984, following its safety

study on airport certification, the

Safety Board recommended that

the FAA “initiate re s e a rch and

development activities to establish the feasibility of soft-gro u n d

a i rcraft arresting systems and promulgate a design standard, if the

systems are found to be practical.” Soft-ground systems use

material that will deform readily and reliably when an airc r a f t

traverses it. As the tires crush the material, the drag forc e s

decelerate the airc r a f t .

The extensive re s e a rch that followed this re c o m m e n d a t i o n

resulted in the development of a cellular concrete system that was

tested at the FA A’s Technical Center in Atlantic City. In November

1996, the Port Authority of New York and New Jersey installed a

400-foot-long arrestor bed for runway 4R at JFK International Airport .

A rrestor beds for runways 13 and 22 at LaGuardia are planned for

1998. This is a major step in mitigating the effects of potentially

d a n g e rous runway overruns at airports in the United States and

a round the world.
Alcohol and Av i a t i o n

Since 1984, the Safety Board has asked the FAA to use the

National Driver Register (NDR) to help identify airmen whose driver’s

licenses have been suspended for alcohol-related offenses. Such

pilots may have alcohol dependencies that could affect their ability

to safely operate an airc r a f t .

After an alcohol-related aviation accident in 1986, the Safety

B o a rd issued safety recommendations that underscored the

potential benefits of an NDR search. A Beech G-18S airplane, which

was on an unscheduled air cargo flight from Milwaukee to Atlanta,

crashed near Copperhill, Tennessee. The airplane was destro y e d ,

killing the pilot. The Board determined that the pilot’s blood alcohol

concentration (BAC) at the time of his death was 0.158 perc e n t ,

well above the limit of 0.10 used in most states to cite drivers for

driving while intoxicated (DWI).

The investigation disclosed that the pilot had been convicted of

seven DWI offenses during the previous four years and that he had

been alcohol-dependent during that period. The NDR re c o rded seven

d r i v e r ’s license revocations as a result of the pilot’s DWI

convictions. Although the pilot had been examined regularly by

designated aviation medical examiners, the FAA did not detect his

alcohol abuse and dependency.

In November 1988, the FAA issued regulations to identify pilots

involved in alcohol- or dru g - related motor vehicle offenses re s u l t i n g

in convictions or administrative actions. The new regulations, which

went into effect in 1990, re q u i re pilots to re p o rt any alcohol- or

d ru g - related driving conviction or administrative action within 60

days. Pilots applying for a medical certificate must consent to the

release of NDR information. To detect pilots with DWI convictions,

the FAA is systematically matching the names of those holding

aviation medical certificates with the NDR and law enforc e m e n t

re c o rd s .

Out of the first 170,000 re c o rds processed by the FAA during its

initial search, about 4,000 driving re c o rds were identified as

questionable and 84 were earmarked for enforcement action against

the pilots. The FAA reviews the NDR for approximately 300,000

pilots yearly.

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Airlines are now re q u i red to perf o rm preemployment, random,

and postaccident drug testing for the presence of certain illicit dru g s

in persons employed in safety-sensitive positions. The re q u i re m e n t

has been expanded to include postaccident testing for alcohol.

The Safety Board has never determined alcohol use to be a

cause or factor in a fatal accident involving a U.S. airliner. The Board

also learned, through its safety study on alcohol use by general

aviation pilots between 1983 and 1988, that the percentage of

fatally injured pilots who tested positive for alcohol was 6.7 perc e n t ,

down from about 10 percent in the mid-1970s.

Parachuting Safety

On April 22, 1992, a de Havilland Twin Otter crashed during

t a k e o ff at Perris Va l l e y, California, after an engine lost power. The

Safety Board determined that the accident was caused by

contaminated fuel from the airf i e l d ’s fuel tanks and the pilot’s

i m p roper actions after the power loss, as well as other factors.

Although the aircraft never rose above 50 feet, 14 jumpers and the

two pilots were killed. 

The Safety Board conducted an in-depth study

of drop zone operations following that accident. It

found that sport parachute operations have

unique pro c e d u res not found in any other aviation

operation. Operators of sport parachute flights

c o n t rol their fuel handling, maintenance, and

other pro c e d u res with more limited re s o u rc e s

than other aviation operations involving

p a s s e n g e r s .

On September 7, 1992, a Beech C-45 being

used for a sport parachute flight crashed near

H i n c k l e y, Illinois, after one of the engines

malfunctioned. The pilot was maneuvering to land

when the aircraft went out of control close to the

g round. All 12 aboard died. 

In both of these accidents, the Safety Board

found that the parachutists were not pro p e r l y

s e c u red by seatbelts or restraints. Had the

jumpers been wearing proper restraints, lives
might have been saved because impact forces were surv i v a b l e ,

p a rticularly at Perris Va l l e y. The Board made recommendations to

the FAA and to the U.S. Parachute Association (USPA). The

recommendations urged the FAA to add drop zone oversight to their

national work plan, re q u i re mandatory use of seatbelts by

parachutists, and develop better safety restraint systems and

seating for parachutists. 

The USPA and drop zone operators are aggressively pursuing

these issues, particularly by changing the behavior of jumpers to

insist that seatbelt usage be mandatory. Now, parachutists and dro p

zone operators are paying more attention to aircraft safety issues.

Since the Safety Board ’s recommendations were issued,

investigators believe many lives have been saved by the proper use

of seatbelts and other new safety practices in survivable sport

parachute aircraft accidents. 

A i rcraft Seats

For years the Safety Board has recommended that the FA A

establish higher crashworthiness standards for passenger and cre w

seats to better prevent seat failures and protect persons in

accidents. In minor-to-moderate aircraft crashes, the occupants

often are thrown about or ejected because of seat failure. The Board

also has testified numerous times before Congress and joint FA A -

i n d u s t ry groups on the need for improved seats.

The Safety Board ’s concern about seat integrity was underscore d

during its investigation of the November 1987 crash of a Ryan Air

Beech 1900 in Homer, Alaska, that killed 18 of the 21 persons

a b o a rd. The crash induced high vertical G forces and the seats

failed. If stronger seats had been installed, the severity of the

occupants’ injuries might have been reduced, and more passengers

might have surv i v e d .

In May 1988, the FAA published its final rule upgrading the

c r a s h w o rthiness of seats on newly certificated transport - c a t e g o ry

a i rcraft from 9 Gs to 16 Gs and, for the first time, requiring that

seats be tested dynamically for their strength in addition to the

c u rrent re q u i rement for static testing.

During its investigation of a 1989 crash of a Grand Canyon

Airlines DHC-6, serious deficiencies were found with the

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c r a s h w o rthiness of the passenger seats. The steel hollow-tube

seatframes had been chrome-plated for cosmetic reasons, an action

that had not been approved by the FAA. As a result of the impro p e r

c h rome-plating, the Board found multiple seatframe separations at

welds that were made during manufacture, and corrosion of

seatframes to the extent that some frame tubes had no wall

thickness beneath the chrome-plating. A Board inspection of 21 other

Grand Canyon Airlines and Scenic Airlines, which owned Grand

Canyon, airplanes found similar problems. Based on the Board ’s

findings, the FAA ord e red the airlines to replace any defective seats.

The airlines subsequently equipped their aircraft with new seats

which will enhance survivability of passengers in case of an accident.

Seatbelt Integrity

In its investigation of a 1988 turbulence incident, the Safety

B o a rd learned that three seatbelts detached from their shackles,

resulting in minor injuries to the three passengers using those

seatbelts. The seatbelts were typical of those commonly used in air

c a rr i e r, air taxi, and commuter airplanes. Tests conducted under the

B o a rd ’s direction revealed that, under certain conditions, the

seatbelts could become detached from their fittings, there b y

rendering them useless.

As a result of its findings, the Safety Board recommended that

the FAA issue a maintenance alert to inspect seatbelts and make

the proper repairs. The FAA issued the alert, which resulted in the

inspections of 27,000 seatbelts in commercial air carr i e r, military,

and general aviation aircraft, thus increasing the survivability of

persons wearing those seatbelts during an emerg e n c y.

Regional and Commuter Airlines

The regional and commuter airline industry has grown immensely

since the Airline Deregulation Act of 1978. In 1992, they carried 45

million passengers to hundreds of communities. That number ro s e

to 62 million in 1997 and is expected to almost double to 117

million by the year 2009. 

Commuter airlines, those using aircraft with 30 or fewer passenger

seats, historically had a higher accident rate than 
airlines with larger planes, which flew under more stringent safety

regulations. Part of the reason for the higher accident rates may have

been that commuter airline accident statistics include bush operations

in Alaska, which pose more risks than the average commuter airline

flight in the lower 48 states. However, some of the disparity in

accident rates may have been the result of less stringent re g u l a t i o n s ,

especially those governing pilot training and qualifications.

The Safety Board issued numerous safety re c o m m e n d a t i o n s

advocating “one level of safety” to bring commuter airline

regulations more in line with stricter regulations governing the

operation of larger aircraft, which call for the installation of safety

devices like altitude encoding transponders, ground pro x i m i t y

w a rning systems, and cockpit voice re c o rd e r s .

In 1994, the Safety Board addressed the larger issue of why

regional and commuter operations were subjected to a separate

level of regulation, and determined that to the extent possible,

commuter airlines should operate under the same regulations as

scheduled airlines operating larger planes. In part i c u l a r, the Board

recommended that FAA surveillance and commuter re g u l a t i o n s

c o n c e rning pilot training, scheduling, dispatch services, airport

c e rtification, airline management oversight, be aligned as much as

possible with re q u i rements for the larger airlines.

In December 1995, the FAA issued a final rule that bro u g h t

commuter airline flights in aircraft having 10 or more passenger

seats under the safety standards of the large air carrier rules. Under

this rule commuter airlines were certified under the more stringent

safety regulations in 1997.

C rew Resource Management

In a number of airline accidents investigated by the Safety Board in

the 1960s and 1970s, the Board detected a culture and work enviro nment in the cockpit that, rather than facilitating safe transport a t i o n ,

may have contributed to the accidents. The Board found that some

captains treated their fellow cockpit crewmembers as underlings who

should speak only when spoken to. This intimidating atmosphere

actually led to accidents when critical information was not

communicated among cockpit crewmembers. A highly publicized

accident in 1978 provided the impetus to change this situation.

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On December 28, 1978, as a result of a relatively minor landing

gear problem, a United Airlines DC-8 was in a holding pattern while

awaiting landing at Portland, Oregon. Although the first officer knew

the aircraft was low on fuel, he failed to express his concern s

convincingly to the captain. The plane ran out of fuel and crashed,

killing 10.

As a result of this accident and others, the concept of cockpit

re s o u rce management, now called crew re s o u rce management

(CRM), was born. Following pioneering work by the National

A e ronautics and Space

Administration (NASA), the Safety

B o a rd issued re c o m m e n d a t i o n s

to the FAA and the airline

i n d u s t ry to adopt methods that

encourage teamwork, with the

captain as the leader who re l i e s

on the other crewmembers for

vital safety-of-flight tasks and

also shares duties and solicits

i n f o rmation and help from other

c rewmembers. United Airlines

was one of the first airlines to

adopt this concept, which is

endorsed by pilot unions and is

now almost universally used by the major airlines (as well as in

other modes of transportation). The Board has also re c o m m e n d e d

and the FAA has acted to implement CRM for regional and

commuter airlines.

The value of CRM was demonstrated on July 19, 1989, when a

United Airlines DC-10 experienced a catastrophic engine failure over

Iowa that destroyed the airc r a f t ’s hydraulic systems, rendering it

v i rtually uncontrollable. The cockpit crew and a deadheading captain

who was a passenger worked as a team to bring the aircraft down to

a crash landing at Sioux City. Although more than 100 people

perished, almost 200 survived a situation for which no pilots in the

world had ever been trained.
A i rcraft Design

Safety Board investigations have resulted in findings of

inadequate design or certification of particular aircraft components.

For example, on April 5, 1991, an Atlantic Southeast Airlines EMB120 crashed near Brunswick, Georgia, killing all 23 persons aboard .

The Safety Board found that severe wear of a component in the

p ropeller control unit on the airplane’s left engine resulted in

asymmetrical lift and thrust, rendering the aircraft uncontro l l a b l e .

During its investigation, the Board learned of three pre v i o u s

occasions when operators found that a propeller would not operate

p roperly during ground tests. Based on Board recommendations, the

FAA re q u i red additional inspections of propeller control units and the

installation of a fail-safe feature to prevent the propeller blade angle

f rom rotating below the flight idle position while in flight.

In August 1995, an Atlantic Southeast Airlines EMB-120

t u r b o p ropeller engine-powered airplane crashed near Carro l l t o n ,

G e o rgia, following a propeller blade separation and secondary inflight damage to the airplane. The Safety Board ’s investigation

d e t e rmined that the imbalance caused by the failed propeller blade

displaced the engine from its mounts, resulting in drag. The drag

resulted in a loss of control in an attempted forced landing. The

Safety Board ’s investigation revealed that the failed propeller blade

had been recently removed and re t u rned to service following an

inspection that had detected indications of the crack. However, that

inspection by the manufacture r ’s repair station did not detect the

crack that led to the in-flight failure. It had been masked by an

i m p roper repair pro c e d u re which eliminated the crack indication. The

Safety Board subsequently recommended the removal from serv i c e

within five days of all blades that had similar inspection indications

and repairs. The Safety Board ’s investigation also brought about

i m p rovements in ultrasonic inspection techniques, blade re p a i r

p ro c e d u res, technician training, and corporate policies on flight

safety critical components.

Changes recommended by the Board as a result of one tragedy

can prevent another. Almost 25 years ago, on March 3, 1974, a

Turkish Airlines DC-10 crashed near Paris, France, when the lower

aft cargo door separated in flight during climbout. The re s u l t a n t

explosive decompression caused the cabin floor to buckle downward

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and jam the flight control cables. All 346 persons aboard perished.

Safety Board recommendations that stemmed from that

investigation led to the installation of blowout pre s s u re relief panels

in the cabin floors of all widebody airplanes.

On Febru a ry 24, 1989, a United Airlines Boeing 747 en ro u t e

f rom Honolulu, Hawaii, to New Zealand with 355 persons aboard

lost the forw a rd lower lobe cargo door during climbout. Although

nine occupants were killed in the accident, the catastrophic loss of

the entire airplane and its occupants was prevented by the opening

of the pre s s u re relief doors in the cabin floor. While the cabin floor

was damaged, the control cables remained functional because of

the modifications re q u i red after the Turkish Airlines accident.

Another widebody airliner had a diff e rent problem that has since

been corrected following Safety Board recommendations. On April 6,

1993, during a flight from Shanghai, China, to Los Angeles, a China

E a s t e rn Airlines MD-11 experienced an inadvertent deployment of all

leading-edge wing slats while at 33,000 feet over the Pacific Ocean.

The resulting severe pitch oscillations led to two fatalities and 160

injuries. Based on results of the Safety Board investigation,

McDonnell Douglas worked with the FAA and aircraft operators to

redesign the MD-11 flap/slat handle, and reduce the potential for

i n a d v e rtent slat operation. In addition, the Board identified that

f l i g h t c rews needed additional training related to the high-altitude

handling qualities of the MD-11 and DC-10 airc r a f t .

On May 5, 1991, a Lauda Air Boeing 767-300ER experienced an

uncommanded in-flight deployment of the number one engine thru s t

re v e r s e r, while climbing through 24,700 feet, approximately 16

minutes after takeoff from Bangkok, Thailand. The pilots lost

c o n t rol, the airplane entered a steep dive, exceeded the maximum

velocity and crashed, killing all 223 people aboard. The investigation

by the Thai airw o rthiness authorities and the Safety Board re v e a l e d

the possibility of an in-flight thrust reverser deployment,

s h o rtcomings in the fail-safe thrust reverser design re q u i rement on

767 airplanes, and lack of flightcrew operational pro c e d u res to

a d d ress such an anomaly. Design changes to engine re v e r s e r

systems that have been introduced and mandated as a result of this

accident have greatly reduced the possibility of an in-flight thru s t

reverser deployment in the 767 and many other air carrier airc r a f t

m o d e l s .
T h e re are many other examples of specific aircraft design

p roblems discovered by the Safety Board. Here are some of them:

■ On December 29, 1991, a China Airlines Boeing 747 fre i g h t e r

crashed about five minutes after takeoff near Taipei, Ta i w a n ,

and on April 10, 1992, an El Al Boeing 747-200 fre i g h t e r

crashed into two nine-story apartment buildings while re t u rn i n g

to land after takeoff from Amsterdam, Netherlands. The

investigations of both accidents revealed that during climb, the

No. 3 engine and pylon had separated from the wing, collided

with the No. 4 engine and caused the separation of that engine.

The combined effects of asymmetrical weight, thrust, and drag

caused the pilots to lose control. The investigations re v e a l e d

that the failed fuse pins in the pylon-to-wing attachment fittings

had cracks stemming from corrosion pits. As a result of the

Safety Board ’s involvement in the Taiwanese and Dutch

investigations, inspection pro c e d u res were modified and an

i m p roved fuse pin was designed and installed in all Boeing

747s reducing the likelihood of a repeat of such accidents.

■ Following the Board ’s investigation of a 1990 runway collision

in Detroit that killed a flight attendant and seven passengers,

redesigned emergency tailcone release handles are now

re q u i red on all commercial and military DC-9s and MD-80s to

a s s u re the availability of this exit in the event of an emerg e n c y.

■ During the Safety Board ’s exhaustive investigation of the crash

of a USAir Boeing 737 near Pittsburgh on September 8, 1994,

that claimed 132 lives,

investigators found that ru d d e r

anomalies could be produced in

l a b o r a t o ry tests. In October

1996, the Board re c o m m e n d e d

n u m e rous rudder design

changes to older 737s. The FA A

and Boeing agreed in 1996 to

re t rofit older 737s with a new

rudder system design. 

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■ In May 1997, a Skywest Airlines EMB-120 had an in-flight fire

in the No. 2 engine after takeoff from San Diego, Californ i a .

The Safety Board ’s investigation determined that a missing

drain plug in the Pratt & Whitney Canada PW100 engine may

have allowed fuel to drain into the hot engine compart m e n t

and caused the fire. During the investigation, the Safety Board ,

E m b r a e r, Pratt & Whitney Canada, and the operators of EMB120 airplanes coordinated an inspection of the worldwide fleet

and discovered many other airplanes with missing drain plugs

that were subsequently capped, eliminating a fire hazard. 

■ In general aviation, a Safety Board recommendation led to an

FAA airw o rthiness directive in 1993 to repair corrosion and

cracking in the wing front spar fuselage attachment assembly

on Piper PA-25 airplanes. Left uncorrected, the problem could

have led to in-flight wing separations. More than 1,200 airc r a f t

w e re affected by the dire c t i v e .

Structural Fatigue and Corro s i o n

On April 28, 1988, an Aloha Airlines Boeing 737-200 airplane

experienced a structural failure and explosive decompression at

24,000 feet while en route from Hilo to Honolulu, Hawaii.

A p p roximately 18 feet of fuselage skin and stru c t u re, above the

passenger floor and aft of the main cabin entrance door, separated

f rom the airplane in flight. One flight attendant was swept out of the

plane during the decompression and killed. Although power from one

engine was lost and there were control difficulties, the flightcre w

p e rf o rmed an emergency descent and landing at Kahului Airport, on

Maui, without further incident.

The Safety Board ’s investigation revealed that the fuselage

f a i l u re was caused by disbonding of the fuselage lap joints and

multi-site fatigue cracking. As a result of the investigation, the Safety

B o a rd issued over 20 recommendations that addre s s e d

s h o rtcomings in the maintenance and repair of the airc r a f t ’s

s t ru c t u re. These recommendations and the Board ’s accident

investigation greatly increased the industry ’s understanding of aging

a i rcraft structural issues. As a result, the FAA re q u i res incre a s e d

fatigue testing on newly certified airplanes. Older aircraft are

subjected to periodic reviews, inspections, and modifications to

eliminate corrosion and metal fatigue.
Uncontained Failures of 

Titanium Engine Components

On July 19, 1989, a United Airlines DC-10 airplane equipped with

General Electric CF6-6 engines crashed during an emergency landing

at the Sioux City Municipal Airport, Sioux City, Iowa, following an

uncontained failure of the center engine’s front compressor fan disk.

Of the 286 persons on board, 111 were killed in the crash landing.

The Safety Board ’s investigation discovered that the ejected engine

fragments damaged all thre e

hydraulic systems and crippled

the pilots’ ability to control the

airplane. The pilots could not

operate the hydraulically

p o w e red control systems but

manipulated the throttles to

c o n t rol the airplane and turn i n g

m o v e m e n t s .

The investigation re v e a l e d

that the failure stemmed from a

crack that originated from a hard

nugget or inclusion in the disk

that was originally about the size

of a grain of sand. The inclusion

had been formed during the

titanium melting process and the crack had been missed during

several inspections of the fan disk. This accident and others that

followed it resulted in a much greater industry understanding of the

titanium melt and manufacturing process and improvements in

airlines’ in-service inspection process which were adopted thro u g h o u t

the industry.

In July 1996, a Delta Air Lines McDonnell Douglas MD-88

airplane, powered by Pratt & Whitney JT8D-200 series engines,

experienced an uncontained front compressor fan hub failure in an

engine during the takeoff roll at Pensacola, Florida. The Safety

B o a rd ’s investigation determined that the titanium hub failed from 

a fatigue crack that originated in a tierod hole at the time of

m a n u f a c t u re. The hardened surface that became the origin of the

crack origin was not detected by the inspection process used during

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m a n u f a c t u re. The detectable enlarged crack was also missed during

a fluorescent penetrant inspection of the hub in serv i c e .

In April 1995, an Egypt Air Airbus A-300 airplane, equipped with

General Electric CF6-50 series engines, experienced an uncontained

f a i l u re of a high-pre s s u re compressor engine spool during takeoff at

C a i ro, Egypt. The Safety Board assisted the Egyptian aviation

authorities and determined that a stage of the spool had failed fro m

a fatigue crack that originated from an inclusion. This investigation

revealed that the crack existed at the time of the last inspection and

that the spool was difficult to thoroughly inspect.

In September 1997, a Canadian Airlines Boeing 767 experienced

an uncontained failure of a General Electric spool during takeoff at

Beijing, China. The Safety Board ’s investigation revealed that a crack

originated from an oxygen-rich area in a highly stressed region of the

titanium spool. The investigation also revealed that a water leak

during the titanium melt process caused the oxygen-enriched are a .

As a result of the Sioux City, Pensacola, Cairo, and Beijing

investigations, the Safety Board has made many re c o m m e n d a t i o n s

re g a rding titanium engine parts that addressed shortcomings in the

titanium melting, disk manufacture r ’s inspection, and the engine

o v e rh a u l e r ’s inspection processes. The actions taken by the aviation

community have resulted in an increased awareness of the titanium

melting, machining, and inspection processes and brought about

many changes to ensure higher manufacturing quality, better ins e rvice inspections, and higher reliability of these part s .

Off-wing Escape Slides

On April 5, 1993, a TACA International Airlines (El Salvador)

Boeing 767-200 crashed while landing at La Aurora Intern a t i o n a l

A i r p o rt in Guatemala City, Guatemala. All of the 224 occupants

safely evacuated the airplane, and only minor injuries were re p o rt e d .

During the evacuation, as the left overwing emergency exit door was

opened, the off-wing escape slide compartment door did not open,

and the slide did not deploy. Consequently, several passengers

jumped from the wing to the gro u n d .

The Safety Board assisted Guatemalan aviation authorities and

d e t e rmined that the slide door could not open because one of thre e

latches was installed upside down and had moved to the closed
position rather than to the open position. The Safety Board issued

recommendations that addressed shortcomings in the latching

mechanism design, installation pro c e d u res, and inspection

p ro c e d u res. These corrective actions resulted in the discovery 

of other improperly installed latches. The correction of these

deficiencies has reduced the likelihood that off-wing slides might 

be unavailable in future emergency aircraft evacuations.

Pitot-Static System Blockages

On Febru a ry 6, 1996, a Birgenair Boeing 757-200 crashed into

the Atlantic Ocean after climbing through 7,300 feet after takeoff

f rom the Puerto Plata International Airport, Dominican Republic. On

October 2, 1996, an Aero p e ru Boeing 757-200 crashed into the

Pacific Ocean about 30 miles off the coast of Lima, Peru. All 189

people on board the Birgenair flight and all 70 people on board the

A e ro p e ru flight were killed, and both airplanes were destro y e d .

During the Safety Board ’s participation in the investigations of

these accidents, it was discovered that the pitot tube had become

blocked on the Birgenair airplane and the three left static ports on

the Aero p e ru airplane were blocked by masking tape during gro u n d

maintenance that preceded the flight. These obstructions in the

pitot-static systems of the airplanes caused erroneous airspeed 

and altitude readings and confusion in the cockpit that led to the

accidents. The Safety Board issued recommendations that

a d d ressed shortcomings in the Boeing 757/767 cockpit cre w

a l e rting systems, pilot training, operations, and maintenance

p ro c e d u res. Industry action in response to these re c o m m e n d a t i o n s

should reduce the likelihood of such accidents in the future. 

Helicopter Safety

In 1996, the Safety Board concluded a special investigation of

Robinson Helicopter Company R22 helicopters following 31 R22 and

t h ree R44 accidents in which there was an in-flight loss of main

rotor control that resulted in the main rotor contacting the tailboom

or fuselage in flight. In all of these accidents, the occupants of the

helicopters were killed. The Safety Board did not find any evidence

of an initiating airframe or engine component malfunction; flight into

adverse weather, such as low visibility or cloud ceilings, was not

27
28

indicated in any of the accidents. The Board found that the R22,

which has a lightweight, highly responsive, low rotor inertia design,

was involved more frequently in loss of main rotor control accidents

than other helicopters studied.

During the investigation, the Safety Board issued safety

recommendations that resulted in re s e a rch by both the FAA and the

m a n u f a c t u rer that led to product improvements including the

m a n d a t o ry introduction of an engine governor and a larger optional

engine. The recommendations also re q u i red in special aware n e s s

training that addressed loss of rotor control events and pilot

p ro f i c i e n c y, and restrictions on operating in certain wind conditions.

The Board ’s investigation and the actions taken by the FAA and the

m a n u f a c t u rer in response to the investigation have been very

e ffective; there were no R22 or R44 loss of main rotor contro l

accidents in the world for more than two years following the

accidents addressed in the re p o rt. 

Fuel Tank Explosions

On July 17, 1996, a Trans World Airlines Boeing 747-100

experienced an in-flight explosion of its center wing fuel tank near

East Moriches, New York, shortly after takeoff from JFK Intern a t i o n a l

A i r p o rt, New York. The extensive investigation and re c o m m e n d a t i o n s

have resulted in safety improvements made in coordination with

Boeing and the FAA. This has led to greater industry understanding

of the hazards posed by fuel vapor at elevated temperatures in fuel

tank ullage, flammability and ignition energies of Jet A fuels,

s h o rtcomings in fuel tank electrostatic and lightning pro t e c t i o n ,

electrical surge protection for fuel quantity indication systems,

i m p roved fuel pump safety, and understanding of aging wiring

i s s u e s .

With respect to the 747 fleet, the Safety Board ’s

recommendations have resulted in fuel system pro d u c t

i m p rovements, service bulletins, notices of proposed ru l e m a k i n g ,

and airw o rthiness directives to correct issues that have been

u n c o v e red. As the investigation pro g resses, the industry is more

a g g ressively addressing aging wiring issues to eliminate ignition

s o u rces in other aircraft models in the air carrier fleet. 
Tu r b o p ropeller Airplane Safety

On Febru a ry 1, 1994, an American Eagle SAAB 340 made a

f o rced landing into the False River Airport, in New Roads, Louisiana.

The Safety Board determined that the captain placed the engine power

levers below the flight idle stop which rotated the propeller blades into

the reverse thrust range. As a result, the engines experienced an

overspeed condition and both power turbines were destroyed. The

investigation revealed that the captain had bypassed mechanical limits

to move the power levers into reverse (beta) pitch to reduce speed

and increase the descent. The Safety Board ’s investigation re v e a l e d

similar incidents of inappropriate use of the in-flight beta and

recommended mechanical lockouts to physically prevent pilots fro m

selecting beta in-flight. As a result of these accidents and the safety

recommendations, the FAA has mandated changes in a variety of

t u r b o p ro p e l l e r- p o w e red airplanes to greatly reduce the possibility of

p ropellers operating in the beta range while in flight.

Flight Safety in Alaska 

Because of its geography, Alaska is extraordinarily dependent on

aviation to meet the transportation needs of a far-flung population.

Also, Alaska’s environment, from adverse weather to rough terr a i n

to active volcanoes, is extre m e l y

challenging to safe flight

operations. Concerned about

historically greater fatal accident

rates for the commuter airline

and air taxi segments of the

c o m m e rcial aviation industry in

Alaska (relative to these same

i n d u s t ry segments in the

remainder of the United States),

the Safety Board conducted a

safety study of aviation

operations in Alaska in 1995.

The Safety Board found that

some of the risks of flying in

Alaska could be controlled if the

state received enhanced aviation

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30

facilities with improved communications, instrument appro a c h

p ro c e d u res, weather re p o rting, and airport field condition re p o rt i n g .

S p e c i f i c a l l y, these improvements were targeted at the most common

type of fatal accident in Alaska: continued visual flight into adverse

w e a t h e r.

In response to safety recommendations issued by the Safety

B o a rd, the FAA has begun to test a system for instrument flight

operations in Alaska that uses satellite-based navigation and

communication technologies, and approved instrument flight

operations for passenger- c a rrying commercial flights using singleengine airplanes. It also implemented a new system for

disseminating information about runway conditions to Alaska pilots.

The National Weather Service has expanded the information that

weather observers can manually enter into automated weather

o b s e rvations and has improved the dissemination of weather chart s

and satellite images to pilots in the state. Also, Alaska has stepped

up its inspections of airport conditions and obtained funding for

equipment and training for its airport employees to communicate

with pilots about safe conditions for landing.

S p a c e

The Safety Board ’s expertise is also applied to the nation’s

e ff o rts to explore space and improve the safety of space flight. After

the shuttle Challenger was destroyed during its launch in 1986,

NASA requested assistance from the Safety Board. The Board ’s

re c o n s t ruction eff o rts were critical to NASA’s determination of the

f a i l u re sequence. Following that investigation, NASA re q u e s t e d

B o a rd assistance in determining the crashworthiness and

s u rvivability of the orbiter and the effects of explosions on space

shuttle payloads. It also requested long-term commitment of Board

re s o u rces in two areas: providing expertise in any future space

t r a n s p o rtation accidents and training NASA staff and astronauts in

w reckage re c o n s t ruction and analysis techniques.

During the Challenger investigation, the U.S. Air Force re q u e s t e d

Safety Board participation in the investigation of a Titan 34D military

launch vehicle explosion that occurred seconds after liftoff at

Va n d e n b u rg Air Force Base. Board investigators located the cause of

the failure, and the flaw was re p a i red before a sister vehicle was

l a u n c h e d .
Following the creation of the Office of Commercial Space

Tr a n s p o rtation within the DOT, the Safety Board and DOT signed an

a g reement for the Board to investigate selected mishaps that occur

during launches of commercial space vehicles. In Febru a ry 1993,

the Board investigated its first incident under this agreement when a

Pegasus SCD-1 vehicle was launched from the wing of a B-52 after

an abort command was given. Although the launch was successful,

the Board found unsafe launch conditions and re c o m m e n d e d

changes. 

31
32
T

he railroad industry transported more than $32 billion in

f reight in 1997, amassed more than 1.36 trillion revenue ton

miles, and employs about 256,000 people. Amtrak carr i e s

about 21 million intercity passengers a year, and rail rapid transit

systems – a major source of urban transportation – carry almost

two billion passengers annually.

Safety Board recommendations in the rail mode have addre s s e d

p roblems in both passenger service and freight transport a t i o n .

Passenger Rail Car Safety

Safety Board accident investigations have resulted in a larg e

number of safety improvements in rail passenger car equipment and

design, injury reduction and prevention, train collision avoidance,

and operations. More than 150 Safety Board recommendations for

safety improvements covering a wide spectrum of rail passenger

issues have resulted in:

■ Seats, seat cushions, and appliances that are now secure

f rom movement;

■ Windows that are impact resistant and available as emerg e n c y

e x i t s ;

■ M i rrors that are shatterpro o f ;

■ O v e rhead luggage racks that have effective retention devices;

a n d

■ Interior surfaces that are rounded and/or padded.

Other Safety Board recommendations have resulted in

i m p rovements in flammability standards, safety feature inform a t i o n ,

and emergency egress such as:

■ Replacement of materials to meet current flammability, smoke

emission, and toxicity standard s ;

■ Installation of smoke detectors with guards to pre v e n t

unauthorized re m o v a l ;

33

R a i l ro a d
34

■ Passenger emergency briefing cards and placards, including

how to use emergency extrication tools;

■ Conspicuous markers and levers to facilitate operation of

doors and emergency windows;

■ P o rtable lighting in the form of chemical emergency light sticks

that can be used by passengers to find their way out of cars

and their way along tracks in the dark;

■ Relocated, reliable, and long-lasting batteries for interior

e m e rgency lights; and 

■ Additional emergency exit windows.

The Safety Board has recognized that community involvement

and on-board service crew training and education are necessary to

better cope with emergencies. Safety Board re c o m m e n d a t i o n s

resulted in:

■ Development of pro c e d u re s

for emergency passenger

car evacuation that ensure

the safety of passengers;

■ C o m p rehensive training and

re-training programs for onb o a rd service employees in

e m e rgency pro c e d u re s

including the demonstrated

operation of emerg e n c y

exits; and

■ C o o rdination and training of

local track-side

communities for emerg e n c y

rescue familiarization.

The railroad industry has also acted on other Safety Board

recommendations to increase railroad passenger safety. The

i n d u s t ry is eliminating rim-stamped straight-plate wheels on

passenger cars which were failing and causing accidents. Railro a d

tunnels used by commuter and intercity passenger trains have been

inspected and equipped with fire hydrant stand pipes, emerg e n c y

communication stations and hookups, and improved lighting as a

result of Safety Board investigations and re c o m m e n d a t i o n s .
S u p e rvision of passenger train crews and the management of

train movements have also been the topics of Safety Board

recommendations which have resulted in:

■ Expanded supervision and management of train operations on

the Northeast Corr i d o r, including mandatory speed and signal

compliance checks;

■ Regular crew fitness for duty checks at re p o rting points;

■ Written notification of speed re s t r i c t i o n s ;

■ Special permission pro c e d u res for trains entering out-of-serv i c e

track sections; and

■ A re p o rting system for Amtrak crew eff i c i e n c y, rule compliance,

and toxicology tests while Amtrak trains are using non-Amtrak

or “host” railroad tracks.

Two Safety Board investigations of passenger train accidents in

1996 at Secaucus, New Jersey, and Silver Spring, Maryland, have 

led to significant recommendations on the physical testing for

qualification of train crews and signal system design. In January near

Secaucus, two New Jersey Transit commuter trains collided head-on

killing the engineers on both trains and one passenger. The Safety

B o a rd determined that the probable cause of the accident was one of

the train engineer’s failure to correctly perceive a red signal because

of an eye disease and color vision deficiency which he failed to re p o rt

to New Jersey transit during annual medical exams.

In the Febru a ry Silver Spring accident, three crew members and

eight passengers on a Maryland commuter train were killed when it

i g n o red a signal and collided with an Amtrak passenger train. The

Safety Board said the engineer and crew failed to obey signals

because of multiple distractions, and federal and state re g u l a t o r s ’

f a i l u res to conduct analyses on the human factors impact of signal

modifications on that rail line. 

As a result of years of rail passenger safety re c o m m e n d a t i o n s

f rom the Safety Board, the Federal Railroad Administration (FRA) is

enacting regulations re g a rding passenger equipment safety

s t a n d a rds and passenger train emergency pre p a redness. These

regulations will implement many of the recommendations the Safety

B o a rd has made to the FRA and the railroad industry to improve the

c r a s h w o rthiness of rail passenger cars and locomotives.

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36

Rail Rapid Tr a n s i t

The Safety Board has long been concerned about rail rapid

transit safety. Almost two billion passengers a year commute on rail

rapid transit systems, and a 1991 Safety Board study showed that

state and local governments have the primary responsibility for the

safety of these systems. During peak operating hours, a single rail

rapid transit train can carry as many as 1,500 passengers. Safety

oversight varies by system. 

Investigations of accidents on rail rapid transit systems have led

to improvements through Safety Board recommendations. Accidents

on the New York City Transit system led to improvements re g a rd i n g :

■ Braking distance standardization and testing;

■ Installation of speedometers and realistic speed control signage;

■ Fail-safe operating standards and systems; and

■ Operator qualifications and fitness for duty standard s .

N u m e rous recommendations were made and related actions

taken after the January 1996 collision of a Washington Metro

subway train at Shady Grove, Maryland. The train overshot an

a b o v e g round station during poor weather and hit a standing,

unoccupied subway train. The train engineer was killed. The accident

investigation resulted in a reevaluation of the system’s management

oversight, and actions were taken to improve and corre c t

deficiencies in the following are a s :

■ Braking perf o rmance, speed control, and the automatic train

c o n t rol system;

■ Operating rules and policies;

■ Communication practices; and 

■ E m e rgency service re s p o n s e .

The Safety Board investigation of a 1991 collision involving

G reater Cleveland Regional Transit Authority (GCRTA) trains re v e a l e d

that a train operator had disconnected the automatic cab signal

system, thus eliminating one means of collision prevention. Coded

track circuits in the GCRTA’s train control system transmit speed

commands to the on-board train control equipment. 
To avoid the speed limitation, the operator in this accident cut

out the cab signal, thus deactivating the automatic train contro l

system. In response to subsequent Board recommendations, the

G C RTA implemented pro c e d u res for re c o rding the use of cab-signal

cutouts to prevent unauthorized operations.

Alcohol and Drug Use

After a dozen years of recommendations by the Safety Board, the

FRA instituted the first mandatory drug/alcohol testing rule for any

mode of transportation in 1986. The January 1987 accident in

Chase, Maryland, that killed 16 people on an Amtrak train was the

first major accident where re q u i red testing showed that drugs were 

a factor.

The rule appears to be having its intended effect. Postaccident

tests (tests re q u i red after serious railroad accidents) indicate that

the number of employees with positive test results for alcohol or

other drugs has fallen from 5.5 percent in 1987 to less than 1

p e rcent in 1995. Random drug testing results (testing at random

re q u i red by federal regulations) have also shown a decline in

employees testing positive for drugs from 1.04 percent in 1990 to

0.9 percent in 1995.

Locomotive Fuel Tank Integrity

During the course of its railroad accident investigations, the

Safety Board has documented many instances of locomotive fuel

tanks that ru p t u red during collisions. In the Sugar Va l l e y, Georg i a ,

and Corona, California, accidents five of the six fatally injure d

c rewmembers suff e red extensive burns and smoke inhalation. In the

29 locomotive derailments investigated by the Board in 1991, diesel

fuel spills occurred in 56 percent of the accidents. Based on Board

recommendations, the FRA, the Association of American Railro a d s ,

and locomotive manufacturers met in 1993 to establish a pro g r a m

to collect data on fuel tank damage and fuel spills. Manufacture r s

have begun to design locomotives with a better protected fuel tank.

In 1997, the Safety Board investigated two Amtrak passenger

train derailments involving locomotives equipped with “integrally

situated” fuel tanks. This type of fuel tank is located within the

37
38

locomotive frame stru c t u re and was found to clearly outperf o rm

frame-suspended fuel tanks. Integrally situated fuel tanks provide a

higher ground clearance than conventional designs. As a result, less

fuel tank damage and no significant spillage occurred in either of the

accidents, despite serious track damage. Historically, severe track

damage has resulted in damage and ru p t u re to more conventional

frame-suspended fuel tanks.

Tourist and Historic Railro a d s

T h e re are over 330 tourist railroads, museums, dinner trains and

special excursion trains in the United States. These org a n i z a t i o n s

have as many as 40,000 volunteers and employees who operate

140 steam locomotives, 1,000 diesel-electric locomotives, and

1,200 passenger cars. Thre e

h u n d red of the passenger cars

a re certified to run on Amtrak

trains. Approximately 1,225

miles of railroad are used for

regular tourist and excursion

s e rvice. According to the tourist

i n d u s t ry, almost five million

people visit these operations

a n n u a l l y.

The Safety Board has

investigated several tourist

r a i l road accidents and made

related recommendations to

i m p rove their safety. The most

significant tourist railro a d

accident occurred in June 1995 near Gettysburg, Pennsylvania,

when a steam locomotive failed and released steam through the

f i rebox door and into the locomotive cab, seriously burning the

engineer and the two fire m e n .

Investigators found that the train crew had allowed the water in

the locomotive boiler to drop to an insufficient level and the boiler

and its associated equipment had not been properly maintained.

Actions that resulted from the accident that have affected the steam

tourist industry include:
■ Addition of a redundant water monitoring system for steam

e n g i n e s ;

■ A re q u i red boiler water monitoring device;

■ C e rtification of steam locomotive operators and re p a i re r s ;

■ Updated and expanded federal regulations for steam

locomotives; and

■ I n c reased compliance for employees and volunteers with the

H o u r s - o f - S e rvice Act to minimize fatigue hazard s .

I m p roved Emergency Braking Capabilities

As the result of an investigation involving the derailment of a

runaway freight train in Cajon Pass, California, the Safety Board

d e t e rmined that an important safety device, a two-way end-of-train

device (ETD) that could be activated in an emergency to assist in

stopping the train, was not properly armed and ready for service. At

the time of the accident, there were no comprehensive industry

guidelines for the implementation and use of two-way ETD

equipment with the capability of initiating an emergency brake

application at the rear of the train. In the past, ETDs did not have

such an important safety feature

and emergency braking could

only be initiated by an engineer

f rom the controlling locomotive

at the front of a train.

A two-way ETD allows a train

c rew to initiate an emerg e n c y

brake application from the re a r

of a train, as well as from the

f ront. During the investigation,

the Safety Board found that the

r a i l road was not pro p e r l y

repairing, inspecting, and testing

the two-way feature of the ETD

on trains operating over

mountain grade territories. As a result of Safety Board re c o m m e ndations, federal regulators now re q u i re heavy trains operating over

mountainous terrain to be properly equipped with a two-way ETD.

39
40
Much of this nation’s commerce travels between U.S.

p o rts and points overseas, and on the tens of

thousands of miles of inland waterways. Wa t e r

t r a n s p o rt moves about 790 billion ton-miles a year and employs

almost 200,000 persons. There are about 78 million re c re a t i o n a l

boaters in the United States and 118,000 commercial fishing

vessels. Cruise ships board about five million passengers a year

f rom U.S. ports. Ferryboats, most prominently in New York City and

Seattle, carry more than 270 million passenger miles a year.

Safety Board marine recommendations have addre s s e d

p roblems in vessel safety standards, re c reational boater education,

and commercial fishing vessel safety.

Passenger Vessel Safety

L a rge passenger ships carry millions of people on excursion trips

and pleasure cruises from U.S. ports every year. Passenger ships

operating from U.S. ports may be re g i s t e red either in the United

States or in foreign countries.

U . S . - re g i s t e red passenger ships

operating from one U.S. port to

another must meet U.S. safety

s t a n d a rds, while fore i g n -

re g i s t e red ships must meet

i n t e rnational safety standard s

established by the Intern a t i o n a l

Maritime Organization (IMO), a

United Nations agency. There

a re only a handful of U.S.-

re g i s t e red passenger ships: two

operating in the cruise trade in

the Pacific, and a few larg e

excursion boats that operate on rivers. There are about 140 fore i g n -

re g i s t e red passenger ships operating from U.S. ports, carry i n g

about four million passengers annually.

41

M a r i n e
42

Since 1979, the Safety Board has investigated 24 accidents on

b o a rd fore i g n - re g i s t e red passenger ships that regularly operated

f rom U.S. ports. These accidents caused 11 deaths, 186 injuries,

and more than $140 million in pro p e rty damage. In a 1989 safety

study and again in a 1993 special investigation re p o rt on passenger

vessels, the Board identified serious shortcomings in passenger

ship safety and issued recommendations to improve the standard s

for structural fire protection, sprinkler installations, low-level

e m e rgency lighting, smoke/fire detection systems, cre w

qualifications, emergency drills, and crew language re q u i rements 

to ensure the safety of passengers on fore i g n - re g i s t e red vessels

operating from U.S. port s .

As a result of the Safety Board ’s recommendations, the U.S.

Coast Guard obtained international agreement to re q u i re fire safety

i m p rovements on all passenger ships. The international fire safety

re q u i rements for passenger ships have been virtually rewritten, 

and for the first time, all of the new re q u i rements will be applied to

existing ships as well as to new ships. Automatic sprinklers, fire

detection and alarm systems, and emergency lighting are

c o m p u l s o ry on all ships able to carry 36 or more passengers that

w e re delivered after October 1994.

Another vessel safety issue is the installation of voyage data

re c o rders (VDRs), which are similar to flight data re c o rders on

a i rcraft. Since the 1970s, the Safety Board has promoted the use of

such re c o rders on various types of vessels and other modes of

t r a n s p o rtation. Automatic data re c o rding devices are useful for

management oversight, and they also provide crucial, factual

i n f o rmation for accident investigation and have played a key role in

identifying and addressing accident causes. The 1995 grounding in

an Alaskan canal of the Star Princess, which was fitted with a VDR,

is an excellent example of the usefulness of these devices in

accident re c o n s t ruction and in improving management oversight. In

this case, the Safety Board found that the pilot and the

watchstanders failed to use equipment available to properly monitor

the pro g ress of the cruise ship’s course. Had this been done, the

p i l o t ’s navigation error might have been detected in time to avoid

the accident. The Safety Board currently is working closely with the

Coast Guard to develop carriage re q u i rements and technical

s t a n d a rds for VDRs with a subcommittee of the IMO.
R e c reational Boating Safety

As re c reational boat use increases, so too does the potential for

m o re accidents, injuries, and fatalities. An estimated 12 million

s t a t e - re g i s t e red re c reational boats and as many as 78 million

people participate in this activity. Recreational boating activities are

conducted on 50 million acres of lakes, 633,000 miles of rivers,

and along 88,633 miles of coastline. The use of alcohol in this

e n v i ronment compounds the possibility for tragedy.

While the Coast Guard and state boating law authorities suspect

alcohol use to be a major factor in the high number of re c re a t i o n a l

boating fatalities (about 600 to 800 a year), creditable national

statistics are not available. There are no uniform re p o rt i n g

re q u i rements or guidelines for collecting this information. As a re s u l t

of a safety study conducted during the early 1980s, the Safety

B o a rd urged the adoption of a clearly defined blood alcohol

concentration (BAC) for intoxication, such as is applied to highway

vehicle operators. In response, the National Association of State

Boating Law Administrators drafted state guidelines in 1984 that

include specific prohibitions against operating a boat while

intoxicated. By 1997, every state had a law concerning boating while

intoxicated, 48 states have a specific BAC definition, and 38 states

have implied consent pro v i s i o n s .

In 1993, the Safety Board issued recommendations to the

states to re q u i re mandatory education, operator licenses, and use

of personal flotation devices (PFDs) for children. Since that date, 16

states have passed laws requiring PFD use for children, 18 re q u i re

m a n d a t o ry education, and one – Alabama – re q u i res a boat

o p e r a t o r ’s license.

Of the many organizations that the Safety Board supports in

i m p roving re c reational boating safety, one of the newest is the

National Recreational Boating Safety Coalition. This coalition was

f o rmed with the Safety Board ’s assistance in 1995. The primary

mission of this organization is to reduce deaths, injuries, and

p ro p e rty damage associated with the use of re c reational boats. The

coalition, composed of numerous insurance trade associations and

other safety organizations, serves as a forum for the exchange of

i n f o rmation about state and federal legislative activities and

education programs. 

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44

Vessel Traffic Serv i c e s

The 1989 Exxon Valdez oil tanker accident in Alaska focused

national attention on the need for a viable vessel traffic serv i c e

(VTS) system to prevent marine accidents. Even before that

e n v i ronmental disaster, however, the Safety Board had been in the

f o re f ront of eff o rts to improve VTS in U.S. port s .

After the Exxon Valdez accident investigation, the Safety Board

recommended that the Coast Guard increase the staffing level at

the Valdez, Alaska, VTS. The Coast Guard complied with this

recommendation and also upgraded its vessel plotting system at

Valdez to an electronic charting display that automatically re c o rd s

the position of vessels with a satellite-aided tracking system. 

After the Coast Guard closed its VTS operations in New York City

and New Orleans in 1988, the Safety Board recommended that the

DOT reestablish those offices. An act of Congress led to the

reopening of the New York VTS in 1990.

The Coast Guard has issued final rules that will re q u i re

m a n d a t o ry participation in the VTS systems in the United States as

re q u i red by the Oil Pollution Act of 1990. Many of the Safety Board ’s

recommendations in its Exxon Valdez re p o rt were contained in the

1990 act.

C o m m e rcial Fishing Ve s s e l s

In September 1987, the Safety Board issued a safety study on

uninspected commercial fishing vessels, which, along with a number

of individual Board accident re p o rts, identified critical safety

p roblems throughout the commercial fishing vessel industry. At that

time, commercial fishing had the worst safety re c o rd of all U.S.

industries. Coast Guard accident data showed that, between 1981

and 1984, an average of 75 lives and nearly 250 documented U.S.

c o m m e rcial fishing vessels per year were lost in accidents.

As a result of the Safety Board ’s study and public intere s t ,

C o n g ress passed the Commercial Fishing Industry Vessel Safety Act

of 1988. As a further result of the Board ’s study and subsequent

accident investigations, the Coast Guard published final rules in

August 1991 to improve the safety of commercial fishing vessels.
These regulations for the first time re q u i red commercial fishing

vessels to carry specific lifesaving devices, including liferafts,

s u rvival suits, and emergency position indicating radio beacons

( E P I R B s ) .

These improvements are having a dramatic impact on the safety

of commercial fishing vessel operations. According to 17th District

Coast Guard data for Alaska, in 1991 and 1992, the average

number of fishermen who lost

their lives was about 25

annually; from 1993 thro u g h

1996 that number has declined

to an average of about 10

a n n u a l l y. Additionally, the Safety

B o a rd sought to improve the fire

c o n s t ruction standards on

fishing vessels carrying more

than 16 persons. Specifically,

the Safety Board asked that the

Coast Guard and the National

F i re Protection Association

( N F PA) to cooperatively develop

a national marine fire safety

s t a n d a rd on the safe use of rigid polyurethane foam and other

combustible insulation used in refrigerated holds on board

c o m m e rcial fishing industry vessels. Both the Coast Guard and the

N F PA have responded favorably to the Safety Board ’s

recommendation and are working toward its accomplishment.

E m e rgency Position Indicating Radio Beacons

In October 1988, Congress passed a law requiring each manned

uninspected vessel operating on the high seas or beyond thre e

nautical miles from the coastline of the Great Lakes to be equipped

with alerting equipment, including emergency position indicating

radio beacons (EPIRBs). Safety Board accident investigation findings

p rovided the factual basis needed to support this action.

Recommendations were issued in the early 1980s following

investigations of the sinkings of uninspected vessels. The Safety

B o a rd pointed out at the time that the cost of EPIRBs on vessels

would not approach the cost of even one massive air and sea

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46

s e a rch. For example, the search for the fishing vessel Amazing Grace

o ff the mid-Atlantic coast in December 1984 cost about $12 million.

In 1986, the Safety Board recognized the need for re q u i r i n g

EPIRBs on uninspected vessels when it investigated the capsizing

and sinking of the Pride of Baltimore, a sailing vessel owned by

M a ryland. The vessel sank so quickly that the manually operated

EPIRB was not released or activated. Survivors were not located

until four days after the vessel

sank. Had the vessel been

equipped with an automatic

EPIRB, the survivors might have

been found sooner during the

massive air and sea search that

followed the sinking.

As technology improved, a

satellite EPIRB that transmitted

data on 406 MHz fre q u e n c y

became available. When a 406

MHz distress signal from a

stricken vessel is received by

g e o s t a t i o n a ry satellites, the

EPIRB registration database provides vessel information for an

a p p ropriate search and rescue response. Accuracy of satellite EPIRB

positions are to within 1.4 nautical miles. The next-generation 406

MHz ERIRBs equipped with integral satellite technology will transmit

d i s t ress position data accurate to within 100 meters.

The Safety Board began making recommendations to replace the

old, less accurate EPIRB with the new 406 MHz EPIRB in 1989. As

a result of the Safety Board ’s eff o rts, federal regulations now

re q u i re uninspected commercial vessels, ocean-going ships, and

other vessels to be equipped with 406 MHz EPIRBs. These EPIRBs

will enable search and rescue units to locate a vessel in distre s s

much quicker and with greater precision, resulting in impro v e d

s u rvival rates and reduced search costs.

In a related matter, search and rescue operations on the Gre a t

Lakes have also been improved during severe weather periods

because of Safety Board recommendations. Three new Coast Guard

stations were commissioned and more ship coverage is pro v i d e d

during November, the stormiest month on the lakes.
Towing Vessel Safety

After the investigation of towing vessel accidents involving the

U.S. towboats F r e m o n t, and M a u v i l l a, and the U.S. tugboat Morris J.

B e r m a n, the Safety Board issued recommendations to the DOT,

Coast Guard, and the industry to improve navigation safety on inland

w a t e rways and towline safety for off s h o re towing operations.

In the first accident, the barge being towed by the Fremont w a s

s t ruck and sank, spilling all of its cargo of molten sulfur into the

w a t e rw a y. The lack of a compass on the towing vessel resulted in

the operator’s inability to evaluate the vessel’s movement into the

navigation channel and into the path of a containership. In the

second accident, a towboat operator became lost and disoriented in

dense fog because of his inability to interpret his radar pre s e n t a t i o n ,

and his vessel collided with an unprotected railroad bridge. The

r a i l road track was displaced and Amtrak Train No. 2, traveling at

about 70 mph, derailed on the bridge and plunged into the Bayou

Canot resulting in the loss of 47 lives and 111 injuries. In the third

accident, the vessel’s towline parted resulting in the grounding of

the tank barge and the loss of

about one million gallons of fuel

oil contaminating the beaches

and shoreline of Puerto Rico.

As a result of Safety Board

recommendations stemming

f rom these accidents,

regulations were issued to

i m p rove navigation safety by

requiring towline and towing

equipment inspections and

maintenance; the addition of

towing vessel equipment such

as charts, marine publications,

compass, or swing meters, radar, and vessel position finding

devices; and training of towboat operators in radar use.

After the Mauvilla accident, the DOT convened an interm o d a l

(marine, highway, and railroad) bridge information system task forc e

to compile information on bridges vulnerable to impact from marine

t r a ffic. Approximately 5,450 bridges were identified: about 3,900

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highway bridges and 1,550 railroad bridges. The task force validated

i n f o rmation about bridge contacts and ownership and distributed

this information to state and federal agencies. Now in the event a

bridge is struck by a marine vessel, the bridge owner and local

e m e rgency response agencies are notified to stop vehicular traff i c

(highway and railroad) until inspectors determine that the bridge is

safe for transportation. 

These safety improvements will not only make towing vessel

operations safer, but also will greatly improve the safety of highway

and railroad traffic using bridges that span navigable waterw a y s .
Mo re than 196 million re g i s t e red vehicles and 176 million

licensed drivers are on re c o rd in the United States.

A c c o rding to the National Highway Tr a ffic Safety

Administration (NHTSA), more than 90 percent of fatalities and 99

p e rcent of injuries in transportation are the result of motor vehicle

crashes. Tr a ffic crashes cost the nation every year over 40,000

lives; over 3.5 million injuries; and $150 billion in medical costs,

lost pro d u c t i v i t y, and pro p e rty damage. Safety Board re c o m m e ndations for highway safety range from human perf o rmance concern s

such as driver fatigue, alcohol and drug use to engineering pro b l e m s

like school bus construction, seatbelt usage, air bag concerns, and

highway design.

Drunk Driving

In May 1988, a pickup truck driving on the wrong side of an

interstate highway near Carrollton, Kentucky, slammed into an

activity bus (a former school bus) bringing children and parents back

f rom a day at an amusement

park. The subsequent fire killed

27 bus passengers, making it

the worst drunk driving accident

in U.S. history. The driver of the

pickup had a blood alcohol

concentration (BAC) of 0.26

p e rcent an hour and a half after

the accident – more than two

times the legal limit in most

states at that time.

The overall number of deaths

attributed to alcohol-impaire d

driving has been declining in

recent years, due in part to

Safety Board anti-alcohol and anti-drug initiatives. Alcohol-re l a t e d

t r a ffic fatalities have decreased from over 25,000 in 1982 to just

over 17,000 in 1996.

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H i g h w a y
50

All 50 states have set 21 as the minimum drinking age, after a

Safety Board study found that teenagers were overre p resented in

the population of drunk driver accidents. The Board ’s 1982

recommendations began the national debate that led to universal

adoption of the standard. It is estimated that the age-21 laws have

saved about 16,500 lives since their enactment.

In 1984, the Safety Board issued a study showing the benefits

of two deterrent programs: sobriety checkpoints and administrative

license revocation (ALR). ALR allows law enforcement officers to

immediately revoke a driver’s license if the driver fails an alcohol

test or refuses to take one. The revocation is subject to subsequent

judicial re v i e w. When the study was completed, 21 states employed

sobriety checkpoints and 21 states and the District of Columbia had

ALR. Since issuance of the study, 19 additional states have

employed sobriety checkpoints, and 19 more states have adopted

ALR laws. Studies have shown that jurisdictions that adopt ALR laws

register a nine percent drop in alcohol-related nighttime driving

fatalities. When all jurisdictions adopt ALR, it is estimated that

2,000 lives will be saved every year.

Despite the pro g ress gained by the age-21 laws, underage

drivers continue to be overre p resented in both alcohol-related fatal

crashes and total fatal crashes. In 1993, the Safety Board issued

nine safety recommendations to the states calling for a review of

drinking age laws and asked the states to vigorously enforce youth

drinking and driving laws and to enact comprehensive laws that

p rohibit drivers under the age of 21 from driving with a measurable

BAC. When these recommendations were issued, 15 states had

some form of low-BAC legislation for young drivers. In less than five

years after the Board issued the zero tolerance re c o m m e n d a t i o n s ,

all states have enacted zero alcohol tolerance laws for drivers under

age 21. These measures are major steps in combatting one of the

single most deadly threats in America – the alcohol-impaired driver.

Reporting Drunk Drivers

On September 9, 1982, the Safety Board issued

recommendations to the 50 states and the District of Columbia to

implement a citizen awareness and drunk driver re p o rting pro g r a m

similar to the REDDI-type programs used in Colorado, Mary l a n d ,

Nebraska, Utah, and Wa s h i n g t o n .
REDDI stands for “Report Every Drunk Driver Immediately.” In

the 1980s, states and citizens embraced the opportunity to re p o rt

i m p a i red drivers as hazards on the road. They did so despite the

d i fficulty of locating a telephone and calling the correct number.

Technological changes in the 1990s have led to the use of cellular

telephones to re p o rt highway crashes and hazards. Calls to

e m e rgency numbers (usually 911) are now so frequent that states

have developed alternatives such as #77 for re p o rting none m e rgency (not life-threatening) hazardous situations. State police

agencies have also developed specific numbers for high-density

locations. Rural states such as Wyoming have re p o rted nearly

10,000 arrests from 104,000 calls in the 15 years of its pro g r a m .

School Bus Safety

School buses carry 23.5 million passengers daily. Safety Board

initiatives from tougher bus construction to better driver training

have helped make school buses one of the safest forms of

t r a n s p o rtation in the country.

In April 1977, following a series of Safety Board re c o m m e ndations, the DOT enacted tougher construction standards for school

buses that re q u i red greater body joint strength, roof ro l l o v e r

p rotection, redesigned energy-absorbing seats, and emergency exit

and fuel system impro v e m e n t s .

In a 1987 study on the perf o rmance of

buses built to the new standards, the Safety

B o a rd found that the new standards had

significantly improved the safety of school

bus transportation, and recommended rapid

re t i rement of all pre s t a n d a rd buses in the

fleet. As of 1994, 14 states had virt u a l l y

eliminated the use of pre s t a n d a rd buses for

pupil transportation: 20 had two percent or

less of the buses in operation; and the

remaining 16 states had developed phaseout pro g r a m s .

In a related 1989 study, the Safety

B o a rd found that occupants of small buses

built to the 1977 federal standard s

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52

generally fared well in the accidents investigated. However, the 

study found that almost a third of lapbelted passengers were

wearing their belts impro p e r l y. Sometimes, the belts had been

i m p roperly modified by employees of the school district or the bus

c o n t r a c t o r. The prompt action of school transportation associations

in response to this study alerted school districts to the dangers of

i m p roper installation and use of restraints in small school buses.

School bus manufacturers also responded to the Safety Board ’s

recommendations urging better emergency door latches to pre v e n t

them from opening during an overt u rn accident.

An additional safety advance followed the Safety Board ’s

investigation of an accident near Snow Hill, North Carolina, in 1985,

and one near Bronson, Florida, in 1987. In 1988, the manufacturer of

the buses involved in the accidents announced it would comply with a

B o a rd recommendation to strengthen floor joints with additional rivets,

thus exceeding the strength re q u i rement in federal standard s .

As a result of Safety Board investigations of a school bus

accident in Carrollton, Kentucky, that involved fire, and one in Alton,

Texas, that involved a submersion, recommendations were issued to

NHTSA to improve school bus egress. These re c o m m e n d a t i o n s

a d d ressed the total surface area for egress, the size of school bus

side windows, and the need for exit doors to remain open during

e m e rgencies. NHTSA issued new standards addressing these

p roblems in November 1992.

Another safety problem that the Safety Board has eliminated is

the use of 16- and 17-year-old school bus drivers. The Board sought

this action because these drivers were statistically overre p re s e n t e d

in school bus accidents when compared to older bus drivers. States

that permitted younger drivers re q u i red them to get a U.S.

D e p a rtment of Labor waiver. The Board provided the Labor

D e p a rtment with accident data, prompting a study. As of June 1988,

the Labor Department no longer allowed states to employ 16- and

1 7 - y e a r-old school bus drivers.
S e a t b e l t s

The safety benefits of seatbelt use in automobiles was pro v e d

long ago. Every day, people are saved and injuries are prevented by

p roperly worn seatbelts. Seatbelt use has increased from 15

p e rcent in 1982, to 68 percent in 1996, saving more than 85,000

lives in that time.

A major safety improvement resulted from a Safety Board

recommendation concerning the perf o rmance of seatbelts in re a r

seats of automobiles. In June 1989, NHTSA issued a final ru l e

requiring re a r-seat lap/shoulder belts in new cars. The federal

re q u i rement was extended to light trucks, multipurpose vehicles,

and convertibles manufactured after September 1991.

These actions resulted from Safety Board recommendations that

lap/shoulder belts be installed at all outboard seating positions and

that manufacturers develop an aggressive program to install

lap/shoulder belt re t rofit kits in existing models. A 1986 Board

study concluded that lap belts provide a significantly lower level of

p rotection than lap/shoulder belts and, in the crashes investigated,

sometimes induced serious or fatal injuries that probably would not

have occurred had lap/shoulder belts been used.

A subsequent Safety Board study documented the benefits of

p roperly worn lap/shoulder belts, and also helped educate the

public by highlighting the degraded crash protection when impro p e r l y

w o rn. Children, as well as adults, have benefited from the Board ’s

findings. Before the release of this study, parents were ro u t i n e l y

advised by safety organizations and NHTSA to misroute the shoulder

p o rtion of the three-point belt around the child’s body if, in the

p a re n t ’s opinion, the shoulder strap came too close to the child’s

face or neck. Children were thus restrained by a lap-only belt, with

its degraded crash protection and potential for injury. Since the

B o a rd ’s study, organizations that promote child safety now advocate

using the lap/shoulder belt as designed, giving children better crash

p ro t e c t i o n .

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Air Bags and Child Passenger Safety

When occupants properly use seatbelts, air bags increase the

chances of survival in severe frontal crashes. But air bags may pose

dangers for some occupants in certain situations. About 35 million

cars currently on the road are equipped with passenger-side air bags

and each month approximately one million new cars equipped with

air bags are manufacture d .

Between 1993 and mid-1998,

61 children died because they

w e re struck by an air bag in what

would have otherwise been a

s u rvivable crash. These

occupants were in the danger

zone when the air bag inflated.

F o rty-four adults were also killed

by their air bags in crashes they

could have surv i v e d .

In 1996, the Safety Board

completed a study on the

p e rf o rmance and use of child

restraint systems, seatbelts, and

air bags for children in passenger

vehicles. The study analyzed data

f rom 120 vehicle crashes that

o c c u rred between 1994 and

1996. Vehicle occupants included

207 children under age 11. Of these 120 accidents, air bags

deployed in 13 accidents in which a child was seated in the fro n t

passenger seat. The study focused on the dangers that passengerside air bags pose to children; factors affecting injury severity;

adequacy of federal standards re g a rding the design and installation

of child restraint systems; need to improve seatbelt fit for childre n ;

adequacy of public information and education on child passenger

p rotection; and adequacy of state child restraint use laws.

The Safety Board also convened a public forum in March 1997

to discuss concerns related to the effectiveness of air bags and

ways to increase seatbelt and child restraint use. Other issues

discussed included air bag-induced injuries; role of air bags as a

p r i m a ry or secondary restraint system; deployment thre s h o l d s ;
complexity of implementing depowered air bags, switches, and

s u p p ression devices; advanced air bag technology; experience with

air bags in other countries; evaluating the effectiveness of air bags;

e n f o rcement of restraint laws; design of child-friendly back seats;

and design of child re s t r a i n t s .

NHTSA participated in the forum, along with re p resentatives fro m

Australia, Canada, and Europe; the automobile industry; air bag

suppliers; insurance, safety and consumer groups; and family

members involved in crashes in which air bags deployed.

As a result of its study and public forum, the Safety Board issued

a series of recommendations to improve the effectiveness of air

bags. Action taken as a result of those recommendations include:

■ The automobile industry sent letters and warning labels to

owners of 60 million cars currently on the road that are

equipped with air bags advising the owners about the dangers

that air bags pose to childre n ;

■ NHTSA re q u i red highly visible and permanent warning labels in

all newly manufactured air bag-equipped vehicles and on child

restraint systems, effective Febru a ry 1997;

■ NHTSA and the automobile and insurance industries initiated

an air bag safety campaign in May 1996. The multi-million

dollar eff o rt is dedicated to educating the public about the

i m p o rtance of putting children in the back seats of vehicles

with air bags, buckling their seatbelts, and strengthening state

seatbelt use laws and increasing their enforc e m e n t .

■ To make automobiles more child-friendly, many automobile

m a n u f a c t u rers provide built-in child restraints, center rear seat

lap/shoulder belts, and adjustable upper shoulder belt

anchorages in the back seats of passenger vehicles, and;

■ Since May 1997, automobile manufacturers have been

p e rmitted to install depowered air bags in newly manufacture d

vehicles. These air bags reduce the risk of air bag-induced

injuries to short - s t a t u red and senior citizen occupants. 

■ C e rtain at-risk occupants now can apply for permission fro m

NHTSA to install on-off switches for one or both front airbags.

■ Education and legislative eff o rts have begun to have childre n

ride in the safer back seat. 

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Child Safety Seats

Between 1980 and 1984, more than 3,000 children under five

years old were killed in motor vehicle accidents and more than

250,000 were injured. This toll exceeded that of all common

childhood diseases combined for the same period. Studies indicated

that between 45 and 70 percent of the fatalities and up to half of

the injuries could have been prevented by the proper use of a child

safety seat. After the enactment of a pioneering child safety seat

law in Tennessee in 1977, other states began to pass similar laws.

By late 1982, such laws had been enacted in 19 states, but most

of the nation’s young remained unpro t e c t e d .

In 1982, the Safety Board launched a special investigation that

demonstrated that children secured in safety seats re m a i n e d

u n h a rmed in motor vehicle crashes that killed or severely injure d

their parents. The Board investigated 53 accidents and found

dramatic diff e rences in the injuries to infants and small children who

did and did not have safety seat protection. In December 1982, the

Safety Board recommended legislative action in the remaining 31

states and the District of Columbia. This eff o rt was followed up a

year later by the results of hearings and further investigations.

Now all 50 states and the District of Columbia have child

passenger protection laws. Between 1982 and 1996, child safety

seats in automobiles have saved the lives of more than 3,200

young children, according to NHTSA.

C o m m e rcial Driver’s Licenses

T h e re are about 2.6 million truck drivers in the United States.

Safety Board investigations of major truck crashes re p e a t e d l y

demonstrated the need for improved driver perf o rmance. In 1980

and 1986, the Board conducted evaluations of truck driver

p e rf o rmance and identified ways to alleviate shortcomings in the

systems for detecting and controlling unsafe drivers. The Board ’s

1986 study endorsed a national license for commercial truck drivers

to help bar unqualified drivers from operating trucks. The Board also

recommended a special license or endorsement for drivers

t r a n s p o rting hazardous materials.
Since publication of the study, Congress has enacted a law

requiring the commercial driver’s license (CDL), which re q u i res most

t ruck and bus drivers to obtain a CDL and prohibits them fro m

having more than one driver’s license. An alcohol/drug testing

p rogram is also included under the CDL program. From 1986 to

1996, fatal tractor-semitrailer crashes declined 30 perc e n t ,

a c c o rding to DOT data.

Heavy Truck Brakes

In 1992, the Safety Board released a safety study on the

p e rf o rmance of heavy vehicle air brakes. In more than 1,500

roadside inspections of big trucks conducted with the cooperation of

state police agencies, the Board re p o rted that 46 percent of the

t rucks were placed out of service because of improperly adjusted

brakes. Another 10 percent were placed out of service for other

brake pro b l e m s .

Safety Board recommendations have addressed uniform brake

maintenance policies; perf o rmance standards related to stability,

c o n t rol, and stopping distances;

and hard w a re changes that

emphasize automatic adjusters,

i m p roved maintenance, and

antilock brake systems.

In early 1995, DOT re m o v e d

a design restriction that

discouraged the use of long

s t roke chambers, which allow

brakes to stay in adjustment

l o n g e r. This action was taken in

d i rect response to a Safety

B o a rd recommendation. Also in

1995, DOT issued final ru l e s

requiring antilock brake systems

on all large trucks and buses by

the end of the decade. DOT estimated that the rule would save 500

lives a year and more than $3 billion annually in accident costs.

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Reduced Vi s i b i l i t y

Thousands of people have been killed on U.S. highways in

limited visibility conditions, including fog, smoke, and dust. The

Safety Board investigated six limited visibility crashes since

December 1990 that killed 40 people and involved more than 450

vehicles. Recommendations were issued to federal and state

g o v e rnments calling for development of a comprehensive solution to

the pro b l e m .

Tennessee, Louisiana, and California, three of the states in which

these crashes occurred, have implemented comprehensive detection

systems and response plans that include the detection of traffic flow

d i s ruptions and pro c e d u res for uniform driver response through the

reduced visibility area. A Safety Board public hearing on the issue

resulted in information that was distributed to all states, and the

Tr a n s p o rtation Research Board compiled and published pre f e rre d

practices in this area. The Board has further addressed this issue by

focusing recent recommendations on intelligent transport a t i o n

systems, especially in crash avoidance counterm e a s u re s .

Grade Crossing Safety

In 1996, 472 people died in highway-railroad grade cro s s i n g

accidents. The year before, 579 people were killed. On average,

1,800 individuals are injured annually. The Safety Board has been a

longtime supporter of Operation Lifesaver, a national voluntary safety

p rogram that addresses grade

c rossing safety through pro g r a m s

in education, enforcement, and

engineering. Grade cro s s i n g

accidents have been declining

since 1977, but the number of

fatalities is still too high. 

In October 1995, a school

bus and commuter train collided

at a suburban Chicago grade

c rossing, killing seven high

school students and seriously

injuring 24 others. A quick
response by all states, in less than 15 months, to Safety Board

recommendations resulted in the first nationwide database to track,

m o n i t o r, and inspect about 3,500 highway-railroad crossings that

have interconnected road signals and rail warning lights. All states

quickly inspected and made safety adjustments to these

intersections. For the first time, this information is available to state

t r a n s p o rtation and education departments and school safety

o fficials to help them plan and monitor local school bus routes and

train drivers to avoid potential grade crossing hazard s .

In addition, 24 states have responded positively to a Board

recommendation that grade crossings with passenger or commuter

train activity be given high priority for the installation of active

w a rning devices. Additionally, in response to the concern s

a d d ressed in a Board re p o rt on the poor visibility aspects at many

grade crossings, some states are seeking legislative action to

reduce highway sight-distance problems. All states now have

p rograms, encouraged by Safety Board recommendations, to

educate the public about the dangers of highway-railroad grade

c ro s s i n g s .

In 1996, the Safety Board issued recommendations to all Class

1 railroads urging them to implement 24-hour, toll-free emerg e n c y

notification systems to permit the public to promptly re p o rt

e m e rgencies at all active and passive crossings. Many railro a d s

have initiated such systems. In April 1998, one Class 1 railro a d

completed the installation of emergency signs at all cro s s i n g s

t h roughout its system.

Center High-Mounted Stop Lights

As early as 1975, the Safety Board recommended that

automobile brake lights be mounted high enough to separate the

function of brake lights from tail lights so that a following driver

could see the lights of at least two vehicles directly ahead. Center

high-mounted stop lights have been re q u i red on all new passenger

cars sold in the United States since the 1986 model year and all

new light trucks since the 1994 model year.

In March 1998, NHTSA issued a re p o rt on their eff e c t i v e n e s s .

The study concluded that center brake lights prevent 92,000 to

137,000 police-re p o rted crashes, 58,000 to 70,000 nonfatal

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60

injuries, and $655 million in pro p e rty damage a year. It also

estimates that the lamps save $3.18 in pro p e rty damage for every

dollar they cost.

Highway Bridge Safety

In 1967, a highway bridge spanning the Ohio River between Ohio

and West Vi rginia collapsed, killing 46 motorists. Since then, the

Safety Board has investigated 12 highway bridge collapses which

resulted primarily from erosion, corrosion, collisions by vessels and

t rucks, poor design, and

inadequate inspection practices.

The Board ’s re c o m m e n d a t i o n s

re g a rding bridge safety have led

to vastly improved national bridge

inspection and management

p ro g r a m s .

The Safety Board ’s investigation into bridge collapses

caused by erosion included a

1987 collapse of a New Yo r k

State Thruway bridge near

A m s t e rdam, New York, and a

1989 collapse near Covington,

Tennessee. In 1997 as a result of a Safety Board re c o m m e n d a t i o n ,

an ambitious nationwide underwater highway bridge inspection

p rogram was completed by federal and state highway agencies.

M o re than 22,000 highway bridges received underwater inspections

for scouring and deterioration. Now all bridges over water are on

u n d e rwater inspection schedules of five years or less.

Earthquake Pre p a re d n e s s

When a 1971 earthquake in San Fernando, California, caused

c a t a s t rophic damage to transportation facilities, the Safety Board

investigated this event. The Safety Board recommended that the

DOT and the states develop programs to re t rofit bridges to make

them less vulnerable to collapse from earthquakes and to re d u c e

the potential for loss of life. Also, the Safety Board re c o m m e n d e d

that new bridges be designed to better resist seismic forc e s .
C a l i f o rnia continues to re t rofit many of its bridges. The re t ro f i t s

and new bridge designs have been effective in limiting damage fro m

e a rthquakes in the last 10 years. The Golden Gate Bridge, the

w o r l d ’s tallest suspension bridge, is undergoing a seismic re t rofit to

withstand a 90-second earthquake that measures 8.3 on the

Richter scale.

The seismic program is not limited to California. New York, for

example, has a program to determine the vulnerability of its bridges

f rom seismic forces and to re t rofit bridges vulnerable to

e a rthquakes and other extreme events such as vessel and vehicle

collisions and scour. The design for extreme events has now

become part of bridge codes throughout the United States.

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62
P

ipelines carry more hazardous materials in the United

States than any other form of transportation. Annually,

almost 600 billion ton-miles are carried in 177,000 miles

of pipe, and more than 21 billion cubic feet of natural gas are

d e l i v e red through 1.2 million miles of pipe. The oil and gas pipeline

industries employ 120,000 people.

The Safety Board has played a vital role in helping to re d u c e

accidents and injuries attributable to liquid and gas pipeline

accidents. In the years 1984 through 1996, the number of pipeline

accidents fell 23 percent and injuries 10 percent. Safety Board

recommendations in the pipeline mode have addressed problems in

safety standards, excavation damage prevention, pipeline failure

detection, and service line shutoff .

Pipe Replacement Programs 

In the 1980s, the Safety Board investigated numerous accidents

involving failures of cast-iron pipe, many of which had been used for

a century. The Board recommended in 1991 that each gas operator

implement a program to identify and replace in a timely manner

c a s t - i ron piping that may threaten public safety. The DOT issued two

a l e rt notices as a result of that recommendation, and re q u i re d

operators to establish surveillance and rehabilitation pro g r a m s .

Operating Standards 

As a result of an investigation of a pipeline accident at Fort

Benjamin Harrison in Indiana in 1990 that killed two people, the

Safety Board found that the Department of Defense did not have

adequate standards to ensure the safe operation of gas pipelines

on military bases. In response to Board recommendations, the U.S.

A rmy Corps of Engineers adopted federal standards for pipeline

safety at all military bases.

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P i p e l i n e
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Risk Management 

In 1972, the Safety Board recognized the benefits of pipeline

operators using risk management principles to identify hazard o u s

conditions and to make system modifications to minimize threats to

public safety. The Board recommended the incorporation of risk

management programs by operators and by regulators into pipeline

safety operations. The DOT Office of Pipeline Safety now has a

p rogram allowing pipeline operators to implement risk management

p rograms that will enhance the safety of those who live and work

near pipelines.

Excavation Damage Pre v e n t i o n

Excavation damage prevention programs were almost unknown in

1970 when the Safety Board first identified excavation damage as the

l a rgest single cause of pipeline accidents and of deaths and injuries

resulting from pipeline accidents. Board investigations, safety studies,

and safety promotion activities have been instrumental in convincing

federal and state agencies, and pipeline industry organizations, and

pipeline operators to develop onecall notification systems, state

laws, and public education

p rograms aimed at reversing the

i n c reasing trend of excavationcaused damages to gas lines and

other buried facilities. As a re s u l t ,

t h e re are one-call notification

centers in all states and the

District of Columbia and

excavation damage pre v e n t i o n

laws in 48 states and the District

of Columbia. Similar pro g r a m s

have been implemented in five

other countries. In the 1970s,

excavation damage to pipelines

was estimated to cause 50 to 60 percent of all pipeline accidents.

While still the largest single cause of pipeline accidents and damage

to other buried facilities, excavation damage now accounts for only 25

p e rcent of all pipeline accidents.
Liquid Pipeline Failure Detection

The failure to identify and promptly shut down failed liquid

pipelines can result in significant damage to the environment. Safety

B o a rd investigations have continually identified the need for

i m p roved monitoring systems, improved means to rapidly shut off

failed pipe segments, and improved methods for periodically

analyzing the condition of the pipe system. Many pipeline operators

have been convinced by Safety Board re p o rts over the last 30 years

to install more effective systems for monitoring pipeline operations

and to install remote and automatic valves so operators will be

p romptly alerted to failures and be able to rapidly isolate those

a reas. More o v e r, many more operators are using internal inspection

devices to identify and remove deteriorated segments from their

pipeline systems. For systems not designed to accommodate

conventional internal inspection devices, re s e a rchers are seeking

ways to modify inspection tools for use in all pipelines. New

pipelines are designed to accommodate internal inspection devices

to detect system weakness before an accident occurs.

Rapid Shutoff of Damaged Service Lines

Many gas distribution systems recognized more than 30 years

ago that the major cause of accidents involving service lines was

excavation damage. Those operators called on their equipment

suppliers to develop a simple device capable of shutting off the flow

of gas in service lines that experienced an abnormal flow incre a s e .

The device developed, an

excess flow valve (EFV), could be

installed in the service line near

the gas main at a cost of $30 to

$50. Safety Board investigations

of accidents confirmed the

e ffectiveness of these devices

and the Safety Board began

calling for their installation in

new and renewed high-pre s s u re

gas service lines.

In the 25 years that the

Safety Board has advocated

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Excess flow valve.
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EFVs, several gas distribution operators have voluntarily installed

m o re than one million EFVs. Regulations now re q u i re that gas

distribution operators install an EFV on new and renewed highp re s s u re gas service lines when a customer requests one and

a g rees to pay the cost. To d a y, these valves cost about $10 to $20,

about the same as a quality home smoke detector.
T

he safe transportation of hazardous materials has been a

continuing concern of the Safety Board. Safety Board

h a z a rdous materials investigations have resulted in safety

i m p rovements in all modes of transport a t i o n .

R a i l road Tank Car Safety

Among the Safety Board ’s achievements has been the adoption

of re q u i rements for headshield protection and top and bottom shelf

couplers on tank cars carrying hazardous materials. On July 19,

1974, in a railroad yard in Decatur, Illinois, a tank car was

p u n c t u red by a box car coupler,

allowing liquefied isobutane (a

flammable gas) to escape and

vaporize. About 10 minutes

l a t e r, the tank car exploded,

killing seven yard employees and

injuring 349 other persons.

P ro p e rty damage was estimated

at $18 million. The Board

recommended that the FRA

d e t e rmine the capabilities of top

and bottom shelf couplers and

headshields to protect tank cars

t r a n s p o rting hazard o u s

materials. Shelf couplers keep

cars together during a derailment. Headshields protect tank cars

f rom being punctured at the ends of the tank car, the most

vulnerable area for such occurre n c e s .

On September 15, 1977, the DOT issued regulations that

re q u i red top and bottom shelf couplers and headshield protection to

be included in the design of new tank cars of a certain DOT

specification used to transport flammable gases and ammonia;

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H a z a rdous Materials

Tr a n s p o r t a t i o n

Shelf coupler.
68

existing cars of that specification had to be re t rofitted. However, in

the six months following issuance of these regulations, thre e

derailments involving the release of hazardous materials from tank

cars killed 26 persons, injured 205 persons, and resulted in $3.5

million in pro p e rty damage. Following a 1978 public hearing on the

issue, the Safety Board recommended that the re q u i rement for shelf

couplers and headshields be extended to all tank cars designed for

the transportation of flammable gases and ammonia.

As a result of other accident investigations, Safety Board

recommendations led to new regulations issued in 1981 and 1984

that expanded the types of DOT specification tank cars that had to

be equipped with these safety features. On September 21, 1995,

the DOT published new regulations that re q u i re better protected tank

cars, including headshield and thermal protection, for the

t r a n s p o rtation of a wider variety of hazardous materials, including

designated environmentally harmful materials. Enhanced puncture

p rotection is also re q u i red for tank cars constructed of nickel and

a l u m i n u m .

The use of shelf couplers, headshields, and thermal pro t e c t i o n

on tank cars has dramatically decreased the incidence of violent

tank car explosions and ru p t u res. Yet the danger still exists, and

accidents still occur.

In a 1991 safety study, the Safety Board investigated 45 railro a d

accidents that occurred during a one-year period, and re v i e w e d

re p o rts of its past major accident investigations and safety studies,

to quantify the safety of transporting hazardous materials by rail. In

1989, about 1.52 million carloads of hazardous materials moved by

rail, and the Board found that in the five-year period from 1985

t h rough 1989, 2,121 railroad accidents involved hazard o u s

materials, resulting in the evacuation of more than 100,000 people.

The study concluded that hazardous materials that are highly

flammable or toxic, or that pose a threat to the environment, are

f requently transported in tank cars that provide inadequate pro t e c t i o n

even though better protected tank cars are available. The Safety

B o a rd asked the DOT to conduct a risk assessment and asked the

i n d u s t ry to establish a list of the more dangerous materials.

Based on Safety Board recommendations issued from the safety

s t u d y, the Chemical Manufacturers Association now re q u i res each of

its members to have an ongoing chemical distribution risk
management program to evaluate such risks and implement risk

reduction methods that are appropriate for the level of risk. In at

least 21 of the 45 cases investigated for the study, the Safety

B o a rd found that local emergency response incident commanders

did not have a hazardous materials emergency response plan to

f o l l o w, and in 19 of the cases, incident commanders and railro a d

personnel had not been in contact with each other to develop a plan

of action in the event of a train accident involving hazard o u s

m a t e r i a l s .

Nine major railroad systems have responded positively to the

Safety Board ’s recommendations for improved coordination with

communities adjacent to railroad yards and along hazard o u s

materials routes; likewise, these railroad systems are taking action

to establish hazardous materials training programs and evaluation

systems for their employees. The American Short Line Railro a d

Association notified its members of the need to meet the intent of

the Board ’s recommendations. DOT’s Research and Special

P rograms Administration (RSPA), with the assistance of the FRA,

published new regulations in 1992 that established training and

testing re q u i rements for any employee who perf o rms any functions

associated with the transportation of hazardous materials. Under

these regulations, rail carriers are re q u i red to train and test train

c rews about hazardous materials emergency response pro c e d u re s

b e f o re they operate a train. These actions will help mitigate the

e ffects of an accident involving hazardous materials rail cars.

An urgent safety recommendation was issued to the FRA

following the Safety Board ’s on-scene investigation of the

c a t a s t rophic failure of a pre s s u re tank car filled with 32,000 gallons

of liquid propane in Dragon, Mississippi, in January 1992. A white

vapor cloud filled the area and ignited into a fireball. The tank car

was of a dual-diameter design, manufactured in 1965. The tank had

a larger diameter at its midsection than at its end sections, and

angled transition sections joined the larger and smaller sections.

Examination revealed a preexisting crack of about 21 inches. Five

additional tank cars of similar design were examined, and three of

them had cracks ranging from two to 30 inches.

The Safety Board found that an estimated 6,000 to 7,000 dualdiameter tank cars were in the rail tank car fleet and that these 

cars were used to transport such volatile materials as liquefied

p e t roleum gases, vinyl chloride, and anhydrous ammonia. 

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Based on Board recommendations, the FRA issued an emerg e n c y

o rder requiring dual-diameter tank car owners to immediately

implement a sampling inspection program. Because 40 cars were

found to have cracks, the Safety Board initiated a special

investigation on periodic inspection and testing re q u i rements for all

tank cars used in the transportation of hazardous materials.

The Safety Board found that DOT re q u i rements were not

e ffective for the detection of structural defects. The FRA and RSPA

published new regulations in September 1995 that re q u i re

n o n d e s t ructive testing of tank cars. Industry associations have

s u p p o rted the Safety Board ’s recommendations for impro v e d

inspections and testing re q u i rements for tank cars, and are

continuing work with the FRA and RSPA to refine testing techniques

and protocols. 

E m e rgency Response

As a result of several accident investigations in recent years, the

Safety Board has issued a number of safety recommendations to

r a i l roads, carriers, shippers, and emergency response agencies

re g a rding communication and coordination in hazardous materials

accidents and incidents.

Following the derailment of nine tank cars filled with butane in

A k ron, Ohio, in 1989, emergency response personnel had

d i fficulties identifying the hazardous materials on the CSX

Tr a n s p o rtation, Inc. (CSXT) train. In response to Safety Board

recommendations, CSXT implemented a training program for

operating crews and supervisors concerning responders immediately

following a hazardous materials incident or accident. CSXT also

established pro c e d u res to work more closely with emerg e n c y

response agencies during wreckage clearing operations and to

re q u i re train crews to maintain up-to-date listings showing the

position of hazardous materials cars in their trains.

As a result of a freight train derailment in Freeland, Michigan, in

1989, a tank car containing a chlorosilane mixture was puncture d ,

causing the cargo to ignite. Because the chlorosilane manufacture r ’s

material safety data sheet had conflicting information and did not

p rovide effective firefighting pro c e d u res, emergency re s p o n d e r s

attempted various techniques over a five-day period before they were
able to extinguish the blaze. In response to a Safety Board

recommendation, the manufacturer corrected the material safety

data sheet.

The Safety Board found in its investigation of the release and

ignition of butadiene from a tank car in New Orleans in 1987 that

e m e rgency responders were unable to obtain pro d u c t - s p e c i f i c

i n f o rmation pro m p t l y. In response to the Board ’s re c o m m e n d a t i o n s ,

the shipper now includes an emergency 24-hour telephone number

on its shipping papers which contains detailed information on the

characteristics of the material.

Shipping and Handling

The Safety Board issued six urgent recommendations to the DOT

within 20 days of the 1996 crash of ValuJet Flight 592 in the Florida

E v e rglades. Two of these recommendations urged the FAA to

evaluate the programs for all air carriers for accepting passenger

baggage and freight and identifying undeclared hazardous materials

shipments, and then, based on

these evaluations, to re q u i re

that air carriers revise their

practices and training pro g r a m s

as necessary. The additional

four recommendations, to both

FAA and RSPA, urged a

p e rmanent prohibition on the

t r a n s p o rt of chemical oxygen

generators as cargo on board

any passenger or cargo airc r a f t

when the generators have

passed expiration dates and the

chemical core has not been

depleted. The re c o m m e n d a t i o n

also urged prohibiting transport

of oxidizers and oxidizing materials in cargo compartments that do

not contain fire or smoke detection systems. 

These recommendations were issued after pre l i m i n a ry evidence

f rom the investigation indicated that five card b o a rd boxes containing

as many as 144 chemical oxygen generators had been loaded on

the aircraft shortly before its depart u re from Miami Intern a t i o n a l

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A i r p o rt. When transported as cargo, these generators are classified

as oxidizers under the DOT hazardous materials regulations and

must be properly packaged, labeled, and identified. The boxes

containing these generators were shipped as company materials

and were not identified as hazardous materials.

In response, the FAA initiated the evaluation recommended by

the Safety Board and developed a hazardous materials education

and enforcement program that focuses on freight forw a rders. In

August 1996 the FAA also issued new regulations that re q u i re all

shippers and freight forw a rders to certify that all packages being

shipped do not contain unauthorized explosives, destructive devices,

or hazardous materials. Additionally, in early 1998, the FA A

published a final rule that re q u i res improved fire standards for

baggage and cargo compartments in transport category airc r a f t .
T

r a n s p o rtation safety cannot be accomplished through the

e ff o rts of one person, a group, or a government agency. It is

a shared responsibility among people who travel, the

companies that provide transport, and the agencies that re g u l a t e

travel. Investigative agencies all over the world have pro v i d e d

valuable contributions to our knowledge of transportation safety.

Those companies that have enacted the improvements voluntarily

and those agencies that have mandated them through re g u l a t o ry

action can take credit for doing their part in improving the quality of

our travel.

In many instances, however, these improvements would not have

o c c u rred without the Safety Board ’s impetus. Board

recommendations begin the process that eventually saves lives and

p ro p e rt y. There are numerous other safety enhancements contained

in current Board recommendations that the Board continues to

pursue. And there are global issues, such as human fatigue and an

o rg a n i z a t i o n ’s ingrained philosophy or “corporate culture,” that cro s s

all modes of transportation and that are the focus of much of the

B o a rd ’s work.

T h e re is no way to accurately identify the accident that did not

happen or the life that was not forever altered through the eff o rts of

the Safety Board. But the men and women of the agency take pride

in these safety enhancements that statistics show contribute to the

United States having one of the safest transportation systems in the

w o r l d .

For more information on the National Tr a n s p o rtation Safety

B o a rd, please contact the Board ’s Public Affairs Office at (202) 314-

6100, or write NTSB, Public Affairs Office, Washington, DC 20594;

or access the Board ’s web page at www. n t s b . g o v.

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