Category Archives: Infrastructure

A New Year’s Resolution We All Can Make: Prioritize Safety

By Nicholas Worrell, Chief, NTSB Safety Advocacy Division

As 2021 ends, it’s time to reflect on the past 12 months and begin to set goals for the year ahead. After all, as Zig Ziglar once said, “if you aim at nothing, you will hit it every time.” So, let us all aim to improve the safety of our transportation system in 2022.

The NTSB recognizes the need for improvements in all modes of transportation–on the roads, rails, waterways, pipelines, and in the sky. Our 2021–2022 NTSB Most Wanted List of Transportation Safety Improvements (MWL), released in April this year, highlights the transportation safety improvements we believe are needed now to prevent accidents and crashes, reduce injuries, and save lives. We use the list to focus our advocacy efforts and to serve as an important call to action. We ask lawmakers, industry, advocacy, community organizations, and the traveling public to act and champion safety.

As a fellow safety advocate, I ask you to join me in a New Year’s resolution: I pledge to do my part to make transportation safer for all.

To help you take steps to accomplish this resolution, our MWL outlines actions you can take to make transportation safer:

  1. Require and Verify the Effectiveness of Safety Management Systems in all Revenue Passenger-Carrying Aviation Operations
  1. Install Crash-Resistant Recorders and Establish Flight Data Monitoring Programs
  1. Implement a Comprehensive Strategy to Eliminate Speeding-Related Crashes
  1. Protect Vulnerable Road Users through a Safe System Approach 
  1. Prevent Alcohol- and Other Drug-Impaired Driving
  1. Require Collision-Avoidance and Connected-Vehicle Technologies on all Vehicles
  1. Eliminate Distracted Driving
  1. Improve Passenger and Fishing Vessel Safety
  1. Improve Pipeline Leak Detection and Mitigation
  1. Improve Rail Worker Safety

Achieving these improvements is possible; otherwise, they wouldn’t be on our list. The NTSB MWL includes tangible changes and solutions that will, undoubtedly, save lives. But it’s only words on a list if no action is taken. Unlike Times Square on New Year’s Eve, we cannot drop the ball on improvements to transportation safety. The clock is ticking, and the countdown has begun—we can’t afford to waste any more time. Make the resolution to do your part to make transportation safer for all!

In closing, I’d like to thank the transportation safety stakeholders, industry, lawmakers, and advocates we have worked with in 2021 and we look forward to working together in 2022 and beyond.

World Day of Remembrance for Road Traffic Victims

By Chair Jennifer Homendy

November 21 is the World Day of Remembrance for Road Traffic Victims. It is a day to honor the 1.3 million lives lost each year around the world in motor vehicle crashes.

Today, I urge everyone to take a moment to remember all those who have lost loved ones in crashes, as millions have done around the world since 1995. Here in the United States, traffic deaths are up 18 percent over the first half of 2020. We are on pace to lose 40,000 Americans this year alone.

My thoughts are with all who have lost loved ones, but especially those I’ve met who lost loved ones in crashes that the NTSB has investigated, and the survivor advocates I’ve gotten to know over the years.

We need to remember these numbers are people from our communities. They are lives lost: mothers, fathers, or children suddenly, permanently gone; brothers and sisters absent from holiday gatherings; friends missing from a baby shower. We record our losses in data tables, but we feel them at the dinner table, and in the graduations, weddings, and birthdays never celebrated.

At a November 10 virtual roundtable on the need for our nation to transition to a Safe System approach, I called for a moment of silence in advance of the World Day of Remembrance. I said then that, for the NTSB, the toughest part of our job is facing family members after a tragedy, explaining that their loved one’s death was 100 percent preventable and that we’ve issued recommendations which, if acted upon, would have prevented the crash and the loss of their loved one.

Then I said that we need a paradigm shift in how we address this ever-growing public health crisis.

For 26 years now, the world has memorialized the victims of motor vehicle crashes, and we have been right to remember them. No loss should be forgotten. But these are unnecessary losses. They must not be remembered only in words.

They deserve and demand action now.

They demand to be remembered with road treatments, traffic calming measures, engineering speed assessments, road safety laws, and other investments that will result in safe roads and safe speeds on those roads.

They demand to be remembered with the manufacture of safe vehicles that should come standard with better technology for avoiding collisions, including collisions with pedestrians, bicyclists, and motorcyclists.

They must be remembered with vehicle sizes and shapes that are less likely to result in the pedestrian and bicyclist deaths that we have seen so often.

They demand to be remembered with ignition interlocks for all impaired drivers, in the development of in-vehicle alcohol detection technology, and in fair and just traffic law enforcement.

They demand to be memorialized with increased investments in alternative modes of transportation, like public transit, which will reduce crashes on our roads, in newly changed laws to improve road safety, and in the enforcement of existing laws.

But most of all, these victims should be remembered as what they were: flesh and blood. Human. Vulnerable.

Put that image at the center of all the other aspects of our roads, and you’ll see the road as we must in order to finally make it safe. Don’t think of numbers, think of people. Put them at the center of every decision about our road system. That’s the paradigm shift that we need—to make our many layers of traffic hazards into layers of traffic protection, so that when crashes happen, nobody pays for it with their life.

This Day of Remembrance, let’s remember that the candle we light to remember victims is more than just a memorial; it’s a light showing the way to a safer tomorrow.

San Bruno Victims and Their Families Deserve Long-Overdue Action

By Member Jennifer Homendy

Today marks 10 years since the devastating natural gas pipeline rupture that shattered a residential neighborhood in San Bruno, California. The September 9, 2010, explosion destroyed 38 homes and damaged 70 others. Even worse, 8 people were killed, 10 people sustained serious injuries, and many others suffered minor injuries.

The Accident

When I think of San Bruno, I struggle with the ‘right’ words to describe the horrific events that unfolded shortly after 6:00 p.m.—a time when many families across our nation are just sitting down for dinner.

In the moments after the rupture, calls flooded into 911, with reports of what many thought was a plane crash, a gas station explosion, or some combination of the two. One caller said it felt like an earthquake, and a fire captain who was on scene said, “It looked like Armageddon.” In fact, the rupture was so explosive that it produced a crater about 72 feet long by 26 feet wide and launched a 28-foot section of failed pipe about 100 feet south of the crater. The released gas almost immediately ignited. Emergency responders arrived within minutes to battle the ensuing inferno, yet it took Pacific Gas & Electric (PG&E) an astonishing 95 minutes to shut off the flow of gas that was intensifying the destruction. Firefighting efforts continued for 2 days, with 600 firefighters and 325 law enforcement personnel on scene.  

San Bruno, CA, accident scene with the crater in the foreground and the ruptured pipe section in the background
San Bruno, CA, accident scene with the crater in the foreground and the ruptured pipe section in the background

NTSB Warnings

I’m not going to get into the numerous failures at PG&E that led to the rupture. I want to focus on those 95 minutes. In December 1970, the NTSB released a Special Study of Effects of Delay in Shutting Down Failed Pipeline Systems and Methods of Providing Rapid Shutdown. You read that right—1970. We found that delays in shutting down pipelines increase the magnitude of catastrophe, and that, when the flow of gas or hazardous liquid is stopped soon after an initial rupture, the effects of many accidents would have been minimized or eliminated. In other words, numerous lives could’ve been saved, and injuries prevented.

Our report highlighted the 1968 rupture of a medium-pressure gas line in front of a daycare in Hapeville, Georgia. Construction crews on scene were unable to locate the buried valve to shut off the gas flow. A few minutes later, an explosion occurred inside the daycare. The ensuing fire engulfed the building and nine people were killed, including seven children. Three other children were seriously injured.

Nine other incidents—all involving failures to shut down pipelines—were cited in the report, and many more have occurred since it was published. The common theme? What we said in 1970 held true in San Bruno and holds true today: “For every one of the accidents cited, there are devices or equipment currently available which probably could have prevented the accident or greatly minimized its effect.”

We’ve been urging federal regulators to require those devices for 50 years! In fact, they’re still on our Most Wanted List of transportation safety improvements.

The San Bruno Investigation

Getting back to San Bruno. In those crucial 95 minutes during which the gas continued to flow, PG&E control center staff knew there had been a rupture along the pipeline, but never once called 911. The three PG&E employees who first arrived on scene, two of whom were supervisors, had no idea how to operate mainline valves. They had to call people who were qualified to operate them, and by the time those mechanics located the valves and got to the first one, it was 7:20 p.m., over an hour after the rupture occurred. Meanwhile, the fire, described by NTSB investigators as a massive blowtorch, was still raging.

Because gas was being supplied to the break from both the north and the south, the shutoff valves closest to the break had to be closed to shut down and isolate the rupture. The shutoff valves were located about 1.5 miles apart, on either end of the break, and they had to be shut manually. Had PG&E installed readily available technology—valves with remote closure capability or ones that would automatically shut off the gas flow in response to pressure changes in the line—the amount of time the fire burned, and thus, the severity of the accident, could’ve been significantly reduced. In fact, this technology could’ve stopped the flow of gas the moment the rupture was detected.

In our final report on the accident, we recommended that federal regulators—the Pipeline and Hazardous Materials Safety Administration (PHMSA)—require  pipeline companies to install automatic shutoff valves or remote shutoff valves in High Consequence Areas (defined as populated areas, drinking water sources, and unusually sensitive ecological areas).

PHMSA’s Response

On February 6, 2020, PHMSA published a notice of proposed rulemaking (NPRM), “Pipeline Safety: Valve Installation and Minimum Rupture Detection Standards,” claiming the NPRM responds to recommendations from the NTSB. It doesn’t. It requires automatic shutoff valves, remote-control valves, or equivalent technology to be installed only on newly constructed or entirely replaced onshore natural gas transmission and hazardous liquid pipelines that are larger than 6 inches in diameter.

Remember the daycare accident I mentioned? The pipeline that ruptured in that tragedy was only 1 inch in diameter. Existing gas transmission lines (like the PG&E line that ruptured in San Bruno), newly constructed or entirely replaced lines that are less than 6 inches in diameter, gas distribution systems, and offshore transmission lines are completely excluded from the NPRM’s requirements.

In other words, PHMSA’s solution won’t prevent another San Bruno disaster. Given that there are 2.6 million miles of gas pipelines in the United States, most of which date back to the 1950s and the NPRM doesn’t address any of them. With those numbers, another tragic accident is destined to occur, and if I’m the member on scene—or even if I’m not—I’ll remind PHMSA and industry, yet again, of all the ruptures we’ve investigated and all the opportunities they had to save lives.

To all those who lost loved ones in San Bruno or in another pipeline tragedy, you remain in our hearts. We are still fighting for you.

A Comprehensive Approach to Bicycle Safety

By Member Jennifer Homendy

Last fall, the National Transportation Safety Board released a report that made safety recommendations meant to improve safety for an important and growing segment of users on our roadways – bicyclists. The report issued 12 new safety recommendations and reiterated 10 safety recommendations.

Through NTSB’s 50+ years of accident investigation experience, we’ve long known that complex challenges, like reducing the number of vehicle-bicycle collisions, requires multi-faceted solutions. In the study, we looked at numerous countermeasures, including roadway design and infrastructure, reducing traffic speeds, collision avoidance systems and blind spot detection systems.

Homendy-bikePerhaps that is why I was disappointed to see the controversy within the cycling community surrounding one of the 22 recommendations discussed in the report – the singular recommendation about requiring the use of helmets. That debate overshadowed the many other important recommendations that largely focused on preventing collisions between vehicles and bicyclists in the first place, rather than mitigating their severity. As an avid cyclist myself, I am very aware of the hazards that exist for cyclists and share the community’s concern for improving bicycle safety on U.S. roadways.

Separated bike lanes and bike-friendly intersections are incorporated in the design of just a tiny fraction of U.S. roadways. So, we asked for more. The NTSB recommended that guidance provided to highway engineers, city planners and traffic designers, include resources that will help increase bike-friendly roadway improvements throughout the U.S.

Along with changes in infrastructure, the NTSB found that reducing traffic speeds can reduce the likelihood of fatal or serious bicycle injuries. Lowering speed limits is part of a safe systems approach that was also discussed in our 2017 safety study on reducing speeding-related crashes.

Collision avoidance systems are broadly effective in helping motorists detect and avoid other vehicles and some automakers have begun adding systems to detect bicyclists and pedestrians.  To encourage manufacturers to include these systems in their new vehicles, and to assist auto buyers in making safety-conscious purchasing decisions, the NTSB recommended that bicycle detection systems be incorporated into the 5-Star Safety Ratings.

The NTSB also recommended that newly manufactured large trucks be equipped with blind spot detection systems, because large vehicles have bigger blind spots that make it difficult, or even impossible, in some situations for their drivers to see bicyclists.

And as a Board Member, I will continue to push for the implementation of safety recommendations on the NTSB’s Most Wanted List that would help make streets safer for bicyclists – including eliminating distractions, reducing fatigue-related accidents, ending alcohol and other drug impairment, increasing implementation of collision avoidance systems and reducing speed-related crashes.

Member Homendy Bike Safety Study Board Meeting

Implementation of our recommendations would dramatically improve the safety of our roadways for bicyclists. But prevention or avoidance will sometimes fail and mitigating the severity of crashes will help save lives. That basic premise of transportation safety, supported by data on fatalities from head injuries, prompted our call for helmets for bicyclists.

The NTSB’s approach to bicyclist safety is comprehensive, multi-faceted and fact-based. All the safety recommendations, when implemented, would help save lives by preventing collisions from happening, and by reducing the severity of those that do.

Most Wanted List Progress Report: Rail Safety

By: Chairman Robert L. Sumwalt

 The NTSB is releasing a series of blogs highlighting the progress the transportation community is making in each mode to advance issues on our 2017–2018 Most Wanted List. This series sheds light on the progress made and what needs to be done going forward to improve transportation safety. This is the fourth and final blog of the series.

DSC02887
Chairman Sumwalt and Robert Hall, Director, NTSB Office of Railroad, Pipeline and Hazardous Materials Investigations talk with attendees at the Most Wanted List midpoint meeting

On November 14, 2017, the day before our Most Wanted List (MWL) progress meeting, we concluded our investigation into the April 2016 Amtrak train derailment in Chester, Pennsylvania. As I offer the closing words of this blog series highlighting the progress made  to address issues on our list, the NTSB is presently investigating the December 2017 Amtrak train derailment in DuPont, Washington, and the February 2018 Amtrak train and CSX freight train collision near Cayce, South Carolina. And, on February 15, I testified before the US Congress regarding the urgency for the industry to fully implement positive train control (PTC) by year’s end. That same day, we also issued three urgent safety recommendations to address findings from our investigations into the Cayce accident and the June 2017 Long Island Rail Road accident in Queens Village, New York.

At our midpoint meeting, I joined members from our Office of Rail, Pipeline, and Hazardous Materials Investigations to lead a discussion on rail safety. While there has been progress with implementing some of the NTSB’s recommendations, the Chester and DuPont derailments and the Cayce collision tragically illustrate that more needs to be done – and quickly!

A deficient safety management system and impairment were factors in the fatal Chester accident. And, like many accidents we’ve investigated, distraction played a role. When the accident occurred, the dispatcher was speaking to his spouse on a landline. We’ve recommended that Amtrak prohibit such calls while dispatchers are on duty and responsible for safe train operations.

The Chester accident also illustrated the fact that drug use by rail workers has been on the rise in recent years, playing a part in seven accidents in the last 3 years and nine accidents in the last decade, compared to only one accident in the prior decade. In the Chester accident, a backhoe operator who was killed had cocaine in his system, and two different opioids were discovered in the track supervisor’s system. During our investigation, the Federal Railroad Administration (FRA) moved quickly to require random urine drug screening for maintenance‑of‑way workers, effective April 2018. Additionally, the Amtrak locomotive engineer tested positive for marijuana, although there was no operational evidence that his prior drug use impaired his performance on the morning of the accident. What it did show, however, is that despite DOT random drug testing requirements for locomotive engineers, such a program did not deter his use of an illicit drug.

Fatigue and medical fitness are other significant MWL issues for rail, and we’re disappointed that the FRA and the Federal Motor Carrier Safety Administration have withdrawn an advanced notice of proposed rulemaking that would’ve supported sleep apnea screening for railroads and for commercial highway carriers. Clearly, there’s still important work to do on these issues.

Regarding another significant MWL issue for rail, strengthen occupant protection, the FRA has made progress toward developing a performance standard for keeping window glazing in place during an accident. Unfortunately, meaningful improvements related to the safety of corner posts, door designs, restraint systems, and locomotive cab crashworthiness have been slow.

The MWL’s safe transport of hazardous materials issue area focuses on transporting energy products in safer tank cars, built to the DOT-117 rather than DOT-111 and CPC 1232 standards. We are pleased to see that the more robust DOT-117 standard is being used for transport of crude oil. Ethanol transport, however, still widely relies on the DOT-111 and CPC 1232 standards. We urge stakeholders to move to using the DOT-117 standard when carrying ethanol as soon as possible, ahead of the mandated deadlines.

There has been little, if any, progress to improve transit safety oversight since we released the current MWL. To exercise effective oversight, the Federal Transit Administration (FTA) must continue to use the authority it gained with the Fixing America’s Surface Transportation Act and Moving Ahead for Progress in the 21st Century Act to promulgate safety rules.

Finally, on the issue of expanding recorder use, the industry is moving forward with installing inward-facing video cameras on passenger trains, which is a step in the right direction. However, we would like to see the FRA move forward on requiring the installation and that the requirement be expanded to include audio recording, and we believe that the freight rule should follow suit. The FTA still has no such requirements for transit rail.

As I offer the last thoughts on our MWL midpoint meeting blog series, I want to thank all those who attended for taking the time to offer suggestions and share their perspectives on the issues affecting the safety of our nation’s transportation system. As we move into the second year of this MWL cycle, I challenge our stakeholders to target one or more recommendations on which they can make measurable progress before this year is over. We all want to have the safest transportation in the world, and it will take us working together to accomplish it.