Marine Safety at Every Level

By Tracy Murrell

The stern of the 85 foot catamaran Spirit of Adventure rests on the bottom of Seward Small Boat Harbor.  Photo credit: Steve Fink
The stern of the 85 foot catamaran Spirit of Adventure rests on the bottom of Seward Small Boat Harbor. Photo credit: Steve Fink

Earlier this year, I wrote about the 100th anniversary of the signing of the International Convention for the Safety of Life at Sea, or SOLAS, first adopted in January 1914, and inspired by the 1912 sinking of the RMS Titanic.

Life at sea is indeed immeasurably safer since the passage of SOLAS. But international treaties like SOLAS and legislation at the national level are never instant, or complete, fixes.

In fact, in May 1914, just months after SOLAS was first signed, the Norwegian ship SS Storstad came out of heavy fog to collide with the RMS Empress of Ireland (“Canada’s Titanic”) on the St. Lawrence River. About 14 minutes later, the Empress of Ireland sank, taking more than 1,000 lives.

I invite those who aren’t familiar with the Empress of Ireland accident to research it further. But the stark fact is that the 100th anniversary year of SOLAS also included the 100th anniversary of another marine tragedy rivaling the sinking of the Titanic.

A new treaty, or law, or technological advance is never enough. Layers of safety have to interleave to protect the lives of mariners and passengers at sea. There are international treaties, national laws, and industry standards, and improving each of them improves safety. But safety depends just as much on people and procedures, all the way down to individual actions.

In the first week of December, the NTSB launched investigators to four major marine casualties – that is, significant accidents and incidents. We launched to a fifth just days before, on November 29. Fortunately, no lives were lost – although there were injuries in some cases, and extensive property damage in all:

  • November 29, 2014: At 4:17 a.m. PST, west of Siletz Bay, OR, the Commercial Fishing Vessel Blazer took on water and sank. Five people were rescued by the United States Coast Guard (USCG). Minor injuries were reported.
  • December 1, 2014: At 7:23 a.m. CST, south of Port Fourchon, LA, the Commercial Fishing Vessel Miss Eva caught fire. Three on board were injured, one seriously.
  • December 4, 2014: At 2:42 a.m. EST, in Eastport, ME, the Eastport Port Authority Breakwater Terminal Pier collapsed, completely submerging three vessels and breaking others free of their moorings, obstructing the entrance to the harbor.
  • December 5, 2014: at 2:16 a.m. PST, the 171 gross ton Commercial Fishing Vessel Titan reported that it had run aground and was taking on water at the “A” Jetty in Ilwaco Channel, WA. The USCG responded and attempted, unsuccessfully, to help the 5-member crew to dewater the vessel. The crew was subsequently evacuated on a USCG motor life boat. The Titan slowly sank, releasing some of the 3,500 gallons of diesel fuel onboard.
  • December 8, 2014: At 9 a.m. AKST, the 99 gross-ton Passenger Vessel Spirit of Adventure was found partially submerged at the dock in Seward Harbor, AK. No crew or passengers were on board at the time of the incident. Damage is estimated at $1 million.

Our investigative work on each of these events has just begun, and it may be months before their lessons are fully learned. But there will be lessons. If the lessons are applied, the circumstances leading to these accidents and incidents can be prevented in the future.

While some suffered injuries in these five events, we will have learned these lessons without loss of life. They will be bargains, so to speak, in the world of marine accident investigation.

I invite readers to read our brief digest of completed marine investigations, Safer Seas 2013. In 2015 we will publish Safer Seas 2014, to share the lessons of investigative activities completed this year. We urge all those who take to the seas – and all who are involved in marine enterprises – to review these lessons.

Countless lives have been saved by SOLAS, national laws, improving industry standards, and better technology. More will be saved by addressing the lessons we learn in future investigations – and by individual mariners taking to heart the lessons already learned.

Tracy Murrell is the Director of NTSB’s Office of Marine Safety

ICAO Celebrates 70 Years

by Christopher A. Hart, Acting Chairman

ICAOLogoIn December 1944, delegates from 54 nations gathered in the Grand Ballroom of the Stevens Hotel in Chicago at the invitation of the United States of America. And today, it was an honor to be in that same place celebrating the ICAO successes.

In 1944, those nations had a vision of a safe and orderly international civil aviation system that would foster friendship, understanding, and cooperation and signed the Convention on International Civil Aviation, also known as the “Chicago Convention.” Fifty-two nations signed the Convention, establishing the International Civil Aviation Organization (ICAO) as a specialized agency of the United Nations. The aviation industry is an international business, where aircraft carrying passengers and cargo crisscross the globe and has greatly benefitted from its establishment.

70 years later, ICAO and the global air transport community came together to commemorate this moment in aviation history. I was pleased to be with ICAO Secretary General Raymond Benjamin; US Secretary of Transportation, The Honorable Anthony Foxx; the FAA Administrator, the Honorable Michael P. Huerta; the Honorable Rahm Emanuel, Mayor of Chicago, as well as the Secretary General of the United Nations, Ban Ki-moon to mark this momentous occasion. During the meeting, a Special Resolution paying tribute to the Chicago Convention’s contributions to global peace and prosperity through the safe and orderly development of international civil aviation was passed.

For more than 40 years, the NTSB has participated in ICAO working groups that have shaped aviation safety. We have worked with our international counterparts to improve aircraft operations and maintenance for civil aviation, to create an international standard for supporting the families of those affected by an aviation accident, and to improve how we work together to investigate aviation accidents.

In the U.S., flying on a commercial jetliner has never been safer, but it’s not risk-free. We must continue to look for ways to improve safety, including working with our foreign partners. International cooperation drives further safety improvements to U.S. products and services and encourages reciprocal support from our foreign partners when foreign equipment or foreign carriers are involved in accidents in the U.S. Only by working together can we ensure that the traveling public arrives at their final destination safely.

Safety: Across a River or Across an Ocean

By Tracy Murrell

The ferry Andrew J. Barberi passing in front of the Statue of LibertyShipbuilders know the old maritime tradition of placing a coin for luck beneath a vessel’s keel during the keel-laying ceremony. Later in the vessel’s construction, coins are placed beneath the mast in the mast-stepping ceremony.

These practices might date back to the Greek and Roman practice of “paying the ferryman”: That is, providing a coin for the ferryman Charon to transport souls across the river Styx into the underworld, should there be a disaster on the water.

In modern times, vessel safety has increased by leaps and bounds. We have learned to rely on better vessels, practices, and training, while continually incorporating safety lessons. Tradition aside, tributes to Charon are less frequently collected for mariners and passengers.

Passenger vessels that ply the open oceans are subject to International Maritime Organization (IMO) rules, which demand that each vessel have a safety management system, or SMS. But domestic vessels – including, somewhat ironically, ferries – are not subject to IMO rules.

For many years, the NTSB has recommended that operators of domestic vessels also be required to develop these systems.

An SMS is a way to bring together all the safety knowledge critical to a vessel’s operation. A good SMS does not need to be lengthy. But everybody who plays a role in a vessel’s safety should be able to use it.

An SMS should include a top-to-bottom risk assessment, to identify the biggest risks that a specific vessel faces in the course of its operations. It should also include the safety-centered practices and procedures that address these risks.

It should provide documents and training for those practices and procedures, and it should provide for internal and external audits.

In 2003, the NTSB investigated a tragic ferry accident in New York. The ferry Barberi struck a pier at full speed, killing 10 people and injuring 70, 19 of them seriously. The captain had left the assistant captain at the controls unsupervised, and the assistant captain had allowed a lookout to leave the pilothouse. Then the assistant captain blacked out at the controls.

Other crew members were unaware of the approaching danger. Despite working public address systems, there were no warning announcements. Only one of the 15 crew members recognized the danger and relayed it to passengers. Even after the ferry struck the pier, crew responses were not coordinated. Crew members were not trained in important aspects of emergency response, such as crowd control.

After the accident, New York City’s Department of Transportation began work on an SMS for its ferries.

Seven years later, in 2010, the very same ferry struck the Staten Island terminal. This time the cause was a loss of propulsion control.

But in between the two accidents, New York City’s DOT had implemented its SMS. Personnel in the 2010 accident knew and understood the SMS, and carried out their designated emergency response procedures effectively.

Employees were trained in 12 different emergency response scenarios, including loss of propulsion control, allision and collision response, and post-accident crowd control.

The pilothouse crew warned passengers over the public address system and sounded the danger signal. The deckhands began directing passengers away from the Staten Island-end.

A shoreside operator of a transition bridge, in accordance with his training, remained at his position and aligned the bridge with the vessel’s main deck. Had he not done so, the bridge could have severely injured passengers waiting to disembark.

In the second accident, nobody died. Three passengers were seriously injured. Forty-seven crew members, passengers, and others reported minor injuries.

When passengers embark on a voyage – whether it is a long ocean cruise or a part of their daily commute – an SMS helps ensure that they disembark safely on the opposite shore.

The NTSB is encouraged by the Passenger Vessel Association’s “Flagship” project, a model SMS that can be adapted to many types of vessel operations. It is also heartening to see operators, like New York City’s DOT, voluntarily incorporating SMS into their domestic vessel operations.

Developing and implementing an SMS does not have to be expensive, and should constitute the new maritime tradition for passenger vessels. Investments in Marine safety are better than tributes to Charon, no matter how infrequently collected.

Tracy Murrell is the Director of NTSB’s Office of Marine Safety

Whoever saves one life . . .

By Danielle Roeber

To-do list: improve transportation safetyThere’s a scene in the last season of the TV series, “The West Wing” when the outgoing President’s Chief of Staff is offered $10 billion to “attack” a single problem that would have a substantive impact. She names highways, explaining that 9 out of 10 African aid projects fail because the people and resources can’t get to the people in need. The philanthropist’s initial reaction – less than excited. Transportation, particularly transportation safety, simply isn’t a sexy issue; “no one will ever raise money for it.”

That’s unfortunate. Before there was an information super highway, there was the real highway. And planes, trains, ships – all of which we still use today to visit loved ones, connect with business partners, and get away from it all on vacations. When that transportation system breaks down in a plane accident, train collision, or highway crash, it can be disruptive to the economy and society. It can make people cautious. Anxiety about flying goes up immediately after a plane crash. Here in DC, people were a little more nervous getting on the Metro after the 2009 collision outside Fort Totten station. But it doesn’t take very long for most people to forget these events and return to their normal activities. Why? Because they accept that the U.S. transportation system is generally safe.

Victims and families don’t forget, though. And neither do transportation safety professionals. We understand that highway crashes are a leading cause of death, particularly for younger people. We know that many more people are killed or injured in private plane crashes than in the dramatic commercial airline crashes that catch the attention of the nightly news. We can tell you just how things can go horribly wrong in an instant, shattering lives and necessitating critical, sometimes costly, changes. And unlike most of the population, we know what it takes to make the transportation system safe:

  • Placing safety at the top of the transportation operations priority list;
  • Dedicating time, energy, and resources to education, regulation, and enforcement;
  • Investing in innovation and technology that can aid, and sometimes correct for, human behavior;
  • Giving transportation safety the public, political, and policy attention that it deserves.

When I finished school more than 16 years ago, I sought a Federal government position. I wanted to serve my country, make a difference. For the last 13 years, I’ve done that by working at the National Transportation Safety Board. No, I didn’t seek a transportation safety career when I graduated; as The West Wing points out, transportation didn’t sound like an exciting career. I guess transportation safety chose me. It’s been a quiet, behind-the-scenes kind of service. And neither I nor my colleagues and other transportation safety professionals will ever know who didn’t crash, get injured, or die because of the work we’ve done. In some ways, this is one of the noblest professions. We work hard to “attack” the single problem of transportation safety, where we’re needed, whether or not anyone knows about it. We do so because we know that each life saved is worth it.

Today is my last day with the NTSB but transportation safety remains a part of me, and I will continue to work in this field. My vantage point may change, but not my admiration for the NTSB nor my commitment to transportation safety.

Danielle Roeber served as the Chief of NTSB’s Safety Advocacy Division.

What does transportation have to do with your health? . . . Everything!

By Natalie Draisin

Transportation is Public Healt graphic

Often, I get some confused looks when I tell people I’m doing an internship at the National Transportation Safety Board (NTSB) as part of my joint public health and business degrees at Johns Hopkins University. “What does transportation have to do with public health?” they ask.

Actually, transportation has a whole lot to do with public health. How did you get to work or school today? If you walked, drove, cycled, or took a bus, you were in danger of a life-changing incident. You could’ve been struck by another vehicle. Imagine the hospital bills, the lost productivity, and the debilitating consequences. Flown on a plane recently? Did your palms sweat a little when the turbulence started? You probably arrived at your destination safely, nonetheless. That’s because your pilot was well trained, following safety protocols and mitigating the inclement weather that in another situation, could have brought the plane down.

If you believe that you have the right to cross the street without worrying about being hit, injured, or killed by a drunk driver, or you believe that you have the right to board a plane, take off, and land safely – then you believe in transportation safety, and you believe in public health.

The two are integrally linked – think about the effects of a transportation incident on our public’s health. When a bus carrying an entire high school band crashes, it has a ripple effect, impacting the rest of the transportation system, the health system, and of course, the victims’ families. Miles of bumper-to-bumper traffic will follow, which could lead to further crashes, along with lost productivity when you, and everyone else caught in traffic, are late to work. Hospitals nearby will receive an influx of patients. In major incidents, it’s often more than one hospital can handle. Victims may not be able to function at the same level thereafter, and their families might be permanently scarred, in desperate need of mental health services.

When a pipeline bursts (pipelines are a mode of transportation, as they bring something from one place to another), it has economic, environmental and health repercussions. Remember the 2010 pipeline rupture and fire in San Bruno, California? More than 4 years later, that community is still rebuilding homes and infrastructure; families are still trying to pick up the pieces. Transportation incidents don’t occur in a bubble, they affect society at large, which inherently includes, of course, the public’s health.

What is it about public health that uniquely positions the field to address transportation, and particularly traffic, safety? Public health is about protecting and improving the health and safety of the population. Public health figures out what’s hurting and killing people, and then uses evidence-based initiatives to fix it. We call that preventing morbidity and mortality. And, according to the Centers for Disease Control and Prevention (CDC) and the National Highway Traffic Safety Administration, motor vehicle crashes are a leading cause of injury in our country – 2,362,000 injured and 33,561 killed in 2012. The CDC estimates that Americans spend over one million days in the hospital each year from crash related injuries. In 2012, that translated into $18 billion in lifetime medical costs, and $33 billion lost in lifetime work, such as lost wages or benefits. That’s a lot of lives changed, expenses incurred, and productivity lost.

Though it may not seem like it, transportation incidents have a lot of characteristics similar to a disease, which public health analyzes through the lens of a host, agent, and the environment. In a car crash, the host could be the young driver; the agent, the impact of the car hitting another car; and the environment, the slippery roads at night. Like a disease, public health can intervene in a number of ways to reduce the occurrence of crashes – for example, implementing graduated driver’s licenses so youth can gain more experience before having full driving privileges, incorporating airbags and seat belts into cars to reduce the impact of a crash, or equipping roads with reflectors and guard rails to make it easier to see at night and in the rain, and harder to veer into oncoming traffic. Also like a disease, the incidence of these crashes can be tracked, so we can see if our interventions are working and revise them when they’re not.

The government recognizes that it has a responsibility to keep the public safe from incidents while using our transportation system, and that’s why they’ve created organizations like the NTSB. It’s not a public health agency, but that doesn’t mean it doesn’t address public health issues. And the good news is that through the help of agencies like the NTSB, we can work towards decreasing crash rates. The NTSB investigates accidents, determines probable cause, assists families, and then issues recommendations to federal agencies to prevent future accidents. This leads to life-saving changes.

At the NTSB, though, I didn’t sit at a desk and analyze crash data. I helped the NTSB address all elements of the public health triad – the host, the agent, and the environment. In the Safety Advocacy Division of the Office of Communications, I helped craft messages to internal and external stakeholders, to obtain support for our recommendations. Working with staff from the Office of Aviation Safety, I’ve drafted some of the web content for the NTSB’s Most Wanted List. I also wrote advocacy blogs about traffic safety, and tweets for forums. Building on my prior drunk driving prevention work, I’ve researched state laws addressing ignition interlocks (breathalyzers on cars to prevent drunk driving), and Automatic License Revocation. Some of these projects I’ve dreamed of working on for years, since I first became involved in traffic safety after the tragic death of a friend in college who was hit and killed by a drunk driver.

Throughout my internship, I’ve picked up invaluable skills. I’m fortunate to work for an outstanding group who were equally committed to developing my skills, providing constructive feedback, while at the same time, finding the synergy between their important safety work and mine. They are equally as talented and dedicated, and they’ve given me the opportunity to work with them on a variety of topics and projects. This team is representative of many of NTSB’s employees, some of the smartest, most driven people I’ve encountered. So, what does traffic safety have to do with public health? Everything.

Natalie Draisin was a graduate student intern in the Safety Advocacy Division.

School Bus Safety Has Come a Long Way

by Stephanie Shaw

School Buses

Twenty five years ago, a crash occurred in Alton, Texas, that changed school bus safety forever. At 7:34 a.m., on September 21, 1989, a school bus carrying 81 students to school collided with a truck operated by the Valley Coca-Cola Bottling Company. After the collision, the school bus continued traveling and dropped into an excavation pit partially filled with water; the bus was totally submerged in approximately 10 feet of water approximately 35 feet from the nearest shoreline. Twenty-one students died. The NTSB investigated this tragedy to examine what occurred and made recommendations to improve school bus safety.

This tragedy allowed the NTSB to shed light on serious school bus safety flaws. In Alton, the children needed to escape through the windows, as the standard exits were either overcrowded or not working. But even with passengers shifting to windows, which were not designed as emergency exits, the exit options were insufficient. Moreover, the children were unprepared for how to react during an emergency. And during the evacuation, children and rescuers struggled to keep exits open. The NTSB issued several recommendations designed to address these gaps, including evaluating the feasibility of making the windows larger, establishing a requirement that floor emergency exits are designed to remain open during emergencies, and developing a comprehensive school bus evacuation-resource guide. Amendments to applicable federal regulations, issued in November 1992, addressed school bus emergency exits and a comprehensive guide was developed by early 1994.

Twenty-five years later, school buses are the safest mode of transportation for getting children back and forth to school. Every day, nearly 500,000 yellow school buses transport about 26 million school children nationwide safely. This week, school districts around the county will observe School Bus Safety Week. A week dedicated to engaging parents, students, teachers, motorists and school bus operators, and many others to address the importance of school bus safety.

As we reflect on the Alton crash twenty-five years later and the 21 young lives lost, we recognize that because of that loss and the changes that were made to buses lives have been saved.

Even Passengers Have a Role in Safe Commuting

By Will Cusey

NTSB Government Affairs Specialist Will Cusey heads for the L’Enfant Escalator on his way into the office.
NTSB Government Affairs Specialist Will Cusey heads for the L’Enfant Escalator on his way into the office.

Although a metro rider isn’t exactly “driving,” the NTSB wanted to discuss other forms of transportation people use to get to and from work as part of our series highlighting Drive Safely Work Week. For me, going to work every day at the National Transportation Safety Board involves a trip on the DC metro rail system. This is true for many others in the DC area who combine to take 750,000 trips each day. Around the country, light and commuter rail passengers take roughly 900 million trips each year. The simple fact is that millions of Americans rely on mass rail transit to get them to and from work every day, and they expect these rail systems to deliver them safely.

But, recently, not everyone has made it to their destinations. Over the last several years, rail mass transit systems have been involved in several deadly crashes and collisions: from here in DC to New York to Boston to California. One of these incidents in particular left a profound, lasting impression with me.

It was June 22, 2009—a day that I will never forget. It started out like any other day: I hopped on the red line at Takoma and rode the metro into work. But, later that day the unthinkable happened. This transportation system that I had taken for granted—that I assumed was safe—caused the deaths of nine people. What made it hit so close to home was the realization that this deadly collision literally hit so close to home—happening just outside the Takoma metro stop. All I could think about was how I could have been on one of those trains that day.

This event completely transformed my view of rail safety. It taught me that investing in the regular maintenance, safety checks, and equipment upgrades of our rail mass transit systems is crucial to preventing tragedies such as the 2009 red line collision. It taught me that strengthening the culture of safety within the mass transit agencies is needed to ensure a safe and reliable future for these systems. And, it taught me that the NTSB has a large role to play in spurring both the mass transit agencies and the federal and state regulatory agencies to action.

Following the 2009 collision, I saw how NTSB drove the Washington Metropolitan Area Transit Authority, the Federal Railroad Administration, the Federal Transit Administration, and other regulatory entities, to improve DC’s aging metro rail system. Now, over five years later, it is evident that progress has been made—thanks in part to the work done by NTSB.

But, more work needs to be done to ensure the safety of every rail mass transit rider. That is why NTSB has made operational safety in rail mass transit a top priority in 2014 by putting the issue on its Most Wanted List. NTSB is constantly making new recommendations, holding public forums and hearings, and communicating with transit and regulatory agencies on how to make our country’s systems safer and more secure.

But, we can’t do it alone! Changing the safety culture within these agencies isn’t easy—we need your help. So, get involved! Follow us on Twitter @NTSB, like us on Facebook, check out our YouTube channel, or sign up for news updates. Retweet and share our content with your friends. And, don’t forget to tell us about your experiences. Tell us why rail safety matters to you and your family.

At the end of the day, people should be able to ride DC’s metro, or any other rail mass transit system, with the confidence that every night they will get home to their families safe and sound. It is our mission here at NTSB to help make that happen.

Will Cusey is a Government Affairs Specialist at NTSB


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