Category Archives: Family Assistance

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.

NTSB Supports ‘Safe Skies for Africa’ Program

By Dennis Jones, NTSB Managing Director

Last week, as part of the U.S. Department of Transportation’s Safe Skies for Africa program, I led a team of NTSB investigators and communications specialists to South Africa to share lessons we’ve learned from our accident investigations. The Safe Skies for Africa program, created 20 years ago, aims to improve the safety and security of aviation on the continent. Our team shared some NTSB strategies with our international counterparts to help them achieve similar outcomes in their region.

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Managing Director, Dennis Jones, talks with attendees at the Safe Skies Symposium in Johannesburg, SA

From my perspective, the Safe Skies program is working. After spending about 20 years in Africa participating in accident investigations, conducting workshops, helping improve accident investigation programs, and training investigators, I’ve seen increased commercial air service between the United States and Africa (for example, there are now US commercial flights to Africa, which wasn’t the case earlier in my career), improved investigation quality, and a reduced rate of accidents involving commercial aircraft.

On this trip, the NTSB team shared a variety of lessons learned from different disciplines. Dennis Hogenson, Western Pacific Region Deputy Regional Chief for Aviation Safety, pointed out that, like Africa, the United States is seeing a high incidence of general aviation (GA) crashes. He told his audience that, while airline accidents have become rare, GA accidents account for most aviation fatalities in the United States. We investigate about 1,500 GA accidents each year; those involving loss of control in flight still result in more than 100 fatalities annually. In many of our GA accident investigations, we’ve discovered that pilots didn’t have the adequate knowledge, skills, or recurrent training to fly safely, particularly in questionable weather conditions, and their inability to appropriately recover from stalls often resulted in deadly accidents. Dennis encouraged his African counterparts to initiate more training and increase awareness of technology, such as angle-of-attack indicators, that can help prevent these tragedies.

Bill Bramble, a human factors investigator, outlined our investigation process and explained how we examine all factors—machine, human, and environment—to understand an accident and make recommendations to prevent it from happening again. Bill highlighted several accidents we investigated in which human factors played a role. But even when a probable cause statement focuses on factors not normally associated with human performance, it’s impossible to totally remove humans from the accident chain.

“Humans designed it, built it, operated it, maintained it, managed it, and regulated it. Human factors are always involved in complex system failures,” Bramble said.

To prevent accidents and improve the safety of air travel in Africa, it’s important that operating aircraft are airworthy, meaning that all structure, systems, and engines are intact and maintained in accordance with the regulations. To emphasize this point, NTSB aerospace engineer, Clint Crookshanks presented a series of case studies discussing airworthiness issues and offered guidance on ways to classify damage to aircraft.

Chihoon “Chich” Shin, an NTSB aerospace engineer, addressed helicopter safety. The number of helicopter operations (emergency medical services, tourist, and law enforcement support) in Africa is increasing, and so is the number of helicopter accidents. Chich presented case studies and highlighted some important safety issues from an engineering perspective.

“The metal doesn’t lie,” Shin said. He called for increased awareness of the safety issues affecting helicopter safety and encouraged action from key stakeholders, such as regulatory agencies and helicopter manufacturers and operators, to help reduce accidents and fatalities. He also touted the importance of crash-resistant recording devices to help investigators determine what happened in a crash and work to prevent it from happening again.

NTSB communications staff emphasized another side of our work in transportation safety. Stephanie Matonek, a transportation disaster assistance specialist, discussed the importance of planning for family assistance after an accident occurs.

“Having a family assistance plan in place, identifying your family assistance partners, and addressing the fundamental concerns for families and survivors that cross all cultures is not only a crucial step but the right thing to do,” she said.

Nicholas Worrell, Chief of the Office of Safety Advocacy, addressed messaging, encouraging attendees to go beyond investigations to teach their safety lessons effectively. He encouraged investigators to raise awareness of the safety issues they uncover to spur action on their recommendations.

Aviation is a global business. Our mission is to make transportation safer the world over by conducting independent accident investigations and advocating for safety improvements. With outreach activities like the one we just completed in Africa, we hope to make aviation safer, not only in Africa, but throughout the world. After all, transportation safety is a global challenge. When safety wins, we all win.

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NTSB Managing Director and staff with symposium attendees

Act to End Distracted Driving: One Life at a Time

By Acting Chairman Robert L. Sumwalt

“Whoever saves one life, it is as if he has saved an entire world.”

On April 26, I found myself echoing this saying from the Talmud more than once at “Act to End Distracted Driving,” a roundtable hosted by the NTSB in collaboration with Stopdistractions.org, DRIVE SMART Virginia, and the National Safety Council. The roundtable brought together survivor advocates to facilitate more effective action on distracted driving.

It was a moving and insightful day, with participants expressing the impact that distracted driving has had on their lives and on the lives of their loved ones. Survivor advocates spoke about trying to give a voice to those who can no longer speak for themselves, turning their personal tragedies into effective advocacy efforts to prevent others from going through what they have gone through. Incredibly, many survivor advocates expressed frustration that they had not done enough. Here are some of the takeaways from the roundtable.

A club we don’t want to be in. Once one participant made this remark— “this is a club we don’t want to be in”—it resonated around the table. It also reverberated in a question another participant asked: “How many of you thought distracted driving would affect you before you lost someone?”

But this “club” exhibited incredible mutual support, gritty determination, and smart strategy, even as its members revisited their losses, relived their grief, and shared their stories.

From pain to passion. Survivor advocates recognized that they’d “taken pain and transformed it into passion and pushed their agenda [to end distracted driving].”

“Collaboration equals change,” another participant said. “Together, we can tackle this.”

“Branch out as an advocate,” one participant offered. “There are so many demographics to reach. It’s not just about speaking to teens.”

“Work with everyone. Life isn’t a guarantee—we don’t know when it will end. Enforcement is the biggest thing that should be pushed out.”

“Technology is advancing faster than laws are changing. Your story can change a life.”

“Never underestimate the power and impact we have on someone else’s life and the world we live in.”

From passion to action. Survivor advocates took their passion and turned it into action.

“Form a coalition. Find people in your state capitol, hometown, etc., that feel the same as you do on distracted driving. Don’t do it alone.”

“We are not alone. There are thousands of us. Stay the course. Celebrate successes. Rest, but stay the course.”

“[Understand the] critical importance of putting a face to the epidemic. Leverage supporters to end distracted driving. Advocates are critical to making an impact.”

“We have to work together. All are making a difference. Little by little, we are making progress.”

“Gain knowledge, meet people, to accomplish the goal to make change.”

“People make this program work. Stay in touch and work with folks and boots on the ground. Don’t take a 10,000-feet-level perspective.”

The power of stories.

“There is incredible power in telling stories. Stories can change the world. I will continue to tell my story and the stories of people I’ve met. I’m optimistic and I look forward to saving a whole bunch of lives.”

“Statistics tell, stories sell. Today has ‘sold’ my heart. Sharing stories defines a person’s character. Bad things will happen, but how you respond defines your character.”

“Your story is being heard. You’ve inspired me to reach beyond to influence others.”

We can all be advocates.

“We all have the potential within us to become advocates. Taking the message with us to our homes, towns, schools, etc., is the best way to honor the loved ones lost.”

“I never thought I would be sitting here. Now I’ve gotten my strength at looking at the grandchildren that were left behind. They have to grow up without their mother. So much information that has been shared . . . friends I’ve made will help me continue to make change.”

“I have a clear pathway to help families who experience loss from distracted driving. Children will emulate the behavior of their parents and other influencers in their lives. “

Impressions from the day.

“There is something bigger here than just what I can control. I’m going to expand my sphere of influence on how to make an impact on distracted driving.”

“United we stand, divided we fall. Don’t give up, we will end this fight.”

“[Today was] confirmation that I want to do this the rest of my life; to be an advocate and improve road safety.”

“[I’m] grateful to have the opportunity to be here, meet other advocates, learn more to continue the fight.”

If this could be you . . .

Everybody processes grief differently. But if you are a survivor who wants to be an advocate, or if you simply recognize that distracted driving requires a big change in our laws and culture, there is somewhere to turn. Advocates have worked together to form the National Alliance for Distraction Free Driving. On its website, you will find advocacy resources, templates for presentations, videos, and other tools contributed by many organizations working to turn the tide against deadly distractions.

As we concluded the roundtable, I said again, “‘Whoever saves one life, it is as if he has saved an entire world.’ You don’t have to save the world. All you need to do is keep one person from dying, and if you have done that, it is as if you have saved an entire world. Your work is important. You are making a difference. And you are saving lives.”

You, too, can make a difference and save lives. Next time someone calls you and you know they are driving, ask them to call back once they’re not behind the wheel. Next time you are with a driver who attempts to text, call, or post something on social media, politely ask them to stop. After all, we are all in this fight together.

ACT TO END DEADLY DISTRACTIONS

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By Acting Chairman Robert Sumwalt

Distracted driving kills, on average, nine people every day on our highways and injures even more. Every day, families are left to grieve the loss of a loved one killed in a highway crash, their lives suddenly in disarray. These preventable tragedies must stop. We must all do our part and take action so that families no longer lose loved ones to a preventable death.

Often, the families and friends left behind after a fatal car crash become survivor advocates, turning their tragedy into action. This week, we will be hosting some of these survivor advocates at our second distraction roundtable, Act to End Deadly Distractions. We will be teaming with Stopdistractions.org, DRIVE SMART Virginia, and the National Safety Council to host this discussion.

I’m excited to facilitate this event, which is designed to focus on survivor advocates’ experiences of what has worked and what hasn’t in their fight against distracted driving. Above all, this roundtable is designed to facilitate effective action. The survivor advocate community will be exploring ways to act in their own towns and states to “move the needle” toward zero distracted driving deaths.

Our first distraction roundtable brought together experts to dive into what we know and don’t know about the science of distraction. At that event one fact became clear: distracted driving is taking lives. According to one market research company, since 2007, the percentage of Americans ages 13 and older with smartphones went from 6% to more than 80%. Although there have always been distractions competing with our focus on driving, these devices are especially addictive and, despite what we tell ourselves, we cannot safely or effectively multitask. To turn the tide will take a change in culture, especially in attitudes about portable electronic devices.

Experience with other causes of highway deaths shows that the science alone will not be enough to stop tragedy. Nor will awareness efforts. Heightened awareness, the right laws and policies, and tough enforcement all must play a role. The NTSB often makes recommendations aimed at changing safety culture within a company or even within a whole industry. We have recommended that states pass legislation to ban drivers from nonemergency use of portable electronic devices. We can’t “recommend” a way to change the minds and behavior of a whole nation of drivers, so we’re facilitating a conversation among survivor advocates and experts in awareness campaigns and in state houses.

We hope that you’ll join us. The roundtable begins at 9:00 am, April 26, in the NTSB Board Room and Conference Center, 429 L’Enfant Plaza, SW, Washington, DC. The event is convenient to the L’Enfant Plaza Metro station. You can also watch the event live at http://ntsb.capitolconnection.org/ and comment via Twitter @NTSB using #Act2EndDD.