In this episode of Behind-the-Scene @NTSB, we talk with staff from the Office of Marine Safety, the Office of Railroad, Pipeline, and Hazardous Materials Investigations, and the Office of Research and Engineering, about the investigation of the 2021 Anchor Strike of Underwater Pipeline and Eventual Crude Oil Release in San Pedro Bay off the coast of Huntington Beach, CA.
For full details on this investigation, including a recording of the Board Meeting, visit our webpage.
The National Transportation Safety Board (NTSB) is an independent federal agency charged by Congress with investigating every civil aviation accident in the United States and significant events in railroad, transit, highway, marine, pipeline, and commercial space. We determine the probable causes of the accidents and events we investigate and issue safety recommendations aimed at preventing future occurrences.
The agency’s investigative and technical staff are recognized for their forensic safety expertise, and with support from the agency’s professional staff, the NTSB is the premier safety investigation organization in the world. In total, the NTSB has conducted more than 153,000 aviation-related investigations and thousands of highway, transit, marine, rail, pipeline, and commercial space investigations, resulting in more than 15,300 safety recommendations. As a result, the NTSB has had a significant and far-reaching impact improving transportation safety for all, with 80% of our recommendations being addressed.
We’ve been getting the job done, even though our budget and workforce has remained relatively flat for the past 20 years. That’s until the 15th Chair of the NTSB, Jennifer Homendy, was sworn in on Aug. 15, 2021.
From her first day, Chair Homendy immediately began implementing her vision of putting mission first, building our agency’s staffing and infrastructure to equip us to better meet the transportation safety challenges we face, including today’s accidents and significant events and those coming in the very near future from emerging technologies like autonomous vehicles and commercial space.
Growing our Workforce
Her first step: fund the agency to grow our workforce. Chair Homendy understood that the agency could not effectively operate with the same number of people that we had in 1997, given the growing complexities of the transportation systems we investigate. Working with leadership across the agency, the Chair secured needed funding increases in fiscal years (FYs) 2022 and 2023, prioritizing recruitment of a diverse and talented workforce, starting with hiring the agency’s first chief human capital officer and supporting a hiring surge.
Under Homendy’s leadership, our workforce has rebounded from an all-time low of 397 employees in August 2019 to its current 419 dedicated professionals. The NTSB workforce is expected to grow to 435 employees by the end of September.
Chair Homendy and Office of Aviation Air Traffic Control Team
Chair Homendy routinely swears in new staff as they are welcomed into the agency by our senior leaders. Just this week, the Chair gave the oath of office to a returning NTSB employee joining our Office of Research and Engineering and new members of the Air Traffic Control Team within the Office of Aviation Safety. That division is now fully staffed for the first time in 7 years.
We also have Chair Homendy to thank for successfully asking the Office of Personnel Management to grant us direct-hire authority, which has sped up the hiring process and enabled us to identify and hire the right talent, for the right job, faster.
Getting Up to Speed Quickly
With so many new hires, agency leaders are focused on ensuring all staff have the skills to succeed. Staff now have access to a Career Development Roadmap with a curated list of educational resources in emerging technology, leadership, project management, data analytics, and many other areas critical to our mission success. We’ve developed and launched a multimodal drone program, including new drones and training for drone operators.
We even launched a new mentoring program in 2023 to connect our seasoned veterans with our newest members to help transfer their knowledge, skills, and expertise. We kicked the program off with a speed mentoring event featuring female leaders across the agency during Women’s History Month.
Women’s History Month Mentoring Event
We’re also investing in our infrastructure, prioritizing funding to acquire long-overdue enhanced IT tools and digital capabilities to improve the customer experience of both staff and those seeking information from the NTSB. This will be supported by the $16.2 million Technology Modernization Fund loan recently awarded to our agency, thanks to an agencywide team led by the Office of Chief Information Officer (CIO) in coordination with the Office of Managing Director, the Office of the Chief Financial Officer, and the Office of Human Capital Management and Training.
If you’ve met Jennifer Homendy, you know she’s a people person. She’s always out there building relationships in big and small ways, internally and with external stakeholders. Our recent ice cream social, co-hosted by the agency’s staff-led Diversity and Inclusion Council (“the DIAC”) and my office, is one example of the Chair’s efforts. The social was a great opportunity to break down our organizational silos, help our new staff feel welcome, and assure everyone that we’re all focused on the same core mission, no matter what your role, as part of Team NTSB.
Driving Change with Data
Ensuring our agency leaders have the data they need to make critical decisions, improve our operations, and swiftly answer data calls from Congress and the public has been a top priority for Chair Homendy.
As a result, the NTSB now has a formal Data Program and Data Strategy Plan. We’ve also hired a chief data officer, who will join our agency in early FY 2024. Already, with the help of our chief data scientist and CIO, our data infrastructure has grown to allow staff use dashboards and data visualization tools to help analyze the agency’s work, identify trouble spots and bottlenecks, and make changes to improve efficiency.
The proof of success from our data-driven change and larger workforce is in the numbers. Over the past 2 years, thanks to staff’s incredible work, we’ve reduced our backlog of 442 incomplete investigations over 2 years old to almost zero, and the average time to complete an investigation has decreased across every mode of transportation we investigate. Now, that’s measurable progress!
Rightsizing our Budget
Growth and operational improvements come at a cost—a fact not lost on Chair Homendy. For the past 2 years, the Chair has been on Capitol Hill knocking on doors and speaking to everyone who will listen about why our agency’s budget needs to be rightsized.
She has also spent the past 2 years proving to Congress that this agency is responsive and nimble, and that we’re improving our operational efficiency. All her efforts to grow our staff, reduce our investigation backlog, and better serve and represent our customers are paying off.
For FY 2024, the House Appropriations Committee approved a $145-million budget for our agency. If granted, it would be the first significant NTSB funding increase since the mid-1990s. The new funding has long been needed to continue to grow the agency’s size and capabilities so we can more effectively accomplish our critical safety mission.
We look forward to entering the new fiscal year energized, better staffed, and prepared to meet new challenges, with a new group of NTSB employees ready to join in our critical mission to make transportation safer for all.
By James Scheffer, Strategic Advisor, NTSB Office of Marine Safety
It’s been 40 years since the large bulk carrier SS Marine Electric tragically sank on February 12, 1983, off the Virginia coast. Nearly all aboard—31 of 34 souls—were lost. But I remember the events of that tragic day as if they happened yesterday.
On that day, I was the 34-year-old captain of the 661-foot, 34,700-DWT lube oil tanker Tropic Sun, the first vessel to respond to the Marine Electric’s early morning distress call.
On February 11, a nor’easter formed off Cape Hatteras and the Virginia coast. On land, the storm was responsible for a blizzard that set snowfall records in several eastern seaboard cities and blanketed Washington, D.C., in up to 30 inches of snow. At sea, it generated 50–60 knot winds and 30–40-foot seas.
On the evening of February 11, while on the bridge, I heard the Ocean City Coast Guard Station side of a VHF radio telephone call to the Marine Electric. The Coast Guard was acknowledging that the Marine Electric had pumps going and was telling the crew to keep the Coast Guard informed if they needed help.
Meanwhile, the Tropic Sun was rolling, the bow slamming into the swells and seas shipping across the main deck—not unusual conditions for a loaded tanker during a nor’easter. Again and again, water covered the deck; again and again, the deck emerged after each wave. We took that for granted. It was normal in a storm.
I tried—but failed—to get some sleep. The Tropic Sun was three hours from Cape Henlopen, Delaware, and another from our discharge terminal at Marcus Hook, Pennsylvania.
At 0315, the radio telegraph auto alarm went off on the bridge. The SOS was from the Marine Electric, which was taking on water and readying its lifeboats for abandoning ship. The crew needed help as soon as possible.
The Marine Electric was more than 35 miles from us. I changed course and informed the local Coast Guard station that we were responding to the SOS. On our way south to render aid, we saw an unwelcome sight, one that still makes me shake my head: vessels that must have heard the Marine Electric’s SOS sailing in the opposite direction.
When we got within a dozen miles of the Marine Electric’s last position, our hearts sank. There was no sign of the bulk carrier on radar. Before daybreak the sea was full of blinking strobe lights, which we recognized as the lights on lifejackets.
I maneuvered the ship in heavy seas to a full stop alongside more than 20 possible survivors floating in the water around 0540. At the time, the water temperature was 39F with an air temp of 34F. They were unresponsive to our calls in the dark/early morning and eerily peaceful, all dressed in winter gear and lifejackets. By all appearances, the Marine Electric‘s open lifeboats had failed to keep them out of the water and alive.
My own vessel carried the same style of open lifeboat.
The Coast Guard requested that I launch our lifeboats to retrieve the potential survivors, but I refused because of the strong winds and heavy sea conditions. The chief mate and I would not put our crew in harm’s way in the same type of open lifeboats that had so abjectly failed the crew of the Marine Electric. At the request of the Coast Guard, I agreed to stay in the area following a search pattern for any missing crewmembers. The Coast Guard thanked us for our efforts, and we resumed our voyage at dusk on February 12.
Later, while discharging cargo at Marcus Hook, some of the Tropic Sun’s crewmembers discussed buying their own survival suits, but then thought of another solution, which I gladly forwarded to management: a request for survival suits for all onboard. Within two trips (28 days), the vessel was outfitted with survival suits, the first ship to be so outfitted in our eight-ship ocean fleet. These suits, also known as immersion suits, are used without a life jacket when abandoning ship in cold conditions.
On July 18, while the investigation of the sinking was in progress, the NTSB recommended that the Coast Guard require immersion suits be provided for crewmembers, scientific personnel, and industrial workers on vessels that operate in waters below 60°F. The NTSB also made a companion recommendation to Marine Transport Lines, which operated the Marine Electric, as well as to industry groups to recommend their members also provide the suits. The suits became mandatory the following year.
The NTSB determined that the probable cause of the capsizing and sinking of the US bulk carrier Marine Electric was the flooding of several forward compartments as the result of an undetermined structural failure. The lack of thermal protection [survival suits] in the water was one of the factors contributing to the loss of life in the tragedy.
As a result of the Marine Electric’s sinking, the Coast Guard’s inspections improved, and many World War II-era (and older) vessels were scrapped. The Marine Electric tragedy also resulted in the creation of the Coast Guard’s rescue swimmer program.
The Marine Electric as seen underway before its capsizing and sinking on Feb. 12, 1983 (Photo: U.S. Coast Guard)
I sailed for over 24 years with the Sun Marine Department, mostly on coastwise voyages on the east and west coast, with the occasional foreign voyage. I sailed as a captain for over 16 years without any casualties or pollution events. The night the Marine Electric was lost served as a constant reminder to me to respect the power of the sea.
Over the past 26-plus years, I have investigated dozens of accidents and supervised more than 200 accident investigations as Chief of Investigations and Chief of Product Development in the Office of Marine Safety at the NTSB. And since then, we have seen the emergence of technologies and innovations that, combined with survival suits, could have helped prevent such tragedies, such as personal locator beacons.
However, I will never forget the night the Marine Electric sank, and neither will the other members of the Tropic Sun’s crew. While events in our lives have sent each of us forward on our separate courses, whenever we meet, our conversations converge on that evening 40 years ago.
This anniversary has passed, but the memory of those 31 mariners will not.
Those of us aboard the Tropic Sun fared far better that night; however, our similarities to the crew that was lost drove home two points about losses at sea. First, if we are telling the story, we are the fortunate ones. And second, nothing is more important than taking fortune out of the equation by making life at sea safer.
By Morgan Turrell, Director of the Office of Marine Safety
New Year’s Eve is a time of celebration and remembrance. Three years ago, on December 31, 2019, as the new year was being rung in across the lower 48 states, a tragedy was playing out in icy Alaskan waters. The fishing vessel Scandies Rose, with seven crew members aboard, encountered severe icing conditions and high winds and waves as it transited from Kodiak to fishing grounds in the Bering Sea. The crabber tried to make it to Sutwik Island to shelter from the storm; however, because of the weight of the topside ice that had accumulated on the vessel and the force of the winds and waves, the Scandies Rose capsized and sank before reaching safety.
Two crewmembers managed to climb out of the capsized ship and swim to a life raft, where they were tossed about for 4 hours in 50‑mph freezing winds and 30-foot seas. Search-and-rescue (SAR) operations, hampered by the poor weather conditions and unsure of the survivors’ location, struggled to find them. Eventually, a Coast Guard helicopter rescued the two crewmembers, but the remaining five were never found.
Our investigation into this accident found that the Scandies Rose’s emergency position indicating radio beacon (EPIRB) failed to provide a position after crewmembers were forced to abandon the vessel. The crew was left without a means of communicating with SAR personnel, who, going off the EPIRB information, were searching in the wrong area. As a result of this situation, we reiterated a 2017 recommendation (M‑17-45) to require mariners to have personal locator beacons (PLBs). This recommendation asks the Coast Guard to require that all personnel employed on vessels in coastal, Great Lakes, and ocean service be provided with a PLB. Unfortunately, this recommendation is still open.
Rescue helicopter search area for Scandies Rose based off position passed in error. (Courtesy: Coast Guard)
A PLB is a personal electronic device that transmits a survivor’s location on or in the water to the Search and Rescue Satellite-Aided Tracking system during an emergency. It’s designed to be carried in a person’s life vest (or elsewhere on their body) and manually activated when the wearer is in distress. PLBs continuously update a survivor’s location.
The Scandies Rose is one of several notable marine casualties the NTSB has investigated in the last 5 years involving mariners lost at sea in which PLBs could have made a difference. These casualties highlight the critical safety need for PLBs to aid in SAR operations at sea. We’ve been recommending that all mariners use PLBs since our investigation of the October 2015 sinking of the cargo ship El Faro, which sank in the Atlantic Ocean about 40 nautical miles northeast of Acklins and Crooked Island, Bahamas, after sailing directly into the path of Hurricane Joaquin. The entire crew of 33 aboard perished.
Three days after the El Faro’s sinking, searchers spotted the remains of one El Faro crewmember in an immersion suit. It’s unclear when the crewmember perished or if any other crewmembers were able to abandon ship; however, had that crewmember, or any others who were able to evacuate, been equipped with a PLB, searchers would have had the essential information to focus rescue efforts. We concluded then that equipping all people onboard a vessel with a PLB would enhance their chances of survival, and, in 2017, we issued safety recommendation M-17-45.
Since the sinking of the El Faro and the Scandies Rose, we have investigated two other marine tragedies that continue to highlight the need for PLBs.
On November 23, 2020, the Coast Guard received a distress signal about 27 miles from Provincetown, Massachusetts, from the EPIRB registered to the Emmy Rose, an 82-foot-long commercial fishing vessel with four crewmembers aboard. The Coast Guard recovered the EPIRB, but none of the crewmembers were located and are presumed dead. The investigation showed that if any crewmembers had been able to evacuate the vessel, they would have been able to survive up to 22.5 hours in the water with an immersion suit. It’s unlikely that the crew had PLBs; however, had they been able to activate a PLB after abandoning the vessel, SAR crews may have been able to find them.
On April 13, 2021, the liftboat SEACOR Power capsized off the coast of Port Fourchon, Louisiana, in a severe thunderstorm. Six crewmembers were rescued by the Coast Guard and Good Samaritan vessels, and the bodies of six other fatally injured crewmembers were recovered. Seven crewmembers were never found and are presumed dead. None of the survivors rescued had PLBs or similar satellite emergency notification devices (SENDs), which use commercial satellite systems, nor did they know of anyone else on board who did.
Other marine investigations we’ve conducted have shown how PLBs and SENDs, when voluntarily incorporated into marine operations, likely saved lives. For example, our investigation of the November 10, 2021, fire aboard the fishing vessel Blue Dragon found that SAR controllers were able to correlate location data from multiple emergency beacons. Similarly, our investigation of the July 23, 2016, sinking of the commercial fishing vessel Ambition found that use of the vessel’s SEND prompted an immediate response from the commercial response center when the Coast Guard did not receive the captain’s mayday call.
PLBs are now widely available, relatively inexpensive, and remarkably accurate. Models typically cost $300–$400, and most offer GPS location functionality that can provide SAR operations with a continuously updated location of each person to within 300 feet. PLBs can be equipped with an integrated automatic identification system (AIS) “Man Overboard” alert that, in addition to satellite GPS location, transmits AIS signals for local assistance from nearby vessels.
The NTSB has been advocating for PLBs for many years now. The Coast Guard should require them, but the marine industry doesn’t have to—and shouldn’t—wait for a Coast Guard requirement to make PLBs a common piece of safety equipment on commercial vessels.
This New Year, as we reflect on the third anniversary of the tragic Scandies Rose sinking, we ask mariners and marine operations to make it their new year’s resolution to invest in their crews’ safety by providing PLBs. Without a doubt, a PLB can avoid turning an unfortunate accident or incident into a tragedy on the seas.
By Stephanie Shaw, Acting Chief, NTSB Safety Advocacy Division
This week, families and friends will gather to celebrate the Thanksgiving holiday. According to estimates from AAA, nearly 55 million people will travel away from home this year, with about 49 million of them taking to the roads.
As we mark the beginning of the holiday travel season, we want to ensure that everyone arrives safely at their destinations. Unfortunately, travel on our roads can be the riskiest mode of travel during the holiday season.
NTSB investigations continue to highlight actions needed by regulators, legislators, and industry to ensure the safest transportation system for the traveling public. Our Most Wanted List (MWL) identifies specific transportation safety improvements needed across all modes. It includes five road safety improvements that address pervasive problems like speeding, alcohol and other drug impairment, and distraction. The MWL also calls for collision-avoidance and connected vehicle technologies and implementation of a Safe System Approach to better protect all road users.
At the NTSB, we believe that safety is a shared responsibility, so for the traveling public, we’ve highlighted some ways you can keep yourself and others safe, regardless of the travel mode you choose.
By Car
Impairment by alcohol and other drugs, unsafe speeds, fatigue, and distraction continue to play major roles in crashes. Here’s what you can do:
Designate a sober driver, or call a taxi, or ridesharing service if your holiday celebrations involve alcohol or other impairing drugs.
Follow safe speeds. In bad weather, safe speeds are often below the designated speed limit. Speeding increases the chance of being involved in a crash and intensifies the severity of crash injuries.
Make sure you’re well rested! A fatigued driver is just as dangerous as one impaired by alcohol or other drugs.
Avoid distractions. Don’t take or make calls or text while driving, even using a hands-free device. Set your navigation system before you start driving. If you’re traveling with others, ask them to navigate.
Ensure you and all your passengers are buckled up! In a crash, seat belts (and proper child restraints) are your best protection against death and serious injuries.
By Bus
The NTSB has made recommendations to improve motorcoach operations and vehicle crashworthiness, but travelers should know what to do in an emergency.
Pay attention to safety briefings and know where the nearest emergency exit is. If it’s a window or roof hatch, make sure you know how to use it.
Ask your driver to give you a safety briefing if you’re unsure of where the exits are or how to use them.
Use your seat belt when they’re available!
By Plane or Boat
These tips can help you and your loved ones in an emergency on planes or vessels.
Pay close attention to the safety briefing! Airline and marine accidents have become very rare, but you and your family can be safer by being prepared.
Know where to find the nearest emergency exit and flotation device whether you’re on an airplane or a boat.
Confirm that you and your traveling companions—even children under age 2—have your own seats and are buckled up when flying.
Don’t forget your child’s car seat. The label will usually tell you if your child car seat is certified for airplane use; the owner’s manual always has this information.
Call the airline and ask what the rules are for using a child’s car seat on your flight, if you don’t already know.
Follow crewmember instructions and remain calm in an emergency.
By Train
The NTSB has made recommendations to improve passenger rail operations and vehicle crashworthiness, but travelers should also follow these safety tips.
Stow carry-ons in the locations provided (overhead and racks). Don’t block aisles.
Review your trains safety information which may be provided as a safety card in your seat pocket or displayed in your railcar.
Follow crewmember instructions and remain calm in an emergency.
No matter how you travel, make a commitment to put safety first.
NTSB Safety Compass Blog 