Category Archives: Infrastructure

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.

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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.

 

Most Wanted List Progress Report: Highway Safety

By Member T. Bella Dinh-Zarr, PhD, MPH, and Robert Molloy, PhD

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 second post of the series. 

 

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Member Dinh-Zarr talks with attendees during the highway session of the Most Wanted List midpoint meeting

We’re now midway through the 2017–2018 Most Wanted List cycle, and we’re eager to learn how this year will measure up to previous years. The past 2 years have resulted in an increase in highway traffic fatalities­­—from 32,000 roadway deaths per year in 2014 to more than 37,000 in 2016­­—so clearly, improvements are vital. We checked in with stakeholders on the progress they’re making to address the most pressing issues, and they’ve updated us on their successes and struggles. Here’s where we stand.

Install Collision Avoidance Technologies

Collision avoidance technologies can reduce the number of deaths and injuries on the nation’s roadways now. Today, automatic emergency braking (AEB) and forward collision warning systems already work to reduce rear-end crashes in equipped vehicles, and we’ve been working to encourage industry and vehicle manufacturers to adopt such systems. In 2017, we cohosted a roundtable with the National Safety Council on commercial vehicle (heavy-duty truck) use of advanced collision avoidance technologies and learned that truck manufacturers are beginning to see high customer demand for forward collision avoidance systems on their trucks. During the roundtable, one manufacturer indicated they were making the technologies standard on their trucks, while another mentioned that over 60 percent of their customers purchase vehicles with technology. In addition, the National Highway Traffic Safety Administration (NHTSA) is making progress on evaluation and testing collision avoidance technologies. We continue to advocate for connected vehicle technology because these technologies can further aid in collision avoidance, especially in situations where vehicle resident sensors are weak. Safety should never be considered a barrier to innovation, but rather, an integral component of it.

End Impairment in Transportation

In 2017, we saw progress on reducing alcohol impairment in transportation. Utah became the first state in the nation to pass a law setting a .05 percent blood alcohol content per se limit, and Nebraska and Oklahoma passed all-offender ignition interlock laws. The Federal Motor Carrier Safety Administration (FMCSA) published a final rule establishing the Commercial Driver’s License Drug and Alcohol Clearinghouse, and NHTSA developed training programs addressing the full range of responses to alcohol impairment, from enforcement through adjudication. Yet, we still need more states to strengthen their impaired driving laws and enforcement. We also need improved “place of last drink” (POLD) data to help law enforcement officers deter future violations, and we need better methods to measure impairment by drugs other than alcohol.

Require Medical Fitness, Reduce Fatigue-Related Accidents

In terms of medical fitness, we’ve criticized both the FMCSA and the Federal Railroad Administration because they have withdrawn their advance notice of proposed rulemaking regarding obstructive sleep apnea, which could have led to a rulemaking to address this important issue for people in safety-critical positions. In the highway mode, untreated moderate‑to-severe sleep apnea disqualifies drivers from operating large commercial vehicles because it affects driving safety, yet clear guidance is needed to assist medical examiners in identifying the condition. Nevertheless, the FMCSA has made notable progress by developing a National Registry of Certified Medical Examiners that lists all medical professionals who are qualified to certify drivers. This is a step in the right direction.

The FMCSA took another important step to improve safety when it implemented the electronic logging device (ELD) rule in December 2017. The rule requires the use of technology to automatically track driving and duty time. The NTSB advocated for such devices for many years because they enable better enforcement of hours-of-service regulations and can lead to reductions in drowsy driving among truck and bus drivers.

Eliminate Distractions

Our roundtable earlier this year, “Act to End Deadly Distractions,” brought together survivor advocates and experts throughout industry and government to discuss progress on state laws. We are beginning to see states consider legislation that would completely ban the use of hand-held devices, which highlight manual and visual distraction, but public awareness of the cognitive distraction that can result from hands-free device use remains very low.

Strengthen Occupant Protection

The good news this year on occupant protection is that motorcoaches are now built with lap and shoulder belts for all passenger seating positions. Now we’re focusing on all motorcoach passengers properly using those belts and using them every time they ride. We are urging primary enforcement of seat belt laws for all vehicles, including large buses equipped with belts, at every seating position, and we’re calling for safety briefings on motorcoaches similar to those delivered on commercial flights that explain seat belts and other safety features. As for passenger vehicles, some states, such as Massachusetts and New Hampshire, are considering joining the 34 states that already have primary enforcement of mandatory seat belt laws. Primary enforcement of mandatory seat belt laws is proven to increase seat belt use and, thereby, reduce the number of deaths and injuries on the roads. Regarding motorcycles, we are concerned that some states are repealing their helmet laws, because we know reduced helmet use will lead to more traumatic brain injuries and deaths.

Critical topics that touch on these highway safety issues are speeding and roadway infrastructure. Our recent safety study on speeding establishes what many of us already know but may not always apply: speeding increases the risk and severity of a crash. Here again, along with other safety recommendations, we’ve identified available technologies that can save lives but are not currently in use. The importance of infrastructure was highlighted recently by our highway accident report on a motorcoach collision that killed 2 people and injured 14 others. An unrepaired crash attenuator, an unmarked gore area, and out-of-compliance signage were cited in the report, in addition to the lack of seat belt use by most of the occupants.

Expand Recorder Use

Finally, we continue to urge all large highway vehicles be required to be equipped with recorders that capture a standard set of parameters. Event data recorders are vital investigative tools in every transportation mode—they help us do our job better and faster by providing valuable information after a crash so we can figure out what went wrong and make recommendations that prevent future injuries and deaths. Unfortunately, in crashes involving large trucks or buses, we are often left with limited data from the vehicle about the crash. We learn much more from passenger vehicles in crashes than from trucks and buses because of the standards NHTSA has developed (no such standards exist for trucks or buses). These standards are critical for large-vehicle operators, who can use recorders to train their drivers and increase safety.

The Most Wanted List midpoint mark allows us to reflect as well as plan and set new goals for the upcoming year. Although we have a long way to go to reach zero fatalities on our roadways, the efforts highlighted above, innovative partnerships and strategies, and bold actions to advance our recommendations are what we need to make America’s roadways fatality-free.

 

Dr. Robert Molloy is the Director of the NTSB’s Office of Highway Safety.

The Silver Bridge Collapse: Don’t Blame the Mothman!

 

By Don Karol

Rumor has it that, just before the December 15, 1967, collapse of the US Highway 35 Bridge in Point Pleasant, West Virginia, a 7-foot-tall monster with large, piercing red eyes and huge, mothlike wings was seen lurking nearby, warning of the impending catastrophe. This “Mothman” was soon blamed for the tragedy in which 46 people died and 9 were injured. Of the 37 vehicles on the bridge at the time of the collapse, 31 fell with it, many plunging into the Ohio River. Fifty years after the collapse of what was then known as the Silver Bridge, paranormal speculation still swirls around the event, perpetuated by movies (like the Mothman Prophecies), legends, and myths. As a civil engineer, though, I put my trust in the laws of physics, materials science, and the findings of the NTSB investigation completed five decades ago, which proved without a doubt that the Mothman wasn’t to blame.

Silver Bridge, Point Pleasant, West Virginia
Section of Silver Bridge, Point Pleasant, West Virginia, that collapsed on December 15, 1967 (source: Herald-Dispatch)

The Silver Bridge collapse was the first significant highway accident investigation in NTSB history. Working with experts from the Federal Highway Administration, the states of West Virginia and Ohio, and leading engineering consulting firms, we determined conclusively that the cause of the collapse was an eyebar fracture in one of the bridge’s suspension chains. The fracture resulted from stress corrosion and corrosion fatigue that had developed over the bridge’s 40-year lifespan. Not surprisingly, no evidence was ever found connecting the Mothman to the failure.

This catastrophic event prompted national concern about the safety of bridges across the United States. President Lyndon B. Johnson ordered all US bridges to undergo safety inspections. Congressional hearings resulted in mandates requiring the US Department of Transportation to develop and implement National Bridge Inspection Standards. In December 1970, landmark legislation was enacted that established national requirements for bridge inspection and evaluation. One would think that these rigorous new inspection standards would take care of bridge failures forever. Unfortunately, during the past half century, that’s not been the case.

1983 bridge collapse in Greenwich CT
A 100-foot-long section of the Interstate 95 bridge over the Mianus River in Greenwich, Connecticut, collapsed June 29, 1983 (source: Bob Child, Associated Press)

On June 28, 1983, a 100-foot-long section of Interstate 95 (Mianus River Bridge) collapsed near Greenwich, Connecticut. Two tractor-semitrailers and two passenger vehicles went down with it, resulting in three fatalities and three serious injuries. We determined that corrosion-induced forces led to lateral displacement of the suspension assembly, which went undetected by the state’s bridge inspection and maintenance programs and ultimately led to the collapse.

On April 5, 1987, tragedy struck again when two spans of the New York State Thruway (Interstate 90) fell about 80 feet into the rain-swollen Schoharie Creek. Four passenger cars and one tractor-semitrailer plunged into the creek, and 10 people were killed. We determined that the New York State Thruway Authority failed to maintain adequate support around the bridge piers, leading to severe erosion in the soil beneath the bridge footings. We also determined that the state’s bridge inspection program was inadequate. Not surprisingly, neither the Mothman nor the Loch Ness Monster was seen in advance of this collapse to forewarn of the impending catastrophe.

1987 bridge collapse near Amsterdam, New York
Divers search for victims in the Schoharie Creek after the New York State Thruway bridge collapsed near Amsterdam, New York, on April 5, 1987 (source: Fred McKinney, Times Union)

Other notable bridge failures we investigated in the late 1980s involved localized flooding and water scouring. One collapse occurred on April 1, 1989, near Covington, Tennessee, when two columns supporting three bridge spans collapsed, sending an 85‑foot section of the US Route 51 bridge 20 feet into the Hatchie River. Five vehicles fell with it, killing eight occupants. Again, our investigation identified deficiencies in the state authority’s bridge oversight. In response to our investigations of these events, additional requirements were developed for periodic underwater inspection of bridges.

Probably the most memorable bridge collapse we investigated occurred 10 years ago in Minneapolis, Minnesota, when a catastrophic failure occurred in the main span of the deck truss in the Interstate 35W highway bridge. As a result, 1,000 feet of the deck truss collapsed during rush hour, with about 456 feet of the main span falling into the river. A total of 111 vehicles were on the portion of the bridge that collapsed; 13 people died and 145 were injured. We determined that a design error in the gusset plates compromised the bridge’s load capacity, causing it to fail under substantial weight increases. Our investigation prompted the development of additional bridge quality assurance and improved bridge inspection requirements.

2007 bridge collapse in Minneapolis, Minnesota
Interstate 35W bridge over the Mississippi River collapsed in Minneapolis, Minnesota, on August 1, 2007 (source: Peter Matthews, Polaris)

On December 15, as we mark the 50th anniversary of the Silver Bridge collapse, let’s focus on the infrastructure improvements we need still need to make five decades later rather than try to place the blame on mythical creatures like the Mothman. Throughout the NTSB’s history, we have investigated catastrophic bridge collapses with one goal in mind: preventing future tragedies. Despite efforts to continually enhance the quality of bridge inspections, unforeseen disasters continue to occur, highlighting the need to thoroughly inspect and replace bridges before they collapse. Supernatural forces do not bring down bridges; neglect does.

 

Don Karol is a Senior Highway Accident Investigator and National Resource Specialist in the NTSB Office of Highway Safety.