By Nicholas Worrell, Chief, NTSB Safety Advocacy Division
Author and leadership expert John Maxwell once said, “Everything rises and falls on leadership.” Leadership is at the core of all we do, whether it’s in our professional organizations, community groups, or personal lives. Success depends on sound leadership.
Earlier this week, I represented the NTSB to more than 200 members of Students Against Destructive Decisions (SADD). SADD’s mission to empower, engage, mobilize, and change is the very essence of youth leadership, and that leadership is desperately needed. The number one cause of death in teens ages 15 to 19 remains motor vehicle crashes. It’s fitting that I would speak at SADD during the 100 Deadliest Days of Summer, where we lose hundreds of teens on our roads to motor vehicle crashes. In order to save lives, it will require a change in our attitudes toward safety, and that’s a lesson best taught at an early age.
The SADD students I spoke to had already taken a major step toward this shift in thinking, simply by attending the event. Our nation’s youth must learn not only how to practice safe behavior, but also how to become the next generation of safety leaders. With that in mind and understanding that strong leadership begins with self, I urged the SADD attendees to develop their own internal leadership qualities, stressing that increased knowledge of self would help them to empower others.
As a safety advocate, I know that a big part of my job is to provide support to those who will one day fill my shoes. I used my opportunity with SADD to plant the seeds that will yield the world’s future safety advocates. It’s important that today’s adults—professional safety specialists or not—work together to train, grow, and prepare today’s youth to be strong, effective leaders that we can one day confidently hand the baton to in the name of safety.
In this episode of Behind-the-Scene @NTSB, we talk with Rachel Gunaratnam, a Hazardous Materials Accident Investigator in the NTSB Office or Railroad, Pipeline and Hazardous Materials Investigations and Frank Zakar, a Senior Metallurgist in the NTSB Office of Research and Engineering, about the natural gas-fueled explosion, on August 10, 2016, in Silver Spring, Maryland. Rachel and Frank talk about the circumstances of the explosion and fire, the probable cause, and the safety recommendations issued to prevent a similar tragedy from happening again.
By Lorenda Ward, Sr. Investigator-In-Charge, NTSB Office of Aviation Safety
As an investigator-in-charge (IIC) at the National Transportation Safety Board (NTSB), part of my job is to launch to aviation accident scenes. When my team and I arrive at the scene of an accident, we come prepared to uncover the sequence of events that led to the accident—whether it was weather, human factors, or a problem with the plane’s structure, systems, or engines. It’s the NTSB’s responsibility to find out what occurred and provide recommendations to prevent future accidents.
When we investigate an accident, we don’t only look for the things that went wrong, but we also look for those that went right. Sometimes these “rights” ensure the accident didn’t become an even greater tragedy, and sharing them can help crewmembers and operators in the future ensure the safest flight possible. A good example of this is a recent accident we investigated in Michigan.
On March 8, 2017, an Ameristar Charters Boeing MD-83 ran off the end of the runway during a high-speed rejected takeoff at Ypsilanti Airport in Michigan. The plane was scheduled to carry 6 crewmembers and 110 passengers to Washington, DC—among them, the University of Michigan men’s basketball team, cheerleaders, band, coaches, and some parents. Fortunately, no one was killed, though some passengers sustained minor injuries.
Rear view of accident scene
I led the small team that was launched to the accident site. On scene, we found that the right geared tab of the elevator flight control system had become jammed. Our investigation showed that this occurred during a strong windstorm that struck the area while the aircraft was parked at Ypsilanti Airport prior to the flight.
Seconds after the captain tried to “pitch,” or rotate, the airplane’s nose up, he quickly realized that the airplane was not going to get airborne. At that time, the airplane was traveling at a speed of 158 mph and was about 5,000 feet down the 7,500-foot runway. Because the elevator was jammed in the airplane nose-down position, no matter how far back the captain pulled the yoke, the nose refused to pitch up. The captain quickly called to abort the takeoff, but the plane was traveling too fast to be stopped on the remaining runway. It departed the end of the runway at about 115 mph, traveled 950 feet across a runway safety area, struck an airport fence, and came to rest after crossing a paved road.
Our investigation determined that the flight crew had completed all preflight checks appropriately, including a flight control test, and found no anomalies before initiating the takeoff. Furthermore, we determined that there was no way the pilot checks could have detected the flight control jam.
It’s important to note that, not only did the captain appropriately reject the takeoff once he felt the airplane was not able to fly, but the check airman did not try to countermand the rejected takeoff. And after the plane came to a rest, the cabin crew also followed procedures to coordinate a careful, safe passenger evacuation.
Also essential to the safe outcome was the fact that the passengers followed the crew’s instructions, so everyone got off quickly without any serious injuries. Unfortunately, too many times, we see passengers delay an evacuation by ignoring crew instructions to, say, retrieve their luggage.
Although the accident airplane crashed through a perimeter fence and crossed a road before coming to a stop, an extended runway safety area that was added to Ypsilanti airport between 2006 and 2009 allowed the airplane plenty of room and time to come to rest safely. This expansion was part of a national program started by the Federal Aviation Administration in 1999 in response to an NTSB recommendation to add runway safety areas to many commercial airports.
Our investigative team learned that three critical factors—things done “right”— helped prevent this accident from becoming a tragedy, in which numerous lives could have been lost:
1) The captain’s quick response
2) The crew’s adherence to procedures, which resulted in a quick and efficient evacuation
3) The addition of a compliant runway safety area
After 20-plus years of investigating accidents, it’s refreshing to me to see an accident in which more things went right than wrong, and where people lived to tell the tale because of good decision making. These cases don’t normally get a lot of attention, but it’s important for us to understand and report out all our findings—even the good—because we see lessons there, too.
By Mike Hodges, Air Safety Investigator, NTSB Office of Aviation Safety
On August 9, 2008, a privately-owned Cessna 182E airplane was reported overdue near Juneau, Alaska. The NTSB immediately started monitoring search efforts being conducted by the US Coast Guard, the Alaska State Troopers, the Civil Air Patrol, and a host of good Samaritans. The search area was expansive and included remote inland fjords, coastal waterways, and steep mountainous terrain. In an effort to start gathering information that was potentially relevant to the accident, we interviewed other pilots flying in the area, as well as Federal Aviation Administration (FAA) Flight Service Station personnel to better understand weather conditions at the time the airplane disappeared. After an extensive but unsuccessful search, search-and-rescue activities were suspended on August 20, 2008.
For all aviation accidents such as this one, when initial search-and-rescue activities are suspended and no wreckage is found, the NTSB issues a preliminary report, available to the public in an aviation accident database that can be accessed through our website. If the wreckage is not located within 180 days from the initial date of disappearance, we complete a final report with a probable cause statement of “undetermined.” The final report includes all pertinent information that was initially gathered at the time the aircraft was reported missing. If the wreckage is eventually located after the initial 180 days, we reopen and complete the investigation.
On October 25, 2017, I was the on-call air safety investigator for the NTSB Alaska Regional Office. Alaska State Troopers notified me that a deer hunter had discovered airplane wreckage on Admiralty Island, about 15 miles south of Juneau, Alaska. We eventually determined that it was the missing Cessna 182E. So, 9 years after the airplane went missing, we reopened the case.
In Juneau, I met with an aviation safety inspector from the FAA, an Alaska State Trooper, and members of Juneau Mountain Rescue. As with most remote aircraft accidents in Alaska, traveling to the scene requires an airplane or helicopter because there are no roads. The NTSB chartered a commercial, float-equipped Cessna 206 airplane, and we flew to Young Lake on Admiralty Island in the Tongass National Forest—the largest intact temperate rainforest in the world.
Flying to Young Lake near the accident site
As an air safety investigator working in Alaska, I often face unique challenges, whether it’s a hike to a remote area to reach an accident site or a wildlife encounter. In this case, after arriving at the northern end of Young Lake, we hiked nearly 2 miles to the accident site, each of us carrying either firearms or bear spray because of the large population of brown bears on the island. We also carried satellite phones because there’s no cell phone reception in the area. The wreckage was in densely‑forested, steep mountainous terrain a little over a mile northwest of the north end of Young Lake, at an elevation of about 1,075 ft. mean sea level. The average tree height at the accident site was about 100 ft.
Landing on Young Lake
When we arrived at the site, the FAA aviation safety inspector and I documented and examined the wreckage. The cockpit and fuselage were destroyed by a postimpact fire. The wreckage of the missing airplane was confirmed via the serial number located on the airframe data plate. Time and nature had taken their toll—the heavily corroded wreckage was covered with dirt, fungus, leaves, and branches. The Alaska State Trooper recovered the remains of the two occupants.
View of the wreckage
Once the investigative and recovery activities were completed, we hiked back to Young Lake, contacted the commercial aviation operator for pickup, and returned to Juneau. Because the location was so remote, the wreckage was not recovered.
Mike Hodges using a satellite phone at Young Lake to provide an update to NTSB leadership
On-scene activity is just one part of our investigative process. In each investigation, we look at the roles of the human, the machine, and the environment. By learning about the factors that cause an accident, we can make recommendations to prevent similar accidents in the future. In this investigation, I reviewed the airplane’s maintenance records, considered the pilot’s aviation training and medical records, and examined meteorological and topographical data for the accident area. As a result of the investigation, the NTSB determined that the probable cause of the accident was the pilot’s decision to continue visual flight into an area of instrument meteorological conditions, which resulted in the pilot experiencing a loss of visual reference and subsequent controlled flight into terrain. The pilot’s self‑induced pressure to complete the flight also contributed to the crash. The final accident report can be viewed here.
If you ever happen to come across aircraft wreckage—or what you think is aircraft wreckage—no matter how old it appears to be, please notify local law enforcement and the NTSB Response Operations Center in Washington, DC. If you’re able, please provide latitude and longitude coordinates of the wreckage location, along with photographs of what you found. The NTSB can then continue investigating what happened, which can help prevent future accidents from occurring. Also, importantly, family and friends of those who died in the accident may be interested in the new information. If you ever have the chance to visit the NTSB Training Center in Ashburn, Virginia, you will see an etched window on the front of the building that states the building is dedicated to the victims of transportation accidents and their families. The display also summarizes the NTSB’s crucial work of improving transportation safety for our great nation: “from tragedy we draw knowledge to improve the safety of us all.”
Today marks the 20th anniversary of the Olympic Pipe Line rupture in Bellingham, Washington, which resulted in the release of about 237,000 gallons of gasoline into a creek that flowed through Whatcom Falls Park. Sometime after the rupture, the gasoline ignited and burned about 1.5 miles along the creek. Two 10-year-old boys and an 18-year-old young man named Liam Wood died; 8 others were injured.
Postaccident aerial view of portion of Whatcom Creek showing fire damage.
Liam had just graduated from high school and was fly fishing when he was overcome with fumes from the rupture. Years later, I met Liam’s stepfather, Bruce Brabec, as a staffer on Capitol Hill. Since Liam’s death, Bruce has been a tireless advocate for closing gaping holes in pipeline safety regulations, many of which have been revealed as a result of our pipeline accident investigations.
This past fall, I saw Bruce at a pipeline safety conference. The discussions over the days that followed left me wondering how much we’ve accomplished over the last 20 years. Is our pipeline system truly safer?
From a numbers standpoint, it’s good news and bad news. According to the Pipeline and Hazardous Materials Safety Administration (PHMSA), there were 275 significant gas and hazardous liquid pipeline incidents in 1999, resulting in 22 fatalities and 208 injuries. Since that time, the number of significant incidents has fluctuated as PHMSA adopted new reporting criteria, with 288 significant incidents occurring in 2018.
Fatalities and injuries have decreased since 1999 to 7 fatalities and 92 injuries in 2018, but that provides no comfort for victims, their families, or their loved ones. The fact is, although pipelines are one of the safest ways to transport hazardous material, the impact of just one incident can be devastating. And although the number of accidents is low compared to other modes like highway and rail, there is much more that pipeline operators and federal regulators can do to get to zero incidents, zero fatalities, and zero injuries on our nation’s pipeline system.
Our recommendation for operators to install automatic or remote-control shut-off valves in high‑consequence areas is a perfect example. In 1994, we investigated a natural gas transmission pipeline rupture in Edison, New Jersey, which resulted in a fire that injured 112 people and destroyed 8 buildings. Pipeline operators were unable to shut down the gas flow to the rupture for 2½ hours. Our report on the accident recommended that the Research and Special Programs Administration (RSPA), PHMSA’s predecessor, expedite requirements that automatic- or remote‑operated mainline valves be installed on high-pressure pipelines in urban and environmentally sensitive areas so that failed pipeline segments can be rapidly shut down. We have been recommending valve installation in some form on pipelines since 1971.
In response, RSPA issued a regulation requiring operators to install a valve only if the operator determines it will efficiently protect a high-consequence area in the event of a gas release.
Fast forward to September 9, 2010, when an intrastate natural gas transmission pipeline owned and operated by the Pacific Gas and Electric Company ruptured in a residential area in San Bruno, California. The rupture produced a crater about 72 feet long by 26 feet wide. The section of pipe that ruptured was found 100 feet south of the crater. The released natural gas ignited, resulting in a fire that destroyed 38 homes and damaged 70. Eight people were killed, many were injured, and many more were evacuated from the area.
In our report on the accident, we once again recommended that PHMSA expedite the installation of automatic shutoff valves and remote-control valves on transmission lines in populated areas, drinking water sources, and unusually sensitive ecological resources. Congress then required PHMSA to implement the recommendation in the Pipeline Safety, Regulatory Certainty, and Job Creation Act of 2011 (PL 112-90).
It’s been a decade since San Bruno, and PHMSA is nowhere near issuing a final rule to implement our recommendation. This issue is highlighted on our 2019–2020 Most Wanted List of transportation safety improvements (Ensure the Safe Shipment of Hazardous Materials).
It’s my hope that over the next few years, we’ll see some real improvements in pipeline safety and avoid tragedies like the ones in Bellingham and San Bruno. With the technology we have readily available today, there’s absolutely no reason for any parent to have to face the loss of a child because of a pipeline accident. I hope that the next time I see Bruce Brabec, we’ll finally have the regulations in place that he’s worked so hard for on Liam’s behalf.
NTSB Safety Compass Blog 