Commemorating Air Crash Victims and Honoring Families, Every Day

By Elias Kontanis, Chief, Transportation Disaster Assistance Division

Last year, for the first time, the international aviation community observed February 20th as the International Day Commemorating Air Crash Victims and Families. This year, on the second annual observance, we join in reflecting on the lives lost in aviation accidents as well as on the vigilance needed to ensure safety remains the priority in aviation.

As important as it is to commemorate, it is imperative that we also commit—commit to ensuring our programs effectively address the concerns of accident survivors and families and provide the information and support needed after tragedy happens.

The NTSB conducts its investigations with the goal of preventing future accidents. We do this work so that no other families must experience the painful loss or injury of loved ones due to transportation accidents. Our objective is, first and foremost, accident prevention. We maintain a steadfast commitment to this because we believe that the only acceptable number of deaths and serious injuries in all modes of transportation is zero.

With our commitment to transportation safety, we also have a commitment to support families by offering information about the NTSB’s investigative process, addressing their questions about the specific accident investigation involving their loved ones, and offering information about other services that may be available. The NTSB’s family assistance team does this every day, not only for aviation accidents but for all transportation accidents involving fatalities investigated by the NTSB. In 2022, our seven-member team provided support for 868 investigations, interacting with 3,480 accident survivors and family members.

The NTSB’s commitment to supporting transportation accident survivors and their family members is long-standing, spanning over 25 years. In that time, we have established some basic yet enduring principles:

• An independent and transparent safety investigation, with a focus on enhancing safety and not assigning blame or liability, is essential to the success of family assistance. Transparency and honesty fosters confidence.
• Rapport and credibility must be established with family members by communicating realistic expectations about the investigation and other aspects of the response. This includes clearly and appropriately communicating limits to the information and services available.
• A well-designed family assistance plan should be flexible and scalable. Rigid constructs break when they encounter an unanticipated force, but when the plan is flexible, it will bend and spring back to its original form when a stressor is applied.
• The entity responsible for coordinating the response should use a unified command concept of operations, enabling organizations to work together without giving up authority, responsibility, or accountability.
• A comprehensive response requires collaboration from multiple government agencies and nongovernmental organizations. Participating entities should focus on the fundamental concerns of families within the boundaries of their mandate and capabilities.

The International Civil Aviation Organization (ICAO) has spearheaded several initiatives to promote these principles among contracting states (that is, countries) by developing a 3-day course designed to provide governments, aircraft and airport operators, and other stakeholders the foundational knowledge to develop family assistance plans. Most recently, the European Civil Aviation Conference and the ICAO European and North Atlantic Regional Office have also jointly organized a workshop on assistance to aircraft accident victims and their families, which is scheduled for February 20, 2023, in Milan, Italy. This workshop will bring together representatives from several countries, family associations, and other stakeholders to share best practices.

Family assistance needs to be an organizational priority, ingrained in the culture and mindset of an entity engaging in this work. More than regulations, policies, standard operating procedures, or checklists, family assistance is about listening to and learning from those affected by disaster. Ultimately, family assistance is about caring for our fellow human beings and treating them with dignity and compassion, the same way we would expect to be treated when faced with an unexpected injury or loss of a loved one.

We stand with our international colleagues in honor of this solemn day, commemorating the lives lost and the families who faced such unimaginable tragedy, and we will not forget our commitments to them in the work we do.

Time for Action: Passenger Vessel Safety Can’t Wait

By Chair Jennifer Homendy

Three years ago, I launched with the NTSB Go Team to Santa Barbara, California, to investigate the deadliest U.S. marine accident in decades.

On September 2, 2019, the Conception dive boat caught fire in the early morning hours, burned to the waterline, and sank less than 100 feet from shore. Tragically, the 34 people asleep below deck in the bunkroom — 33 passengers and one crewmember — were trapped. None of them survived. 

A plaque to honor the 34 victims of the Conception dive boat tragedy on September 2, 2019, sits in Santa Barbara Harbor. Photo by Rafael Maldonado, News-Press

The Conception tragedy was my first marine investigation as an NTSB Board member. As I have previously shared, I am forever changed by the time we spent on scene—especially my time speaking with the victims’ families.

Unfortunately, they are not alone. Including the Conception, the NTSB has investigated seven passenger vessel accidents since 1999 that have claimed a total of 86 lives.

Eighty-six lives lost unnecessarily. Eighty-six people who’ve left behind bereaved families and friends.

Enough is enough.

It’s time for meaningful action to improve passenger vessel safety — and it starts with the U.S. Coast Guard (USCG).

Our Marine Safety Partner

The USCG is NTSB’s closest marine safety partner. Our relationship is an outstanding example of government collaboration focused on saving lives and improving safety.

It is no exaggeration to say that we could not carry out our marine safety mandate without the USCG. Every accident we investigate is supported in a variety of ways by the dedicated men and women of the USCG, and my sincere thanks goes out to every one of them.

Many NTSB marine safety recommendations are directed to the USCG because, as the industry’s regulator, they are best positioned to improve safety.

Improving passenger and fishing vessel safety is on the NTSB’s Most Wanted List of Transportation Safety Improvements (MWL).

Lessons from Tragedy

There are currently 21 open NTSB recommendations to the USCG focused on improving passenger vessel safety. “Open” status means the recipient of our safety recommendation has not, in the Board’s estimation, sufficiently addressed the safety risk.

That’s 21 unacted-upon opportunities to prevent further passenger vessel tragedies, like the Conception. 

Every day that an NTSB recommendation lingers as “open” is unacceptable. But, sometimes, we must measure inaction on our recommendations not in days, weeks, months, or even years.  That’s the case with several NTSB recommendations to the USCG.

Here are some of the safety gaps the USCG needs to address — all of which are on the MWL.

Fire Safety

The Conception is a heartbreaking example of the need for rigorous fire safety standards for small passenger vessels.  

We determined the probable cause of the accident was the failure of the operator, Truth Aquatics, to provide effective oversight of its vessel and crewmember operations. The lack of both oversight and adherence to certain safety requirements allowed the fire to grow undetected.

We also found that the lack of a USCG regulatory requirement for smoke detection in all accommodation spaces and inadequate emergency escape arrangements from the vessel’s bunkroom contributed to the undetected growth of the fire and the high loss of life.

As a result of our investigation, we issued 7 new safety recommendations to the USCG and reiterated a prior recommendation calling on the USCG to require safety management systems (SMS) on U.S.‑flag passenger vessels.

The Conception disaster was so compelling that Congress felt our safety recommendations needed to be codified into law. Legislators mandated the USCG implement our recommendations in the Elijah E. Cummings Coast Guard Authorization Act of 2020 as part of the National Defense Authorization Act.

The USCG took an important step to carry out this congressional mandate by issuing an interim rule, most of which took effect in March of this year. We look forward to the final rule implementing our recommendations.

Until then, our recommendations from the Conception investigation remain open. 

Safety Management Systems

The second safety issue involves SMS: a comprehensive, documented system to enhance safety. They’re so effective that the NTSB has recommended SMSs in all modes of transportation.

For nearly two decades, we’ve called for SMS on passenger vessels. This call to action is on the MWL, which is our single most important tool to increase awareness of important needed safety improvements.

The first time we issued a marine SMS recommendation was due to the October 15, 2003, ferry accident involving the Andrew J. Barberi. The vessel struck a maintenance pier at the Staten Island Ferry terminal, killing 11 passengers and injuring 70 others. We issued a recommendation to the USCG to “seek legislative authority to require all U.S.-flag ferry operators to implement SMS.”

Congress granted the necessary authority in 2010 — but the Coast Guard still didn’t act.

We then investigated a second accident involving the Andrew J. Barberi. This time, the ferry struck the St. George terminal on May 8, 2010, resulting in three serious injuries and 47 minor injuries.

Between the 2003 and 2010 accidents, the New York City Department of Transportation Ferry Division had implemented an SMS. Based on differences between crew actions in the two accidents, we concluded that the SMS benefitted passenger safety.

But the USCG still didn’t act on our SMS recommendation.

Several more accidents followed — in all of these, we determined an SMS would have either prevented the accident or reduced the number of deaths and injuries:

• In 2013, the Seastreak Wall Street hit a pier in Manhattan, seriously injuring four passengers; 75 passengers and one deckhand sustained minor injuries.
• In 2018, a fire aboard the small passenger vessel Island Lady killed one passenger and injured 14 others.
• In 2019, the Conception tragedy claimed 34 lives.

The USCG initiated steps in January 2021 to implement our SMS recommendation by publishing an Advanced Notice of Proposed Rulemaking (ANPRM). In the ANPRM, the Coast Guard discussed that the NTSB “has identified issues associated with failed safety management and oversight as the probable cause or a contributing factor in some of the most serious casualties involving U.S. passenger vessels.”

That was over 18 months ago. We’ve been calling for such a requirement for almost 20 years. We will persist for as long as it takes.

I look forward to working with Admiral Linda Fagan in her new role as Commandant and call on the USCG to prioritize the rulemaking in the weeks and months ahead.

The Work Ahead

When it comes to safety, time is of the essence. That’s why we fight so hard for NTSB recommendations: to improve passenger vessel safety and save lives.

On the third anniversary of the Conception disaster, I’m calling on the USCG to act on the 21 open NTSB passenger vessel recommendations.

Doing so can’t undo past tragedy — but it can prevent similar suffering for other families.

I can think of no better way to honor the memory of the 34 Conception victims, whose loved ones we hold in our hearts today.

February 20: International Day Commemorating Air Crash Victims and Families

By Elias Kontanis, Chief, NTSB Transportation Disaster Assistance Division

This year, the International Civil Aviation Organization (ICAO) designated February 20 the International Day Commemorating Air Crash Victims and Families. Although ICAO has addressed various aspects of family assistance for decades, this is the first time a day has been set aside to remember and honor all who lost their lives in air disasters and their families.

ICAO’s interest in family assistance dates to 1976, with the inclusion of a recommended practice in Annex 13, the document that outlines standards and recommended practices for accident investigations. The following is a brief timeline of significant ICAO activities related to family assistance.

• 1976: Contracting States (that is, countries) whose citizens are involved in a crash are granted access to information about the crash investigation and play a direct role in identifying their citizens. This recommended practice was strengthened to a standard in 2001.
• 1998: The ICAO Assembly acknowledges that “the policy of the ICAO should be to ensure that the mental, physical and spiritual well-being of victims involved in civil aviation accidents and their families are considered and accommodated by ICAO and its Contracting States.”[1]
• 2001: In response to Assembly Resolution A32-7, ICAO issues Circ 285, “Guidance on Assistance to Aircraft Accident Victims and their Families,” a keystone document for countries interested in developing family assistance programs. Circ 285 provides guidance on the various aspects of a comprehensive family assistance operation.
• 2005: Provisions are included in Annex 9, “Facilitation,” to enable victims’ family members to expeditiously enter the State in which the accident occurred. Additional provisions address repatriation of remains and emergency travel documents for family members and accident survivors.
• 2013: ICAO issues Doc 9998, “ICAO Policy on Assistance to Aircraft Accident Victims and Their Families,” and Doc 9973, “Manual on Assistance to Aircraft Accident Victims and Their Families.”
• 2015: Annex 9 is further amended with Recommended Practice 8.46, which encourages Contracting States to establish legislation, regulations, and/or policies in support of assistance to aircraft accident victims and their families.
• 2021: ICAO convenes its first International Symposium on Assistance to Aircraft Accident Victims and Their Families. This 3-day event, hosted by the governments of Spain and the Canary Islands, provides an opportunity for participants to share best practices and lessons learned to support the development of family assistance programs. NTSB Chair Jennifer Homendy and I were honored to participate as guest speakers at this important event.
• 2021: ICAO’s Global Aviation Training Section begins developing a 3-day course designed to provide Contracting States, as well as aircraft and airport operators, the foundational knowledge to develop family assistance plans. The NTSB is a proud partner in this effort.
• 2021: ICAO proposes elevating Recommended Practice 8.46 to a standard and developing a new recommended practice encouraging aircraft and airport operators to develop family assistance plans. Again, the United States stands with a significant number of other States in support of this initiative.

Through the Aviation Disaster Family Assistance Act of 1996, the United States committed to addressing the needs of passengers’ families following an aviation disaster. This commitment continues to grow. Today, the NTSB is the lead federal agency responsible for coordinating federal resources to support the families of air crash victims, as well as the victims of any other transportation disaster the NTSB investigates.

As family assistance specialists, my team and I work every day with the families of those lost in transportation crashes, trying to shed what light we can during some of their darkest days. We provide information during a time of uncertainty, address questions, and facilitate access to services that help loved ones navigate the loss they have suffered.

We have this charge in common with family assistance specialists all around the world, and we work collaboratively with international colleagues to enhance family assistance programs worldwide. We offer representatives of ICAO Contracting States seats in our family assistance course to help them develop or enhance their family assistance programs. We deliver presentations and participate in discussion panels overseas on family assistance, and we assist ICAO in developing its 3-day family assistance course.

Over the decades, the strength of survivors and victims’ families has humbled us. We have seen them organize not only to support each other through the grieving process, but also to advocate for change to enhance transportation safety so that others never have to face the same kind of loss.

We at the NTSB stand alongside our international colleagues in honoring the International Day Commemorating Air Crash Victims and Families. No traveler likes to ponder the possibility, however remote, that a flight will crash. But, if the unthinkable happens, the NTSB and our counterparts around the globe are dedicated to supporting crash survivors and family members.

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[1] International Civil Aviation Organization. Assembly Resolution A32-7. Resolutions Adopted at the 32nd Session of the Assembly. Montreal, Quebec; Sept. 22–Oct. 2, 1998.

Two-years Later: Conception Tragedy Still a Reminder that More Should Be Done to Improve Passenger Vessel Safety

By Chair Jennifer Homendy

Two years ago today, a preventable tragedy became one of the worst maritime events in US history.

At about 3:14 a.m. on September 2, 2019, the U.S. Coast Guard (USCG) received a distress call from the Conception, a 75-foot-long small passenger vessel operated by Truth Aquatics, Inc.

Preaccident photograph of the Conception (Source: http://www.seawaysboats.net)

The Labor Day fire began in the early morning hours, as five crewmembers slept in their upper-deck crew berthing. Two decks below, thirty-three passengers and one crewmember slept in the bunkroom. A crewmember on the upper deck, awakened by a noise, noticed a glow from the aft main deck and alerted the remaining four crewmembers that there was a fire on board. Then the captain radioed the 3:14 a.m. distress message to the USCG before evacuating the smoke-filled wheelhouse.

Crewmembers tried to get to the bunk room through the main deck salon but were blocked by fire and smoke. Unable to reach the bunkroom, they jumped overboard. Two of them re-boarded the vessel at its stern but were once again blocked by smoke and fire. Ultimately, the five crewmembers who had been sleeping on the upper deck survived. Two were treated for injuries. But tragically, the 33 passengers and one crewmember who had been asleep below deck in the bunkroom lost their lives in the fire.

Small passenger vessel Conception at sunrise prior to sinking (Source: VCFD)

Along with a multidisciplinary NTSB team, including marine safety investigators and specialists from the NTSB Transportation Disaster Assistance (TDA) and Media Relations divisions, I launched to my first maritime investigation as a Board Member. During my time on-scene, I met with the families of those on-board the vessel and gave them the only promise we at NTSB have to give, that we would find out what caused the fire aboard the Conception, in hopes of finding ways to prevent similar suffering for other families.

Our investigators, along with the USCG, the Federal Bureau of Investigation (FBI), and the Bureau of Alcohol, Tobacco, Firearms and Explosives (ATF) were carefully recovering wreckage. They examined a similar vessel to help learn how it was built, and how escape might have been thwarted for so many. While we conducted our safety investigation, a parallel criminal investigation was underway.

Yet despite difficult circumstances and the limited evidence left after the fire, the NTSB was able to identify critical safety issues, determine the probable cause, and make important safety recommendations. If implemented, these recommendations will help prevent a similar tragedy from happening again.

NTSB investigators found that the Conception had no smoke detectors anywhere in the main deck salon where the fire likely started. But incredibly, there are no passenger vessel regulations requiring smoke detection in all accommodation spaces. The vessel was also required to have a roving patrol to guard against and raise alarm in case of a fire or other emergencies, but there was no evidence that such a safeguard was in place, and the USCG has difficulty enforcing such an important requirement aboard small passenger vessels.

Furthermore, small passenger vessel construction regulations for means of escape did not ensure that both escape paths from the sleeping compartment exited to different spaces. On the Conception, the only emergency routes from the passenger accommodations exited into the same space, which was fully engulfed in fire.

Finally, our investigation highlighted yet another company with ineffective safety oversight. When the Board met to deliberate the report on the tragedy on October 20, 2020, we determined that the probable cause of the fire on board the small passenger vessel Conception was the failure of Truth Aquatics, Inc., to provide effective oversight of its vessel and crewmember operations, including requirements to ensure that a roving patrol was maintained, which allowed a fire of unknown cause to grow, undetected, in the vicinity of the aft salon on the main deck. Contributing to the undetected growth of the fire was the lack of a USCG regulatory requirement for smoke detection in all accommodation spaces. Contributing to the high loss of life were the inadequate emergency escape arrangements from the vessel’s bunkroom, as both exited into a compartment that was engulfed in fire, thereby preventing escape.

The NTSB reiterated its Safety Recommendation (M-12-3) to the USCG to require all operators of U.S.-flag passenger vessels to implement safety management systems (SMS) considering the characteristics, methods of operation, and nature of service of these vessels, and, with respect to ferries, the sizes of the ferry systems within which the vessels operate. An SMS is an enormously powerful tool which helps a safety critical company identify hazards and mitigate risks.

Additionally, we issued seven new safety recommendations to the USCG to:

• require new and existing small passenger vessels to be equipped with smoke detectors in all accommodation spaces, which are interconnected so that when one detector alarms, the remaining detectors also alarm.
• develop and implement inspection procedures to ensure vessel operators are conducting roving patrols when required.
• require a secondary means of escape into different exits from overnight accommodations that emerge into different spaces than the primary exit, and that those routes are not obstructed.

While these regulatory changes may take time, the NTSB also recommended that industry groups such as the Passenger Vessel Association act voluntarily to install smoke detectors and improve emergency egress routes. Finally, we recommended that the company that operated the Conception implement an SMS to improve safety practices and minimize risk.

The Conception investigation report is an excellent example of the NTSB’s ability to complete investigations in a timely manner, resulting in effective common-sense safety recommendations. It is now up to the USCG and industry to make these essential changes to improve safety and prevent the horrendous loss of life we saw two years ago on Labor Day weekend. The NTSB added Improve Passenger and Fishing Vessel Safety to its Most Wanted List in 2021 and will actively advocate to ensure these safety recommendations are implemented.

We Can Do Big Things. Just Look at Positive Train Control

By Member Jennifer Homendy

After 50 years of investigation, advocacy, and persistence by the NTSB, positive train control (PTC) is now a reality across the country!

This video highlights the NTSB’s more than 50 year effort in investigating PTC-preventable accidents and advocacy for this life-saving technology.

PTC systems use GPS and other technology to prevent certain train collisions and derailments. It could have been lifesaving in the 154 rail accidents that have killed more than 300 people, and injured more than 6,800 passengers, crewmembers, and track workers in major accidents stretching across the nation, from Darien, Connecticut, in 1969, to Chatsworth, California, in 2008, to Philadelphia, Pennsylvania, in 2015, and DuPont, Washington, in 2017.

But let’s step back and marvel at this real achievement—and the effort it took. Safety improvements are never easy or quick. It took more than 50 years of advocacy by the NTSB and historic action by Congress to make PTC a reality. For many of these years, the NTSB was a lonely voice for safety, pushing for PTC despite opposition from railroads over the price tag and technological hurdles.

I know how tough the battle was because I was there. As staff director for the House subcommittee charged with overseeing rail safety, I played a role in ensuring that any effort to move legislation forward to improve rail safety included the NTSB’s recommendation to implement PTC. When I got to the NTSB, one of my priorities was to ensure that mandate was implemented.

It truly is remarkable in Washington to keep such clear focus on PTC across so many administrations, through so many changes in Congress and at the NTSB.

Earlier this month, I had the honor of moderating a panel of current and former NTSB leaders and staff who recalled the long, bumpy road to PTC implementation. NTSB Chairman Robert Sumwalt and former agency heads Chris Hart, Debbie Hersman, and Jim Hall recalled their own contributions and noted how remarkable the agency’s sheer persistence was in a time of short attention spans and quickly changing priorities.

It was so uplifting to hear their personal reflections of their time on the Board fighting for PTC, and their continued commitment to the agency and its critical safety mission. But it was the staff panel that really defined persistence. Generations of rail investigators and other staff worked every one of the 154 PTC-preventable accidents over the decades, launching to horrific crash scenes only to discover similarities pointing to the same solution: PTC. They spent holidays working. Missed birthdays and anniversaries. Completed their important jobs regardless of on-scene obstacles and personal priorities.

Recording of the January 14, 2021, NTSB live‑streamed discussion about Positive Train Control implementation.

The public doesn’t often see what goes on behind the scenes at accident investigations, after investigations are completed when recommendations need to be implemented, and the tremendous work required to keep those recommendations at the forefront of discussions to improve safety. As stated in the first panel, board members come and go, but it’s the staff that keep these critical safety issues alive. It was truly remarkable and heartwarming to hear their reflections of the agency’s work and how that work has impacted public safety, as well as how it affected them personally. I hope it gave the public a sense of what it takes to stay focused on an issue for five full decades.

Was it worth it? You bet. PTC will save lives.

Other safety improvements have also taken many years to implement. Midair collisions were dramatically reduced by the Traffic Alert and Collision Avoidance System (TCAS). That took decades to put in place. Airliner fuel-tank inerting systems, which addressed fuel tank explosions like the one that brought down TWA Flight 800 in 1996, also took years. And let’s not forget about the long fight for airbags and seat belts in passenger vehicles. All these transportation safety improvements were strongly and relentlessly advocated for by the NTSB.

We can do big things in America. We can save more lives on our rails, in the sky, in communities where pipelines are located, on the water, and on the highway. But major safety improvements like PTC take time, money and, perhaps most of all, incredible perseverance.