Examining the Safety, Operations and Oversight of the Cruise Ship Industry

By Earl F. Weener

Earlier this week, the Board held a 2-day, public forum entitled Cruise Ships: Examining Safety, Operations, and Oversight. The forum provided an opportunity to learn more about cruise ship operations, and explore the various safety issues involved in operating a cruise vessel. With more than 20 million people expected to take a cruise in 2014, we believed it important to focus attention on cruise ship operations and understand what measures the cruise line industry uses to ensure cruises proceed underway with appropriately trained crew, well equipped and maintained vessels, and adequate measures to address emergency situations.

The forum was the NTSB’s first public event on the safety of cruise ships, and we were fortunate to hear from the International Maritime Organization; the U.S. Coast Guard; various vessel owners, operators, and class societies; and other industry groups, including both domestic and international interests. While the topics covered the various safety regulatory schemes applicable to the industry, we also learned more specifically about efforts the industry has undertaken to improve safety in the wake of several recent high-profile accidents.

As I listened to the presenters and engaged them in discussion, I was particularly pleased to hear of the increasing practice of adapting proven safety tools from the aviation industry to the marine industry – notably, bridge resource management (or BRM), electronic data monitoring and analysis (bridge operations quality assurance or BOQA), and pro-active internal audits to maintain standards (marine organization safety audit or MOSA). Like the aviation industry, the international marine community has come to value a safety management systems (SMS) approach to developing and maintaining a robust safety culture. It only follows, then, mariners should also come to value these safety tools, as they provide a means to achieving and maintaining a successful SMS. Programs such as BOQA and MONA provide the underlying data critical to threat and hazard identification, whereas BRM is a proven mitigation strategy to address human error. It is gratifying to see cruise lines plot this course and as a result, I believe they, like the aviation industry, will also see dramatic safety gains.

In considering the 100^th anniversary of the Titanic tragedy in 2012, the cruise ship industry has vastly improved the safety of cruise ship operations, and I encourage them to remain on course with responsive actions to address shortcomings in the wake of recent accidents. However, I also find it interesting, and I believe it is due to the global nature of these two industries, how both the aviation and marine industries have come to similar conclusions in identifying SMS as the best approach to improving safety within their respective modes of transportation. It is said copying is the highest form of flattery. In light of the recent rail and pipeline accidents under investigation by the Board, going out on a limb, I doubt the aviation and marine industries would be offended in the least if the rail and pipeline industries engaged in some flattery. It should not take the nature of a global environment to convince an industry to do the right thing.

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Earl F. Weener, Ph.D., took the oath of office as a Member of the National Transportation Safety Board on June 30, 2010.

Carburetor Icing – Not just a Cold-Weather Issue

On Monday, the NTSB released the probable cause of a General Aviation (GA) accident that occurred March 15, 2012 in Niceville, Florida. The NTSB determined the pilot’s use of carburetor heat was inadequate, which resulted in carburetor icing and subsequent loss of engine power. The pilot and passenger died.

On average, carburetor icing causes or contributes to two fatal accidents per year. The NTSB has identified a number of factors that lead to these accidents, including the failure of some pilots to recognize weather conditions favorable to carburetor icing and inaccurately believe that carburetor icing is only a cold- or wet-weather problem. This recent report on the Niceville, Florida crash reinforces the need for GA pilots to give extra attention to carburetor icing regardless of a flight’s departure and landing locations. For more information, see the NTSB’s Safety Alert, Engine Power Loss Due to Carburetor Icing, released December 2013.

You Can Never Be too Prepared for a Disaster

By Michael Crook

Tomorrow starts the NTSB’s training course, Transportation Disaster Response – Family Assistance.  I and my colleagues in the NTSB’s Transportation Disaster Assistance (TDA) division will spend the next three days with other presenters helping attendees to understand how any organization involved in transportation accident response can most effectively support accident victims and their families.

Long before I came to work at the NTSB, I took this very same training course while working for Pinnacle Airlines as the Manager for Emergency Response, Security, and Flight Safety.  I know from my 16 years in the aviation industry that airlines strive to make each flight as safe as possible.  When something goes wrong, however, having a plan in place and obtaining the necessary training can make all the difference in working with accident victims and families.  I know this from personal experience, having worked 11 aviation accidents as either an emergency responder or accident investigator, most recently when Colgan Air (Continental Connection) Flight 3407 crashed on February 12, 2009 in Clarence Center, New York.

My first accident after taking the basic family assistance course was the October 2004 Pinnacle Airlines Flight 3701 crash in Jefferson City, Missouri.  Unlike in previous accidents to which I had responded, I felt better able to prepare and guide my team on what the day-to-day challenges would be.  I now understood the families’ motivation for information and how the families’ needs differ depending on whether they are passenger or employee families, where such employee-related matters as workers compensation may need to be addressed.  I also felt better able to respond to the emotional impact of dealing with personal effects.  In addition, this was the first accident in which my team and I had to address the needs of displaced individuals on the ground whose homes were destroyed, a requirement for airlines that was mandated after the crash of American Airlines flight 587 in 2001.

Federal legislation specifies that domestic air carriers, foreign air carriers, and interstate intercity passenger rail operators must provide comprehensive and effective family assistance.  The lessons learned in this course, however, have significant value for any organization involved in emergency response.  For example, as part of the US Army National Guard, I have responded to several natural disasters, including the 2005 Hurricanes Katrina and Rita, and the 2011 tornado in North Alabama.  What I learned in the TDA course was particularly important as our National Guard Disaster Relief teams worked to understand the victims’ basic needs and to establish community response centers.  TDA training courses often draw a varied audience of emergency response organizations.  In addition to the almost 20 airlines and 5 airports sending representatives to tomorrow’s class, we have representatives from multiple local, state, and federal agencies as well as attendees from the cruise line industry, mental and behavioral health organizations, and pipeline operators.

The NTSB’s TDA team doesn’t stop with this family assistance course.  In addition to other courses available at the NTSB Training Center, we travel around the country to conduct trainings and briefings on transportation family assistance response for airlines, airports, local and state agencies and professional associations.  The bottom line is to ensure an effective response for the ultimate customers of the service: the family members of victims and survivors of transportation accidents.

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Michael Crook is the Coordinator for Transportation Disaster Operations in the Transportation Disaster Assistance Division, Office of Communications.

When It Comes to Hazardous Weather, We All Need to Communicate for Safety

By Dan Bartlett

Next week, three of my NTSB colleagues and I will attend Communicating for Safety, the safety and technology conference hosted by the National Air Traffic Controllers Association (NATCA).  Although NTSB Members and staff have previously presented and attended this conference, this will be the first year that the NTSB will have an exhibit, booth #7.  This gives us an excellent opportunity to highlight one our Most Wanted List issue areas, General Aviation: Identify and Communicate Hazardous Weather.

When it comes to improving hazardous weather awareness in General Aviation (GA), at least three parties play a critical role: the GA pilot, air traffic control, and the National Weather Service.  A common and dangerous misconception that can lead to tragic results is the assumption that one of the other parties has better weather capabilities than “you” do, so frequent communication is critical.  One of our goals at this year’s conference is to emphasize the role of air traffic control in hazardous weather awareness by using case studies.  Let me give you an example.

On the morning of July 9, 2007, a Piper PA-32-260 encountered severe weather and broke up in-flight over Tyringham, Massachusetts, killing the pilot and pilot-rated passenger.  On the afternoon of the previous day, the instrument-rated pilot had contacted Bridgeport Federal Contract Facility Automated Flight Service Station to request predicted flight weather conditions for a 0600 departure from Wiscasset, Maine, to Columbia, New York.  Bridgeport advised the pilot of potential marginal weather along portions of his route and suggested an instrument flight rules (IFR) flight plan, which the pilot subsequently filed.

During the course of his flight, the pilot spoke with two approach controllers.  The first controller advised the pilot of hazardous weather conditions.  Approximately seven minutes before the accident, he also advised the relief controller that it looked like the Piper pilot would have to turn and that he wasn’t certain if the pilot had weather radar.  For the next five minutes, the relief controller made five routine radio transmissions, but none to the Piper pilot.  About a minute before the accident, the pilot advised that he was encountering hazardous weather and requested to divert to the south, which the relief controller approved.

Despite the fact that a relief controller had been briefed to turn the accident airplane due to weather, the relief controller failed to issue weather information or initiate a flight deviation around known and clearly observed weather, despite very little traffic and a light workload at the time.  The NTSB determined that the probable cause of this accident was “[t]he pilot’s inadvertent encounter with thunderstorms during cruise flight. Contributing to the accident was the failure of air traffic control to appropriately issue weather information and initiate an in-flight deviation around known and clearly observed weather.”

This isn’t the first accident we have investigated where weather guidance from air traffic control could have made a difference.  As air traffic control investigators, we understand the primary responsibilities of air traffic control, but  also know that the provision of additional services is not optional, but rather is required when the work situation permits.

The overwhelming majority of aviation-related deaths in the United States occur in GA, and historically, about two-thirds of all GA accidents that occur in instrument meteorological conditions are fatal.  It seems appropriate that at Communicating for Safety, the NTSB will stress the vital role that communication plays in driving down the accident rate.  So please come find us at booth #7 to learn more about steps you can take to make the skies safer for the GA community.

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Dan Bartlett is an investigator in the NTSB’s Office of Aviation Safety.

Quick response to Recommendations improves safety on Chicago’s rails

By Robert Hall

Photo credit: CTA

In our almost 50-year history, the NTSB has issued 13,945 safety recommendations.  Admittedly, sometimes the recommendations go unaddressed.  Most of the time, however, changes are made and safety is improved.  In fact, of the 13,945 safety recommendations, only 2,077 (about 18 percent) have not been implemented.

Here’s a story about two recommendations and the quick response from the recipient.  On September 30, 2013 during rush hour, an unoccupied Chicago Transit Authority (CTA) train collided with a CTA train in revenue service carrying about 40 passengers.  Although 2 CTA employees and 33 passengers were transported to local hospitals, all were treated and released, and thankfully no one died.

Very early in our investigation, we learned that the unoccupied train had been stored at a terminal awaiting repairs when it began moving under power and entered main line track.  Despite repeated attempts by the automated system to apply brakes when the train passed a stop signal, the train resumed each time because the master lever on the operator console had been left in a setting that allowed the train car brakes to recover and reset from the emergency brake application and proceed through a mechanical train stop mechanism after a momentary stop.

On October 4, we issued two urgent safety recommendations addressing the need for redundant protection to prevent unintended train movements.  Less than one month later, the CTA released three Rail Operations Service Bulletins and one Rail Maintenance General Bulletin as an expedient means to safeguard against future occurrences.  By December 5, the CTA had fully implemented policies requiring that all unmanned consists are shut down and the motor cabs secured to ensure that unoccupied CTA trains are not powered up while stored or on hold for service and to ensure that the propulsion and brake systems are left in a condition that would not facilitate unintended movement.  The CTA would also now mandate the use of wheel chocks and other operating safeguards against unintended train movements.  Moreover, the CTA had identified 39 locations at 10 yards  where the CTA would install derails to prevent unintended movement on to main lines.

Our investigation into the cause of the accident is ongoing, but we have learned in almost 50 years of investigations that often a series of events leads to an accident and multiple opportunities to improve safety exist.  The CTA didn’t hesitate when presented with the facts, and Chicago is safer.

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Robert Hall is the Director of the Office of Railroad, Pipeline and Hazardous Materials Investigations.