All posts by ntsbgov

40 Years Ago: London’s Moorgate Tube Crash

By Christopher A. Hart

moorgateundergroundOn February 28, 1975, the world’s oldest subway system suffered one of its deadliest-ever accidents. At the London Underground’s Moorgate terminus, a train failed to stop, continued through an overrun tunnel equipped with a sand drag and a hydraulic buffer stop, and crashed into a wall.

Forty-three people lost their lives in the accident, and another 74 were injured. The U.K.’s Department of the Environment investigated the collision and reported that the accident train was found not to be defective. While the sand drag and the hydraulic buffer proved ineffective in the circumstances of the accident, another factor continued to draw interest for decades after the tragedy.

Why did the driver of the train not stop?

Since the driver was among those who died in the collision, the answer will never be conclusively known – in the conventional sense.

After the accident, however, a system dubbed “Moorgate Protection” was proposed, which would automatically slow trains at dead-end termini. Within a decade, “Moorgate Protection” was in use at all such termini in the London Underground.

Technological improvements have saved lives and prevented property damage and injuries in all modes of transportation. In the world of passenger rail and mass transit, we’re in a far safer world today, now that technology can act as a backup and prevent accidents even when human train operators do not.

NTSB recommendations urge the use of technology as a safety net when the human train crew fails. Positive train control, or PTC, uses technology to warn train crew members, and if necessary, apply the train brakes, when trains might strike one another or enter work zones from which they are barred.

For passenger rail systems that operate between cities, Congress has mandated that PTC be implemented by December 31, 2015.

Congress took this action in response to a 2008 collision between a commuter train and a freight train in Chatsworth, California, that killed 25 people and injured more than 100. In 2013 a Metro-North commuter train derailed in the Bronx, killing four and injuring 61. Both of these accidents could have been prevented with PTC.

The NTSB has been urging a forerunner to PTC since years before the Moorgate Tube Crash. The NTSB’s position goes back to yet another deadly train crash in 1969 in Darien, Connecticut.

This year, “Implement Positive Train Control in 2015” is on our Most Wanted List of safety improvements.

Railroads have until December 31 of this year to comply with the law and implement PTC. After 45 years of NTSB recommendations, and more than six years to meet Congress’ deadline, we should not have to wait any longer. The time to act is now.

The anniversary of the Moorgate Tube Crash is a fitting reminder that PTC can provide an essential backup to the behavior of a human engineer.

Extending this deadline is extending the length of time that passengers and crew members go without this vital backup protection.

As Rail Hazmats Rise, So Must Safety

By Christopher A. Hart

Scene of the Casselton, ND derailment and fire. (Photo: Ken Pawluk / AP / December 30, 2013 / latimes.com)

Increasing concerns about the transportation of crude oil and other hazardous materials through American communities have brought rail tank car safety to the forefront, and recent derailments have provided a fresh reminder of the need to improve the safety of transporting these materials by rail. Since 2006, a rapid increase in rail transport of flammable liquids has led to a growing risk to life, property, and the environment. Two commodities in particular, crude oil and ethanol, have led a massive surge in hazardous materials traffic, and a corresponding rise in the number of derailment accidents involving these products. The sharp and continuing upward trajectory of these shipments emphasizes the urgency of a commensurate response in safety measures, which is why the issue of Improving Rail Tank Cars is included on our 2015 Most Wanted List.

Last week, on February 16, 28 tank cars in a 109-tank car CSX crude oil train derailed near Mt. Carbon, West Virginia. Some of the highly flammable cargo released and ignited. One home was destroyed, at least one person was injured, and residents in a half-mile radius were evacuated. The accident came just two days after a February 14 crude oil unit train derailment and fire about 50 miles south of Timmins, Ontario. While the causes of these accidents have yet to be determined, much more needs to be done to heighten safety in this environment of rapidly increasing hazmat rail transport.

The United States now leads the world in crude oil production growth, and in Montana’s and North Dakota’s Williston Basin Bakken Region, output now exceeds a million barrels per day. In response, America’s railroad shipment originations have increased from 10,800 crude-loaded tank cars in 2009 to more than 491,000 in 2013. Ethanol shipments have surged as well following the provision in the 2005 Energy Policy Act for incremental increases in the production of ethanol for motor fuel blending. In 2013, ethanol was the second most transported hazardous commodity by tank car with over 291,000 shipment originations.

Over the years, NTSB investigations have raised several concerns about the three major aspects of this problem. First, safer operations, to reduce the likelihood of derailment. Second, if there is a derailment, better tank car accident performance, including the lack of puncture resistance, poor thermal resistance — that is, ability to withstand a pool fire without energetic rupture — and inadequate top and bottom fittings protection. And finally, if there is a derailment and a release of hazardous material, more robust emergency response.

In June 2009, a deadly derailment in Cherry Valley, Illinois, resulted in 13 breached ethanol tank cars, a post-accident fire, one death, several injuries, and the evacuation of 600 residences within a one-half mile radius. As a result of this accident, the NTSB issued comprehensive safety recommendations urging the Pipeline and Hazardous Materials Safety Administration (PHMSA) to require newly manufactured and existing tank cars authorized for transportation of volatile ethanol and crude oil to have enhanced tank head and shell puncture resistance systems, top fittings protection that exceeds existing design requirements for DOT-111 tank cars, and bottom outlet valves designed to remain closed when subjected to impact forces.

Meanwhile, the tank car industry recognized the need to reexamine existing standards for DOT‑111 tank cars. In 2011, the Association of American Railroads (AAR) requested PHMSA to amend the Hazardous Materials Regulations with proposed standards for DOT-111 tank cars used for Packing Group I and II hazardous materials, the two highest categories of this kind.

In the absence of any federal rulemaking, the AAR issued casualty prevention circular CPC-1232 in 2011 to amend industry standards and specifications. It called for tank cars ordered after October 2011 for crude oil and ethanol to have marginally thicker normalized steel and half-height head shields. The AAR also required top fittings protection for cars ordered after July, 2010.

Prompted by an increasing frequency of accidents and the ongoing lack of regulatory action, the NTSB held a public forum on April 22-23, 2014, on rail safety and the transportation of crude oil and ethanol. It was clear from the proceedings that regulators, railroad industry, tank car builders, and tank car owners continue to disagree about the level of protection needed for both new tank cars and for retrofits to the existing DOT-111 fleet. Amid this lack of consensus, the safety risks continued to grow.

In August 2014, with the PHMSA notice of proposed rulemaking finally in place to mandate new standards and operational requirements for trains transporting large volumes of flammable liquids, there were approximately 15,000 tank cars built to the marginally improved CPC-1232 standard. Though proposals in the current rulemaking would make a significant improvement over CPC-1232, another 36,000 of these cars will be built for crude oil service by the end of this year. Unless swift regulatory action is taken, the effect of new tank car safety rules could be weakened by a vast new fleet of cars built to older and less-safe standards.

Last year, more than 2 million loaded tank car shipments of hazardous materials commodities originated in the U.S. and Canada. These frequently transport essential commodities such as fuels, lubricants, fertilizers, and chemicals that are staples of the national economy. To meet this need, the rolling stock is huge, with about 236,000 railroad tank cars in hazardous materials service throughout North America. Safety, however, has not kept pace with the sheer demand and vigor of the market, potentially placing many who live amid the complex rail network in danger. As noted above, this safety improvement effort must also include safer operations, to reduce the likelihood of derailment, as well as improved community knowledge and emergency response, but as part of that bigger picture, we strongly urge industry and regulators to take action and reverse the trend set by tragic accidents such as Cherry Valley, Illinois; Lac-Mégantic, Quebec; Casselton, North Dakota; Lynchburg, Virginia; and Mt. Carbon, West Virginia, by demanding the most robust tank cars available to lessen the consequences of rail accidents involving hazardous materials.

For more information on NTSB efforts to improve rail safety please visit our Most Wanted List Implement Postive Train Control in 2015 page and our website www.ntsb.gov.

On the Front Lines of Road Safety

By Nicholas Worrell

Nicholas Worrell and Florida Representative Irv Slosberg at the Dori Saves Lives & the Allstate Foundation’s Driver Education Conference.  Representative Slosberg’s daughter Dori was killed in a DUI crash in 1996.
Nicholas Worrell and Florida Representative Irv Slosberg at the Dori Saves Lives & the Allstate Foundation’s Driver Education Conference. Representative Slosberg’s daughter Dori was killed in a DUI crash in 1996.

Each year the Dori Slosberg Foundation hosts Dori Saves Lives & the Allstate Foundation’s Driver Education Conference, a gathering of instructors, administrators, and others. Today, I had the opportunity to represent the NTSB and address attendees at the conference.

To the untrained eye, driver education instuctors might appear to be average middle-class civilians. But to me, they are front-line troops for road safety. Each and every one of them are in a battle to keep Americans alive and safe, against an “enemy” that takes more than 30,000 American lives per year: roadway fatalities.

Traffic crashes used to take many more lives. In the early 1970s, more than 50,000 people died on our roads each year.  We’ve been beating back this enemy steadily over the decades. Our weapons have included better safety technology (including air bags and electronic stability control), stronger laws, high-visibility enforcement, and what educators do – driver’s education and training.  Yet motor vehicle crashes remain a leading cause of death for Americans, particularly those between the ages of 13 and 19.

Our message to these front-line troops was simple: reach out! We have made progress in road safety, and can still bring more weapons to the fight through state graduated licensing laws. But in terms of teaching and training, even the best traditional drivers education program needs reinforcement by peers and parents.

People think of their cars as personal space. Unlike pilots and railroad engineers, we don’t demand recurrent training throughout an everyday driver’s career. We don’t highly regulate personal drivers’ behavior. Driver educators must reach drivers in a very short time period.

 Enough time to teach, but not enough time to train; not enough time to send kids out to meet an enemy that still kills 30,000 Americans a year.

 That enemy continues to add weapons to its arsenal. Distractions from portable devices are on the rise. While we’ve made big strides in fighting drinking and driving, we’re only at the beginning of understanding data on driving under the influence of drugs. And we have only started to understand one of the enemy’s favorite secret weapons: fatigue.

And the enemy continues to deploy these weapons against our youngest, least experienced drivers first, making it all the more critical that our front line safety troops use all available time and resources.

 Our front-line troops need a force multiplier, something that extends the impact of every weapon they can bring to the fight. Driver educators need allies to follow through on the message once they’ve delivered it.

The force multiplier is not in their classrooms. It’s not in their road training. It’s not any of the things that they themselves do. Our front-line safety troops need someone else on the front lines with them, amplifying their messages.

 They need peers to talk to peers, like the fine young men and women who participate in The Dori Slosberg Foundation, NOYS, Impact Teen Driver and FCCLA. And they need parents to take advantage of the long time period between a first permit and full driving privileges, drilling kids in the lessons that they teach.

Furthermore, our front-line safety troops need parents to model good behavior – not talking on their phones, not texting at the red light, not distracting themselves with activites that don’t support the driving task, and certainly not drinking and driving, or driving on insufficient sleep. Kids learn from what we tell them, but they learn more from what they see us do.

So parents, if one of our front-line safety troops – one of our driver educators – reaches out to you, recognize their service, and listen to what they have to say. If you have a teen at home learning to drive, be that force multiplier for our front-line safety troops. Join them in the fight for road safety.

 Take your teen out to practice, and model the best behaviors behind the wheel.

Acts of Love: From Valentine’s Day to Presidents Day

By Rob Molloy

All this week we have posted blogs about “Acts of Love,” selfless actions that people have taken to improve the safety of family members, or even the safety of people whom they have never met. Tomorrow is Valentine’s Day, and while couples mark the day with chocolates, flowers, special dinners and the like, safety advocates pursue their daily labors of love year-round.

To round off the week, we’d like to also remind readers that Monday is Presidents Day – a day to celebrate Washington’s and Lincoln’s birthdays, and, as it happens, a red-letter day for new car sales.

But we’re not forgetting about our theme, Acts of Love. With Valentine’s Day coming this close to Presidents Day, maybe it’s time to think of those you love when you’re deciding what you’ll drive.

In the market for a new car? Consider its safety features, even beyond the required ones. Does the car have collision avoidance technology, such as lane departure warning, forward collision warning, adaptive cruise control, and automatic braking?

At the National Transportation Safety Board, we think these types of advances should not just be luxury items – they should be standard on all new cars. For now, look for these features. They might just keep the one you love alive.

And if you’re looking at a used car, even from a relatively late model year, look for one with electronic stability control, which has only been standard in all new vehicles since model year 2012.

What about the new features in cars that help me stay connected with your loved ones in your car? Don’t they improve safety also? Not necessarily, some in-vehicle systems could distract you – or your beloved – from focusing on driving your vehicle. In particular when they make it easier to use your hand held devices in your car.. Even though these systems can eliminate manual tasks like typing texts, dialing a number, or using a hand-held phone, they can still cause cognitive distraction, decreasing your attention to the driving task. One of the most frequent causes of vehicle crashes is driver inattention.

So even if you’re dazzled by the present generation of available distractions, you might be best off making a promise with the one you love: If one of you calls or texts while the other’s driving, he or she gets a call-back – as soon as the one driving finds a place to pull over. And take a brief look at “Disconnect from Deadly Distractions,” on the NTSB Most Wanted List page.

If this Saturday reminds you of all the wonderful, unique things about the one you love, don’t forget those irreplaceable traits on Monday, if you’re at a Presidents Day sale. Protect that special someone while you’re shopping for the vehicle that you’ll both be driving for years to come. It’s an act of love that any car shopper can take.

Rob Molloy is the Deputy Director of the Office of Highway Safety

Acts of Love: What Color Wristband Would You Wear?

Joel’s Story:

I remember sending pink roses to my daughter Casey for Valentine’s Day. Pink was her favorite color.

Casey was killed by a distracted driver. She was 21. After Casey was killed I feared that she would be forgotten-she would not graduate college, find a career, marry, have children and continue to make a difference in the world. I became an advocate for distraction-free driving and now devote most of my time to those efforts. I tell my daughter’s story to keep her memory alive and so that her life and death will save other lives. I am and will always be a grieving parent- I live and my child is dead; I have a future and my child does not; I try to make sense of how and why my child died but cannot.

Joel Feldman PictureI wear a pink wristband to remember my daughter. But I am not alone in wearing a wristband to remember my dead child. Many other parents wear wristbands to remember their children killed by distracted driving. We exchange wristbands to remember each other’s children and I wear wristbands given to me by other grieving parents. On my right wrist are those for the girls-lavender for Katie, Green for Toni and R.J., purple for Heather and orange for Chloe. On my left wrist are the boys- lime-green for Conor, blue and white for Paul, gray for Reece, black for Connor and orange for Owen- grieving parents, struggling to make sense of something that defies explanation, wearing wristbands in our dead children’s favorite colors.

Motor vehicle crashes are the leading cause of death for U.S. teens. Seven teens ages 16 to 19 die every day from motor vehicle injuries. Teen drivers ages 16 to 19 are nearly three times more likely than their elders to be in a fatal crash.

Teen motor vehicle crashes are preventable, and proven strategies can improve the safety of young drivers on the road. One of those strategies is to prohibit the use of portable electronic devices while driving.

In 2002, the NTSB issued its first recommendation related to cell phone distraction following the investigation of a crash involving a novice driver who was distracted by a cell phone conversation with a friend. She veered off the roadway in Largo, Maryland, crossed the median and flipped the car on top of another vehicle. That phone call cost not only her life, but also the lives of four others.

Since then, the NTSB has joined advocates like Joel and so many others to carry the message of the need to disconnect from deadly distractions across the Nation.

Today, NTSB Safety Advocacy Nicholas Worrell had the opportunity to join Joel at the American Association for Justice to speak with lawyers, professionals, parents, and students concerning the dangers of distracted driving.

The responsibility for the development of safe driving behaviors isn’t solely on our teens. Studies show that teens are influenced by and listen to their parents. In fact, teens whose parents drive distracted are 2-3 times more likely to also drive distracted. Children really do listen to what we say. But more importantly, they watch what we do.

Joel’s message to parents is simple, “Be the driver you want your child to be.

He challenges each of us to answer the question,

What driving distractions would you give up if it meant saving your child’s life?” http://youtu.be/7blscraKHDs

Joel Feldman’s daughter Casey was killed by a distracted driver in 2009. After her death he founded EndDD.org.

Acts of Love: A Father’s Choice

by Stephanie D. Shaw

DUI infographic showing amounts of alcohol to impairment levels.Andy’s first DWI charge came when he was 25. All his life he had seen family and friends driving after drinking, and this was not the first time he had done likewise.

Marriage had not changed his habits, and neither had his wife’s announcement that she was pregnant with their first child. In fact, that announcement began the sequence of events that led to his first DWI charge.

“I did what I thought I was supposed to do,” Andy says. “I went out with my buddies to celebrate. I was exactly three miles from my home when I was pulled over.”

A young college-educated professional with a good job, Andy had a lot to lose. But he had grown up thinking that driving after drinking, if a little risky, was normal.

Do you?

Continue reading Acts of Love: A Father’s Choice

Acts of Love: Family Matters

By Paul Sledzik

Tragedy stresses the bonds of love with unimaginable force. Each of us faces the death of a loved one with an individual response, making generalizations difficult. In our work in Transportation Disaster Assistance, we’ve seen the entire range of response, from anger to incredible grace and understanding.

Some families use their grief as the catalyst to ensure others don’t suffer a similar loss. We see this often in the aftermath of transportation accidents. Not wanting the loss to be in vain, and to honor their loved one, they advocate for improved transportation safety. Some do it alone, while others form associations with others who lost family in the same accident. Sometimes, families join together to focus on a specific transportation safety issue that goes beyond the accident to prevent future losses. More often than not, they look to the NTSB recommendations as a source of independent information to focus their advocacy efforts.

Flight 3407 memorialThe family members who lost loved ones in the crash of Continental Connection flight 3407 in 2009 are a remarkable example.   Their efforts for substantial improvements in aviation safety resulted in the passage of the Airline Safety and Federal Aviation Administration Extension Act of 2010. This week marks the 6th anniversary of that accident, and the families were on Capitol Hill last week to continue their advocacy during the FAA reauthorization hearings.

Many of us are aware of the efforts of Mothers Against Drunk Driving, which grew from a mother who lost her daughter to a national movement. Similar grass-roots groups or individual families promote safety in wide range of transportation modes including fishing vessels, cruise ships, motorcoaches and school buses, trucks, and highway and auto operations. The Survivors Network for Air & Surface Medical Transport, created by survivors of air medical accidents, supports survivors and family members of air and surface medical accidents and works with operators to mitigate risk and improve safety.

President Clinton signing the Aviation Disaster Family Assistance Act of 1996.
President Clinton signing the Aviation Disaster Family Assistance Act of 1996.

Family members have sometimes taken on advocacy to improve the treatment of other families who have endured losses in accidents. The Aviation Disaster Family Assistance Act of 1996, which began with a grass-roots effort by family members impacted by major aviation accidents in the mid 1990s, has had a profound effect on improving the services and information families are provided following major aviation accidents in the US. Similar rail passenger legislation was passed in 2008.

The implementation of family assistance continues around the world. Last year, with the urging of aviation accident family member organizations from around the world, the International Civil Aviation Organization passed a policy document promoting the humanitarian support that countries and operators should undertake to effectively support family members and survivors after aviation accidents. Nations including Japan, Brazil, China, South Korea, and Australia, and the countries of the European Union have crafted aviation family assistance legislation that ensures appropriate support for families and survivors. Family members who suffered through poorly coordinated accident responses in the past have worked to pay their efforts forward to other families they will never know—the ultimate act of compassion.

Transportation systems move people so that they can conduct business, enjoy a holiday, or spend time with loved ones. When an accident happens, the impact is often measured by the human element. The resulting individual suffering, although sometimes played out publically, is very private. Family members who bravely step out of their private suffering to honor their loved ones are truly acting out of love for all of us.

Paul Sledzik is the Chief of the Transportation Disaster Assistance Division