Category Archives: Transportation History

Time for Action: Passenger Vessel Safety Can’t Wait

By Chair Jennifer Homendy

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

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

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

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

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

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

Enough is enough.

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

Our Marine Safety Partner

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

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

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

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

Lessons from Tragedy

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

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

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

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

Fire Safety

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

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

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

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

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

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

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

Safety Management Systems

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

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

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

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

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

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

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

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

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

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

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

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

The Work Ahead

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

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

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

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

Ready to Answer the Call

By Lorenda Ward, Chief, NTSB Air Carrier and Space Investigations Division

When I read the Chair’s blog, “A Call to Action from Kennedy,” I asked myself, “Are we ready?” Not for commercial space exploration, but for the next commercial space accident investigation.

One of my responsibilities as the chief of the NTSB’s Air Carrier and Space Investigations Division is to ensure that our senior aviation investigators are prepared to respond to a commercial space accident. As the Chair outlined in her blog post, with the growth of commercial space launches and reentries, it is not a matter of “if,” but a matter of when.

What if we get the call today?

The NTSB has done a lot over the last several decades to prepare, including establishing the Quad-Agency Working Group with the Federal Aviation Administration (FAA), NASA, and the US Space Force, to build those important relationships between the agencies before a bad day happens. We meet regularly to discuss lessons learned and best practices from past investigations to ensure we are ready for the next investigation.

We also have a lot of training opportunities for our investigators that are above and beyond just attending industry conferences. Several years ago, I helped create a spacecraft design and systems engineering training course, as well as a commercial space externship program for our investigators to learn about the different space vehicles. We also take part in mishap tabletop exercises where we discuss the NTSB party process with both government and industry organizations. By far though, our best training opportunities have been the “on-the-job training” investigations that we’ve taken part in over the years. These investigations have provided us a great understanding of multiple launch vehicles and systems.

Responding to the Call

I remember leading the last fatal commercial space accident involving Scaled Composite SpaceShipTwo (SS2). I was actually at the site of another commercial space mishap, examining the recovered ordnance, when the SS2 accident occurred. Because of the possibility that cellphone signals could detonate unexploded munitions, our whole team had left our phones on the bus while we were at the storage location.

An FAA investigator who had stayed back came running into the bunker, saying we need to go now. I didn’t ask any questions and it wasn’t until I got back on the bus that I saw my boss had been repeatedly calling me for half an hour.

When I finally talked with my boss, he told me I would be the investigator-in-charge (IIC) of the go-team to investigate the first fatal commercial space launch accident. All the federal investigators (NTSB and FAA) had to work our way back from Wallops Island, Virginia, to DC. I had to keep pulling over to be patched into conference calls, so the commute took a lot longer than usual. At NTSB, we do not take calls while driving as distracted driving is a serious issue on our roadways. We have an agency-wide policy that prohibits staff from using a cell phone while driving. I remember at one point telling management I would never make it back to DC if I had to keep pulling over.

For the next 9 months, my focus was determining what happened to SpaceShipTwo. The accident occurred on October 31, 2014, when SS2 broke up during its fourth rocket-powered test flight and impacted terrain over a 5-mile area near Koehn Dry Lake, California. One test pilot (the co-pilot) was fatally injured, and the other test pilot was seriously injured. SS2, a reusable suborbital rocket, had released from WhiteKnightTwo, the carrier vehicle, about 13 seconds before the breakup. SS2 was destroyed, no one on the ground was injured by the falling debris, and WhiteKnightTwo made an uneventful landing.

SpaceShipTwo released from WhiteKnightTwo (Source: Virgin Galactic WK2)

Scaled Composites (“Scaled”) was operating SS2 under an experimental permit issued by the FAA Office of Commercial Space Transportation (AST) according to the provisions of 14 Code of Federal Regulations Part 437. The investigation identified several safety issues, to include the lack of human factors guidance for commercial space operators, missed opportunities during the FAA/AST’s evaluations of Scaled Composite’s hazard analyses, FAA/AST granting waivers from regulatory requirements, and an incomplete commercial space flight database for mishap lessons learned. The full report, safety recommendations and docket material, are available on the NTSB investigation page.

What Went Wrong?

The probable cause of the breakup was Scaled Composite’s failure to consider and protect against the possibility that a single human error could result in a catastrophic hazard to the SS2 vehicle. This failure set the stage for the copilot’s premature unlocking of the feather system which led to uncommanded feather extension and the subsequent overload and in-flight breakup of the vehicle. The accident vehicle had onboard video recording (cockpit image recorder) capability and the recording was obtained from a telemetry ground station located in Scaled’s control room at Mojave Airport, Mojave, California. This video was a key part of the investigation, showing cockpit displays and what actions the crew members took.

The Party System

All of our investigations use a party system, meaning that the operator and the regulator will be part of our investigation, at a minimum. For the SpaceShipTwo investigation, we invited Scaled, Virgin Galactic, Butler Parachute Systems, and the FAA to be parties. Scaled built and tested SS2 and had delivered WhiteKnightTwo to Virgin Galactic before the accident. Scaled had planned on transitioning SS2 to Virgin Galactic toward the end of 2014.

WhiteKnightTwo hangar visit during on scene phase of investigation, Nov. 2, 2014, Mojave, CA (Source: NTSB)

At the end of the investigation, a couple of the party members mentioned that when we first arrived on scene, wearing our blue jackets with giant yellow letters, they had no idea what to expect or what they were in for. They thought they were being invaded. For this reason, and others, we like to meet with commercial space operators before an accident, so we can explain the NTSB investigation process before we show up on their doorstep for an accident investigation. That initial reaction turned to one of trust as the investigation progressed. They said they were glad we led the investigation and had learned a lot from us. We, in turn, also learned a lot from all the parties.  

Some party members also mentioned that they felt like full participants in the investigation, and that their voices were heard. To that point, the investigation would not have been completed in 9 months if we did not have the professionalism, openness, responsiveness, and willingness of the parties to trust our process.

To return to the question that I asked myself on reading the Chair’s blog: “Are we ready?”

Yes, we are ready. Nobody is more ready. This is what we do: Investigate. Communicate. Advocate.

A Call to Action from Kennedy

By Chair Jennifer Homendy

This week, I visited NASA, Boeing, Blue Origin, and Space-X at Kennedy Space Center (KSC) in Florida. KSC has been a leader in space exploration for over 50 years. The Apollo, Skylab, and Space Shuttle programs took off from there, as did the Hubble Space Telescope, the Mars Rover project, and New Horizons, the first spacecraft to visit Pluto.

To visit Launch Complex 39A and stand where the Apollo and Space Shuttle astronauts once stood before they launched into space was humbling, and as I watched Space-X’s Transporter-5 launch and land from the balcony of Operation Support Building 2 and the return of Boeing’s Starliner Spacecraft virtually, I was reminded of how important it is that we learn from the past as we advance into our future.

Exactly sixty-one years earlier, to the day, on May 25, 1961, President Kennedy addressed a joint session of Congress and laid out a truly ambitious goal: landing a man on the Moon. Not just landing a man on the Moon but returning him safely to Earth. He called for national leadership and implored Congress and the country to take a firm and sustained commitment to a new course of action, “a clearly leading role in space achievement, which in many ways may hold the key to our future on earth.” And he demanded that the whole of government, working together as one, dedicate themselves to jumpstarting a future he knew was in the best interests of our country.

The vision that President Kennedy laid out 61 years ago continues to shape our nation and the world. Today, NASA is developing its deep space rocket, the most powerful rocket it has ever built, the Space Launch System (SLS), while commercial space companies transport cargo for the federal government and private businesses to space as well as to the International Space Station (ISS). These companies have also begun transporting passengers.

Commercial spaceflight is a rapidly evolving industry and shows tremendous promise. Over the last decade, Federal Aviation Administration (FAA)-licensed commercial launches and re-entries have grown tremendously, from 1 licensed launch and 0 licensed re-entries in 2011 to 54 licensed launches and 6 licensed re-entries in 2021. The federal government needs to be prepared for these exciting technological advances. For NTSB, that means ensuring we remain ready if an accident occurs. If the past has taught us anything, it’s not a matter of “if” an accident will occur, it’s a matter of when.

The NTSB has investigated accidents involving space vehicles for over 30 years. In 1986, we participated in the investigation in the Space Shuttle Challenger disaster; in 1993, we investigated the Orbital Sciences Pegasus accident; we again participated when the Space Shuttle Columbia disintegrated on reentry and 7 astronauts died, in 2003; and in 2004, we assisted NASA with the Genesis Sample-Return Capsule crash investigation. More recently, in 2014, we investigated the in-flight explosion of SpaceShip Two.

All this is to say, we aren’t new to commercial space. The fact is NTSB is world renowned for its reputation as the “gold standard” for thorough, fact-based, independent investigations of accidents in all modes of transportation, whether those accidents occur on our roads, railways, waterways, or in our skies. We have been at the forefront of safety and the advancement of new technologies and new ways of moving people and goods for decades. We’re used to new challenges, and we’re ready for them.

The key to our success is our independence. That independence is what sets us apart. We aren’t tasked with exploring space; that’s NASA’s mission. We aren’t tasked with promoting, licensing, or regulating the safety of the commercial space industry; that’s the job of the FAA. Our entire mission is focused on determining what happened when a tragedy occurs, why it happened, and issuing safety recommendations aimed at preventing it from happening again. In other words, our one and only goal is to save lives and prevent the reoccurrence of terrible tragedies.

These past few months, I’ve spent time with our safety partners at FAA and NASA in hopes of ensuring we’re all prepared should tragedy occur. I’ve done this because I believe that the disparate arms of the federal government must work together to ensure the safety and success of this burgeoning industry. The commercial space industry is American innovation at its finest. As a government, we don’t want to get in the way of awe-inspiring technological innovations we once thought unimaginable, but we want to provide guardrails and cooperation, guidance and protection of the public, and we all need to work together as one to make that happen.

Sixty-one years ago, President Kennedy called on us to work together for the best interests of our country. The need for all of us to work together resonates as much today. I call on our safety partners at NASA, at FAA, at the Departments of Commerce and Defense to work with us and the stakeholders who I visited this week, among others, to ensure that safety remains a top priority alongside commercial space innovation.

Reflections on International Women’s Day

By Chair Jennifer Homendy

Who will be speaking? The Chair? What’s his name?

That’s what I overheard a reporter asking an NTSB employee just a few weeks ago. We were in Pittsburgh, where I was on scene for the agency’s investigation into the collapse of the Fern Hollow Bridge.  

I couldn’t help myself and jumped in with: “He’s a she…and it’s me!”

The reporter was mortified and apologized profusely. We shared a laugh and went on to have a great press conference.

NTSB Chair Homendy at a press briefing on the NTSB investigation into the collapse of the Fern Hollow Bridge in Pittsburgh, Pennsylvania.

Even though I responded with humor, that exchange was just one example of an unconscious bias that women encounter every day. Of course, unconscious biases can reflect one or more “-isms:” racism, ableism, heterosexism, ageism, classism, etc. 

In all fairness to the reporter, he responded appropriately. By that I mean he acknowledged his mistake and apologized sincerely. He wasn’t defensive and he didn’t invalidate my reaction. His response showed real humility, which is why we were able to move on so quickly.  

What You Can Do

I offer two suggestions for small but powerful ways you can recognize International Women’s Day and #BreakTheBias.

First, accept that no one is free from unconscious bias. Work to become aware of the ways you may show your own “-isms” and do what the reporter did: own the error and offer a genuinely sincere apology. Fight the urge to say I didn’t mean it like that. The only way to ensure you do better next time is to respond with humility.

You can also be intentional about using words that communicate a sense of belonging. When backed up by action, the language we use can change the culture from one of exclusion to one of inclusion.

Women in Transportation

Increasing the representation of women in all transportation modes will go a long way toward combatting unconscious bias. Consider the following statistics:

  • Aviation: Women hold only 8.5% of FAA pilot certificates. Female flight engineers, 4.3%; mechanics, 2.6%; parachute riggers, 10.1%; ground instructors, 7.8%; air traffic controllers, 16.8%; dispatchers, 19.7%.
  • Highway: While 49% of all workers nationally are women, only 18% of infrastructure workers are women. Moreover, in 20 of the largest infrastructure occupations, less than 5% of workers are women. And 7.9% of truck drivers are women.
  • Marine: Women make up just 1.2% of the global seafarer workforce. While this represents a nearly 46% jump from 2015, it’s not nearly enough.
  • Railroad: Women hold less than 8% of rail transportation jobs and the latest Federal Railroad Administration report acknowledges that “recruiting and retaining a diverse representation of employees remains a persistent issue.”
  • Pipeline & Hazardous Materials: Over 80% of hazardous materials removal workers are male — and just 15% of civil engineers are women. As for pipeline, women make up 10.8% of the pipeline transportation workforce and 21.8% in natural gas distribution. Unfortunately, these numbers drop even lower when it comes to higher-paying technical jobs in the oil and gas industry.

We have work to do, including here at NTSB. Our latest state of the agency report showed that our female workforce is 7% below the civilian labor force — something I think about every day. I’m only the fourth woman to serve as Chair since the agency was created in 1966. This is a message I’ll be sharing at the upcoming International Women in Aviation Conference.

When I was appointed to lead the NTSB, I made the decision to be addressed as Chair Homendy. I didn’t make this out of personal preference, but for the next woman to serve in the role. Perhaps, if we de-gender the office, the fifth female Chair will have one less bias to break.  

Black History Month and Transportation Safety

By Nicholas Worrell, Chief, NTSB Safety Advocacy Division

Our stoplight system—red for stop, green for go, and yellow for caution—benefits every motorist in the nation. Yet, most people don’t realize that the system was invented by a Black man whose father was formerly enslaved: Garrett Morgan.

A largely self-taught inventor and a hard worker, Morgan was the first Black person in his city of Cleveland, Ohio, to own a car. In 1923, he realized the need for a yellow signal after seeing a crash at an intersection, and the rest is history. As a result, our roads are much safer today.

But they’re not equally safe for all communities. As Chair Jennifer Homendy has said, “Black road users are not as safe as their white counterparts—and these disparities are unacceptable.” For example:

  • Traffic fatalities among Black people increased by 23% between 2019 and 2020, compared to an overall increase of 7.2%. (NHTSA)
  • From 2010–2019, Black people were struck and killed by drivers at an 82% higher rate than white, non-Hispanic Americans. (Smart Growth America)
  • Drivers are less likely to yield to Black people walking and biking than white people doing those activities. Black pedestrians were passed by twice as many cars and experienced 32% longer wait times for cars to yield to them than white pedestrians. (National Institute for Transportation and Communities)

This month, we celebrate Garrett Morgan and all Black leaders who’ve worked to improve transportation safety. We should also take this time to examine the shameful statistics and work to address their root causes. We can’t address the problems different communities face in transportation until we recognize the diversity of the communities we serve and the disparities between them. These statistics beg the question: How much of the full transportation safety story are we overlooking?

Members of the transportation safety community must understand how—and who—transportation tragedies strike, and we must engage the communities we want to help in designing solutions. We need representatives of all colors, creeds, and perspectives to improve transportation for everyone, regardless of their race.

Garrett Morgan improved life for all in the U.S. Yet during his time, a time before civil rights, overt racism was so common that it was literally built into our transportation system’s asphalt and concrete bones. We owe it to Black pioneers like Garrett Morgan—and to all the traveling public—to make transportation safety more equitable.